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A TREATISE 



cnr 



DISEASES OF THE BONES. 



BT 

THOMAS M. HARKOE, M. D., 

rmomtom or nrBsnr m ths coixxok or pRmciun aks iDBsiaNfl. bttboioii or tbk 

XXW TOKK HOaPTTAI^ BUIKVON QW BILLITUB aOHFtTAI. nTBOaOK or TSI BOOSK- 
▼ZLT HOSFtTAI., OOVBITLITirO BTTBaXOW Of THE HOUVT BIHAl HMFITAI., 

or THE BiRAxamae' hospital, or tki itats woxah'b 
xoanxu^ aid or tb* bobskbt ahd emu)'! 

■OtriTAL, KTC, STO. 






NEW YORK: 
D. APPLETON & COMPANY, 

Si9 & 561 BROABWAT. 
1872. 



K. 



C^J 



BsTZRXD, Mcordliig to Act of Congrwa, in tha jmt ISTS, 

Br D. APPLBTON ft CO.. 

b the Office at tbe UbiuUn of Coogreta, at WuUngtoD. 






DEDICATION. 



TO 

My cdUea^uea in the Suboioal Depabthent of thb New 
ToEK Hospital, IdediccUe this volume m ffrat^itl reoog- 
nUion of tvamiy yeari profem^mal OBsociation, iUugtrated 
hy a thoitsand tokens of friendship and confidence, and 
untnarred hy a single cloud of estrangement, unbroken hy 
a singU Jwur of distrust. 



PREFACE. 



Toe book winch I now offer to my profcssiona! brethren 
eoiilams the Biibstancc of the leotiirea which I huvo tlelivered 
iiiiring tlie past twelve years at tbe Coll*^ of Pliydiuiaiis 
and Sargcune of this city. It does not claim to ho a com- 
plete compendium of all thnt i& known on the subjects of 
which it treats ; for bo much has been learned in bone- 
pnthology since Stanley^g work wae publitUied, now nearly a 
(quarter of a century ag«>, that I have not liad the leiaure, 
and certainly not the ability, to write soch a treatise. I 
hare, therefore, in the arrangement of the different parts of 
my work, followed rather the leadings of my own studies 
and observations, dwelling more on tliose branchea where I 
had seen and studied most, and perhaps too much neglect- 
ing others where my own experience was more barren, and 
lerefore to me less interesting. I have cndeavarcd, how- 
rer, to make np the dcliciem-'ics of uiy own knowledgu by 
tbe free n» uf the materials scattered so ricbly tlirougti our 
periodical literature, which scattered leaves it is the right 
ami the duty of tlic Bystcniatic writer to collect and to om- 
UkIv in any account he may offer of the state of our science 
at any given period. In 'all casus where I have thus made 
use of the hibors of others, I liave given credit in the text 
to the authors fi-om whom I have quoted. 

The study of Diseases of the Bones has had for me a 
life-long interest, and my opportunities for its cultivation 



VI 



PEEFACE. 



have been ample. I can only r^ret now that tlicae excel- 
lent advanta|,'«s Lave not been tamed to better account, and 
th«t my industry and perseverance have been so far below 
iny privilegeft. For tliis, my apology, not my excuse, must 
be, a life Bomcwhat actively devoted to the practice of my 
j)rofegsion and to its public teaching, leaving me less time 
to devote to acicntific studies, than those studies, for their 
Bucccasfnl prosecution, imperatively demand. 

In iltuBtmtiiig tlie work, 1 have not hesitated to borrow 
largely from my friends. By the kind pe^nit^&ion of the 
publisliers, I have availed myself of a largo number uf admi- 
rable woodcuts &om Fagot's work on Surgical Pathology, 
and from BillrotU's work on the same subject, translated by 
HnL-kley. Alt the oi:iginal illustratiuns, mainly taken from 
specimens in the cabinet of the JCew York Iluiipitnl, were 
made for me by lldr. Joseph Harley, of this city, and are, I 
think, remarkably fine examples of his beautiful art. The 
photographs, on which eo much of the success of a woodcut 
depends, were made by Mr. O. G. Mason, tlie accomplLahed 
photographer of Bellevue Kospital. 

I cannot too wannly express my thanks to my profes- 
sional frictids, who have in every possible way encooragcd 
aud ni«isted mc in my work. I uau only say that, if tlii^re 
be any merit in the book, it is largely tlie result of their 
kind and active coiiperation, and that & good share of the 
most valuable observatiuns have been contributed by their 
generous fi-leud£faip. 

If the reading of my book should afford as mncli pi-ofit 
as tho preparing of it luis given yie pleasure, J shall liave 
reason to be abandantly aatlgfiod witli what I have done. 



New Tohk, March 6, 1873. 






OOITTEKT9. 



IJrTBODrOTIOV 1 

PiRT I. 

DiaXASES OF Boyx. 

Chap. I. — Hypsbtbopht ahd Atbopht op Bofs .... 18 

n. — iHFLAJfKATIOIil' OF BoKK 19 

m. — ScpFuiuTioiT ra Boss 2T 

IV. — Chbosio BnmoiTB Absoebb of Bone .... 88 

T. — DrfFTBK Sttfpdbation. — Osteo-Mtelitis . . . . 4B 

TI.— EioiBTB 54 

Tn. — MoLUTiBS OseiuH — Malacobteo^ 74 

VIlI. — Fbjioiutab OflerCM 83 

IX. — TrBBBCirLi.B Dibeabe of Bone 65 

X— Oabus 94 

XL — Neobobib 119 



PART n. 

TITMOBS or BOUTS. 

Ohap. I. — Oartilagisods Ttthobb 217 

n. — OesEOCS T0MOB8 288 

m. — FiBfiors AHD Fibroid Tukobb 266 

IV.— Myeloid Tcmobb 276 

T. — ^PtruATHiG TnuoBs or Boss , . 288 

YL — ^TtJKOBB OF THE Javs 800 







I 



A TREATISE 



(nr 



DISEASES OF THE BONES. 



THOHAS M. KiRKOE, M. D., 

or ■ umwK T nr tbm cwi-ums or PBmoujra ion) nTsaioNs, sxresxcm or rax 
TOBK RCMpfTAih njBOBON or aKLLKTux HDBpiTu^ euBOCOiT or TBI Boon- 

TBLX BOSFTTAL, OOXaCLTnH) SITBOBOS Or TSE BOUHT OIKU HMPTUL, 

or TBI btbabsbbb' BoanTAi^ or tbz itatb wdkih'i 

mmxAi^ iJtD or tbk vrumxi axd oaiij>'B 

KOcnTAi^ BIO., nc. 



^^ 



VitOiCAt 



^'^ 






V. 



NEW YORK: 
D. APPLETON &. COMPANY, 

St9 & 651 B&OADWAT. 



1872. 



• .•••••■ • •>••• t 

•* . • • • • • .•>••• 

• • •• .••• • • ><<>••• 

• *■ ■•^■fl « ••■•*»* 



Bktxbkd, UGordlDg to ActofCongnas, In Um ;ear IBQ, 

Br D. APPLBTON A CO., 

b the Office of tbe LnHmrlu oT Congiesi, mt WiflUnston. 






DEDICATION. 



TO 

My coUeaguea in the Subgioal Depabti^ent of ths New 
XoBK HospiTAZ^ I dedicate this vol/mne in gratefid recog- 
niUon of twenty yeari profesgional aseociation, iUuetrated 
hy a thouscmd tokens of friendship and confidence, and 
tinmarred by a single dmtd of estrangeineni, urthroken hy 
a single hour of distrust. 



9 



DISEASE OF TUB BOSES. 



and in some d^ree to 6U])i>Iy tlie loss of the original. Simi- 
Jar partial rej^enernUonn have l«f*n ohfiorved in aniinaU when, 
in experimental operations, entire bones, vritli tlieir perioetetun^ 
hare been removed. 



4. Repair. — Eacli of these procceaea of jfrowtli, develop- 
ment, and ror^ncrntion, is abundantly provided for in tho 
flkelotons of thfwe luwcr animals to whieU allusion has been 
made in former iiarapraphs. Of repair, however, in the proper 
sense of the term, tbey are not capable. A fractured coral 
stem is a liopole^ severance; a crubhcd glicll, in that portion 
from which the luiiirml haa retired, '\» aM unchangeable injury. 
Even in that |mrt which it btill inhabits, no proper rcgiair of 
^tbe injary to tho shell takes place, though the animal protects 
ita body from the eifectB of exposure bv forming a new calca- 
reous layer opposite the damaged spot, by which the mischief 
u rather conii>eiisutcd for than healed. The same is true of 
the Crustacea. In a lobster w]u»«c claw had evidently been 
broken by contact with some sharp, hard edge, I recently ob- 
eerved the mode by which the seriona wound was closed. The 
injury was evidently an old one, and still remained — a gash, as 
it were, in the iip])er edge of one of the large claws, nearly an 
inch in depth. The opening was tliorun^hly and neatly cloged 
by calcareous matter, which had been dei>08ited by the vascu- 
lar nieuibrane wbicb secretes the shell, and the injured part 
waa tliUH separated from its old relations to the; surfncc of tlie 
animal. Ho deposit was found on the broken edges, but by 
time, through the attrition against the gravelly or atony 
bottoms in whicli ihey live, the sharpness of the edge was 
eraoothed off so perfectly that it was only by e:(amitiing some- 
what carefully that, the scar conid bo difttingnished from that 
left by a proper healing of the tidaue. In all such cases, and 
in eimitor instance* among the Insecta, tho absence of repair 
does not at all depend on the want of reparative power in the 
aiumal, but simply on the excrement itious nature of the skele- 
ton, which is, iu that sense, no longer a living part of the 
body, and cannot, therefore, in its injuries profit by the im- 
monse reparative capacities of tho animal. The same animal, 
and by a law evidently of comi>onfiatioM, which cannot rct>air 



iSTHODUcnoy. 



ft 



a componiMl fVncture of it< fllicU, am reprodtice, it may l>e, the 
entire limb, if the injury happen to be severe enough to tear 
it from ita body. 

CoQtriuted with these imperfect efforts in the lower anl- 
^nulei, we find in the hifjlier BfnmrnaHa, and particularly in 

1, that the repair of injured hone in among the most heauti- 
ftil and perfect of all the reparHtire actions: 1. Its most strik- 
ing feature ie that it is intrinsic : that is, it dependi> for itf* i>er- 
fection on the perfect life and high vital organization of the 
bone-6tructure itself. 3. It is reliable. Under all circumetancca 
, of age and condition, and nndor all deprece of injnry M'hicli do 
'not compromise the life of the injured pai't, it may be eo surely 
counted on, that occasional failun^ excite our surprise, and 
eon in moat ingtanccs be csphiiucd by Rome mechanical inter- 
fermco with the process, mthcr tlian by any want of inherent 
power of repair. 3. The repair is economical. Ko more ma- 
terial is employed than nocei^aary, and this material is so pcr- 
teotly transformed into booe-ti^sue, that the micro6copi> cannot 
dialingutsh between the old and the new formation. 4. The 
repair is complete. Although, in the liighest Vertchrata, the 
rejiairing material is thus carefully economized, the result of 
the process is that the bone is, at the point of injury, as strong 
as, and usually stronger than, it was before^ so that, after the 
»Ung process h perfected, a fracture would be more likely to 
jnr at eome other point than at the scat of the perfectly- 
mended original break. Finally, the process \b so arranged 
that its result is shapely. No deformity is left beyond what 
is the necesfiary result of the displacement of the broken fmg- 
roentfl. The uniting medium is so proportioned, and bo ar- 
rnirged betweet) the parts it is intended to heal, that, after the 
process is comjdeted, no tuperaLundance remains, and, if the 
broken ends have been maintained in perfect apposition, so 
shapely and bo i»erfect ia the resnlt, that it is ol^entimes diffi- 
cult to decide that a bone has been broken, when it is ex- 
amined long after the injury, or, if the fact of fnictnro is 
known, to point out the precise spot at which the fracture was 
fiituatetl. 

h is true that, in some of the "Vertebrata below man, the 
onion of broken bones is accompanied by a superabundance of 



10 



DI8EABBS OP TIIB B0SB8. 



the o^nifiv nmterinl of repair, and that Iienc-e the union in these 
animab is accomplished with a clet'oi'ming' prominence of the 
callus ut tlie ^cat of the fracture. But thia apparent imperfec- 
tion in the process h so eviduntlv iu obetlience to ccrtu'm 
mechanical comiitions of the injured jmrt, counuoted witii the 
impuAriibility of securing its abiMiUite rest, that it should rather 
be rei^anted ua an admirable illuistnLtion of adaptability to clr- 
cnmstancea of tlio reparative force, than any impugiiuieut of 
the power and periection of that force ilsclil 

5. J}iseaw. — I have classed the liability to disease as one 
of tUo cvidencee of the high vital eiulowmenta of bone-ti&euo ; 
and while I am not prepared to maintain that there is in the 
capacity for varied mid serioua digeai^e any direct indication of 
high organization, yet it must be uckuowledKed that, under 
our present dii^pon^atton of sorrow, such liability i& in fact al- 
ways assoeiAted with tho^e ti^^uc^, and, indeed, with those 
Anioia1» wlio hold the highest place in the scale of complex 
organization and varied function. Comparative patholog}* has 
not yet been studied so carefully as ita importance iu illuBtrat- 
ing Unman dii^casc would ecciu to warrant, but enough has been 
learned to give us some valualile hints. Thus, as a general 
law, I think it may bo stated tliat the reparative power in- 
creases as perfection and complexity of organization diminish. 
I know that this law is not by any meant) uniform in its appli- 
cation to the different classau Into wlucb we divide the animal 
kingdom, but, for our present purpose, it ia quite safe to accept 
it aa a general fact that reparative power indi-eatjcs as we de- 
scend in the animal scries, and that, while in the higher auimals 
moderate injuries are often followed by fatal cousequences, in 
the MoUusca and the Articuhtta we find species in which whole 
limbs may be reformed after detachment, and, in the Radlata, 
some th.it can reproduce an entire and perfect body out of each 
of the fragment* to whicli accident or design may have re- 
duced it. This reparative force, thus readily called forth by 
injury, we may be pretty snre, I think, is also ever present as 
an antagonist to disease ; and that, hy the ever-present virtue 
of this powerful controlling agency, disease in many of tlie 
lowest animals is either altogether prevented or is only allowed 



DfTRODrcnON. 



fl 



to aaenine its lowest, simplest^ and loast dangoroua iiianife&- 
lationa. 

Thud, I believe it mijjht be maintained that the proneness 
1o diieuo is in an invcriie ratio Co the reparative potccr, and 
that therefore the aniiiiaU highest in the scale are tlioee most 
likd}' to ^how varieties of severe and coiuplicated di&onJer. 
The Baine principle seeuie to me applicable to the relative 
liabilitv of the diflurent tJKaues of the t-aiiiB iiidividuiil. Th^ise, 
for exampio, of the lowest class, enjoying a mere vegetative 
li^, as tendon, aponenn^id, and cartilage, wo find but rarely 
cthe auhjectft of disease, and, when disea?pd, their artections are 
commonly of the simplcet character. Disintegration fi'om the 
effectd of inflanimatiun i« almost the only morbid process we 
knun* of in the tendon, and uloeratiun in it^ varied furms iij the 
chief di^eaae of caililagc. It is in the higher, more Taacnlar. 
more actively living tissues, that tbo moat varied, the moat 
frequent, the most iutercating, and in all respects the moat 
important, raorbid changes arc observed to take place, the care- 
ful study of the minuter rtlmdei* of which i^ the difficult and 
laborious ta^k uf the modern studuut of pathulugy. 

Among the:>ti higher tisenes^ bone, oa wu Lave seen, holds, 
by right of its elaborate vital provisions, a very high pofeilion, 
and this position it abundantly vindicates hy the immense 
variety of the shades of its morbid actions, a* well as the fre- 
quency and severity of its diseases. We shall tind ny morbid 
condition of the soil parts of which a counterpart may not be 
found in tho bones, and few of the tissues present so largo and 
varicil a catnh>guc of diseafct; as this same apparently insensi- 
ble, and^ to the CArfle^^; eye, luwlynirganixed, bone-substance. 
It is liable to every fonn of nutritive uluinge, aa in hypertrophv 
and atrophy; it is subject to its own pocaliar constitutional 
disorders, as in rickcta and nislacostcon. It is prone to inflani- 
jiiacion ill all its fonn?, and illustrates most admirably its every 
variety and every grade, and at llie suuie time sympathizes so 
keenly with every const itutiunal taint that a large chapter in 
the history of syphilis and scrofula must he taken fmm tho 
behavior of these ]>oi8ons toward tho bones. Ita nofter por- 
tions are invaded by caries and tnbende, while every part is 
liable to the inBidious visitation of morbid growths of all forms, 



12 DISEASES OF THE BONES. 

both benignant and cancerous. In short, it is a microcosm in 
which the whole story of disease is to be traced, and yet which 
presents many phases of morbid action, so entirely peculiar to 
itself as to entitle its study to be ranked among the most 
interesting and fruitful provinces of the great domain of Pa- 
thology. 



PART I. 
DISEASES OF BOIS^E. 



CHAPTER I. 



HVPlCltTUUl'llV ASD ATROPUT OF W}»K. 

"BosvA, Hko tlie soil parta, are liable to livperlropby from 
two claMca of causes: 1. Tliuso wliich nre morbirj in tbelr 
action ; 9. Tliose wliich are unconnected witU any appreci- 
able diseased condition. Of the morbid conditions of bone, 
tennioatiug in an increase of their dimengione, \re ghall have 
very fretjueat ozcasion to epeak beruatWr, and we aUall find it 
to be oue of the commonest restdta of lung-eon tinucd inflam- 
matory disease in all its forma ; so mnch so, tbat an cxpc- 
riencefl eye can pronounce, with much accuracy, tbat chronic 
ioflammation haa existed in a bone, from an ingpection only 
of its enlarged Bize — an enlargement wliicb, in the hypertrophy 
from disease, is usually accompuuied vf'iXh more or Less distor- 
tion and detbrmity. 

In the cases of hypertrophy of bone which occur without 
apparent morbid cause, we find the condition usually limited 
to a single bone, as the fcmnr or tbe tibia, which, by ita undue 
(trowtii, makea floch a disproportion between the length of llie 
litnba th»t ^rious tamencss is sometimeg thus pi-odnced ; and 
it ii always well for Bur^^eous to take into account the possi- 
bility of such a condition in nLeai<urin^ the leni^th of the two 
limb^, to clour up doubtful points of (Uiijinosis. Such enibar- 
Taasment in the Btndy of obscure cases is epoTcen of by Bcvcral 
aathorg; and in, the New York Ilospital an instance presented 




DISEASES Of BO:^ 

hself, wlicre only the history of & previouft elongation of tUo 
fumur expInineJ b discrepHnry in the symptoms "which we 
eouhl not otherwise compreliend. 

Mr. Stanley speaks of several of those cases of simple hy- 
pertrophy where the affected b«5nefi had be- 
come curved, and Mr. Paget givea a curious 
instance from St. Bartholomew's Hospital 
Miwentn, where, the tihia Imvinj^ become 
hypertrophicd while the fibnla remained 
unchanged, the tihia had hecoine curved 
outward in order to accommodate ita in- 
crejiso to the unaltered fibula, to which it 
wn» tieil by itA ligamentous attachments 
alioTe nnd below. Fig, 1, taken from Mr. 
Paget's work on "Surgical Pathologj-," gives 
a Tery good idea of the deformity. 

Hypertrophy of bone may, however, be 
the result i>f increase in the duty which a 
given bone is called on to perform. Of this 
compensatory hypeilropliy the lietit example 
with which I am acquainted h shown in a 
si>ecimcn in llio museum of the Collc^ of 
Phyeicians and Surgeons. The young lad 
from whom it was taken suffered fhim an 
acute necr<.»eis of one of his tibiffi, involv- 
ing almost tliB whole length of the shaft. 
For some reason, the reparative actions were 
very imperfect, and almost no involncrnm 
Pio. t.-<Fiwo p»eei.> ^^g formed, so that, when the sequestrum 
became loose and was removed, no new bono replaced the loss ; 
and, though the wound healed, and he was able to go about, 
yet the tibia was represonlcd. for f^evoral iTichem, by a more 
fibrous band, in which hut little boue-deiMwit could l>e de- 
tected, nnd which gave no support vvlnitever to The limb. 
Uiider lliet^e circumstanctt, he was advised to nao the limb as 
much as {loiuible, which he did, and gradually fonnd that it 
began to be stronger, so that heftire Ids death, witich took 
plnce within two yenr^t of the operation, he could bear con- 
siderable weight upon it. Tho bones of both ]ogi are pro- 





nrpERTRopmr axd ATRonnr ok bonb. 15 

served, and s)ion- the tiUfa of the dittcaM^d aide rcplacf d in its 

middle purtioii hy a mere fibrouB cord, with pome nodules of 
bone continuous with the eoiinci boue above aud below, but 
nut fiued togtithor iu tbu middle ; so that the supporting power 



Tw, t.— (Fmn Vvw YtA RoBpluJ UoMQin.) 

of the tibia ii as uomplL'tely abrogated a;^ if it had suffered a 
fracture which had not united. The fibula of that side, how* 
crer, bus undergone bypertroph^v, most marked opposite the 
deficiency in the tibia, and so con&itlerable tlinT,on comparing 
it with it«i fellow of the oppot^ite side, it is at least tliree times 
Ita Mi|>erior in thickness and alrength. A more peifoct illn&- 
tration of simple conipensalory hypertrophy, and a more beau- 
tiful mfluife«tation of the intelligent action of the laws of nu- 
tritive reparation, can bardiy be found. (Fig. 2.) 



16 



DISEASES OF BO.VE. 



Another form of hypertrophy of bone is Ibat which affects 
the bouKt oftho face, and ia conimoiity ^pokon of as Uie ivory 
exostosis. It consists of a very derifto hii'1 solid growth, wliich 
slowly involves llio hones of one side of the face, more com- 
monly in tlie neighborliood of the orbit, and whicb gradually 
converts them into a tomor of great size, which projects from 
the snrfaco of Che face, and which encroaches on the cavi- 
ties of the nose, eye, antrum, and month, in such a way as to 
produce the moat serious and sonietimos the most dangerous 
deformity. A large number of cases of this curious form of 
hypertrophy hiive been collected l)y Mr, Heath, in hin admi- 
rable essay on the "Injuricii and DiseaiiCR of the Jaws." The 
diseaso is iisnally painless thronghont its entire coarse, except 
where it inflicts pain by its encroachment, and it is unaccom- 
panied by any evidences of iullammatory action. It seems to 
affect adults of middle age, and is not traceable to any injury 
or connecteil with any constitutional taint. The progress of 
the disease is extremely slow, and presents ordinarily no other 
features but those of simple increase. This form of hyper- 
trophy, however, is fto much allied to the tumors which atfect 
the bones of the face, that its more particular description may 
be couvenietitly reserved for a future chapter. 

Atrophy of bone mo6t comniouty presents itself as the 
cfinsetiiieiice of long - continued disuse ; but severiil other 
c!iuBe« soinotimos produce it. Thus, Mr. Curling has shown 
that, in certain cases of fracture, where the injury involves the 
trnnk of the nutritious artery, the trsgrnont of bone which is 
deprived of its vascular supply from that source will some- 
times undergo a process of atrophy, and that ia this way non- 
union is sometimes produced. Atrophy of bono is likewise 
seen in those cases of localized paralyaie under which the 
whole limb wastes away, and in young children never attaiiu 
its proper development. Disuse, however, may, I think, be 
said to be by far the most common canse of atrophy of bone; 
and, inasmuch as a certain amount of dimioishcd activity accom- 
panies the action of all other causes, it is difficult to prove tliat 
any one of tbem is sufficient to produce the condition without 
the ftAsistance of some degree of diminished functional activity. 

Two forms of atrophy present themselves: one in which 



HYPEBTROPny AKD ATROPOT OF BONE. 



11 



tliere h pimply a diminution in llie nmouiit of Iwno niate- 
il ; and one in which there is at the same time an cxce6> 
rive dcTC'loproent of fal. Tht'se two tbnnft correspond to the 
two conditiunft of atrophr met with in the soft p^irts; and, 
witilc it ia not possible to define precisely the circa uistances 
nuder wliich eiich occurs, yet 1 think it would he correct lo 
Miy that, generally, the luitiple atrophy is host ieeu in cases 
where the chnnpe tnkoe place very gradually, nnd frum simple 
disuee, wliile the fatty degeneration \«. inaat i^lrikiiig where the 
flfl'ection h somewhat acnte in character, particularly if it be 
,j^Mfiociate<l with nome inflftinmatorr action abont the part di*- 
F' eaMd. Thitii, the most striking example of simple atrophy 
tliHt I have 8een, ia in a stump of a tibia, where the end of the 
liinh lietow the knee had not been used for support lor niiiny 
yeore. Here the hone i& raretiod, its eavitics ctdargcd, its 
walk thinned; hut, in other ret^pecte, it is normal. On the 
other hand, the most marked instjincc of fatty clianj^ is in the 
l>onc« of the leg of a lad upon whum Dr. Stevens iierfomied 
exjoction and wiring of the fragmcnTA of an nnnnited com- 
j»oiiud fracture. After giving the poor boy a long and faithful 
trial, the limb was umputated. The bones are small and light, 
and almobt pliable, hut tlicy are so much imbued with fat that, 
though the specimen has l>een in the cabinet of the Nt*w York 
IIosjHtal for ftliont twenty-live years, it still, in warm weather, 
dUtils oil enough each season to destroy the vaniifili, and run 
down on the stand upon which the specimen is placed. 

The occurrence of atropliy from diauee has some important 
practical relatione. First, u hone in a condition of progressive 
atrophy most he very liable to undergo other changes, in obe- 
dience to mechanical influences acting upon it. X have now 
nndor my care a lady who had rigidity and a ncious position 
<rfftbdoction of the hip-joint, following a delivery, accompanied 
bv convnlftion.4. For many months she has not been able to 
use the limb, and, though there is no marked shortening, yet 
the trochanter of the affected side has fallen in so much as to 
leave no doubt that interstitial absorption of the neck and head 
of the hone has taken place to a very marked extent. vSinnlar 
changes we see in old luxations ; and in atrophied limbs, where 
unfavorable positions bare been assumed, we see the hone be- 
3 



1% 



DISEASES OP ROSE. 



coming alisorhed anJcr the influence of 111© pressure, or bent 
by the gradual action of tiic force exerted, to ji ilcfiree which 
W6 would not exjieet in hoinul, healthy bone. But iH>rhai)s ihe 
moat important practical deduction from the history of atmphy 
is that whiL-h iticnlcntes extreme care in nianipulatinns with 
bonea which have long been disused. The fact tliiit disuse for 
a few months, or even for a few wceko, will redncc the resisting 
power of bone, should never be foi^otten, and was iitijirciwed 
upon my recollection, in the moat emphatic but uuplea^sant 
manner, by the following ease: 

Patrick Barry, aged forty-two, was admitted to ilie New 
York Hospital, t)ctoher 23, 1854, with a dislocation of left feiuur, 
of seven weeks' standing. Tlio syuipiomfl were unequivocal, and 
the head of the bone could he felt on the dorsum of the llinm. 
The man was of good musenlnr development, Imt the limb wag 
flabby and wasted from inaction. Attempts were made to re- 
duce it by Reid's method of maaipulatiou, and, being unsuc- 
cessful, were abandoned for the ordinary metliod of Sir Astley 
Cooper. Extension was made by pulleys, and, while a strong 
movement of adduction was heing made by my own hand, a 
crack was heard, and it immediately hccjune evident that the 
neck of the femur had broken. On taking otTthc piillcya, the 
crci>itU8, the form, and all the eymptoms, made the diagnosis 
clear. In the original minute of the case, the remark is made: 
" With regard to the fracture of the cervix, wo were all sar- 
prisod at tho slight amount of force which was ooni|)etent to 
produce such a mortilying accndent." A i-imilar ncciiient oc- 
curred to one of my collcHgues in attempting to reduce an old 
dislocation of the elhow-joint. "While making extension, and 
at the same time trying to flex the forearm on the arm, the 
humenu gave way, and a very oblique fracture was Ibund to 
have occurred about a handle breadth above tlie joint. These 
nutVirtunate occurrences (and moat surgeons have had n einiilar 
e.\perienee) should lead to the greatest care in using bones, 
which have long been dtBUscd,- as levers in reducing displace- 
ments, remembering that groat pi>wer Is developed hv the lever- 
action, and that t1ie bone-tisHue is not so strong to resist as it 
ig in an unclianged bone. 



lyPLAJniJlTION OF Do.xa 



10 



CHAPTER 11. 



IXFLAMMATIOir OP OOSE. 



Tub process of iufiammntion in bone presents many modtfi- 
cation&, dne to the peculiar strnctarc in n-hicli it occun;. It.i 
eMential character Is the same, howcrer, and the laws which 
gorem it iu the eofl parte nre thoee which ro^ilate it in tho 
boiu-s, due allowance bciu^ niado for tho dcuHity ami inlrncta- 
bility of Uie tii%uo involved. Ab in the suiter ti^^ucs, fo hi 
the hones, we may conveiiienily arrange our gtndy of* iiiflani- 
tnation into diyUions embracing tho various cifccts of the 
morliid process, as phown at eitch Bta^ie of its proprw^ ! fi'i". 
_while it is well understood that no absolute line separates one 
from another, and that one stage Is constantly mingled 
rilh another durin*; its progr^sH, yet, for praetical piiri>oses, 
we ehail recognize that each case n»nmea ita ini])ortance from 
the prominence of one or more features which give it iw in- 
dividual charaetfr, wJiifh featnw's are those of some particular 
stage or effect of inlhtniination. Thus we may include under 
one head all thoge iuflammations of bone which are attended 
with organization of the exuded products. A second clnsa may 
embrace those in which the exudation goes on to purulent 
formation. A third will indude all thotio casc^t in which ul- 
ceration and destruction of tissue by motuunlar disintegration 
take place, emhracing moat of the eaaca called caries ; and a 
Unt will embrace that large clasa in which death of tissue is 
the eonso<|ncncc of the inflammation, as in necrosis. 

InAammation of Bim^ with Organhation. of (he Itifiam- 
maf^fry Products, — The case* coming under this liead are, 
uImo«t unifunuly, of a elironic character, and of a moderate 
difgree. Tlieir causes are habitual ex|>osuro to wet and cold, 
injuries of modcrnte severity, and sanietimcj^ a constitutional 
vice, either acquired, as syphilis or scnrvy, or original, as 
KT(tfnla and its numerons allied taints of tlie blood. Their 
fwithi.'Iogical anatomy eeyms to be a low grade of inflsniination 
p«r>iiding a certain part or the whole of a bone, and which, 



80 



lilSEASBS OF BONE. 



after It has been fully developed, presents mlcroRcopical clinr- 
RCtere wliicb have uow been pretty thoroughly invest if;:n ted. 
To the uiiaiUed eye, ihe bone is of diBtiuctly pinkish or ruddy 
hue, usually in putchea uf irre^rular extent and shape, and dif- 
fering nmimg theniBelves in deplli of color. The tonipnot tis&nc, 
116 well at4 theHpongy, i^how^ thi.^ iutlnmniatory rcilne^, thnugli, 
of eourse, in a less degree, and, when thuB n^vldened by inflam- 
mation, lias nAually lost soinc of its appaivnt density. The 
periostenm and the mednlU usually participate, in a marked 
degree, in this vngcular change, ae they do in all tlie morbid 
actions of bone. Indeed, writers are genernlly agreed that 
they are both of them intrinsic parte of bone, and that ttie study 
of their diseases cannot be and onglit not to be didsuciated 
from the diBeaaca of the bonc'tiesuo it^lf. Someliniefi, it is 
trnc, rhc inflammatory actions are mainly contiued to the 
{^rio^tenni, and more rarely to the mednlln, but the neighbor- 
ing bone is always more or less implicated, and must necessa* 
rily bo BO, because its vessels are derived fi-om. and form part 
of, the cireulHtion of the ni em Ij runes by which it is covered. 
After the inflammation lias existed for eomc time, the bone 
begins to be onbiret'd, utiowing llie addition of new hony mat- 
ter to its original Biihsfance. This enlargement showTi itself in 
two principal ways : first, by increase of size, and, secondly, by 
increase of density — two conditions which, thoQgh uisiially 
asHociatcd, are not by any means constantly soj and heuce, 
among the numerous spceimeuB of inflamed bone which encum- 
ber every pathological mnsenni, wo find t^omo which are merely 
enlarged, in all their diiiion»«ions, about the seat of intlamina- 
tion, without any manifest oonsoUdation of tisane, and others 
where the bulk has not undergone any marked cliange, while 
the increased weight and solidity show that abundant inter- 
stitial deposit has been taking place. 

Under the microscope the first noticeable feature is the en- 
largement of the ITaversiun canals. Tliis takes jdace in obedi- 
ence to the reqnirements of the increasing vessels, for in a con- 
dition of health the canal is so nearly tilled by tlu) vci«el which 
traverses it, that little or no enlargement of the hitter can take 
place without some yielding of the former. So true is this, that 
it is believed by roost pathologistfl that this impossibility, io 



lUUATIOl 



TONa 



21 



bone, of yielding to tlie preesure of a sadiienly-iiicreasinfr cir- 
ciilatioti, id one principal reason why acute iiLtlaitiniatJuii of 
bone is 5o liable to produce necrosis. Id more chronic and 
modtirftte Attacks, thero !« time afforded for tlic bony canals to 
enlarjre by absorption, and thus allow the gradual expansion 
uf capillary vv^seU ; and lieiiuc* there; is usually little or no lia- 
bility to aBcru:^i6 where the inttainmatory jirocetM aosuuietr this 
doliberato and sometimes extremely tedious course. Hc&idea 
thi» eiilargiMticiit of tho llavcniaii canals, the lactmot a.Uo 
nndergfo a change both in size and shape, and the same is ob- 
served in the canslicnli. Mr. Harwell, in his admirable ac- 
count of the«6 changes, itays : " The lacnns have iucreatwd still 
more ia size aud breadth; ereu those of tho Haversian By»- 
tema are very broad, oval, or are rudely circular ; their interior, 
initead uf remaining dark, has, as it wcro, opened out into a 
light space, marked by light-colored round spots, surrounded 
by dark Hncj, or vice ver*a, according to tho focus and direction 
of the light. Some of thorn arc very granular; others, more 
rare, are crowded with round, cell-like bodies, forming a mul- 
berry niasi, which appears to staud out above tlio bouo>surfaue. 
Thu cau»li(iuli, remaining large in nntnber, have increased in 
size chielly at their cummencemcnt in titc lacuna, so that they 
appear t<i open into that ejiace by a broad month like an e-*tu- 
ary. Tlioy are throughout more mnrkc^l than the normal 
tube; tbey branch al^ in many tngtancea into three or four 
ohanneU, aud, sometimes, at the spot wheuce these branches 
diverge, a comiidembLe enlargement in the main truuk U 
perceptible, a» if at that point a new lacuna were being 
formed. While those changes arc going on in tho lacnnm and 
eanaliculi, a change la aI;to noticeable in the granular Bub- 
stance of tho boue-ti^sne itself. The granular character 
becomes more distinctly marked, aa if a partial disintegra- 
tion were about to take pla<^e. and the bone were ubont to 
break op iato its original particles. Wluit i* the precise mean, 
ittg of this change, has not been, so far as I know, positively 
determined, hut Mr. I'oUiu dues not hesitate to attribute the 
general granular appearance of nn iritlamed bone to an en- 
largement of the oriiicos of tlio eanaliculi, sucb as has l>cen 
almve deserilwd, which, when the bone is macerated, gives a 



as 



DISEASES OF BOyE. 



dotted or granular a]>j>earaiit« of the aurfacee on which thej 
o|ien. The further iiiitTifrtfoiiiciil changes in inflamed bone nre 
merely tlie more advaiictHl stages of what hua already been 
described; the bone-atriicturo gradually disintcgnitee ai)d dis- 
Bolves away, and this to an extent and in o manner which 
vary considerablyt according to tho characters of the inflam- 
mation and the tendency wliich it develops. CtmetHiuent, how- 
ever upon these merely destructive actions, we eooti begin to 
bee aonie atlempti> at reparation, and, in the moderate form of 
inflammation we are now studying', tliesB actions soon aa.siime 
tlie prominence. Into tho natural cavities of the Imne now 
enlarged by tlio processes we have been Btudying, wc soon 
have ]iourcd ont the plastic exudations which are the reeutts 
of the inflammation, and which begin to show oTgnnization. 
This organization leads by a strong and almost unvar^'ing ten- 
dency to the development into bone, so Hiat we soon begin to 
find new bone deposited in all the vacancies and porosities of 
the old. By means of those two processes, tho first one of ab- 
Borptiuii, and the second one of <le[KiSLt, we have two conditions 
of bone produced, which are spoken of by writers as respectively 
rarefaction and condensation of bone. When in any given 
case the absorbent actions arc in excess, and more particles 
are removed than are replaced, then we may have an expan- 
sion with rarefaction of tissue, or, as it has been termed, osteo- 
porosis. Wlien, on the other band, the destruction is more 
than compensated by the deposit of now bone, then we have 
en expan&Ion with consolidation of tlie inflamed bone, so that 
it beeomes harder and heavier than natural. The enlargement 
of bone, with expansion. or rarefaction of tissue, is the rarer of 
the two, thongh Mr. Stanley says, "I have learned that the 
simple SH-elUug of bone, from expansion of its tissue, is one of 
the mutst frequent alterations to which it is liable.** We hsve,in 
the cabinet of tlio Xew York Hospital, a specimeu which shows 
this condition in a remarkable degree. It consistit of the iMmcs 
of the knee-joint taken from a patient, a young adult, whose 
limb was amputated for long-continued disease of the joint. 
The whole bone is enlarged, without marked deformity, but 
every part has undergone a sort of atrophic change, by whicU 
the external lamina, the plates of tho cauceUi} indeed everj 



u 



blBBASES OF BOSS. 



The other condition, viz., onlnr^ment 'with conf)oli<1fltion 
of tissne. U rertaiiilr the most frequent of all the changes pro- 
ctuc&d by inflammation iu bono. It ])re£eiits itavM' uiuler threo 
di&tiuct forms: 1. Mere enlargement, by which all parts of 
the bone Micm to havo increafic<l ho etjnally that tlio apparent 
'Btnicftnre ia not altered, except perhaps by exaggenilitni ; 3. 
An enlargement in wfaiuli the tissue is condeneed in stich a 
moDucr that the orij?inal cavities of the bono arc encroached 
■aiion by the new deposit ; 3, One iu wlueli 
the action ecoms to be contined tfi the pcri- 
o&teal hurfoee, and wliere we liave some- 
timca the moat abundant deposits on that 
ftnrface, with pcrliaps little or no change in 
the bone itself. Fig. 4 is an example of re- 
markable thickening and iiuUiratiun of the 
anterior wall of the tibia, and &\f,o of the 
femur. The thickened portion is ns hard 
u ivory, which it niticli rcriemhlea in ap- 
pearance. This change probably onpinated 
in periost«al inflammation. Of these three 
conditions, I tlnnk the latter is the mure com- 
mon, hut in all patliulo<;ical collections 
each of tliese forms nboundt*, sometimes ex- 
istinjr Beparately, and very often all com- 
bined in the same epecimeu (Fig. 8). The 
tendency of the pcriustcum to inflammatiuu 
is recoi^iiized by all pathologists ; and it is 
f- this inflammation of the periosteum, rather 
fO rban of the bone itself, which leads to tho 
formation of the surface-deposits, which 
often present tliemselvert in suuli uhundunt 
masses ami with such varied and sometimes 
fantastic shapes (Fig. r>). Thia affection 'u 
one of tho forms of tertiiiry sypbili!*, but it 
U also met with where no sncU disease exist*. 
pm.nwMoMtwn 6f coikOT It sometimes presents it&elf as one of those 

«r PliTiidaiu and Soi- » a i* i • i i i 

(MDK.) vapic forms of ditiease whicli are looeely 

classed n9 rhenmatifim or neuralgia. Tlie following is a good 
illufltration of one of its most common manifestations. A gen- 



■C' 



;?^>K-^ 



DJnjLHMATION OF BONB. 



u 



tleman, of alwut forty jcars, caino under my care, many years 
o^o, for a severe attitck of iicnrHlgiii, as Irn culled it, in one 
t»f liU Icgfl. Tlie |iain was soiitLHl along the anterior a.spect 
of tlie titiia, and woa ftn^otnpanied by great tendemetia 
of llie Itoiie, eo mucli so tliat he could hardly bear it to 
be touched. He was a man ordinarily in ^od houltli, and at- 
tributed biii attack to exposure to wet and cold, and iiiformod 
nie that sevurul limeti witbiti a few rear^ he liud had i^linilar 
eei^urcs. The atiaek had come on rather suddenly a few days 
^before my Hceing him. The pain was paroxvtimal, and, ae he 
described it, intolerable, when at its heipbt. I found some dif- 
ficuliy in procuring him relief, but finally the attack wiWided, 
«nd then I discovered, when the tenderness would permit the 
exauiinatiou, tluit the tibia waN-eidarged, apparently by a de- 
posit of bone on ita whole anterior surface. On pressing with 
Bome firmness, it conld Ikj perceived that the deposit was quite 
abundant, an^t, lliough distributed pretty evenly over the sur- 
face, was itself vtri'irret;ul«raii<l rough, giving to tlie linger the 
idea of the akin being stretche*! over a niass of coral. ThiA, he 
informed me, was thereat of habitual tendcrncAti, and had been 
for years subject to occasional attacks of neuralgic pain sucli as 
above dcbcribed. Theee attacks laid him up fi>r a week or two, 
and, for some time alter hi« recovery, walking was painful, and 
in fact he wa& gradually fulling into n t^tate in which he wtmbl 
have to consider himself as permaneutly disabled. I attended 
him in one or two other attacks simitar to the one doAcribed, and 
found them l>ecoming more frequent and severe, and leaving 
the bone each time le*s free from soreness and pain in the in- 
tcrvd& I put him on the constant nsc of moderate doses of 
the iodide of potassium, which (reemed to have a g':>">d effect in 
relieving and diminishing the frequency of the attacks, but it 
was not until I had establitdied a nitric-ncid issue, on tlio U])per 
>art of the aide of the leg, that the panixyums gradually ceased 
Itogethcr. Ho has worn tins issue ever since, and, though the 
>n«-ilepoi>it on tlie tibia has undergone no material diminu- 
tion, it is no longer any source of annoyance to him, and he 
walkft on the diiteased leg almost &s well u nj^on the otlier. 
Sir. Stanley thinks that, when once bone has become enlarged, 
no medicines have anyetlect iu reducing it. At the same time 



36 



DISEASES 



he is a warm advocate of the efficacy of llie iodide in redauing 
inflammation of bone, for whit* li, indeed, he regards t!ie rumedy 
aa aliiKjtit a speciiic. 

The ottier conditions of enlai^enicnt, in trhicli the bone- 
tissiie itself is more especially implicated, may be studied to 
great :idvantiig4! iu the avti<jus which go on around n ^ues- 
iruDi Jo an advanced case of central necrosis, Ttiere we shall 
find, if thft cQse ho a recent one, and the processes active, that 
all the original Ixtiie, around the central dead piece, takes on 
an iuvolucral action, and thickens and strengthens, so a^ to 
compeusftle for the loss suatained. Tliia condition may be re- 
garded ahuost as a phyaiological one, in which Nature adopta 
this method of providing for the danger iullicted by the repara- 
tion of the dead piece. This preoents as good an iilustnitiou &» 
we can have of simple hypertrophy from intiamuiation, and 
ehowB the bone-tiasuo mei-ely increased in quantity, without 
any miirked change in Btnicture. If, however, these actions 
are prolonged by the continued resifienco of the Bcqne^trutn 
within the cavity of the bone, then wc liavc a gradual thicken- 
ing and condensation of the hitherto merely enlarged involn* 
cral portion, which iu old cases seetns to attain to tlie density 
of the hardetit ivory. Besides these cases of necrosis, there are 
many other* whose clinical history bus not, so far as I know, 
been very thoroughly Btudied, where after years of rhoumatic 
and neuralgic pain in one or more of the boiies, perhaiis with 
a syphilitic or ecrofalous taint of the system, and a life of 
habitual privation and exposure, we find after death several of 
the bones presenting marks of infiaiumation in their increased 
size and density, indicating processes which have been going 
on for ycare, and yet without any marked point in the hintory at 
which we can say that osteitis, at* a di^^tiu^'tattcctioii, coinnicncetL 

The treatment of chronic inflammations of bone is not very 
sfttisfaetory. Much can be accomplished, however, in the ear- 
lier stages, by local bloodletting, blisters, and the careful use 
of mercury, and, in the later stages, by i«sues and derivatives. 
The cases, whose pathological anatomy we have been studying, 
are apt to bo so vague and indistinct in their outlines during 
lite that systematic treatment for osteitis is generally either not 
instituted at all, or is bo mingled with other therapeutic indica- 



SUTPUJlATIOIf XS BONE. 



tf 



tions w to be very miicli lof>t sight of in suniming up the re- 
fettlts of the whole case, "We can, however, accomplisli mock 
iti rvlivviitjf the paro-xy^ine or uttnckb ut'aeutur uitlaiuuiatiuii to 
which thific chrouic caiies are alwnvs liable, nud, bjr the iodide of 
potash, with issaceand countcr-irntatioii, wc can bo far arrest the 
progress uf the iiiHamriiatory .actions tlmt thoputieiii no longer 
Bofferaany incoavenieiioe from his disease, except that arising 
from the weight or deformity of the affected limb. As for the 
iafloeuce of retuediea on the deposits uf bone from iiiflauuua- 
tioD, anthoritics are pretty well agreed that nothing is to be 
eii>ecled. Mr, Stjinley eayrt: "Upon enlai^-d and indurated 
bone, medicinra have uo etfuct; its condition will be penua- 
nent, . . . Hut, against tlio tenderness and irritation of the* jicri- 
oatenm, wtiich precede and accompany tlie morbid changes in 
the bone-5, treatment may be directed vx'ith the beat effect, par- 
ticularly the local application of mercury to the limb, with the 
adininiatratioD of iodide of imtaEaium and &iir&uparillu." 



CHAPTER la 



BCPPCaATION IS BONE. ' 

As in every other part of the body, bo in bone, t:nppnration 
preaente itself under two distinct forms, vii. ; ]. Where the 
action is circumscribed, and the pus*, as it forms i* eimtained 
iu a cavity, and called an abscess ; and, a. "Where the a<-tion !» 
not circumscribed, but npread^ extengively through tlic affected 
part, and the resultant pus is infiltrated ihrouj^b ihe KubNianee 
of the botie. These two forms have bo great differences in 
their pathol<^caI characters, as welt as in their clinical sig- 
nificance, that they will bo coiiveuiently studied as separate 
affections. And, first, for abscess of bone. Here, it will 
be understood, that we do not now include in our *tudy those 
rarioutt collections of matter which form bo litijH)rtAnt a part in 
the palhohigical progress of caries and necrosis. These must 
be considered herearter, and thus our field is narrowed down 
to the comporatiTcly small number of eaaes in which tlie ab- 



S8 



DTSEASE5 OF BOKE. 



scess character is not only tlie primary but the only feature of 
the diitcnse thri>ug!ioiit it.") whole conrse. Such abeceesee pre- 
beut theniiielvcs in thre«fettuatione: 1. lu the caiicelluu^ struct- 
nre; 2. In the medulla; and, 3. Betveea iiie p&riosteuui and 
the bone. As a general fact, it may be stated that all i>f thcgo 
abssceeeea are vt' a chronic character, or perhaps it wouhl ho 
mure occnrate to say, that they ore made up of a scries of &nc- 
ceesive attacks of acute or subacute intliimmation, each of 
which Bidwidcs to a certain extent, but, by their constant recur- 
rence, finally lead to the foruiatiun of the ahsce^, and thus givo 
to the M'hole cat!e a chronic course, though made up in part of 
acute elements. Thus, to take one ca§e as on ex&niple : Bernard 
Hiley, aged twouty-oiie, whs admitted to the New York Hospi- 
tal, June IB, ltJ&7,wictiH<]it«eai-cd condition of the lower half of 
the left tibia, of wliich he pave tlie following history : About 
seven years previous, he had, without any aMignable cause, a 
sodden attack of acute inflammation in the upper part of this le^, 
■wliiith was attended with severe pain, rapid and considerable 
eweUing, and suppuration, which di&char^-d itself on the ante- 
rior part of the limb at the end of about tliree weeks. The 
inflaniuiatory symptoraB eubsidwl, !iut the absceaa continnod 
0]>cii for almut a year, when a small piece of bone cauu* away, 
and it Hoori healed up. He had been much reduced in heallh 
by tliii* attack, and vtaa not yet alile to walk about, when, aa 
the abscess above healed up, pain and swelling gradually came 
OD in the lower part of the le}?, and, after niue weeks, an ab- 
8Cess formed and opened, a piece of bone came away, and eoon 
after the uore liCHle<l euuiidly. Several cither abscefts.es tomied, 
in the same way, during the next four ycaru, though they were 
not all accompanied with a discharpe of hone. Since this 
time. 6ay, for the last thi-ee years, he had been improving in 
health and strength, hot the lower half of the tibia had been 
theaeat of frequent atlackfi uf pain, kbting for a few day», not 
attributable to any partieuhir causae, and Ufiually relieved by 
hot fomentations. The tibin i» now very much eulai^ed in ita 
lower half, hut there is no evidence of any fommtion of nnitter, 
and, during the intervals between hi« attacks of pain, he ia 
able to walk about, and to use the limb freely. The; pains are 
always most severe at night. There is no suspicion of a syphi- 



surPCRdTiOK ur boke. 



ss 



litic cause. He lefl Irflitncl quite well on the 17th of the pr& 
Tioiis nionlb, and on the lit ol* April he received ii jjrctty bard 
blow from a rope, ocro^s thu disea-st-d tibia, which produced a 
r«y bad attack of pain, with sdine swelling, wliiub, however, 
goon iiu1>:i=idftd, and, when ho landed, he was ait well as uanal. 
By walking alxtut the streets another at tack was produced, and, 
altogether, he found himi^olf bo much annoyed with these re- 
pcattMl attacks of pnin that he became very anxious to have 
something done for his relief. The lower half of the tibia was 
inach enlar^jcd, very hard, slightly tender to the touch, and of 
a constant Icniporaturo ecnsihly above that of the eurrounding 
parte. There was no point more Bcnsitivo tlian the rest, nor 
any evidence of matter seekiu<; the eurfaco. Ue sayt^ Uiat his 
painit, even at their woret, are not very severe, and it is rather 
on account of tlicir constant rceurrenco that they have hecomo 
60 very di»ti-e««ing to him. From this history of localized pain, 
entailment, and increased heat, ab^sese was suspeuted, and, 
aOor he had been in the bouse a few dayman optimtiou was 
jtertMruied, which it was hoped wyuld have a good effect on 
the chronic osteitis, even if no matter ehoixld he found. The 
tibia wa-^ exposed on its anterior surface, and n trephine was 
carried deeply into its snlistani-e, about tlie middle of the great- 
est enlargement. When the instrument had reached the centre 
of the hone, pu* began to ooze from the snw-cut, and, on re- 
moving the diik, we found we liad opened into the cavity of 
an ahsce**, from which two or three drachms of pus flowed out. 
Tlio walls of the cavity woro smooth antl even, and no dead 
nor bare Wne conld be diflcovcred. The wound was dressed 
lightly with lint. No unfavorable aymptora occurred. The 
snpporntion gradmiily diminished, the wound filled up from 
the b<jttom with healthy granulations, and he was discharged 
from the hospital, .\ngnst 2oth, without any ix-turu of pain, 
and with the wound almost entirely healed. This caiie is a fair 
epectnieu of the ordinary form of the disease, thongli some ]>a- 
tienls sutler much more acute pain, and in many tlie diseaae 
is prolongpii through a much greater period of time. The seat 
of the aft'eetion is commonly the expanded articular extremity 
of the Iwne, and, not nnfrequently, tho abacess is situated bo 
near the joint that its increase tends to involve the joint-cavity, 



»0 



DISEASES OF BONEL 



and its rupture to take pluco into it (Fig. C). Of this, numor- 
ous examples are on rcciird, nnd it need liardly be said tliat 
iliiA relation tu the joint becutncs, in suck 
iiistunccs, the troportant feature of the case, 
demanding an early Tccognition and a 
prompt ovacuation, if any hope is to be ou- 
tertuined uf saving the limb, and, perhaps, 
the life of tlie patient. The* clinical fea- 
tures of this difieasc seem to be mainly 
tlioM? of chronic osteitis, bat characterized 
by the freqiient recurrence of attacks of 
pain, and other evidences of increased in- 
flammation, each of which attacks subt^itlcet, 
leaving the bone gradually enlarging, EOmO' 
what tender to the toneh, nnd a little hot- 
no. iMFram EfWiw.) ^^^ ^j^^ j^ gi,„,,i(| i,^^ Qg ^\^f. principal signs 

of the condition of chronic inflammation which maintains itself 
iri the intervals between the ftcnto attacks. The diairTiosis of 
abscess cannot in all cased be made with certainty, but with 
snch a history of frequeutly-recurring attacks of acute inflam- 
mation, supervening on a condition of p<'-nnanent osteitis, wo 
shall rarely be wrong in snapecting the existence of pus. Oo- 
caeionally tlie pus makes its way through ite bony cncjisement, 
and a]>proaches the surface, as in tlio fulluM'Ing instance; 

Pierce Dobeny, aged twenty-four, was admitted into the 
iS'ew Turk II.ps])ttal, March 2-S, IKfiO, with an affection of the 
upper part of the left tibiii, of which he gives this at-count: 
When he was almut nine years old, he had an attack <if inflaip- 
ination in this leg, which tennitiated in absce^t*, with the di*- 
chai^ of a small fragment of bone. This process lasted two 
years betbro the wounds were all healed, and left the limb 
tender, but witluiut any new attacks, until he was twenty years 
old, when another attack came on, which wai^ relieved by two 
blisters. This left the bone conj^idurahly etdarged, and more 
tender than ever to the slightest injury. Three months before 
his admission, ho had another attack in tlie upper part of the 
bono, which had never entirely ceased, being better and worse 
at times, but on the whole gradually iticreaning in severitv. 
At the liniQ of adniisttion the swelling occupied the upper third 



SUPPniATION IN BONE. 



31 



of the Hbia, approarliing the knee-joint — which, however, is 
not involved, llo suttercd a good deal of pain, which was 90 
Aggrav»tu<l hy (-.^ervisu tliat hti wiui c»bli};ud tu knvp tiiB bed. 
Tbero waa a general itiflummatory tliickuning of the eofl parts, 
but it amid easily he distin^aished that a solid cnhirfreinent 
of the iKiiie made ii[i the- bulk ot'llic ruinur. Fliicttiatioii could 
be perceived on the central most prominent part of the aweU- 
injj. The limb, on measurement, was nnc inch lonj;cr than itB 
fellow, which was found to be due to hypertrophy of ihc entiro 
tibtu, the result doubtless of the long-continued a£Bux of blood, 
from the frc<|ucnt inflammatory attacks of which the bono had 
been the subject. Hid general cMiditiou was good. The diag- 
nosis here was clear, and on the 17th of March an operation 
|Vas performed, by raising the inte;;ument3 by ii crucial inci- 
-aion and exporting the Rurfaec of the enlarged tibia. In doing 
this, a small quantity of pus was found between the skin and 
the bone. On wiping this pus off, it was found to have ex- 
uded from an irregular oi>ening in the bone ab'jtit thruo liuei! 
in diameter, into whicli u probo being passed entered into a 
loonsidorablc cavity tlllfi<l with pus. It was an ai>^oe^ in tho 
'cancellous substance of the head of the bone, wliich, having 
perforated the external com]}act shell, was uiuking its way to 
the surface. Uy tho ehigel and trephine, the anterior waU of 
the bony cavity was largely opened. It was found of feuffiuient 
size to contain a large bickory-not, and no seque>truni exmld bo 
discovered. iVs thcro Iiad been no external dii^i-harge, its entire 
indepemlenee of necrosis was denionstratLHl. IfJs recovery was 
perfect and without accident. He was di^harged from tho 
hospital, cured, Septcmlwr 19, 1860. 

The treatment of these cases consists in tt free opening of 
the abscess, and, happily, it is a treatment which is usually en- 
tirely successful Mr. Brodic was the first to call attention to 
these absceesee and to their treatment, an<l he bus publit>hed the 
details of aovea cases in which ho established the diagnosis of 
nboecsa. All his caAes were in the Iicad of tho tibia, and in all 
but the first he had the hnppiness of cnring his patient by ojien- 
jng the absc(»3. In the first case the lindi wiis amputated, and 
the patient died; and it was by the careful study of thisunfor* 
tannte ca«e that he was led to recommend the treatment after- 



32 



DISEASES OF BOXt 



■ward adopted, witli bucIi satisfactory resnlts, in tbe six snccese- 
ful cases. Tbe upcratiuii ciiiiMJAla in cxixi^in^ the bone ai the 
proper point, aiwl intnxhicitig a Muall Ire- 
phinc, hnryinj^ it deeply enongli in the en- 
larged iHjne to reacli the uuitter. The so- 
loctiou of the exact spot for niakiug tlie 
opening h u point of mucli inomeDl, for a 
few liues' de\*iution niifjlit lead to n dit>ap- 
jiointment in titidiiig matter; niui Mr. Rro- 
die epcaks of one snch cnec as occnrring 
nnder his ot«ervation, -where '' a verr ex- 
pcrieiiced Iio&pitnl-Eui^on applied the tre- 
j)hiiic f'fr a supposed nliecess in the head of 
the tiliia. No nlwcef^B, liowever, watt dis- 
covered, and in contwquenee the Hnih was 
amputated. On the parts licinjf examined 
aflerwftrd, the ahsceRs was discovered at a 
email distance fi*oni the perforation made in 
the operation ; and it wm ])luin that tlie 
removal of o small portion more of the bone 
wohM have preserved the patlent*s litnb.'* 
In suc'li a case it would he proper to make 
another opening, or what i», 1 think, belter, 
to search for tbe abscess by cnttinp away 
the bone at the bottom of the trephine-cnt 
by a email £r«)nge-ehiflcl. In this way it can 
nirt'ly biippon that matter will escajw de- 
tection if it really exists, acenmnlnted in an 
abscons, Thonjcb on this point JEr. Stanley 
makes this very senBible remark: "At the 
Bamc time it mnet be recollected that the 
smallest qnaiitity of pnndent fluid confined 
Fte. TMs«F To* Ho*, within ft bone h&« l>een the aonrce of very 
'"'^^ severe sufferiivj; ; a?Kl that when mixed with 

the MoofI, wfiic-h in gpnornl freely escapes from the inflamed 
cancellous loxtnro around the ahiaee^s, tho pnmlent flnid inight 
not be di«inetly recognized. The chnracter of the flnid escap- 
ingfmm the boiieshould therefore be closely pcrutinized," Fig. 
7, taken from a epeciuien in tbe Kew York Ilot'pital Mnsenm, 



CHRONIC SLfUOt'S AD8CBSS OP BOEiS. 

IOWA the clian£;c3 produoed b_v an old alisccss in the lower end 
of the feinnr. The bone is niiioh rhickene<l,the9iirfaee covered 
by peri'jeteni prowthe, and an oblique openin;^ on the posterior 
part abows where the uUcew bad discharged into the popliteal 
space. 



CHAPTER IT. 



cnBONic anorors absoess of bone. 

Bsncia the ciues of ab&ceMt of bone u;1iicl) have been di»- 
cxuaed in the previoua chapter, and which have been so well 
describe<l hy 5(r. IJrodie, there arc a ecrtnin nunibrr uf others, 
in which, with u aimihir comniencomont, a very diftercnt prog- 
re« is ohservedf and in whicli the dieebsed aotiouR, though 
qoite aa distreasing and perhaps more tedious and intractalde 
under onlinBry management, present the features not so much 
of ftbecOM as of itA effects ; not so mneh the chnractet8 of the 
priniarv di^Me as of ita consequences or &eqnelse. I refer to 
cawa in which the inflammation of tlie bone bepliiii a« au acute 
attack, pacing mptdiv i[ito «n]>puration, mid in which the ab- 
8ct!a^ thiu rapidly formed, tinds its way early to the surface, 
through the eorapaet external shell of the bone, and is dis- 
charged, to the temporary relief of the siifferingfiof tho patient, 
thoiigfi, it may Iw, not greatly to his advancement toward a cure. 
From thi? point begins the marked difference in the progress of 
tIio«c caac* which Mr, Brodie describes, and thoae to which I 
wii>b now to direct attention. In the former, the abscess, once 
rell open, goea on raptdily to a cure. In the latter, tUe opening 
it being tree, and probably not being direct, accumulations of 
matter take pbu'C wfttdn tlie cavity, and newinflanimutionsand 
enppnrat.ionrt are excited iii tlie bone-eubstance surrounding the 
originitl focus of dirsease. New nlwcessca arc thus formed, 
wbieh cither break into the original cavity, or didcharge them- 
lelves tipon the surface by forcing their way through the com- 
pact outer layer of the bone. By the repetition of thia proctaa 
tlie bono prailnally bccomcB tho seat of an inflammatory hyj>et^ 
trophy, and tke patient ia harasijed for months by the cunstitu- 
3 



DISEASES OF BOKB. 



tionfll dietnrbance nnd ]>ain acoftmpanying thew rcjicated «iip- 
puratione. After a time, varying in JiflPerent imlividuals from 
a few weeks to many laontliB, tlie diapoBilioa to funu new aV 
scegges sccnis to ecase, perhaps because all the cancellous tissue 
of the affected region ha« become involved, either in stippara- 
tion or in by] >er trophic induration ; ami the Imne is left per- 
forated In «l] directions by two, three, four, or more sinuses, 
pciierfllly all coinmunieating with one another and with a cen- 
tral excavation or chamber, which marks tht* position of the 
origiTial abscess. From these openinj^ U discharged, often in 
considerable abundance, a ttiinnish pus, sometinie» offensive, 
varying in its quantity and quality with the condition of the 
patient's general health ; wliich discharge, from tlie sliape and 
position of the ctiannels through which it comes, is indirectly 
and iui;[H?rfe(Ttly evacuated, and by itt^ retention keeps up and 
aggravates the chronic inflammation which is early set up in 
the surrounding bone-tissne. 

In this state the ynrU may continue without alteration for 
an indefinite period of time, the disease not showing much di»- 
position to make encroachtuents, but evidencing no tendency 
whatever toward improvement. The system, gradually accom- 
modating itself to the existence of the disorder, becomes accus- 
tomed both to the drain nnd the irritation, and the general 
health h often completely reestablished. The diseased bone 
becomes entirely a local affection, only troublesome fi-om the 
amount of i>aiu and soreness ex|verienced — an amount which, 
in ditferetit cases, varies from a slight feeling of tenderness to a 
constant and severe gnawing pain, both conditions being occa> 
sionally interrupted by more or less pcvcro attacks of acute 
inflammation, generally accompanied by an iiiereaj^e uf su{>- 
puration and sometiinea by severe constitutional disturbance. 
In this condition, the presence of the disease does not interfere 
with a certain amount of use of the Hmh ; and thus patienta are 
ftometimcs willing to endure for an indefinite jieriod the pain and 
inconvenience which attend it. We have in such cases an op- 
portnnity to learn the natural history of the disease, and may ap- 
preciate the amount of its tendency toward a cure — a tendency 
which, existing fifteen years in one of my patients, and abont 
SLJCteen years in anottier, had not sufficed, at the time of opora< 



fllNCOUB ABSCESS OP BOI 



30 



tloii, to leave any evidences of reparation, much less of ccire. 
Among diseases which do not tend to proj^reasive di»orj<ani«ii- 
tioD, thiii 13 a rare degree of obfttinacy, ajid the reaaon of thia 
intractftbility and indisposition toward a cure I take to exi^C, 
not so much in the nature of the diseased actions as in their 
anfavurable physical conditious, Thus, though the character 
of mflatomatiOQ in the bune may be perfectly simple and 
healthy, yet the resulting abscess has aesiimed the i'urm of a 
deep cavity, communicating indirectly and imperfectly with 
the surface by mcana of narrow, ill-plaood, and often tortnoas 
cnnttlfi. Such a condition f>f abaceas in the soft parts is recog- 
nized as extremely unfavorable for the healing process; how 
much more so when, as in bone, we have not only an nufavur- 
able shape, but an unyielding wall, which deprives us entirely 
of the immcnee advantage which, in the treatiucut of similar 
absceseoe in tho soft parts, we derive Irom pressure in approxi- 
mating the walls of the suppurating cavitiefi I 

This view of the local cause of the obstinacy of theae cases of 
chronic abscess of bone is still fiirther strengthened by ieveral 
considerations. In the first place, there seems to be no necessary 
or nsnal connection of the inflammatory action with any constitu- 
tional vice, as scrofula, syphilis, or any other contaniiuation of 
the general system. On the contrury, the aSecUon seems to 
occur by preference In young, vigorous, and robust persons, and 
generally as the immediate consequence of injury, or of ex- 
posure to cold and wet, or some other well- recognized cause of 
local disease. In the second place, the effect of remedies ad- 
ministered with a view to their constitntional or alterative 
effect seemd usually to be inappreciable in producing any cura- 
tive change in the diseased part ; and, when any such favyrable 
effect is seen in diminishing pain <>r improving discharge, it is 
merely temporary, and the power of the remedy for good is 
in exhausted. This was abundantly illnstrated in three of 
jy patients, in whom the diseaao had longest existed, from 
whose previous histories, as well as fix>m my own persevering 
effort* in the use of remwUes. I arrived at the conclusion th.-»t 
the cure was not to be accomplUUed, nor any important im- 
provement secured, by any form of internal medication. Last- 
ly, and in contrast with the inefficiency of medicine, the effect 



36 



'IH9BASES OF DO? 



of the operation, by which the phTsical conditions alone can be 
affected, eeems to me tlie strongest proof that it is upon these 
physical cuuditiuiis that the difficultTf depeud)-, a conviction 
whicii I think luiist force Iteclf upon the mind of any one who 
1)05 watclitid thij beuuLiful ruparative appeuraucoe M-hich the 
wound pTei^Dte from tlic moment of the upcrRtioii, and the cer- 
tainty and soundness of the euro which follows its thorough 
performance. 

The following case:* will serve to illuHtrate the main features 
of wliat I think may properly be termed chronic ginwrtu ab- 
*«« qf hone : 

Cabe J.— George Brown, aged nineteen, a German eeamao, 
carae to the Now York Uospitiil, November 17, 1857, with a di»- 
easetl condition of bin letl tibia. It commenced aliout fourteen 
montlis previoutily, after severe exposure in going runiid Capo 
Horn, and seemed at tirst of a rheomatic character, attacking 
first one anblo and thc-n tlie other. He was recovering from 
the lameness caused by tliis attack, when, witliont evident 
cause, the inflammation concentrated itself upou the lower part 
of the lell leg. lie was again contined to his b(?d,&ud suffered 
much from pain and fever. An ahsce&s formed in about three 
wncks, and broke on tbo anterior ruHhcp, about four inohee 
above the joint. Tho KwelHug and intlanimation continned, 
and, during about five montlig, he was scarcely ever able 
to leave hts bed, except on crutche;?. During this time, ab- 
eee*iseit formed and broke at several ]>oints of tbe sM'ollen limb, 
and, at ditTerent times, ten or twelve minute pieces of bone 
came away, the largest not bigger than a pea. Por tbe last 
few months, since tho acutor symptoms have subsided, he baa 
been able to go about most of tbe time, bnt nut withuiU great 
discomfort and inconvenieuce. On examination, the lower 
third of the tibia was found enlarged to more than double its 
natnral size. Over it the tissues were thickened and braivny, 
and the skin preuenled the oritices of several sinuses whicli led 
down into the substance of the bone, and discharged a modern 
ate ([uautity of pus. The probe, passed into any of these, goea 
deejily into the bone, and encounters some rough, exposed, 
bony points, but no distinct or considerable surface of seqnca- 
tmm can be recognized. One of the o{>6ninga on the anterior 



oBBoyio smrrous abscsss op boye. 



tt 



larface eommnnicates with anotber near the raalloolaa intcrnus, 
W Cftn be shown hy patisinf; in two probes, ono at citlicr orifioQ, 
and making them toach in the middle. The ankle-joint is, 
and long htu been, a little swollen, and eomowbat stiff in itfl 
movements. His general condition is that of a lietilthy and 
vigurouft young man. No suspiciou of any syphilitic taint. 

In the light of omr prerioas experience, the diagnoeis here 
raa clearly niatlo out, of siiiuouA nl>scc£«i of hone, and the o|>- 
'Vrstion for ib« cure was performed by Dr. Van Buren, on the 
I9lh, as, from the proximity of the diaease to the ankle-joint, it 
was feared that iiiflauimation might at any moment exU*rid to 
it* cavity. By the trephine and chisel, the whole anterior wall 
of the cavity in the bone was remnveil, and every sinne treoly 
ox[NK7ed. They were alt found to coinmnnicato with a central 
cavity, as large as a hickory-nut, wiiich lay bo near the ankle- 
joint, that there appenrod to be merely a thin sbell of bone be- 
tween it and the cavity of the joint. The ainnfto*, which opened 
on the anterior surface of the bone, were entirely exposed by 
removing their bony covering. Two sinufte**, however, pene- 
trated the bone bo deeply, and had their external orifices bo 
£ar back, that it was not thought best to cut away all their 
■zttcrior wall, for fear of too eerioualy weakening the luiiie. 
The portioDii of their track which were nearest the central 
cavity were therefore freely exposed, while their opetiinga 
tbrongh the compact shell of the tibia were k'ft untonctied. 
The whole of theae cavities were lined by a vmooth, ooft, red- 
disfa, and very vascular membrane, which, to the finger, felt 
Terr thick, and fecemed to be composed of abundant firm gran- 
alatioDS. Through thi& membrane the bone-tissue oould be 
felt, but it was not anywhere extensively exposed, or apiuirently 
di-^a^ed. The hone cut through in the operation was of mod- 
erate finnncaa, and appeared to be eimply hypertrophicd. It 
bled fi-cely when cnt. The wound was dressed with a view 
to it0 granulating and tilling np fri^m the bottom. Although 
a slight attack of erysipelas occurred on tlie third day after the 
operation, every thing went on as favorably as could be desired. 
[ealthy suppuration umncoii, with good, ftrm, florid grunnla- 
>n8, and the wonnd tilled np rapidly. On the 15th of Decem- 
ber, it waa noticed that the sinuses whose oritlcos had boon lad 



88 



DISEASES 01^ DOSE. 



OQ the inside of the limb bad healed entlrelj. lie ia entirely 
free from pain. No intomipUon occniTod in the progress of 
liift cure, wIiicU was complete when be M'aa discliarged from 
the hospital. 

Case II. — Edward Smith, afied nineteen, I saw at BcllcTno 
Hospital, by the kindnetts of Dr. C. D. Smith, under whose cliarge 
the patient w.-b3 admitted. He had presented bimaelfatthe 
hospital, November 11, 1857, with au enlargement of the lower 
part (if the left tibia, wliiub, be Baid, had commenced with an 
ouute attack of Inllaiamutioii of the le^, last July. This attack 
be attributed to a very prolonged exposure in fishing for oya- 
ters while the water was yet quite cold. Ho went to bed 
ill that night, and the next morning great pain in the lower 
portion of the leg announced the commencement of a severe 
iiidainmalion, which aoou leriiiinuted in suppuration. It was 
opened in about two weeks, and a large quantity of offensive 
matter discharged. Several other abacosses formed at int^ervals, 
and from tlieiii timall fragmentti of dead bone WRrc discluirged, 
thi.' birgetit not bigger than the finger-nail. Ho continued to 
suffer a great deal of pain and discomfort about the limb, and 
the irritation was so great, and so easily aggravated by han- 
dling or by exercise, that he was confined to bis bed dnring most 
of the time. When admitted, his general condition, though 
obviuurily affected by long-continued suffering, wa* tolerably 
good. The lower third of the tibia was much enlarged, and 
the integumenta over it thickened and inflamed. Five orifiocs 
were situated on the anterior surface, into each of which a 
probe could be paased deeply into the substance of the bone. 
Here and there the probe seemed to grate against bare bone, 
but no distinct sef^nestnim could he discovered. The lowest 
orifice was about two tingerti* breadth almve the ankle-joint, 
which waa not in any way involved in the disease. The dis- 
charge was not large, but was Romowhat offenaivo. The case 
was pronounced to be one of sinuous al>s<!esw, without necrosia, 
and the operation was perfonned by Dr. Smith on the 28rh of 
November. By the trephine and chisel, the sinnsea were care- 
fully followed through the bone, and their anterior wall re- 
mrtved, thus laying them freely open to the bottom. They 
were all found to communicate with one another, and at the 



CHRONIC SnmOUB ABSCESS OF BONK. 



3» 



d«ep«6t part of their cou«e, toward the lower part of the bone, 
the cuvitj expanded bo as to admit the end of the linger, but 
at DO point was there any distinct or con^tderahlo chamber; 
which, in moet eases of this disease, tiidicateB the f^cat of the 
>ri}rinHl absc-ess. No sequestrum was found iu anj part of the 

'cavities, but their walls were, in place*, rough or granular to 
the feel, giving the imprcuion of an ulcerated or carious con- 
dition of the aurrounding bone-tissue. Tlie external aspect of 
the en1argc<l part of the bone was rough, and Ihc pcriuetoum 
over it much thiokened. The pieces of bono cut awa_v by the 
trephine and chisel showed tlie natural spongy substance of 
the bono hypertrophied, but not otherwise altered. 

The wonnd was drciiscd lightly with lint. Some tri6ing 
feverish reaction foHowed the oi»eration, but healthy grannla- 

'tion was soon cstablishe<l, and, on the Ktth of December, he 
r&B reported at: improving rapidly. Dr. Smith since informed 
me tliat the further ])rogresi) of the case was satii^factory, and 
that the wound healed entirely, and apparently eoundly, 
witliin a few weeks after the operation. 

These two caaes are presented, as among those best illus- 
trating the n3ual characters of chronic sinuous abaeess of bone. 
Aa deduced from these, and a number of other oaaee, it appears 
plain to me that the pathological anatomy of the disease ia an 
inflammation of the cancellous tissue of the ends of tlie long 
bonee, rapidly terminating iu su))puratii)ii. The matter tlius 
rmpidlj fonned early approaches the surface of the bone, and 
soon reaches its compact outer aheil, which it pcrforntea, and 
then, without olifitruetion, attains the surface of the integu- 
ment, and is discharged. The deep cavity in the bone, thofl 
commnnlcating with the surface by a narrow and indirect 
cfaannel, is not projierly evacuated, and the lodgment of pus 
in its most depending portions provokes anew iiitlaumiation 
id suppuration, which extends the original excavation, and 
oflea finds its way to the surface by some new channel ; and 
thus, by a rej^titioii of the original morbid process, tho disor- 
ganization of the bone assumes the extent and severity with 

^■vhich it ultimately comes under oar notice. These repeated 
iflammations cannot occur without exciting vascular action in 
the sarronndiog parts, and we have, accordingly, intiamuiatory 



40 



DL'^EASES OF BOHE. 



hypertrophy induced in the gfiect«l portion of the bone, and, 
later in ihp dJAoaiw, induration and ebarnatiou, particiiilarly 
about the ab^c-c^od and their coiinectint:: RinuiKS. With tliis 
aorion in the bone, we have a ourre6|>oiidiri<; chronic iuflamtna- 
tion and thickening of the perioateain, with osseous do]K>sit3 fptwn 
it« inner surface ; no that the aarfact-s of the hypertrophicd poi^ 
tion« of bone, when stripped of thmr periosteum, have a roujjh,' 
irregular, (rranulated appearance, in all respects similar Co the 
6Ui-face of the iiivohicnitn in caeee of iiocrosia. 

The dis(;hargB, during the earlier periods of the complaint, 
varies in quantity and quality with the varying activity of the 
inflamrnatioii ; hut, in the later stages, wlien the tendency to 
abscess- formation is exhausted, and the parts have become con- 
solidated by clironic inflamniation, the disctiargc is moderato 
in Liuaiitlty. and, in quality, gvuenilly thin, »oiu«tiuiu9 eanious, 
and very rarely oifeni^ive. Caries of tlie walls of the cavitiea 
may occur if the constitution be pradispoeod to scrofula, 
cnn(a?uinated by eyphilia; and, in the same way, nocrutii« of 
eiimll poriioiiA of thu oi-iginal, or of the niorhitlly-iiKliimted' 
cancellous tiasuc, may take place, as an accidental oomplicatioa 
of the case ; hut neither eariea nor necrosis has any thing to do 
with the original character of the atfecliun, nor do they usually 
play any iutportant part in its later history and progress. 

A most important feature in the ntmtuiuy of tliese cases is 
the disposition shown by tlie absaetfaee to approach, and to 
involve tbo joint near which they arc situatoil. This tendency, 
in the mere chronic fi>rm of the disease, when the abucas has 
not been able to make it* way to the surface, but remains a 
source of irntation, pent up within theswolli.'U end of the boue, 
is recognized by Mr. Brodie, and, indeed, by many other ob- 
Borvers, ns one of the most dangerous fcatnres of the disease. 
The same tcndoney is observable oven in the open abscess we 
are de»terihing. Though there be no pent-up fluid seeking an 
outlet througli the joint, yet the tendency seoms very strong 
for the excavations to extend toward the nearest synovia! sur- 
face; and, even when no communication takes place, the in- 
flammation of all the tissaoB round the abiicess easily spreaila 
to the joint, and, rather by its constant recuiTence than by its 
immediate severity, seriously comprotnisea its integrity. 



n 



cimoyio siNTTOcs ak^cbsb of bonb 



41 



The Bymptoms of tliia affection liavo alrciwly been bo fully 

jribeil OR not now to require re**aiiituIatioii, Imt its resera- 
ince to and its dia^'noBb I'ruiii necrosis demand a mooieut's 
notice. The resemblance is striking and obvious. The a^o 
of the patient; the most comnioQ onu.>ies uf nttauk ; the carlv 
symptoms of indammatiun of the bone, tenninntiD!; in siijipu- 
ration ; tlie nDmerons and sncceftsivo openings ; the enlarge- 
ment and indumlion of the affected re^g^ion ; tlie unchnniring 
and Intractable character, and the interminable dnrationof the 
diMBso — are all marks of identity, which, I believe, habitually 
deceive carelcM oliservcrs, and which require, for a pro|)cr dis- 
crimination, much care and a thorough knowledge of the two 
diseases, and their distinctive characteristica. There are, how- 
ever, Bonio foatnrcs which nro diagnostic. 

And, finit, wc have the situation of the affection. In ne- 
crosi?, the compact, and, in abwegs, the cancellous fitructnre, 
are respectively the parts implicated. HVe have, therefore, ne- 
ordinarily affecting the middle portion of the lung buucs, 
lich is mainly compact tissue, M'liilu abscess is formed nt the 
enlarged extremities, where the mora vascular, and therefore 
more liii^hly-organizod, spongy tisuno prevails. Howniiifonidy 
this low h obeyed I cannot say, but in eight cases which 1 have 
seen there has been no exception to it 

Secondly, the actions set up in necrosis, partienlarly if a 
large portion of the calibre of the bone has perished, ore for the 
formation of new bone around the dead ecqueBtmni, and, eon- 
joently, tlie enlargement is w>nimoiiIy very great, from tlie 
hicknci^ of the involucrnm, wliich, it must be remembered, 
more than supplies the place, as far as mere bulk is eoncemcd, 
of the bone destroyed. On the other hand, the actions whici> 
go on in connection with abscess are merely those of thicken- 
ing c^tho surrounding bone, by a process of inftummatory hy- 
pertrophy, strictly analogous to the induration of the tissues 
round any series of chronic abscesses in the soft parts. The en- 
largement, therefore, which aoeompanies necrosis is very great, 
white that which exists with abficesa is comparatively morlerate. 

Thirdly, the early history of these cases of abscess of bone 
shows that, with each opening formed, there is nsually cast off 
m imaU piece of bone, a few days or weeks after the opening 



43 



DISEASES OF BONE. 



lias taken place. This does not occur with the absces»]8 of ne- 
oroBis; and it appears to me tliat the eKplaoution of the diifor- 
ence between the two aflcctionfi, in this respect, ia not dilHciilt. 
"Where suppuration occur* within the subetance of a bone, it 
may well be supiwjsed that the rapid couree uf tbe matter 
toward the anriacc, bursting, as it wore, tljrongb the outer 
shell, before the slow actiL>ii of the o-iseoua vepsels can pruvide 
b^' absorption fur it(> quiet transit, will or may, in many oaeea, 
produce the death of a BmuU portion of the compact tiMua 
which ofl'ered the finit registaneo to its progivM ; winch small 
fragment thus killed will Rcparnte and make its appearance, in 
a longer or shorter time, after tbe opening of the abscce*. In 
Decrotiis, on tbe other band, all the compact ti»tjiie implicated 
diee iu mass, suppuration occurs outside of tbe dead bone and 
between it and the periosteum, and no geparatiou of fragments 
usually takcA place until the whole masg begins to loosen from 
ita attachments. Tlie pieces which come away in abscees of 
bone are described as being very small, and are often likened 
to a finger-nail ; and I have so constantly met with them, in 
the history given me, by the patients, of their earlier symptoms, 
that I cannot help considering them as very characteristic. 

Fourtldy, I think that there are, generally, le&s pain, loss In- 
convenience, less inability, and \e»s diweharge produced by the 
ahsceee, in its clirouic condition, than by uecrosis, while tho 
sequestrum is present. So nnicli so is this the case, that it 
must be extremely rare for a patient with a large sequestrnm 
in his tibia, for example, to be able to be about his ordinary 
occupations with the same degree of comfort as ia ol^en en- 
joyed by tho«e affected with the chronic abscess. 

Lastly, the most important of all the diaguodtic signs is de> 
rived frora the infoniiatioLi given by the probe. In necrosis, 
there is nsually no difficulty, if the openings be free, in finding 
the bare and rough surface of the sequestrum. In the abscess, 
on the contrary, with openings equally free, no bare bone is 
discorercd, or, if any appears to be touched, it is so slight and 
so uncertain in its indications as to leave us in doubt whether 
the sensations may not be prodnced by the nide use of the 
probe, rubbing oH' the grauulatiuns from the surface of other- 
wise healthy bone. 



CEROyiO SINUOPS ABSCESS OP BOKB. 



43 



From tite view which has been preeeiited, of the aiitttomicu) 
featoreg of this affection, tlie ehamcter of the operation nccea- 
•ary for it* core 'm directly dediicible. If tlie difficulty Ho 
fsaeutially in the pliyeical coaditiona of the pHrts, tbou the«e 
physical coiiditioDs luaet be altered. If tlie ubscees lie deep 
fruiu the surface, it niu^t be freely exposed to that siirfaoe, aiid 
made, as nearly as may be, a part of it. If the channels through 
which it is discharijed be narrow and indirect, thoy should bo 
made large and dire<'t. In short, if the obstinacy of tlie affec- 
tion depend upon \t& character as a Binnons abscess, then that 
character mast be destroyed, as completely as ptwsible, by cuii- 
Terting it into an open wound. In carrying out this indica- 
tion, it tau&t bo remembered that it is a cardinal one, and that 
upon the thoroQj^hness with which it is done will do|>cnd the 
rapidity and cotnpleteneas of the cure. I aiti entirely uonriiiued 
tlint tlie failure in one of my earliest coses was dae to the fact 
that, not fully appreciating the importance of thoronghnesft in 
the operation, I c*>ntented myself with opening the cavity of 
the abecees by removing a portion of its anterior wall, but did 
not, as I now think it necessary to do, remove the entire cov- 
aringof the suppurating ciivity, both upward and downward, 
ftnd convert it into a more gnxivo or excavation on the Biirface 
of the bone. Another case, of ab:*<;e.-w of tlie femur, which oc- 
cnrrod to me soon after, presents an illustration of the same 
principle, and leads me somewhat to doubt the general applica- 
bility of the o]>erattoa to abBoesses in the femtir. The diseased 
boue is BO much more inaccessible, covered as it is with the 
tliick, mnscnlar mass of the thigh, and tho oporatlou necessary 
for fully ex|HMi[ng it is so serious and extensive, that 1 fear, in 
moat coses, it would be left incomplete, and therefore iueffeet- 
aal. Besides, even if the o]>crution be well and thoranghly 
done, the aappurating cavity in the bone ia so covered in by 
tliick, soft parts that, by their healing, it in a very short time 
approaches again to tbe character of a cavity with narrow ont- 
let«, and tends to reassumu the appearance and behavior of a 
sinuous abboese. Wlien, however, the operation can be thor- 
oughly done, as in tho tibia, and in most of the other long 
boncA, and when, in addition, all the li>4tu1ou% track? can be 
•ko freely laid open, the cure will be speedy and complete. 



44 



DiaUflES OF BOKB.. 



It is asaally 'best to commence the operation witli the tro- 
pbine, and panicularly iu old cases n-here tbe osseous tUauo a 
apt to be miioh ooiifiolidutiid from lonj^-uoutinued and frequent 
inflammation. Alter exposing the main canity hy tbe tre- 
phine, then with the ji^nigo the whole of its anterior wall, and 
Buch other j)art6 as may seem necessary in following up the 
flstuloiis tracks, may be chiselled away. It in very desirable to 
have the toumiqnet applied to the limb ahure, not so much 
for the savini; of blood, of which there is usually but little lost, 
but with the view of keeping the cut-boiie sorfncee clean and 
dry, 60 that we may be able to judge correctly of the coune and 
condition of the various tracks which it may be nece(>8ary to 
follow. As fur us pnicticahle, there is no doubt that it is best 
tu follow up and lay open cacli of tbe sinuboa which lead fmm 
the central cavity to the surface. That this is not absolutely 
necessary, however, is shown by the sati-ifactory rcsnit reported 
in Caw I,, where two sinuseia, which penetrated the hone qaite 
fer back, were from motives of prudence left untouched, and 
neverthek'dtt healed rapidly aud souudly m tho re^it of the 
wound began to till up. If the principal part of the operation 
be tlioronjihly done, thifl will, 1 think, he usually the case with 
any siuusea which may be allowed to reitiain. In any raw 
where it seems necessary, no hesitation need be felt in making 
deep and extensive chi^ellings of the bone, for the repair is 
abond&nt and certain. We have here to deal with original 
boDe-tiasue, thickened and hypertrophted from loiig-eoatinued 
inflanunatory action, it U true, but with all it<t original repara- 
tive capacity une.\l)nugted and unimpau-ed. The case is very 
different from tho involucral covering of necrosis, where we 
arc dealing with an entirely new funriation, nne wliiidi h itself 
tlie product of BHri)ri»ing vital and reparative energy, which 
energy may be supposed to have, at least in a great degree, 
exhausted itself in the formation of the involucrum, leaviug no 
excess to be available in a process of reformation after its 
destruction. At the same time, it is well to avoid weakening 
tho bone by unnecessarily cutting away its substance, a» wa 
never can be certain but that, by some mischance or misbehavior 
of the wound, or of the conatitution, the reparative actioua 
may be delayed or imperfect. 



'fiWrUSB SUITDBATION.— OSTEOMYELITIS. 45 

The nftertjcatmeiit h ut^uu11,v the e>iti)|ilest possible. Bj 
liplit dressinps of tbc wound, which is of course left wide open, 
it griiiiulatcs from the bottom, and pcnerally begins to heal at 
itft edges before the excavation i» tilled op, No tents or 
6poiigi» or deep dressings with liul will be reqaiii'd, and time 
unlv ii nGoessary to coiuplcte the cure, Af> soon as the wound 
Iia& licgim fairly to till up and to contract, if it be otherwise in 
a healthy condition, the patient hIiouM he allowed to po about 
Willi a r"llor-baiulage to aii])port the linih, that he may secure 
the benefit of air aud exercise. If an nnheAlthy condition of 
the sore* should perisi^t, or if caries of the bono should be sus- 
pected, constitutional treatment will of course not be neg- 
lected ; but, in a Urge proportion of the cases where the oper- 
Ition has been w-dl done and thoroiigblr done, nothing fur- 
ler will be required to restore the patient to perfect health. 



CHAPTER r. 

DIFTOSE BtTPPUEATIOX. — WTBO-WTTrrnR. 

In strong contrast with ab&eeas of bone, we liavo that form 
of inflammation in which the suppurative action h not limited 
by a wall of librinc, but is diffused throughout the whole sub- 
stance of the bone. Tlus form of disease has loug been recog- 
nized by eui^ical writers, but particular attention lias of late 
U-'en drawn to it, by observations made iu the Crimean and 
Italian campaigns, and in our own late war of the KebeDion. 
It -seems to be, in a very eminent degree, a disuse of crowded 
militarr hoapital:*, where, from the necessity of the case, the 
hygienic conditions ore often extremely unfavorable, and it is 
cmnparativtly unknown in civil practice. It ia a condition 
induced, ahno^t exrhit^ively, by injuries of the Iwnes, and is a 
very serious and fatal complication, both of amputations and 
of reseclionB. From the fact that its most prominent features 
are developed in tlie mediiltai'^' cavities, it lias received the 
name of oetco-myelitis, or indammation of the murrow of the 
bone, though it mnst be understood that its oftects ore by no 



SIBBASSS OF BOKE. 



means confined to the medolla, bnt very often involve all the 
component part« of the bone affected. The clinical hi&torv of 
the diiiease seems to bin thnt, after some injurj^- ur operation on 
A bone, which has involved it^ medullary cavity, 6ytn|)toiiu of 
iodaiDRiation of Uie bune be^in to kIioiv thcaiHelve^. Thece 
symptoms are usually a dull, heavy, aching pain in the bono, 
great tondemegs on moving or handling the part, and very ftoon 
Boine Rwollinj; of ttio Burroundinf^ fioft jiartfi. Witli tlio super- 
vention of these aymptoms, there is usually noticed a change in 
tlie appearance of the wound. The discharge diniiniahes, and 
for a time driex np ; the granulationa lose their reparative as- 
pect, aud present a dry, sometimes a slougliy appearance; the 
whole j^roup of pymptoms indicating that (>Qme serious disturb- 
ing cuu^ has arretted favorable progress of the wound toward 
healing. With those, constitutional symptoms, usually of a 
very formidable character, oi-o developed. Sometimes a chill 
may annonnce fhe iiivasitin of the dtscnse, and very commonly 
irregular rigors are present during its courw. Fever soon 
comes on ; at Urst^ of the inflammatory type, soon changing to 
the typhoid character. DoHrinm h often an early sign, and in 
all easea the nervous power neeme to be rapidly exhauiited, and 
the patient soon presents those signs of prostration which so 
commonly accompany the severer fonu^ of constitutional irrita^ 
tion. Very often the symptoms merge into those of pyicmta, 
with severe rigors, foUoww! by slight fever, and very profuse, 
exhaui^tivo sweats, rapid emaciation and loes of strength, shrir- 
elling, bluenesa, and maceration of the surface, low, muttering 
delirium and death, often aa early as the third or fourth day. 
If, while these symptoms are in progress, the diseased bone can 
be watched, it will lie seen to present an inflammatory rednesa 
of the ex{>oged medulla, which, however, soon begins to be 
specked with purulent dota; aud a thiu, ill-luoking pua, in a 
very short simce of time, begins to ooitH from the opened me* 
dnllary cavity. At the same time, the poriotteal surface shows 
that it participatoa in the morbid action, and the membrane is 
soon detached from the bone by a layer of exudation which 
rapidly bocomns purulent. Kxamination of the part after 
death, or after amputation, reveals the fact that these changes 
reach far into the medullary cavity, in fact usnally involving 



DIFFUSE STPPORATIOK— OSTEO-MYEUTia 



4T 



the whole of it, and often extending more or lei<a into the can- 
cellous ti»»ue both above and below. Dr. Lidell, who obserrod 
the disease iii our militan* hospitals during the war, hm foiind 
three conditions of the marrow whidi he regardii as stages of 
the digease, and which he denotninatco — I. Comification, or 
hepatization ; 3. Snppuration ; 3. Mcu-titi cation. The firet 
sta^, or that of cartiification, Dr. LidoU deacrihca a& charac- 
terizeii by a re<Uieuing, and increase of licnMty and tenacity, 
of the medullary substance. The color, he Bajrs, varies from 
coppery-red to crimson, to brown, and almost to black. In this 
stage, tlie normal proiwrtion of fiit in the medulla is dimin- 
ished, and the ceUular elemenl& of the medullary enbstance, viz., 
the niarrow-cellg, are increased in qnautity, and become gran- 
ular in appearance. Of course, tJio (juantity of bli>od in the 
part is much iucreaded, and it is ohtterved that tlie inflamed 
medulla blecdft easily wlieii injured. The M^cond stage, or that 
of sappnmrion. supervenes on the former, and ifl the cliarncter- 
ifitie condition of the diftcose. In acntc oatco-myelitia proper, 
the suppurative action is not limited by the fiiirronnding cami- 
fication, hut all the tissue tends to break down rapidly, and iu 
fact siuiuttanvourily, into the purulent state ; just m, iu difl'use 
inflammation of the subcutaneous cellular planes, the whole 
afftx'tod rejiionis in ftstnte of induration to-day, and to-nmrrow 
the whole indumtc<ldi(itrici has become softened and iufiltrated 
with pn.<L ThiasuppuratiTc softening is more or lens complete 
in different caicfl, and p^oes somelimes to ?o great an extent 
tliat the semi-fluid marrow slowly oozes from tlie bone, a turbid 
mixture of pa«, oil, and dt^integrHtcd marrow-celU. In that 
mt're healthy form of simple inflammation of the medulla, 
[;which we sometimes meet with iu civil practice, it is not un- 
smmon for the Bupparativo action to be circumscribed by the 
limiting iridumtion in the form of a perfect ahsccsa, but in this 
ailynamtc form of the diBenBe we are now oousidermg, and to 
which specially the name of OBteo-myelitis has been given, we 
find the chamcieristic behavior of the non-limited, diffuse, or 
infiltrated euppurntioD. This peculiar tendency of the pus to 
diffbw itself rapidly orer all the affected region of the bone 
Moms to be only another evidence of that depressed vital power 
which disarms and defeats healthful constitutional reaction, and 



DISEASES OP BONl 

makes the rliseMO bo dreaded and so faUl. Tlte third staj;^, or 
that of mortification, is only another step iti the proce^ of de- 
etmetion. The inflamed titisne has not vitality enough to di»- 
intoprate by the slow prooees even of diffuse anppuralion, but 
gives up tlic conteet and yielda iu masa to complete, and often 
very rapid, death. 

Tho above ontline of the clinical history and pathological 
appearance in oatco-myelitis is drawn from oaHes ia whioh 
giiiisliot or other injury of the b(;no has been the oanse of the 
diseaso. The fiillowing case is an excollont exiunplo of that 
form of tlio atleciion where tho wholo bone, including the 
niednlla, takcB on acute suppurative inflammation 'from causes 
apparently too trivial to explain the occnrrence of -such severe 
coiiBeqncnces. The case was reported by Dr. Sands lo the 
Pathological Society, and I condense it from the account pub- 
lished in the M^-dical Record', May 15, 1871 : 

" The |nitieril was an active, liciilthy boy, nine years old, who 
was attacked, Fehniary 12th, with severe pain in the kuoo. 
Some tendeniesB wae ob^rvod about the knee, though it oould 
bo moved witlumt pain. Tluti pain and tendcmesa continued 
for a day or two, Imt were soon accompanied with fever and 
an elevation of temjwrature to 103. On the toiirth day he 
was delirious at night, with a pulse of 140, and feeble, the 
tongue dry, and every tiling indic;ating serloUB dlsca^i*. The 
tendemcBs had now difl'iisc*! itself along the whole thigh, deep 
pressure upon which gave groat pain. There was no effusion 
into the knee-joint, and now no tciidcmcss about it. There 
was no swelling of the thigh, and he wat^ able to move it with 
some freedom. Careful nicasurenieni showed the left tliigh 
to bo an inch larger in' circumference than the right. The 
pain was paroiryflmal and very Rcvcre. On the fitVh day he 
■was much worse, delirium incesi^ant, pulse failing, temperature 
rising. Tho thigh waa now considerably swollen, but not 
cedctuatous. Ho died ou the uioruing of the sixtJi day. 

"■At the autopsy, the only part of the body examined waa 
the femur, but the appearances of this bone sulliuiently ex- 
plained tho nature of tho Irouhlc. The left thigh was not meas- 
nre<) ju^tt before death, bnt af^er death it was found to bo two 
inches more in circumference than its fellow. Tho dissection 



DIFFUSE StTPPCTlATION.-OiSTEOJirELITB. 



iflde by an inoiaioa on the outer aBpect of tbe liinl). The 
mnscles were sotiiowhat iiililtrateij, but otberwiae lioalttiy. 
There were no appetiranved of iiidHiiniiHtioii, until the ]>cri»^ 
tcnra wail rcftcUed. The outur surtnce of this menihr&.ne, 
throughout nearly the entire lenj^h of the shaft of the feiiiur^ 
was Burroutiflcd with pos, accumulated in greatest quantity at 
a point beUiw and a point above, on the oater a«]»eet, and be- 
hind tlie superior extremity of the bone, undemeatli the quad- 
ricopd fumum. So far a^ could be aecertatnod, there na^ no 
perforation of the |)erioBteuin. ThiK membrane was the Beat ot 
ftu acute fodoma. and separated more readily from tbe 8u1)jaL-eiit 
bone than it should. On raiaing it from the bono, there wcru 
fiuiall depOHits of puft here and there, lying lietwcon the at- 
tached aurfncc and the bono, but thcRe deposit? were not so 
much in quantity as those on the external aspect of tlie mem- 
brane. The hip and knee joints were perfectly liealUiy. 

" On section of the bone, it was at onc-e seen that tlie focus 
of the disease was the interior. The whole of the marrow wna 
fonnd to be hypcncmie. In some plaeea it appeared very soft, 
and iiiicrminp^led with pafches of a whitisli-yellow color, which 
were due to ditHuent i)urulent material. It appears that thia 
infiltration extended np toward tbo cpipliyRiii, though it was 
not traced through the epiphyse:d line in either direction. 
There is no evidence to show that the extension of the disease 
from within outward has been one of continuity. There are 
no openings in the bono or periusteuiii. Ko far ng I have ex- 
amined, the inHamuiation accnicd to have occurred by conti- 
gnity." 

Dr. Kdward Curtis, who made the microscopical e.tamina- 
tion of the specimen, gives the following account of the ap- 
pearaiiccii presented : 

** On Mctiou i)f the bone, the marrow, throughout ita whole 
extent^ appeared redder than normal; that in the medullary 
eauil of the shaft being of a darker shade than the marrow 
of ihe c-ancellated tissue of the extreinitiL'3, Iq the mcdntla 

the shaft, ofijiecinlly in the upper half, were numerons toci, 

rfaere the substance was of a palo cream-yellow color, like i»n3. 

TbU material, on microscopic examination, was found to bo 

Duunly composed of closely -aggregated, small, roundish cells, 

4 



60 



DIBKASE8 OF BOyt 



smaller tlian puB-corpuecles, pale, and very finely granuliur, 
without viftible nuc-Iei, embedded in an extremely viscid j^raiiu- 
lar siilwtanco. Very little of tlie usual fat of tlic meduUu 
was present in tliis yellow material. The briglit^red pulp of 
tlie inflrri>w of tlie shaft presented a much smaller proportion 
of fiimilar cells to those just deficribod — a greater amount of 
fat and granular matter — and was gorged wttli blood. In tlie 
eaneellaled ti»6ue of tlie extremities, the marrow wa« hyper- 
O-Hiiic, but the examination failed to detect any ubuormal ueilii- 
lar element*i.'' 

Dr. Sands considered that, in this case,tlic modnlla waa the 
etartiug-point of the inflammation, though the prnt-mortsm 
appeanince* indicated that the disease was rather further 
advanced in the periosteum than in the medulla. I do not 
tiiiitk such a distinction can often be made in these acute bone- 
inflammations; to my mind the case affords a elafifiieal illustra- 
tion of the great patliologieal law that, in euch infljimmationa, 
the whole bone, both periosteum and medulla, is inrolved; if 
not in all parts equally and simultaneously, yet aofiiciently so 
to show that the mischief developed in each part is the re«nU 
of a proceft* of diwased action pervading the wlnde bone, and 
really belonging to it as an entirety, even although it may seem 
to oommeuee at one point and spread to the rest. That this 
was tlie uourao of the disease in this particular case, would 
seem to he shown by the fact that, at the end of six days, all 
parts oF the bone were so nearly equally implicated. It soeme 
to me extremely probable thnt. if thJB Htlle fellow }i ad been 
able to maintain himself under the first onslaught of the in- 
Bammatiun, the case would have terminated as an ordtnaiy 
example of eomplete necrosis of the central parta, if uot the 
whole, of the shaft of the femur. 

The recognized causes of osteo- myelitis are ufinally con- 
nected with Bome injorv of the bone, as in contusion, fracture, 
amputation, or rejection, injarie* which seem much more 
liable to 1)0 followed by the disease, if air has admieslon to the 
wounded bone. In military practice, it is thought that the 
transportation (»f the wounded is a fertile can«o of inflamma- 
tion of the bone, as we know it to ho of the soft psrt^; winch 
lie round it. The jolting of compound fractures, or of resected 



DirFUSB STPPCR-ITION.— OSTEO-MTEI.TTra. 



51 



jointu, over rough military ronds, muat neces&arily indnee a 
mMiing of the wounded bones against one another, whereby 
inflnmmation would be produced, and even in stuinps the con- 
tusion of the flaps against the bone may very well be supposed 
to Bet up inflaniraatory actions, which may involve the bone aa 
well aa the soli parts. Dr. Lidell lias particularly noticed this 
point, and alludes to the corroboration bis viewH have receivei) 
from several eiirj^eons who have directed tlieir observations 
toward ttiia matter. 

But, of all the canwa which may produce this disease, none 
Is BO efficient as the impure air gonoraled in over-crowded mili- 
lAty hospitals. The disease maybe said essentially to depend 
upon bad hygienic conditions, oud it is because these bod con- 
ditions ore particularly liable to bo found in lar^ hospital.'^, 
that it is in thei^c establishments wo £rid it almost exclusively 
present. Dr. Lidell observes: "Observation has shown that, 
other tilings being equal, the wards of a hospital that are mout 
impure in respect to their atmospheric condition generally fur- 
nish the largest proportion of fatal cAses of oeteo-niyelitis. Ob- 
servation has aliiO shown that t>urgical patients — for example, 
those who have sustnined gun shot- fracture, or umputation, and 
are treated in the portion of the wani where the air is moat 
likely to stagnate, for example, ihe comers — are considenihly 
more likely to become affected with dcistrnctive osteo-myelitia 
than tUooe who are treated in other portions of the same ward 
where the air U more free from im|>unttes. Observation has 
farther showTi that surgical patients treated in hospital-tents, 
if they are properly pitched and policed, are much lesK liable 
to be seized with fatal o&teo-myelilis than a similar class of 
patients treated in the wards of a hospital bnllding." Thoao 
views are amply confirmed by the more limited experience of 
civil practice, where the few cases that do present themselves 
can always be traced to the same vitiation of atmosphere, 
which at the same time shows its ill influence by the produc- 
tion of erysipelas, pyiemia, gangrene, and typhoid, to all which 
osteo-myelitis has undoubtedly many close relations. 

The treatment of this dangerous affection might porbnps 
properly be said to consist in its prevention, and it is certain 
that, in this direction, much may be accomplished by carefully 



BS 



BISKASES OP BO!fB. 



ref^uIutiBg the hygicuic couditiuas uf the wounded man. 
Tliftse liv^ienifi prw^ftutioiis are undoubtedlv the firat and iiiot*! 
important features in the niaiiftgerneiit of osteo-mvelitia, and, 
ey«n when the disease has alreadv declared itself in u given 
individual^ hie chaiicos for life would mainly depend upon 
wliiit could he doiio to imjjrovu liis hygienic eurroundiog*. 
Removal from the place of original infeotion, separatiuu from 
others 8uficrin{» from giniilar disease, cliunge of bedding and of 
clothing, seni]iulon!t cloaiilincits, and tihundance of pure air, 
will often modify most favorably an attack which thrcatcnod 
to be fatal ; and, in the absence of this kind of care, miHtiirj 
Burgeons are often oblijfed to witness the utter inefficiency 
and even worthlessness of every other speuies of mam^ment 
whether medicinal or siii^iaal. NovertlieleM, there Ib sorae- 
thhig left to bo done hy both general and local treattnent. 
The charwcter of the^enonil treatinont tnnsi ho mainly that 
wliieh supports the strength of the patient through a disease In 
which that strenjrth ia sorely taxed. The best food which the 
fttoniach will receive, offered in Bneh form aa to bo most easily 
digested and assimilated, with such atiiuulanta a» will not ex- 
«;ri^*rato the aenter symptoms of inflammation, together with 
the exhibition of such touiu mediciueri us will help to tiustatu 
the nervous |H)wer, or prevent, as far as may be, t]iBrai)id disin- 
tegration of the tissues; these seetn to he the ninin indications 
of jfcneral treatment. M''ith rcjjard to looal treatment it mast 
always be borne in mind that, in all forma of lione-inflamma- 
tion, th<* impriftonment of the inflammatory products within 
the nnyJekUng hone or the scarcely leM tractable periosteum, 
forms one of the most important elements of suffering and 
of danger, and that llierefore the tirsil consideration of the 
fiurgeou tihould bo, a& far as possible, and as early as possible, 
to give the freest issue to any such in6anirmtory sccrotiona as, 
hy retention, would be likely to be injnrioiia. For this reason, 
wounds in Llic soft part^ ehonld be freely and unhesitatingly 
opened, in such a way that gravity will assist in keeping the 
diifchargos free, «nd, if necessary, free incisions should expose 
the bone to our view. The tense and inflamed pcrioeteum 
may often be incised longitudinally, so as to remove it* presa- 
ar« on the bone beneath, and iu eome instances it haa been 



DIFFUSB SUprTRATION.—OKTEO- MYELITIS. 



53 



leil, if thore l>c not froe exit of the contniudl fluids, 
£o perfbrato llio bone willi a trephine, in opdfr to aiFoivi »n 
eur route by which the iiijarioiis diiiils may find the Furlace. 
Thvse Bomewhat summary prooeedinji^ are JDstiticd by two 
ojusidc-ratiuiis: Fi rot, the immediate effect of the retention, 
nDiler pressure, uf the fluids within the bone is, to enlarge the 
srca of di»eafie, and intentiifv itB Bevorlty ; and, secondly, the 
eontinuance of the pre-^ure ^ouu leads to diisintegrHtioti mid 
death of the bono-tissuc involved; and, if the patient ehould 
happily recover iVom hi» primary di^v-aRe, he has still to en- 
connlcr in dreadful seeondnry conseqiienne?, in the shape of 
pytemia, caries, and iiecr<>»ia. Again (and thia i^ the really 
practical que.-ilion in the treatment of osteo-myelitis), wliitt are 
the chances which the removal of the diseaeiKl bono affordel 
The firet efforts made in this direction were made by arnjmta- 
(ion or ex»ectiu[i of the affected bones, ami with a very unsatr 
Ufaetory success. Vallette, in the Crimean War, and Jiihs 
Rous, in the Italian eampaij^s, di*co«raj»ed by these ill results, 
a<lopte<l the plan of exartieulation, thereby removing the whole 
of the affected bone, with a succexs which they report as ex- 
tremely marked. Mr, Thomas Lonymore, in a paper rend be- 
fore the Hoyal Medieal and Cliirur^t^-iil Society, February 8, 
1865, combats thew vtewB of Drs. Vnltette and lioux, and in- 
sists that a greftt many of these cjifipfl may be sfived hy allow- 
ing the disease to gf> on t-o it4 full development, and then, by 
removing the sequestrum, he saya the stnmp may be saved. 
These view* of Mr. Lonymore I consider imsoiitid and founded 
OQ BD ermneou-'f pathology. The tubular sequestra of which 
be speaks, and which he regards as always the result of osteo- 
myelitis, have in fact no wnineetion wluifever, iii inottt caswi, 
with this formidable diBeaKe. It is a fact which I think the 
carefnlly -recorded experience of any practical aui^oon will 
verify, tlmt the cases in which these tubular sequestra are 
found are the very cases which, perhaps, have done the best iu 
their earliest stages, and that the first eymptonis have been 
after the wounds have nearly closed, when gradually-increas- 
ing pain and soreness of the stump, with an increasing instead 
of a diminishing di[*i;harge, have led to the dlucovory of a 
thiokoned bulbous condition of the end of the bone, which 



54 



DtBEASES or noxE. 



after a cortain time has been found to contain a tubular «e- 
que»tnim. This is not the historv of oateo-njjelilis, and I 
oonAclentlj believe that, in most cages, no form or degree of 
nicduUarjr iuflauiiiuition has preceded their furmatlon. Xhej 
ai'u d<;iieiident upon the cutting off, in the aiupiitatiun, of tlie 
nutritious artery of the medulla, whereby death of the inner 
fihell of the bone, which receivca its supply from this artery, is 
produced, wliich dead shell only anuuinices its presence by the 
irritation and discharge which it excites, after it is separated 
from the living tt^ue, and has become a foreign body, and by 
the involucml thickeuiug which it produces around the &eque«- 
trura, giving tJio enlarged bulbous feeling to the end of the 
1)0110 in the stump. I have given, in the chapter on Necroeie, 
a full expusitioTi of tny viewB on tliiB matter (eco page 119), and 
1 think a right idea of the pathology of this iroublesouie form 
of neerosifi is in no respect more necessary than as it boars 
upon these practical qucMions of ostco-niyclitis. 

Tn mv judgment, therefore, the conclusions of Drs. Yallelte 
and Koux are not invalidated by the reasonings of Mr. Long- 
more, and the recommendHtiun of these gentlemen, who bad 
Boen so much of the real diheiiee in its earliest stuge«, to ampu- 
tate always, by removal of the whole att'ected bone, remains a 
sound maxim in surgery, and one which is fortified by a grati- 
fying snccess in its perfonnanee.* 



CHAPTER TI. 



EICEETB. 



Itiozrts 18 a disease so rarely seen in our country that 1 
have no experience which would entitle me to speak of it au- 
thoritatively from my own observation. In the Old World, and ' 
particularly in the lai^e cities, it would seem to be common, 
and onr heat accounts of it are pictures of the disease as it exists 
in Paris and London. Many writers have given excellent de- 

■ e*i!, itUo, a TaluaMi! paper b^r II. Allfii, II. I)., M.S. A., OH OttotMo^eHtia, In 
AMtriean Journal of Jftdieal Seiencra, January, 1866, 



RICKETSL 



65 



scripttons of the aScctiun, and its ditfcrcnt flaafcana bavc been 
most oarefuliy jiiveBtigaled b,v very able o1werver«^ m that 
tbero is perhaps no disease moru tliorougbly studied and better 
understood. I know of no better account of what la know non 
the eabject than that wliich i& contained in the admirable lec- 
tnr«d of Dr. William Jeniier, piibliiUied in the Mtfdlaal Tltti^ 
and Oateittf, of London, during the year 1S60. These lectures 
are the mure valuable, inaemucb a^ they are not a mere r^sttme 
of other men's ideas, but are fonudcd on tlie autliora large ex- 
perience in the Hospital for Siek Children. 

Rickets, e%'idently, is not to be regarded as in any proper 
ficnw a primary diaeafie of the bones. It is u peculiar condition 
of the (general system, showing itself by many striking aymp- 
toms, of which one very important claw present tlienxselves in 
the bones. So important, however, and so characteristic, and 
so constant, are these bone-changes, that the affection very 
naturally ranges itiieU' atuong boue-diseases, and t^y^teraatic 
writers have agreed to give it a phicc among these di^ordcra. 
The first Bymptoms of the digease show themselves usually from 
the third month to the beginning of the third year of age ; not 
commonly much later, and very rarely earlier than these dates. 
Some writere speak of congenital rickets, hut the best authori- 
ties deny its occurrence. At tirst, there are usually some vague 
and undefined .-iviuptom!^ of deranged digestion and vascular 
action, which perhaps, at firat, are not characteristic, but their 
continuance, or perhape their recurrence, eoon ebowa that suin&- 
thing more than mere temporai-y disorder is premint. Dr. Jcn- 
ner [Kiiiits out three syniptonitv which, even in the earlier stages, 
are characteristio of rickets : The first is an unnatural and pro- 
fufo perspiration about the head and nock, and upper part of 
the chcfit. This sweating lii out of all pi-oporti<m to the heat 
of the room, or the exercise the child may have taken, and hIsd 
out of proportion t« the same action on all the rest of the sur- 
face ; fur it uonstautly happens that the abundant perspiration 
will be lieea ou tiie upper purta of tlie body, while the rest of 
the skin is perfectly dry. It is mostly in sleep that tlieae 
drenching sweats are observed, but they may occur at any time 
from the most trivia! canses. A second symptom of approach- 
ing rickets is the desire of the child to be cool at night, leading 



DISEASES OF BONE. 



it to tlirow off tT)c bodclotbds, and lie exposed, ^vnn dDrinj; 
cold weather, and wlien other clindrcn are disposed to be well 
cuvenHl. TliU s^'iiiptuin, it is true, is so coiniuon amoti^ chil- 
dren otherwigti perfectly well, that it cannot be considered as 
by it«!]f eharacterifitic, Imt yet Dr. Jeiinor in8i!^tfl that its 
prominence nnil coiiAtamty are tto decided oa to distinguish 
the rickety children, as a class, from ottiers, in a ward where 
all are sleeiiiii^ toother. A third symptom, and I siit^^iect a 
more characteristic one than either of the preceding, is a gen- 
eral tendernees to the tench of the whole body. The child 
BcemB to shrink from even the gentlest prepare, or the most 
can^fiil handling. Not only thie, bnt his own movements seem 
to give him ])ain. Dr. Jenner eavB: "The child finffering se- 
verely from the general cachexia which [irece<les and acoom- 
paniee tho progrei>sivc stngca of the bone-di»cH^e, ceases its 
gamboln; it lieu with outstretched limbs as quietly as poftsiblo, 
for voluntary movements pro<liice pain. Its nnwillingnoAS to 
be moved is so great that, as Stiebel has observed, it will cry 
at the a]>i>ro]ich of Uiom who have been accnstouicd to dance 
it — of thtiiie at the sight of whom it previuuttly manifested 
extreme plcat^iire. As the dit'oase prioresses, the child gets a 
peculiar htaid and Btoady appearance; ils natural lively ex- 
pression is replaced by a pensive, aged, languid aitpcct ; ita 
face grows broad and sqnare, and, when placed npright on its 
mother's arm, it sits, as she says, ' all of a heap.' Ita spine bends, 
aud its muscles are too weak to keep it erect. Its head seems to 
sink between its shoulders; its face is turned a little upward." 
Those indications of constitutional cachexia may be more 
or less distinctly develo]>ed in individual en^n, and may occupy 
a longer or t^lutrter siiacc of time. Hut soon the peculiar fea- 
ture of the disease begins to show itself, namely, a chanjrc in 
the condition of the bonea. Sometimes, wc are aasinred, that 
this change in the lioneft showfi itself itt the same time M-ith the 
constitutional symptoms above described, and sometimes even 
before their appearance. la eome cases, too, there is little or 
no couatitutionat sulfcring fn>m tho beginning to the end of 
the disease. These, however, are the exceptions to a rule and 
mode of progress which arc tolerably regular and constant Dr. 
Jenner cloaeifics tlio most striking anatomical lesions in rickets 



RICKETS. 



57 



Diiiier eeven hoade, of which &vo have reference to changes iu 
le hrnif^, and two to alterations in the sott ports. Thus, he 
ijTB we hare: 

1. Enlargement of the ends of the long bones, 

9. Sorteiiing of all the bones. 

3. Thickening of the flat bonee. 

4. Deformities which follow from mechanical causes acting 
on the softened, hones. 

5. Arrest of growlh of the bunee, ninscIeB, etc- 

6. Certain IcBions of the pericardium, lungs, and Bplcen, 
the direct oouacqneneo of the thoracic deformity. 

7. I..WB constant hnt hijjhlv-importnnt changes affecting 
the nutrition of the brain, epleen, liver, lymphatic glands, and 
other or^ran*. 

1. 7^ Enlargfimnt of the Etuii of t/i^ Lotig Bone*. — This 
Eooins to be one of the earlieist and most ili^tinctive feittures of 
thn dii=eaae. It is observed in nil the bones, bnt i& most striking 
in the wriat, the ankle, the elbow, the knee, and the articular ex- 
tremities of the ril». TIio chan}^ seems tn he one in which the 

tilapnona eobstance of the ends of the hone is developed tn 
tcCM, without, however, any increnso in the ossific action, so 
tbtt the end of tlie bfone grows lai^er than it fliould be at the 
given nge, while oeeltieation is retarded, and hence we have 
the joiiit-cnd of the bono not only eiibir^^t'd hut f'ol^cr than 
natural from the aliscnco of cah-apcoiis dfpnsit In the exHp^ierated 
cart ilagi nous tissue. The periostenm. ia also very considerably 
thiekcntHl over tliis cnlarfjetl end of the bone, thus adding 
Tenr' materially to the dt'fonnity which ia so characteristic of 
the early stages of riclceta. 

2. The Softening of all the Hones. — Thiftie the most peculiar 
most iut,i.TV:^tIug, and in many rei^pecta tlie nio^t important 

feature of riekets. It haa accordingly been very oarcfuUy 
stTidied by all the writers on thisi^uhject. It is pretty certainly 
ascertained that this sotlening of the bones depends iu most 
cases upon a want of a due proportion of earthy salts in their 
eompofiition. Thu.% as a general statament, it may lio Baid 
that, while in healthy bone wa have one part of organic, and 
two parts of inoi^anic matter, in rickety bone the proportion 
is exactly rcvereed, and we have, iu a given weight of bone, two 



98 DIBEABSS OF BONB. 

ports of organic, aimI oitly ono part of iiioi^nic constittiente. 
Besides this, however, there ia a rarefaction of the boue-tisaue 
which may or may uut coexist with the changes in its chemical 
compositiou. Ofthuse two cuuditiona of the bone, Kukitanaky 
Boys : " The texture of the bones is aflccted iii two waya, of 
which Boiiiettuies one preponderates, and sometimes the other. 
In tlie fln^t case, the bone h rarefied and incroH^ed in bize, ex- 
panded, in foet. A pale, ye]lowish-red jelly h effiiaed into ita 
enlarged canaU and celU, into the medullary cavity, and even 
under tlie periosteum. The bone itself is abundantly supplied 
with veseeU, and full of blood, and its color is, therefore, darker 
than natural, and red. Occasionally thin chango roachoe to 
Bucli a decree that the cells iif fipongy bunes, and tho6e in the 
interior of inedullary tubes, become exceasively dtstendEMlt andj 
aa their walls disappear, arc merged in latter cavities : medul- 
lary cavities at last become single, gpaciong chambent, and the 
bones uncommonly eoft and fragile. In the second case, in 
addition, it is deprived more ur teea of its mineral constituents; 
and fiuuiotiiues it is completely reduced to iu* eartiiuginou* ele- 
ment, and appears like a bone that has been steeped in acid. 
The bony cor])ugclcs are empty, and their rays havo disa|>- 
poan^il, and. when this iii the case, the lamellar structure is here 
and there obliterated ; at other part^ the laniellie ap|>ear. as it 
wore, to have fallen asonder, and the corpuscles are seen quite 
distinctly interposed between theui. It is iijx^n this condition 
that the softness, the flexibility, etc., of rickety bones depend. 
These two conditions exist together, as has been remarked, and 
eometimes one prejionderutes, and sumctimcti the other; it ia, 
however, remarkable that, in ea&OB of general rickets, the reduo- 
tion of u bone to its cnrtJIaginous elements so pre])oudenites in 
Bomc bones as to go on even to completion without any trace 
of rarefaction.'' Ue gives, alito, the following analysis of a 
scapula and a humerus afiected by rickets : 

Soapuln — spec^ilio gfa»Uy 0.013 

CartiloKo, veseeU, anil ffit 81.13 orgonio coaatllaeitta. 

BiUJil |ibo«pl]Kto of lime sntl of 

mAKncat* 16.00 \ 

Carbuiiute of Itmo £.01! »■ tf<.88 inorganio coiifltttouita. 

S«lt«, soluble In water OM \ 

"Hi* humerus oocituiut-d 10.54 per cent, vf fat. 



nCKBTS. 



SB 



This may bo compared witU an onitlir'sU wbicb be gives fur- 
tber on of a Rinipic indnralion o( the skull of a lunatic : 

Specifi« irrsTitjr 1.911 

CartiJa|» and resMls 8S.41 organic oonstita«fit«. 

BflBitl pUosphau of Ihne, oto 54.10 

C«rboD»t« of lime 10.4fi 

Fbospbato of mafinesia. 1.00 

Mta, solable in water 1.04 



6iM Inorganic ooD«tIta«nta. 



Or with tho following, taken from Carpenter, of the hcaltliy 
bone of a man twenty-five years of age : 

CartlU^ and fat 31.08 orguiio consUtaeot*. 

PhMpbnto of Ittne, etc S9.88 

CarboniiU of lime 7.38 

PliosFrbat« of iiiBtiD«**>ft 1.83 

Salta, aolnble in water 69 



68.B7 inorgonio contftltnenUL 



Besides theso changes in the chemical composition of bone, 
there is anotlier less distinctly noticeable, but perhaps not le^e 
important, wbich exists in tlie animal matter of tlie bone, 
whereby it ii »> altered that, on boiling, it doea not yield either 
chondrin or gelatin, as is the cume in Lealthy curtiliige and 
healthy bone. What precipe relatiuii Ibia uhunge niiiy have 
the sufloned condition of the hoiiu-subt>tau>ee has not yet been 
'clearly aseertAined. 

3. The ihiekening of the jtut hones of Uic cranium scorns to 
be another illustration of the irregular nutritive behavior of the 
jbone-snbstnnce in rickets. The thickening n associated with 
le other changes noted above, and ig sometimes very great. 
It is D»ual1y just at the growing margin of the bone, and least 
at the centres of ossification, obeying tlius the same general 
law by which the earliest and mogt marked changes in the long 
bones are found at their extremities, where growth is most 
active. 

In contrast with this excess of deposit, we hnvc. in some 

I, a« an early rachitical symptom, a deficiency of bony mat- 
ter in certain points of the cr.inial bones, which has been called 
craniotabes. This curious affection is most frequently seen in 
qnite young children, and affects the posterior parts of the cra- 
nium rather than the lateral or anterior. It consists of a defi- 



60 



DISEiBK OF BONE. 



ciency, probably from al>sorption, of the earllij constitueute of 
tbe bone, iii circumscribed, irrcj^ular, and eomctimes nuiueroua 
epot^ ; tliesc Juficieiit ^inU uut being fuuiid at the ns^ifyiug 
ed{^, but ratber in tlie central districtgof tbe bone wlicrc otiGi- 
lication has been longest complete. The following pa«» ia re- 
]>ortcd by Dr. A. Jaeobi, in the A'^uf York Medical Jmtmal 
for November, 18B3: "A clitid aged five months died after 
having snfl'ered from freq^uenl cnnvulftioiis dnring a fortnight 
preceding '\U death. Tbe convulsion was iiKoally annonneed 
by an attack of laryngitimuB gtridutus, but no other cerebral 
symptome were uianUe:<t. In otlier reepect^, it bad seemed to 
I>o a tiderahly healthy child, thougb. it presented the enlarged 
epiphyseal extremities of tlio long bones bu ulmrauteribtic uf 
rickets. 

"On examination after death, the dura mater was found 
tightly a<lhercnt in the situation of the lamlnloidal suture. The 
upper portion of the occipital bone and the lower portion of 
the parietal bones liavu beeu reraoved, and, on holding thom to 
the light, there are evidently a great many places in which 
there ia apparently no odscouB tiseuo whatever—especially is 
thiii the ease on (ho right side. I forgot to state that the occi- 
put i»f the child ap|Mjared atone portion to be flattened ; this 
condition can now be appreciated in the general configuration 
of the bone-j. The right parietal is evidently the one which is 
most affectetl; the left parietal bone bhowa a number of very 
difitinct, softened epots, in which there is no appearance of bony 
ttsAuc. Thp)ugh one spot, where I had previously removcil 
the pericranium, I wa< enabled to^jay to aeo a large tetter. 
There was softening of the cerebral Bub«tance, and there waa 
further some effusion in the anicltnoiil sac» wliicli, judging fr*>m 
tlio fivrnptoms, mnst have occurred during the last days of life. 
There wna a little effusion in the spinal canal, which would 
flow down into the cranium when the child was turned over." 
All the other organs were healthy. The periofitemii was very 
easily stripped otf the parietal bones. 

In the Amt^ican Journal of OhsUtruv, published in New 
York, in the number fur Noveinber, 1870, Dr. Jacob! has pub- 
lished a very full ami very able paper on tbe subject of eranio- 
tabee, and its relations to the other better-known rachitical 



I 



91 



cfaang(». Ho says tliat tlie jn-culiar cliangc wo are considering 
IB apt to commcnco at nUout Ilie age of three or four months, 
when the rachitical condition ol' tlie cranium can uauallv be 
appreciated bj the finger gently pressed upon the softened 
(pot«. Dr. Jucobi considerg that "the clinical cnu^e of the 
>redilectiou ot'rachiticai uUurptioii fyr the occipital portiou of 
the head tau&t be eonj^ht for iu Che recumbent posture ut' the 
infant. The wlinlo cranium ^*ls «>ftened, more or less; the 
Bide uit which the [laiiciit it; montty n-t^ting gets Hattencd, and 
the corresponding oblique diameter shortened, but absorption 
■will tiilce place at a number of spots which fulfil the following 
conditions: 

"L Hadiilical depobtts must have taken place very copi- 
ously. 

*^ 2. The weight of the brain most fall on the softened spot. 

" 3. The prcfifiure of the pillow mut^t form a (bird tactor. 

"Thus, in evcrr instance, one of the sides is tlattened — 
mostly the right— and the majority of the aoftened spots are 
found on that flattened right fiide.*' 

Dr. Jacob! considers the prognosis of craniotabea as no more 
nafavorablu than that of the other signs of the racUiticat dis- 
oase, provided there be no compliuation on the part of the brain 
or it« membranes. The liability to this complication gives 
a somewhat grave character to the prognosis. 

4. The importance attached to the snftenM condHion of the 
V&nt* in this disease is derived from the fact that this altered 
condition leads to deformitU'A ivo-m mechanical causes acting 
apon the skelet4in. and that these d(^formities become pcriua- 
neutly impressed upon the bone as the original disease disap- 
pears, thus leaving its life-long and inetlaceublc traces behind it ; 
traces whieh mark themselves as the causi>s of soinu of tlio most 
serious diseases and dangent to which the frame is liable. These 
changes have been very carefully studied, and occur most dis- 
tinctly and most commonly in the spine, in the thorax, in the 
pdvis, and in the long bones of the extremitiee. The spine 
presents an increase in its natorAl curvatures, and the change 
ia Uierefore usually contined to the antero-posterior directions. 
A lateral carve of the spine is somnlimes associated with other 
more marked aatero-posteriur curves, but, as a primary or a 




^ 



63 



DISBiSe OF BOKG. 




principal cbange, lateral cunature ia rare. Tlie cervical rer- 
telini! are so eofVeiied that tlieycan no Ii^iitrer &u[»[>ort tbo preat 
weight of the head, wliirli theroforo fiilU either liaekward or 
forward. Dr. Jenner explains itAfiillitig most coinmonly back- 
ward bv the de*)ire of the child to aee what is going on around 
it, which it can do more easily with the head thrown back than 
when it is allowed to fall forward on the etemuni. There ia 
aIm a curve developed in t&u dorsal and lumbar region, which, 
in the dor««l region particularly, is sometimeg extreme, and 
forms a very important element in the ncoom- 
paiiying deformity of the chest. The femur 
becomes curved outward and forward (Fig. 
8), tho tibia outward, and these curves be- 
come much increased as tho child hogina to 
walk. The radium and ulna are also Horae- 
what bent, according to the muscular actions 
they have l>cen subjected to, and are not nn- 
freqnently twistcil a* well as bent. The bu- 
\ Dicrus usually beods about the in^rtiun of 

»^^ the deltoid, and the clavicle, from trananilt^ 

^^jj f^ _ ting hII the tbrces which act upon (ho body, 
fBJjK^^ throngh the n])]icr extremity, is often bent 
^^^01^ at several pointy and at a very considerable 
i'M.&— {iM«iifl RHMpiui angle. 

The deformity of tho thorax is very marked, 
and cxercisefs no doubt, a great iiiflnence on the health of tho 
child, by the imperfect manner in which, both from its shape 
and ii3 BoftnesB, it performs its part, in tlic respiriitory acta. 
Dr. .Tenner believe* that this is a very important element in 
the mortality of rickety children, who may be attacked with 
any j>ubnonary inflammation ; the diineafie demanding increased 
play of a chest which cannot fully respond to the demand, and, 
therefore, cannot lend to the little sufferer that aid which tha 
increased expansion of the cavity brings to healthy cliildren 
Buffering in the same way. In regiinl to the change of shape. 
Dr. Jeimer says : " Tho back is flattened. The ribs ore bent 
at an acute angle, where the dorsal and lateral Tcgions unite. 
At thftt part, the lateral diameter of the thorax is tbo greatest. 
From it the ribs pass forward and inward to the point where 



09 



tTiey iinito with tlieir carlllagcs ; on tliat line the lateral diume- 
ter of the thorax is the len&t, the ciirtilageH curving; outward 
before turning in to unite thcrasclves to the Btemum. Tho 
fternom is thrown forward, and the antero-poeterior diameter 
of the thorax is abuonnally great. The conAequence of the 
direction of the ribs beinjf inward, and of the eartiluj^es out* 
ward, is that tlie thorax ii> grooved, from above downward, on 
itB antcro-Iateral face, from the first to the ninth or tenth rib ; 
the deepet^t part of tho fntrow Ixiing jnet oiitsido the nodes 
formed where the ribs and cnrtilages meet This groove ex- 
tends lower on the left than on tlie right side, bnt it is deeper 
on tlie fifth and rtijcth rih» on the right than on the left side; 
(he heart and liver respectively supporting, to liome extent, 
their corresjKinditig ribs. The poiut« of niaximmn recession 
correepoiid to the lifth, sixth, and seventh rib^. A little helow 
tlie level of the nipple the chest exparuU considerably, the 
chest*wallH being borne outward by the liver, stomach, and 
aplecn. If we examine the thoracic walls from tho inside, the 
appearanee ifl most remarlcablc : wlierc the rtbs join with the 
cartilages there are much greater projections than on tlie out- 
si<le; but the eleventh and tweltlhs nbti, whiclt are not intlexed, 
hav6 the same enlargement on the in&ide as on the outride." 
Add to these statements as to shape the fact tliat the b^mee are 
yielding from their softness, and add still further the fact that 
the muscles are weakened in their tone as well as their texture, 
and I think it is not difficult to understand how much below 
the normal standard of healthy children the respiratory power 
of rickety children falls, and how little it is suited to meet tho 
inurea«?d respiratnrj' neeessiliee of severe disease. 

The pelvis, in rickets, undergoes chnnges, not less marked, 
but perhaps less eonatant, in their effect upon tho shape of the 
•tractiirc. These consequences are due to the weight of the 
body being transmitted through the pelvis, and received upon 
the heads of the femora, and as this weight is very varyiug in 
ita action, according afr the diild walks, or creeps, or sits, or 
lies, or us either of thes.e motions pa'pouderates over the others, so 
it most necessarily be with the resulting deformity, it showing 
the effects of pressure in that direction in which the pressure 
i& most frequently and most forcibly made, and varying there- 



DISEASES OF BOKB. 



fore with the hnbitua] muscular actione, as well as ^-ith the 
habitual atlitndcfi and po^Itiung ho t-cruU tu Aiwiiinu. llic in- 
tert>fit altHC lie to these changes in the rickety pelvis dtpcudd 
mainly npon the effect of the resiihinp deforiuity, in so eliang> 
iiij^ the iiizc and form of the outlets tlmt the proeesa of par- 
tnrition, in after-life, may l>econie difficult or imposisible. It 
is mostly to these changes that are due those dreadful caeea 
in which the obstetric prautitioiier u utilised to rc&ort to hiB 
motit fearful, and, unlortutjately, uiut^t doubtful cxi>cdientM, to 
tenninate a process, wbich ig only impeded by the mechantcal 
Uisproportioii between the head of the child and the openinge 
it inust travonw. These terrilile deformities arc produced 
mainly by rickets, bnt M>metimea also by the die«Me of the 
boned known as malacosteon, a disonee which ha« this in com* 
inon with rickets, that in it the textunj of the bone h softened, 
and yields to pre8t!.ure. This pressure is considered to act dif- 
ferently on the pelvis in theae two diseases, bo tlmt it Is^ tluiught 
that the dcii:<ruiity 4if tUo pelvis prtiduced by rickets and that 
by malawtetcon differ so iriucli that, by mere inspection of the 
hones, the diaeases can generally be distinguiiihcd from one 
ftiiothcr. In general terms, the difference can be exprewed by 
stating that, in rickets, the pressui-e acts from before backward, 
BO that the promontory of the sacrum approaches the pubis, 
thereby narrowing the Bnteri>-|io»terior diameter of the outlet, 
while the transverse diameters are incrpiieeU; while in mala^ 
costcon it Bccms tliat the pre&snrc of tho femora, on each side, 
tends to thrusting in of the sides of the pelvis, so that the lateral 
diameters are diminished, while the antero-poeterior are length- 
ened, giving tho outlet what Dr. Tyler Smith call* a rostrated 
fonn. Besides these two modes of deformity there is a third, 
more rare than either, in which the pehds is oblicjucly distorted, 
the pubis being thrust citlicr to one side or tho other of the 
median line, so tlial the pelvis has a twisted appearance, and 
the lines of the outlet dtHer on the two sides, according as tho 
pelvis is pushed to one side or the other of the promontory of 
the sacrum. Of this oblique distortion, NaegoK- was the first 
to give a doscriptioTi, in a special memoir which lie published 
on this subject, in which he details, most accurately and care- 
fully, the feutm-es presented by tliirty-eoven obllqueiy-distorted 



EICEETS. 



W 



peW«s, wlijcli lie had tlio opportunity to study. Writew do 
not scC'iii !o ajrrt'e tlmt tliis peculiar detbrmity w ever tlio Rolo 
pcbult of rii^keis, or of malacoateon. NiuJ^el6 belicvL-a tlmt it 
in an original failure in tlio process of dovclopineiit, and he 
gives many reajioiis fur l)i« belief. Of the prui»er rickety pel- 
vis. Dr. Tyler Smith says: '* The sacrum, in such ease*, ia 
plueeil more horizontally than natural ; the promontory pro- 
jects forwarfl, and sinks, aa it were, into the cavity of the pel- 
TiK, BO a& to bring the fourth or tiftU lumbar vertel»ra into the 
position naturally occupied by itself. Thotiacruui ii3 Miuewhat 
diminiehod in depth, tliough not eo luueh bu ha in the ease of 
malacosteoii distortion; its vertical and lateral curvaturea are 
both diminidhui), and the bone Is consequently very much flat- 
tened. The apex of the sacrum and the coccyx are bent acutely 
forward and inward. The wlnjrs of the iliac bones are some- 
what flattened, and everted, and carried budily forward toward 
the anterior part of the pelvis. The Rvniphytis pubiij is some- 
times projected inward, t>o as to <;ive the inlet of the pelvis an 
hour-gtosg Hhape. The tiibcroBities of the iitchia arc separated, 
90 as to increase both tlic transverse diameter of the outlet and 
the width of the sub-pubic arch." 

5. It is only, however, when we add to these statement* 
the fact tliat arreH of growth always accompanies the dis- 
tortions of rickets, in a ^'oatcr or less do<;rco, that wo can 
_ibnn a proper idea of the actual change produced by the 
and the amount of impcilinmnt which the two eon- 
ditionft combined may produce to the passa{;c of the ffctat 
head through the outlets. On this point, Dr. Alexander Sliaw, 
in Ilia admirable cssayft on rickets, in the Me^lico-CMruiffical 
J'ran^actiom^ vol. xxvi., saya, in a foot-note: "To aseortaiu 
the average amount of this detieiency, and tlius jud^ of the 
sliare which the coueequeiit emallness of Ihe pelvis has in im- 
pedia<! the pa»aago of the child in pai-turition, and causing 
difficult labor, I took tiie mcaaurementi of tweiity-nine de- 
formed pelves, from patients of the female r^ex, am] compared 
them with those of the natural female pelvis. The result was, 
that the deformed pelves fell short of their normal dimensions 
by nearlv one-quarter of their proj'er size. So tlmt, in women 
distorted from ricketfi, two distinct cbu&»j give n&e to dillicult 



«6 



DISEASES or nONSL 



labor : First, tlio distorted condition of tlio pelvis, coii.a«qnent 
on tlie softened state of the bones, and the compression t» 
which thay hn.ve been sulijected. SecuudI/, the general stnall- 
netis of the houee dupuudiug on tho pelvis hiiving^ h3«n origi- 
nally, at childhood, of reumrkabljr diminutive bizc, and oa its 
growth having Iwen interrupted hy tlie attank of rickoia." 

The changes which riekotij priKluees on the shape of the 
head have been particularly studied by Mr. Shaw; and ths 
reeulta of his numerous obt««rvation« lead him to Eieveral inter- 
esting conclusions: Fir^l, that the size of the whole head in 
rickety persons h below the etandnrd diincnaious. Secondly, 
that tlie degree «if dofii^ieiicy iw greator in the fsiCR than in tho 
crunium ; and that therefore, thirdly, the apparent great size ^j 
of the hciid in these ^lersons is duo, not to the actual size of tha^f 
cranium, hut to its disproportion to the size nf the face. Tlie ^n 
mode in winch this disproportion in prodnced seems to be by a 
failare on the part of the rickety skcIetoD to obey that Uw of 
development which Mr. Siiaw, in liis most ingenious [mpers^ 
has tihown to be a universal one in tUe heoltliy itiflividniU. JIq 
shows, very clearly, that the bead and up;)er part of the body 
are, in the foRtus, devctoped much in advance of the pelvis and 
lower extremities, and this, for obvious reasons connected with 
the well-being of the foetus and of the young infant, and that 
from the time of hirtli this unequal development of the upper 
over the lower parts of the body is graduully disappearing by 
the iiicrea«Ki rapidity of growtii of tho lower half. In rickets, 
he is satisfied tliat this aocelerated rate of development of the 
lower parts of tho btKiy is checked, and upon tlits theory he 
explains the cliaiigcs which rickets impresses upon the skeletoo. 
It retains its infantile proportions rather than those of adult 
age, and tliis he proves to be a fact by niimeroua and very 
careful measurement statistics. The same law, which he shows 
to gnide the development of the whole body, governs also the 
devetopuient of head and face. The cranium uf the ftetus boars 
a much larger proitortion to the tUce than dues that of tlia 
adult. Ill rickets, this disproportion more or less remains, and 
the face does not gain on tho cranium as, in tho healthy indi- 
vidual, it should (Jo, and therefore^, as all (lie parts grow to- 
getlier toward adult eize, the face is, like the lower extremities. 



BICEBn. 



67 



¥ 



left behind in the progresa of development, and the adult pre- 
sents some of tlio featurofl of iufaiilile proportion, while, per- 
haps, the wholo frame may liavo attained a fair avera<^e ^izc. 
Id speaking of this eti'ect of rickets. Mr. Sbaw Bays: "Besides 
causin}; a general Binallness of the head, it will occasion a dis- 
proporiiun heiwecn the portA of which it conaiflts. Ab the two 
divisions, the face and the cranium, grow respectively at ditt'er- 
ent rates of activity, it must follow that, when the vliolc pro- 
cess is interniptfd for a certain time, the **toppage will have a 
Qtor^ decided vtlect upon the one than njioti the other ; upon 
tha division which j^ows at a rapid rate than upon that which 
grows at a more moderate rate. Ilencc. a^ it i& tlio face which 
is develujHKl in the most active nianiier, nnd tijt- cranium which 
iQcreflses at a slow rate, we may expect to find that there will 
be a very considerable defect in the bizc of the face, nntl only a 
trifling defect in that of the cranium. In other wordu, in per- 
sons whoee growth has been intemipterl by rickets the face will 
appear extraordinarily diniinntive, while ihe cranium will re- 
taiu about its natural dinien8i*on&." Tlie effect of these changes 
is, ae a general nile, to give, not only thu api^earatice of undue 
size to the head, but, from the Rmnlhie.ss of the face, the fore- 
head appears broad and t^tjuarc, and often eo prominent that 
the facial angle is very conspicuously increased. This promi- 
nence of the forehead, when associated with the precocity in 
the mental faculties, so common a charactcrifetic of rickety chil- 
dren, gives the impression of a finely-dei'eloped head, and, cim- 
Kqueutly, of great intellectual promise. Too much stre&s will 
not be laid upon these delusive appearances, when it is remem- 
bered that the actual development uf the liead is beluw the 
normal standard, and that precocity is apt to show itself in 
ncrvou?, excitable, delicate children, from whatever cause this 
bodily state may arise. One curious rcanlt of Mr. Shaw'a oarc- 
fol meosarementa relates to the size of the orbital cavities. 
These be found unvarying in tlieir dimensions, whatever might 
,be tlie size uf the skull. In speaking of a table, in which he 
ives nimierous measurements of their size, he says : *' If this 
list Iwi examined, by running the eye along the line of figures 
which shows the measurements of the orbits, it will be per- 
ceived that there is scarcely an appreciable difi'erence between 



6S 



DISEASES OF BOX£. 



tlie dimensions of these part* in an^- of tlie ekulla. 'Wbether 
wo tako the rickety bkulU. tliu^i: of Maoflnrc) gizc, or the &ku11 
of the giant, tlie diantctere ut' the orbits measure the samo in 
aJl. Aa they are nut beUiw the Btandanl diinenKiona in the 
rickety ftpecimcn*, $o tbey are not above them in the giant." 

Fig. 9 is a dmwinfj of a specimen, recently de]»ufiitud by 
Prof. IIumpLry in tlie Anatomical Museum ot" llie University 
uf Caiubridgt), and gives a good idea of uost of the cbauged 



^I 



7ia.». 



prodnccd in tlie vflrions parts of tlie skeleton by this disease. 
Prof, llumpliry publishes a full aoeonnt of this case in the 
Jburnai of Anatomy and J*hi//iiolwff/. for Xoventber, 1B67. 
In this connection, it ia proper to notice the effects produced 



RICKETS. 



ty rickets on the process of dentition. All the nctions cod- 
iiL'ccod with thid proceed seem to be imperfectly accomplished. 
T!ie evolution of tlie teeth begins lat*.', it is shiw in heiiig com- 
pleted, and the Ufeuf the teeth iisapt to terminate e&rlj, either 
by their falling out, or by a rapid ly-des true tivc carles. Those 
Bifects 9eem to be produced by tlie coiistitiitionAl weakneea, 
which elaborates, slowly and imperfectly, the complex phase* 
>f dentition, but perhai^^ also, in a very great degree, they are 
letenutDed by tlie want of proportion between the teeth and 
the jaw in whicli tbey grow. The teeth have their normal 
size, the jaw has not, and that gradonl change by which, in a 
healthy individual, the relative proportion between the teeth 
and the jaw is constantly being maintflin*>d is, in the riclcety, 
materially checked, 1*0 that, a* the teeth pnah forward to the 
surface, room is not afforded them, by the proper expansion of 
ibe jaw-bones, for their emergence in the regiiUr and orderly 
manner on which go miiL-li of their nsefulness dcpendt«. Hence, 
we have the teeth crowded, irregular, and imperfect, appearing 
above the jaw late and slowly, giving rii^c to many painful and 
sometimes aertons Bympt^ras, arising from the mecJianical ob* 
Btmctions against whiL-h they have to contend, and doing poor 
and painful service while they last, to be lost early, either from 
decay or from want of a well-developed alveohLrbase, on which 
they might be maintained. 

"We have now remaining two clafutea of anatomical legions 
oharacteristie of rickets, which show themselves, not in the 
bones, but in the saVt, parts. These are — 

6. Qtrtain Lseiona of the Lungs, Pf.ricardium, and Sp/^n, 
iJi^i Direct Con-ifquetn^ of tha Thoracic Deformity. — Of the 
Inngs, we have two conditions which are ahni»rinat, viz. : 1. Em- 
physema. 2. Ckillap&e. These two conditions of the hing-snb* 
fttancc are both of them evidently due to the unequal pressure 
exerte<) on the liitigg by the deformity of the thorax, and by 
the imperfect action of such a thorax, in accommodating iC^eir 
to the varied neceasitios of respiration. Of the emphysema, 
Dr. Jcnner says it is " that variety which has been termed in- 
Bufflati'in. It is mere over-disteniion with air of the veftieular 
tissue of the lung. Tt invariably occupies the same situation 
in the lungs of the rickety child, viz.^ the whole length of the 



70 



PISEASra OF BONB. 



anterior l)or<ler of both lung?, extendiiij; backward for n 
tlii*ee-quarters of an inch Jrotn the free margins. The emphj- 
Keuiatuus porliuii U eeparutod from the healthy part of Lbe lung 
by a j^ruove funned by ct'lIap&eO lung. The groove of ool* 
lap&ed li&sae correapoads to tliose projections of the ribs inward 
which arc eituatod at the points whcro thoy iiuitc with their 
cartilage!!." The ooDapee ia soinetirnctt cotitined to thiit border 
or groove above noticed, bnt it is extremely common to find 
lai^c portions of the posterior and inferior parts of the 
lungs ia a state of collapse, which sometinira extunds to tlio 
superior Iobe«. Thug it U a pathological tkct of much impor- 
tance that, in rickety children, not only do ve havo imperfect 
formation^ and diiuiDished power of action on the part of the 
thorax, but we have an iinperfoct condition, more or less ex- 
tensively per^'ading the luiig>Bubstauce it^If, a fact which lias 
much signiticancc when, through atreas of disease, unusual de- 
mands are nmde upon both thorax and lung, to meet the re- 
quirements of increased aeraliun, which the affectiyo uf the 
lnng8 imperiously calls for. Besides these anatomical lesions 
oftlio lung>>, authors notice certain white gpots or patchctt on 
the surface of the pericardium, and on the surface of the spleen, 
which would went to have excited more attention than their 
importance entitles them to. They correspond with (he points 
where the pressure of the deformed thorax is most constantly 
felt by the organs affected, and are doubtless produced by ihecon- 
stanl attrition of the projecting bone against their serous surface. 

7. Importfltit Changes a^'ecting tfi4 Nutrition of the Brain^ 
Sj)leen, Liver, Lymphatic Qlaivd^, and some other Organs. — 
These eliauj;es occur gradually, and witliout any signsof inflam- 
mation, and are thccvidont expresRLon of aeonstitutional cachexia 
which they in their turn tend very malerially to aggravate. 

Thetr most common seat is in the lymphatic glands, which 
are apt to bo extensively, often universally, diseased, and with 
them the spleen is almost certain to be mure or le--s implicated. 
The other orpanB enumerate*! are less frequently the seat of 
this peculiar change. The pathological stiite seems to be on« 
in which an inCiltmtion of what Dr. Jenner calls an albuminoid 
exudation, througlmut Ihe substance of the organ, elowly takes 
place, much aflcr the manner of infiltrated tubercle, which so 



RICEBTS. 



n 



thnronjrlilT incorporates itsicKwilli thcsii!)Rtanco s»f the affected 
tiisuo that U& orif;innl texture is entirely lost, it ftssiunes a fatty 
ur waxj api>earunce, aod loses, more or Igba completely, its 
foDctiorial puwer. After Btatiug tliat the lymjjlmtio glands 
ibua attected are cun&iderablr enlar^jed, Dr. Jcnner tbiia dc- 
ecribes their appcanincfe : "' The cut surface of the glands is 
feiufratarly pale and iranspareiit, oonqiact, smooth, tulerably 
tni>i.-^t, and, to the unaideil eye, uniform in appearance. The 
snb^tancc is tough, and the gland heavy in proportion to its 
ftize. In rare cases, instead of being pale, the glands may be 
purplish in color." Of the spleen he says: "It u increased in 
atze: the increase may l>c either triQing or extreme. Tims I 
have Micn it little larger thati in health, and I have Eccn it 
measure att miuOi as eight iiiclie^* fruin alwve downward over 
it8 convex eurlace, and four inches from side to side. It U 
noTcr adherent to the parts adjacent, aa a spleen containing 
lulwrt-les fifVcn i», and its capsule generally U scarcely, if at all, 
lhi«,-ken<-d. Its anterii^r border 19 pretty shai-p ; it 'i» firm to 
the tomdi, and smooth on the surface ; ita weight, regard being 
bad to iU i;>ize, strikes one an cun>>iderable. The t^ubsftance is 
too^h but elastic, and the thinueet sections can be cat with 
fociiity. The cut sDrfaec is remarkably smooth and transparent 
It ia n<it unlike what one might suppose would he ita appear- 
ance if the whole organ were infiltrated with glue. Only a 
little pale blood can be expressed from the cnt surface. TTsually, 
the organ is pale rod, but occasionally it is dark i>ui-jple. The 
more tnuitipareot any given part i^ the paler it i«; the most 
trantipnretit parts are almost eolorle!>s. Tlie splenic corpuscles 
•re 8«mjetiiues more readily seen than in a healthy Bpleen; they 
may be mistaken for gray tubercles. I have never seen in the 
spleen of rickety children the sago-liko little nuissefl, so often 
present in the spleens of those who die of pliibii^iK." 

With this anatomical change in tliesu orgrttifi, and veir 
much in proportion to its extent, we have the constitutional 
cachexia becoming more marked and more diatinetly progre*- 
sive. Em.^ciatiyn is sometimes extreme, mnsftular power grows 
gradually letus and Icbs, the derangements of digestion become 
more and more constant, and the little patient either wastes 
gradually away, or succmubb to the attack of bronchial or in- 



DISEASES OF B0:;E. 



lesiiniil inflanimatiftn, whose effects hh weakened organization 
is itot ubie to cuiiteml willi. Dr, Jcnticr thinks that tlic Uiofit 
common cftiiae of death in rickcte in nciilu bronehitifl, and 
explains ira fatality by the iniperfet-t action of the soft and 
yieldinir walU of ihft thorax. He also saya what seema very 
astonishing, that to rickets ia due, in Ix^ndon, directly or indi- 
rectly, a larger percentage of infantile mortality than can be 
credited to any other single disease. 

With regard to tUecaiLses of rickets, nothing very positive 
ha* been a-seortnined. It is very certain that it prcva-iU prin- 
cipally amoTi^ the poor, thongh it is sometimes seen in the 
children of the rich. It* ]irevalence is certainly favored by 
bad hygienic surroundings, but the same may be said of every 
diatlietic disease ; au<l why these unfavorable conditions should 
produce in one region rickets, and in another ?crofnia, as a, 
prcpiinditrating discano among the infantile population, di>cs 
not !toein cleiir. It has been pretty flistinctly shown that it \b 
not Iieroditary, and yet, when one eliild in a family has the 
diftcaas, those born afterward are extremely apt to show traces 
of it. Dr. Jenner thinks that the state of health of the mother 
has miicli to do with the ocenrretice of rickets in the children ; 
if she be feeble, delicate, ill nourished, atid ill cared tor, she 
will be muL'h more likely to have rickett; in her children than 
if she were 3tr()ni' and robust in licrown health. Phthisis and 
rickott have no neceswary connection. Statistics show that 
phthisical parents are no more liable to hare rickety offspring 
than thoie who are nut phthisical ; and it appears that scnjfula, 
the twin-sifter of tuberculoi^is, 'a not by any means commonly 
aasociatcil with rickets in the same individual. Bad food, had 
air, bad clotliln;^, bad habits of life, and expo.inre — in short, all 
those eircutnstancos which are generally combined in the 
raiserahle, crowded, filthy habitations of the poor, and which 
BO manifestly affect the general mortality of the districts where 
these haliit»tion3 are crowded together — all these have an un- 
doubted influence in producing the disease ; and this is more 
pruL'tlcally interesting because it is in this direction that we 
muKt look for our principal means of controlling and curing it. 
In, fact, the treatment of rickets, aa such, is entirely unsatisfac- 
tory; and the very natural Idea, that, by supplying an excess 



RICKETS. 



73 



Ihy matter to (lie stonuioli, we should cure a disease clmr- 
SCfCTuscil mainly l>y its deticieiiuy, hm not ^iroved in prat-tico 
to be wfU founded. Not only is (here no specific for rii^lcets, 
bat there is no 9|Jecific twatment. Every caee must be studied 
by itself, and maaiiircd on the jjeneral principles of constitu- 
tional treatuient. TUe tirst cares are liy^iunic. Improve as t'ai 
be the homo and the bnhits; and, uf the.'^e, none are so 
rinj»6rtant as the hnbits with regard to footl. The cliildren of 
the poor ftro always fixl improperly. E!ven with tlitiAc who are 
iuduftrioas and llmTing, and who, tlierefure, have the means 
of Bupplyinj? a Rufficiency of good food to their families, we 
consttiUtly liud tlie younger children, partic-iilarly the infants 
of from one to two years of age, fed ou food too stimnlating 
for their stomachs. There eeema to be in the minds of these 
people a kind of pride in seeing their babies eittin<; at the 
table' with tlicm, and, even belbi-e they are weaned, pitrtnking 
of the strong food which miikea their parents' ordinary faro. 
It re<ju>refl gome time, much cai-e, and sorae trouble, to prepare 
the milk'food which should be the principal fond of every 
child under Two years of age. From these two com^ideraticrus 
arises the hnbit, almost univcreal, of givini>; the children wdiat- 
crer they like to eat, and rather letting them feed them.-elve«, 
than taking any paind to ])rovide or prepare for them fund such 
aa shall be sniiahle for the digestive power of their tender 
etoniachs. Tliis is imdoabtedly a common causo of disease 
among the poor. The strong bear it, while the feeble die 
under it. In rickets there is so marked a tendency lo de- 
rangement of the digestive org!in)>, that it would seem thiit the 
regulation of the food was a point of even more than ngnal 
iiDportaiiee, and its proper quantity and quality a prttiic sub- 
ject for the watchfuhioas of the physician. After the care of 
th© food comM that of the air, the exercise, the clothing, the 
cleanlincM, and the Inmdrcd other things which go toward the 
making of goo<l blood and strong muitcle. In the regulation 
of many of these points much can ho done, for it must be 
remoml»cred that a large proportion of the errors committed 
in the«c respects arise mneh more from ignorance and Inattcn- 
ti'in than from aotnal poverty. 

Iti regard to medication, the main indication is to improve 



DISEASES OF BOKE. 

nutrition. Tonics, fucIl as iron, nud cod-liver oil, arc uioet 
comiiioaly useftil, und spoliativo and dcprcs&tng treattnent, 
gucb as ig UBually called tho antj|ihlopt^tic, U badly Ixirne. 
PartieiiliLT cautioti h required in managing the acute ntlectione, 
wliicli po frequently eupervene in the course of rickets, that 
too much reduction of the powers of life he not produced by 
the very remedies we use to save it Mercury and hloodlet- 
ting are both reprcibated a« dangerous by the best aulhoritiea, 
aud the cure of thu practitioner sbotilil bo to accunipliiih his 
ends with the uiildest nieaua oom])HtiblB with sucueeH. Each 
ease and each uninplieation niiist be judged by iu<clf, anil 
treatoii both hygieiiicully niid mc<lic:tnully, according to it« own 
indications; bnt, iti all, the one main fact must l>e conatntttly 
kept in view, that we are dealing with a diathetic ditioiiiie, and 
one wliotie tendencie** are all towaid a feeble reaction, and a 
diniiuiohed reparative power. 



Cn AFTER VII. 

uoLtrrras oBRnn* — malaoosteos. 

A ccttTAiN numhoT of eases present themselves in the adult, 
in whicli a Aot>ening of the boneA takot place somewhat like the 
•oftoning of rickets, bat in which the accompanying featurea 
do not wiin-ant us in placing the disorder in that class. These 
case^ are quite rare, and are scattered over the records aK indi* 
vidual cases by single obaervera, few writers having lind an 
oppitrtiiiilty of obsorving any number of tliem, and none, lUero- 
fore, liaviag had that Ifiiid of exphtienM wliicth can only arise 
from a comparison of many examples of a given diseaae. From 
these recorded case* the general history of the diseaae mny be 
gleaned, and yet, S" connidrrahlft arc the diversities of ciiarao- 
ter among (he individual cases, that it is ditHcuU to present a 
clear piuliire of the afiet-lion, such as can be recognized by ita 
own charactenelic^ and diiitinguihhed eafiily trow other disor- 
ders to which it is closely related. 

The cascB thus far oh&erved have occurred in youug or 



HOUrriES OSSIUM-VALACOSTBON. 



* 



in!d<Ile-age«1 ftdult% a littlo more frequently fimong females 
thao atiiuQg malud, uuU so often in cuunectiou wUli the puer- 
|>eral 6taio as to varrant tKe opinion that tliis state U at Least 
■ Atrong prodi»|Mwing cause of the disease. In a few inetanccs 
jc had seemeii to he tninsiniited fmin parc^nt to chiU. ^'itb 
these exeeprions TcrjT little is known of the came of the dis- 
eaao. 

The changea that take place in the 1>on6 eeem to rary con- 
ftiderablv, hutU in their nature and in their extent, ia di6ereut 
owes. In all, however, a ^i-ailtial {litiiiiiulion, and in some an 
entire diitappearanee of tlie uarrhy aaltsof the Uono. takes place ; 
ft chanj^e ujjod which, of eonrsc, the main features of the dis- 
MAe depend. TIua chnnge takeit ])]nce gradually, and invades 
more or lew completely all the hones of the skeleton. In &ome 
cases tbiji l<>«d of the earthv oon^tituenta seema to be ahno6t 
the outy chanp^ which t»kes place, the remaining animal auh- 
stance not having underj^ne any very marked alteration. In 
oilier, and much the larger niimhcr of inatancf^, marked do- 
goueration of all the cum)K>nunt elements of the hunc-titu^iie ia 
found. Thu!* the original strueturcs arc often replaced by fat 
or tree oil, and this 'n so common a fejitiirc that Mr. Paget is 
inclined to regard the affeeliun as ea^entiidly a fatty degeuera- 
tiou. -This fatty uliauge involves the wliole bi^ny biibstance, 
and, when exce&sive, converts the bono into a bag of soft, oily 
sultritance, enclosed in the pcrio^itenm. wlileh itself may not he 
materially altered from the healthy condition. That it is not 
ft fftltv degeneration in all casc^*, however, is shown by certain 
exaniple)» where the replacing material is of a gelatinous nature 
aoii presents few or do traces of fat, anU certain others where 
the amount of fat in the bone does not vary from it^ normal 
prij|)tirtii>n. The change in the bone someiiiiin^ iiividve.s the 
oompact and the cancellous atructiires eipinlly in its progress, 
and when this U the case there is a gradual diminntion of the 
finnnoaft of its texture, which permits it to bend inatead of sits- 
tiiining mechanical force. This flexile condition of bone ift 
sometimes found to the mfrst marvellous degree, and lu all the 
boDe« uf the skeleton, and it seems tu depend fur its produu- 
tion upon the evenness of the process in all parts of the bono 
at once. Sometimes, however, it happens that the central can- 



it 



DISEASES OP BOyB. 



cetlons portions are far ad^Hiic^d in the degeneratire cliaiiges, 
while the external compact uliell, yielding more slowljc, is onljr 
thinned and weakened, but not yet disorxanized. lii thiis con- 
dition tho bone doea not bend so readily as it breaks, and we 
have produced flometimoa one and sometimes many fractures, 
arising from so slight a Ibree as almust to eccm spontatioooa. 

Tlie microscopic study of tho altered bone shows ao tctt 
different ai>peaninces in different cases that it can hardly be 
mid that any thing distinctive haa Xteen d{;gcovered which char< 
acterizes osteomalada as contrasted with rickets. Still the 
general featureB of this di9ea3e, as displiived liy the niicrawiope, 
are not the aamc as tliosc of rirkols. FoUin says: "The altcr- 
arions in this case are very diflen^nt from those which are es- 
tablished as belonging to the rickets of children. Thus, in the 
osseouK layers of recent formatioi), wo find an alteratioti in the 
bone-corpuscles, which have become elongated, fusiform, and 
without regular borders, and have taken on the character of 
the eloinents of iibrous tiiwiie. More deeply we obsorvo bone- 
cells which have become irrugnlar, enlarged, with sliiiiiiig out- 
lino, and with a disappearance of their canaticnii; they eon- 
tain sometimes small drfips of oil, and gometimeii granulations 
gruuped together. The I'uudarueulal »abi)lauee of Uie bone 
prei^euts an infiltration of fatty granulations, which impairs its 
transparency and gradually invades the surrounding parts. Tho 
Haversian canals are also infiltrated. Tims, when wc examine 
by the microscope a section of one of these ITaveraian canals, 
we see in the centre a darkiKh [>art formed by a mass of blood* 
globules, and around this mass a cavity with distinct bordora, 
tilled with little drops of oil, with fatty gmnulatunis, and with 
niarrow-eells in process of forrnatidn. In the medullary tissue 
we find hypcrtrij])liy of the marrow-cells and an increase in 
their number, as is also the case with the fatty cells." Mr, 
D.ilryniple, in a case which he examined, found some peculiar 
caudate cclU, which induced him to regar<1 the disease as ma- 
lignant in its essential clmraclers, and other observers have 
given accounts varying in many points from those given alKjve. 
It would seem, therefore, that the microscopical appearances 
vary with the other peenjiarities of each case, and that tlms far 
no features can be said to be absolntely characteristic. 



M0LUT1E3 OSSITM— MALaCOSTEON. 



11 



Tlie v^-iuptotiiaof tins disease seem to bv more uoilbna tliaa 
the i>uthological a[ipcaraiices. la tlic earlier Bta^cit, tlio ])a- 
liciitd couiplaiii of vague, wandering pains, at firet not 
ceTerCt increased very nniol) by exercise, and accompanied bj 
a diitreesing seuae of weariuesB, which is but little relieved bj 
rc6t. Tlicse pains aro sometimes periodical, and ot^eii acconi- 
jMUiied, particularly after exercise, with severe crampe. Writers 
speak also of a tenderness and eoreness to the touch which 
much a^^avatee tlie siifleringvt of ihu {>atic]kt. As thcee symp- 
toms advance, the goneral state of the patient deteriorates. 
He becomes feeble, emaciates, and bc^ne to have irrejrnlar 
fever, followed by very copious and exIiauRting ftweat.i. The 
digestive power begins to fail, a change very much baetened 
by the condition of the teeth, which soon become so looee in 
their Bockcto, from the softening of the alveolar pro(.■e6l^es, that 
tliey either drop out, or give intinilc inconvenience and dia- 
comfort in the attempt to masticate. Of coiiree, when the 
softening of the thorax lias reached an extreme degree, the 
function of respiration must be imperfectly pertbrnied, and an- 
otlier serious enibarraesment is added to the load already preea- 
iog so heavily on the powere of life. The teriiiiuutiou of much 
the largest Dumber of cases ii fatal, after a longer or Kborter 
coarae of enflering; but a ceilain number of recoveries arc re- 
ported by various authors, nod in particulor NaiJgcM cites a 
case in which the Cawarean section v:&^ pcrfnrnied on a woman 
vbose pelvis was so deformed by an attack of osteoiiialacia 
that natural delivery was impossible. Other recoveries are alao 
Spoken of, in which the deformities produced by the softened 
state of the bone remained, permanently imprcitscd upon them. 

Dnririg the course of this dii^eai^e, tlie most Airiking symptoms 
are due to the mechanical results of the yielding of the soft- 
ened booe«. The lower extremities are bent and twisted in tho 
most remarkable manner, and. after the patients are bedrid, 
the upper extremitie*, u]ioti which tlicy now have to depend 
for muvetnents of all kinds, begin aUo to be dit^torted. Tlie 
erantal vault sometimes undergoes a change, being cither flat- 
tened bv compression, or rounded by flic weight of the bniin ; 
bat these changes are pronounced to be rery rare. The spine 
u deformed mainly by an iucrease of its natural curves, and 



IB 



DISSASES or COKE. 



tlie changea in Uie thorax are dac mainly to the position at the 
patient in the bed. If 1ih lio constantly on his I)ark, the an- 
tero- posterior diatneterd are diniiiiislicd. and the chest -oarity 
b«comca broader laterally and shallower from before back vard. 
If, on the other hand, he lie habitnnlly on h\» side, tltc change 
in the form of the chest becomes marked by an antero-po6te- 
rior increase, aud a lateral diminution in diameters, together 
with such othur deformity as the twisted position of the epine 
may impress upon it. In tliu i»elvie, these dianpea are very 
marked, and have been particularly studied. We have al- 
ready seen how the form of the pelvis ia affected by riekcts. 
In innlacosteon, the deformity presents features so different 
that vriters contend that the disease can be distingni^hed by 
the defonnity ; ricketa exercising its effects mainly by a diiat* 
nutioa of the untero-posterior diainetere, while osteomalaoiA 
usually proijiioca a cuntrnction of the pelvic circlefi tn a lateral 
direction. Thiti distinction, however, is not to be relied on too 
implicitly, for several antliors epeak of cases in which riclceis 
produced a lateral defomiitT precisely similar to that ordiuarilv 
resulting from osteomalacia. The general fact, however, r^ 
mains, that in malacosteon the deformity is pro<luced by the 
yielding of the sides of the pelvis. Dr. Tyler Suiilh thus sums 
up these changes: "The general effects prudnced in malaooft' 
teon are: narrowing of all the dJainpters of the pelvis, but e»* 
pccially of the transverse, whether of the brim, cavity, (.r ont- 
let. Tlie an tero posterior diameter of the brim, or rather, the 
distance from the promontory of the sacrnm to the symphysis 
pubis, is, relatively to the transverse diameter, very much in- 
creased; absolutely it is somewhat less than natural. The 
pubic arch is very much narrowed; thetubero^iticsof the ischia 
are approximated ; tbo sacrum is very mnnli incnrvated, and 
the acetabula aro much chiscr together than in the normal pel- 
Tia ; the ilia, instead of being carried bodily forward, as in the 
rickety pelvis, are folded up, and the iliac fossa is made to re- 
semble an obh'qiie furrow, running frum above downivard." 
Br. Matthews Duncan, in a paper published in the Edit^mrgh 
KoidKlif Journal for A[ir!l, 185.>, lias very carefully compurcd 
these deformities with one another, and gives a scricit of in- 
genious diagrams, by which he iHustrntes, by accurate measure* 



MOIJ.mES OSSIUa— HALACOSTEON. 



* 






^ 



roent« the flifferenoc priKlnced on the absolute anrl relative 
dianietors bj tlio two dirtoasos. His di'iiioiistratiotiA are verj 
full aud clear, and minutely establish the difl'erence in the etTcvt 
of the two disea««« on the form of the pelvic — a diflerencv, the 
general tl'aturvs of which aru euffiek'ntly cxpres&ed iu the litate- 
ment£ madu above. 

The arine, in mnlocoBteon, hae Bometimes preecnted marked 
alteratirmfi in qtinlity and ap[u>nriincp, and ficveral uf tlie ear- 
liest wrirers have recorded cases where it deposited a copious 
sediment of a white, clialk-like anh^tance, sometitneft deaorited 
as a murtar-like material on cooling, or after eva{>orHtion. 
Later and more thorough obeervations have shown this siib- 
stanco to be mainly pho?iphatc of lime, and the idea was natu- 
rally 8U};j:fcifwI that this might, therefore, throw some h^ht on 
the pathology of t)ie disease ; the wa^^te of the bone-earths 
throngh tlio kidneys explaining very satisfiictorily their disap- 
pcarancc from tlio boncB where they properly belong. This 
renal view of the pathology of malacosteon, thocigli so proniis- 
ii^, ha» not bonie the te»t of larger experience; and it is 
funml that, in a certain proportion of the cases, there is at no 
time any ohnn<;e in tlie urine which will in any way correspond 
to the dianj^ea in tlic bones ; in I'aet, tlint there ifi, in some cases, 
no deviation wimtever from the Iiealtliy constitution and ap- 
pearance of the renal eecretion. Still, thongh the urine may 
not baTe ftn{iplie<l a key to the real pathology of niulacoeteun, 
its changes in this diiieutie are certainly worthy of oarcl'ul con- 
sideration, and we can hardly regard as merely accidental, 
phenomena which pre&cnt tlicniselvcs in cei'tainly the larger 
proportion of cases thus far recorded. Be-^ides the more nu- 
merous cases in which an ckccsb of phosphates has been Ibiind 
in the nrine, there arc ftomc where other f^ubstanoes have been 
diwswcred which did not belong to its healthy condition. Thna 
Mr. Dalrymple reports a case on which Dr, Bence Jones made 
tomQ oljservations in the *' Philosopliical Transactions," vol. 
Ixvt., in which he i^howB that the |K-culiar matter in the urine 
which Ur. Dalrymplc had described wa^ in fact, a dentoxide 
of albuinfm. conibined with water »o a." to form a hydrate, Dr, 
Jonea Aays: ** There was as mnch of this peculiar albnminons 
substance in the urine as there is of ordinary albumen in the 



» 



DISEASES OP Boya 



blood. So far, then, as the nlbnmen is concerned, each ounce 
of urlno. pai^sed was equivalent to an otinc« of blood lo»t. The 
peculiar characterii<tic of this li^drated deutoxide of albumeo 
VW6 ita BoluLilitT in boiling water, aud the precipitate with 
nitric acid being dissolved by lieut, and refoniicd vtLen cold, 
hy this reiiution, a simitar substatice in tniall quantities ma)' be 
detected in pus, and in the secretion from the Te^iculat eeiui- 
nales. This subtitance inuHt bo Bj^^uin loolted lor in aculo casea 
of mollities osifiuni. Tlie reddening; of the urine ou the addi- 
tion of nitric acid might, perhaps, lead to the rediscorery nf it. 
When found, the presence of chlorine in the urine (of whic-li 
there was a anepiciou in the above case) idiould be a special tub- 
jcet of investigation, as it may lead not only to theexpbinatiou 
of the formation of tliia eubBtanec, but to the comprchengion 
of the nature of the disease whiuli afleeta the bone^." Mr. 
Krichsen refers to the analysia of the urine, in a case of Dr. 
Mclntyre'fl, published in the " Medico-Chimrgical Transac- 
tione," vt>l. xxxiii., in whieli an animal substance, diffei lug in 
must of its clieiuical reactioua iroui albuiuen, vai fuuud in the 
urine in ^reat abundance. 

In illustration of the frcncral foaturce and coniBe of this 
Bingular dittcaso, I add a Kkctc-li of the famons case <^ Madame 
Supiot, one of tlie mot<t remarkable, and prububly the best 
known, of any on record : 

Elizabeth Querian — afterward Supiot — came under ob&er- 
nation in the year 1753. Slie was then thirty-eis yoars of Bg«. 
She had had three children and one miscarriage, without any 
scrioufl accident. She had twice liad fall:^, which produced 
more than usual swelling and lameneKs of the limb injured, 
but no fracture. She had had, however, nincli aching pain in 
her extrcinities, and of late had not been able to Buatain her- 
Belf OD her feet without fiuffering. She had now been bedrid 
from this cause about two year*. About a year betore — that 
is, in 1751 — »lie had commeuced to oWeiTe a milky eediment 
in the urine, and about tho eame time the bouee began to 
bIiow some ovidencea of Boftcning^ and tlie legs to a^unie a 
distorted position fW>m the relractJon of the muscles. Thia 
was accompanied by a very great increase of the pains in the 
limbs, which at timeft were intolerable. At first sight, the 



JIOLLlTtES OSSITM— MALACOSTEON. 



Rl 



woman, a^ slio lay in bod, eecmed to have neither feet uor \e^ 
nor iian<b. It eeenieii tliat tho body tonniimted at the pubis. 
The tbigh-l)one had curved so »j^ lo allow the fimi and tlie leg 
to tnm np by the side of the body, so that the left leg inclined 
to be under the back, and she yould on this side lay her head 
OD ber foot. The rij^ht thigh-bone was siinilnrly heiit, and the 
wholu extretiiily drawn forcibly against the right side of the 
body. Tliu patient could not move herself in bed. Dffuciition 
and urination were not interfered with. Tluo vii>lent eepara- 
tion and twitttlng of the thighft, however, caused sutKcient 
pressure on rhe crnral vessels to interfere in some degree with 
their free circulation of the Uood, and conse«]iientIy some 
ONlematous swelling of both liiubti existed. Ttie thorax, sink- 
ing down at certain points upon the lungs, interfered with res- 
piration, and at times kIic spat sunie blood. The tipper part of 
the Bternnm was proitiiiictit, tlio lower jiart gntikeii in. The 
clavicles were more than upiially protninent at their stenial ex- 
tremity. The humerus was curved about its middle from with- 
in outward, as well as the forearm, so that the middle part of 
tlie right arm wa* habitually applied against the internal mal- 
leolus of that side, while tlie middle of the lull arm rented ou 
the upper part of the tibia, jui^t below the patella. She could 
make no use whatever of her limbs, being able to move only 
her head ami tho left arm. She could also eeparate some of 
ber tingcrft slightly, but could not bend any of them in the 
slightest degree. The right hand much atrophied. Her teeth 
were discolored and loose, and the guma ewnllen and ulcerated. 
When an attack of i»ain came on, she often had severe fever, 
followed by profuse sweats, which were apt to be followed by 
the eruption of papules or pimples, which caused vei-y distress- 
ing itching. Ilor mcnAtruatlim was regular, hut waa exceed- 
ingly apt to be accompanied by very serioua exaggeration of 
ber other disorders and suflcrings. 



6S 



DISEASES OF BONE. 



CHAPTER vrn. 



VBAOILITAB OSSIUU. 



A WEisxumo of the texture of tlie bones, rendering- tdera 
more tliau usa&lljt- liHble to be broken from eli^lit catHca, is 
found to occmir in the course of Beveral very difiVreut dweaaes 
of tlic boiio-tiseue. Thus we have seen that certain conditions 
of malacostcon present great fragility of the bones, while it is 
■well knowrt that carcinomatons infiltration will sometimes &o 
weaken them that fi-actnro occurs on the slightest possible prov- 
ocation. Several instances are reo^jr^led where, both in mfdoi- 
co^tecn, and in coceer, the thigh-bone hat> snapped ae^under 
from turniiii^ in bod, and the arm-bone from an attemjit to 
raise the body in bed on tlie elbow. But, besides tliesc eases, 
there are certain individnals in whom, with itll rhe eridenoea 
of good health, wo have a degree of brittlenefla of the bones 
which exposes them in a remarkable degree to the occurrence 
of fractiu-e, and In whom fractiiree take pkce from the moat 
trivial causes. I had under m_v care, eume years ago, a gentle- 
man, then in middle life, who Imd from various aocidentti seven 
times fractured one or both bonea of the forearm, and on one 
of these occasions the fraotnre was produced hy somewhat too 
cordial a sliake of the hand. This gentleman was rather slender 
in his formation, with small hands and feet, and delicate limbs, 
but was always a iiealthy and active man, and the fatUer 
of a large family of woU-formed children, none of whom j>re- 
eented any trace of this peculiarity of their parent. A gentle- 
man of, our profession, who ha.-* practiswl many years in this 
city, has twice fractured lii* leg hy a slight stumble in passing 
along the street, lie a\m haa the slight frame and delicate 
formation which characterize the female, but ho was, at the 
time <:if receiving his injuries, in exCfllent health. He has 
since suffered severely from rhcumatiem. Mr. Stanley allndes 
to a case under the care of Mr. Ariiolt, in the Midille*ex Hos- 
pital, whore, " in a female, aged fourteen, the first fracture 
occurred at tho age of three years ; altogether there were 



Fiur,iuTA3 osarov. 



83 



V 



I 



thirtj-one fractures in different bones, and in some of tliem the 
fracture was many tlmcB repeatwl. Many of tlie fractures 
occurred from the sUglitest effort, and there waa no difficulty 
iu obtaining their union. In a dieter of tliiii patient, six yeurs 
of age, there was the eauie condition of the hones, favoring 
tbo occurrence of fractures. She had suffered nine fractures 
since tlie age of eij^lit months." Otlicr writers e]*ak of tliia 
pecntiarity as belonging to several memlicrs of the same family, 
and there are certain chwr in whicli it* hereditary character is 
anqneationalde. An iiifetanee is mentioned by Dr. rauli, of 
Leiptic, in wluch, for three generations, certain individuals 
of a family have suffered from extraordinary fragility of the 
bonet:. 

These cases are sucli as appear to be nnconnected with any 
diiVOBC of the bone, or any oonatitntiona! disorder, the patient 
enjoying a gi)od degree of health, and capable, ordinarily, of 
fnlfilling the duties of life in a satitifactory manner. There 
are others, however, in which some symptoms precede the con- 
dition of fragility, and these symptoms arc generally rather 
TBguely spoken of as chronic rheumatism. Thus Mr. Sinnley 
Kports the case of a woman, aged twenty-six, who was ndnnt- 
ted into St, Bartholomew's Hospital, with a fracture of the left 
femar. "She stated that she had suffered rheumatism in this 
limb, and that, three days previously, the fracture occurred as 
she waa crossing a road. She was placed on her back, with a 
straight splint <m the outside of the limb. When i^lio had been 
in the hospital about two mnnllis, while lying perfectly quiet 
in hcil, she suddenly cried out that she felt a severe pain iu the 
other thij;h, and that the bone had Ijrolten, The house-surgeon 
happening to be in the wai-d, found the right femnr fractured 
iu its centre. At gubsecjuent and distant periods, witile con- 
finc^l in bed, a second fracture of the left femur occurred, a 
little above the knee, and fractures of both tibia?, imniodiately 
below their tulx-rii^ilies. She reniiiined in the hospital above 
two years, during which every effort was made to obtain the 
anion of the fractnrc^ Throughout her general health was 
unimpaired, the appetite pood, bowels n^gular, and the nrine 
pert'ectly natural At the expii-ation of two years ftoni the 
occmrence of the first fracture, the patient left the hospital, 



B4 



DISEASES or BO>!E. 



both lower limbs boing powerlew, and, whon tnovod, aeverel/ 

piiiiitnl. None of tlio fractures had titiiteil, and both liinlw 
were ahortened to the extent of several inches, with conuder- 
ablc distortion." In another caao mentioned by Mr. Stanley, 
tlie Bvniptoins were very similar, excepting that the pfttieni's 
boaltb gradually broke down, and she suffered constantly with 
geu<;rul weariness and acUiu^ in the bones. She died about 
four months after the first fracinre. *' A portion of the re- 
ccntly-fnic'tiired femur exhibits a thinninf* of its walla from 
the afi6iiri)t-iori of its inner IftminiE, hut without sotWiing of 
its textnre; it retains the hardness of healthy bone." A man 
was received into the Xew York Ilospit*! a few years ago who 
had received a fracture of the clavicle from a very tri»*ial canae. 
He told Its that he had been Hulferiug for ^ome week» with 
rheumatic pain, aud frreat tenderness about tlie bone, for which 
ho couht givo no explauation. His general hoiiltb was good, 
and ho had no syphilitic history. Tho l>one was found broken 
near its middle, and wjia exceedingly sensitive to the touch. 
This was not confined to the point of fracture, but extended 
along the whole clavicle, which was nianilbstly thickened 
through all its middle portions. The Innb wa? drewed in the 
Uitual way, and the only uDconiniou feature noticed during the 
progress of the euro waa that an utiuenal amount of bony 
matter seonied to bo thrrjwn out. forming apparently a thick 
ferule of callus around the fractured ends. He was put ujkon 
the nne of full doses of tlio iodide of potassinm, and, when be 
left the hi>spital, the fracture was imite'I, but the bone re- 
mained considerably enlarged, and very tender npon pre&sare. 
"With ri^ard to the result of fracture in these case« of frii- 
gillty of the bones. It seems to be different in the two classes 
of cases. lu thwe where no disease exists, and where, there- 
fore, the i>athology of the eafio may be considered to l)c a mere 
delicacy and slendemcss of eoni^trtiction of the bone, it ^enig 
to be generally conceded that we may lio|»e for a very rapid 
and very perfect cure. Indeed, it would seem that the ease 
of the cure bore some proportion to the facility of the fracture; 
many of these patieuts being reported as having much les* suf- 
fering and trouble during the union of tlioir fractures than oo- 
cnr in ordinary cases. lu many of the oaeee, however, when 



TTBERCULAR DISEASE OF BONE. 



85 



tbc rhoumatic paioB, gliowinj; Oiseascd nction nbont the bones, 
ha<l existed ia a. unrkod degree and far a uonsidcrHbli; period 
of time, ilu; siifl'trings inflicted by the fracture wero very 
great, and the union slow or imperfect, sometimes failing altn- 
pethcr, nnd in some instancea indiicin<j ao much constitntional 
irritation a* finally to wear out the power* of life. The projt- 
no««, tlierefore, oeemA to depend more npon the sound condi- 
tion of the bone at the time of fracture, than upon tbe degree 
of mere fnigility. 

With rt^ard to treatment, it would hardly seem prolinble 
thttt what may bo reijarded oa a mere peculiarity, »nch aa ob- 
tftiiu in simple fraj^ility, eould bo iiirtuencod in any impoitant 
d^ree hjr me<licinesor regimen. Still, I can conceive, in cases 
whcpe the peculiarity sliows itself in early life, that, by a robust 
regimen, and carelid attention to all the details of hygiene, 
ftometliUig may be done to strengthen slender bonea as well ii» 
lo impn>ve a slender constitution. In those cases where sume 
iiillaiiimiiuiry nction has giveu riee to the paina called rheu- 
roatia, of which aome of thcRO patients enniplain for a long 
period lietore the first fracture, I am in hopes the iodide of 
potoMium may prove of benefit ; though my own cxpcrioueo 
is limited to the ease mentioned aVtove, and in that the result 
waa not very definite. Finally, I fear there are a nrunber of 
cases where the dii^aso i^ general, where it is aevcre, and par- 
ticularly where it has been lon^ continued, in which nuthiug 
am be accomplished but the palliation of Buffering. 



CHAPTER IX. 

TUBKRDl'LAK DISEASE OP BOXE. 



That tme tubercle may exiat in bone, I believe is denied 
by few pnthologiata ; that it is a common affection of hone, is 
denied by many of the mf«t eminent. Tn the earlier days of 
the revival of patbological anatomy, before the microscope had 
ntTvaled its immcnfie multitude of factfi, leading ns to rewtn- 
sider and to change all our generalizations on the niitnre of 



86 



DLSEASES OF BO) 



morbid products, pathologists cosily found tnbercle in bone, 
and ^mvd it a prominent position in bone patliolug\*. K^lntoa 
took the lead iu tltis department of study, and hh chapters on 
tubercle in bone were among tlie earliest, and have ever since 
been recognized as among the beat of the publicationa on this 
subject. He accept* and describes cvcr_v form of tubercle from 
the minnte gray grannUtion np to the most extensive infiltra- 
tion of crude yellow tubercle, and has no hesitation in bring- 
ing thetn all under the tubercular category. Later wrilers, 
among whom h Mr. Barwell, whose careful and conscientious 
BtudicB entitle his opinions to great weight, have been disposed 
to limit very much the use of the term tulwrcle to those in- 
Btancea iu which the normal history of tubercle can be dis- 
tinctly made out in all its Stages, and to exclude from the lUt 
a large number of those affections of bone in which a plastic or 
degenerating lymph assumes the form, and sometimes rather 
closely imitates the behavior, of true tubercle. In fact, when 
we reflect how close this resemblance is between tubercle and 
degenerating lymph in the soA parts of tlio body, where the 
difficult problems of structure are so mucli more ensilv nnrar- 
dlcd than they can be in tho hard and nnmanagcablc tiMue 
of tho bones, we can easily find reason for being particularly 
cautions in pronouncing a judgment on changes which we can- 
not always satistaetorily appreciate, a judgment which there- 
fore wo are apt to found upon imperfect analogies rather than 
npou careful observations. It is Bcknowledged by all that there 
is hero a debatable land, in which it is impossible to decide on 
each individual instance as belonging cither to one category gr 
the other, and it is therefore eminently wise not by any violent 
generalization to throw all cases under cither head, reserving 
opiuionI^ us to tho ttiberculoii!) or non-tuburculons nature of the 
various de|>osits, until oar knowledge shall he more extensive, 
or at least more accnrate. 

With these ro^crvations we may say that tu)>crele in bone 
presents itself under the two forms usually descTibed, of gray 
graniihilion and of crude yellow tubercle. The first is com- 
monly regarded as the elementary form of the disease, or at 
least the form most characteristic and uaeqiiivocal, and there- 
fore, in settling the question of tubercle in bone, it has been 



TTBERCTLAR DISEASE OF BO>*E. 



87 



Bongitt for with particular anxiety. It U iti this search that 
the hardness of the borie-»ubst»n»! tnteqto^ej ttiiuh great diffi- 
itQUiea^and it is only bv the most tedious iiiid curoful disacction 
ihat we can arrive at any clear view of the pathoh^ical condi- 
tions we are stndying. N^laton, however, persevering tn hia 
inrestifjations, claims to have Bcvcral times sQcoeeded Jn de- 
monstrating the presence of the gray graonlation. He aays, in 
describing one of lu!» cliasectionii : " Fn the centre of the spongy 
tissae which occupies the base of the great trochanter waa 
found a inai^s, of six or seven lines in extent iu all diroctiona, 
formed by tlie iiij<»rcj;ation of pumll |ieaily granulatioiiii, of a 
half a line in iliflinuter, and of un opaline-white color. Many 
of theae granulations, and particularly thoae which were placed 
near the periphery, were snrrounded by a little osteons shell, 
so thin anil transparent that at tir^t Right it could not he recog- 
Dize*! ; in fact, it* presence coold only be demonstrated by the 
resistance it offered to any attempt to pierce it with the point 
of a needle. Some of theso granulatiurib praHcnted, in their 
centre, ii yellow opaque point, evidently the indication of com- 
mencing transformation." This seems a distinct olnflcrvation 
of the gray granulation, and there arc several othcrri on rvcord. 
The crmlo form of tubercle, or that in which larger nuii^ses of 
the opaque yellow material are found varlonsly dit^scniinated 
through tlie bone, is not only more oasily recc^iizable, hut is 
much the more common form of the deposit In the bone-tis&ue. 
Both these forms of tubercle are asually found iu masses more 
orlej;s isolated; often so distinctly separated fi-om the suiTonnd- 
ing tUsueb tliatsonte authoi-!j have dotcrihed them as encysted. 
Both forms are recognized in the Btift parts, and imrticuhirly in 
the luu<r>, AS sometimes assuming the character of iuHltrations, 
and nu'loabtedly the same Is true in bone ; hnt it must be ac- 
knowledged that, for the gray, transparent form, the demon- 
stration in bone must be difticult and uncertain. Xelaton. with 
hi§ usual careful minuteness, describes this iittiltratiou, and 
gives a case moat particularly and thoroughly studied out, in 
rhich this inliltration existed at a numhur of ]ioints in the 
;ram and pubis. The case seems a clear one, but the want 
of microscopic examinations must always canso it to be received 
with ftomo doubt as to its real nature. 



98 



DISEASES 



TbQ crude yellow tii1>orc1c ie not aiicomnionly infiltrated 
througli the t>i)uti^ KuliHtatice of the lone. Tlie iioniml ttbHue 
does not seem to be displnced by the deposit; Kimplj iu inter- 
stices are occnpied by it, and its cavities filled np by it. Some- 
times the depoiiit ia firm and Rolid, sometimes softer and cheeky 
in its coiwifttence, and eometimea it ia not easy to prononnce 
whetber we have under view an infiltration of soft tubercle, or 
of ingpig«ated lympli. In ita microscopic charuvten. the tuber- 
cle uf bnue haii no different fuatureii from thutiu ut' tubercle 
elsewhere, and, Lu itB behavior after it ia deposited in the tift* 
Buca, it obeys the saiiiu laws and ^m thruu^b the same trans- 
formations aa in the lungs or in the lymphatic glands. Clini- 
cally, these ehangcB hare some peculiariticit iinpre!^>;e<l upon 
them bv the ivpntlinrifies of the ti.-isuo in which thev are devel- 

V I ^ 

oped, bnt, in all etwential particulars, tubercle in bone presents 
the same history as tubercle in the soft parts. The first change 
noticed is that by which the gray tuiierclo changes to the yel- 
low. This change cuuimenccij in tiic central part5 of the tu- 
bercle, and gradually proceeds until tlie whole is transformed. 
Wliile Ihiri prncc8t4 h going on, we usually have an increaae in 
number and -iizo of the depoaitd, so that, M-heu the change is 
completetl, we have large crude tubercles replacing what were 
at first small and scattered gray granidationa. That this 
change doet> occur, most of the best aulliorities agree; but, that 
it is the invariable law of progress, is more than doubtful. 
That some gray granulations, by aggregation and the yellow 
change, Iwcomc crude yellow tubercle, may be considered na 
certain ; but it is equally certain that many, and ]>erhaps most, 
of the crude tuberclen we encounter, have never bad any pre- 
vious stage of gray granulation. Once having reached, how- 
ever, the stage of crude tubercle, the changes are more distinct 
and more constant. The tubercle itself tends usually toward 
Bofteuiijg (Fig. 10). This change also commences in the centre, 
and bpreads to the circumference. While it is going on, in- 
flamuiatory action begins to be developed in llie surround- 
ing sotl parts, the products of which, mingling with the soft- 
ening tubercle, favor its disintcgi-ation ; while, being retained, 
they add to the local irritation. Soon, a process of ulceration 
begins, and the cancellous tissue slowly breaks down, forming 



TUBCBCULAR DISEASE OF BONE. 



89 



irregnlar cavities, which nt first contain, mingled togetlier, 
the substATice of the softened tubercle and the ]nirnlerit 
results of tlie surrouudiug iuflarnmation. Tiie rate at wliich 
tli9 cliaugea go on i» very vari- 
ons. In the cireiiinMiriheO tu- 
bercles it h said to bo more slug- 
gish than in the iiifiltrntcd form, 
id igain, the harder deposits 
inge more slowly than those 
originally of a softer coufiistenoe. 
Xn all castes, a wider and wider 
area is involved, atid the disca&o 
finally makea its way to the outer 
compact slicll, which, either by a 
process of iieeronis, or by n con- 
tinuation of the procerus of ulcer- 1 
•lion, is finally perfurHlwl, and 
the matter comes in contact with 
tbe Boft parts fturrounding the 
diBefls«4l reginn of bone. These 
bai-e been already involved more 
or less in the inflammatory ac- 
iioDd which, for so long a time, 
bare been going on in the bone, 
and tiiey arc ready to contrihuto their share to the mixed, ftemi- 
flnid mafis which ia Rtniggltng slowly toward the nurt'nce ; and 
thoa we have formed the tnbercular abscees, which finally opens 
on lb© integument, and di&cbarges a fluid composed of soJtened 
tubercle, mingled with the pus derived from tbe inflamed lia- 
anee which have been traversed, and also the detritiiti of these 
tmtice as they have yielded to ulceration and molecular disin- 
tegration. From this point the changes vary in different caseB. 
&ometim&^ thi:* seems to bo t}ie terinination of the (uborcular 
action, and re}»arntive dispositions begin ts dhow themselves as 
soon aa the evacuation of the morbid products is completed. 
Healtbj granulation begins, the cavities in the bone and the 
aoft parta are gradually filled np, and a perfect cicatrization 
terminates the diseoi-c. This farurable behavior is, however, 
the rare exception, and, though ultimately we may hope, in per- 



Fio. 10,— (Trvm BIDivUu) 



00 



DISEASES OF BOiN£. 



rra^H 

□CS.V 



hape a larf^e number of cases, that a cure will talce place, it is 
not commonly realized «-ilhout a period of protracted local 
<liseaiiei wliieli gives to the tuberuuliir luurbid processes their 
peculiar character of obfitinacy and of danger. These traits 
they well deservo, and are exemplified in two wbvb: l''irjit, we 
may have in the tissues, itnmecliaCely ^iirrou tiding the orijciQal 
focQft of diitonae, a new deposit of tubercuhtr matter. This 
now usually of the crnde yellow variety, and of the softer fo 
It k more commonly iiitiltrated in the surrounding ti»gDCS, 
bringing larger and lar^jcr dietricte under its baneful influence, 
and guiiig tlirough the fiaino destructive prueesfeee above de- 
scribed, llie whole series of ulmiigCB being rt-peatud indetinitc- 
ly, until the local ravages and tlie constitutional cachexia to- 
gether bring either limb or life into a hopeleas condition. 
Secondly, even if truo tubercular deposits can no longer bo 
foond to take place, we constantly have the ulcerati%*o actions 
slowly going on, forming new excavatious, reacliing into new 
regiuus, keeping up foul and profuse dischai^'s, and, in short, 
presuntliig all the wull-knuwn and mucb-druadcd features of 
tuhcrciilar caries, &o bopeieps in treatment, and so fatal to tlie 
joint upon which it is slowly making its deBtrnciive invasion, 
Thrtvugli all their course tbci-e changes are slow and delibemte, 
characterized by acute intlammation only a» an occasional ac- 
cident, and accompanied by a condition of the general system 
of which the local behavior is merely the expivasion, and which 
in its turn is constantly dctoriorating from the irritation re- 
flected U]Hm it from the local disea^. 

The siippumtion wlncli accompanies (bis process prcscuts 
often some peculiar feature*. Sometimes the amount of pus 
formed is very small, never collecting into abscessses, but, re- 
maining intiltrated among the degenerating tii^sues, seems to 
take no further active part in the process. Thus we have u 
unfrequently exteusive tuberculous destruction of the bodi 
of the YcrtL'tprie, and yet im abscess may ever make its a]>pea^ 
anoe. It would seem as if the absorbents were able to dispose 
of all the dying particles of tissue, as well as all the pus for- 
mations, go rapidly that uo accumulation could take place, and 
it is well known that theao cases often go tbrctugh their whole 
course, and arrive finally at a complete cure, without the for- 



TUBERCULAR DISEASE OF BONE. 



mation (certaiulv witbout the appearance) of any abscesB wliat- 
ever. But, though extensive tubercular diwaHC may thD& oc- 
casionally oxiBt without the formation iiT distinct ah-^CPt^s, yot 
the general fact is that, some time during the course of the dis- 
ease, abscosaea do form, and it ia their course and behavior 
which give their peculiar character to all the later stages of the 
affection. Sometimee tbeee abscee&es slowly reach a certain 
iu/i, aud then sceiu to remain stationary, aud even to retro* 
j^ade. Such are occaaioually seen on tUo front of the doraal 
rertebriB, where caries ia arrested and a cure beginning. Some- 
times forming slowly, they grow out from the diseaeed point, 
and receiving from the tidsues around them very firm walls, 
tliCT gradually extend in various directions, and, with curioufi, 
fontautic shapes, insinuate themiselve* between and among the 
inusclea and the bones and the oi^ans, until tliey reauli into 
r^^iotts i>crhap6 far distant from their point of origin^ " and 
hang like huge lootihee," as X6laton cxjirct^^ctt it, "on tlio aides 
of the vertebral column." He giveei a drawing of a apeciraen 
in which these bags have been dissected oat from the gnrroond- 
ing tisanes and left hanging from their points of attachment, 
and their appearance a« thus seen certainly justices hia biniile. 
Bat again, withuut appropriatiug to itself any bucIi distinct 
sac, tlie matter may gradually pu^ti its way, without iiiflaniiiia- 
tion, without pain, ol\en without any symptom marking ita 
travehi, until it comes ta the surface at a ])oint far distant from 
its soarcc. Thi^ ia most fauiiliarly il1nf>trnted in the psoaA ab- 
•ceas, accompanying di^a&e of the bodies of the dorsal verte- 
brae ; and there are on record nu!uerous examples where the 
pas has wandered to the most wonderful distance!!, and showed 
elf in the most eilraordiuary situations. The oixlinary 
>nr&c of psoas abscess is vory slow and vf^ry painlesi;, and 
often it happeuB that the matter announces its pretteiice by a 
flnclnating tumor below Foupart's Hj;amcnt, wliile its course 
along the sheath of the mmw-Ie has not been attended with suf- 
ficient inflammatory action to give rise to any pain or tender- 
neM that might serve as a warning of the mischief tliat was in 
progreu. In thcso cases there seems to be a mere burrowing 
of the matter along the areolar interstices, almost without lim- 
iting inilammatury deposit, and therefore without the distinct, 



DffiEABEB OF BOXE. 



firm, and wcll-devclopcd cyst whicli in otlier cases encloses 
tlio pHB, ard very much i-estrains ita distant wanderijipii. A 
eoiiiewtmt similar UUtary iiiuy he given of the abscetsHee wliich 
form in uoiinectiou wilU tuburculiir cariL>sof the joints. Some- 
times tlitv funu with nmcli evidence of iiiHammatorv nctivitVi 
break earlvj nud dificbarjre good bnaUhv pus, and boom put on 
a reparative aspect, which may rasult in tiieir prompt healing. 
(Won, however (and tins is particularly the case with the hip- 
joint), they form slowly and travel q^nictly to a con&idcrablo 
distance along the interninscular epaces, and then bulge out, 
forniinp^ a pninless, colli, fluctuating tumor, whoso only vital 
activity during uionlhi;, and oven years, may be displayed in a 
gradual and oflen exireinely sh^w inereage in size. This con- 
cealed suppuration, escaping orir notice during the earlier part 
of the disease, fMimetimca add* suddenly to the gravity, huth 
of our prognosis and of our diagnosis, and the possibility of its 
latent existeuue should always be recognized and carefully 
watched. 

After opening, these ahsce^es usually continue to behave 
as their previnufl demeanor would lead ua to expect. The cav- 
itipi* fihow but little elasticily or tendency to contract, and it 
is only after a long time that the abscees contracts into a 
proper fistula, and, even when this hno occnrred, we arc never 
quite sure that some deej>er parts of the original cavity may 
not remain uncontractod, and may yet be burrowing in some new 
direction, to enrprise us with a new opening in some distant 
Bpot. The fistula; thus formed di«;liarge a matter which varies 
in its quality according to tlte coniliiion of the diftcased bone 
on which they depend. It is very apt to present the apjiear- 
nnccB characterietie of caries in its onlinory forms. It i* thin, 
Bometimea curdy, often acrid, excoriating to the surface over 
which it flows, and particularly, if the tubercnlar carle* be in 
active progress, it is fetid. The furtlier clinical history- of these 
abacessofl dei»cnda on the course of the disease of which they 
are Kvmptomatie. If this be healing, the alwcesses will also 
gradually heal, leaving dccp-floamcd and purple-colored scare, 
n^nally adherent to the bones over which thcj have been situ- 
ated, apt to reulcerate froiu trifling causes, and only after many 
months becoming sound and white, and free from tendemcM. 



TTDERCVLAR DISEASE OF BOXE. 



03 



r tendency of these Mare to contract in every direction was 
etriliitigly gliown in the case of a young pirl, who recovered 
froiu what seemed to be r case of «tniinoiis diseaae, probably 
taberctiloiis, of the liip-jolnt^ during the cuiirse of which, many 
■bsc««>dett formed, leaving many sinuses running fruin the dis- 
ea-^d joint, and opening at vurious points on the surface. 
After all tlie sores healed, and her health became reostabUahcd, 
eho grew fat. The scura of the healed Biunscs had contracted 
down Ml tiraily as to make doep f<i3Aic at the point where each 
of them presented at the surface, and the wall of fnt rrtund 
each of theio gave them the appearance of a very deep ntnbili- 
CQ6, at the bottom of which wiw the soar. The»e, Buattered, to 
the number of six or seven, over the bnttock and hip, gave it 
a moet extraordiuar}- appearance; If, on the other hand, the 
disease of bone, on which the ab&ccss primarily depends, be 
prugreseivo er even stationary, the abticesses remain, wjnietiinea 
the source of a good deal of irritatiun and annoyance, and 
sometimes so quiescent that the patient has no care for them 
except the daily dressing tlioy require. As a general rule, 
their further history and cour^ are intimately assoeiated with 
the primary bon&-diftea&o, though occasionally it will happen 
that, Of- said above, they will «how a dis}K)sit:ion to accmuulate 
the pus in some of their irrejpilar cavities, which pus, thus pro- 
vented from a rea'ly outtiow, a«imctimorf burrows silently and 
extensively into regions where we do not expect to find it, 

Tbe disease thus described is most frequently found to 
affect the cancellous rather than the hard portion of the bones, 
Buch as the vertebral bodie'^, the uarpus, the tar^U'?, and the 
articnUr extremities of the long bones. Mr. Paget makes the 
importnnt observation tlmt, " when it affects bones that are 
arranged in a group or wiriurt, it is usually foiiml in many of 
them at once. Thus several vertebne, or several carpal or tar- 
sal iKtnes, are commonly at the same time tuberculous; yet not 
often so equally bnt that one of tliom appears fiist and chiefly 
diseased; while, in thoKe gradually more distant from it on 
either side, tbe tuberculous deposits are gradually less abun- 
dant, la like manner, the p.irt,s of boiiCK that net together in a 
Joint are, usually, at the same time tuberculous.^' 

The treatment of tubereulous disease of the bones is, as for 



94 



DISBAflDB OP SOKE. 



as itR contititational cliarauter is concerned, no different irom 
the treatment of tuberculous diwase elst^whero, and it eeems 
Kcareely worth while to repeat here whnt hiis been eu well said 
by BTStctuatic writers on tnberenloais. The local management, 
however, preswntii many features of individual importanee, and 
demandft our most careful study. So mnch of this local treat- 
ment depends mure on the e£rect« than on the nature of the 
affucliori, and so much of it is included in the history of the 
treatment of caries, in its vnrious forms, that I reserve all that 
I have tft say r>n the subject till we have discusaed the latter 
disease, to which nearly nil the cases of tuberculosis are so 
nalurallr related. 



CHAPTER X. 



CABIBe. 

Cajhes is a condition of bone in which sitppumtion and 
utcerHtioti are combined, but in a proportion so rarviiif» that it 
Las been f^uiid somewhat difHcult to give a conci&c dvliuition 
of the di^ea^e. Different authors, looking at the prominence 
of one or the other of those pi-occsses, have described it cither 
as a supi)unition or an ulceration, as one or other action seemed 
to them most important, and hence, perhaps, there is no disease 
in which there ia more apparent discrepftncy of view and of 
Btafement than in this. Without atteniptin*;, thei-efore, to de- 
iine caries, I will content myself with describing it as a disease 
of the cancellous structure of lione, eharnctcrized by a chronic 
or fiubafute inflammation, terminating in suppuration, which 
is partly infilrrated, and partly collected into abscesaes, the 
cavitiea of which abscesseB, after they have discharged their 
contents, hiive a tendency to ulceration, whereby Bometimes 
extensive destruction of bone-tissue results. With this there 
are usually to be marked some abortive attempts at reparation, 
such as larjje, flalihy j;ranulutii)nt; protruding into the ulcerated 
cavities, and irrcj'ulnr and inclTectunl deju'witiotis of new bone 
in and about the diseased parts. It is essentially chronic id 



dJOBR. 



05 



ter, sliowin^ very little diapoBitiun I'ownnl liealing, 
■nit it 19 generally associate*! with some eoustitiitiuiialciicliexia, 
or local nnfavorahlc condition, on which iU exiateucp seems 
to depend 

Commencin); our stuJiea with this peneral descTiption. we 
frholl lurtlitrr find tliat uaries somotiuius presents ittrfil'iu; a dis- 
order arising from some slight exciting cause, and running its 
course without any evident connection with or dependence 
upt^in any uiher di.-tease or injury ; while Konietimeii it h mani- 
festly dependent on some disease or injury of wliicli it seems to 
be the consequence and effect. This seems to me to justity a 
distinction into primary or iUiojiathic and secondary or symp- 
tomatic caries, a distinction which I think a found in Kature, 
and will be useful in practice. 

Taking, now, a ca£o of primary or idiopathic caries an a t^i^c 
of the ditH^ase, we shall find that in a yuiiiig person, who has 
probably already presented some of the evidences of a Rtmmons 
disposition, a slight swelling, with some pain and tundornesfl, 
presents itself in, wo will say, a wrist- or an ankle-joint. Tins 
is at first attributed to»ome sprain or other injury, and then 
to rhenmati^m. The inconvenience caused by the alfection at 
this stage may be ver}' ttliglit, and the patient niiiy continue to 
use tlie limb without distress; but soon stiffiie*6 after exercise, 
and more or Ic&!> pnin on motion, begin to show tlioniRclvcs, 
and the joint gradimliy grcwa more disabled as tlic disease 
advancea. The affection becomes more and more markedly in- 
flaniniatory, involving the surrounding parts in its increase, 
but evidently centring its effects ou the bonee of the tareua or 
car|m9, rather than on the ankle- or MTist-joint. Gradually, 
and generally very slowly, the motion of tlie parts gets to be so 
painful that tho limbbeeomoA entirely di&alded, and sometimes 
constant pain is experienced indeiHindent of any movement, 
{Miin which 13 worse at night, and aggravated by damp and 
ehangeablo weather. Soon the inflamraatory signs begin to 
concentrate tliemeelves at one point, and a fluctuation and a 
pointing announce the formation of abscess. These abscesses 
are not usually large, and, when they break, discharge a mod- 
erate amount of thin, iluky pue. Little or no di&poif'ition is 
shown toward any healing action in the abscess, the discharge 



Sfl 



DISEASES OP BOXE. 



^y 



from wliicU coiitinuea, general]}' con^ieting of a thin, acrid 
irritfttiiijc, ami baii -smelling \>\\% in nioderale quantities. No 
relief oftlie »yniptomft, but rather an exaggeration oftiuftering, 
oceure atWr the absc&M ba.4 broken, and, if not bctbre, now cer* 

tainly, constittitional sympatkr 
begins to declare itself, i'ever 
of a beetle character deTelr^a 
itself, emaciation is marked, and 
the patient becomes a confirined 
invalid. The progrees of the 
coiiBtitutional s^-mptoms varies 
very nnicU in different individ- 
tialp, the general deterioration 
progressing very rapidly in 
some, and in others so ftlowly a^ 
scarcely to be marked, even 
when local dcatmction has made 
extenMve progrese. Of conrse, 
the size and importance of the 
joint, and the extent of the dia- 
case will have much to do with 
the gravity of the general aftbc- 
tion. New abscesses now form 
at rarious points ronnd the dis- 
eased centre, deformity incrcaaee, 
and sometimes, as in the knee, 
displacement of the joint -sur- 
faces takes place, owing to the 
Ws of tone En the ligiiments, 
which may proceed bo far ns to 
gimnlate a real Inxiition. These 
absoo8&os, particularly those nceompauying caries ol' the ver- 
tebrte, are often of the cold variety, aud extend iMjnietiuies to 
a great distance from Ibe original seat of the disease. The 
pBcma abBGCSB is an example of thii^ ])at1inlogical fact, and we 
often iind the matter travelling into very distant and nncx- 
pected regions before it approaches the eurface. Fig. 11, 
copied from Ericlwen's work on Surgery, shows the extensive 
wauderiiigB of an ab&ceea originally developed on the onterior 



PlO, ll.-<rrDro ErichiicDO 



CAJUBS. 



or 



Htrfuce of the Uodics of tho lumbar vertebite. The soft parts, 
in the^e contirmeil conditlonfi of airic!*, are extensively iinpti- 
cateil, beiaj; Oiickencd and coiitioHOated by the inflaiiinmturj 
exiiUutiuti^, and traversed in ratioud directiooa by siimeea, 
whicli lead, ottau iudirectly, from the difteaj^ bune to the sur- 
face. This condition, oiico cstubliiihed, may last for an iudufi- 
nite pcrioil, and may have one of two terminations; It may 
either ^ttle down into an inactive and uncbanj^inrr condition, 
hteling for raonths, and even years, witliout any rnaiiilerit pro*;- 
ress ; or it may go on tlirough a process of local dttiorganiza- 
tton and genftral dojireciation, which brin*:* tho patient to the 
|K>)nt where both life and limb are imperilled, and wliere the 
iDterferouce of art 14 imperatively demanded. If, on tlie other 
hand, tt favorable change is to take place, we have aj^in one 
of two results to hope fur: Firt<t, an improveincut iu all the 
conditions of the part, and a gradual restoration U> health, with 
such an impairment of the joints aftV>ct«d oa shall not entirely 
interfere with the ugcfnIneAs of the limb; or, secondly, in the 
more advanced cases, we have to hope that, if the destructive 
actions Ite arrested, a gradual consolidation shall take place, 
aueh Se will permit a return of ftoundneit!^ to the di!<«aiied ti»- 
Buei, thoiigli at the expense of an anchyioais either partial or 
complete — au anchylosiij, the iU-cffect« of which mechanical 
in^rcnuity can often very much neutralize, and winch iu some 
iuftiancee surgical art can ineai^urably improve. 

Symptomatic or eecundary caries has, of roni^e, no such 
distinct history of its own, hut is developed in couoection 
with some injury or disoiute of the surrounding soft parts, upon 
vhich it depends. Long-continued destructive inflammations 
of jointa very often produce this carious condition of the bones 
which compose them. Thus, wo ofleu find, in white tswelling 
of the knee, that the ditiease 1ms involved the head of the tibia, 
and sometimes the condyles of the femur so far that the bono- 
dbease has asiiumed the prominence both in prognosis and in 
the indications of treatment. Tliie is sometimes particularly 
fell markeil In the conditions of joints which have been de- 
fed by inflammation ftdlowing penetrating wounds. In 
tcasea it is well known that the cartilage rapidly disap- 
under the influence of the inflainmaton- actions set up by 
7 



K 



DISEASES OF BO\B. 



the woQiid, and the articular lamella is oarlv exposed. From 
this the i iifla 111 ina lion gain^ ruatiy accesg to the eaiiuellous tis- 
8iie nndoriifHtli, and wc have intiltrated aappumtion and carjea 
as the common consequence. 

The evmjitoms indicating secondarr cftrien are nsnally to 
mioglud with Ihuse of the original disease that it !« not easy 
to separate theui. The exteu&ion of the joint swelling &«> aa 
manifesily to eiiibnice tlie joint ends of the boiien; the tender- 
ness and pain in the heads of the bones; abscesses breaking at 
a (listJince from the joint nnd over enlari^nienta such as above 
describefl, and the detection of cnrions hone by the prohe — the*e 
are the most striking and iinef^nivncal »ymptx>m9 of thia form 
of caries; but it may be stated that tlie long continuance and 
destrnctive behavior of joinl-«tfeclion« gonerally niay lead to 
tlie suspicttm that cartes of tlie articular extremities of tlie 
bones has ttiken place. 

From thia sketcli of the clinical features of the two varie- 
ties of caries we may now jimceed to a sfudy of iu psllnilopi- 
cat anatoiny. Beymil u doiiiit. tin- tirst morbifl conditions 
which would he found in a bone which was fatlhtg into caries 
would ho those of inflammatory excitement. Increased vasca- 
larity thi-onghout the cancellous tiiisue ia, however, a patht>- 
logical fact eornetimee difficult to verify. The violence caused 
by the saw leaves a surface which always seems too red to bo 
heHUhy, arul in young people the circulation in the heads of 
the long bones is so nctive that in the most healthy s^iecimens 
we find what seem to be the evidences of great and irregular 
congestion. Much care, thercfurc, must l>e exereiscfi in dceiil- 
ing upon the cxlatcneo of diseased states of the circulation in 
these case.*, and conchisiouB should not be too positive. The 
increased action is soon accompanied hy exudation. This exu- 
dation — at fir^t a reddish serum — is infiltrated thruugh the 
bone, and lon.li very sjim to he eonvortod into jms — a pns, 
however, which docs not assume a very perfect form, and 
whicii at tirst seems disposed to remain digscmlnatcd rather 
than to enllect in the form of abscesses. This imperfect sup- 
puration hiis no doubt often been mistaken for true tubercalar 
infiltration of hone, which is certainly a rare ciuidition, but it 
should he remoiubered that the lines between true tubercle and 



CASIES. 



00 



/\«. 



imperfect snjipiiration are not very deaiiljp drawn, and that, 
tliongli it i* extremel;r' rare to find in bone a deposit wlnuU 
iiuawurs the de^crijition nnd obeys the hiwb of tubercle, yet we 
do often titid, in this imperfectlv-de- 
Teloped euppnration, in eumfiihjiia 
frnbjects, eoniething whicli, hiMtdogi- 
callv and pathologically, very closely 
assimitates to it. As the disease pro- 
grw8G«, it takes on more and more dis- 
tinctly the characters of di&eeminated 
Kuppnralion, and collections of mat- 
ter, gradually aecumulatinf;, hegin to 
ehow tlieinselvch, at varimiiH points, 
forming abscessve«. Some incrcBee in 
activity accompanies the fonnation 
of these abscesses, and tliey neek tlie 
snrface with some signs of acute in- 
flammation. They point and brealt, 
or are opened by tbu isurgeori, and 
diiKtbarge a small quantity of mat- 
ter, whicb, according to the activity 
tif the inflammation, has more or 
lew of the eharacter of healthy pui». 
Frequently it presents the thin eurdy 
or flaky character which is consid- 
ered characteristic of btriiina. These 
ab^ceues »how no tendency to heal, 
and yet a reparative disposition is 
crinecd by largo granulaTiniis, soft, 
flabby, which spring tip and Hi^iially 
till to a great extent the suppurating 
cavities. Instead of being tnily re- 
parative, however, the presence of the-se granulations is not in- 
c<)mpatible with an nicerative action by wliich the cavities ore 
being slowly enlarged, and the cancellous tissue more and more 
exterittively broken down. This destruction of the bone-ti»sue 
Iff a coinplicHt^d ]iroccss, and seems to be mnde «p of two kinda 
of action, one where the hone- substance undergoes a change in 
which its earthy clement is absorbed, and the other a true pro- 



V, 



/ ( 



no. llLH.^'T«ID auboih.) 



100 



DISEASES OP BONE. 



cess of a1eerati%'e 

moved (Fijr. 12). 



absorption whereby the altered bone is w- 
The t:haiige5 wliidi go uii !u bone during 



tliJA proees)i are extremely interesting, and buve been fully 
inve-^tigatcd by many recent olifterror^. Mr. Barwcll, in liia 
work on '* Diseiwea of the Joints," gives a very full account 
of hia obftcrvationa on this aubject, which seem to have been 
made irith great care and thorou^bncd^ He considers the 
first change to be an enlargement of the laoimre and their 
canaliculi. The lacuna gradually loae the elongated shape 
and ajiprosch to circular or broad oval. The canalicnli are 
larger and tiiure numerous, and t^eem tn open into the lacnnm 
by hrnad mouthd. Where the cauiLticuli intercieut each other, 
there seom to be new »paccB formed, which assume the charac- 
tent of nenr 1acnnn>. Thu^ there is a positive inoreaite in the 
nnmber as well as the size both of the lacunae and canallcnli. 
Daring this change, the bono-aabstance itself undergoes a 
transformutijn, wliiuli conimoiiees nearest to the llaversian 
canal or cancellns and spreads outward. The bony eab- 
stance becomes grannlar; that is to say, it looks as tf it 
were composed of dark and liglit dots placed close tt^ether. 
As this change spreads from the Haversian canal or cancellns 
outward, the margins of the cavity Ioac their diatinctaeas of 
outline and become very irregular; in partft the edge is gone, 
the cavity is therefore on that side iiiereased ; in other parts 
the spotted bone-tissue appears to mingle, or to be continuons 
witli some granular euiitcnts of the cavity. It is quite evident 
that, in iherie placufi, tlie hone-tiKsna is eotlened ; one can trace 
the gradiml eun)])]etion of the process, from suuje point which 
is only slightly spotted, to the part next the cavity, which is 
a mere pnltnccous granular muss, in which many of the dots 
have the appearance of nuclei. 

"Another change in the cell fonns part of this softening 
process, viz. : that aa tlie dotted or granular condition reaches 
a certain stage, so do tliu canaliculi disappear; llicrcforo, of 
course, from that side firsts which is turned towani the cavity 
(Haveroiun or eaneellar), Ihcy vanish by simple shortening, by 
recession from the eiiiirely sortened bone, until they are re- 
duced to mere little rudimentary projection;* on the surface of 
tlie cell. At this time the cell itself is visible, as a granulated 



CAKIES. 



lOI 



dark bag, more or less traiwpBrent. and very Uiglily refractiog, 
whioh projoctfi frtmi thn wall of tjic scarcely-resiBtant bone, and 
is of lar^ size ; it bnlges out and eeenm Kvrollun, projccta more 
and more, and at last breaks awav from tta attacbmenl, and 
lies among tlie »ot)ened debria in the cuvil;t', still retaining ita 
dark color. In breaking awnj, however, it often leares behind 
those of its canalicnti \rhicb were turned away from tbe cavity, 
and wbich may often be seen on the edge, bnt wliich soon dis- 
appear as aofteniiig goes on, spreading outward. Frequently 
aeverwl amaller cells trume uiil of die liLciina, insteiu] uf one 
large one. In tlii* way a lamina between two C!in«elkius cavi- 
ties very soon disappears, from softening on both sides: in tliia 
way^ also, circlet after circlet of coll* aronnd an Haversian ea- 
nal eaves into the cavity, and thus the ^vt^teni nicltti awuy and 
Isavcj} around the vessel only a soft granular and eellnlur 



-^^ 



^-.^^' 



V Fig. IS shows tbe worm-eaten appearance of carious 
bone under tbe niicroocope. 

By tbeM proceuca, tho bon&-subat-ance becomes gradiiallj 



tOfl 



DISEASES OF BOXEL 



disintegrated, so that, befure actual nlceration ban taken place, 
it is BO aul'teuet] that tbe scalpol or even the probe can be read* 
iJy pushed ttirou<;h it. In &onie points the bo no-e1eti tents &ceta 
to disapficar entirely ; in mo^t, however, Home of tbe orifpnal 
framework remains sn as U} inaintniti tlie shape of the part. 
Not iinrretjuently, tVoni iliis iM)llened condition of the joint- 
ends, great deformity results from unoqnal yielding to preas- 
ure— a circumstance which, the vertebne excepted, I have 
more frequently noticed in the knee tliaii In any other joint, 
and one which, if a f&Torable change takes place in the origi- 
nal disease, loaves holiiud n distortion which is permanent and 
irremediable. As the process of ulcerattun goes on, some parts 
of the bone-subdtanee are apt to die, givtti;; rise to small n*- 
quealra, gencrully upon tbe ulcerated Burfaccs, which thns at- 
tract less attention, because easily cast out with the dl^chai^jes. 
These sequestra which iiccoiupany caries, however, are ucca- 
eiaually of considerable »ize, and ai^sume great iiuportaDCO 
when, as is sometimes the case, they involve the articular 
lamella, and fall into the Joint-uavity ; thus forming a com- 
pliL-ation which renders the destruction of the joint almost a 
certainty. Where much of this necrotic action acconipaniea 
caries, the disease h spoken of as caries iiecrotica, 

While these destnictive actions are going on, reparative dia- 
poaitions show themselves unequivocally, though Jtieffectimlly, 
in the diseased parts. We have already noticed the tn.xuriunc 
granulations which fill the cavities of the Bbscc^ses; the lione- 
tit^siie sliow!4 t.hii same tendency. Hr. Bnrweil ihiiikK he hu 
ascertained t!mt, in the carty (icriod of the disease, the Iwny 
lamellflB become tliickened and indurated, as one stage of the 
inKammatory process. This must be a pathological fact ex- 
tremely ditficull to verify, but, be it as it may, it is certain that 
Inter in the disease new bony deposit is ireen around the cen- 
tral points of carious lione, as alinoi^t a universal fact. Somo- 
times this is only noticed 1o Iho extent of some slight surface 
incrustations ronnd the diseased spots, but commotily there 
are considerable thickening and consolidation through the sub- 
stance, and often a very groat amount of stalagnntiiMlepoait 
on tbe whole of the neighboring surfacM, and sometime* ex- 
tending to the nearest bones, which may tJiemselves be entirely 



CARIB9L 



103 



free from otLer signs of diwaso (Fig. 14). In tlio C4irie9, so 
common, of the Ijodies of tin- verlelirse, this deposit is often 
Ben to be ver}' cxteiisivo, tonuiiig bridges of bono between 



I 1 



hj^'Tii 






i.'*SNh*- 



^ 



Flo. tt-<Froo> BlUmll.) 



sm^ 



Fm. is.— (Pnini Sew York IlMpl- 
talMiwmUD.} 



ndgliljorin^ vertebiw, as if to Btrengthcn tlie coltimn, while 
le (lipase is still iirogressinp ; and as frtvoraWe ulianj,'e8 be- 
[in to take j>Iacc in the carious parts, fresh Hnd etrotiger tjevel- 
0^>mentA "f new bone are olwerrtd, wliieh iiiuilly {\ii-e together 
in one solid andiylusia the verlebnu whoec Lodite bavu been 
more or less completely destroyed by fbo iik-erHtion (Fig. 15). 
TiThen a cure is about to take place in ordinary caaeft of 
caricft, the nlc(*i"!»tive action cen^e*; the granuUlioii-sidwtanca 
XMnme^ a healthier and firmer cluinicter, and gradually or- 
gauizee itself into ti««uc. The piippiiration ceaseB, and the in- 
flammatory rongPBtion diminishes. New bonp-dr| osit. formerly 
confined to the ontftkirts of the dipoa«o, now ia (!e]-ositt'd ro aa 
in part to rratore the defiuipnciea which have oorurred. Some- 
times this action is a prominent one, the grnnnlations spring- 
ing from opptwito bones coalescing and ossifvirig; and in ihia 
way wo have true anohylosis aa one of the uietbods of euro in 




104 



DISBASBS OF BONE. 



1 



* 



bones wliicli have Wen long and exteniively earions (Fig. 1(1), 
A motliticatioD of this cifiiHerviitive Hction is Hnnetituei ob- 
eerved in cariuus boned wliiuh have furmtul part of uu articular 




Fio. !&— (TV«m Jt*m Tort iroqiltst Vowani.) 

tion; that the opposed &iirfftcc«, from irliich, pcrhape, cartilage 
has long been romovcd, as beuUliy autJuii la rasiitued. become hard 
and «mootb, so ad ta allow of a ctirtttin amount and frL>i>doin of 
motion, which tolerahly preserve tlie uaefuIncBS of the mem- 
ber. TliiK indnrfltion of the Riirfaces is somptnnes fio complere 
as to aosuniu the tippeurance of ivory or porcelain, and hence 
it is otton Bpoken of ua the poreellanotis or ivury-Uke chati}^. 
Fitially^ in cases whom the riivi4^«s of the diseuHo hnve not 
been so extensive as to dimirganizc tlio neigliburin^ joint, we 
may bare a recovery bo perfect as to leave no impairment of 
funclioti, and no traces other than the cicatriw-s l)oth in the 
bone and in the 8iirroundiii|; soil parts, which must necc^sariljr 
follow the ulcerative actions which have been going on. 

Curies, in all it^ forms, ia cmphiiticidty u disease of the 
cancellous tis-tuc; indeed, it would be somewhat difficult to 
comprehend how the compact substance could take on the 
actions of primary caries. A secondary invasion of the com- 
pact suhatanee in the neighborhood of active caries, whereby 
it is grotluaily changed in it« Btructnre by a process of oeteiipo- 
roflis, and then invadml by the ulcerative actions proper to 
caricB, i^* not at all uncommon ; hut any such afticni developed 
aa a primary nffection must be rt-gm-ded oa exnpcvlinply rare. 
The bones most comnmnly iiflectcd by primary caries are the 
the bodies of the vcrlobnp, the tarsal and carpal l>onM. The 
joint-ends of tbp tibia and humerus nre. amonp the long liones, 
the nioi*t frequently attacked, but no hone is entirely exempt. 
Fig. 17, from the New York Hospital Cabinet, shows the ex- 
tent to whieli carious dcfttniction will sornetimea proceed. 
The specimen hero represented is from "a mulatto waman. 



i 



SHIES. 



108 



wlio enflcrctl from escnicintiiig pain in the left car, witli dcaf- 
uwa and swcllinj;, for scvt-ral niotitlis, ot the end pf which tiDie 
lie died comatose. Patient had nud<;s and other bvinjitoms of 
Brpliilie. On oxamtiiatiun, the disease wa« found to have do- 
stn^'od aUuuijt the whole of the petrous portion of the tempo- 



H' 



£??:>£ 



m 



.r 



■■■-^fe 



^>V: 



F»o. n.— <Ffma Sow York nii»[>ttAl MuiFiitn,] 



ral bone. Tlie dura mater liatl been either alworhed or decom- 
posed, and an immense collection of pus extended nlcrng the 
wholt; «f the hftso of the hrain. After maceration, the remain- 
der of the temporal and a larp; part of the left half »'( the 
oeeipital bone, extcndinjj into the foramen nia^um, the left 
portion of the body of the uphcTioid. and a part of tlic arch of 
tlie BtloE, were found to have uniuibkd to pieces, thus leaving 
a hole admitting the closed liKt." 

The disease ta almost entirely confined to pereons below 
tfie «(je of pnhertv ; though a few cases of eariea occur in 
hiphljr'-f-crofidouB .vounp: adults. The carieB of the vertehiTP, 
independent of injury, is almost unknown after puberty, wliile 
the diecaso in the t&nius and carpne is occasionally seen in ibe 



adult. In general, it may bo Btatod tliat primary carlea ia an 
affection of cliildliooci and early maturity, while, strange to 
say, secondary caries is of compatHtively rare occurrence in 
childhood, but frequout iu tho injuries of bone and inflamma- 
tions of joints wbich occur in adult life. It would seem as if 
the abundant vitality of the child protected biiii against sccoa- 
dary cariiw, as a consequence! of injury; but that that very 
abundant vitality, if tainted with coustttutiunal vice, tends to 
crop out in priinnry curies and its allied di'^euses in early life : 
wliile, if the individual survive these early periU, the conitl- 
tutional taint seema often to disappear in a vigorous nialurity, 
and with it disappear the peculiar tendencies to disease vrbich 
characterized and imperilled hia childhood. It need hardly be 
added tliat no bone and no age are entirely protected against 
secondary caries. 

The prognosia of caries is always bad; that is to say, 
wherever the dii-ease ha* fully developed itself, seritnis conse- 
quences are eure to follow. Thei^e consequences may be lim- 
ited to some local destruction of borie-tisi<uc, which may be 
repaired to sof^h a degree tliat the form and usoftilncsa of the 
bone may not he lont; or they may be so severe that destruc- 
tion of joints and peril to life may become imminent — peril 
from whicli flmputation or cxsectinn alone can extricate the 
BuBcrer; or, tin;dly, in not a few cases, either in spite of the 
resources of snrfrieal art, or because we cannot brin;; them to 
bear, (loath will be tlio result. In primary caries, every thing 
seems to me to dt-pend on the condition of the constitution. 
If this bo dce]5ly tainted with scrofula, tho case is ainuwt hope- 
less from the bej^inninf^. If", on the contrary, the scrofulous 
manifeatutions are not marked; if the system be in a tolerably 
vi^rorona condition ; if the rerae'lies and the regitneu employed 
have the effect to invigorate and improve tlie general health ; 
then wc have a good ground for hope that the local disorder 
will prove tractable, and particularly if our romediea are 
brought to bear early in the cose. Indeed, I think this an ele- 
ment in ]>ro;fnoitis second only to the constitutional state ; viz., 
the stages at which tlie rliflease falls under surgical care. If 
remedies and particularly regimen, can be wisely employed in 
the earlier and forming stages of carious disease, I do not 



CAMfflL 



107 



hesitate to class it anmng the manageable affections. If they 
arc not aflordeJ till the ilestruclive features of the di^ense ure 
(lerelopcil, we can tlo little to avert it* consetjnences. Youth 
doCA not tieem to modify the prognosis so favorably as in other 
dueawfe, as the strumous taint of young subjects seenie to be 
more distinct and more di»a«trQus than in those somewhat 
older; but, nevertbelei>.s, I think it may be safely said that, 
other things being apparently equal, young eliildrcn do better 
with carious disoaae than tlioso in thoneigliborhood of puberty. 
One other clement in jirognopirt should not i>c overlooked, viz., 
social condition. Those who from wpnltli and intpllJ^nce can 
command, and will use with steadiness and perseverance, all 
the best resources of art, have a vastly better cliance in tliid dia- 
eaae of securing afavomble re!:ult, than can be looked for in those 
-whose circumstaoces will not permit them, and whose intelli- 
;nee will not ^nide them, in the wise um; of iriean>;\vliO(ie earo- 
ful application may have to be continued through long and 
weary months, and perhaps yean", of doubtful and aTixions care. 
Tliat the treatment of caries is, as a general thing, ex- 
tremely onsattii factory, I suppoie no surgeon of any experience 
would be disposed to deny. And yet, uio»t good surgeons do 
not hesitate to acknowledge the efliency of certain rciuedieSf 
and certain modes of management, in particular stages and in 
particular conditions of the disease. The study of treatmrmt 
may here be advantageously divided into two stages or periods; 
one wliich represents the commencing or inflammatory stage, 
and the other which has to do with the eunsiequences and 
effects of the inHammation. It is manifest that these penoda 
cannot be deiineil with accuracy, and tliat they must vary in 
different individuals, and yet in mo.4t eases ttiere can \w dis- 
tinguished a period where the inttammation is going through 
it» stages of ct^ngestion and effusion of scrum, of ]ymi*h, and 
of pus, when the inflammation itself is the main feature of iha 
disease, and requires to be tlie main object <d' attack in the 
trealment. Aguin, when the results of this infiHuiniation liave 
developeil themselves into absces.<t, ulceration, necrosis, and ex- 
tended disorganization, it is no longer so much the inflamma- 
tion, as it* results, that we have to do with, and the^e conse- 
quences now have become the main features of the case, whilo 



Ids 



TWPiw OF BONE. 



the inflnmtnatory action ifeelf may have ceased to be an object 
of special consideration. ] n the firs! ataf^e, then, xce hare to deal 
vttli an infiammfltion wtiick ifl eiAentially subacute, and will 
hardly bear active depletion. Nevertiieless, a few leeches over 
the affected part, perhaps repented at intervals, will certainly 
euutrol tlie teiidenie&6 and pain, and seem to have a good efl'cct 
in pre|)»iiti{i tlie way for other remedies. I have eonielinies 
employed this treatment in the earlieist stages of hip-tlifleaae, 
depcndint; on osloitis, witli a t;ood effect in quelling the noc- 
turnal atrwcks of pain, with which the first stages of this affec- 
tion are eometimes actroinpanied. Two or three leeche* behind 
tlie trochanter in these cases have seemed to me to do ^ood, 
particulai'ly if repeate<l at intervals of ton daya or tM'o weeks. 
At the eamo time free local depletion is not uMowable. The 
local actions are too Blug;j;iish, and t^o niueh dependent on con- 
stitutional caiiseB, to he lavorahly modilted by considerable 
losses of blood ; and it shonid always bo remembered that the 
vital powers of the jiart are to be taxed heavily for many 
weekd and months, and it would be very poor preparation for 
fluch effort, to weaken tbe part by too much cr too frequent 
local hlecilinfr. liJiftterB may also he of service in relieving 
pain, and it \n reasonahlc to bolierc that a pnt;ilive advantage 
may be derived from counter-irritation, particularly if periov 
teal surfHces are the oeat of the inflammation. We ai-e cau- 
tioned by most writers against applying blister* too near the 
•eat of an inflammation, a caution which probably in acute 
BynovittI affect ions of tlio joints is a wise one. In cases of 
oeteitiB, which we fear will pmve to be carice, however, I h%ve 
never Iiesitated to apply my blister immediately over the atfeot- 
cd part, and have always felt that its action vvjis iiTicful in pro- 
portion to the precision with which it eonld be brought to Iiear 
on the threatened locality, and I have never realized any injury 
which t^eemed to mc attributable to transmission of the surface 
irritation to .the ])arts beneath. In the use of blisters in these, 
and indeed in all cartes, I have the conviction that it is their 
primary effect which ie the valuable one, and that they are very 
poor and very unconif(»riab]e derivatives. If any sucli pcrroa- 
nenl drain is desired, it is much better attained by an uiaue or 
seton, and I never uow keep my blisters sore. 



CARIBa 



100 



Tlie more powerful derivatives, the Jasne, tlie *eton, etc., 
have ill former tiinefi been verv generally leparded MJtli high 
favor in tlie trentiiicut of eaj'ie?; but wliuther their itiiportance 
h»A not Iieen oxo^^ratcd, admits, I tliiiili, of a quci^tiai). Mr. 
Brodie speaks tnihe!)itntiii<;lv ; ho sHVf,: '* I much dunbt vvbethor 
BOtons and issues are ever u^^efiil, excojit in suine cases in which 
the <)i^n«c has its seat in tlio hip-joint.*' Mr. Barwell gives 
them crc'^lii for doiii};; socno good in the earlier or iiiflammatorj 
stage, but denies them all value iu the second or destructive 
condiliuD of tho bono ; while he ackuowlcd<;ca that their ap- 
plication, and particularly in the form of tlie actual uautery, 
has u marked effect in arresting the puiii of the disea.se — an 
arrest wbich he iiuistft is always very lempurary. Buth from 
reasoning and experience, 1 bave been disposed to accord a 
higiier value to them: rcmedioa than iti given thcni by tlie-se dis- 
tinguished writers, but every thing, 1 tliink, .depends on the 
character of the individual case to which they are applied. In 
tbfise sluggifth, painiesa, dluwly-progresHing disorganizations of 
the bono which are fuiiiid in connection with wbat wo ealt 
white swelling of the joints, where every local action seems the 
expression and ret.ult of a cont^tiluiional cacliexia, and when 
tho ordinary demeanor of inflammation is entirely marked by 
that cachsxia, I acknowlcigc that little or no betietit ia to be 
derived from thiscla;** of remedies. But in all those, perhaps 
more ouiueroas casee, where the inflammatory pn)i:i!ssO!4 »how 
some of their normal activity, and wliurc it is rather the appre- 
hension that the vital actiuris will be modilied by titrnmoua 
sloifjisline-^s, than that tliey aetually indioato the presence of 
that unfortunate taint, and where great sensitiveness on motion 
or 095 shows that more acnte actiun could be easily lighted up, 
and when particularly the case is complicated with, and, as it 
were, interrupted by, attacks of acute inflammations from no 
Tery obvious caiiacs, then 1 eoneeivo that wo have in perma- 
nent derivation a very important means of cimtrolliug and 
oflen of curing the disease. In tliese eases the seton or issne 
(and I greatly prefer tho iiauc), placed a little distance above the 
affbcted bone, and m arranged as not to interfere with the ap- 
paratus which is to )mi applied, nor with the motion wliich by- 
aod-by will have to bo made, and kept running with ituue-poaa 



110 



DISEASES OF BOKB. 



-until tlie actions begin t« indicate clearlv that the tendencies 
are towKrd c^nre, and then allowed to ditninigli in amount 
of suppuration, and gradually to dry up, ib, a& 1 l>cliore, a 
very positive agent in promoting the cure. In llii^ resj 
the aclunl caul^ry liohU a high imsitioii. Its primary aclicMi' 
is fto peculiar and cnerjjeric that it controls with great cer-^ 
tainty the AymptoiiiH of the disease fur a time, and iO restdt 
ant i^ue is the beH that can be made. In the most acute' 
case^ when much pain i^ an early and prominent eymptum, 
consider it peculiarly valuable. 

The MAC of mercury in osteitis tending to cnrica has also 
been the subject of much dittereuce of opinion atnonjf good 
surgeons. My own experience in unequivocal, and has im- 
pressed me strongly witli Ua value in appropriate cam^ And 
thetie.will embrace the early stage of a large proportion of the 
whole ; all, indeed, excepting IIiobo of very feeble constitution 
and irritahle lihre. Two ways of using inercnry are commonly 
employed with entirely dltterent indicatiouB, one aa a purga- 
tive and the other a^ an alrorative. The purgative action ia 
Bappo«cd to clear the intestines of such vitiated secretions as 
oppose their proper action upon the alimentary maa<>, and ii 
tb» way indirectly improve the cliaracter of the nutritive a( 
tions, while the alterative etfect, obtained by the contini)uiis| 
admini.-^tnitioii of suiall iIosca, is Ruppo&ed to kIiow itaelf not 
only in an improvement of these nutiitive actions, but nUo and 
principally in a direct effect upon the course of the inflammf 
tory di^JLte whicli it is BU]n>ORcd to affect favorahlj". Btitii' 
these modes of using mercury are nwful in this disease, la 
the forming stage of »uch cases as occur in patients of tolerable 
vigor, and with inflammatory symptoms of some activity, mer- 
curial purgatives occasioniilly adniinislered have the happiest, 
effect in improving the general condition of the system, tun 
often in directly relieving some of the mofit distre-wing of the 
local symptoms. Mr. BnrwoU very happily illustrates this ef- 
fect by the well-known inflncnce of mercurial cathartics in cer- 
tain casps of strumous ophthalmia, where such surprising relief 
16 often found to accompany their proper employment. 

The alterative method also has its value in cas^ where the 
progress of inflammation seems steadily onward, increasing it 




GARIEB. 



m 



area and accompanied h; digtrGOAJng pain am] ^tariingf^ at night, 
with fever, niorc* or k'ss distiiiclly developt'ii, at irre-iiihn- inter- 
vals. In therte cme& the tarel'nl use of calomel, comhincd with 
opium in small do^es, has seemed to me in many inittanceK to hare 
had the happiest effect, both on the sufferings of the patient and 
on tlie progress of the di&eaae. In more chronic, less distinctly 
inflammatory cases, I have much confidence in the controlling 
power of the hichluridf, ustd in excecdiugly Bninll doees, say 
tJie twenty -fourth or thirty-Becond part of a grain twice or 
tlirice a day, combined with tonics, and pereevcringly employed 
for wf?eka or even montha. I need hardly say that in all the 
mctlifxU of employing mercury its injurious effects shonhl be 
carefnlly guarded against — hypercathnrsie on the one hand, 
and Salivation on ihe other, l>eing likely to inflict more mia- 
chief than the happiest influence of the drug can connjensate 
for. 

In regard to the necessity for rest of the disensed pnrt dur- 
ing the earlier ataget) of uaricit, all aiirhors art* agreed, and their 
jiidgnient is in accordance with the instinctive feelings of the 
paiient. Much, however, depends npon the thoroughness with 
which absolute rest is not only indicted on, hut by approjiriate 
arriuigements secured. In the acute case:*, when the disease is 
iti the lower liinlw, the bed is the only Becnrily against injuri- 
cus and painful niutimi ; and even in bed it i? ullen necessary 
to apply Rome apparatna to the limb to eecwre it against in- 
voluntary and accidental movements. A9, almost all cases of 
carieA oecnr in immediate proximity tn joints, the treatment 
of tlie l)one<li*©a8e involves, in all its stages, the proper man- 
agement of the joint, and here the indication is to keep the 
joint immovable in order to give rest to the inflamed bone in 
its neighb<irhood ; and miich comfort, and I am sure much ad- 
vantage, is seenred to the patient liy splints so aiTanged as to 
secure him against the piiinfiil movements to wliifh iicoident 
or mnscniar Bpasm makes bira continually liahlc. About these 
points there can Iw Init little diversity of opinion or practice, 
but the more important question presents itself: IIow long 
ehnll abtHilnte re»t he maiiitaineil, and how goon and to what 
extent may use be allowed i I believe thcro is no more im- 
portant practical point in the history of these diseases, and I 



lis 



DISEASES OF BOXB. 



am Biire there is none rcquiriag mora careful nod enliglitonod 
judgnieiit. 

Tlie importance of tliis {Htint arises ont of the fact that dis- 
use of a limb is certain to be followed by atrophy, and atrophy 
means deKoneration. Now, where this degciieratioii of all the 
tiK»nu6 of A limb has been going on through inonthA of di»U8«, 
it fteems to me to be certain that the reparative )>owere of tbe 
part must bo depreciated in a proportional decree, and I have 
long been of opiiiitHt that umny caues of uhroiiie surgical dia- 
eaAo arc prolonged itidelinitely, and gometiiues brought to an 
nnfevorablc issue, by this losa of reparative vitality, from t»io 
long-continued disuse. It is confts-iodly a difficnlt point to 
decide when passive motion and when active use should be 
allowed in the^o caaes, and I do not feel competent to lay down 
dietinct rules by which pmelice sliouU here be guided. The 
general priiieijde:^ of action are that, as soon as active inflam- 
mation hns sufHeiently suhi^Ldefi, the use of tlie limb will pro- 
mote the vital ai^tivities which have been Luld in abeyance by 
diaoae ; and that, therefore, we should endeavor to seize the 
moment wh'^n inflammation will not be aggravated, and when, 
therefore, nutritive activity will be increa.'^ed by appropriate 
exercise of the limb. In judging of this, we must be giiide<l 
prineiptdty by two symptoms, viz., the Imat and the tenderness 
of the part. If boat have fiteadily and permanently sutisided, 
until tlic ordinary eondiilon nf the diseased part ia oneof natn- 
ral tompprarnre, oa appreciated by the hand or by the thermona- 
eter, and if at the Banie time tenderness have so far dimiiiisliod 
that moderate pressure is no longer painful — always pr>vided 
that the other morbid signs have also been undei'guing a favor- 
able change — we may snpposy that tlie time for coijaidering the 
qnostion of pasaivo motion has arrived. And ]>erluips there b 
no bett3r way of ascertaining the fact than by cautiously mak- 
ing the experiment. When, Ihcrefore, circiiuHtancM seem to 
indicate tltjit the proper time haa come, careful ami very slight 
movements of the joint should bo made by the surgeon's own 
hands, for thi<s is a (htng that should never be committecl to 
tha patient or Ins attendant?, repeated daily or at such inter* 
vals as may seem best. Undoubtedly all local symjitoms will 
be increased for the time by suuk a proeedare, wbioU in its 




peHbrmance will j^ire the patient mticli pnin. This need not 
nocc&iiatilv f<jrliiil ite re|)ctLtion, and ti_T no nicaiia intii(»i.to!>thAt 
it id not judiciifUB, amj it i* tmlv l>y iw ulterior ctlect tliat the 
wi^oni of the manipulation can he vindicated. One practical 
prew-'pt, for the cltnicul enforcement of which we were all ia- 
<)ebted to Dr. Alexander IJ. Stevens, then Siirjyomii of the N'ew 
York Hospital as well as Professor of Surgery in the CoUego 
of PlivBiciaui and Surjiconif-, geeuis to me a kuIc ai>d useful 
guide in this mutter, %'ix. : if the pain utid teuderuesii produced 
br passive motion last more than twenty-fonr liimrH, we have 
done too much ; if, on the other hand, liow much soever pain 
wc niav give in the manipulation, its effects have entirely 
passed away by the same hour of tho next day, we may be 
encourage<l to prooeeiL "Witliont claiming this rule to be a 

itive ffiiide, I can say that I have found it a very uiteful 
tant in my own case*, and one whieli hua very rarely seri* 
oa&ly misled nte. Anotlier and an icn])ortant point is still to 
be decided, as to when the use of the limb may he advanta- 
geously |>enniirBd. Tins qnr-^l ion will no doubt gtMit-rally ilo- 
«ide iraclf, as the results of passive motion arc duvelopcd, but 
fitill aises pre.'ient thein-elve>t where pasHive niotiou has been 
souielinies employed without nianifest injury, and yet, where 
no tmpruvemcnt follows, and where the general atrophy of tlie 
limli is ao decided at^ to lea<l tu the belief tliat noihiM<^ but the 
ainiuLuB of use will brin;; about a healthier reparative eondi- 
tioo^ In these cases careful but courageous use, ]icrAcvorlnglj 
and judiciinisly iriMsted ujmn, seems the only way of si>lving 
the |>rolde:ii — a solution wliiirh h Romettmos among the liappi- 
est and most saiisfactory of stii^ical therapeutical results. 

Id seeurinf; the complete rest, so necessary in the earlier 
stages of caries, position is most carefully to bo attended to. 
The limb will ui^nally have assnn]erl,if the diseafie have been 
long in existence, a pcKtilinn to which the patient haa been in- 
Btinctiroly led by finding it most comfortable. This position is 
D^aally one of moderate flexion of the joint implicated, if it be 
» lar^ joint.aa the knee or elbow, %vhile the wrist or ankle 
will iiu kept nearly midway iK^tween flexion and extensioa, 
which will be for the wrist nearly a Btrait;ht position, and for 
the ankle about a right angle of the foot with the leg. It otten 
e 



114 



DISEASES OF BONK. 



LappeiiB, liowever, tliat tliis jiosition has been allowed to bo- 
come ft viuioiis one, and one which, if maintained till a oiire ' 
accnm|tli»hed, would leave ihe Hmh in a mure or kt^ <leforin( 
and useleea condition. The!>c faulty positions may l>e almc 
invariuhly rectified 1»y ^adual and very earefiil extension whic 
may he applied by tho apparatoa nscd for securing the roBt 
the limb. Our inAtrtiment-makent make a very excellent light 
frame, well padded with sirft leather, which, moving on a hinge 
at the situation of the joint, can be dexed or extended by ^^ 
Bcrow. This Aorew U moved hy a key, which is retained by tl^f 
eur^'on or the nurse, bo tluit in unruly children no lettinp up ' 
of the pressure can he aceompliahed without pro|ier advice. 
By the steady and p'i'lofil a]]i>lication of a gentle force, the 
rectification of position can iii-uatly be acconiplislied without 
division of tendotis. With some snrgeona thi* division of ten- 
dona and contracted mui^cles ia much resorted to, and inucli ad- 
vantage is reported tm hein^ pained in the treatment, in relieT- 
ing both the fipasmodic and tho ])ermanent contraction of tl 
mitsclea. My own experience doea not entitle me tnpronoum 
on it8 ralne, as I have rarely had occaaion to resort to it. 

If the c&iiC have heeu under onr care from tlie onset, theil 
there is a mode of securing rest to the limb, the most couiplct« 
and comfortable that can he attained, which preventct any 
aihiHty of a fiiulty position, and which is attended with 
very great advantaj^ of relieving the pressure of tlio j( 
surfaces against one another, prodnced by the tonic contraction 
ot the muscles surronnding the joint. I alhide to what is now 
commonly spoken of as elastic extension. Extension is applied 
to the limbs by means of the adhe^iive bands, and the weight and 
pulley, as is now universiil in the treatment of fracture"! thigh, 
an{l this, in the case of the knee or hip, is made while the 
patient if- tying on the back, and at other joints in varying 
positions according tn the part involved. Somewhere Wtween 
the pulley and the limb, a band of India-rubber is intnHlac 
through which all the traction passes, and this hy its elasticil 
ao equalizes The extension that it is ntways in uniform actioi 
and can bo borne without the least inconvenience, 
advaotiigeg of this mode of managing the oarlieibt stages 
joint atfcctious are incontestable ; and in oariee it cannot be 



CARIEa 



110 



I 



leEB important, both to the comfort ant) to the cure of the 
patient 

When carii», as is too often the case, provca unmaniiffcable 
bv all the remedies employed to check itft progress, we have 
often presented to us ft surgical prvblera whieli deals with the 
results of the carioua disorganiKatioo, aud in which the maiti 
qaoetiOD w, What shall bo donu with the liopulesbl^'-diueaMHl 
bone, and in what way can it best be prevented from inflicting 
injory on the surrounding healthy tiasiica, and on the patient's 
general health ? This problem emhraces the destruction or the 
removal of the diu^ased hone, and mnst, of course, in its full 
decUion,de|>end upon all the particular circnmatancea of situa- 
tion, degree, age, general couditiun, etc., whicli give individual 
character to the ciwe. Some general considcratious, applicable 
to all eases, however, will help ur in the solution of each par- 
ticular problem. The destruction of the diseased tissue luiiy 
be effected cither by the stronger eachorotics, or by the actual 
cautery. The difficulty of HmiTlna; the action of a canatlc, 
and the nucertainty of its effects, have been, I snppose, the 
reasons why they liave not n^aally been employed for this pur- 
pose; while tlte oompluteuess of the destruction, and the cer- 
tainty with which wo can calonlnte upon its extent, are good 
reftflons for preferring the hot iron. Ilic most favorahio cases 
for the use of this method of treatment must he those where 
the disease is either not extensive, or is mainly situated over a 
•arfiice which can be easily reached by tlte application. To 
such cases the iix)!! is applied nt a full red heat, holding it on 
the diseased part until its full etfect is produced. Of course, a 
careful preparatory exposure of the bone will be made, mid tlie 
soft partA <lruwn aside, and carefully protected against the heat. 
The destruction of.tlssne thus produced is usually not so deep 
m4 woald at first sight appear, hut it is pcrfoct, and the whf«le 
burnt substance now occupies the wound only as a sequestrum, 
which soon separates and is cast off*, leaving either a healthy 
granulating surface, or one which indicates that the diseased 
tissue is not all removed. If this be found to be the case, then 
tlie application must he repeated at proper intor\'al3 as ofren :u 
msy be ueoessary. The older writers speak very highly of thia 
method of attacking caries, but it seems to have lost credit 



110 



DISEASES OP BONE. 






with the more modem gni^eons; perhaps, becaasc theTi 
operatioDft for removal of dUoiuod bone huve attracted do mo 
of their atteiitiuu, and are, afWr all, tlie uu)y o))eriittons to 
relied on when tlie cariuus disease lias invulvcil the j^router 
port or the whole of a hone, or of several contiguoas bones. 

The operation uf exseetion or excl^riou of bone in comj>ara- 
tively a nuxlem one — Mr. White, of Manchester, being com- 
monly regarded na the tirat who, hy n defineil and purposed pro- 
cedure, undertook the removal of carioua hone, he having re^^ 
moved the head of the humerus for caries iu the year lTOd^| 
Since his time, eai^eonft have bsen gnidiially growing to the ap- 
preciation of the important Atep thus indicated^and no operation 
hafif duriu}^ llie IhaI lifty years, cotnmandeil more univei'sal in- 
terest than that of excision of carioua bone, particularly in 
connection with the diseases and injuncA of joints. The pri 
ttiple of the operation h founded on the fact that the cartes* 
localized in ita action, and that, when the ditseaeed parts ai 
rt-'inoved, healthy reparntivo processow may ueoxi>ected tobegin^ 
and the succe&s of the operations founded upon this prineiplo 
may be properly said to have inaugurated a new era in the 
treatment of iH[*ea'«ed comlitions of the joints. Ex*ection has 
now been practised on almost every bone in the body; «n<I 
while the value of the procednre varies much according to the 
locality affected, yet no doubt remains of the great valne and 
inijiortanco of the operation itself. 

The o|H>ratiun eori6i.--tti in exposing the diseased bone by 
api>ropriate incisions, and then, with the eaw, or the buiie-for- 
copa, removinp; all that portion which l-* iinplifatcd in tlie dl*- 
order. As this operation is so commonly iierforineil for caries 
a.4 a part of joint diaurgnnization, it is uitiially perfornie<! in 
ench manner as to expose and remove bntli ot the opposed joint 
surfaces, and it is tliii^ operation which is meant when we speak 
of exsection or excision of the joiiito. In 0}^K>ratiiig thus, 
great care is to be taken not to interfere any further than is 
nouei>sary with tondlnoua insertions, in order not to impair tlio 
efficiency of the mu»riikr actions of the joint, and aUo not to 
remove any more of the bone than diaeas3 msbc9 necessary. 
It is Irne that Nature h.i» wonderful resourcas Jn repairiu;^ the 
mutiUtioD of this procedure, and surgeons have not hesitated 



oniESL 



m 



V 






to remove fieveral inclies of each bone wbcre it has l>een clearlj 
neceflsarr, but the rule of BiiTiiijr all lliat may be sarcd ia none 
the less imperative, and the Auc«es>i of tlie procedure wilt, in a 
good dej^rcc, depend ti]>en tlie amount of bone wUicli is taken 
»w«y. Wliere tlie operation is successful, one of two rei^ulta ts 
realized: tirirt, [ho woiimlod Eurtaucs Lake oti a liciilthv action, 
and the bone grantilateis and » uuiciiig medium thuB forms 
which ultiniatelj becomes iirm enough to produce an unciiylo- 
eU between the oppttsin*; bone*; wliile, at tlie same time, all 
diseased action cea&cn, and the Aoft partei cicatrizo aoundly. 
Tliia is the result mofit ctinimonly aimed at, and, jirobaMv, 
always most desirable in tlie lower extremity. In the upper 
extremity, however, a certain amount nf motion is hoped for, 
and quite frequently a useful degree of it i« attained. Tlie 
uniting medium does not cotni>IeteJy aotidify, but remaint: euf- 
fieiently yieldinj; to imitate some of the movements of the 
original joint; while, if Ihc tcndinonit insertions havo not boon 
too exleiisivply diftturbed, the mui^clea n*nme their ]M)wer, and 
an amonnt of voluntary motion is rcgiiined which is olteii ex- 
tremely valuable in the shoulder, the elboir, and the wrist 
joint. In realizing these two different rwults, of courhP, much 
wilt depend upon ttio n>an»getnent nf the limb after o]>eratLon. 
If firm anchylcsis is desired, abM)luto rest will lie most care- 
fully muintained during nil the cure; while, if motion i» sought 
for, properly conducted pat-sive motion will be the principal 
means of arriving at the resolt desired. 

The MiwesK of tliese operations has been extrpmely sntis- 
factory, and, when we consider lliat the alternative presented is 
amputation, we can hai*dly accord too high a position to this 
preat conftrvativc triumph of modern surgery. Two moditicn- 
tione of tiie o])eratioii of exciiiion for caries have lately been 
presented to the surgical world, by men of eminent repute, 
both claiming superiority over the rivdl iini[K»sal, as well as 
over the old operation. These arc hmught forwarti reftpective- 
ly hy M. Oilier, of Lyons, and by M. Sedillot, of Paris ; both 
ar« fortilieJ by a eonsidei-able number of cases, and both are 
reasoned out with gwat ficientilic ability. M. Oilier claims 
that the trus method of excision is what he cailti the Aulvperi- 
obteal section ; that is, one in which the diseased bone is re- 




118 



DISEA8B8 OF BONB. 



moved, leavtiiK behind its periosteal eovering. Acizordiiu; to 
liU views, which indeed arii thtisc jfciieraily received, the peri- 
steum U the great byue-produoer, very greatly superior iu this 
power to any of the sarrouuding tituuea, or even to the boue 
itself. If, tlmrutbre, in any oxsectioris of hone, we leave the 
periosteum behind, wo have the element of reproduction of 
tlio bono to help ns in ttie reparative procesfles which we are 
anticipating; so that, if every thing proL-eeda favorably, we 
a<!eoinplw!i, by sub-pcriostcal resection, not merely the removal 
of the disease, but the regeneration of tbo Itono removed, so 
perfectly and to such an extent as makoa the result more per- 
fect and more complete than can in any other way be accom- 
plighed. M. Sedillot contends that the perioaleum cannot be 
relied upon to do its full regenerative duty iu these cases, and 
that the only way to Eccure a complete retbrmation of the bone 
to be reniovod, is so to proceed as to leave a thin shell of bone 
attached to the periosteum, from which shell lie says there will 
be the most perfect possible regeneration of the hone removed. 
His operation consists, therefore, in scooping out all the dis- 
eased bone-tissue, leaving behind a thin layer of bone, attachod, 
of coiir^ie, to the periosteum, and forming thus a thin shell 
which uiaintaiiis the shape and size of the bone removed, thna 
preventing^ according to M. Sedillot, the deformity which 110- 
cedSfirily follows the other operation, and which, M. Sedillot 
beli()V(!3, will not in any material degree be preventeil by M. 
Ollier's sub-peri osteal method. Much has been said, and many 
cases have been published in the journals, by some of the most 
eminent surgeons of Europe, on this subject, and the reault 
of all the diacussion seems to be that neither operation is en* 
titled to exclusive preference ; but that, while the old operation 
is the only one which can be performed in perhaps the greater 
number of cases, yet there are a certain number in which the 
new operations will realize many of the advantages claimed by 
their enthusiastic originators. Active minds are indnstrionsly 
employed on this interesting subject in every country, and the 
apiirociation of the various operative methods bids fair to be 
soon practically settled. Mr. Hancock, in I/Jiidon, has done 
more than any other man to illustrate and enforce M. ScdillotV 
views, and very [iiuuerous experimenters in Europe and in this 



NECROSIS. 



119 



country have proved tlie value of M. OllierV important sug- 
l^tions, Wliile, therefore, satiie features of tlie opunitiuii of 
cxsection of hones may still 1>c considered as not yet fuHj and 
finally decided opon, the genfrrat valae of tlm operation and 
ita efttimation m a fiurgical resource are gaining daily, and it 
now ranks as one of the most valuable cuutrlbutioud of modetn 
Bcieoue to conservaliva sur^^ery. 



CHAPTER XL 



S1CROSI9, 

Tub death of bone, so common in its occurrence, either as 
a primary and eeflenttal, or at) a secondary and iiccidentui eir* 
cnmstance, is one of the most extensive and interestinjj^ sub- 
ject* whicli bone pathology presents. For the frequency of 
ita occnrrence two circn instance*, connected with its vascular 
supply, [ireseut theuieelveo in explanation : Fii-at, the porioa- 
teum contains a larger part of the vessels whose i-mall brandies 
pas£ inward to supply the snperticial or sub-jteriogteal layers of 
bone-tii^uc, and upon ihc. integrity of thi-( niiimUriirte, and upon 
Its close adhesion to tlte hone, depends the eontinnauce of this 
jpply of blood. Now, it so happenB that the ]ierio9tenm is 
ible to injury or inflammation, which may eiiher destroy it 
m tUu, or, what is more common, may cause an etfusion be- 
tween it and the bone, which, separating it from the bone, 
destroys the continuity of circulation between the vessels of 
the perioBtenm and of the adjacent Iwne which tliei^e vessels 
sbonld nonrisli. In this way, there is no doubt, many super- 
iicial necroses take place, and a considerable proportion of the 
thin exfoliations we so otten see after slight injuries are thus 
produce*!. 

But, in the second ]>]ace, there is, in the expansibility of 
bone-Ciwue. another and more widely operating cause of necro- 
■u. All the circulation in the substanno of bone is through 
Tessek traversing liony canals which they entirely iill, and 
■wbich canals, therefore, compress and support the vessels on all 
fiiJes. Under the firat stimulua of inflammation in the soft 



parts, it is well known tbat the veMels are crowdcU witli bio 
HO as to be largely dilated in thoir mlibrc. Thi^ ililutatio^ 
would Beeni to be a nc(.-C!»ary rnouliaiiicHl result of tlie iucrease^^ 
(juantity of blood forced into tubes whose walU arc capable o^l 
yieliiing, and it wonid also seem to l>e a nocewary vital action 
whereby the yielding veasel grown more capable of traniinit- 
ting the increAfied current of blood, which, without thie rulief, 
would be damrnetl up and stsg^iate in the capillaries of the 
part, thu8 arresting entirely the eircuhitioD, which, if life is tt^- 
continue, should only be retarded, not stopped cntirrly. Olfl 
this yielding: to dilat)n<r force, of eourBc,tlie vosseU of the hone 
arc by their position entirely incapable. In bone inflamn)alion, 
therefore, the blood, attracted by the new stitnuloa, crowds the 
nnyieMiTi}; capillaries so urgently that transiniKviua of the cuqH 
rent beeomee flower and slower, tlie thiiiuer parts of the bltjo^* 
move on, while the corpuscleg become more and more janiiucd 
and packed in the channel now relatively too email to receif^H 
their increased number, until presently the current is arrestc^i 
nitogctlicr, and the circulation erases. 

Thus it would appear that one e^Acntial element of scote 
inflamntaltDn of bone is &ucb a mechanical condition of the 
afiV'ctod ]>art as directly tends to the destruction of life — a 
destruction, the certainty of which depends probably more on 
the aeutcnesg of the attack than on its severity or extent. 
That thiR is so wc arc in-'triit^tctl by obser%'inj; that the delib- 
erate actions of chronic inflammation, though extensi^'C and 
severe, sre very little liable to produce nocmsi!>, whatever 
other diuastrtnii accidents they n;ay entail, apparently because 
the vascular moretnents are of such a character as to give time 
for the vessels and their bony canals to nccommodatc them- 
selves to clmnges whicli, in tlic acute in Ham mat ions, hurry on 
the Imne to death. Tliefte considerations may also serve to 
explain the fact that the compact tissue of bone la more liable 
to necrosis than the cancellous. In the cancellous tissue a 
large part of the circularion is difitributcd tlirough the medulla, 
the terminal capillaries alone entering the bony channels, and 
hence any increased livdraulic preaaure is received, in great 
part, U])ou vessels which have the space in which to expand. 
In the compact tissue, on the other hand, the whole vascular 



KECROSIS. 



Ifll 



iy>tom of the part h contained within the ripd Uavcrftinn 
canals, and the pressure ia resisted wjiiallv by the capiHarics 
L aud the veaseU from which tliey spring. Hence, duuhlleise, 
B the coui]>arative froquency in the one and the rarity in tho 
■ other tiiSi^ue of an accident, wliich han, in its nature, no ele- 
" incnts of (liflerence heaidea the mechanical one upon which we 
are now insist! n^. 

IFrom thfl «iudy of the*e JntrinMC prediftjWAing conditions, 
•we may deduce the most important exciting cause of necrwis, 
tiftincly, inflammation; or, in other words, we ni«y appreciate 
lh« reason of tho acknowledged fact that inllannnation id the 
^reat producing caii»o of necrosis. All those ucciOenta and 
exposures which are likely to jndu2o, and all those conditiotm 
of the system wliich favor, the oecurrcnco of inflainmaticn in 
Rny of the eomponent Ittt^im^ of the bone, may be regarded as 
the exciting and iire<Jis]H)sing causes of necrosis. 
H Of the predispo^itig causey we have those that are local 

»nd those that arc general or constitutional. Thus the snper- 
:fli.-Ia1 ftitnatiim of the tibia, and its con^ieqiient ex|ioAnre to the 
'^icidsitade« of teuiperuture, are thougfit by some to be Die ex- 
■jjJan:ition of iti greater Kubility to necrobis; an explanation 
'%vhich will certainly stand, in tho^e cases where the diseuse 
follows injury, to which the hone is more liable from it* ex- 
j30Bed situation. At;atii. the condition of tiio rireulatinn in the 
lower eitrenittic^, as intlnenped by standing, exrrciso, etc., is, 
cionbtless, often a pre^H.^po^ing canse of bone inrtammalion, 
^nd, therefore, wmetinien ufneerosi*. But the nio»t nneqniro- 
^5al of the predi.-; posing caiujos are those which may be termed 
c=oastitationaI. In the scrofulous and in the Byphilitic there is 
*»iauife3ted a tendency to hone-discnse ; in fact, a predisposition 

IX.O necroitfi, which only recpiires a slight exciting cauec for its 
development. Jiesiiles these, there are certain nhnidcr, deli- 
<£ate. feeble [lerHons in wliom no syphillia and no scrofula can 
l*c detected, and yet who show a proclivity to necnwis, which 
is evidenced by the repeated attacks, perliafM at fAr-ilUtant 
T^riiH^s, of the di#ea«e in varirms situations, and provoked by 
exciting causes so insignificant as often to leave us in doubt 
'A'hether the ftfiectiuii might not be regarded as spontaneous. 
To these ought to be added those enfeebled conditions of the 





ISS 



DISBASBS OF BOKK 



BysCem which are underatooU to favor mortilication,BUch as the 
condition tiuluced by lon<( exposure, ]>rivation, and ImrJsliip, 
aud ]>artieularly the conditwn following severe and exliaiutive 
difteasei, as scnrvy, typhoid fevers, and such other disorder* as 
may be presumed todiuiiiiisU Ihe power of the circulatioa to 
luaititaiu itdeli' ugaiust the tsudduu a»saitU of iiitlaiumatioQ. 

AVilh these prudtspusitiuti^, both local and general, the ex- 
citing cBUtws of necrosia may ho enumerated aa — 

1. Kt/xmire to Wei awl Cold. — I bftllove this to be a very 
common cause of the dittraap. It would seem aa if exposure to 
mere cold, while it has great influence in producing dui>erficial 
mortification, did not ettpecially conipromii*e the borie«; wliite 
the combination of wet and cold is one of the moat common 
Cftiuea of indamniation in tlie osteons gtructuree. The modtf« 
operandi, on the b^jiiee., of tliie partieulur e^cpodure id not mora 
eaally explained than the action of the same cause in producing 
catarrh, bronchitis^ or rhcnmatism. All chat can be i^aid is, 
that it ftocmtt to be an analogt^nitf proc-u^it in the case of the 
bonet!, intuiitiified by the fact that tlic bones most liable tu 
suffer are those most liable to direct expoftTire to the injurious 
cause, ax the bane.4 of the feet and the shaft of the tibia. It 
would seem, also, tlmt the exposure must be prolonged tu 
order to produce ittt effect, for we tiiid that mo^t patients 
report their attack as having come on after long tniniping 
through snow and ahish, or ut\er bathing too long in rather 
cold water, or some such exposure as has been prolonged suffi- 
ciently to act as ail exhauster of tUo general power of resist- 
ance, as well as a depressor of the local circulation of the part 
about to be affected. 

S. Injury. — In a variety of ways injury may serve as the 
Btarti tig- point of a bonu-lntlaiiinnition, which shall terminate 
in necrosis. Oontasious, lacerations, pmictaros, detachments 
of periosteum; fractures, strains, l)cndlug>4, and crushing of 
the bone it^lf ; lacerations and expotiiires of the medulla are 
all causes of inflammation of bone, which may take any one of 
the many courses which in such cases is determined by the 
cunstitution and the surroundings of the patient. As a direct 
and immediate cause of death, injury does not often act. It ta, 
rather, by setting u]> of iuflatnmatory actious, which, by on* 



NECROSIS. 



IflS 



» 



influences, shall bo so modified na altlmatelj to pro- 
doce ft t'atftl effect that injury' acU ; and tbuA wc may i-onflidcr 
violence as ratber the iudii*eot and fiecondaiT, tlian as the 
direct and immediate, cause of necrosia. The inflamniatioDB 
whicli lullow injurj,- to boues arc gciicrallv lor»lizLH.l aliuut llie 
injured parts, and are niuderate in ibuir accei^c>iuu, t^u that it is 
not till Buppuratiun ha& taken place, ur exputture to tUe air has 
urrcd, that we tind, ad an ultiuiutc result, that ii limited 
mcroeiit has taken {)laee. Tlii^ iii well illustrated in certain 
compound and comminuted fractiirca, where the injury to the 
tone is about as severe as it can be, and yet where, it' the frac- 
ture behave otherwise well, we expect no necrosiB to occur; 
and it ift only after long suppuration, aud perhaps denudation 
of periosteum, and exposure of the bone t<j the air, und to the 
putrefying dischargcB of the wound, that we find a email por- 
tion of the end of the broken fragments has fallen into necro- 
sis. But besideii these caws wliieh may represent the behavior 
«f bone after injury in a beallhy condition of the system, and 
■under favorable circnmstancca, there are a certflin number in 
"wliich — a strong [)redix|K)rtitton to bone diwase existing — a mod- 
crate injury will be the starting-point of severe aud destructive 
inflamtuatiou, rapidly tvruiiuatiug in necrosis. Here the ex- 
diting playa »o much less importrutt a part than the predis- 
^oging cause, that it is often dilticult, as before remarked, to 
l-»c rturo tliat the injury has had any thing to do with the pro- 
<3action of tbc mischief. 

3. Mercury. — The glomatitin resulting from the use of mcN 

<5ury sometimes involves the bones of the jaws in its progress. 

*!l?he Bctiott here is more fret^ueutly lliat of cartes than of ne- 

^Jroais, mainly because the alveolar, rather than the compact 

t.is£ue of the bone, is attacked. "We do, however, occasionally 

find [Ijat the inflammation creeps along the periosteum, scpa- 

>*ating that mcndiranu from the bone, and producing actual 

necrosis, generally of a limited portion of the jaw-bones. I 

<io not knonr that I have seen a general or even an extcnsivo 

Qecroflis from this cauw, the most contiidorabtc having been 

observed in easea where caneram on's has existed a>i the pri- 

loary disease, wlii»se de]>endence oa the influence of mercury 

baa been more than questiuuable. 





12« 



DISEASES OP BONE. 



4. P&ospAortts.—Ur. Heyfelder, of ^Qreinlkcrp, first calk'd 
nttentioti to the fact that tbc opernTivos iu inutpli-factorieft 
were liable to a peculiar form of necrosi* of the lower jaw. 
His observatioa» were publUhed in 184o, aad since that time 
the disorder has attracted the attention of siir;;tiuiis in all par 
of the world, and iiiuuli rticordetl experience has accuuiulutiM 
giving us a tolerably complete idea of its pathological ha wcI 
as ita idliiical historr. It is uiidoubtcdlj produced by tho 
prevalence, in the air which the sufferers have long been 
breathing, of the fumes of pliosphoms. These fmnes are 
mostly in the shape of phosphorouit aetd, which is jrenerate^f 
when plio«]thoi-us i« bnrnt in attnosplieric air. How this"™ 
vapor acts — whetlier by being absorbed into the eystem, and 
acting through the general circiclatton, or whether it» action is 
lacftl, producing its effecta by coming in direct contact with the 
parts liiiblo to bo poisonod by it — h a question ujMin wUicb 
much difference of opinion has existed. It is posblble that 
both modes of UL'tlon iniiy be combined; but one fact, which 
point* very Rtronj;ly to the local eliaractcr of the cauiu;, i^fonnd 
in the statement that thoite operatives wlio have eonnd teeth 
are rarely affected with the disease, while those who have un- 
sound, cariong teeth, or spongy guuis, are extremely liable to bo 
attaclced, and, in particular, it is stated than any who are ex* 
poaed to tfiH phosphoriis-finneH tH>ori after the extraction of a 
tooth are almost certain to Buffer. This would seem to render 
it pn^Uablo that phosphorus, or rather, perhaps, phoitphorons 
acid, has a direct poisonous effect upon the jaw-bone^, and thilM 
poisonous effect must be much increased by the solubility ofB 
the gas in tlie fluids of the mouth, by whtcli the poison is not 
only cimcentnited, but brnuglit into ea\v contact with all parts 
of the buccal mucous membrane, acting tliereforc with peculiar 
intensity wherever tho protet-lion of the epithelinin la removed 
by tdccration, or where any breach of surface lets tlie jioiaoned 
fluid into contact with the bonc-tiasnos to whicli it holda m 
mortal an enmity. Why the Schneiderian membrane, wbiub, in 
the samo manner, and at Ie:u<t to an equal degree, U exposed 
to the poisonous fuuie^, U not liahlo to equal injury, it is qo^h 
easy to explain. ^| 

6. SypAilig. — Many of the aecondary and tertiary symp- 



KECH08IS. 



ISS 



tonis of svpliilis raanifeet themselve* on the periostenm, pro- 
wv^ ulteii a fep:irat)uti Sotwceu that uiL'iubruiie and tlie bone, 
iich 16 followed b_v a netriwis. Tliure are also cases where, in 
llic progress of tlie dn.'iidriil ulcuraliun wliiuhsrphilia sometimes 
prodncee in the facial, buccal, palatine, and nosiil rej^onB, 
large poiiion^ of the giibjaeent bone die, luid are s4?]»arHted en 
maMt". Still further, tliere is a form uf syphilitic disease of 
the ftlcnil-hones where the action terminates in the death of a 
■portion of the bone, and this death erec-ps slowly and prad- 
iiailv over &uch extensive districts of the skull, that in some 
i&»tancoi) altuwt the wliolo vault of the eraniiim i» linull^ in- 
Tolved in the destruction. In tlu«e. and in sotne niher less 
uinrkcd caj^^s, the [Hiison of syphilis seems to be directly re- 
sponsible for tlie deMruction of tlie bone, and this ia mnde more 
evident br the fact, hereafter to he more particnhirly studied, 
that mt>sl of these cases of ejphiliclc necroeis have, in their 
hifrtory, features which are quite ditferont from the ordinary 
manift>»tatioiis of the diDea^e, and which are eulirely cliaracter- 
ietic of the notion of a specilic pi>is'>n, 

6. Fefera. — It i« ijfipularly believed that ferera do frequenU 
Ir produce ncerf^'^is. antl hence one pnpuhir name of thedi^ea^e, 
viz., fcver-^ore. It certainly U obticrverl tliat, after an atlnok 
of iiVQT, necroaia declares itself; and it mu?t he neknowleilged 
that the depressed e<jndition uf the system, which v\U\^ during 
and after long-continued and severe fever, is a predisposing 
Cai]H3 stmngly favoring the occurrence of the disease. I am 
Dot. however, prepared to say that it i« a Roiniuon result of the 
idiupathie or of the t?pecitic fevers. In my own experience. I 
hoTo I>een a little surprised that I have been so rarely able to 
1race necrosis a« a sequel to any regular iitnn of fever, as ty- 
pbiM or scarlatina, the In'story of which has been di^itiiict and 
QDequivocal. Itather, I am inclined to believe that, in most 
ca^e*. where thia disease has been said to have followed a fever, 
it hi6 been one atleetion from the beginning, and that afiection 
ha» been an o^teiliiT teniiinating in necrosis; the earlier stages 
of the disease Iteing characterized by fever, more or less con- 
tinued in type, during which the local sympEoms were either 
Dniwnallv "light, or were overlooked, ami in which, the lever 
Abating when the absccw had discharged itwlf, the local disease 



m 



DISEASES OP BONS. 






came to be considered aa tlie condeqiience of the fever of which 
it was in reality the can^e. Tliat tltie ia tbe ca^o in a Urge 
mujority of so-culled fevur-t»oreti, I tael very confident; that. 
is uniformly &Oy I will not positively assert. 

The seat of necrosis varies very greatly. Mostly oonfint 
to tlio cnnipaot tissue of tlie lon^ tiones, it may affect the can^ 
cel1oii» in any part of the skeleton. Of the cases in which the 
canccllons tissue is the Be>at of proper neerosig, I think the 
greater part will be found to be instances in which the affec- 
tion has been afisociateii with cariei*, and in which, therefore, 
tho necrosis is a secondary rather than a primani' feature of tiie 
disease. This is the fact with a great many ca^es of those nl- 
cerations of the bone, with necrosis, which accompany the ad- 
vanced stage of joint dcstroctiun, atul it 'n sutnetimea obscrredfl 
that a small seqnestrum of the cancellons tisane of the articn-^ 
lar end of a bone h a fatal clement of a joint diseaw, which 
might otherwise prove manageable. There are, however, a 
tain number of cases in which the death of tho epungy tissut 
is the primary clement of the disorder, and in wliich necrosis 
commencing thus, preoeiita all the ])utholugieiiI history of tl 
disease ns it occurs In the compact tissue. Of this, I have' 
aeen two examples in the os calcis, wliich I have had an oppor- 
tnnity to verify by operation. Wo have, in the New York 
Hospital Mnseum, one specimen illuatrating this fact, in the 
upper end of the humerup, and one, a syphilitic specimen, in 
the lowet- end of the tibia. Again, it is often observed that 
the cancellous is involved with the compact tiwue in extensive 
examples of the disease, as in the necrosis cf the shaft of the 
long bones, involnng some of the expanded extremity ; and, 
in the spreading form of necrofica of llie buiiCt* of the cranium, 
the diploe does not seem to offer any material check to th»^ 
progress of tho necrosis, becoming itself affected almost w^g 
rapidly and neatly to the Bftrne extent ap the external table, 
which iseenis to be the primary seat of the malady. These, 
however, it must be noted, are only offered as exceptional facta, 
and in contrast to them it should he stated thai, in many cases 
the compact tisfluo dies, while the cancellous in immediate con- 
tact with it lives; and thus we have produced those tubular 
sequestra in which the onter compact shell of the bone onl} 





NECROSIS. 



lay 



I 

I 



I 

I 



I 



hiu (lied, Icnving a living centro or axis of cancelloiiA tissue 
which lias been able to maintain its vitality. Tliia I hove 
several tiroes observed in thfwc case* where nccroBi? dt^clorea 
itself after compound fracture, and I have been much cliscon- 
certed t(> find thai, at\cT I hud removed tlio ntot^t superficial 
and accessible layer of dead buiie, a similar layer surruuiided 
tH© whole shaft, the extraction of which necessitated a long 
and difficult operation. In thia way are produced the varie- 
ties we notice in the extant of nceixi.-iis. These varieties may 
be classified AS — 1. The superficial. 3. The internal or central, 
3. The complete, where the whole thickness hot not the whole 
length of the shaft ia involved. 4. The total, where the en- 
tire bone has perished. 

It is interesting to observe, in this connection, that certain 
bones are more liable than others to the disease. Thus we 
hare, according to Mr. Stanley, the tibia fliiffering mncli more 
freqaently than any other bone. The femur is next in order, 
but at a great distance from the tibia. Then wc have the 
bumerns, flat cranial bones, lower jaw, last plialanx of finger, 
clavicle, ulna, radios, fibnk, gcapula, upper jaw, pelvic bonee, 
fttemuni. ribs. Tliia peculiarity uf the tibia, ilit^puriing it in bo 
eminent a degree to nocrusis, tieetiiii to he most mnrkcd in it3 
upper expanded portion, where not only do we see necrosis 
occurring very fro()nont.Iy, but many furms of inflammation 
and alMcesR, and a largo proportion of tin? malignant as well 
as other tumors of the bone, find their favorite seat in this 
portion of the tibia, M. Oilier lia§ thrown some light upon 
this siihject, by the general law which he haa dii^cnered, that 
the extremities, both of the femur and tibia, which form the 
kncejoint, have in them^lves a much greater amount of 
power of growth and develoiiment than tlie other extreuiitios 
of these bones, which form respectively tlic hi[)- and anklo- 
jointe. This interesting «l>r€rvalion hsis many practical rela- 
tions, and, among othe^r^, it i^eems tu explain how it is that the 
head of the tibia plays BO important a part in the disoaso^ of 
the skeleton ; being more highly vitalized, it is more active in 
all the processes of health, and therefore probably of disease, 
than other portions of the skeleton, lower iu the scale of vital 
activity. 




I2S 



DISEASES OF BOXE. 



In proceeding now wJtli tbe further stndy of necro&U, 
wi\l ho convenient to take a tvpicMt example of the diseaae^ 
a cane ocimrring in a vouiij; healthy poraiHi, in the lihafk of tl 
tibia, and of moderate extent, and mako it the baniii of system* 
otic study. In ptirsuflnt^ of thiit ataAy we shall have tu n<ttic« 
— 1. Tlie pftlln>h)jrifjil cciiidili'Hiii and changes which the 
presents. S. The symptoms accompanying and charactcrizii 
those oonditions. 3. The treatment appropriate to each ctagi 

1. 2Vie Pathological Von<fit!on4, — The lirst condition whit 
can be recognized in a case of commencing necrosis is, vitliont 
donbt, one of inflammation, iiivolvin*;, wc will enppotie, the 
greater part of the ahail. I do nut know of any ohecrvutioE 
which liHve thrown any light on this pcint in the liurann &n| 
ject, hut. rensoniiif^ from what is oh?er\'ed in experiment* ii| 
aninialti, it scenia prohahio tliat tlic whole bone partakei ni< 
or less of the inflatnmatorj- congestion, of which the centir 
part of ihe shaft is to be the principal seat. This inflammatci 
congestion probably is manifested most distinctly by the v( 
sels of the porJosteum, and by thotso of the medulla. "Whether 
any increased vnecularity can bo appreciated by the eye in the 
cninpact. snbMtanco of the bone, I cannot, affirm. In the portion 
■which dies nnder this inflnniniatory effort, no furtlicr obvious 
change occurs. The circulation ceases, and tlie section of Ixw 
is no longer as^sociated in atiy of the vital changes which go 
about it. The dead portion of hone, or sefjnestrum, a^ it 
called, very shortly becomes of a uniform, pale, waxy, yelloi 
ish-wliitc ui)Ior, differing very slightly and yet distinctly trot 
the color of living tKinc; a diflca'mH! which, I think, is eoine- 
what exnggcnited hy niacunition and drying of the bona, under 
wlncli condition we most commonly see it. During all the 
further changes of the disease, the 3e<[UCBtnmi nn<lergoej* no^ 
change of api^earance, except that it may be aocidentalh 
tingtJd by exposure to tl)^ various fluids and cases develop* 
about it. The most coniiiiou of these accidentul colorations 
tho &et|ue.Urum is the brownish black which it sometimes pre- 
eentt^, where it has long been exptwed to tho air, in such a way 
that the eurfaco «hall l>o alternately wet and ilry. This, mainly 
a surface color, utops abruptly at the point where ths seques- 
trum 19 constantly covered over by soft parts, and i» so ahiJii 



I 

I 



I 



I 



Ihat prolongwl maceration will scarcely remove it, Wliat the 
clit^inicA] nature of the diange h I do not linnw ; bntoiie would 
natnrally suspect tlie liydro6iil))hur)e Hei<l, g^eTierated in the de- 
composition of the pua, tobe the active agent in its prrjcluction. 

The acriona which accompany this death of a portion of a 
bone in the surrounding living textures are mirre intereetiug, 
more distinct, and more important. The outline separating 
tlic dead from the liviu}? bone is estrcraely irregular, made bo 
by tiic fact, probably, that eaeh vascular twig docs not fail to 
maintain itMiU' at pruciiiely the eanio level, some Kuetuiniiig life 
a little further or a little lunger than their neighburtt. The 
cncvenne^ of outline thus produced in rather more marked in 
the cancel1uu» than in tlic compact gubstance of the bone, and 
give* to the extremities of the scfiucfitrnni, where they encroach 
«pc<n the cancellous tissue, a paiticnbrly irregular, fiasured, 
and branched outline. When the reparation takes place 
through hard tione, it is sometimes quite smooth and even in ita 
outline, llie part of the bono covered by penotiteum preaeots 
usually a more even and natural aurt'ace. Here the line of 
Bcparation ih aceumtely between the periufitouin and the btnie, 
BO that the sequestrum is jnst as smooth and regular as tbo 
natural bone woald have been if macerated ; while, at the 
points whore dead and living bono bavo separated, it iii, as 
stated before, extremely irregular and uneven. 

The action of separation is accomplished by a proceita of 
molecular death, and tlio removal of tbo particles of living 
tissue next in i^ntfu-t with thuise which have died. The>«e piir* 
tides ore removed by the vessels of the living part, by a pro- 
cess of absorption, which, in bealthy and young aubjects, gooa 
on with considerable rapi<lity. Much donbt formerly existed 
on this subject, whether the line of EWparation was at tlio ex- 
pense of the living or dead bone; a donbt that had this prac- 
tical importanec, that it left unsettled the question as to 
whether the sequestrum is capable of removal by abf^irption, 
3ir. Ifunler showed clearly that the action took place on living 
partiehs only, the dead taking no part in the proL-cPs ; and 
this view, so entirely in consonance with our ideas of patholo- 
gical action in other tissues, id now universally accepted, 
'Whether all the bone-matter is removed by absor]>tion, or 



ISO 

whetlier some portion of it is cast ofT in tho diftchargos, is 
Another question of some interest, perhaps more pathological 
than i)ractical. Mr, Dransb^r Coyper^s obserrationB go to uhow 
very distincti}' that pua, in the neighborhood of diseased and 
exfoliiitiiig I)one, contains much more than ito usual pn>porfiua 
of phnsjibnto and eorbonnte of liine, leading to the itil'crence 
that a portion at least of the honc-tnatter was tlirown off by 
the piiB, Tliese obaerrationB of Mr. CooperV, which have t>cen 
mncb fjnoted, are not publitihed in full detail, the pajier in the 
JUWtca/ Oazetti, for the year 1845, being merely a sketch of a 
lecture given by Mr. Cooper on these subjects, and are imj>er- 
foct, as far as relates to our point, in not »pecil'ving the nature 
of the (liiKiascs of tho bonee on which the ob^rvations were 
inade. Wliile, thereforct they prtrvc that pus from diseased 
hone contains an unuisual proportion of tho eletnentd of bone, 
there is nothing in these observations to sliow that exfoliation 
i* aooomplisliod by any other than a protrcss of absorption. 
Indeed, tlie microscope makes it pretty clear that it iii a pure 
act of ali***rptii>n ; for all oljser^-ers agree that the lirst step 
in tlie ])roces6 ik a removal of the earthy matter§ from the bone- 
tissue, whieh is about to be the seat of the chatige; and subse- 
quently to that removal, while the bone is in the condition of 
fibrous tissue, the real ulcerative or absoi-ptive process goes 
on. This being the case, it would hardly seem likely that, as 
the ulceration is progressing in a tiAsne deprived <tf its earthy 
conatituonta, any of those earthy constitnenta could be found 
in the disjcharjrea. The act of Reparation begin* at the surface 
of the bone, and proceeds in depth, till the whole interval be- 
tween the dead and living tissue presents a space, generally of 
one or two linos in width, so that, when the proccia is complete 
and tlie deail bone separated, it ii* fmiiid ti» be lying loose in a 
space or cavity which 16 conwderably too large for it, and in 
which, therefore, it can be moved about Bufficlentlv to indicate, 
to the surgRon, by thia mobility, that it is eniirely (separated 
fWtm its connections. 

The surface of the living bone, looking toward and formh 
the wall of the cavity in which the sequestrum lies. correwpondiN 
pretty accurately with the general outline of the dead portion; 
and, probably, if the bone were macerated immediately after 



IfECROSia 



1S1 



eeparatioD was accomplished, tbia oorrespondonco would be 
still more perfect ; bnt, as haa been remarked above, the cavity 
is larger than the sequestrum by all the space in which absorp- 
tion of tiesue Las proceeded. This space is not always main- 
tained without change ; tor it is noticed in old oa;sea ttiat the 
cavity is sometimes much lar^r than the seqneetrum, though 
no bone has been discharged ; and our present views forbid us 
to bolieve that the dead bone can undergo any alteration in 
size. It wonid, therefore, seem pretty (Krtnin that this oa- 
Jargement la caused by absorption, provoked, probably, hy the 
movements of the sequestrum, or by its pressure at particular 
pointa, a view which is strengthened by the fact that the en- 
largement is not constant nor uiiilbmi, in some cases being 
only at limited portions of the cavity, while the rest embracea 
the sequestrum so tightly as to prevent its moving freely, even 
in the macerated specimen. 

This spaoe between the living and the dead bone is not a 

JTacQuni during life, though it appears so when the bone is 

Idried, It is occupied, and usnaliy pretty nccaratcly tilled, by 

fiof^, luxuriant granulations, which, springing np from tlie 

living bone on all sides, fonn a bed in which the sequestrum 

lies, and by which its injurious contact with the living bone- 

tieene is prevented. This layer of granulation-substance, in a 

healthy Bubjoet, is of a firni, ruddy appearance, and represents 

lilature's endeavors to repair the miwdiicf which baa occurred ; 

»hich endeavors are of course ineffectual, on account of the 

l»Mence of what has now become a foreign body. Never- 

Aflew, though the main object for which they are thrown out 

Wis to be accomplished, yet the secondary purpose of protec- 

^ and support to the loose sequestrum is scarcely of loss im- 

pwtance for the c^untbrt of the individual ; and it is worthy of 

"oiark, and 1 think of special adniiiiitioii, that thin admirable 

^lion fulfils its duties so well, that the patient may carry a 

'•^e and rough seqnostrum for many years, without ever 

Midg sensible of its motions, and without the least sensation 

'Jisnflering from its contact with its living tissues. This arises 

'loni the fact that Nature not only provides this soft layer of 

P''>t«ling granulatiouR, but makes them so firm and so callous 

^ their endowuiente that they are entirely insensible to any 



1S2 



DJSEASBJ OF BOXB. 



pninful contact, while they are eafficicDtl^' con^ibtent to eecura 

tlio iiimiodility of the otlierwise loorie Hcqii&jtriini. 

Tliu graiLiilutioiiH tliuii liTiiiig the cavity aecreto a modcri 
qiiiuitity of pus, which iintis its way out of mme of the ojv 
in^ in the aurrounding hone. In a Iteiilthy person ibid dis* 
clmrge ia exceedingly small in qnantJly, amounting, eveu trom 
a large cavity, to only a few drops lu twoiity-four houra . , 
Tliis, however, in Ituhlu to tlie greatest variutionB, both |^H 
quantity and quHJIty. In some c&sm the dii^charge is so eoS^^ 
Htaiit iirtd profuse as to be in itdclf an element of ditngcr to the 
paticnt'n life; and there are others where, tenipnrarily at lea&t, 
it ceasps altogether. It may alway.'i be accepted as a favorable 
sign, when this discharge is ftmall in qnanlity and healthy i g 
a[>})earance ; and it should always excite apprehension of pZ^^H 
gre^ii-ive local dii^ase when it !« ill-cc<niiitioned and profiiM^ 
MingJL-d with tliis pus. blood is sotnetiines seen, doubtloes ftom 
the friction of the rough Beriuestrum against the granulations; 
and. when it in from thiii source, it is H«ually in very moderate 
quantiticft. Largo quiiiititic-i of blood, issuing rajiidly from a 
case of necrofiU, indicate a diiTcrcnt source and a much more 
Bcrioua danger, ns will bo hereafter particularly explained. 

■While tliiii process of separation has been going on, ol 
changes have been taking place in the Burrouudlng soil 
wfiirh we mufit now study. Nature, as if anlicipating the 
result which muBt follow ilie separation between the dead and 
living bone, summons up her reparative activities to snpplj 
that sn])'iiort to the limb which is about to be destroyed by her 
own bands; aud, long before the actual fkdution of conlinoity 
has taken place in the shaft of the bone, we find that the com- 
peuBatory strengthening process has made Bufficient pi-ogreM 
to prevent any evil oonBe<iue»ces from the break. This pro- 
cess consists esfiontially in an os^ilication, springing fruni tbe 
parts surronnding the dead bono, which, reaching from the 
living bone above to tlio living bone below, bridges over the 
breach, and forms a sort of ferule of new bone, wliich, by its 
abundance and perfect organization, more than supplies the 
wanting support. Oat of this important and very interesting 
procetts grow many of iho most iitriking features of the disease 
we are studying, both clinical aud pathological ; aud it may oven 




NECROSia 



IH 



be affirmed tlmt moet of tlie indications for and tlie sncuees of 

inv treatment ttint may l>c mstitutecl fur the cure of (lie tiiiii- 
cliief, mu^t be t'onnded on a careful consideration of tliis nction 
of Nataro, and that upon its ]Kirfcction or imperfectiou trill 
necesaarilv depend the future naefnlne^s of tlie member. 

It i^ now j^ueraUv conceded that the new bone is derived 
from four diSereut Bources, vix., the perioeteam, the medulla, 
tlie old bone in immediate proximitv, and the iiearei<t Kiir- 
rounding soft parts. These arc all believed to contribute Uieir 
shtre in supplying the new material, but under very varying 
einmmstances; and there are few quei^tions upon which opin- 
Utm have been more fluctuating and contradictory than upon 
the relative efficiency of each wmrce of supply. From the 
time of Duhamel, whose first memoir was published in 1739, 
the opinions of most of those w!io have made tbiu a subject of 
itudy, has l>een unor)iiivm;al in favor of the periosteum as the 
principal agent in tins otwification ; and more recently M. OlHur, 
of Lyons, has demonstrated, by a seriea of careful and well-con- 
ducted experiments, fortified by abundant obacrratiou on the 
human eubject mider various conditions of disease, that not only 
Is the perioBteuni the principal source ofossific supply, where 
boofl bas been removed by dii^ease or uperation, but that, in fact, 
the other parts mentioned play a very subordinate and insig- 
nificant part in the prot-ess. M. Oilier coruln'Otod hisoxperi- 
nenial observation!; on dops, cats, rabbits, lambs, pi^eonR, 
rtc^ and carefully studied to make the neoessary operations in 
a manner as to interfere with Ids results a^ little as po«- 
In this, by practice, he became very skilful, and hence 
^ operations deserve more confidence and illustrate more 
■distinctly the points he wishes to make, than those of most of 
lie experimenters who have preceded biui. Some of tlio most 
^Important ilcductions of M. Oilier are — 1. That the periosteum 
le great source of rcprtxtuction of bone under all ordinary 
imstances. 2. Tliat the poriostcnm prcsonta two layers, 
*" »in«r and an ontcr one, of which the inner alone is endowed 
^'^ix the I>one-prodncing power. 3. That the medulla is not, 
iixlcr ordinary circumstances, disposed to the formation of 
'^'^ Iwne ; but that it is, under conditions of irritation, capable, 
^ a certain extent, of such production, but always in a much 



134 



DISEASES OP BONK 



inferior degree to the periosteum. 4. That the bone- substance 
itself may also give rise to & gruwtli of new bone, but that ita 
]»i>u-er)4 are mimh more limited than thoee of the medulla. 
fi. That though in coriain exceptional cases the sorroDDding 
Bolt parw can aceoiitphsh a partial bony reproduetioii, y 
practii'allj speaking, such reproduction is not to be expect 
when the whole, or a portion of & bone, with ita perioatenm, 
removed. Those views of M, Oilier are so nearly in acco 
ance with the opiuious of the best observers who have p 
coded him, and aru so well defended in his work, that I think 
the.v may be acTeptetl as expressing the view most general 
received ou this Bubje(;t, and ao being as near the truth an 
present state of science permits iw to arrive. Keverthel 
there are not wanting' tliosc who ditt'er fnim him t^oto ca'!o. 
recent observern, Manny, of Lyons, qnotetl by il. Oilier, a-^se: 
that in bid experimonti^ he had succeeded better in procuring a 
repi-oductioii of lout bune by removing tlian by preiierviug the 
pcrioiitoiim; and lleiii, of Daiitziu, though lie does not deny 
the utility of the ]»eriosteiim, thinks that the surrouuding tit . 
sues may very well replace it. ^H 

In the case of necrosis, wliicb we are now studying, w^^ 
will aiippogc that the whole of the middle portion of the shaf^ 
has pcnsbcd. In such a case, the dead portion ia inimcdiatcly 
surrounded by its periosteum, and in contact above and below . 
with tlic living portions of the shaft, tlie medulla being sup- 
posed to have perished with the bone. Wo have here, tli 
fore, only two sources from wliicli the 8U]t[ily of new bone c 
be derived, viz., tlio periosteum and the adjacent old burie. 
is obMjrved of the periosteum that it soon l>cginB to vascn 
ize, and take on granulation action by its internal surfi 
which surface is separated by these granulations from conl 
with the sequestrum. We have already soon that, at 
point where the dead separates from the living bone, the sui^ 
face of the living boue bccotnes also covered with a layer of 
granulations. It is in these, probably, that the further changes 
occur. It was formerly held tliat the^e granulations were the 
furmiitg stage of an exudation or plasma, thrown out in a tlaid 
state, which, coagulating, developed itself into the new bone. 
Yirchow has shown that, at least in many e^camples, such 



NECROSISu 



19$ 



ndatioD does not occur, and hi» theory h, that tliere u no such 
.thing a» spoulaueous organization of liviiig foruis iu any ex- 
uded fluid, but that auuh actiuuii are to bu referred to a gruwtli 
or pruliferatioii, as be terms it, of germe whicli, already exist- 
ing iu the tie«ue, asBume tlio actions of increase and develop- . 
ment under certain conditions of excitation. Wlicther Vir 
chow's vievB arc to be accepted in all their extent, or, indeed, 
■whether they are applicable to the question before U8, need not 
now be insisted on; but it is doinowliat iutereKtlng to obberve 
that, after the lapse of more than a century, DuLaniei*8 original 
idea, that the perioeteuin itself is conrerted into tlie new bone, 
u ao nearly identical with that which Iho di&tinguishcd Berlin 
|irofe08or now so atrongly and so ably advocates. 

The i>eriostenin then gradually hecomea thieliened and va^ 
cnlorized, and on its internal aspect begin to be seen the first 
trace* of ouification. Thia action, it must be rcmember'ei], 
begins very early in the case, and may be considered to be 
complete generally in the same apace of time that is occupied 
Itv the »cparatiuu of tlie dead from the living boue. Irarge 
quantities of now bone are deposited thu& round the seqiics- 
trnm, antil finally it iH^eomcs enclosed in a easing of new bone 
'wlucb i^ in rc;ilit.y nmch more bulky and nnieli htrnnger than 
the original bone, whose loss it ia intended to replace (Fig. 18). 
The pna which ia ftccreted from the granulation surface finds its 
"way out through fistulous openingiii, at variuui« points iu the 
}>erio«teum ; and, as new boue is not deposited at these open- 
ings, they remain as outlets through the bony ctising by which, 
hrough fibtulffi reaching iv the cutaneous surface, the pus finds 
These ojxdiingg are termed eloacee (Fig. 19). 
While this action ia talcing place in the periosteum, the 
tone-tissue, which borders on the cavity containing the sequea- 
mm, IB presenting analogous phcnimiena. It is becoming vaa- 
uUrized, and giving origin to granulations wliidi have a ten- 
iency, when the se'iuestrum i* removed, to be converted into 
»one, and thus assii^t in filling up tlie vacuity which haH 
Dccurred. It is noticed, however, that this action is extremely 
imiied, and by itaolf couBtitutcB a very unreliable source of 
apply. In eases where the perEiwteuui ja not preserved, t]ie 
imount of new growtli, from the ends of the living hone, will 



138 



mBKMSBi or BONEL 



not sen-e even to unite tlie extremities of the gap, inncli 

to fill it n]\ In oa?cs, again, wbere the periosteum is [« 
and cuittributes its usual diaro to the filling up of the eai 



I'm- 1 ^.— OThini BIttmtli ) 



vm. iBMrMoi I 



the new bone wliich it depoftitfl, and that which oomca from thi 
endn of the old bone, are bo emnlganiateH together, that thi 
etiare of each cannot be reco<!7iized, and it is only by obftervinj 
those cases in which the periosteum does not enter into thi 
rep&racivo action, that we can diBtinctly see how very ]iiuite< 
a. jiower of producing new hone is exhibited by the old bono ii 
in neighborhood. 



NBGBOSra. 



187 



The sequ(93trum being thus separated, and the loea b»ing 
T^-pMired, or rfithor compensated for, by the g^rowth of new 
l>«z>ne, the getting rid of the Rcqnestrum is tlie next point which 
clori-nands onr attention. In tho*e furinu of necrosis where the 
cl^ad |K>rtion ia small and Buperficial, there u UBUally no en- 
d<z»i^ure of the Kcqtieiitrurn witliin tlio invuhieniin in ouch man- 
w^ar ti to prevent itd extrusion ; bo tliat no ineohanical obstruo- 
tioxi prevents its bei>i>^ cast out. We iisnally olwerve, there- 
»<**"<:?, in sTjp.h cases, that, as soon as it is entirely loose, the se- 
<l'ca«2strum hegins to make its way to tlic siirfa*ie, in obcdifinco 
**> ^ law by which foreign bodies, Kidged in the tissnes, find 
t'li^ir way toward the nearest enrface by which they can con- 
■^'^T* ieu lly be discharged. The process seenis to be one in which 
*"<5 granulntions press on it behind, and are absorbed before it 



?^^^^^ 



Pw. »^-<TiviB Bmra^) 



•J» RBch a way that it gradually workB toward the surface, and 

^ 'i.Uy prujeirtft at one of the tistuloue tiperiiiigti, whence it ia 

*^*^«i]y withdrawn (Figs. 20 and 21). Thia deposition of tlieso 

*^**^-ll nequestra luay servo to iudiuate to ua tJie intentions of 



TM. n^FVoin Binrath.} 



. *t-iire with regard to the larger ones, which we are now par- 
larly studyiTig. Tfie intention undoubtedly ia to extrude 



icii 



^^^ largCT as well oa the emaller sequestra, and the extruuon 



138 



DISEASSS OF BONK 



would, I doubt not, be mora often accomplished if it were not 
for tlie meclianical obfitacle which is preeente<l by the unyield- 
ing iuvolucrum in wliich the dead bone is imprisuued. £xam- 
plee are uot uutrequeut in our luuseuuia uf large sequestra 
which urc gradually llburuting theuieelves from trupri^nroent, 
and projecting themselves toward tlie sorfaco. This courae is, 
perhaps, sometimeB deteiinined by a large and tavorn hi y-Bi ta- 
unted cloaca, or potwihiy by a partial absence of involucruro 
at a cerlaio point ; but while it may not often serve to free the 
patient from hid encumbrance, it does certainly »how that there 
is probably ill alt cases a tendency, wore or less decided aa it if> 
more or lega reBiiited, to the spontaueoue extruBion of scqueetra. 
Tliis action, though conservative in its intcutiou, is not with- 
out its datigers and inconvenioiu«s. We have, in our mtieeum 
at tlie college, a sjwcimen in which Buch a sequestrum, thna 
partially extruded, has eroded the popUteal artery, causing the 
death of the patient from hemorrhage ; and 1 have seen 
another case in which destruction of the Icnee-joint, with com- 
pete bony anchylosis, was produced by a similar cause. SV'bile, 
therefore, it is important to recognize the fact tliat there is a 
tendency toward the throwing off of these foreign masaee, by 
Nature's s]K>ntaneou»; actions, yet it will be found that in 
practice not much can be expected from her efforts ; and, as a 
general rule, it maybe stated that, where the seqiiestrnm is 
enclosed in a bony iDvolucruni, »urgical assistance is required 
to remove the mechanical resistance to it* expulsion. Where 
this ast^intancH is withheld, the case will pass on for years, evea 
for a long lifetime, witliout any material change either in the 
condition or the position of the biequeetrum, which has now be- 
come the mere mecUonieal cause of the t*yinptoins under which 
the patient will thus long continue to sutter. Of this imprison- 
ment of the sequestrum within the ii>yolucrum, Fig. Ifl, taken 
from Erichiieu's surgery, is a good example, tliough the cloace 
are commonly much smaller, and the imprisonment therefore 
more complete, than liere exhibited. 

The 6ym|)tomB which characterize these different stages of 
necroeifl may be atudiod as belonging to the three periods in the 
pathological changes, which we may mark as — 1. The period 
of inflammation, by which the necrosis is originally produced ; 



HECXOSIB. 



IW 



2. The poriud of sequestration, during which the separation is 
procce<]iiig and the invohicrnm Ueiiig formed; and 3, The pft- 
riiid of retention, during which the secjoeatrutu rtiuiiuuD as a 
foreign l>odj within the iuvulucnim. 

1. The iutlaniniatiuii which produces 8Uoh a necrosis ait wo 
{have choftcn for our t^'pe of the diacofic i* almost invariably 
an acute attack. At a certAin pcno<], after the action of Rome 
of the canaea we have noticed ahove, pain and swelling attack 
llmh, which eoon becomes the wat of severe and mutiifeet 
monoui inflammation. The whole limb (the leg, for ex- 
ample) is involved in this inEunimation, which indeed oiXen. 
extends to the foot below, and to the thi^h above. For lliis 
(reason it is often difficult, in the early eta^cR, to decide accu- 
JTatel^ where the efleetfi of thia viulent and extensive action are 
lo concentrate themselves. It is in this stuge that most of the 
mistakes are made by practitioners of limited experience, and 
the disease is looked upon as eryaipelas, simple phlegmon, or 
rheumatism, nntil the progrcaa of the case throwa light npon 
its nature. No man can with certainty pronounco a positive 
diagnotiis, in all ca»e8 of inl^amnintion, which are to terminate 
in necro«ia; hut the pu!>!)ibility of euch a chain of symjitums, 
tdepeudingon osteitis, Imutiiig to necrutiis, being bonic in mind, 
pt is not likely that the careful observer will long be deceived. 
This inflammation occurring. a» it does, in young and &orac- 
timeA rignroufl subjectt^, pa^iset thr»ugh ita ritagea rapidly, and 
Boon terminates in suppuration. We have seen that the tirst 
texudationg probably take place between the periosteum and 
the bone. It its liere, also, that suppuration begins, and^ Bepa- 
rating the periosteum from the bone, distends that membrane 
Bfi far as itfi unvicUling nature will permit. This is the period 
which is accoin])aiiied by the most urgent itymptonig of fever 
and pain ; and when the periutiteuin gives way, and the matter 
escapes into the surrounding gutl parts, the severity of the siil- 
fering is eomewhat relieved. Through these &oft parts, which 
^participate in the general inflammation, the matter makes its 
pray to the surface, »t:>metime8 only after having accumulated 
a very lar^^e extent. Naturally or artificially the pua is 
finally evacuated, aud the first stago may be regarded as ter- 
minated. This stage is marked by very severe constitutional 



DISBABES OF BOJfE. 



1 



SIO, 



difttarbance, rerj- high inflammatory fever, utid acHve delrrintn, 
somfJtimes exi^tinj! during all the earlier dajg of the attaci 
This fever with delirium is uften mistakou for typhoid fever- 
the delirium marking tlie local uomplaintf so that attention 
not called to the ButTcring litnh, till intlnmmation hnii made 
extensive progreM, AVlien tlio pua is evacuatcil, a sensible ittt<^ 
provement occurs in the gencriil symptoms, as irell as in tha^f 
local sntteringa. The fever abates rapidly^ the paina cease in 
a great degree, the great swelling subsidea, and every thing 
eeeme rapidly returning to a condition of health. Here, again, 
a false hope is apt to be entertained that the cnre of the 
sccss will he the cure of the diseaBo, and the patient is flatter 
that he will *.n»n he entirely well. Instead of tliifi, however^ 
it is found that the abscess does not heal. Fistiiloui^ o[>enlngs 
continue to discharge pua, the limb remains swollen and ten- 
der, and it is liable to occasional recurrencGa of inflammation, 
which are Bometiines almost m severe M the original attacl^H 
and are attended by the formation of new eiippnrative tracka^^ 
which at new points coiiiuiunicato with the cavity of the in- 
volncruni. On examining the limb at this time, it is fonn 
tliat the rtwidling and indnration of the aoft parts arc gradnally 
disapi^earing, while a deeper and firmer enlargement ih taking 
their place, which ib manifestly due to the grndnal formation of 
the involitcrum. This ia the condition of the limb during tlie 
proceee of sequest ration. 

When the sequestrum is fully detached, and after the in* 
volncruni itt completely forroed, no marked cliange takes placo 
in the symjitonis. The absccs&cs have gradually contracted 
down to flstnlffi, the orifices uf wliich present n few large, soft, 
pouting granulntionj*, which are characterislic of the presence 
of a foreign body at the bottom of the iistnla. The soft parte 
have resumed their natural condition, and the deep involucral 
■welling has become of a bouy hardness and almost insensible 
to pressure. The diwharge continues con&taut, but usnally 
smalt, from the tistulous tracks, and the patient, having recov* 
ered his general health, begins to use the limb with more and 
more freedom. This state of things may continue indetinitely 
with but little variation. If the flstnlm show a distpositton to 
heal, the matter accumulates and gives rise to a renewal of 



'4 



NECROSIS. 



141 



tome of the old sitfleriiigs until it agniii fiii(]!> it^ way to the 
iurface. Asa rule, the tistulas do not henl even for a sliort 
time, and I believe never ponnaiH'iitly, while the acqueslrum 
cnntinites onremovod. 

I have tlui!^ prt'tnented an onlliiie of the ordinary coiirae of 

one of the moat characteristic and common forma of necroHis. 

Dnring the course of this diftoaae the patient is exposed to sev- 

eral sunrt-es of dunger which are worthy of being sepamtely 

noticed. In the tirst place, wlioii the death of bone has in- 

vulved the tit^i^neB near the joints, these may become itnplimitcd 

directly or indireclly in the coiiBeqnenuo» of the disease. It is 

always noticed tliat, when the sequestrum \a near the joint, 

the finrroiindinjj inflammation rcnchoB to the fibrous striicturea 

of the joint, which gradually grows stifior and stiffcr, until the 

use of the joint is fierionsly impaired, anrl often till complete 

immobility is estfthlished. Tliia is particularly marked in cnsea 

of necrosis of the lower end of the femur, where the knee-joint 

is apt to become the seat of a fnl&e anchylosis, which is oden 

complete enoujrh to entirely aholi^ih ite movement*. This is a 

condition which is a necesBnry etmBoqiieneo of the proximity 

of the dtsearti!, and one whii-.h therelWre cannot lie entirely pro- 

vtnted. Something may be done, however, by encourai^ng 

the patient to practise the movements of the rigid joint sys- 

'ematically and regularly, and thus in some doa;ree obviate the 

iiicreaae of the trouble. But, the most important practical 

indication to bo deduced from this well-kiiowti tendency to 

'loimirment of a ueijjihburing joint ie, to remove the cause of 

tJ»e impairment as soon as jmssible, by getting rid of these* 

^Uestrnm. If for no other reason an operation is required, 

tliia ie alwayfl a goo<l one. T had under my care, a few years 

ftfjo, a member of onr medical class, who had suffered for years 

»ith necrosis of a limited extent in the lower end of his femnr. 

l^or Bonie reason he had not been advitied to have it operated 

On, and he had submitted to its annoyances, and had attended 

Wtaree regularly, until ho began to find that tho knee, which 

had long been getting stiff, whs fa^^t becoming n$eles>t. lie 

then consnlced me, and I advised an operation, which was |>er- 

formed, and a considerable soqnedtrnm, of the compact layer 

of the condyle* joat above the joint, was removed. The wound 



143 



DIKEA<!ES OF BONE 



henled rapidly and perfectly, but the fttiffncsa of the joint was 
no raoro tractable thftn it had been before. Under tliei^e eir- 
cninRtances, anxious to till a lioi^pital appointment wbicli hi^H 
merit had secured liim, ami ambitious to dietingulbh liiaiself i^| 
hi« profensioti, he begged me to try forced flexion of the joint. 
The urii^nul ivouud uiacJu in the operation being several months 
healed, and there l>eing no evidence of any di&esse abont Ilia 
joint, I thought it a favorable caw for this proceeding, whio^| 
I accordingly adopted. Placing him under ether, and harin^^ 
arranged a couch with reference to the leverage of the leg, I 
made the most powerful efforts to brealc up the adhesions, bo^f 
with only a partial succew, which, though it procure<l him soni^^ 
increiise in the movement of the joint, did not satisfy him. At 
his arj;ent request, and Bvinpathizing with bis brave dotormi- 
natidii to fit himself for lifo'a duties, I made, a fow weeks after, 
another attempt, and, being better prepared with my meohani- 
oal arrangomenta, and perhaps being more determined to sno- 
ccod, I made more strcnnoua efforts to move the obstinately- 
rigid joint, when all at once, while I was trying to force flexivi 
as 1%r as I could, something gave way with a snap, and t1 
joint yielded in the most satisfactory manner. I was lihookf 
to tind, however, that tbia Buccesa had been secared at the ei 
pensc of a considerable laceration of the integuments of the 
anterior aapcct of the joint at a point where there had lieen 
gome cicatricial adhesion of the akin to the Ixme, fmm long-past 
inflammation, and etill more alarmed to find that this lacera- 
tion, of some inch and a lialf long, admitted the finger into 
the cavity of the knee-joint. I infitantly closed the wouud^ 
and pliiced the joint at perfect rest, and had the good fortm 
to secure immediate union, without a bad aymptom on the pa 
of the joint, and I had the Batiftfaction to find that I had gain* 
a degree of flexion which was amply Rutlicient for the ordinary 
use of the limb, and which he not only retained, but by pcrs^ 
Tcring effort cimsidcrably improved upon. ^m 

Anotlier mode in which the jointe become involved b^H 
necroeie, and fortunately a rare one, is by death of cancellous 
tisfluo reaching to the articular surface itnelf. When this oc- 
curs, there is sometimes a protective inflammation which shot 
off the general cavity of the joint from the effects of the sepi 



NECROSIS. 



Ui 



nlion of and sappuratiuii round tlie se<i^ueatrum, and tlie dead 
piece niav bo removed without really opening the synoviiil cav- 
'ty ; or this protective inflammation may be wantinf;, or of an 
ontiMltliy character, allowing contact of iho morbid fluids with 
liie BTRovial cavity, and tbos producing a general artliritis 

Iwhicli is apt to be destructive in its tendencies, the more so 
''^m the constant presence of the exciting eause. Of thin we 
f***! ft good exemplification in a Bypliililic piitieut in the New 
'Ofk Hospital, who had Iwen long suffering from disease of 
***e lower end of the tibia, embracing the internal malloolnB, 
■^liis falling into necrosis, involved the joint in acnte attack of 
"•Qamination, which soon rendered amputation necessary. The 
*P<seimen, when macerated, showed a considerable disk of the 
^irtilaginons BurGice forming part of the sequestrum, which 

I'^a.s ohnost ready to separate. Similar facts have been re- 
ported in many instances; and the whole subject of the dan- 
6*r to joints from their proximity to aecjuestra is most iinjMir- 
^*Ht, as suggesting the early removal of the dead portion of 
*one, Itcfi.rc the evils apprehended have had time to ncenr. 
A second danger in necro^iis is hfcmorrhage. We have 
*^en that the sequestrum when meparated has a tendency to 
, *"Ork its way toward the surface, and that, when it is not re- 
■ '■steil hy the imprisoning involnorum, a largo 8ec|ni)strum will 
**^riietime3 be thus extruded. In working its M-ay i.hn.s among 
'■*♦; ti^wuos, it is liable to eneounter some arterj* of importance 
^■^lich may be eroded by its pressure. In vessels of moderate 
™2c, and sometimes, doubtless, in the main trunk.* themselves, 
'* «.tiire institutes a protective process against such erosion, and 
'^e vessel is cloeed by fibrine before itJicoatsare perforated, and 
"'fc'Untrrhage is thereby prevented. Unfortimately, however, it 
L^'^^sj sometimes happen either that tlie protective action is im- 
Hf^'Wuct, or that the destrnctive effect of the shar]") edge of the 
~oc»T,fl jg (Qf, sudden and rapid for the calibre of the v(WHeI to be 
I eritircly sealed, and hajmorrhage takn^^ jdaee. Tiiis accident, 
■■* for as T have observed it, always takew place in the largest 
""tinks small ve.-«ftels being so much more likely to be safely 
plxiggoJ than large ones, and this patholi>gicRl fact has, I think, 
P*Gat practical significance; for, if we can confidently pn)- 
li^iunoe that the h«morrhage, in a given case of necrosis, has 



144 



lytSKJiBTS OF SONS. 



ita eoiiree in tlie erosion of a lar^^ tmiiK, ana not of a »«***^ 
hraiifli, it h evident that the caae IVom that fact aaamuef* *••* 
iniportfliico which is immediate and preaaing. And it id tl*" 
more ncccftflftrv that this should be fully appreciated, bee* i*^ 
these hiemorrba;^ are someliinos exceedingly' deceptive *" 
their hehavior, and ponie oi those wliieli first occur, even fr<^*^ 
the lai^cfit tnuik», are quite trivial in amuunt, and are eos ^ ''^' 
checked, or Bt«p spontaneoui^ly. This is extremely apt to d^ 
ceive the surgeon into the belief that the tleediup vessel is ta *-* 
large, and that tho danger \a not great. It may be afnC 
mifltake. 

"Wc have, in the college mnsenm, a bcflutiful proparati*^ 
taken frum a medical gentleman of this city, who bad b»' 
suffering fruin necrosis of the feirinr for many years. Ou 
sudden, without osaijifnaMe cause, ho was attacked with hitJ 
orrliaf^e, the blood flowing <]uito freely for a time from the S 
tuh>uA ojicTiings, and then ceasing of its own accord. Once ^ 
twice hk'eiling recurred, always stopping in a short time apo"i 
taneously, but nevertheless reducing him considerably by t>J 
'wbole amount of blood lost. Finding the bleeiling so modera'fl 
and so controllable, neither he nor his medical advisors toc^^^ 
serious alarm until a day or two after, wheu a rapid and pr'^^'' 
fine baernorrhuge brought him utmost to death's door. In th ^ 
unprotniting stale amputation was |)erfonned, hut too late t ^ 
save the unfortunate gejitlonmn from a death clearly due to ^ 
non-appreciation of the pathological eondition which the spec?"*'' 
men most Radly illnfltrntes. It showi* a lat^, shar]>-cdged 
qucBtrum, which, having partially emerged from its l»ed, ha- ■^'^ 
worked ita way down toward the popliteal apace, and the: 
by erosion, opened the po|>liteal arterv. By contrast, auotb^ ^ 
caae occurred to my colleugue. Dr. Gurdou Buck, who hi 
under hia care a boy of about twelve or fourteen years of ag^^^ 
with a very esteneive nenrosie of the femur. As it was during 
the hot Eeason, and, as the patient was much reduced by hi- 
disease, an operation was postponed, and the boy was allowe*^^^-'" 
to go about, hoping that hia health would improve as the coolft 
Beaton arrived. In fact, ho was improving very greatly, whew 
after a moderate walk, he found lii« pantaloons and shoe of th^ 
diseased side filled with blood. This bleeding stopped of iueltf 



NBCBOSIS. 



145 



lat, from ita extent and rapidity, Dr. Buck belteval it to Iw 
fri)ina main trunk, and 6t<:KK] reiulj' uii tlie iK-casloii of iu re- 
cnnciicc, wbicii fioon took plauo, to anipiitute the limb, vbicfa 
be did quite high np, and tlie boy's life was saved. I>i9ftection 
allowed thnt the upper sharp point of the itcqneslrun) had 
optned llie femoral artery not far from tlie origin of the pro- 
ftnida. This specimen i» preserred in the Kew York Hospital 

i biivt} examined carefully, during tlio last twenty years, 
tliirteeu oaees of necrueis in which hienmrrhage uccurrcd of 
Mffidont severity to require Burgiual intert'erciico. In every 
one of these it wna the iiiuin artery of the rc^on wliich wtu 
lluMDKe of the haemorrhage, except in one ease, and then it 
»« ilic vertebral which Iiad licen eroded by a fragment of 
dewilione, from a pistol-wound, wliich was in a favorable fetate 
'>f be&ling when the fatal heemon-hago occurred. In each ca»e 
tt» cuats of tlie artery were eroded evid«iitly by tlie direct 
Mntact of a sharp edge of the eetjiiestrum, with one exception, 
Mii then, though the main artery was opened, and a sharp 
•Wio^tmin- WIS quite near, we couhl not pronounce positively 
tint tbe hole observed in the side of the artery was actuidly due 
to tbe pressure of tbe sharp edge of bone. Tbe number of 
•'•onmtiouB is too small to decide the point that Birall vcsrcIa 
"wet bleed from the cause we are studying; but the testimony 
^f thflM! few ie so nearly uniform that I think it may safely bo 

epteil as a pathubigical law, and I am quite £urc it alfurds 

'tonndest practical indication. Precisely what that iiidica- 
^1 is, must I>e settled by tbe fcatiucfi presented by each case) 
^l it is hardly ncccsaary to say that the remedy does not con- 
""t in the mere removal of the cause of the mischief, thnt is, 
w shtrp edge of the dead bone. When thnt is removed, 
*^ temaius the opened artery to be cared for, and, if my 
P^'tiMi i? correct, that this opened artery is a main trunk, very 
"'lleliope can be entertainer! that Nature will be able to clo&e 
"8*oniide(I vessel withont assistance from art. 

Two courses present (hemselvea to the burgeon in this sen- 

w* eaiei^ncy : Tbe Unt i*, to make an attempt to reach and 

He the ft-oimded vessel ; and the second is, to amputate if the 

'"gstiire cannot Kifely or successfully be undertaken. The 

10 



149 



DISEASE OF BOKE. 



point of urgeot importance, howerer, U, in mj judgment, not 
to delay till a findden jriish of blood places jour jmtient be- 
yond tlie linpu uf benf^fit from niiy operation, l>c it ever jl 
clenrly indicated, or ever &o skilfully perlurined. ^M 

Tlie two foUowinj^ cases, which have recently come nndcr 
my observation, illustrate extremely woU the points of practice 
I have here dwell upon : 

Martin Clancy, aged twenty-four, an oysterman,wrts admit- 
ted into B«]levuo Ilut^pital, October 29, 1809. He was extremely 
feeble and exsanguine, and stated that he had been bleeding 
for five dfiVB from an ulcer in Ids thigh. This bleeiliug had 
occurred snddcnly, without obvioas cause, and had stopped 
Bpontaneously for a time. It had recurred acvcrHl times in 
the same unprovoked manner; and by the frequency of thew 
bleedings, some of them very large, he had been reduced to 
his present alarming c:onditi«ni. He hud worn a tourni<juet 
fur many hours before his arrival nt the hospital, put on by his 
snrgical attendant out-of-doorfl. It was clear, from tlie exami- 
nation of hia ea^e, and frarn its previous history, that he liad 
had necrosis uf the lower part of the femur, dnting back [K}ren 
years, and several openings existed in the popliteal region, 
from which the blood had issued. The probe detected a large 
eeqnestrum, lying Wse and quite superficial ; and the question 
in cousultation wa**, What was the vetjsel o[jened 1 From the 
amount of blood lost, from the spontaneous cliaracter of the 
bleedings, and their pcrsiittent recurrence, and from tlie situa- 
tion of the fieqtiesCrum, we hud no hesitation in deciding that 
it was the popliteal trunk that was injured, and in determining 
to cut down and remove the aefiuestrum, and, tf p<Msible, 
apply a ligature to the artery. The operation wa* ]>erfonned 
by Dr. A. B. Mott, and was tndy a difficult and delicate one. 
An incision, seven inches long, was made over the course of 
the arten', embracing as many of the fistulous orifices as pos- 
sible, and soon a large cavity was e.\posed, occupying most of 
the popliteal space above the knee, in which lay loose a large, 
flat, shari>*dgod sequestrum, evidently formed by the death 
of the Gompaot layer of the posterior sui'face of the femnr, just 
ttbovQ the condylea. Thirt removed, left a bed of granulations, 
in which it had rested ; but no hemorrhage could, at the mo- 



KBcRoeia 



uy 



atenl, bo indaeed, by which a oXovr to the tnjiired artery might 
be pruned. Tlie operator was oljliged, therefore, by a moat 
tedloaa and caiitioiin dissection, nmun^ pnrts consolidated by 
loi^-eo&tinued intlflmination, to search (or the artery, guided 
bjtpuUation, which, in this indurated condition of ]>artii, and 
iuthereeble state of the circulation, was of very little aseist- 
ttec After a long search at the upper part of the cavity, the 
wtMy iras exposed, and carefully traced dowiiM'ard, until wo 
fcttived Bt a ra^'^ed opening on its side, from which, on loosen- 
ing tlie toorniquet^ tlie blood now epurtcd freely. A ligataro 
Tu applied above and below the opening, the two ligatures 
Wng tlwut an inrh apart. The wonnd was only partly closed, 
living itg central portion open, and was drewed lightly. Ev- 
•7 thing went on favorably. No hteinorrhage occurred, and 
tlw niMi pained rapidly in appearance nod in strength. The 
wonml granulated well, and tillrd np po rapidly, that, by the 
Mth of December, it waa alnuwt healed, and on the Slst he 
*** di.'icharged from the hospital. He could then, about nine 
*MkB after the operation, walk quite well, though he could 
Hotftei the foot. No pulsation in anterior or posterior tibials, 
Hiiliealtb seemed to be perfectly reestablished. 

Tlie second ca^^e was not so fortunate in its results, and is a 
"Meworthy illustration of the foruiidable iiatury of I he accident 
■*are studying, bccnuae the gravity of the Bituation was fully 
"Ppreciated from the moment the accident occurred, and every 
"•init that Acience and skill could <io was done, and done 
I*omptlr, withont achieving the saving of the patient's life, 
"•e cage occurred in the practice of my friend Dr. George A. 
ftters, of this city, and by his kindness I had the opportunity 
^^ndy the specimens in their recent state. The patient was 
' Wntleman about forty-five years of age, of ordinarily good 
'*»lth and active habits. Ho had had several attack* of in- 
"iiimation about his knee, the earliest one occurring in child- 
lifKxi; nnd on one occasion he had had a slight exfoliation of 
™iie from the lower part of the femur. Ho bad of late ycara 
^ilirtly recovered from the etfecta of rliese attacks ; anrl, with 
">* exception of a slight stiffness and lameness of the joint, he 
Wintered himself a well man. Dr. Peters was summoned to 
»o Bt his residence, out of town, one Sunday morning in Sep- 



148 



DlRFJiStS OF COKE. 



tember, 1869, and found tliat lie bad hod that raorniug, wbile 
uinkiog eome eli^ht mtivomont io bed, a eevero liaaiuorrhnge. 
whicli bad rexhmcd him to an alarming |Ktiiit uf pro^Tration. 
Tlie history given was, that about twu muutbB jirevioualy, an 
iii^itniniation bad declared itaclf in tbc old seat of disease in 
the ham, and had f^one on slowly to flupptirntioii, nnd had be«u 
oiK-iied by his attending; surgeon in two places. The iiilJuu- 
mnlLon euUided somewhat, but the abscess did not Leal; and, 
though hu was able tu keitp about liia but?ine^, he Buffered 
more or less coiietant inconvenience ("rom liis disease. He had 
only been coDfioed to the bonso a few dayn; and, beyond a 
slight inori'nBG in local BufffTing, no new featnres had devel* 
oped themselves when the haemorrhage took place, as aboi 
alated. 

The bleeding had been so severe, that, althongh no recar 
rence had token phice, his alarming condition warranted the 
mo»t extreme measures to prevent a renewal of it. The wound 
was iheroforo opened freely, and a large cavity exposed, occo- 
pyliig the popliteal apace, the bottom of which cavity was the 
posterior surface of the lower end of the femur, in a condition 
of extensive disease, with a bare and very rough surfaoe es- 
tending several inches up the bone and downward, so as to 
involve (he knee-joint, into wbidi, through the ulcerated Uga- 
inentum Witit>lowi, the finger eyuld easily be paseed. A small, 
thin, and very ^barp detached fragment of bone lay loose jii 
the cavity. The condition of exten-iivo disease of the femur, 
the opened knee-joint^ with the almost certainty of the |,ioidit- 
eal arter}^ being eroded, eeemed to justify and to demand am- 
putation of the limb, which was performed without delay, 
almost without loss cf blood. So great was the deprestiion or 
the system, that no proper reaction took place, and ho dieA 
during the night following the operation. 

Od examination immediately after the operation, tU«y 
large cavity, mentioned as occupying the popliteal space, wft» 
lonnd to extend fur round the femur on each side; and into it, 
therefore, the whole posterior and lateral surfaces of the eadl 
of the feiniir formed a eort of projection. All the houe-snrfao0 
thus exposed was bare, rougl), irregularly eroded, presenting 
only licro and there a granulating surface. The knee-joiut waa 



I 



■u J 



NECROSIS. 



UO 



filled witTi pus, and rapidly disorjranizinjr. The popliteal ar- 
sry ran along tlio sui)erlicial w»ll of this cavity, but very 
lose to the exposed bone-eiirface, and, at aI)out ihu centres of 
le popliteal npace, -was opened hy a clean oblique cut, just 
BQcli as is nsaally made in t!iu operation of veneiieution. X'l 
otlier detached Bequestruin was found. After maceration, the 
e»il of the femnr waa found to be li^bt, porons, and spongy; 
tho Hiedullari' cavity very large, and the cancellous tissue very 
OJXiii, iJoih the pofitorior and lateral, and sonio of tbo anterior 
■bi'l^ces of the bone, were irr^ularly eroded, the posterior 
Diutali the more deeply. Almost all the compact portion of 



'v^j 



V>l 



>h. 



^-<m»i :i. Y. iid^HUdMo*^ 



m. A— (nam S. T. Botpltol Umaonm.) 



I 

^'G &1iai>, where it is not d^troyod by erosion, has become 
PWoni» m- well a^ thin. At aeveral pointss where tlii^ compact 
'•niina tttiU reniiund unde«troyed, a dull, white, opaque appear- 
<Dco of the surface indicates tliat it liaa suffered necroM'. 
^U a neiTOfncd plate, scparatin;; from the posterior surface, 
*W undoubtedly llio cause of tho wound in the artery. Tlie 



ISO 



DISEASES OP BOVB. 




same necroaed appearance penetrate*! at points into the s 
Btanue of tltu caiiculloug tissue, wltich had evidently been 
teusivety iiitiltrated with jnn. In ^uiuu ^niiut^ stuull cavities 
existed, which doabtleas hod ooutained pus, and which did nut 
communiuato with the wirJ'acc. No loose sequestra wuru to be 
found. At the paint of amputation the bone Jias hecoin< 
harder tliun natural, with aonie small exostotic growths on 
outskirts of the inflamed region. 

That the danger from haimorrhage in necrosis is a real a 
ft formidable one, even in circumstancaa most favorable for 
prompt fturpical assistance, will perhaps more clearly appear 
from the gtatcmout that, of eleven cases whicli I have met 
with, mostly occurring in tlie New York Ilo»pitaI, eix hare 
died. In ten of these every thing was promising well when 
the htcmorrhago occurred ; and in every case but that of the 
vertebral tiic injured vessel was ncoe&sihle to ligature, or tho 
lirab might have been removed by ampntation. Tlieac tliioga 
taken into consideration, my recommendation of promptness 
in operation receives an emphatic indorsement. Delay in 
Lope of saving the limb is fatal to life. 

Fig. 2'J represents the lo«er end of a femur where ampat 
tion wiis performed tor hajuiorrhago from the popliteal arte 
which had been opened by a sharp soquogtrnm dfitaehetl from 
tlio posterior snriace of the femnr. The specimen is curions 
from the peculiar manner in which the bone ie perforated bv 
the actions going on round the bed from which the sequestrom 
came. It is in the New York JlospJtal Museum. 

The last danger to which I ehall oUude is exhaustion. Ii^i 
a feeble eubject^ with extcueivc necrosis, wo sometimoe hat^H 
thrown upon the powers of Nature more than they can beai^^ 
The reparative aerions, which ehonld be promptly and health^n 
fully excited as Boon aa the inflammat'Ory Btagc is pa^-tod, ai^H 
replaced by the continuance of inflammation in a subacnt^^ 
form, accompanied with a profiifte ficcretion of pus, JTo proper 
involucrum is formed. The tiseues are largely infiltrated with 
inflammatory products. The tenderness mid pain do not dis- 
appear, Tho Hue of separation forms slowly and imperfectly. 
In short, tho whole prooees is a morbid instead of a hcalthj- 
oae ; and the patient's condition oorresponds, in an excited. 



ill I 

om 
>ns 



NECR0!?1& 



131 



wntHble pnhc, irregular hectic fever, want of appetite, oma- 

cUtiun, and all rhuhc nutiKtruus orideiici^-H ^liat tnflaininutiuii 

ntLi.^r iliitn reimraiioii is going on about, the iieat of disease. 

Here, every thing depends upon the BiirroundiDgfl of the 

patient, and tlic aswidiiity with which wholesome and proper 

reg^Tnen is brought to beiir upon the overtaxed power*. The 

^t of air, the beet of food, touics, iuvigorants. stimulants, will, 

Iwppil^', in moHt cabce, carry the patient through thu period of 

Miij^er; but, if the condition do not suun improve, if the ex- 

""usiion be gaining upon you rather than yielding to your 

efforts, remember that tlds very condition is reacting upon the 

^'^Qal state, and making had condlliuna daily worAC, and tt is 

*eU to be very circnms]*ect lest, in the anxiety to save a liinb, 

^"011 sacrifice a life. This form of danger from exhaualion be- 

"^iigs to the early stages of the disease, and depends very much 

'*|x>n original weakness of coTistilution. Wlieuonce an involu- 

*^*Tim has formed, and the patient hna recovered a partial use of 

** is limb, the danger of exhauRtion from continued ilrain by tlie 

Suppuration, in ray own observation, is eonfinod to those in 

Mrhom some other accidental complications have conspired with 

tlio original disease to depress the vital powers, and in gucb 

Ciues the source of danger belongs more to the complication 

tilian tu the primary disorder. 

Having ilius passed in review the principal features of a 
case of necrosis which hns been selected as a type of the dis- 
ease, Tve must now look at aomo daises of cases in which im- 
portant deviations irom this standard course present thcm- 
**h'e*. Among these varieties of necrosis entitled to special 
etvdy we have — 1. Superficial necrosis or exfoliation. 2. In 
"Widfc of bones near joints. 3. In cranial bones, 4. In jaw- 
**"©•. 5. After fractures. 6. AUer amputatiuna. 7. With- 
**t suppuration. 8. Witliout exfoliation. 

X. Super^eial Jfneronis, or KcfoHat'um. — This simplest and 
''*''** common form of necrosis ditlbrs from that we have been 
""^ying, mainly in the fact that we trace little or no evidence 
*J *»-riy reparative or compensatory process wlieu the sepaxa- 
*'*'** is taking or has taken place. Uence we have no involii- 
''^^13 enclosing the eeq^uestrnuj, which usually lies exposed in 



102 



DISEASES OF BONE. 



the cavity of the BUppurating soft. part*. The jrranntalioi 
whicii fiyrm its l(c;(I, art«r seimrntioii U complete, i*M?h it with- 
out difficulty toward the surface, where it cither tiiakes its waj^ 
out with the di^chai-gc, if it be small, or, if it be large, preeentH 
iteelf at the openinjj of one of the fi*tulK, whence it eiui eiisily" 
be removed by the eiirgeon. lu this way a larj;u iiiinibcr of 
slight iiecroees, produced by detachments of periot^tctlDl, or after 
fractures or after opemtiont; on l>oiies, pass through tlieir va- 
riouB Btagus so easily and with so little disturbntjce, as scareely 
to constitute a coin plication of the wound, or materially to re- 
tard it« healing. There are certain cose-S however, where this 
Btiperflcial necrosis hccomes formidable from its ehaf>e and ex- 
tent. It gometiiries happens that a considerable portion of the 
Burfiice of the boite undergoes necrosis, so thnt the shaft of «^ 
long hone may present on all sides, and in the greater TMJrtiori^ 
of its length a necrofiii*, whieli is entirely cuperfieial, affecting 
only the outer coni]iaet layer. As a sjMjntaneoufl diRcaee thi» 
occurs most often in children, in whom some sudden inflamnin- 
tion of the periosteum has produced the disease, withont the 
bone itself being seriously implicated. This was well illa^^ 
trated in the case of a little boy who recently died in the Ne«r^ 
York Hospital. He was received in coiiae(|ucuce of injuries 
from the passage of u rail-car over Ins right foot. About i^l 
week ailcr, he began to complain of pain in Ida left tibia, which 
was not known to bfi injured. This wna the lOiii of Jnly. 
Soon phlegmonons inflammation developed itself, occopying 
the whole leg, and extending above the knee and below the 
ankle. Aupn^i 12M. — The abscess was opened, giving iBsue^ 
to a very lai^e amount of pua. The matter found vent ilH 
several points, and it soon became evident that the tibia was 
extensively diticased. The probe found dead bone at all [mints,, 
the integuments were undenniiied, the disehargo fetid, and tl 
little fellow suffered grearly. Tic was rapidly sinking from bis 
disorder, when amputation was proposed to save his life. Ifc^ 
was refused by liIs friends, and lie was soon reduced to a raorf^ 
skeleton by hia sufferings and the immense discharge fmm the 
cavities. He lingered until the 20th of September, when he 
died. The whole tibin was fuund to be diseased. The exier- 
nal compact shell had died almost in its whole extent, and at 



KECFtOSieL 



153 



>T two points a partial exfoliation Lad commenced. With- 
in this uDter (lend shell the Uoiie-tisi^iio wtu iu a i^tutu of iu- 
flani Illation. It waa congeetcd with hiood, eufter than natnral, 
extenMvcIv eroded on its epiphytal cxtretuitiefi, and from 
several points eTnberant growth of layers of new I>ono, still 
Boft, showed an attempt on the part of Nature ttt furm an in- 
Tolucrum. So oofl was the bone-tissno of tho head of the 
tibia that it broke off in removing it, and could be crushed by 
the fingers. The Bequestmm, if removed, would have foriuetl 
ft thill tube, rcprcBeuting all the external layer of the shall of 
the tibia. 

2. JVecro»U occtirring in Jlmih of Bones near Joint*. — 

Here the signiticant feature is, the relation of the disease to 

llie articular cavity. The sequestrum may cither extend into 

the joint, or it mar lie near it witliont involvini; tlio articular 

lamella. In the first caj*e, the danger of destructive intiain- 

matioD of the joint is very great, and in many instances, I 

thiuli, I have seen evidence lliat the presence of a BUiall ee- 

qtieetnim has been the cause of au unfortunate tcniiination of 

* Joint disoaf*, which in other respects miglit have had a 

"ivorahle iasue. Tlil-i id the result unually to he anticipated 

**"cre the sequestrum reaches actually into the joint, but I 

''ave seen more than one inatanec where this condition ob- 

"'ired, and where, nererthcloiw, the integrity of the joint was 

*ot. ci>mpnjmised. Thus, I liad a young man under my care 

""**« had, oTer the external malleolus, a foul and ill-behaving 

y<2«r, which was probably syphiHtic in its origin. It had ox- 

f t'^ for many months, and, when I saw it, had cxiK>Ked a (njii- 

^'^^rahle portion of the external malleolus, which, dead and 

_ , t'onned ihe boltum of the ulcer. Seeing that in all prob- 

'-*'lity the sequestrum involved or would involve the articular 

Iy^'-fice, 1 feared the consequencea to the joint when the scpara- 
**^t] shrtuld tv^cnr. His general condition wa.'v fttrengthenecl by 
t*l3ropriate treatment; the character of the sore improved, and 
'**'Twoa the dead piece became movable. It was not dia- 
** *'l>ert until it had become very loose, and then, being removed, 
^ Were agreeably surprised to find that no itdlammafion oo- 
^^^-•■»cd in the ankle-joint, though the separated jMece showed a 
**wiierabIo portion of tlio articular surface, which had been 



oo 



164 



DISEASES OF BOXB. 



applied agninst tlio outer eiirface of the ftistragiiliis. "We kept 
the joint very etill tor a wiiile, until praiiulation was well ad- 
vaticed, aiir] tlii^ii cnrcfiilly iillowod a Ittllc ii)t>veiiicnt. It wae 
well borne, and gradually increasud, until a very BHlinfactory 
amoant of niotinn wnA gained, tlie joint nil tlio time reinainiug 
free from any indication of inflammfltion. The only explana- 
tion of thh interesting fact ia, tbat ftnirounding adhe«tTe iti> 
flammation Imd cU«»ed off tlie general cavity of tlie joint from 
the actions wliidi -n-ere ^.c^'^^ oa round the dead banc, 
which WU8 thu^ placed practically external to a joint of u-hieh 
reiitly it foniied a piirt. Tliis fortunate tenniniitiou must bo 
rare. Its occafiioiial occurrence should give ub encouragement, 
and keep us from dcepairing in ainiilar api^arontly hopolcu 
case?. ^M 

A much more frequent case is that in which the seqnestnitf^ 
doea not reach to the joiut-aurfaccs of the bone in which it ii 
Bitiialed, but, lying very near these joJnt-tinrt'iLceii, iiivolveei tlium 
in the intiamniatory actione of which it ia the centre and the 

cause. Of this, Mr. Stanley gives an iiiterciiting cxamplo in 

the case of a young girl of sixtoeii, who was attacked by 
inflammation of the head of the tibia, wliich was followed 
necrosis. Successive attacks of inflammation of tbc joint 
curred at intervale diu-ing sixteen years. These attacks tiunl 
grew more and more threatening, until the knce-joiut became i 
fierioubily involved at^ to rcndtir amputation iict^eftsary. On 
amining the limb, there was found '^ a dead ^lortiun uf the can- 
cellous tissue, about the Btzo of a hazel-nut, firmly impacted 
in the interior of the bead of the til»ia, half an inch below it4 
npper articular surface. . . . The soveralstractnrcsof the joint 
had undergone the usual changes consequent on long-continued 
inilamuiatiou ; the eyuovial moaiLraue wa& thick and pulpy, 
With lyinpii adhering to its free eurfaco ; tho crucial ligaments 
were softened, and tlie articular cartilages wore in part, ab- 
iorbed." But, bottidca theao more rare cases where destruetire 
disease of the joint is produced by the proximity of a &eiiaea- 
truin. there are a large nurnlier in whicli, by a slower prooen^ 
a stiffneas of the neighboring joint \a produced, which mij 
»oon amounts, if the condition be not obviated, to an ancbylo- 
fris. This is one of the aerious consequences of necro«is, and 



>TCBOSIS. 



190 



unfortunately it Is one which does not ceaM when the necrosis 
it cured ; for, by the long continuance of the ancLvloeis, and 
the conseqnent Oibuse of the joint, iii coiistitu<;iit partcj Liive 
tteeome to adherent to one another by OT<;a]iized librine, and &o 
changed from disiii^e, that but htlle can be dune to restore its 
tuefbhiCfts. It t^hiiidd Ire borne in mind that this ini^dicaiion 
of the neighboring joint may occur in caw^s wliere the necrosis 
it iK't in the imntedinte proximity of the joint, but at eome lit- 
^a diataoce from it. I have now under my care a young gen- 
lleuiui tn whom necrosis of the femur took place about three 
tears b^o. I recently removed the getjucstrum, which occu- 
pied a very lur^e ^hiiro of tha shaft of the femur, but did not 
Approach within ptir!ia{ifi an inch of tlie knee-joint, and yet 
the knee ii^ hopele^ty ancliylosed, and liaa heuit so for many 
wonlhs. I think 1 have more frequently observed this condi- 
tion in the knee-joint than in any other, and more frequently 
•* a con>equeuce of necrosis of the lower part of the femur 
*^*n of the upper part uf the tibia. This tendency to the 
imjiliqation of ueigliboring joiuts eeeuiB to me to offer eome 
practioal 6n<;pcition8 in tho maaagemeiy; of the disease: 1. 
'*herc we helieve tho necrosis not to invade tlio joint-8triictnres 
weuisolvra, but merely to affect them liy proximity, cannot 
^'lething I>e done to obviate the consequences of these sncces- 
■'*■« attacks of inflammation, by rigorously inHuting on prop- 
^y-conducted passive motion, after each attack subfiides, and 
^7 courageously keeping up Buch atteutiou to the motions of 
_'* joint as tihall prevent or diminish its tendency to hopeless 
"gidityi 3. Let nu time be lost in performing the operation 
*Wl removing the sequestrum. Every day's delay inerejiEes 
*|*^ risk of inflammation of the neighboring joint, and adds to 
'^gidity which is rapidly making it useless. 
^H connection with, these cases, I may here allude to tite 
1^*^^ that the eaucelluus tissue, in some of the short bones, as 
™ Ujose of tlie tarsus, is sometimes the eeat oi necrosis, pre- 
"tiQg features somewhat peculiar lo its situation, 
* bad, in IWlcvno Hospital, a carman, ajre<l thirty-one, in 
JwiUary, 1868, who presented a dirioased eonilition of the os cal- 
^^ *hich at first puzzled me. Ten years ago, he had injured 
«* foot by Blriking oa the heel in jumping from a height. In- 



ISS 



DISEASES OF BOXE. 



flammation followed of the whole region of the heel, whi 
niter several weeks, temiinated m the openinjj; of ftii ahwc 
aud the disL-harge of matter from the inside of the heel. 
R month afterward, a fiimilar upcntn}^ took plaoc on the oatsic 
The inflnnunRtion sulwidcd, hut the openings had never lieiiU 
He hnd been ahle, most of the time, to use the foot witbo 
much inconvenience. I examined the foot carefully, on ll 
19th of February. There wa* ftome enlargement and thjcke 
ing of the whole calcaneal region, and the two original opc" 
ings remained nearly opposite one another, and connnunict 
ing, 80 that a probe could bo parsed through the bone, froi 
one to the other. The probo iliftinctly touched dead boni 
A surgeon, who had seen him boiue weeks previously, lia_- 
pasfted a seton through the bone, and letl it there. It ha 
excited but little action of any kind. The history led mo t 
Buapect that it was a case of central necrosis. I proceed* 
therefore, to eipose the outer surface of the o» calcis, and cat 
fully eiilarg:ed the upcnin-; which ted into the subBtaiice uf th* 
bone. As soon as it wat? large enough to admit my Htlle iin 
ger, I diiseovorod a Iposo ectjuestrum, irhich, as cautiously 
poissible, I e,\traefe(l, not without brefilii?ig off i;oiiie of it 
prominent poiiits. It was of tUe size and somewhat the sba| 
of ft BTnall nutmeg, and was compofted of the cancellous tei- 
ttire of the hone. It was shrivelled antl fipparcnt-ly partly d< 
composed, by long esposure to the air and to the foul Bccretioui 
of the part. After remos'ing the sequei^trurn, the tingcr couh 
be iiitroihiced into a cavity, the walls of which were cotct 
witli thick, firm, anJ apparently healthy granulations. Th< 
patient made a very good reooveiy. One other case, alnioet 
identical in its features, has oecnrred to me, in a lad of tifteen, 
in whom a similar operation was followed by a like 8atig.factory 
rcault. 

Again, it happens, but I suspect very rarely, that the whole 
bone (lies, and remains enclosed in the bag formed by the pert- 
osteum. Tliift condition presented itself in a son of the liev. 
Mr. P., whom I saw in consultation with I)r. J. L. Little, in 
January. 1868. Ahont flveweoks previously he had noticed, 
about the insertion of the tondo Aehilli«s, a swelling which had 
come on gradually, and which he attributed to a twist of the 



>-ECK0SI3. 



157 



<fMSe receire'l eomo time before. TIhb ewelliug iiiflained and 

Wftened, aad a very larjre absciss soon (ietilurod itself, iiivulv- 

"ig the whole calcaneal r^ion. Tbia soon broke, and dis- 

'J»ar{?Ml freely from two openings. TJiese oi>enmg«i wbich 

"'Ore on tbe side of tbe oa calcie, bad been laid into one, tbns 

^^potfing the bone tu ea*y exploration with tbe finger. An 

"•^^caa was found enrrounding tlie whole of tlie os ealcis, and 

"*o finger could bo parsed around %o && to toncli tbe bare and 

^"ideally dead bone on all sidcB. The disease was confined, 

** far as we could jiidpe, to the 08 calcis, wlucb was already 

'^^^eiied in its attjiebuiunta, both to tbe agtra^aliiti and to tbe 

'^^Vioid. There was ^-oat thickening and indnration of the 

***R parts forming the \ralls of the abfwcsa, and a vcrj- lai^ 

^lachai^e of pas. lie ^niFer-ed much from pain, and was raj>« 

*dly depreciating in general liealth. 

Regarding the ease as one of entire nocroHiA of the oe, eideJs, 
Uid tielicving that the destnietion was confined to that IionD, I 
lieiutily cunrnrred in Pr. Liitle'rt proposal to remove the dead 
bone, instead of amputating the limb. It vms dune by Dr. 
little without ditficnlty, by making a free opening, so as to 
gtt control of tbe bone ; and then, careftdly separating its liga- 
mentous nttaebments, it was easily removed. As far as ooidd 
be ascertained, the part.4 left beliiuil were in a suinid condition. 
Ko evil behavior showed ilAelf in the healing of llie wound. 
Granulation look place slowly, and the wound tilled up with 
Dew material, the sha^te and size of the licol being in a good 
preserve*!. This, Dr. Little informed me, finally con- 
blidat«d by l)One, so as to afford a verj' good instance of ro- 
genoration of bone from its periosteum. 

8, The third variety of necrosis which I deem worthy of spe- 
cial etndy is that whiph octnirs »k i/i^ rranial bones. It is not 
easy to aay why the disease should differ in its behavior in 
these bonea from tbe course it presents elsewhere ; but that it 
does BO is abundantly maniffest. The moiit striking i>eculiari- 
Hea of necrosis in this situation ara nndnly two ; 1. Au indis- 
jMMitiou to the Bepanition and casting off of the dead iMiue. 2. 
A disposition to spread shtwly and gradually, so as to inviulo 
large tracts of neighboring healthy bone. Theao two fcnturea 
Knder this a formidable disease ; and, as they directly interfere 



168 



DLSEASES OF BOXE. 



■with the reparative action of thediseased part, will explain whj 
it is that iiecrosJB of the eranial bones ts so frwineiitly a fati 
dleorder. It ia tao&tly aa a conseqaence of ityphilis that ibia 
pecntiar form of necrosis artsee; but I have reason to believe 
that in otlier cBchectic conditions of the avHtem, when nc- 
&y|>liilittc history can be traced, more or lew of tlie Bame ]>e- 
cnlioritica occasionally show tbemselveR. I can best ilhistrate 
the disease by giving a tj'pical case, which was undisturbed b^ 
surgical treatment. While at Fortress Monme, in the sjtrin^ 
of 1S62, Mcriellau's army then lying Iwforo Yorktiiwn. I was 
ukod to eee an officer of the regular army, who waa giitlcrin^ 
from Bypbilitic rupin, I found a yonng ^ntlcuian cororcd 
with laj^ crusts of rupia, and so reduced tliat ho was ol>liged 
to keep hi.i bed. He was unahln to go on with the army, and 
finally was sent home, and he came under my care in New 
York, Ilia caee wa^ a moat difficult and di«tre**ing one, from 
the extent ami neverity of the ulceration following the falling 
of tliti scabs. lie jmrtly recovered under the uee of liberal 
doses of iodide of potasj-ium, and was able to go to his homo 
in the country. I saw him again in the nest year, greatly 
improved, but not welt. I lost sight of him then for several 
years, when my old friend turned up in the wards of the Xew, 
York Hospital, in June, 1868. I was shocked to see biin coi 
crcd with sores and Bcabs and searB, emaciate<l to a f.keletoi 
his vuiee altered by the det^truction of part of tho palate, am 
it was long before I could helievo him to be the same man. 
He was in a deplorable condition ; but the nuiet alnniiing fei 
ture to mo was the condition of his head. The scalp pi-esente 
at aereral points large ulcerations, covering alt»^ethor on< 
half of ita surface. The bottom of these ulcers was eonstitnted 
by the bare, dead, and blackened surface of the cranium, 
which was manifestly in a condition of necrosis over at least 
one-hnlf of the vault. Exuberant but pale granulntionft sur- 
roimdcd these very irregidar patches of necrosis, and an abun- 
dant fetid dirtcbarge flowed from their Burface. Some of tin's 
discharge, however, came from beneath the bone, where thor« 
were several irregular, worm-eaten looking pcrforatioTis through 
the dead layer. On pushing back the granulations, healthy 
living bono could easily be brought into view, and a Ud4 



KECHOSra. 



ISO 



someirhat dUtinct could 1)c traced 1>ctwcon tlic dead and living 

parts, wlikdi at some joints Blioweii a dis]iositiiiii tu si.'|iiimtiiiii, 

so tLat at one or two points ntong tliis etSffe coiisidernble exca- 

vationa, of a rery irregnlar outline and of rnrriug depth, conld 

be fteen, pome of tliein penetrating the slaill, and givinji U»\iq 

to pna, which evidently came from beneath the bone. In all 

the rest of the line no distinct evidence could be traced of anj 

tttteiupt at fepanitlon of llie dead from the living' tissue. Tlie 

i>oiLe in the iminedinte neighborhood of the dead tissue showed, 

»t B«me potnta, an increased vaaculnrity, hut no other change, 

Tliiit (vinilitinn had hftcn brought nUout by n serits of nmrbid 

■ctions, commencing a Jiftle nioi*e than a year ago. The fir^t 

thing noticed was a small, paiiifii!,and tender swelling, several 

others fhowiug themselves nearly at the same time. These 

utcrea^ed, soon suppurated and ulcerated, and at a very early 

period presented dead bone on their floor. A great deal of 

ptin attended tlic^^e iilcerationt:, and made it difficult for liini 

to plfloe hia head on Ids pillow without sufTering. His general 

(eelilenees, and the long continuance and inveterate behavior 

of in* disen^, made him ca^e t;o hopcle>u that norldng cr>uld he 

don* except by a cordial and invigorating regimen, with ano- 

ilyne* in full doses, to try to rouse up his faiUug powers. But 

little was aceomptished. however, and he lell the hospital in 

the latter jMirt of August for his Iionie, to <Iie a few dayB after 

Bft rtfiwhcti ii, with symptoms of inflammation of the brain or 

ita nipuingee. 

Here no enrgicnl operation was at any time practicable, 
>tt(l (he di*c.ise followed, therefore, an iindisturbeil course. In 
'he following caries removal of the dead boue was practise!, 
^th a result which, thongh varying a little in different caees, 
**» oti tjic wliole, far thmi cneounigirig ; 

Sarah Atwood, aged twenty-Pour, was admitted to the New 
*<*fk IloBpitfll, June 14, 18.^0. with a diieawd comlition of the 
**'*<» of the forchca<l. Six years lieforc she had had sx-philis, 
'***t followed by any secondary sycnptoing. About a year aftcr- 
*''*H she suflFered much from lieadache, followed by the appear- 
•J^ceof (wuiiful gwelliiigs on the front part of the heiid, wliich, 
*"*r alwut six months, ikiftenetl and suppurated. New oi)en- 
"^ have since formed, and all have oontinued to discharge. 



100 




DISEASES OP BONE. 



Bhowing no inclination 14) heal. Ilcr goneral conditioB v 

eood, an<l elie lias no other ftccoiidnry tn»nifi.'stationi>, Ft've 
listuloiH 0}>cnirig8 now exi^t on the anterior part of the -ot 
frontis, at the bottom of eacb of whicli the probe detects bure 
and roiiph bone. On the IStli uf June tlie late Dr. John Wn.i- 
eon, then in attendance, made an iucii>ion through the line oi' 
ulcere, and laid up a flap exposing the di&casod snrfnue, vliicJi 
occupied at least six winaro inulies. The )>eri(«tenni wa* ^^ 
easily iitrippcd off fn>in tbc bone that it was evident it coul<l 
have had no \-ital connection with it. The eurfacc of the <ii*- 
eaecd bone was rough and irregular, and rai«<l from its jirojte' 
level by elevations and bos-ses which showed that a prooes»<jt 
thickening had been going on. Several openings proMnlc^ 
them^elveti in the niid^t of the diseased regiou, from vbit^li 
pua flowed out, evideotly from a epace between the hone tQ<l 
the dura mater. It Beeincd, from the altered color and the 
bloodleswiiefiB of tho part, that it wais enrirt'ly dead ; and wbeo 
the perio3tenui was still further 6tri]>ped up, so as to esjn**^ 
tho surrounding healthy bone, the contrast was very markeil- 
Ko line of separation, however, showed itself at any point 
and this seemed tlie more remarkable, as there waa reasos 
believe Itiat the death of the bone had occurred at least t 
years previously. It was determined to remova all tUe 
bone, and this was done, after long and patient perseveraiic 
in chiselling and gouging and gnawing the dead Ixmo unt" 
]i%'ing bone was reached. In this way the whole dead porti*^'* 
was removed, eomotinies consisting of a snj>ertieial layer, ti"* 
involving the inner table ; at other points involving the who**' 
thickness of the skull, and leaving exposed the grauulati '^'^ 
snrfat^c of the dura mater. ^M 

Tho behavior of the wound was very satisfactory. Gnu»-^P 
lations sprung up freely from tho dura mater and fnmi tt^ 
gnawed surface of the Ixme. Tovrard tho close of July ti*^ 
iimi and hard swellings occurred on llie parietal bone, near t 
vonud, one of which suppurated and discharged through t 
wound, and the other diiwippeared without suppuration, 'if* 
necrosis followed at this time. About the 8th of September tw*' 
sequestra, of an irregular form, and together latter than * 
quarter of a dollar, separated from under the still-«pe: 




7^ 




NECROSIS. 



101 



rf tlie woiitmI. These pieces, on exnininattoii, proved to be 
ftwii the margin of tlie surface left alltr tlie operation, o» they 
ibo*ed the marks of the rongeur. Tins must have boon, there- 
fore, a B|>n«ui ol" the necrosis nfter llie ojicration ; but it is well 
wwrtiijr of remark that Katnre had been able, iiiider tlie altered 
comiitionii induced by tlie opcrsition, to effect a separation in a 
few weeks, which elie had not been able to accomplish during 
tliB prerioua three years, Ko sijfn of cerebral diAtiirbance 
rinired itfvlf after the operation at any time. NomnherXat. — 
All liai gone on favorably ; the cavities left in the operation 
D€Ui|; filled np and ncai'ly healed. UnAirtunately, however, 
tJ«re ifi too iinich roasi>n to fear tliut the original disease ia 
prpgreeeing, and thus tar it is not controlled by reitiediee. 
New diatricts of Iwno were being invaded by the disease when 
•hewfta discharged, January 9, 1860. 

TliU WHS the tirat case of the kind I had stndied, and I was 
miicli diMtppointcd at it« treacherous behavior. The first 
fiiTorsblB j»rogress batl not led me to expect that its ravages 
*onlfl he resumed, even during the apparently healthful beal- 
'"K^f the woniid. I was nut so nineh surprified, therefore, 
^''ica in tho next cose which occurred I found a aimilar dlspo- 
•itioa. 

James TTnghcfl. aged twenty-seven, was nrlmittpd into the 
ifewYork Hospital, January 2.5. 18(5.1, with necrosis of the 
woes of the cratitiim. lie had had chancre and bnbo eight 
jBjirs before, the bubo suppurating. No evident syniptori]* of 
•Bcoiidary B^-philis followed, though at various timets he had 
•uffered much trom pains in the bones. Some months previous 
**> 'lis wlmit^ioa, he found a painful swelling on his forehead, 
*ld soon after another on the vertex, and another on the right 
*'*'e behind t!ie ear. These B!uggi^hly cnlfirged, and, after 
*"OBt six months, opened and discharged pus. The wouuds 
aarentver healed. The orifices were punting, and the probe 
"Het-twl dead lK>ne over a considerable surface, covered by nn- 
^Wiiined integument. An operation waa performed on the 
'wiex, which was the point most extensively diseased, in the 
Wier part of lSf!5. The bono was exposed, and the diseased 
B*^ was found to embrace about two 6quai*e inchei^, of an ova] 
wttn. This was bore of periosteum, of a browuisb color, and 



162 



DISEASES OF BO.VK. 



evidently dead. The living was BOparatcd from the dead bone 
by a line of dunmrc»tiuii, wliicli was tolerably distinct, bat 
which showed no evidence at any jioint that eeparatjoti had 
commenoed. With the ii>ngeur the dead bone was thoroQgliljr 
gnawed away, till, at nil pointti, living, bleeding bone W8» 
reached. Tiie wound was dressed Hglitly. ImjierJ'ect nttempU 
at granulation were observed for b time, but it soon became 
evident tlint the wliole burfacse of the wouttd was dead, and 
that I !io nficrofiis was extend iiijr. He left the lioepilal in Dj 
cember, 18t35, and soon after entered Bellevue Hospital. Al 
he had been in Bellcvuo nbont a year, the diseneo having, iT 
tbe raeau time, sjiread very extensively, Dr, F. li. UamUl 



J -.---^^ 



,*.'■*?■-. 



(^ 



m^' 



^ 



"n^ 



Flu. Si^BcUeviw llMplui Uuhqih.] 



pcrfortiied an operation, November 2fi, 1860, for the remoi 
of ihe di'iid buDP, hoping that by this time, nearly two y\ 
having clapHcd since tlie commencement of tlic disease, »}par 
tion would have taken place. To some extent his anticipittinn& 
proved con-ect; and one large jnecc, inpliidtng the whole 
tex, catiie away iilmost without diffienlty. At some 
however, even of this piece, the separation was not compl( 
and the bone had to be broken in order to remove it. At 




KECROSIB. 



16$ 



eral other pewxls similar operations were performed, removing 
larger or Rinallcr piec-ea of piirtiHlly-separnted dead bone, a 
t part of tlie bone removed cnibraeicig both tables of ibe 
kuU. 

Hi* present condition, July, 1863, Khows all ilie central 

part of the crown of the head occupied hy a depressed scar, aa 

IsLw^ aa the paira of the hand. Of this Bcar^ n portion about 

t^vn tnchcji bv three evidently has no bone nnderneatli it, tho 

whole thiekTiesA of the craniniii liavine; here been removed. 

Thetnovement* of the brain can be felt and «cen at this point. 

ome irregular ossification has taken place in this central 

pacvj bat, where this is found, soinv hair is growing, showing 

l>at at these points the integimient^, an<l therefore probably 

e pericraniorn, had been preserved. On the right side of 

"is central &*ar, wliieh eecins soundly healed, are nntncrous 

F>«Dings, which leml down to dead bone, showing thai, aiter 

•e lapse of foor yearw, the progress of the dieense ia not 

■Titrted. His general health is good. Ko stgna of syphilitic 

^H The portions remove<l in the two largest pieces embrace 
^^"<nit ten s<j(tare inches, of an irregular square shape, exten<l- 
^P*>^oa either side of the itiediuu tluc, the uagitlal suture run- 
I* > »ig through nearly ite niidille. The surfaces are iri-cgnlar. as 
I *• Torm-catcnT whieli is siill more marked on the edges. The 
I '*"»'^t portion of each of these two piccefl shows that the dia- 
***«c haa embraced both tables of the skull. The signs of tho 
fc^^'iginnl gnawing operation are seen in the upper surface of the 
^■^"tnoved fiequestrum, and the external nurface around this point 
* <lseply staiued of a brownish-black color (Fig. 24). 

A third ease occurred in the hospital service of Dr. Gordon 
IRnclt. John IlKbcrt*-, aged thirty-three, was admitted into the 
N"ew York HowpilHl, January 18, 18fiS, witli extensive necrosis 
**■ tire skull. Twelve years before, he had had a chancre, fol- 
lowed by a non-suppurating bubo. Secondary apnptonis en- 
•'^ eruptions on the skin, sore throat, loss of uvula, and 
PtiiH in the hones. About ten months before hi* admisaiuu, a 
fwldigh swelling commenced on hia forehead, which snpjuirated 
"Wly, breaking and discharging pus about eight niuiiths ai\er 
1^ oommcncemcnt. Similar sorcb have eince appeared at inter- 



164 



DBEABES OF BONB. 



vols, scattered on t)ie top uf the bead. H'k general hcaltli h 
bet'n gmx]. On admittdion thf.>re were nuiiieroas uiidrmtin 
ulcers wsittcrtd over the front and up]>er jiart of the head. 
Tnrving in size from tliat of a pea to that of a dollar, and 
pree*iitiiig dead bone more or leps exposed to view. The dioE 
charge was coiigiderablc, and fetid. The eurface of the deac^ 
bone has not the smooth, even iip])earan(% of a bone which Ii 
diu<l ill full healtii, hut ^irei^ evidence, hr ha rongliiteAa ani^ m 
irregular erosions, that some changes, prubably inflaniroatorr^g 
have preceded it3 actual death. Some of these erosions pea 
trate the thickncM of the akull, and give issue to matter fro 
beneath the bone. At those point* the piiUations of tbe brain csi 
be seen. On tlie 2ith of Jarninry Dr. IJuek proceeded to a\ 
uperatii>ii in trhich he proporiod t*i remove nil of the dead bun 
wliiuh eoTild be w»felv got awav. Scveml of tlie anterior nleei 
were laid into one by coniniuiiicating incisiotis, and the flap^rr 
raised, thuscxposing largely the diseased surfaces. It was fonn 
that the wludc surfaee was dead ; hut, though a lino of deniarc 
tion cduld be distincrly traced, separation had taken place at l 
few points. The bone in the immediate neighborhood eeeni 
perfectly healthy, "With the j'ontteur ]»rlneipidly, by a mis 
proeefeB of breukiiig and cutting, thu wlude of the cranial poi 
tion of the frontaJ half of each pnrictal, and a portion of eac!^^ 
temporal bone, were removed, exposing the dura mater over th 
whole of thia extensive surface. Thin membrane was thie 
ened and grannlating. The posterior half of the vault of tb 
cnniuni, which was found to be in tlie same condition, was 
served for a future operation. 

For a few days aft:er the operation, all went on well, ana 
the wound put mi a healthy, reparative appearance. On th- 
Ist of February, liowever, lie had a ehill, followed by fcv. 
Thin WM repeated alter eeveral days. Gnidually headache an 
blindnew came on, and soon at^er cunvuUionB, coma, and deal 
on the 18tb of February. 

Inflammation of t!ie meninges was found, on poet-tnorUa^^ 
u.xaniiMatL(>n, with inimcrous sinaM abscesses scattered tbn>ngk:^ 
the most superficial purtion of the brain-substance. The n&— ' 
oroaiii was found even nioro exIeiiiiivD than we had supposed^ 
occupying the whole of the cranial vault (Fig. 25), 





XBCROSia. 



IQS 



Several otTier cases nf tliis forruidablo (liBoaso Iiave occurred 
on'ler my observuti'uii, but tbtee seem Buflicieiu to illufitriite ita 
jliiiinil fwitores. 1 ha\*e tried to trace the processes preceding 
-nth of tlie bone in several of these case», but can ouly say 
,t it Beeoift to be a slow pix>ce«« of iuf aumiutiou, iii nbieb 



"^ 



.-•'■ 



'i 



^Z^ 



A 



Flo. t^L-lX. T. llMjiitoI MuKBm.') 

t^Rit^timcfi a mere vamL'tilaritr of the bone abont to die is do- 
^•''ed; in iilher ciu-cs llic bone is t!ii«kenod ; in otliera a dnjioi^it 
"•• praiiiilBr, |iuniit*e-]ik-c appearjince titlces ji](ice on tlic 6iir^ 
"We, but wlieiber from tlio Iiono before ita dealli or from tlie 
iifu^ tisenee after deaitli, I have not yet been able to detect. 
"R>'n. erosions and iilcoratitpria of the rliReiiAcd boiie are die- 
™^«retl, which most of coitr^c have taken place lieforo actual 
'*''lli hofl occurred ; but the whole process is so jrnidual that 
* i« not eaoy to pronomice at any moment wbnt part of the 
"*■* is still ative and active, and wimt iiidead and nnchangin};. 
That the pecnbarities of the disease now deecribed dej*nd 
"pot* Mime eonstitntinnnl vice, nn<l not npon the patbolojriciil 
™''pf*ilion8 of the cranial lionen, ■u'oidd seem to be clenrly 
'''*'Wnl)v the behavior of the-se same bones under other condi- 



106 



DISEASES OF BONE. 



tionfi. Thus gitople truumatic causes produce, iu the crauinDi, 
a nccrositi whiuli differs in none of its clinical features from 
uecrosia o(x*urriug cUcwhorc. For example: John Murphy, 
aged twcnty-tiix, tn June, 1S6S, i^truck tlie top of liis head, in 
riMng from a stooping piwition, ngainst the iron surface of sonoo 
mai:hincry he waa cnj^agcd iu oiling. The contui^cd part in- 
flanieti and fanned an abscesis, which, after dischwging, retiUed 
and coutiuucd to close and open severul times. lie came to 
the New York rio-^pital in August, about two uiontlia after the 
iujurv, witli the wound etill utiheakd. The probe deteotod 
deiLi! bone. Another opening fornieJ, leaving a eonaiderable 
space between the two oriticea where the nndcrniiued integu- 
ment covered bare bone. On tho 92d of Septembel* an incision 
wa§ made joining the two openinp?, and then extended so m 
to expose tli3 dead surface. It was found Dearly round in 
Bliape, and about two i;quarc inches iu size. A prol>e intro- 
duced uniter the edge of the sequestrum, which showed clear 
evidences of separation, loosened the wliole piece, and it came 
away entire. The main portion of this piece was a thin plate 
oomprinin^ the outer table only, but at several points tlie wliole 
thickness of the brme was involved at these pointa. In the 
grannlatiiig bed, from which it was removes), the pulsations of 
the brain could be seen. The wound healeil rapidly, and the 
patient was discharged cured. Iu another case, a mau waa 
brought to the hospital, wi^uuded by a pistol-ball at the upper 
and posterior part of tbo neck. In trying to iraL-o the ball, it 
was found to liavo sunk down deep in the iiuHcular mass be- 
tween tlie occi])ut and atlas, but we could not tind it. Great 
inJiiiinniatiou and extensive 8Uppiirati<in followed, and, after 
many weeks, dead bone eonld he felt by the probe. In due 
time an operation was done by Or, IT. B. Sands, by which the 
occipnt was exposed by a long incision, the muscles being 
partly incised and partly detached. It was found that the 
bottom of the wound was formed by the occipital bono in a 
condition of necrosis, and thnt the aequeatrnm was already 
loose. By eareful manipulation the whole piece was extractetl 
in sha]>o and size much resembling the squamous p<»rtion of 
the temporal bone, and some of it embracing both tables of 
the skull. In the centre of the piece reiuoved wu found the 



KECROSB. 



167 




. c>pening made by the ball, wbicb was also found lying loose in 
^H "Kdm wuiiiid. Tho niui: made a rapiJ recovery. 
^V A^iiti, as illiitstratiii^' another i'oTui oi tiixrotih of the l^kn]l, 

B «• man wiw etruck at the battle of New Orleans by a j:Uiicing 
I ^^Mill -which braised the vertex without brenkin>; tho ukin. 
AtiRcesd fonned at the injured point and ri>iiiaiiie(l iiiihealer]. 
^onie months after, I saw hini, and, fiiuliiig dead bone, made 
in incision and removed several pieces, embracing the whole 
:hicknes& of tie bono, wliicli, from the cleanness of their edgoa, 
^ ~^crere undoubtedly fragineiitft whifli had begn broken by the 
^p-^CDriginal blow and bad ^ubt'equently died. 

^^ With rcp;ard to treatment, these simple traumatic casca are 

i^=»tiriructory enough; but in the con&titutioiiat form my own 
■^^xperienoe is not encouraging. !Nune of the uttual remedies 
^^smploycd Iittve seemed to exert any intliience on its course, and 
^^urgical intert'crenee ia apparently able to effect only the re- 
'^huova] of tho conaoquenceit of the diAcnae, without arresting iu 
~^B>rvgreft«. It is true, perhaps, that in the hopes of spontaneous 
-^L3 eparation we Imve wasted time and abated etlort in the iidmia- 
^^Sstration of remedies; and it is much to be hoped that eume- 
^^thiiig may vet be discovered that will at least control tJio march 
^L^f lUia obstinate and dangerous disorder; Init thus far I have 
^^^rio endence that any remedy has any positive influence, in 
■^^^irresting its fatal march. 

The folluMing ca*o I condense from Dr. Agnew'* report, 
^"^irho kindly sent me the specimens frum which the lignres are 
'^aken: W. C, aged tbirty-eight, had Eutlerod with otiti* 
- ^^tnedia of both oars fnim the ajje of six years, lie retained Iiis 
"bearing partially until nhuiit tliree years before Dr. Agiicw 
^3aw him, when an ncnte attack of deep-seated and very severe 
inflammation in the right ear terminated in complete deafness, 
«cciinipanic<i with paralysis of the portio dura of that side, 

"The patient came under my obsen-ation for the Hrat time 
on the 16th of Ap-il, lSfi3, presenting evj-lences of great suf- 
fering and debility. He hail gufl'ered greatly for months from 
gnawing pain in the ear, insumuiu, lutiti of appetite, and dizzi- 
neaa. An examination of the external car wa? effected with 
great difficulty, on account of its cxeea^ivc tciulerticss. The 
concha, swollen and inflamed, was elevated by a dense inflam- 



168 



DISEASES OF DONE. 



Fuhta. 



:> 



Riatory tumefaction, circumscribing the external meatus, 
tending biinkward over the mastoid proceea, aiid forvvt 
Along the z}'<;iiiiia. Projecting from the meatus wag a liirg^_ 
peaivshapod polypua of a dent>e iilirouB character, bathed byl^| 
constant flow of utinking pus. Deblriiig to get to tlie bottom 
of the case, I placed the patient under cliloroform^and removed 
the polypoid maas by means of h wire snare. 
In nttcmpting to push the snare to the bottom 
of the meatus, I encountprcd a solid obstacle 
in the region of the midtile ear. winch subso- ; 
quently proved to be the seqnctttrum, repi^H 
sented by the accomj)nnying woodcut. The 
ealibrc of the external meatus had been much 
reduced by boggy swelling of its eoft parts, MM 
that I was compellod to niaUo as free an incision^ 
^ as possible to enable me to reach the fteqnestruio^ 

with a pair of small dressiog-forcepft. IlaTin^fl 
got the body in the grasp of the forceps, a slight rocking motion 
with traetion eiiabted uie to extract it. 

*' It will be observed that the sequestnim includes the 
of the labyrinth. The crichlea ia eliowii laid open by caric 
and two of the semicircular canals are seen in part. The l< 
of bearing aiid paralysis of the seventh pair were explained. 
Two views iu fac-similo are given of the sequestrum in the 
woodcnt, and an attempt has been nuule by the ariifj to repre- 
sent the eroded appearances. The remains of tbc anterior 
semicircular canal are indicated by the letter G; am) the 
cochlea B, opened by caries, shows the lamina spiralis. Th( 
vestibule is bereft of its furniture and iibnodt obliterated. 

"After the operation (he patient rapidly regninod liisbealtli 
and by the 3il of January, 1.S63, tbc external meatus bad be- 
come closed by cicatrization. The pnralysis still remains." 

The patient was Bubsequeiitly seized with an aciite otitis 
interna of the left ear. wlticli went on to suppumtian, and 
proved fatal by extension of tho inflammation to the brain.. 
On jjojft mortem tlio dura mater covering tho petrous portion 
of the temporal bone was very much thickened, and a small 
abscess was found in the Urnin imniediateU' above the diseased 
bone. Fig. ST shuws the appearance of each external meataa 



KECE0S18. 



ICO 



after maceration. Both of tbem are enlarged and irreguUir, 

from coriona ulceration, and one of tlicm altnost closed by an 

oeseons proMrth, us large aa a pea, springing fi-oiu the ulcerated 

'nikTi'ln of the meatus. Smaller exostoses of the liatiie kiud 

^ro fynuiug at several other points round each meatus. 



^ 



Wm. ST^^TnuB a •pedBMn id Dr. Msvir'* mDactioa.) 

A fourth class of cases worthy of special litudy embract's 

^■•^ose wliiuli OL'ciir in thejawbonea. Of the cases of necrosis 

^*^currinrf in these bduee wo have a frreat variety, which differ 

^** »io im]Kirtant respeet from cases of necrosis elsewlu-re. We 

^^■^^'e among them, however, two special clnBses requiring pur- 

**^u!rir nienliiMi, and these — i. Thoscr occurring in conseqncnco 

^* the eruptive fevers. 3, Those arising from the poisun of 

^•^oaphorns. The eaaes occurring after eruptive fevers were 

. *^t brought to the notice of lliw profcf^Ritin by S. I. A. Salter^ 

** a jiaper published in Guy's Iluspital Kcporta. Their de- 

I P^^f]ence ae a cansc upon the eruptive diBeaae he considers 

PfOvtd by their almost invnrinble association, and ho givcjt the 

*t>Uowing account of the symptom*; "A little child hasjnst 

T^^^orerod from one of the eruptive fevers, most probably scar- 

^*->>"ia; the caae has been in no way unusual n& to its severity 

"^ "tsconrse: within six weelca or two months of the passing 

'^ «f the acute Bymptom3, tenderness of the mouth is com- 

;'** ned of, and the mother notices fetor of the breath. ITjion 

"^I^«cting the month, the gum is seen to he peeling from the 

™K^ of the jaw around the neck or necks of some temporary 

|w*t|i (,]• teeth ; pus is diMiarging, and more or loss dead bone 

**^Xpo8cd. The denuiialion of bone progres-ipes rather quickly 

"* *leptb, but usually not, after the tirnt, in lateral extent: the 



170 



DISEASES OF BOXE. 



temporary teeth at tlie affuuted pari bccotne loose nnd of)en 
fall aiit. There is no swelling, and no oBsifyingcallns uformcd 
in the region of the necroseci bone. In a few weeks from tlio 
tir»t of tlicito BTDiptoiDf^ tlic scqiicfttrum itself become* loo^e^ 
and i& easily removed, leaving a large gap and a raw grauu- 
latitig gurface which rapidly )ieal«. The necroeia aluiont aUvaya 
includes ihe bone which euiibtttutcs the loculi cutttainin^ the 
develujiitig pcnimiieiit tet-th, as well as the alveoli of the tem- 
porary ; but it does not go fartiicr, and in the lower jaw the 
l>aao of the bone is very rarely affected." Mr. Salter further 
Bt^tcfi that thiA aflectioti occurs only after the emptive fevei 
and that it nttackA cliildroii from three to eiglit years of 
He regards it a» a ftcli-IiiTiiting disorder, re(|uiriiigunly siicb ' 
ment a» local cleanlineAd and general suppurtiog regimen. Tl 
resulting defurinity arises principally t'roin the loss of the teetli.' 

The caseii of necrosis uf the jaw* from c.\pei;iiro to tlie turn* 
of phoHphorutt make a much more tntereistitiig and a inncb moi 
inijKirtant ulafa, and have during the past t'evr years attracted 
great deal of attention. They present tlicmsclveft, alnuwt 
cluftirtly, among llie operatives in the match-inaiiufactorif 
and only in tlinse whohave been long exposed to the putisouom' 
emanations. Tlie substance whiuh sets as the [irodueing catu^^ 
of the miiKfliief h nndunbtedly photrpliorus-va|iur, nsnallj e^| 
isting as plitvsphorous and ]>Iio&phoric acid with prohublv some ^ 
free phosphorus, it was at one time tliuught that arsenic was, 
in some degree at least, connected with the ]>roduction of ihe 
necrosis, this substance being contained in some ordinary and 
impure specimens of pbosphonis. This snspicion has nut been 
veritied, and it is now, alter careful iriveiitigatjyn,believe<l that 
the ])hosphuruB alone its the puitiuuuus agent, The ctlicient 
action of the cause seems to depend mainly on two things: 
first, a long-continued exposure to the poi^n ; and, socondljj « 
Bume condititin, either of the teeth or gunjii, which favors tlM| 
entrance of the poison into direct contact with the tissnes. T^^ 
regard to the lirBt, writers arc unanimous as to the fact tliat 
it is only after very prolonged exposure that necrosis oocnrs, eo 
much so that there are scarcely any eases'on reeonl in whlcfe^ 
Eome years have not elapsed before the disease dovui<iiH;d itscl^H 
Tiie dangerouB ex.pu£urti takes plaoe in only two dopartmcnta 



NECBOSIS. 



1?1 



of the tnaniifncCnre, viz., tlio dipping-room, and tlie counting 
•oil packin*; rooiiu. In theee tlie patients are subjected to an 
itraosphcrc conatantly imprej^ntofi with the funie* of phoa- 
pboniA, anj thiii air ia stitl further contaminated hy the fi-erjnent 
catching tire of tho matches, which generates a large quantity 
of phofephuroiifl auid, and that, too, in the iuimediiite nt-ighlior- 
biKxl of ihe face of the patient, gu thut it in extremely vmy for 
the puisunouii fumei^, whiuh are quitt; soluble hi water, to Rome 
in direct contact with the niueous menibranca of the month 
artd no^, and aUo with ttic bronehial mucous surface. Why 
the poison of phosphorus does not affect the Sdmelderian and 
bronchial mucoui* membrane doe? not appear; bnt the fact 19 
Stated by Von Bibra and OeiDt, whoi^e work on thissubject is the 
most complete we hare, that there is, among the pntieute thus 
exposed, no special tendeiiL-y to bronchial or naaal catarrh, and 
no etrecW are noticed on tho bijno npun which parts of theee 
membranes are spread. These effects seem to be retwrved for 
the bones of the upper and lower jaw, and in these bones, after 
ft prolonjied exposure to tho poison, the first symptom* of the 
diaeaeo appear. 

But, secondly, it would appear that somothinj^^ besides thia 
exposure b nocensary to produce the disease, and this soinething 
is a carious condition of the teeth, or an ulcerated condition 
of the guraa. it wa* early observed that this condition of tho 
mouth was a prcdUpoaing raunc of tho iliscaso, bnt it was only 
after long oljAervation of accumulating ca^s^ that it was shown 
to be a nniform and an indijipcusably exciting cauie. l^oue of 
tbo^e whose teeth were perfect, and whutie guma were wuiid, 
were ever atiiurked, while soundness was maintained, but if 
caries attacked the teeth, or ulceration the gums, or, woree than 
all, if a tooth had been recently extracted, then the persona so 
affected bociime liahlo t*i the devohiptnetitof tliodijwarte. From 
the alow action of such a cause one would be led to anticipate 
that some evidence of oon-ftitntional vitiation won;d precede 
the local manifestation. Thi-t doci; not >ieem to be »o, and 
those who ^ufFsr most are oftentimes the most vigorous and 
healthy of the worlsmen, maintaining every indication uf con- 
stitutional snundnet^H up to the momeiit when the local ditiease 
b^n6 to iufeot and involve the general system. 



11% 



ttESABEB OF BONB. 



The first Rjmptoins of the disease, tlien, are strictly local. 
A ttK)(lific!ie IS geneniWy t)ie tirst complaint, and tlua may l>e 
intermittent, returning at irregalar interval^ until it becomes 
a constant and very digtressing symptom, 6)>rendin(; over the 
whole side of tlie face. The giima now begin to iiifliime and 
ulcerate, aod the parts about the jaw become tumefied. lu- 
flauimation of the whole aflectcU part is now active, and soon 
an abseess foriiit^, iit<ually diKbiirgiiig itself alongside of one of 
the teetli throiijrU the iilcenited alveolus. Kow, retraction of 
the gnnw from tlie teeth, aud uxiK>suro of tlio bone of the jaw, 
gratlaally come on until, in a great many cases, the whole 
dental arch projects into the cavity of the mouth bui-e of perj- 
oateutn, and perft'clly dead. Nuuieroua einuitvii iibually furm, 
•ome ojKning into the mouth, and some ou the cuEitueous sur- 
face, (ind from these escapes in large quantity a fetid piis, 
which, enn&tantly Sowing into the mouth, ia ouq of the most 
oJferij^ve and diKtrc^i^^ing flymptouitt of [he disease; umch of it 
must be swallowed, and can hard!}' fail to add to the derange- 
ment of the digestive function, aU'cady impaired by the prognjw 
of the malady. Aft the disease advances, involving a greater 
and grcBter portion of the jnwbone, the swelling of tlio face 
becomes eiiorutuus, and the aapect of tli« {mtieiit, particularly 
if both sides be invulved, is hidecms and revolting. Suon Uie 
system begins to sympathize, and eruacintiou and hectic are 
alowty devclopeth In this respect a good deal of difference is 
observed, according to the irritability of the patient's conatiCn- 
tion, some being ntfected earlier iu the diaensc as woH as more 
Beverely. But one iHjint hafi been distinctly settled, viz., that 
the constituTional symptoms do not show themselves until after 
the local di^ea^e has niauifeeted itself; the poison, though acting 
extremely slowly, nut appearing to influence the general health 
nntil it docs go thruiigh the eH'uct of the local nivagcs; of the 
disease. The constitution, however, once aflccted, ra|>idly gives 
way under the constant Bulfi^ring and exhausting discliargea. 
The patients become pale and eiiniciated, the digestive system 
giving oat early; hectic fever is establishes!, the strength fails, 
and the patient diea worn out by months or even years of paln- 
fal dii^eaM!. 

In regard to this point, of the constitutional impairment 



KEcnosis. 



173 



not depending on the direct action of Llie poUon ii3>on tlie 

ftj^stein. Or. Geist is very explk-it, assLTtin}; iiiieqinvocally that 

tJic liealth of the nperntivea, nut ixfleeteil with the local diseafie, 

B 18 tks good ajt, it' not hcttcr than, that of operatives in other nianu> 

B factiiriep. ITe^joes filill t'urthor, and Mates that, although the 

" «^Ti)i and irritating funieti of tlie pliosplioruft are Bo conetantly 

>iiliuled. no peculiar prevalence of bronchitis or ua«ul catarrh 

1-1 UJ& been nuUeud to occur. These facts, tojiethcr with the 

• '"ttcts aU)vc fitiitcfl, that the dlscaw) nuvcr occurs in pericctly 
^a«ttlthy mouths, but ahvays rcrpiires a cnrlous tooth or an 
■^aleerated pum for the startinjj- point of the inflanimation. sccin 
^<3 fihow very conduBively that the action of the poison is en- 
tirely local, a view wliicli becomes more important whep we 
H^^dress onrFclvcii to the prophylaxie of the complaint. 
H Tlie »wc1liiijc about the necroxed jhw feeU very hard, and 

|i;^jve« to the touch the ide» of an invohicniiti forming about 
' tlio dead bone, hut, so far ns I know, no proper involucruni ia 
«iver funned. There in found on diftf^^ction a great thickening 
a^nd induration of the timu(^ about, tlinhone, but naotvfiticBtiun 
of them. Between the Rcparatod periosteum, however, and the 

■ dead bone, there i* noticed a material which 1 believe is not 
found in any other similar disease. It consi^tit of a grayish 
]f>owdery deposit, which in varying quantitle;^ is tuund. to 
^<lliere citlicr to the bone or to the grum.hiting surfaco nf the 
vsavitv in wliich it lies. 8unii;tJuies thiti depiwit adheres 
^k closely to thei^e grantilHliont<, and, having some consistence, 
■Tonus a tolerably tinn layer, which Bcema very much like an 
. iiivohicrura. It will bo noticed, however, that this layer is not 
H ft proper (k^ification of the ftunviunfling ti^tAnes, but a mere 
lainina npon the surface which cnn, witli more or less facility, 
\ie peeled off from the granulations on which it lies. On ex- 
ttmination this eut>staiicc is found to powew a choniical con^ti- 
tntion and a niicroiscojiiciil structure which in that of true bone, 
hut dilferiiig troni true bone in tlie complctenc^ of ttn develop- 
ment. Von Uibra says : " The Haversian canals exiiibit in part 
a larger diameter than ihose of normal hone, nud are emjity. 
.... They are not parallel with the general direction of the bone, 
but are placed at right angles to the latter; they interlace with 
one another, sometimes expanding to form aacs, sometimes 



tu 



DISEASES OF DONE. 



'Hi 



contracting and enditig vritli open rooaths on tlio snrfa 
Tbe*e moulliB are more minute in the most recent depoait/ 
and appear larger in oldvr la_ver^ Tbe bone-corpmctes are 
roQDtlcd off or angular, and their circntiifbrenco is iea dixrided ; 
during the progress of the formation of the dejtosit they are 
very large, and ilioir contour pro[»ortionolly undeHiied. Thejr 
appear tilled and dark -nolo red. At first tliey arc iighter, and 
they hflx'e raini€cHtio[i3 like tlio^ uf normal bono, which 
increase in number with the age of ths deposit. . . . The 
matrix of the new dei>osit h at first very brittle; at^er the 
deposit has been exposed to the process of absorptioa it 
siiow^ a powdery appearance, as if spriuklod with a coara^^ 
powcler.*' ^M 

TUia deposit seems, therefore, evidently to represent an 
attcm|>t on the part of Nature to form some new Iwnc to tak< 
the ptace of that which is destroywl ; bat it is also evident t) 
this attempt fa!U short of the success which it usually attaii 
in uthcr cases of necrosis, Why this Involacral cllort should' 
be so imperfect and so uii6iicceii«ful, it is not easy to say, hut 
the pathological fact cannot he gainsaid. The following ap<^| 
pflaraiices ivero noted in a ca^o which occurred nndiT the care^" 
of Dr. Wilhird Parker, at the New York irospitiil, and give, 
perbiips, a correct idea of the usual pathological condition, with 
reference to this pumice-like deposit: In exposing the bone 
alter the tirst incisions, " it was noticed that in some parts, par- 
ticularly along the base, the bone was entirely separated from 
the Aolt partti by a tittppiirating and granulating surface, sue 
as is ordinarily ^een bt;twceii an involncruni and a sequustrut 
white at other points the flap was peeled up from the bonj 
surface by a proco*s somewhat like that by which the <lura 
mater is peeled from the sknl1-«-ap, or like that by which the 
periosteum can be pt^eled from tlie surface of an inflamed bona. 
This raiding of the flap revealed tlie bone, presenting two dif- 
forenl conditions of its surface: one a smooth, naturnl, evidently^ 
dead surface ; the other a rougti, granular, and irregiilnr8nrfao%fl 
to which the soft parts adhered as above stated, and whinh did 
not seem (u be dead-bone tissue, while at the same time it wu 
not the usual vascniar-bone surface of an invulucrum. The 
smooth dead bone was in contact with pus, the other of coane 



iioli^ 
imfl 




NEC: 



w« not. After fully ex|)OBnig ilio bone & clialn-saw was intro- 

duced near the sjniph^T^ii^, and tliebudy of ihc boiiewus iliviileil 

and raiMii from ite bed. As M-itli ilie outside, so wiili the 

inner aspect of the Itonc, some of it was separatt'd from the 

soft jtarts by a suppurating surface, and fumie of it adUerod 

*'»ther strongly lo the aun'oundiog parts. So etronj; was the 

AcIHwUin that at the up(>er part of the angle and neck 

portions of the hony deposit Oaked otV and were left l>cUtiid 

'*' the bed fi'um which the hone woa being removed. Tliis hod 

^■very appcaranoe of being an invobicrum at first si^ht, and wo 

'^^■^re in ftonie doubt »« to whether it was bcAt to leave it. On 

n»ing tbe handle of tlie scalpel, however, tlie soft parts were 

*aei|y peeled from it, and it was enucleated and removed. The 

J^'^'bone tieparated as usual at the joint and came away entire, 

^»Jci without any oonsiderable force. The removal of tbe bone 

■^^1% a bed which was composed in part of suppurating and 

Sr^amilHiing i^urfuce, such as is usually left- on the removal of 

* *equentruni, and in part of a wliitlsli, rough, vai«ular fiurfaee, 

booking not nnliko the surface of the dura mater recently ]>ecle<l 

'■"^rn the skull. Tliis seonted ulearly to be the inner »;irtace of 

'•le periosteum, which had been adherent to tho rough deposit 

**** tbe fturtace of the hone, and from which, beyond a doubt, 

'"O de|Kisit had been poured out There was no osseous de- 

I*^ftit in the periosteum, and no Bumaniding os--^iHcation, as 

***^glit l»e expected around so large a seqiie«tnini; in short, 

JV^tliing but thickened tissues represented the involucpum. . . , 

■I lie examination of the jaw allowed the whole hone to be 

'^^ad, but not much altered from ttb natural appearance. On 

*«ie outer and inner i^iirfaceB of the jaw there was an irregular, 

ft^^iiuhir, atahiginitic deposit of hone, somewhat firmly adlie- 

^•it ti> the dcjid surface underneath, and looking better organ- 

***Hl and more osseoua in its appearnntw than the pumice- 

*'ko dejKwiit as it is usnnlly described. The deposit was in 

'^iiiirifli niuro or less complete, and varieil in thickness from a 

"^Q lo neurlr lialf an inch. ... In the main this deposit was 

••iiHirent to the dead surface of the hone by a i^ort of mecliani- 

**» adhefifon, but in some points, particularly at its edges, 

"•^rc was a thin nieinhrans between them, so that, while the 

^i\ij1o was wet, sotno motion could Uc made between the bone 



I 



!»a 



DISEASES OP BOXE. 



and its fabe involucral covering (Fig. 23). Under the micro* 
Bcupe, ttidbuny character of the depu&U wus nniuistakable.^' 

It i* iigreed tiy nil the ubbcrvcra of tliu di&oaAo that the^ 
reparation after the removal of the necrosed lower jaw is vc 
complete, more so perhaps than in any other hone in the bod;? 
In this respect, therefore, it would seem tliat Nature pian^ licr 
reparative work Bomewlint difTercntly Iruro tiie uiode she olse- 
■wliore adopts. In all ordinary cases of necrosis, tlie periofttenno. 



i=«^*. 



•-'V-" 



Tlo. et^-{!T. T. nwpltal UniMaiB.) 



Tvhieh 13 the principal a^pnt in forming the new hone, begil 
itft work heforo a breach is made in tlie dying hone, and si 
ronndft the part which i« dead and about to separate with a 
layer of new bone, so as to be ready to meet the accident 
separation wliidi is about to occur; and before the sequealmni' 
18 removed, or even loose, euoufih involuemm has been fonned 
to finpply the loss. This ndtnirahlc provision seems to he in- 
tended to prevent the linib from being rendered useleea during 
the prouosft of separation, by guppljinp a temporary support 
which shall be coinpctent to maintain the functions of the dyii 
hone thronf;boiit the whole process. 

In the lower jaw this provision does not seem to be mac 
There is no new bone deposited about the seqiiostrnin autil it 
is got rid of; and it is a curious fact that, however long the 
sequefitrum nmy be iillowed to remain, the fiirtnation of i 
bone is still withheld until the foreign body ehall ho taken 



KECROSIK. 



«7 



I 



oi* the vaj. Alter this disturhing caufiO is removed, luiwever, 

tbu priK!t?«s of reparation is vcr>' quickly ehtablifliocl, and with 

nssnlte wbicli in some inniiincee ar-e tnily wonderful. The 

general sIiaiMj of the jnw h preserveiJ, tho angle is distinct ; the 

coiVinoid process can be felt, and the mnfcles seem to have as 

firm uud favorable attachoiciu as ever, while the muveinenta 

of (lie jaw ape entirely preserved. An excellent illustrfltion 

of this regeneration wa* prcoented iu ouo of our ^'ew York 

Jiospital ca^etf, wbicli oceurrtd in Dr. IlaUted's care in 1850; 

"'e uperatiou of reiiiovai of urie-lmlf of the jaw was performed 

"Q Jatiuury, 1857, and in IJccembcr following I have noted: 

** The half of the jaw ronutved h replaced by firm bene, il) 

"^liich the angle'of the jaw is marked, though not qnite as 

•cute as it should be, and the coronoid prot>t»a h mIso clear. 

TliB wh<de new U»ne is a little ttmaller than the ori^liml, but ia 

A remarkable imitution of it. Tlie alveolar border U prominent 

*"**> the mouth, and he can chew upon it very well." In an- 

^*l»er case, the one already moniioned, where, »t two dititinrt 

|*per«iirins, the whole jaw was removed, I have retorded : 

Stime months after the ojieration," referring to the last one, 

1 8«w liini and wus surprised at the snuJl amount of defonn- 

An ingenious denlist had adapted a pair of plates with 

to the absent jaw with great success. The ]dalL's rested 

firm cicalriciiil niu»a whieli occupied the pluce of the re- 

•ooved Itone, Imt it waa not certain that any deposit of bony 

Stutter had taken place." These two cases present a difference 

**' result which I think ha* some interest aw bearing ii]ion the 

'**ture and oignificanee of the pumice-like deposit. In the 

"f^t there was rapid and complete regeneration by bone; in 

*•'<* latter no bony deposit idler the hi])se of nearly a year. 

. ^t ''.V referring to ihe liif^toiy of the two cases, 1 find tliat, 

"* the finit, it is explicitly stated that at the time of oi)ertttion 

were was no bony inrolncrum, and no pumiee-liko deposit; 

*''»le, in the secoTid, the pnmice-like deposit wa-? in very 

peat abundance. In the first, therefore, we find Nature delay- 

■"g all ossific action until the ecqiie?itriim was removed, and 

Wen Ijeginniiig it i>romplly and carpying it on efRticntly to the 

l^tfect regenerfttion of the lost hone; in the socoud we hava 

8 premature, imperfect, and uusaccesaful attempt at ossilication 

IS 



ifa 



DISEASES OF BONE. 



before the seqnestrnm is removed, in which the ilispositi 
form a new bone in trittercd away, ta tUst after tlie opera' 
there ^-etiiB no tu[u)eiK:v left tuward uHsitiuatiuii, aiid a fib 
cartiliige is nil that Nature seems willing tu undertake, lliif 
seems to me is a fair view <if Iho w^nitieance of tlii* peciil 
deposit — peculiar, I believe, to the phosphorus t-aMS, and I i 
therefore ditipo&ed to regard it when in great abumlnncc ae 
evil iii;;ii, and tu fear tlmt its |)rese!ice, before tlie ofierath 
indicAtes the absence of a more healthv and useful ossific^ 
afterwnrd. f 

An iiiiportant practical question here Hrises: "NVliat shall 1 
surgeon do with tliii; layer ef itiiperfeel hone-deposit when he ' 
counters it in hia operntions. Hhall It be removed ur fihall it 
left! If we believe that it is eapable of Taking part in lb 
generation wliieh we hope fur, after tlie rtinoval of the 
then it ishould be lell:. If, however, we believe that it is in 
pable, both from it8 nature and the situation in wliich itisfoni 
of taking on nny higlier orgaiiizatiun. and thus becoming pi 
of the new btine, then it would be bettt:r to remove it. Vfi 
out having any facta positively hearing on this point, I a 
clined to consider it in the light of an exereinentitioussubst 
not available for regeneration, and therefore to he rcmo* 
whenever it adheres to the granulation*. Fortnoalelv, I] 
question U most eommonly solved for U6 by the do[>osit adh 
ing to llio <U>ad bone rather than to the granulation^, anil be! 
removed with the Heqiieetruin, to which it is sotnclimca vg 



i 

in 
>ni 

1 




Fin, Sit, -(Froai Bclteno Ho«p<t&l Miuoum. opimtnl on Ij Dr. Jibim S, WML) 

intimately adherent. Fig. 20 shows almost complete refo 
tion of lower jaw after phosphorous neerosis. 



NECUOSra. 



179 



The upper jawbone U aleo liable to the ravagea of the 
ph-MpUonifrdiseaso. Indeed, the gtati&ticB piven by Bcvei-al o1> 
s«rTer8 show thai it ie affueteil nearly if nut quite a» often »» 
the lower jaw. The (lisonae in the upper jaw presents no fea- 
tures diffyrent from those already described, except that all 
observers agree that very little, if any, bony rcpien oration tjiktsf 
ptce. The {jap, left by the fall of tlie He<]iio>!trmn, in tilled 
oj A firm fibroaa, or even tibro-eartiln^noiis 8llb!^tanee, wbieh 
pvtially obviates the deformity, and aUo serv-es by its firmiiesB 
^A a tolerable substitute for the absent bone, but ii»ually no 
^^ssiflcatiun takes place. 

The pn>wiKieii' of this formidable disease is more favorable 

*lt»n would at first &ij;ht appear. The disease Iming «o c&gen- 

tially localt aud the general system only involved in i*ynipathy 

^*ilh the local ditMirder, we have usually a prompt recovery 

'^^lien the local caii«e of irritation itt reinovcd. The principal 

"^^riters on this nubject mention very few caBes wbieb proved 

***tal, and in our New Toi'k experience of the last twenty ye.ire 

■* do not reinembor one which destroyed Hie. This favorable 

f^*^}<;^o8iB, after the diseape has necompliehed its destruutive 

*^*iisAion, must not lead ua to expect to find it tractable or nian- 

*^eable in its early Biajjjefl. It will rather bo found that whnn 

^^tice the local action of the poison Um detdare*! itself, no re- 

'•^val of re«tidence, no ceftsation of exposure, no mit^Ical treat- 

'orit, no complete removal of the dead bone, will arrest the 

^*^pre«a of the forming disease, or limit its rava|ro8 when fully 

*i«?\-eloped. It would rather seem that, when once the loeal 

l*oieoning ha& been ho complete oa to pniducc the initial f>yni[)- 

*'*^rQ of the disease, we may count with much confidence that 

*^ will proceed tiirouj'h all its stages, not much influenecd by 

^-'Je remedies cr regimen with which we combat it. 

"With regard to treatment, from what has been already said, 

^e can hope for but little in the direct control of the disease, 

"ttt much can be done which shall mitigate snflering, and per- 

''spa shorten its jwriod. And first, as a matter of course, 

'*'»»oval from expoeure to the fatal fnmes nnist be insisted 

<*. All favorable hyjficnic conditions niH!*t be seeiirifd as far 

» circnm-ttancefl will permit, and, abox'O all, cleanlincM of the 

itteased parts by frequent ablutions, ao that the discharges shall 



380 



DISEASE OF DONS. 



be liept fi-oni becoming i]ecou)]ioAe<I, and in that state iindlE 
tiieir nay into tlie dtoinnch. For this piiq)o*e, warm woti 
freely aiul frequently nseU is the muat efficient of all dctun^miti 
hut, owing to llie eoreiiess of tlje jmrtw and tlie dilficulty t 
Tnolioii, lidlh of the tongue nnd tlie jawi^, jtnticiitA are unwUlic 
or curt'le.-* about its UtM*; and it is better, partiiiiilarly with ti 
least intelligent, to make siime formal prescription nliiifh vri 
be tnaeli more lilieir to receive attention. A weak sololioD ( 
tinetiire of inyrHi, perhaps eomliined with a few drops of Laba 
rnqiie*B soliitiun of chloride of eoda, makes an excellent and ni 
didtigreeable wash, ivlueti gently etimidatet; thegranidating sa 
faces while it clean^f!^ the nmutli. Attention mn^t also be psi 
to the diet of the patients. They cannot ehew, and the foe 
mn^t therefor© be sott. The conilition of the month prereO' 
them from enjoyiivjj the taste of what they eat, and thi*, wit 
the want of appelite, will lend theiii to neglect tUetiitielvefi ] 
this important particular. It is therefore the sui^on's dnl 
to see ilint tliey have ilie rijrhl fuod, nnd that they (lartahe c 
it in proper quanlitlt^ and at ])ropi>r inlervnU. i^lilk an 
meat-soops, with egfcs, will form the most convenient m 
nonrishinp forms of (iiet, varying the form lo suit the changln 
tai*te. Tonic?, as iron and quinine, and hitteis, will be apjn^ 
priate an medicines, while, in many cascft, stimulants will 1 
required, either in the tiiihler tlirin of ale or porter, or in tl 
more tlecideil sliapc of wine, whiskey, or brandy. This invtf^ 
mting rcjrinten is ealU-d for in almost every ea»c, in the lat'i 
and innre prolonged periiKl after the first abscesses have brokej 
and while the profuse iLn<1 fetid discharge is creating a consttl 
drain npon the patient*^ strength. ^ 

The niuiii question, however, remains as to local mana^ 
mcnt ; and here two viewB prevail : One party, fascinate 
perhaps by the conservative fiuh-periostoal &nrgi;ry of M. Ollie 
is led to devote a great deal of attention to the condition c 
the periosteum surroiitiding the dead bono, and by varioi 
binnt in>trumentg thni«tt in between the mend>rane and U: 
bone to eecnre its separation and perhaps to hasten the proces 
TlK*e manipulations are kc-pt np day alter day, ijiving tl 
patient a great deal of pain, wounding and bruising the tcnd<i 
surfaced, and exciting sometimes not a little cousccutirc influ 



IBl 

Tkation. Tliia prcliminiLrv trpatincnt, as it ib regarded, is io- 

tc?mi(Hl to prepare the patieTit for tlie HtiiiI sepnration ot tlic 

Ixjne, when the time for oporation coniL's, bo that the seqiicstnim 

i>l:iall come away eafily, and the periu^tettin i-liiill not be iuvulvud 

■^^^ith it. I cannot help believing tliat tliie> is bud siirper}-, uiid 

I tliiuk 6u for two rtstiions: Fir^t, I do nut believe tbiit with 

Wk.'Txy iustruiueiit, be it ever eu lle.\ile and 6o delicate, we ciui 

^«>Uow the line of sepiiration in b bone so irregular as tlio lower 

oi- nppcr jaw, nor C!»n we accuratelv appreciate the extent to 

"^-liich the separat!i>n is going to tato place. We constantly 

^■"«3n tbo risk, therelore, in trying thus to interfere with the 

X> roce*6, of wandering from the space which JCnture intends to 

3*e-avc between the iwrioetomn and the bono, ami aUo of |;i»irig 

*"i«.nUer in the separation titan Tfatiire piopOHCS to go. Secondly, 

■^^r* gain nothing by eiieh a courac, for Xatiire wil! certainly and 

Bfcocnrately limit the disease, and the space between the dead 

^V3d living will be JHst a« perfect and jnst as distinct as we nan 

r~r-% aVe it with our instruments. The operations are useless fur 

t-l^etnd pi*opoMxl, und injurious in their tfl'ect upon the natural 

F^^MgresB of the discnsc. Their pnnci|ilc, ttierctbre, a» well as 

*^^t».eir prartice, is in tii}' judjjinpnt e(|nally iinatmnd. 

I would recommend, therefore, no intcrtcrcncc with the 
'-^ » «eii»e. except so far as concerns lettini; out matter as early and 
*~«^ly as may be, until the time sUall come when the removal 
'■^^ Ilio dead raaea may be wisely undertaken. And here I ISear 
"^^rgeone are loo ajit to err on the side of liiwte. The diseaHe 
^^ wdistreftsing, its features BO nlfeiisivo, both to patients and 
*'*»e»d*, its progress is so unmarked and so slow, that the natii- 
*>U tendency is to operate as soon us possible in order to be rid 
Of W much enflerinj: and annoyance. It ia extremely desirable 
Uiat no operation stiuuld be nudertakeu until separation bL' tio 
Complete that the dead can ent^ily be removed from the livinp: 
pnrta. This remark, however, has reference more to the con- 
nections of the hone witli it.H articulating t-avily, and with the 
wft parts which environ it, than to any separation which may 
be looked for in the continuity of the bone. The ligamentous 
And tendinous attachments of the bone nt its articulation will 
in the course of a few wecktt ov monthi; bccumo so looscnud 
that, if the whole articular extremity be dead, aa is usually the 



18S 



DISEASES OF BOXC. 



be 



of its bed bv 



of 



twisting tnotiQD, 

bv tim uxerciAci of a moderate force. Tlie pcrio&teani wUI i 
ftcparntc from its sidea iit [mrbaps a shorter periot), !^o ibat every \ 
part is dctacbabtc excepting at the point where the diMaaod | 
gide h contiiiuou:* wit}i the Aound. Here, Xatitre secnid upain 
to fttil ill accompIUhing lier uitual ta&k. Separation either does i 
iiot tako plaue at aH, or taked place so aloM'Iv and so itnpertectty, ^ 
that we cannot wait for its completion, aud iti evcrv cuae which 4 
I bare seen it has beeu iieceivsarv to divide the hone at or near -^ 
the fiymphvHia, so as to |;ct away M'hat woa at all other points 4 
easily eniicleAble. This nlowncss of neparatii)!! eeeina to me^ 
eharacteriUic of the jawbr>ne:» in all their necnucs^ from wbat— 4 
ever caiiiie, where the doud p»rt oiubraceii auy Ihiii^ beyond tb«0 
alveolar toargiris. I have niitrkei the same iudispobltion to<^ 
separation iu iLiaxillary'netiro»L;i after frneture, as well as in theis^ 
iieerosi.'t whiuli oecins from exclusive aalivation. In cnncrtiuLtfri 
orU even in very young children the process of bone eeparatioojM 
h marked by the same shij^^r^dhneait and delay. Thi^ fccneralB 
counw would lead to the belief that it bclonfi^d to the boiie£3 
itself rather than depended un any particular condition of dia— ^ 
eutic, to undertake the duty of separation slowly aud reluo— 1 
taiitiy. ] 

The operation for the removal of tlie ^questrnm will ba^ 
modified according to the extent of the diicusc. If one entira^l 
half, or if the m-IioIc homi lie dead, then it is neccRsary to roaktf^ 
a free incision along tlie base of the jaw, iVom above the angle^i 
to ncHr the syinplivtis, and, cuttiti'i directly thrwnj^li the thick — 1 
ened ti^ues which reprewiitthe Involuerum, expo&e tUesoqnc»--H 
trutn freely. The jaw ebould next be divided at or near tlie^ 
BympliyaiB by a chain-6aw, by wliicli proceilurc tliehalf we wish -M 
to reniovo bocoiiioi) nianageahlo. By now carefiiliy removing i 
tlie adherent tissues from all sides, and following this di^^^ectioQ 
up to the articular condyle, we arc soon able, by a sort of twist- 
ing, tearing moveiuent, to drag tlie whole mass from all it£ 1 
reiimintng attacUineut«, aud it usmilly comes uway entire. If 
both sides nre affected, the operation is to be reiieated on the 
reintiijiiiig half. If, fis ie very often the case, the condyle is 
Btill livin<^ iind sound, then no force wo can aafoly use will 
bring it out of its socket, and the operation should bo completed 



NECROSIS. 



189 



bj catting or sawing off llie bone be.rond the diseased point, 
mftking siittj to cut tlinmgli Imalthy, living lione-tirtoue, elae 
some of tbi) sequestniia would be left beliind. Very little 
cutting ia retjuired atW making; the tirst iiici-tlon, and ther« 
is rjuvly any considerable bcemorrliAge. After mulcing sure 
that all fragments or Alices of bone are removeO, notbitig re- 
loaing but to bring the wound carcAilly lojjiutiier with tiite 
sutureii and [lrci» it lightly. Sometimes it i» well lo dress the 
cavity with lint from Ibe inside to keep tt in better sliapc while 
it is granulating. Tliii* is not always necessary, Imwi-vor, aa 
the ftrmnesa of the consolidated tissues gencndly ke^ps the 
outline of the jaw tolerably siip^wi-lcd. The wound generally 
beliavcB extremely wfll, healing rapidly, and witliont uecident 
or cornplieatiuus. If the disease be limited tu a portion uf tlie 
twdy of the jaw, then nn incision ^vill hare to be made through 
sound, living iMine on both ^tidcit of tho dead piece, in order to 
remove it. Sonietimefl in these more moderate casen, and even 
in the most extensive, the operntion has been practised through 
the mouth without external incision. This i:) of course a more 
tedious procci^s, but wherever it can be done I think it aliould 

attcni|>te<l. particularly in females, to sare the delornuty 

so extensive a scar. 

With regard to rccnrrenee after removal, it ia not very un- 
fwqnent, even if The patient be not again exposed to the vnporn 
of pbo«pliornft, fur the disease to extend beyond the limits of 
the operation, or to ^how itself in i-oine new part either of the 
upper or lower jawbones, and to require a aecond operation 
perbap* as formidable as the tirs-t. This, however, must be, if 
Uie lirst operation bo not too hastily performed, an unusual 
occurrence. 

The upper jaw preaents some features in which it differs 
from the lower jaw in tliis disease. It is attacked ncnrly aa 
freijuentlr aa the lower jaw, but generally to a more limited 
extent. The de^tnielion it mostly confined to the alveolar arch, 
in had cases, however, involving the hone more extensively. 
There ia bnt little of the immense bniwiiy awelliug which 
repre<eut« the involuernm in the lower jaw, and there seems 
to be a irreater readiness to effect the sei>aratiiin of the fie(|ucri- 
trum. Tlie operalion is Udually simpler, performed more easily 



184 



DISEASES OF BOXE. 



1iiroi]<fh the month than ia tlie cnse {n the lower jaw, and o»n- 
ei«t8 iiminly in trcoin);r mucous membrane so as to permit 
tbe pulling out of the loutenetl dead itians It is also to 
noticed that no reparation b}? bone takes place in the upper 
jaw, and Koiin^oly any ['ompensaiin^ fibronfi deposit tills np tlie 
void. The defVirniity ia very greiit, therefnre, and it is furtunate 
that the art of the dentist enables In'ni to remedy, in bo eatis- 
faetory a manner, l»otIi the deformity and the disability. 

5. JV'(?tTO*t« o/Ur Fractures. — Notliing U more comint 
than to 6nd the ends of the broken bone, in compound li-aeturefi, 
in B state of nccrot^fi. I^ng expuecd to air, in contRfl wii 
pUB, and with the i)erioi?teuin jierhaps Btrijiped up to a certaii 
extent by the original itijnry. it is nut iturpriaing that the mc 
exposed and the most injured bone-fibres Bhould be liable 
die. Accordinf»ly,wefind it rather the cxccptit»n,in cnn)ponni 
frftctiires ill adults, that the wound heals soundly without imy 
exfoliation of bone. Moat commonly the broken end »hcds. 
the I'lid uf two or moro nionUis, a small section of bone, whinh' 
tindt! \\^ way tu tbe 6urE'acc, and is easily removed withont its 
prosciii'o hiivitig in any material degree interfered tsiih th 
pnmipt nnd complete nniting of tlie fracture. This nccroftii 
however, may be more extensive, more of the bone may I> 
involved, and thna ve hare sometimea one or more coi 
siderable seiiueatra lyinj? between tbe ends of tbe bon< 
inteiforing with their uniun uud keeping up an cxeebSiTO' 
and an iinnecesfiary eiippiiration. In these cases the earlier 
stages of the fracture may not be cliaracterixed by any unfa 
vonible symptoms. Tiie wounds may go on favorably towai 
healing, aiul union may oreur of the broken bone; but the 
wounds do not actually heal, and solid union is delayed. Fistn- 
lous openings lead down to bare, dead bone, and the whole 
region uf the fracture j>reseiits an uniibual degree of tliiekening 
and indui-ation. Tins state of things may continue indeliiiitely: 
and, indeei), the patient may be walking nbout on hiA limb,^ 
month after month, and yet no houe cunuw away, and the 
wound does not lieal. Or it may happen that nuion m ii 
perfect, or altogether prevented by the jireeence of come ni* 
important M-'nuestruni between the t'r»gments whicli have other-? 
wise every disposition toward healthful repair. In one ea^e, 



KEcnosis. 



185 




lanion of s broken fcmai* liud been di'laved for many months 
V^r a fragment of Jeatl bone lying; cro3swi.se between tbe end*; 
^h-iid a f^ble bridge of delicnte bone is tlie onl^' attempt M-hicU 
tlie specimen sbmv« toward tbe union of tbe fragments sepa- 

tet], hy this foreign body, nearly an incU from oite anotber. 
TbiA condition of thinjrs is broiigbt about in one of two 

ay3. Either the ends of tbe fragments die from exposure in 

lie wound, or e\m original fm^nientA, aeparated more or lese 

ompletelv from the ftliaft, die from the aaiiio exposure won 

er tbe aecid«!it. Tbe differenue can be easily recognized 

■ ■! examining the sequestrum, which, iu tiie former case, 

SiJ^'ill alwaya present the irrei^ulBr worm-eaten surface, whicb 

s. Tiows where it has been dotacbcd by n prooe,is of absorjition ; 

^^bile tbe latter ehowe, on all sides, the evidences of original 

Ejractnred surfaces. 

Fig. 3ft idiowa the enda of each fragment in a compound 
^"racture of tibia in a state of necroi-is, with the line of separa- 
tion well marked, at a little less than an inch from the fnu-ture. 
Itotk fniguients are affected to about the same e:ctent, aud tbe 
^epo^ition of calhis from the living bone, above and below tbo 
line of Reparation, is linnily I>cgim, though fie^'cml wfckc had 
elapsed since the injury. This seqiuwtrum, when detached, 
'Vrould have presented one surface of original fracture, and one 
"^•here it was irregular from detachment by almorption, showing 
"^iiat it was not an original fragment which bad died, but a 

t^ieco separated by Nature long after the injury. 
Fig. 31 shows the appearance of a dead, original fragment 
■bt aiiu. It was taken from a man, nineteen year< old, wlm 
kiifered n compound fracture from a full. He struggled for six 
month* to repair his injury, but at the end of that time no 
utiiim Lad occurred, and an operation was performed by cutting 
dowTi at tbe seat of fracture and removing (be large seqnestruni 
which lay between the brokeu extremities uf the bone. Exanii- 
Dntion allowed this to be un original fragment separated at the 
time of the accident, and <lying in coiit^equenec ol" its detach- 
ment from the eturronnding living tii^Kiies. It lay almost trans- 
versely between the bonea, and, although the yonng man lin- 
gereii four months after the remov:il «f tbo dead piece, yet 
scarce any union was accompHshedj a feeble bridge of bone at 



186 



IP B0» 



tlte posterior part of the sjiace beinc^ all tliat ^N^aturc ooulA 
accomplish. In tlie preparation of the specimen tbo I'raginent. 
wua I'eplaued iu it^ original position, and 60 appears iu Um^Ai 
wood cat. 



•^l 



Tib. U^H. T. IIm]>IuJ Mu«<runi ] 



rtu. St.— t:t. T. nniMui xiumko-) 



inpl^^ 



Tliif! tlejith of detacliei] fraj;ments ia rot uncommon in com— 
pound, but I tbink it must be oxceedingh- rare in siinpl 
fractures. Tbe following i* an intereiting example: A 
entered tbe Kew York Hospital in Octat>er, 1S54, with a KiiiipU 
fracture of bntb tbigbt* and a fracture of tbe lower jnw. For 
about tbree weeks nolhinjr uufavorabte ]>re?ente(l ittwlf ; but at 
tbo end of that time it was observed rliat the ricbt tbii;b was a 
poofl deal swollen nt rbe scat of fracture, and be had Iiccn cor 
plaiuing of pain and tenderness about it ibr several da>'3. 




KECBOSIS. 



187 



about a week puppuratiun was eA^ideot, aiij a large qunntitv of 
matter waa evacuated by hiciiion. The al)Hcefti* did iiul lieal, 
the unioQ of tbe fracture did nut take plat-e, and tiindlv dead 
Iwne could be discovered by the prube, wliile a great deal of 
solid tbickeiiiug surruuudcd tiiu seat uf fracture. Kevcrnl 
woiithii urtorwrard au cperatiun was jM-rforiued by cutting down 
upon the fracture and rrmaviiig tbe dead portion of bone. It 
was found to be a fragment, embracing nearly tlic whole tliick- 
uesa of the femur, whicb Imd been orij^inally separated at tlic 
tiiue of tbe accident and liad died entire. Its snrfaccg Khowcd 
very diptiiiclly tliat it liad not licen separated by any |jrocet>)> of 
absorption. The patient ultimately got a good limb. Whether 
in this caiM3 death of tiie fragment took place irora complete 
Mparation, and tbiu produced tbe ab^cetu, or 
■whether the suppuration caused thedeatbuf the 
partially-detaelied fraginetit. I never waa able 
to determine, but it is so extn'mely rare that 
•oppnnilion takes place in a simple fracture 
that I incline to the first explanation. 

Again, there are poiiio caseB in which neero- 
'flb after fracture involvcR larger portions of ihe 
Ikone than are either exposed in the wound, or 
than can be fluppoRed to be nftected by tlie iti- 
jory. In theae cases it tunat be supposed either 
that an acute oeteitii* has sjiread frum the point 
of injury, or that a suppuration lias detached 
the ]>erio(*teum fn>m tlie bone, in either crm 
extending the area ot tbe dit*eai-e till it soine- 
tiine» 18 found to involve tlie greater part of 
tbe shaft (Fig. 32). 

Tbe indiearinns of treatment are here very 
clear. At>er allowing full time, i^ay an average 
of three months, for the Bpontancous detacb- 
nient of the sequestrum, if i« best to proceed 
at once to Hn operation for its removal. A 
iintnril anwillingness is felt to interfere with 
the proccaaes of union of tlip frneture by a Rerious and disturb- 
ing operation, but this unwillingncps will cease if "we rcilect, 
fintf that the dead bone is Itself an obstacle to good union ; and, 



rio.M.-0*r. iro.pl. 

UlUUKVn.) 



188 



mSEASGS OF BON'B. 



Becondlj, tlint in old conii)ound fractures tlie effipol of free inci- 
sions, and free mnnipulatioii with the fraj^monU, ia geuerally 
to improve the Blugpsh action of the partii, and to insure 
a more rapid and eolld tintoii. So true is this, that in one^j 
or two doubtful cuseu. where I have cut down withont find- 
ing unv duad bone, 1 Uave found tljc eundittoii of the frac- 
tore improve m moflli, apparently from the &timulu8 of the 
operation, tlmt I have had no reason to regret my mistaken 
diagnosii*. Of course no nnnecessary violence should be done 
W'hicli might break np uniun already aecured, and no more 
boue-substiiuce i»liould be removed than Id absolutely neceMary 
to ineurc access to the feijuestrum. In one case recently, in 
the tliif^h, I was oblif^ed to break np t!ic niiion in order to get 
at the deiid i<ieee which whk wedged bi't\viM>n the overlapping 
fragments. No evil coTisequenccs eiieued in this ussCf however, 
and I have got an excellent thigh. 

Fracture may occnr in a Iwne wliich is the Robjeet of nccro- ' 
sis, and may involve tlie involucruni either in its forming or its 
eonipJeled condition. Thu fracture of the involucmm tlnring 
its forming Btage ia probably rare, beuausc, though it ia the I 
wcakeflt period of the new formation, yet the limb is usually bqi 
little moved, in the oarliiT and intlnintnatory stages of the dis- 
ease, that it ia not very h'able to be injured. By the time the 
patient is able to u?e the limb nitli comfort, TCiiture ha* usually 
accompiished the soUditicHtion of the new bone. After ibut 
period I suppose the bono is usually less liable to fracture 
through the involucruni than elsowhere, on account of the 
abundant materitil provided fur i^ccuring Ihe strength of the 
bone at the point of d!aca?!C. The aeeident does, however. 
oceasionally oecnr, and may happen eitlier before the rpmoval 
of the sequestrum or at some period after (>iK-h removal. The 
following case illustrates the fracture of the iuvolaeruin while 
the Be(pi(.'Ktruin si ill remain? imprisoned: 

Mr. C, aged about thirty, a strong and otherwise healthy 
botcher, had been under the eare of my friend Dr. Jamea 
Fcrgiis3on, with necroisis of the lefl os bracliii. A large sequeft- 
trnm was lying loose in a cavity in the middle portion of the 
sbalV, and was ready for an operation, whidi Dr. Fergosnon had 
repeatedly recommended him to have performed, Mr. 0., 



NECItOSia 



189 



owever, had postponed tlio operation from time to time, nsliU 
Tin pa^'c him but filijrhl Inconvenience, »iui InteHered but little 
ritli tlio [iropet'iiliiiii of \m biisinesa. On one 00011*1011, in try- 
to lift a heavy piece of tncat to hnng it on a hif;h hook, he 
lit a sadden snap in the centre of his diseased Hnii, wliich f«ll 
IpleiM to his Bide. The bone had broken directly thryiigh the 
iuvoliu-riini, and had torn its way through the ii)teguutfnt», 
uiuking a had compound frarture. Bt-tween the fragments, in 
a hir^i^e cavity wliieli was now f|uite ex]Kised,eouId he seen and 
felt the Bcquei-tnini, which itself had not autVered fracture. It 
•was in tills condition of thinirs I saw him in consultation. The 
fir*t thing to he done was evidently to remove the forei<ni bodv. 
TIjis was easily done by rotntinj; the arm so as to separate the 
fragments and thus more fully expoao tlio Bequestnmi, Then, 
\ty a few touches uf the chisel, it w»^ released from it» lied and 
removed. This reduced the injury to a mere coiiiponnd frac- 
ture without complication. Tlie displacement was easily ro- 
duced and cattily retained, the hroad, hr'.>keti Ciurfacos of the 
involucruiu Htttng accurHtely into one another, and mutually 
sapporiinn; each other. The tiinl) vcai placed in an angular tin 
splint, and retained in it durinjr all the time of its nnion. The 
cure went on as raiddty ha I evf-r saw in any compound fracture, 
though the lur^ involuural cavity wa» somewhat slow in tilling 
Up. The wound, however, finally healed, and lie had a per- 
fectly Bound and stronp artn. It is at least el<;htceu yeare since 
the fracture, and Mr. C. has had no trmihle with it since. Two 
other cases of a (tlniihir ehanietor, and equally fortunate issue, 
have occnrred to me in the New York Htwpital. 

The next case is one in which fractnre took place several 
months after the 9i;']ueetruui M-as removed, and is very interest- 
ing in showing some of the remote effects of such an injury,, as 
irell aa 8omo of the serious emei^encles that may arise iu en- 
deavorinjj to ohvialy them : 

Mr. L, a mei-chnnt In New York, cnnie under my eare in 
tlieaprinicof IS'O, for the relief of a deformity of hln left femur, 
of which he grave the t'ollowing history: At eight yeiirs of age 
he had an attack, resembling acute rheumatism, of the lower 
part of the Ictl tltigh. For about a yesr the limb continued 
Tery painful, and tiindly an abscess appeared under the knee, 




190 



DISEASES OF BOSE. 



and 



led. Some time after tluA a ftstnlons 



was opened, come time airer uua a nstnions opening 
pearcd on the outride of tlie tlii<;li, iienr tlie knee, and the 
pci'ontl fistula formed on the inside. These openings uontinued, 
to disrhiir£re, and tteveral Rmall pieces of bone camo away atfl 
interrals. nnfil he wa4 about ejo^hteen ;?ears old. when lie pulle<t 
awBj a Boque«trnin ns lar^e as his finger. Souti nl\er this all 
the wounds liealed. AHont eighteen tnontha after, he was 
thrown from his liorw, an*! sustained a fracture of the thigbij 
directly at the point whicli had been the eeat of the necrostE 
The fracture was treated with a long flplint, which was kept oi 
for eij^ht weeks. During the Hrst few days he was aUiiwwl to 
move himself about in the bed, but durinfj the rest of tha^ 
treatment he was kept quiet. When ho left hift bed the limbfl 
was quite Btmi^ht, but afterward gradually became bent out- 
ward, the deformity increasing slowly up to tlie present time. 
Four yenra aj*o another abscesa appeared on the inside of the 
tlii^h, aljoiit a hand^a breadth above the knee-joint, followed by 
a fistulit, which lias ever eiiice continued to dii^chai^e. During 
the last month the dif-ehariro ha« inereased. Latterlv there has 
been some inf1nniinat<ir>' patn about the knee-joint. Thinlcs 
that the sensibility of (he left foot and ankle has been IcM 
than that of the ri^lit. Ilia jirescnt condition is that of vi^rorooa 
health, though he thinks it has failed a little in the last fe« 
month*. The thigh is l)cnt at the jiiiiction of the lower an{ 
niidtlle third, or a little Uidow thi^ point, f«o ac to make a (^nl 
proniinenee ontward, throwing the leg out, so as (o make vcr^ 
serious deformity, and to give him a most iingaiTity walk. Tlie 
limb, however, is strong, and with a cane he can walk well.^ 
The fistula discharges quite freely, though the probe does ao^| 
come in contact with dead bone. The knee-joint is ([nhe rigid, ' 
and gradually becoming mure and mure so. It has on N;Tcral 
oocasiuns been swollen and painful, so as. for a few days at a 
time, to prevent \m going down to his business. ^1 

On the 2lst of May. 1S70, Hssisted by Dr. George A. Petera," 
Dr. Chamberlain, and Dr. Delafield, I undertook an operation 
for the relief of the deformity, and for the removal of any 
Bequestrinn I might find. An incision wiw made, beginning at 
the tifttula and extending upward, by which the surface of the 
bone was reached, and, after much labor with tlie thickened 



KKCROSB. 



101 






2>^ viostenm, and the conAotldated tidsncs around it, was exposed. 

J^3"«3 dead hone wna ieen or felt, nor coiild wo find anj* cavity 

'^•T' 1 • ip|i might contain one. Attempts were then made to break 

■tl»<s t'einnr, but tliiB could not be accompH*!ied «nii], hy the 

1» a eel, the bone had been cut nearlv tlirough. After fracturing 

^l»^ bone, and cutting and Btretcliiiig a few rebi.iliiig apotieu- 

ic libn.-8 on the inside of tite iitnb. the. duformitj whb easily 

»»«l1 coiiijiletelv obviated. The two portions of the fii^mur were 

»^<5^rl_v in a straight line, and the limb did not ajipear shorter 

tV»Kfc.ii its fellow. While pressing the limb inward, ao ba to 

^^ «"»».ii;hten it more perfectly, ft sudden giwh of arterial hluod 

^*~«>Tx the wound announced the rapture of a large iirtery, wljich, 

fV«3»Tfi the situation and the aize of the stream, we cuuld not 

'^*>«»bt wftii the popliteal. Preseurc was inntantly made with 

* '^^ fin;;er on, the iliae, and by Bpono;efi in the wound, and the 

^**'*v was Ptoppeil, but not till tnncli blond liavt Iteen lost. 

*^«Ae artery was tht-ii souj^ht for in the wound, and, iifter infinite 

^■■Oijble and labor, wlint were suppowsl to be the two ends of 

*'ie Uccratc<l artery- were secured by a ligature, and the liffim- 

**''^lingo ceawd. The limb was put up with the extcDsion 

""■T^paratns, with weijrbi and pulley, in the usual manner. The 

'*ir«jjth and shape of the limb were entirely eatisfact'iry. 

lie came out from tlie tntluenee of the ether, and all seemed 

*** ^ivell that I left him in ebarpe of Dr. Dehtfic'Id, tfikiiifi the i)ro- 

^''■^tion to have a ttmrniijuifl left hiOHoly round llie liiidi, T had 

****t arrived at my houfie more than a few niinutee «-hen I waa 

**"'r»ni<>ncd with the mesanjte that lie was bleeding severely. I 

"**"»!< Dr. Gurdon Buck and Dr. Peters with me, in coaeultation, 

*'^<i on OUT arrival wefonnd that the Ugiitures, one or both, had 

'r*pi'd off, or tliat they had not, alter all our <'are, been fairly 

I*'**-<^e(i on the vessel ; for thngusli of blood had Ueoii as great and 

*^* *~apid n-s at the first, and the pntient was in a very alarming 

****■! « of prot^tration. The question was between lif^alure of the 

®'"*^oral artery and amputation. Inasmuch as tiic ligature ronid 

****t ftfJd materially to tlie danger of gangrene, the arterial current 

'**^* fif already interrupted by the lacemtion, we conclnded to tie 

*^ artery htw "3own in Scarpa's triangle, and take what chance 

'*5Ve was for Bavin;r the limb. This was accordingly done. 

l^rom the groat loss of blood, the prolonged aneesthc^ia of 



19S 



several lunirs, and tlie slmt-k of three Berere operations, Mr. I* 
■WHS very niucii prostrated, and fur several days rallietl vfrj 
slowly under careful toiiiL- and Btimulant regimen, v,ith t1i« 
cantious adminiittnitiKn of the be-it fuud whicli hia slomnt-^ 
would bear. During tliis criticaJ temi, however, while l»i^ 
capillarjf eirculatiou was so extremdy enfeehletl, the iiijar*?*^ 
1itn1> was (itrng^rlliig t'ur life. All ])ret>i=;iire from the banda^^^ 
was removed, mid, as the surface was white and cold, modcf*«*.<* 
nrtifieial heat was applied by Rand-bags jdaced ftriiHn<l atitl ***' 
some difitante from the limb. The rcRult remained several d f^^* 
in sflR^vense, bnt grndnally the (ircnintion failed more nnd m c**^ 
corapletolv, until June Ut, when the evidences of mortifiait 5«-'i 
were so distinct that ainpntation was performed about Y-l'** 
middle of the thigh. The stump did well in every parlienl «* '* 
and he rapidly regained his health and strength. 

A careful dit«ection of the amputatwl limh was made, Ai^* ^ 
the po])lilr!t] arlert- found to be lacerated just opposite t:I»* 
fracture which I hiid made, the ends of the torn resael bei>*i 
widely separated; no trace of the original ligatures could t^* 
found. The nerve was intact, as was aUo the vein. All tli^^* 
were very closely bound to the bone, apparently by the c*>*^" 
dengalioD of the surrounding areolar tii>6ue, li-om llie infla***' 
matory actioTi which had for so many years been goiug on ■ * 
the iieigliborhood. The eilgesi of thw fnieture were not particr*-*' 
larly sharp, and it Bcenied to mo that the explanation oftV»* 
accident to the artery was, that it was Mrctclicd by the stniigl-* ^^ 
enirg of tlie bones in such a way aft to he pressed upon direc* '^ 
by the ends of the fragments, and, being incorporated wilh t J'* 
surrounding consolidated tissues, it had lost its elasticity a»* 
its power of eluding pressure, and it gave way. The knce-JM ■* 
ghowed traces of recent inflanimation, and was extremely riga*-'' 
Thn amputated end of the femur, alter luaccration, was fous* 
to be ihiclver, harder, and Jieavicr than in a natural slate. Tl» * 
was iiuibt noticeable immediately abunt llio ]>oint of old fr»*^ 
tnre, where the Iwne was thickened by involucml Bc!ionar»^ 
deposition of eallus (Fig. 33). Tlic outline of the old fractn*"* 
could be distinctly traced. About an inch below ihe point ^* 
which I had broken the bone, a small opening of the size of * 
pea led into a cavity in the bone about largo enough lo contai** 




I 



^'Od, where the tissue was (inn, porous boDO, but nowhere 

J^^^eellooB. The cavitv wus reticulated, but not rough in its 

"^^fiiee, not indicating any thinf; like caries. No aequeatriiiu 

^%8 fonnfl in it, thongh it donbtlew had contained one which 

^^d citlier disinteprated and come away in the discharges, or 

**ad been l'>st in the nuiceration. 

With regai-d to the prognosifi of snch fractnres of llie in- 
^olncrani, my experience has led me to expect their prompt 
*nd firm nnJon, proirided the originfll dl^ai^e wss in a favor* 
Ible condition, and tfie seqiiestrnm could be entirely removed. 
6. 2f^cro*U after Ampfitati out. — It happens after a great 
rnany amputations that tlio healing of the stump ia delayed l>y 
■ small amount of necrosit; of the end of the sawed bone. A 
ring- of bone, injured by the violence of the saw, and romain- 
13 



194 



DISBASeg OP BOVB. 



ing e:tpo*e(l to tlie air und to thefliiida of tlie fluppnrating 
surface of tlio etump, dies niul separates, usitallj iindin<:r its 
way to the eurt'aco eome wec-ka after the amputatiou, without 
iiiterlering witli tho heaiiugyf the wound ill any other way 
than to delay it (Pig. 34). Jii certain uther eiisve, fortunately 
much more rare, the necrosis prcscnte more extensive and more 
formidablo features, soinotimcs involving alnioat the whole 
flhaft in it* destructive resnltfi. Thi^ form of necrosis is most 
commonly seen in tlie thigh-bone, and always in its compBct 
portion. I have occasionally observed it in tlte humerus, and 
more rarely in the radius and iilnn. The clinical history of 
8Dch a cose i^ about as foliowg : After an amputation uf the 
thigh, every thing makes a fialisfactory progress during the first 
few weeks. Tlie woutid IiohIk kindly, the ligatures come awar, 
and both patient and surgeon Hatter themselves with the hopes 
of an early cure. It is observed, however, that though the 
ligatures arc all away, and no apparent cause exists to i>rovent 
the healing of the tsmall portions of the wound whiuh stUI 
remain open, yet the wound does not heal, but continues at one 
or more points tu di^ehiu'ge matter in quantity altogether out of 
proportion to the apparent granulating sni-faco. So<>n the sores 
take on tlio exuberant pooling appearaiico of tlie granulationB, 
ri>nnd the orifiisos from which matter is discharged, which at once 
lead to the snapioiori that there :s dead bone at the bottom of 
the sinuses whitb terminate at these opeuingH. The stump 
continues tender, and now, perhaps several weeks aflcr the 
amputation, shows more iiithimmatory disposition than it did 
soon after it wa# made. The stump is also swollen and bullmos 
in its appearance ; and this swelling will he found to bo due to 
an enlargement of the Biid of the bone, which is most marked 
at the sawed end, and dimiiiiBhea gradoally toward the tro- 
chanters. A probe, introduced at one of the fistulous ojicnings, 
easily recognizes a considerable portion of dead bone, verv near 
the surface and easily accessible fyr removal, Tlie patient is 
feverish, and suffers a good deal of uneat^iness, and perhaps 
pain in lliu stump, which he is very much disappointc<1 in not 
finding healed after several months of confinement. If, now, 
an incision be made on the face of the stump, and the end of 
the bone exjiosed, there will be found a ring of dead bone^ 




NBCROeOS. 



195 



partly concealed by bony growth, which riiijr represents the 
sawed end of the iKme. It will be oliservod, however, that this 
ring iloea not represent the whole thicknetM of iho shaft, but 
rather its inner lamina, which, being dead, is surrounded by 
liring hone, by whieh it is eovored in aa by a thick and well- 
formed involucrum. On seizing this ring of bone, with a 
«troug pair of forceps, it. will be found to be movable, but it is 
only after very powerful tnictiou, combined with twisting tiiid 
I&teret movements, nnd sometimes after their long and ener- 
getic continuance, that the Bequeetrum startB from its bed. and 
we draw forth one of those long, irregular tnbcH of dead Itoiie, 
of which specimens can now be seen in erery musinm, The^e 
tubes con-espond to the inner lamoHffi of the femur, or that 
which looks upon the medullary cavity of the bone, as is ehown 
by the eize of the inner cavity of the tube, which h that of the 
medulhirj' eanal ; and by the appearance of the aurlace*, wliicli 
on the inside are those of tlio medullary canal unchange^l, 
while on the ontflide we have tlie irregular, worm-eaten fiurface, 
which indicates that by a process of absorption it has been 
eeparate^l from the outer lamella?, which have maintained their 
vitality. Not only ha« this outer portion of the bone niain- 
taioed it$ life, but it lias thickened and enlarged itself so aa to 
cau.se the bulbous expanf>ion of the end of the bone in which 
involucral expansitm the itcqncstrum has been enclosed. These 
secinestra vary in size from two or three to eight or nine iTiehcs 
in length. They are generally more or less complete cylinders, 
bnt here and tbere are »ometiiaos found openings, through 
which lx»ny granulations from the involucnim may sometime-* 
shrx>t, thu« loL-king the sequestrum fast in its bed, and mnliiiig 
it difficidt or impOf*!*ihie to rt^movo it without a conBiderai)le 
oporalion. The following ciiftc ilhistratea this particular difli- 
colty, as well as the genenil features of the disease: 

James Thompfion, aged twenty-six, had his lofl thigh ampu- 
tated, May 12, 1^155. in the New York Hospital, for an injury 
to his knee-joint. The etnrap healed favorably, till only a fiinall 
ulcer remained, and he rapidly recovered strength and health. 
In August it was ubs.erve«l that tlie wound had ceased to c(m- 
Iract, tliat the end of the femur was much eidarged, ami a 
probe, pa£8e<l in throngh the nicer, detected doad bone. Tho 



196 



BONE. 



stQinp now hegAn to be occaiiionflll'r painful, the discharge in- 
creased, and lio was evidently losing ground. About tlie first of 
Sfjftctiiber a small incision vm made, and tlie whole circle of 
the cut end of the femur wai» found necrosed. An attempt was 
made to pull ont the dead piece, but it was firmly fixed and 
was loft. The mischief in the stump went on increasing. 
Abeceases fonned, and opened in various directiona. Tlie dis- 
charge became very profuse, and the patient mnch reduced by 
fever and pain. About the tirat of October the end of the 
fitunip was again opened, and the sequestrum well exposed and 
eeized by a pair of powerful forceps. On making \erj strong 
and steady traction it became evident that tlie piece was loo«e, 
and soon it (Started from its bed, and was drawn out alwut 
three-quarters of an inch, but heyund that jtoint no force could 
move it. It could be pu.shed back, and it conld he moved a 
little from side to side, but it tiouUI not, with all onr force, be 
drawn any farther out. Supprnting that it was locked in by 
bony gramtlationg from the involncmm, it waa left drann ont 
as far as it would oi^uie, and eiu:h day traction was made npori 
it, hoping thus to cause the absorption of the new bony deposit 
which impeded its extrication. Tliia result, however, was not 
realized, and at the end of a month the sequeBtrum was aa in- 
extricable as ever, ntid the condition of the stump, a< well aa 
of the patient's general health, was rapidly deteriorating. On 
the 2d of November T made a free incision over the anterior 
and outer face of the atump, and, exposing the involucrum, I 
couHuenccd removing it mund the end of the projecting Beqnea- 
trum. The removal of thrue-qnartcrs of an inch all around did 
nnt liberate the ftcquestnim. I then broke up some osseous 
matter which had formed a sort of cylinder within the seques- 
trum, and thus I discovered that from this internal oesification 
a spur or i)roces» of bone passed through an opening in the 
sequestrum, and joined itfiolf to the iuvolucruiu witliout, thus 
nailing the loosened bone in its cavity, but permitting it to 
move backward and forward about three-fonrths of an inch. 
This spur being cut by the chisel, it was found (hat the seque* 
trum was released, and it was easily drawn ont The stump 
improved immediately after the removal of the dead bone, and 
healed slowly. He was discharged cured, May 6, 1868. Tim 



KEOtOSia ^BHh 107 

opk«ration drew my attention to this inner cyliiulcr of bone, 
■Wl-i ich, as far as I know, has not been noticed by any wlio have 
^Titien on tliis subject. It plays so important a jtart in tliia 
dittcase, that I present the continuation of Uio Iiistory of tlio 
*»>OTe cara, in whicli the relations of this inne-r cvUnder became 
'*"«>Te distinct. Tlio man continued wcU dnrinj^ tlio eummer 
"^Xlowing Ills leaving tbe boepital, but imfortunftt«ly b«d a fall 
^^l^icb caufl«d reulceratJon of the i^tiimp. lie came back to tbe 
^*^*^pitaU and. as tlie soft parte had trom long-continued disease 
*'**'iuil; away, leaving the tbickeued end of the bone nnduly 
Prominent, tills thick bulbous end waa exposed by an in- 

^^**»ion, and one inch »ncl a half of its extremity sawed off. 

B ^^ii left the sttitnp in a good uon<iitiou to heal eoiindly, which 
*t did withont farther trouble. On maceration, the removeil 

I'^t^mont proved to be perfectly Bonnd and healthy bone, but 
"Vety much changed in «i7.e and form. It was twice the diam- 
eter of tbe 60und femur, and the expanded extremity bnd a 
Toiigher and more irregular Biu-face. The section ebowed its 
stmcture to he that of a double cylinder, the outer one being 
rery thick, the inner one being quite thin. "Within the inner 
c}*litid<T the medullary canal exifited of a size and appearance 
I qnite nutural. Riftween the outer and the inner cylinder, a 
^P narrow, cylindrical, vacant apace existed, from which it was 
I evident that the sequestrum had been removed. The substance 
of both cylinders was spongy and porous, indicating clearly 
that the changea were of recent occurrence. Figs. 85 and 3il 
show these nppearnnces very distinctly. 

The explanation of the occurrence of these sequestra, and 
the reason of their peculiar configuration, have not attracted 
much attention from surgical writors. Mr. Syrne alludes to 
them as produced by injury done to the medullary membrane, 
whereby the inner lamina of bone nouriBhed by that racm- 
brano dies and exfoliates in a tubular form, an explanation 
which, aa far aa it goes, seems to nie correct ; but what the 
uature of that injury is, and how it i» brought about, are 
que&tious which yet remain to be answered. If wo admit 
tliat the necrotuA is of the inner laiuellffi next to the medulla, 
and this seems to be ntideniiible, then, inasmuch as these 
inner lamcllee receive their nouriBlimcnt trom the medullary 



k 



108 



DISEASES OF DONE. 



i^ 



ftrtorics, it vonid seem certain tho-t tlie mischief must be doe to 
Bome action in the medullary uirculation, whereh^' this partiui^H 
lar portian of tLe bono losua its vascular 6U])plv. ?»ow, tlii^ 
may be prodncod in variouB waya. It way be, for example, 

that t}iu medulla ib Ifillcd by the direct rioS 
lence of the saw, as we often see lacerated anc^ 
contused wonnda elsewhere mortity on their 
BiirfacG. That this id often the case, and thi^| 
such a death may explain tJie narrow ring of^ 
bono wfiich uHeu cxfuliatee from the Bawcd cnc 
I am not disposed to deny; bnt that snch ^^< 
lenee coiihl extend ro far as eight or nine inch< 
up into the stump, and produce its effects witb-_ 
out entirely destroying the medulla itself, 
does uot Beem to mo reaaonalilo to believe/ 
Again, it might be eupposod that inflamnialiun 
attacking the raedtilla. and suppuration oecnr- 
ring, might separate the hone from the vascular 
substance of the medulla, and thus produce its 
imct'Ofiis. But such an iitflauimation wonid he 
accompanied, we may well euppoee, with very 
marked and ])r<)l)ably very serious symptot 
both local and general, such as accompany 
teo-mytjlitis, wherever it occur*, under other 
cumetances. Ko such symptoms are present,' 
however, in cases whcro the most extennive sequestrum is 
found; in fact, the eases presenting this trouble are usually 
most favorable in their demeanor during all the early period 
of thoii' healing, many of them not presenting a had symptom 
until tlie evidences of necrosis begin to Bfaow 
themBelvep, and even then thefe evidences accu- 
mulate slowly from day to day, not being pre- 
ceded by any thing which can stand for an ap- 
parent cause. We are, therefore, it Pet-ms to 
mo, debarred from assuming either direct injorr^ 
Fio.sii,-OT.T.H«i- of the medulla, or Bnp]>urative inflammation 0^| 

it, as the ca«!>i3 of these peculiar sequestra. 
Some cause must he found wliieh will e?qf>tain all the ph* 
QonieDa, aud thiB cau»e, I think, it is not difficult to arriro 



Fi«.»-o«.r n«« 

plUl MUMOIU.) 



■c./ 

1 




XECROSttL 



199 



IT wo suppose that the nutritious artei^ of tko bone is divided 
either by tlit saw wliile in its bony canal, or Ity tlie kiiile before 
it has entered it, then we have the vaseiilar flu]ipl}' of the 
medalla temporarily anspended. The inner lomcUm of tho 
bone, def»en<Ung for their supiily on the medalla, are also 
deprived of their circulation. The medulla itself, having vas- 
cnlftr connections with the upper, spongy, and more vascular 
portion of the bone, gradually recovers its eujiply of hlood by 
anattomusie, and probably never dies from thift twiiporary cut- 
ting off of itB circuliitiun, but in the meFin time its eiivnltitiun 
i» so enfeebled that it can Mipply nothing to the bore, and this 
"na no resource but iti its anaMomosiB with the outer himolliE, 
itoiirislied by the periosteum. Tho vessels of the outer kmellce, 
**iMtoniosing with those of the inner lamellie by cftpillaries 
^ncloeeti iii unyielding walls, cannot dilate with sufficient 
'^pidity to meet efl'ecljvely the sudden demand U]>on them, and 
tUDa it happens that for a time the circulation of the inner 
•^toelhB is entirely suspended, eometimes suttieieiitly long, I 
"*lieve, to bring alKjut its death. This will account for the 
''©crosia presenting no symptoms until the presence of the dead 
"<*ne begins to announce itself. It also explains wliy the n^- 
P^oaia Hmits it-ielf to the inner lamellfE, and wliy the seqne&truni 
** etiibraced between two tubes, odc the outer periosteal por- 
'*^*J, which has thickened itself gradually into an involuerum, 
^-'xi the ollior a Ihin eyhndur of osaiticatiou of the surface ot* tlie 
'**©clulla, which has recovered all its vitality after a teniponiry 
*^«iicnt;ion of its circuhitioti. It will iiUd explain wliv it is that 
*-*ie npper end of the sequestrum grows thinner, and branches 
*'' to slender tenninnl spiculm of a very irregular and fiometimes 



fa 



V 



'ta*tic form. This is the outline of pnrts dead from loss of 



^l"*i|l:iry circulation, a loss which is better and mure quickly 

^^^'^i pen sated above, by the greater facility of auastowutic su]> 

***J^ in the upper, spougT.', thau in the lower, compact portion of 

^** bone. If this be acceptwl as a possible explanation of the 

"■^Onomena before us, it remains to show that it is a probable 

'***■- This we arrive at by observing the course of the nutri- 

_ ^^v»a artery as it enters the bone. In examining tbrty-fivo 

. *** ora coutaiued in several museums in this city, I found that 

^ "fcATenly-three the nutritious foranieu was eituated about the 



200 



DIF^ASK OF SO>fE. 



jnnction of the upper and middle tliinl, aud in twenty-two it 
was at or near the middle of the bone. In BerMut ioatailces it 
wad double. The direction of the canal, in eTery inBtance, was 
from below upward. The artery it€elf U giren off Irom the 
middle perforating braiicli of the feiuorol, and rone upward ^B 
certain distance before it enteni the canal, and ihxxi we have ^H 
space of un inch, more or less in different individuals, in which 
if the knife or aaw happen to fall it will divide the artery, and, 
when wc consider that this dangorons inch ia, in twenty-tw^_ 
ca«es out of forty-five, at the very middle of the bone, we ca^| 
well believe that it will be traversed either by the knife or by 
the aaw, in a considerable proportion of the amputaCionK of tl 
tUi^b, which are done tlLrough its middle third. 

7. Necrosis wiihout Sujfpuration. — The occurrence of su] 
piiration in cou&cquence of necrosis is so anivcrwil t]iat its occa^ 
Kional failure to demonstrate its pi-eecnce, by abAccH^<i and Kstntte 
leading t^) the Burfaee, becomes worthy of special cont)i«leratioa^| 
Mr, Stanley remarks: "Only a siugle exception to this has^ 
occurred within my own observation, which wa« in an instance 
of neci"0.'irt affecting portions of the inner himellffi of the femur 
and of the tibia in tlie same individnal. Here the perished 
inner lainelhe have completely separated from the living bouej 
yet there ts no fititulous paitsage in the walls either of the femi 
or of the tibia." I have now under my care a case of a youi 
gentleman, aon of a medical friend, in whom all the eymptor 
of necrri'iis developed thonisolvea more tlian a year ago, and jt 
no abscess having formed, we have been in doubt as to th^ 
nature of the case, till within a few weeks, when a »welIiog 
occurred on the inside of the thigh, tlie femur being the bone 
supposed to be involved, which swelling gradually assnmed the 
oxtenial form of abscess ; that ia to say, it was prominent from 
the surrounding surface, somewhat red on Ha apex, and gave 
an oljftcnro feeling of fluctuation. After watching it for a 
number of weeks, hoping for more distinct evidences of matt«r, 
and finding no progress, we determined to make an cxploratii 
incision. This was done, and, after pawing deeply doi 
toward the Iranc, through brawny, thickened tisane, wo came 
upon a cavity from which flowed a small quantity of pus, but 
which was mainly occupied by a soft, reddish -yellow saUstanc 



\BCROSIS. 



201 



of ajelly-Iike conBiBtencj", which could be Bcooped out of tho 

cavity in qnantiriea, but Kccmed rather like imperlect grannla- 

tJon-sobstaiice than like any moditicalion of pne. The cavity 

'>^ing cleared, eiteo&ive necrosis of the posterior surface of the 

ftiTDor wa* discovered. Thie delay or ftbeence of the eipns of 

* «» jtpnratioQ lias occurred to me in one or two other in^tauue«, 

<^v^d hH£ led me to be cautious in poeitiveiy dc'cidiiig Hgiiiuet 

f J^a.* exifiteneo of necrosis from the mere absence of the ordinary 

iJ^:m mnifestations of the formation of pus. 

8. y^ew^i* without ErfoiuUi&n. — I have already spoken of 
tVxe indisposition to separation which is manifested by certain 
es^jes of necrosis of the cranium, and also of the lower jaw. 
'At lie eaijie hesitancy to cast off the dead bone is eeen in other 
c^».«ee, principally, I suspect, in those of a syphilitic character. 
^MSMiB fiiilowiii^ case is an exauiplc: 

James Recket, aged thirty-eight, a seaman, was mlnnited 
i:a:»'to the New York Hospital, March 9S, 1S57, with epilepsy 
&.x^d amanrosis, supposed to be connected with an old injury of 
tti.« head, and for which he was trephined by Dr. Van Buren 
owx the 30th. He had, at the same time, an oval ulcer on his 
1^^ I^, which was about three inchus hmg, and nearly two 
ixichei! wide, the bottom of wliich was entirely formed of dead, 
Mactj and fetid hone. He said that ho had had syphilis a great 
t*^aiiy times, and that this sore fonned on his Ipg about seven 
months ago. For at least four months the bone had been lying 
®*posed and black on the bottom of the ulcer. It was an in- 
dolent sore, and but Htde tliickening of the surrouiidiug tissues 
^^<i no enlargement of the Uune existed. On pressing rudely 
J**^ tlie bone it gave no paiu, and it was observed to bo entirely 
"*Wnovable. It was thought best to remove the dead portion 
Y^ ^ne, and for this purpose the integuments were niisiHlfrom 
•**B unterior surface of the tibia, all around the blackened and 
*^«l spot, which was found not to extend any farther than the 
part wiilch lay exposed in the nicer. On clearing the surface, 
** »ign of a line of demarcation could be seen between the 
. ^^<\ and tlie living part*, and much less any furrow or other 
,***<iation of conunencing Hejmration. A slight irregidar ninr- 
"** of new bony deposit existed at points near when? the living 
^ tlead bone joined, but the only way of diitingiiishing be- 



902 



ZnSBASES OF BOXR 



tho 



tween tho two %rna in the fact that one part bled when chiselled 
and the other did not. Taking this as our guide, the chisel 
was freelj- but carefully need, until the whole surface bled 
freely. In order to accomplish this, nearly the whole tblckiiese 
of the uiiteriur wall uf the tibia was removed, and a consider- 
able portion on eaeli side, the necruais having occupied, like a 
saddle, nearly the anterior hnli' of the ooinpact snbstaooe of tho 
hone. There was no more indication of any conimencii 
process of neparation in ilie internal and deej>er point 
union between the living and dead bone, than had been ob- 
served at the surface. No serious accident occurred during 
the healing of the wound, the bone granulated sluggishly, 
but witiiout any further necrosis, and the wound was nearly . 
liealcd when be was discharged from tho hospital, August IQH^ 
1857. ^ 

Anotlier instance of marked indisposition to separation oo 
curred in a cnae of necroais which pres>ented features which, in 
many respects, \7erc so peculiar that 1 venture to give the fait^d 
tory in detail: ^H 

Charles Junes, aged twenty-tliree, by occupation a clerk, bad 
suffered for many years with a diseased condition of the tibia, 
of which he gives the folloM'ing account: At about the age of 
eight yvara be had an attack of inthimmation of the left leg, 
whi{;h left The bone enlarged, and the seat of more or los« cott^H 
Btant tendemeM, heat, and pain. About the age of tbirteefl^ 
an incision was niado down through the thickened bone with a 
trephine and chisel, but no sequewtriun was found nor any pus. 
This operation, liowever, was fullowed by some iniprovemei 
in the condition of tho limb, and, after the wound healed, 
remained dlniiiiislied in size, and less troublc&ome to him. For 
eight years the disease remained in a qniot condition, until 
nbont two years previous to my seeing him, when an nbecen 
formed on the anterior face of the limb, which did not heal, 
but degenerated into an open ulcer, at the bottom of which 
could be felt exposed bone. This ulcer increased gradually 
until 1 saw him, in Marcb, 1S59. At this time it waa tivo 
inches long, by one and a half broad, and the entire hwe of i^Jj 
was formed by the bhuUenetl, necrosed surface of the tibia. ^^| 
gave him but little pain, but the discharge from it was eon— 







NECSOSIS. 



SOS 



Gid^rable, and of so abominalile an'! penetrating an odor tliat, 
with every attention to cleanliuees, he could not keep himself 
free from it ; and it was maiul_)' lUis wliicU made Ijim anxious 
to have suinetbing done for the relief of Jiis ditieatie. AltliuugU 
tliere was no eipi of looseninj; of the dead parts, yet the fee- 
qucAtruin waa ao superficial and so aocei^silde that we had no 
tiesitacion in reoomiDendiug art operation, wliiuh waA pert'orincd 
bji* Dr. Buck. It consisted in still further exposing tlie front 
of the tibia, by dissecting back the integumenta. and then, with 
'clxitels and gouges, renjuvlng the dead masa. ^Ve did not find 
nacrely death of bone, as we expected, but, as the chisel re- 
£U«^vcd the most saperfieial tdaekeiicd layer, it was found to be 
rraerely the exposed and dne<] i^urfiice of bone, which, at a line 
cur two of depth, presented a condition of intiltmtcd siijppiira- 
tioD. As cat I)y the chisel, the bone presented very much tlie 
Aj^^kpearHnce of a lunp; in the third stage of liepatization, though 
tt».« pu6 was 80 concrete tliat none flowed out. Aa the jfougc 
f» ^;> petrated more deeply, the eubt^taiiue of the boue became more 
v^^kMalar and Jesi> iiitihraled with pu!^. Tlie dibcased part waa 
tl-x oronghly and carefully reraoved, and wbb found to have pcue* 
tx-^ted at its central portions about an inch toward the centre 
*>4r the bone, which, of course, w»3 much tiilckened and ciinsoli- 
d^lwi by long-con tinue<i disease. The surface left on the corn- 
el ^tiijn of the operation seemed healthy, waa fully vascular, and 
pr-««nted the appearance of bone the vessels of which have 
lx*«ti enlarged by the proximity of long-c on tinned inflamuia- 
^*on. Great constitutional irritation followed the operation, 
^id for a Jong titne he remained in an exceedingly depresacd, 
noTvuuB, and feeble elate. Gradually he rallied, and slowly 
'^oijvalcMred. The wound granulated over a groat part of its 
surface, but the mai^ns of the excavated bone seemed to take 
**** a condition v&ry eitnitar to that which existed prenous to 
*°e operation. This etriking difference, however, existed in the 
^"avior before and after the operatiijn, viz.: that after the 
j^^t^tion the dead parts separated, and some exfoliated in a 
^'■'Vsctly natnral manner, in the course of a few weeks, while 
^**^»nj the operation separation refii-icd to commenRo, even 
^'Or the lapse of years. Ilia condition remained nnsatisfac- 
'y> with every evidence of Bright's disease of the kidneys. 



204 



DISEASES OF BOKB. 



The wound was gjaniilating langnidly, and slowly improvini 
whou lie died August IT, IbGS. 

It is not eaej to explain why it is that in these cases tl 
failure to accotupUsh separation ehimld bo &o marked a t'catt 
even after the lapfifl of bo long a jirriod, l)nt I think ilitir in nil 
the ca^ea; I have olxterved there liat> becu ^oine general cachexia 
which may stand for one step toward the solution of the prob- 
lem. In the jaws it eeems to be the poi»on of phosphorus 
mercury; in many other caees it may be scrofula; but I at 
qaito certain that mnch the lar<::rer number of cases are con- 
nected with syphilia; and it is reasonable to suppose that the 
peculiarilieB uf the behavior of the disease arc due to the 
peculiar constitutional conditions under which it is developed. 

The general principles of treatment of necrosis may, it seet 
to me, he very easily and nflturally deduced from the Iiistory 
the disease as it has now been given. Three indicatiom^ pi 
thenisolves: I. To prevent or relieve tlio iuHamniatJon upon 
which the necroBis depends, or which arises in consequence of i| 
2. To protQote the eeparalion of the dead from the living boii( 
8. To remove or to facilitate the removal of the sequeatram : 

1. To prtT^fii or relieve Ii\^<fmmation: — So evident is th~ 
dependence of necrosis upon intlanimation, that we migh| 
safely say that by prerenting inflammation we can prc^-cnt tl 
necrosis. It very rarely happens, however, that we can in 
reality prevent an mflatnniatioii, in the etrict eerise of tl 
wunl ; but the same principle is illustrated in those ci 
where, by the prompt abatement of the inflammation, we pT 
vent its evil consequences. There arc two ways in which ihl 
prompt abatement can be attained : the first by the very active 
tise of antiphlogistic remedies locally applied ; and, secondly, 
by removing the teusiou and pressure produced by accumu- 
lating eSTLiiiions, by making free incisions down tlirnugh the 
periostenm to the bone itself. The first plan is illiwtrated 
the ease of whitlow, where, by making free tiso of leecl 
and other antipldogistics^ in the earliest stages, we can of 
Bucceed in putting a prompt period to proccssca which we 
know, if not thus treated, are very sure to be followed by 
necrosis of the affected phalanx. The principle is applicabl 
to all infiammations aficcting the hoiios, of each acuteneea 



KBCROSIS. 



SOS 



severity as to lead ua to apjirebend necroeU. Of course, in ft 
Jaige bone, like the tibia, wc htionld not expect to attain the 
a&nte complete results that we often do la tlie finger, but by 
tiae active aud eoergetic D8e of autiphlogistic treuttueiit, tn the 
C&rlier ttujies of iiiflauiitiation, we may mitigate the severity, 
ifcud, I believe, may niuteriully abridge the dcetructive tetiden- 
ciee of the case. 

The second mo<le of abating inflammation, that hy mak- 
iug free incisions throngh the membranoiis covering of the 
1>ones, 19 useful at all periods of the diseoEc, but, of conr&e, 
<U9 a preventive mcoeurc, most effective during the earlier 
e't-ages. In the lai^e lionet, and particularly in the deeply- 
seated ones, it becomes bu Berknm an o)}C>niiion, however, that, 
iix the nnccrtBioty of diuguosia which generally chomcterizes 
rl~i.e earlier perio<ls of ncerosi*, it may he doubtful whether 
i t can often be available. I have known it to be employed in 
OK^e case in ttm city, in a little boy, in whom a auddeu inHum- 
ation attacking the shaft of the tibia, an incitiiou wua made 
y the late Dr. John Wat«ua, along the whole anterior eurfnco 
"■ the bone, dividing the perioateom down to the bone. In 
1 1 » It* case the iiiflaniination had existed long enough to pmduce 
et't^usion l^tween the bone and periosteum, fitr tlje latter mcm- 
b>sr«De gaped open on being incised, exposing bone already bare, 
i^^lich soon Ixfcame evidently dead. No good effect coidd be 
t»~*wed, in this instance, on the progress of the disease, for the 
^^liole ehaft of the tibia necrosed, but our conviction at the 
tiTiie W!i8 that, if the incision could have been made early, it 
*^"^>ght have been more effectnal, at least in limiting tlie extent, 
Sf Hot in preventing the occurrence of necroeis. The enonnona 
^'<^»nd made in this mode of operating, and the exposure of 
*"© bone to the air, arc serious objections to it, and niuet very 
'^'Ocli curtailitit application. In these respects the snbcntfr 
"^^H^ section offer* advantages which I think entitle it to a 
'not© extended trial than it has yet had. 

53. To promote tfttf Separation, of tfte Dead from the Living 

'^*^m,^And here, the first question which ])resenta itself is, 

**■*>. any thing he done to promote this separation? I am 

. '*t*«fled to answer this qnesti^'ii in the negative, as far as ro- 

*^e to the disease in its ordinary tbrms, and in tolerably 



S06 



DISEASES OF BON'S. 



healthy oonstituttoDS. It may well be conceired, however, 
that there may be certain eouditions, both of the part and 
of tho general Hyet^in, where sluggishness and inactivity char- 
acterize tlie morbid actions, and where stinnilation, Iwth local 
and general, would seem to be clearly indicated. The local 
Btimuhints would be those which we would uae in a corre- 
sponding ca«e in the sotl parts such as a solution of Rome 
Btimiilatlng tinctnres, or of the sulphates of zinc and copi>er, 
tho liali^amd of Peru and of fir, either made intu aa ointmont or 
applied pure, or a weak Milutiuii of the bichloride of morcnry. 
Each of those clat'-ses of stimulante, in itci appropriate case, 
either applied to tho granulatinR aurfacea, or injected into the 
suppurating cavities, may have, I do not dotibt, a good efft-ct 
in promoting the separation of the sequestrum, if Nature be 
dilatory in bringing the eepnration about. At the eame time 
eucli general remedies as will improve the general vigor, ar.d 
increase the tone of all the active functions of the body, will 
also assist in bringing about the desired reenlt. But it seems 
to me that it is wise not to do too much in this dirtMstion, lest 
our stimulation excite new inflammation, believing that Nature 
will, in the large proportion of cases, do more and better for 
us than we can do for her. And, as dediicei^l from tbi& same 
view of the cose, I would object to any mechanical means 
being adopted, by inBtruiuontfi introduced eitlicr between the 
separating buue^, or between tlie periosteum and the lione, in 
the view of expediting the aeparatiou, or of preserving the 
periosteum, believing that this instrumental interference will 
not do good, and will he tiablo to do much harm. 

TAi Remcvid of thfi Sfiq\ieAtruni.-^li\\CTe are a few cases of 
this diseaae where the necroais is slight, and where it ts near the 
liurface of the Imdy, iit wliich A'liture is comi>eteut to ca^t off the 
ecquestnini and reiriove it fruiu the body without the assistanve 
of art. In all cases, however, whero tho dead part haa any 
conaidernble size, and particularly wiierc it lioft deeply from the 
surface of tho body, botuo procona of ctlrication in necessar y, , 
cither from its encac!ement in the new bony formation, or fra^^| 
the soft parts which surround it, and these procesaes sometini^^ 
asiume the pnj]K>rtions cf a most formidable operation. Takiug' 
it for granted, tbeUj that some operation will be required, two 




NEOSOSia 



80^ 



questions preeent tbemselvee: first, as to the time when, and, 

omi, aa to the mode in wiiiclt, the operation ehidl be per- 

"orxned. The time when an ojieration for the removal of a 

rtecjuestnim Bliall be un(Jertaken, other tbingft heiiig equal, will 

depend upon one thing only, namely, the tact of the separation 

ff the dead from the living bone being so perfectly accoin- 

pliaLed that, when the seiiueatrum h released from, its sur- 

i^>Ufflding entanglementa, it cau be easily and entirely removed. 

_ A-Tty condition short of this is a coutra-indiuation of the opera- 

I tioii. And this for obviona reasong. If separation have not 

completely taken place, though we may be able to seize and 

*"'iug away the bulk of the sequestrum, yet wc run the ri?k of 

leaving behind some of the undetached portion, and this will 

■ Usually happen at the deepe&t and most inaccessible portion of 

H the wound, and thus the operation fails of it* purpose, which 

V ^1 the complete removal of nil the dead uiuss. Again, if ^epa- 

'ation have not taken place, we may lind ourselves unable to 

^«Uich the sequestrum at all without risk of fracturing the 

I "uiie whose integrity we are trying to save. Tliiii is an acci- 
Ueat which has aometimes happened where snrpeona have felt 
*tiiec«aary, for reasons peculiar to the case, to disregard the 
>Ble, and operate without waiting for complete looiiening of the 
Seqneatrum ; and it has this peculiar feature of disadvantage, 
that, if under such circurastancee a fracture do occur, there 
is left between the fragments a ]>ortion of unrenioved scques- 
train. which makes a very serioue eomplleatiuu of the case. 

■ This rule of surgery, then, being accepted, the next point ia 
tonsecrtaiu the fact of eonipleto separation, as an indication that 
the time for operation has arrived. In many easefl this pan bo 
done, with great ease, by the touch of the probe, which imme- 

■ tliately reveals the fact that the dead piece is movable; but 
there are a number of cases which present themselves, where 
the ascertainment of actual separation is not so eiisy. The 
granulations which spring from the walls of the cavity in which 
the sequestnnn lies, hy pressing upon it from all siiles, may 
hold it so tirndy that no movement can bo elicited by the mere 
pressure of the probe. Under tlieee cirnnndtiincci«, if one probe 
be introduced at one opening, and another through another, 
some distance ofl* then, by making pressure alternately, with 



S08 



oue and tlie oilter, a eee^w uiotiou of the sequestrum mtiy be 
perceived, which is sutlicieiit to prove that it h entirely de- 
tached. Again, bj introducing a Btraight steel sound down to 
the dead bune, and making forcible prewure for a moment, and 
then relax inp it, repeating the inanceuvre Irequently, and with 
considerable force, the loose piece will gradually be pressed^ 
down into the soil granulations, and make thna a space 
which its movements can !« readily appreciated. There 
main, however, acertwin number of caww in which no ]>!iy3i( 
examination will entirely satisfy ns that the bone is looeo, and 
in theee CHSes we have to trust to prubabilitieu. If the death 
of bone have been aseertained to have existed fur a certain timi 
if the discharge have been about uniform during this time, 
the other gymptoms have undergone no change, and if 
orifice of tlie einuscs show the pouting, exuberant granulatioi 
then we may believe that aeparatioii has occurred. The lenf 
of time required fur the completion of the process hae not 
been ascertained, nor is it supposed to be uniform, but I have 
been accustomed to think that in a healthy adult about three 
montliB would be a safe period to adopt, varying of course 
ftouiewliut in individual casts. lu children ^paration takes 
place much sooner. 

Having afecwrtaincd that the tieqnet'lmm h loot^, it is then 
the duty of the surgeon to remove it. As a general rule, nothing 
ia to be gained by delay, and the presence of the dead maes ia 
alwavK H ^urce of suffering and danger. Two conditions of the 
Bequestrum jiresent theniBelves in reference to an operation; 
one where it ia covered in and imprisoned only, or nminjy by 
the boH parts; and one where it h so encased in invohicral for- 
mation tliHt it cannot bo extricated except by cutting awny wime 
of the newly -for tiled bone which encloses it. In the first con- 
dition but littlo ia required except, by incision of the soft parte, 
to liberate the bone; but sometimes, wlien the sequestrum is 
flmall, and when it lies very deep from the surface, its libera- 
tion ia not thus immediately effected. This is often an elnba^ 
raasment which we encounter iu trying to get rid of tliose 
inmll sequestra which form on the ends of tlio fragments 
compound fractures. These, sometimes, without being 
closed in any bony casing, are so inaccessible, from th< 



SOB 



depth, and perhaps their concealed position between the frftg- 
mcnti^ that an incUion of the sott parts docii not help m much 
in tlieir reinoval. lu theao cases the nee of the »)pc>ng^tent, 
\>y dilating the wound, givee na a better acce«« to tlie foreign 
IkkIt. and enables the forceps to open more readily, and thu* 
to seize iiMre firmly the presentimg part. It is important, in 
eacli cH^s. to uee repeated tents until the wound h largely 
dilated, iind to thriiftt them well down to dead bone, bo that 
I the thttnnigh dilatation slial! rcneh the imprirtoned seqneritriim. 

■ "Where the dead bone is closely encased in the involuerum, 
\ ilien a more serious and well-considered procedure become* 

neces&arv. Tlie first step of these operaiioua should consist in 

erpoeiug t|ii> most accessible Eurlace of the involuerum, so as to 

bring it under the reach of tlie trephine and the chisel. In the 

L tibia thii! is of course tho anterior surface, but in souie of the 

■ ^eepor-«eatud bones, aa the femur, it is a matter of nice cou- 
H Bidenitiuii uh to tlie side on which to H[>proach the eicqueetnim. 
H Aft agenerul rule, that aide on which the B^tuloua openings exlat 
H *ill present the Boquestrnra most superficial ; but thia may not 

~ he ilie most favorable direction for the incisions by reason of ira- 
P*«^nt vewelfl and nerves, as is often felt by the surgeon to be 

ithe case in those common ca«e« of necrosis of the posterior sur- 
ftee of the femur near the knee-joint. Here, tho presence of the 
srtery and nerves is an embarrii*«ment which is to be avoided 
"J a circuitous rutJier tlian a direct api^roacli to the discastsd 
'H>ae; and u& a general rule tluti approach in usually made from 
"•o oater side of the thigh, paaging down between the vastus 
**t«mnB and tho bicciw, more flafely and more convonicntly 
•han from any other direction. In each caho this jjoint must 
"^ <3ctcniiine<l for the case itself, but it seems to me very ini- 
P°*1^^ant that thia preparatory 6tep should be &o taken that the 
*"*^ace of tho involuerum can be freely exposed. By so doing, 
pt only doe* the sui^eon give himself freedom in the use of 
'* instruments, hut he has tho opportunity to judge as to tho 
^t places and the best manner i>f fipptyiu^ them. 

liaviufT exposed the involucral surface, it will generally be 
****ti(| \Hi»t to enlarge some of the cloaciu, wliich such on expoA- 
Zf® Teveols, by chiHclling or trephining the shell of new bone. 
"**" my own part, I prefer the gouge to the trephine, which 
14 



210 



DIABASES OP BON'S. 



latter instrument I rarely use in operations for iiecrost 
gouj:^ isinttde largf, witli llie cutting edge oui}' slitjlitlv 
and terminating at rigbt angles witii the aide of the insti 



fukST. 



O.Tta'ANN uco. 



whicb right angle ia fsliglitly rounded (Fig. 40), thiia givii 
very delicate corner to work with, where delicacy is 
and a powerfnl inatrument where heavy cutting ia to 



Fib. 




It is well to have several different sizea, and I have fot 
small gouge, wilh a rounded cutting edge and a curvt 
(Fig. 42), very useful in deep cavities. Fig, 41 repi 




straight-edged cliisel, whicli ia very useful in Bplitting d 
ing a firm bridgo of bone, and is often the only instri 
whereby the eequestrum itself, when it is necessary, 



rui. 40. 



G,Tl£MA/.-!H tCO 



divided. Fig. 43 represents n metallic hammor, with itC 
loaded with lead, which makes Jess jar in etrtkiDg on th«j 



KBCROSia 



an 



than an ordinary hammer, and is mnck more compact and 
porteble than any fonn of mallot. Fig. 44 repreBents a strong 
elevator, which is nsed to great advantage in separating tlie 
tongh, thickened periosteum from the bone, and altio in looeen- 



FN. -U, 



a. TlLMAMf Aog 



uig and dislodging deep sequestra. Fig. 39 represents the 

Ifwi^ojir, or gnawing forceps, by which Bm»ll pieces of bone 

can lie cnt away at each bite of the instrument, and tlni? the 

luvolucral covering can bo removed piecemeal in any direction 



Fu, 41 



ii.riEMANN ^Ci^. 



""^ to any extent. Figs. 37 and 3S represent convenient 
"►rtna of strong, long-beaked forceps for removing eeqnostra 
"^ni deep cavities, or through email openings in the iuvolu- 
crnno. 



Tio. tt 



G. TtCMANU A CO 



W These instruments arc made, Bomo of them expressly for 

'"^» by Xefisra. Tiemann & Co., to whom I am indebted for 

^tao Ulustratious presented. 

" ^y these instmments Rnfficient of the shell is removed to 
**P<*ae the scqiiestrnm, and now an examination may bo; made 
"y Horing it in varioua directions, to ascertain in which di- 



ne, m. 



i.t&UH'UHX. 



SIS 



DIBGABES OF BOKE. 



roction the further cuttiiiKs of the involucrum can most ad- 
THntagcously be made. Theso arc tliim to bo cotitiuucd, odIt 
eo far kg U nocessarr to Hberate the dead bone, and no uiore, 
fur I believe it is a patholc^ical fact, well aacertained, that very 
little restoration of removed involucrum takes place, particn- 
hirl^' in thoi&e past tlio earliest }'uath. In tlii^ e»auie view, there- 
fore, we should bu particularly careful not to weaken the bone 
in its transverse diameter hy uiinece!>s»rj removal, gaining the 
required space, as fur as may be, by longitndinal ratlier than 
by tran-tvorec chiacliings. Having thus ex]>oscd the eeqneetmni, 
it may be seized by forcepp, and, if it he loose, it can nsnally 
be (li-awn from its bed thmiigh the opening made by the chi^l. 
If it be too long, or otherwise too large to be thus extricated, 
the chiselling of the involuenmi maybe continued nntj) it is 
releasetl, or by Lioton** byue-fyrceps the sequestrum may bo 
dlviUeU so as to be removed in two or more pieces. All these 
detftilB mn*t be left to the discretion of the surgeon, ho bearing 
in niinil, as cardinal priiiciplerf of the operation, not to remove 
liny more involucrum than it; nececiaar}', and not to mutilate tbC 
scfjucstrum in any such manner as may prevent its entire re- 
moval. And here it may be well to put in a word of caution. 
Ko one who has examined many sequestra can fail to have ob- 
served huw irregular their cxti'emitics are, and how apt they are 
to termiiiiite iu tine, deiictite spiuulte, and sometimes lamellic, 
which extend some distance beyond the main mass of the 
sequestrum. These delicate prolongations may, by careless 
manipnlation, be easily broken ofl', and thus may be left behind 
in the miwt inaccessible part of the cavity, an accident care- 
fully to be avoided, by making aa little twisting or angular 
movement of the serjuestrnm as possible, the surgeon aiming 
lit draw it directly from its bod rather than to twist or pry it 
out. After tlio sefjuestrum is thas removed, a careful exami- 
nation should be made with the finger and with the proTic, to 
inake sure that no fi'agments of dead hone he loft Iwhind. 
Occasionally we find some iimBll piece thus remaining deep in 
the wound which our forceps will not reach, and which con 
only be approached by so serious an extension of our incisioM 
that we hesitate to undertake to search for it. In such cqsob it 
i^ better to leave the dead piece, after making aoro that there 



NECROSIS. 



313 



ii opening in tlio bone sufficient fur its paasago, triiRting tliat tt 
will gradually be extruded bj the granulations so as either to 
he cut oat or brought withiu eney reach of the forceps. This 
power of the granulations to push a acqueKtrum from its bed is 
Seen not merely iu this diti(>osition of small fragineuts, but also 
in the movements whereby extensive sequestra arc eometiraes 
ftiored toward the gnrfacc, and arc sometimes east out atto- 
geiher. Thig is in obedience to what eeema to be a general 
ia.'w, that all foreign bo{IioB shall find their way to the surface 
of the body, a law which we sec abundantly illustrated in small 
^Tid «n{)eriicial exfoliation^^ and the execntiou of which id only 
''->l:wtnu;ted in the larger sequestra by the circumstance of their 
t>^ing irnpri&oned withiu au unyielding case of bone. 

The wound should be dressed lif^htly, and allowed to granu- 
le* *e. Tt is rarely worth wliilc to do more than looeely to ap- 
F**~oxlmBte the edges of the incited integument, ab<}ve and 
*>^alow the wound, eo as to diminit^h the aumunt of granulating 
^''^^M. Tface. If, a9 h the practice with aomc surgeons, the wound 
^^^ staffed full of lint, some of it is apt to get entangled in the 
•^^^my granulations as they begin to spring up, and to be diffi- 
*^ "*^».1t to remote. Some of the lint also gets caught on the 
''^■^^ ^:gb eilges or surface* of the chieelled bone, and thus becomes 
^ * :£cult of removal. No advantage comes of this ]>ackirig of 
t into the wound, and rny own habit is to spread tliree or 



•"-"^ ^»ir pieces of tbin patent lint with cerate, and hiy them lightly 

J "^^aat within the «lgos of the wound, pressing them downward 

**^ tn the cavity, and then la^'ing charpie lightly over tlicni, as 

•^^i «icb a^ may l»e necessary to fill out the vacuity. In this way 

i*.o dry surface of lint comes in contact citlicr^ith bone^grann- 

^=*-tions or with chiselled bone, and no annoying adhcsiuii of 

*^»« dressing will take plare. Wlieu euppuratiuii fairly Ix-gins, 

tlx« lircssings loosen easily, iind are removed without pain, to 

**^ renewed in a sirailar manner as often as tiio discharge makes 

'* ttecessary, making tliem lighter and snniller as the granula- 

tiong diminish the auppurating cavity. The wound n:*ualiy 

fthova great activity in healing, and in a few weeks is reduced 

''oirij to a narrow gi-auulating line; but we must not be de- 

*®_""ed. The cavity of the involucrum is very loosely tilled 

*'*th. soft granulations, and a probe can still be passed deeply 



2!4 



BONR. 



ioto the bone. Indeed, the final filling up of the involucral 

ciiritj- 18 a very slow process, and so, therefore, i» the final 

hualing <ji the wuuud. I liHv« watched boidc of lay cases for 

months, and one case of the tibia for 

years, before the cavity was entirely closed 

and tho wound hwile*!. 

Afler cicatrization is complete, a mod- 
elling process ia inetituied, which slowly 
diminiahea the deformities caused by the 
diflcaae, and p^ves the affected bone as 
innch shapeliness as it can receive after 
go exteuMve destruction. The inrolncral 
oulargcmcnt gradually diinintahe6, the 
rouglnie:»se3 and irrec;nlaritiea are smooth- 
ed oJf, wliile the cavities left by the fall 
of the Rcqncatrum are, to a certain extent, 
filIo<l np hy the gramilationa, ITgually, 
however, this tilling up ia far from com- 
plete, and a jip'oove or depres»iou, more or 
lusa coiisidtii'ahle, marks the situation of 
the cavities, into which depression the 
cicatrix einka. As haabcen before stated, 
these depressions, which are moderate in 
the living aubject, are much deejwr in the 
maccrntod bone, which then ehowe tliat 
very little Imay restoration haa takeu 
place, what has been ponretl out serving 
t , ^i rather 1o sinootli over the irregolarities 

^ V ^ of the woand in the bone-tisaue than In 

fw.tf.-(iJo,Biiiroti.> '^^y considerable degree to fill it np. Of 
course in j-oung persons, and particuliirly 
iu children, tho reparation is more perfect. Fig. 4I>, taken 
from Billroth, Bho\^-s these changes two years after the removal 
of the seciuestrum. 




PART II. 
TUMORS OF BOS'E. 



7int acknowledged difficulty of claMafviiig dleensed is met 
**:li in full force in sttemi»tiiig the Btiidy of tamore. The 
****.Tiietora, indeed, of weH-inarked specimena arc sufficiently 



tit 



^tiiict to make it very cnsy to distribute them according to 

'*2ir ea*iIy-reeognij!cd fenturcft ; but so many tuniota present 

. **-Tiertiun, irrejiiilar, or mixed appearances uud behaviur, that 

Viecomes an estreuiuly difficult task to arrange them in aucll 

'^'ay a5 that they ^luill fall iiatnrally into clas&eK suftieicntly 

^'*^<5li characterized to be of nee in our ob&ervations on the iudl- 

~*<3nal. The method adcpte«i by mmJcm pathologists, of ar- 

^^*^ging tumors by their anatomical structure, is doubtlese the 

^-*«9t and most convenient ; but the difficulty is only mitigated, 

^^ot removed, and the very accuracy and perfection of the uii- 

^^^roftcopic diagnotiis show uk fthades of ditfereiice whicli, while 

^bey enlaj^e our knowledge of the individual, may scriooHly 

'^Dterfero with our arrangement of the cla^s, Thu:^ the main 

"iilesrnres of the eartilHginnue tumors of bone are dufficientlj 

-dUtinct to be easily appreciated, yet the microscope shows that 

the cartilaginous element puts on so great a variety of forma 

that it iA at times hard to recognize, and often so uncertain 

fn its signification that we sometimes feel act if the physical 

qaalitiea of a tnmor, as perceived by the unaided eye, were a 

more reliable tc«t of it« character thau tbo minute di&aection 

of the microscope. Again, thu artatomical characters are not 

always the same in all parts of the same tiunor. We maj 



210 



TtTUOBS OF BONE. 



hare cartilage in one part, bone in another, and unequivocal 
cancer in another, in tumors wliicb present nutliin;^, in tbcir 
history or appearance to the eye, that indicates the reason of 
tlio tlitference in their eeveral parte. Still further, Uielr con- 
Ettitnent clcinenta undergo, in eome instances, changes so dis- 
tinct and so complete that it iii fair to say that a tihrona or 
cartilaginous tuirior is converted into a bony tumor; a cyst, T>y 
proliferation, is changed into a solid tumor; or either of thei: 
may be converted into a malignant form, and, after perha 
years of slow, benignant K"*wtli, may put on the rapidly-de- 
structive featured of the cnce])liaIoid. It is evident that these 
considerations must make a Eti'ict cla^iitcation inipo«»tble, if 
we expect from IL an arrangotnont by whielj every tnmor aba]! 
bo assigned to its proper piit>ition, and each division ehall have 
its exact and proper liuiita, into which each individnal shall, liyj 
virtue of its anatomical construction, be received. W'e mu* 
perforce be content, tlierefore, with ufiiiig Buch cla»si6cation 
we may adopt, only with a view to the convenience and aims 
anee it may aflbrd us in describing and eludying individual' 
cases, withuut relyiiij^ too much upon it as stamping each speci- 
men with niiirkt? which shall be bo auiuifitakuble that wo can 
at once assign to it its place in tlie catalogue, and thereby be 
saved the necessity of investigating its individual peculiariti 
and dispositions. Used in this way, we sliall find the classic 
cation now commonly adopted, by which tumors are arranged 
according to their anatomical stnictnre, to be the best and most 
convenient we can use, and one which will perltapi' t^erve 
better than any other In our study of individual Bpecimcns. 

Tlu) arrangement usually adopted by Tfritera is a diriaioi 
into— 

1. Cartilaginous tumors. 

3. Osseous tumors. 
8. Fibrous and fibroid tamora. 

4. Myeloid tunmrs. 

5. Vascular and pulsating tumors. 
8. Cystic tumors. 
7, Maligtiant tumors. 
These principal clasaes embrace many subdivisions, and in 

treating of them I shall hot always strictly adltcrc to the order 



be^j 

ie^ 

ea^ 




CARTILiOIN? 



HBT 



Sir 



CHAPTER L 



OAartLAoiHors TTMOsa 



in xrliich tliey are here plnoed, departing from tliat order, how- 
ever, only when, for the saVc of clearnciw, it seems more con- 
Tfinienl to arrange them into somewhat difiereut groups. 

H CARTHJioisons tnmore arc characterized, as a olass, hy their 

"l*oe«6sing the anatuinieal elements of cartilage. In a very 

^®*^ proportion of theeo tumors, the microecopical elements 

"•^ iilcnticat with those of the normal cartilage; in some, how- 

*^er, tliey depart from the normal ty|x;, presenting many vari- 

^*i««, Rometimea loaving much tlouht aa to their nature. One 

*^'*icf circnmstance, which may be noticed as eharactprijitic of 

'tti« tumor, ii the gi-eat diversity of microecopic forma which 

?^<^ epecimeu, in ita different portions, may proseut. Mr. 

&get, on this point, reniaiks: "This diversity of mieroeicopic 

*^»^js is enough to baffle any attempt to describe them briefly, 

^* to oseoeiate them with any correspunding external charae- 

*^n in the tumors. The niort diverse forma may oven be seen 

^itle hy side in the field of the inicroBcojie. But this diversity 

"Is important. It has its parallel, so i'nr as I know, in no other 

innocent tumor; and the cartilaginous tumors form, perhaps, 

the single exception to a very generally trno rule, enunciated 

by Bruch, namely, that it is a characteristic t>f the cancerous 

tumors, and distinctive between them and others, that they 

prefeont, even in one part, a multiformity of otomeDtory shapes." 

JVlr. Paget, in hia excellent chapter on cartilaginous tumors, 

from which the above extract h taken, given a full account of 

the varieties ho noticed in the careful inicror-copio examination 

of tilYeeii specimens. His general conclusions are, that the 

Tariations are shown in the basis or inlereellular suhstanco, in 

the i-artilaginous eclls, nnd in their nuclei. Firist, in the inter- 

ceiliilar substance, he remarks that it varies in quantity, eome- 

tfmea b^ing largely in exceea, with very few ceUe scattered 

through, and sooietimefl in small quantity, with a great pro- 



2ia 



TUMOBS OF BONE. 



poQilerancc of cells, wliicli seem to make up the whole 
of the tnnior. It varies nl-so ia coii&iRtenct*, Hometiiaeg finn^ 
aud sometimes ver^* 8u>t\ ; and iii texture, eome specimeu^ liav- 
ing a traiiapareiit, uluiunt structureletis buals, while the mo6t 
present more or loss diBtiuct evidence of a fibrous plan, tha 
fibres differing not a little among thcniwtvcr;, in their sUap 
size, diutiuctuesij, aud arrange uiout about the cells. The 






FiiB. 4T-— <Pwui pBgirt.> 



laj?e cclU thcmselvea vary also very greatly. Sometimes they 
are targe and abundant, soinetitiiB^ few and small; sonie have 
tlio roniided shape of the normal cartilBge^x;Il, and some dif- 
fer widely from them. Sometimes their outline is dark and 



r^^.j> 



Vm. 4a,— (FVoin Point.) 



tut. M.— (Pmn nw«.} 



distinct, eomstimes eo faint as to he almost imperceptible, anL 
occaaiomvlly there seems to he nn cell-wall at all, the nndei 
beinff embedded in the hyaline substance without any cell-en- 
closure. The nuclei also present many v&rieties. Somotimoe 



CARTILAGINOUS TUMOBS. 



219 



tliej ore aingle, BoinetimeB two or mora are eeen^ and Uieso 

aiJpiirenily a<K|ainiig for tbeinBclvca the diameter of primary 

cells. Sotnotinioes they show nucleoli, often they do not (Figs. 

46, 4", 48, 49). Some are small, round, and clear in outline, 



F». eO^Fraia Fictt.) 



710. U^Hf^vm FlK«b) 



*^*^Xjers are large, pale, and indistinct ; some are granular, and 
^<=*'KJio show globuliis of oil in their interior. The uioet nmrkiMi 
*^<^ "Nation from the uaual ajiijearanci; of the nuclei is that in 
"^^X:a.ieh they present an irregulur branching outline very much 



:i: 



IK 1^ 



\ 



Via. SL— (From CanH «ad Eurtor,) 



*^«mbling the shape of the bone-corpu&cle (Figs. 50,51,52). 
*lufi is so common timt Mr. Paget noticed it in seven of his 
^^ses; and altliough lie does not admit that it is any indication 
^f a commenoement of a proceaa of o«aification, yet, in view of 



220 



TTltORS OF BO>X 



the well-known fact that these tnmora have a great propen*itj 
to OBsify, it would seem reasonable to 6iippo6e that lliis striking 
chaoge waji one uf itti earlie&t mauifebtHtiuus, attd out nnphilo>'> 
sophioal to a8!>uiiie that it was ao, in the absence of positive 
evidence that it wns not In fact, Mr. Queckett, in his leo- 
tnres ou liiiitolog}', adopU thia view of their nature. Making 
all dne allowances, however, for these various deviations, the 
fact ^ill remains that this c1aB;< of tumors ii charncterized by 
anatomical features which are, in the main, identical with 
those of normal cnrtilage ; an identity which their cliuieal his- 
torj? very strongly coniirms. 

Tlie causes of Ihewe gi-owths cannot often ho discovcj 
They do owaBionally ecein to arise irora, an injnty, Uiough 
more fi-efjuently than other forms of tumor. A case, recently 
amputated at BeUcvue llug])ita], commenced in a finger, a]>]>ar-«k 
ently in consequence of a bruise against the mantel-piece. Thc^Vp 
commence their gi'owth moat commonly in childhood and early 
youth, though inManoes arc recorded where they have made theii 
Hriit appearani-e in old age. Their ijrowth is painless, and comi^ 
monly quite slow, though in exceptional instances a rapid rat 
of increase is observed. This more rapid development is usually* 
connected with soilness of to.xture, and a great preponderanco 
€»f tell-formation, and is very constantly observed in the recur- 
rent tnmors after removal. In Iheir \x»mi\ demeanor they aro 
undoubtedly benign, and when once tliorongldy removed they • 
flje not likely to reappear. But here, again, as in fibrous ani]^| 
certain other tumors, we find sometimes a dispositinn to retnrn 
after removal, and to involve new and distant part^, and finally, 
to destroy life by their more and more extensive encroachments, 
whith gives them the malignant character which their liistolo- 
gieal examination cannot explain. On the other hand, if tlie 
removal be not complete, the disease will certainly grow again, 
though somctimca not till aiter a long inten-al. I rumovcdthe 
finger of a man from whom Mr. Cus.ielc, of Dublin, had, nearly 
twenty years before, cut out a cartilaginous growth, which sprang 
from the surface of the first phalanx, and whii-h liad remained 
well for many years, and then gradually grew again to a sizo 
greater than that of the original tumor; but yet which presented 
no other anatomical characters tlian those of normal cartilage. 



lUis- 

cj-edfl 
ImufM 

-tiy^ 

rly 

eir^ 

i 




carttlagisous tumors. 



331 



J8at there is anoUicr point in the pathological history of these 

"fcuraors wbiL'li h too well asecrtaineil to bo parsed hy without iio- 

'^ice, tliAt in, tbcir relation to inali^rianL-y* It i^ dithiuilt, in any 

^cwe, to prove tUat, in a given growing tumor, a change cornea 

.*over il« anatomical ctmutinic-nts, ivhercbj it aMuines the charac- 

'^ur ut'mahgnancy which uriginaUy it had not; but i& it certain 

Tlhat tumors which, in e\'cry mark and sign, gave evidence of 

"being simple eartilaginouR tumore, have, aitt.T a longer or ahort- 

-*r period of slow and painless increflse-, »w:\i m oknra<:toiTze8 the 

development of benignant growths, taken on a more active, 

3»pid, and destructive bebaWor, and terminated with all the in- 

■^cations of the most virulent nialigiiant-y I But, atill nioru', the 

cartilaginous is Bometiuies mingled with the canecnms element 

ia the eauic tumor. Of this Mr. Paget gives a wcll-markofl cx- 

rfWiple in a tumor of large size which was taken from the front 

*pl the lumbar vcrtebraa (Fig. 53). In this cAse the two elements 



•'/--. ^.K 



m 



« 



^rp 



'WP 



Fw. U.— <FWioi VagBt.) 



^^^ ^ mingled in an irregular manner, each lobule retaining its 

J ^^*Jiar eharacterifetics, and nbmit in the proportion oflmlf-and- 

. *- Tbis I 3upp<)8e to ho a rare spccimpn, but it ilbistrates, 

^ temarlcable manner, the affiliation between cjirlilagiuoiu 

^~th and cancer, whQe at the same time it pr&!»eut« them u 



fiSS 



TUMORS OF BONE. 



essentially distinct formations, and maintaining that dislincti< 
even when combined in a tximor which was fer advanced in i( 
development. Mr. Paget abu alludea to another c-aee, whet 
cartilage and medulliiry i-auccr were Hfiiociated in a tumor 
the testicle, whicli Iiatl been growing about eighteen moni 
Vii-ehow and several other writers have deecribcd similar 
bin at ions. 

The size which those tumors fiometimes attain ie extraoi 
nary, eiirjiasHing tho8e uf any other formation, if, pcr]u|)6, 
except the fibroiis. Mr. Paget sjieaks of one which he eaw in 
St. liartholomew's IIoBplUd, in which, " within three months 
of Ms first noticing it, a cartilaginous timior increased to sat 



i 



\ 



\ 



Vw, 54.— <IWii Pns«t) 

an eittent that it appeared to occupy nearly the whole It 
of his thigh, and was as large round as my cheat." He 
tions another, umpiitate<l by Mr. Frogley. in which the tmnor 
extended from the knee-joint to within an inch of the trochan- 
ters, and measured nearly three feet in circnmfcroncc. Sir 



OABTILAGmOUS TOMORa 



223 



PbHip Cmmpton's caae, however, gurpiBs^s all others that I hare 
seen reenrdetJ. In this rcmarkalile case, a cartilnj;inoiis tumor 
of the tliigli wm nix feet atid a half hi ciri-nnifcrciice, being, 
therefore, a little mure than two feet in diarnctor. Fig. S4, 
taken frum Paget, gives a good idea of the general features of a 
large cartilMginoos tumor growing from the upper part of the 
hnmems. It wfta nearly thirty inchea in cireumlercnce. ITic 
Bpecinifii is in the museum of tho College of Surgenus. 

The change* that cartilaginoUB tumors may undergo, form 
an importout and charactcrtetio part of their history. Thcfro 
cliangC6 can hardly be looked upon as representing n definite 
teadcney which will bo realized more or less completely in 
every speebuen. Kather, they muBt be cunsidei'ed ae excep- 
tional and accidental, us the fnct is, thitt unclinngciiblcnces is 
almost 08 characteristic of the mrtiiaginovia «a of the bony, or 
etcn the fibrouR, or fatty tumor. Hut, neverthclees, changes are 
BOtice<l »o often as to require a special f^tiidy both iinatoinical. 
Mid clinical, if we would understand all th.it we should know 
about tliem. Thus we bare first a softening. Sometimes tho 

rhole tumor, as it grows larger, grows sotWr; indeed, tliis la 

'the usual fact, partitnilarly wliere Uie increaiie in size is rapid, 

sad hoi it£ parallel in many other Jiard tumort^. which, iis they 

grow Ini^r, are apt to become softer. Tliiy chango, liowever, 

■(does not seem to be ^eccB8.^riIy connected with any alteration 

'structure, and perhaps may bo cxi)laincd by the greater suc- 
cnlence and hM>scr texture which the gr^twing musa assumes. 
There is another fonn of sot^ening, where the alteration begins 
in the central part* of the tumors, and gradually inr^lves their 
BQbstauce, tmtlt a large part of the mass has undergone the 
change, while perhaps the most superficial portions still maintain 
Uieir original appearance and etnicture. This eentnil witlcning 
is BometimoB so complete that tho whole tumor is involved, leav- 
ing only a thin Rupcrficiiil layer of unchanged material, and giv- 
ing a cystic character to the tumor, wliicli becomes more striking 
as the wall becomes thinner, and the central parts more tluid. 
most cases, the softened portions of the tumor aasume the 

jpearancc of greater translueency and o!o-ame»iii,"8o that they 
have been likened to fresh fish-flesh, or even to Jelly. When 
they have become so soft as to be fluid, the appearance is often 



S34 



TtmORS OF BONE. 



am- 

ii 



likened to honer, and, when this honc^-Ukc nuterinl U dietrib- 
utcd about tUo masfi in many sniall cells or cj&te, the appoar- 
anceA are strongly su^eetivc of colltiid. 

But there is another mode of Boflening, which is more sci^H 
ous, iuasmuch as it commonly iuvolves the commeacotnent of i^ 
process of dcBtrnction. Thia may be^n with a proocss of inflam-^ 
niatioo, or may be a rapid sottoning, to which inflammation 
afterwiirfl superadded. Kxamincd in the earlier stage, tho ps 
shows broken-do wnilii>sue,d^eTieratingfibrtne,blood-corptwcI< 
and ]>u&-cclla, variously intermingled. The pnxltict^ of iuihtm- 
matiun collect in a foeus, forming a sort of absce&K wliii-h bnitka 
and dici-hargcfi ite contents. TTlccmtion now b^ins, sometimiis 
with slungliing, and we liave iiuitatcd In all reepecta the bchn%'- 
ior of the moat malignant growths, an imitation which is carried 
out, unfortunately, through nil the worst and most destructive^ 
phases of malignant dieoi^iiization. I do not pretend to ss^H 
that such a process may not in some cases tenninate in simple 
deali-uctiou of the growth and be followed by a proper healit 
process, but it nmet be confessed that, when snch action is o1 
aerved in a uartilagiiiouci tumor, the rmuionable apprehension 
that the ill belmvior is uidicative of ill character, and that tl 
originally benign tumor has assumed tho nature as well as 
behavior of a maligiiant growth, and will probably vindieate its" 
claims to be so considered by uhtmately destroying tho patient. 

Again, we have a change into bone. This change, from the 
well-known relftttons of cartilnge, might bo considered ad the 
natural one, and might be expected to bo frequent. Some de* 
gree of it h not rai-c, and yet it would not be correct to repre- 
sent the o^ilie change as very common. It presents itself un- 
der two principal varieties : First, in a cartilaginous tumor 
growing on n bone, we may have the o6siti{«tion shooting out 
from the orighiat bone, and gradually encroaching upon the 
tnmnr, until it is more or lesfi largely converted into a bony 
mass ; or, secondly, wo may liave osstficatiou eonmiencing in 
the centre of the tumor, or in many detached centres, and thcM 
centres may gradualh' increase until they coalosco into one. 
Many examples are seen of both these methods of oe*?ificaEion, 
and it is uot uncommon to find them eombinsd in one spedlH 
men. Sometimes the process is limited and imperfect, and tlie^^ 





CARTILAOIXOUS TUMORS. 



2S5 



ire hftrc small bony (<piculie Bb<»otiiig into the tumor, ur stn&U 
isolated mnssea awitlcretl through it, or BomeiliiiL's the process 
is more energetic and detennined, and vrc have the whole mass 
converted into solid bone. The quality of the newly-fonncd 
Tjone Tsries much ; sometimes being n nicro ftmor[>honB calca- 
reous infiltration, but often presenting evcrj' feature of the moat 
"])erfeetly -formed hone, so perfect that we cannot trace in its ex- 
ternul features or in its luicrotfeupit-al chnraeters any. dlHeroneo 
between the (trigintil aiitj the morbid foniiatiuus. 

In a certain number of fa,Bt;B, the ossification of the tumor 
commences so early in it* hiatory, and proeeeda so regularly as 
the tumor grows, as strongly to impress us with the idea that it 
19 the normal progress of the disease, in whieh, atVcr a certain 
jteriod of eartitaginons existence is passed through, the strncture 
ia gradually replacrcd by bone, by virtue of a continuation of the 
same forces whicli formed the original tumor. The beKivior 
<tf these tumors seems very much the same as the actions which 
iake place in normal development in the cartilaginous extremi- 
tleBoftho long bonos in the child, the original layort* of tlio 
now growth heconiing o!isitl(!d while new layers of curtilage are 
forming on their anrfico. So definite and orderly is this dispo- 
otion, that it ia not easy in every case to decide whether the 
tnmor ebonld be considered as a cartilaginous growth ossifying, 
or an osseiius growrii developed in cartilage, llenee, several 
of the older writci-s, and mere lately Follin, have made a new 
clffltt of these cases, and have studied them under the namo of 
osteo-e;iriilaginou8 tuniurs. Tliere seems to he some reason for 
this fenhdivit>i<in, imtl perhaps some jiracliuil advantages may 
arise out of it. The following case presents a atriking example 
of these peculiar features. I puhli!*li it here by permission of 
mr friend I>r. Van Buren, in whose practice it occurred, and 
by whose kindness I saw the patient at several periods of hia 
history : 

Elijah A'audenhoof, of New Jersey, of good constitution, aged 
forty-three, came under Dr. ^'B^ Bnren'a care in May, 1848^ 
with an immeuBe tumor, involving the lower half of the femur 
of the left fide. About twenty years before, ho had wrenched 
ihe left Imee in \\TcstlJng, and some three months after this 
Etdeot he first noticed a swelling about the knee-joint, which 

IS 



ssd 



TPMOHS OP BONE. 



litis ninco elowly increased in size, gradually citenjing up the 
thigh. At this time, the tumor involved the whole ciirurufor- 
enco of the limb, extending Irom the knee-juint upward an tat 
:iB the middle of the femur; it was huinorably connected with 
Uie hoiw, aud meusurud tweuty-eight inelifs in c-ireuiiif€>ri.Mice. 
Ou its mituriur at>[>CL-t it wm generally spherical in 6ha{>e, with 
very slight irreguiarilies on its surface; ]>o8teriorly it was very 
irregular mid cmgs^', presenting eeveml liard, prfijoi'ting, knobby 
ciiiinencca. It had everywhere the feel of hone (itrtTf*! with 
a tjiin Layer of tissues. It was not tender to the t»uch, although 
there wfle a point where the Rkin had recently sssajned a dusky- 
red appearance, which caused some complaint, apparcully the re- 
sult vi' simple tension of the integuments. There were uu largo 
veins observable on Its surfeco. The tumor was Tuore promuient 
ou tbe posterior aspect of the limb thjin elsewhere, and seemed 
to terminate abruptly about six and a half inches above the 
condyles of the femur ; anteriorly it shelved otT more gradually, 
and extended apjjarently gome four inches tarthcr upward. Tiho 
knee-joint waa but slightly movable, but its motions were nut 
aceiiinpnnied with pain. During the ]>rewnt year he liad suf- 
fered almost constantly with a dull, aching jwiin in the tnmor, 
which was invariably more severe at night and in damp weather. 
This pain seemed to be gradually increasing in intensity, ftud 
had of late deprived hiui of sleep and dimiaislicd his appetite. 
He was also losing flesh, and had a jmlso more fixvjiient than 
natural. The limb was amputated at about the middle of the 
foitnir, on the L*<>th of May, and the amjmtation was folluwfl^ 
by a rapid rectivery. ^ 

"The tumor, ou e\nmiua(ion, presented a iiingiiiliceut speci- 
men of true oBteo-curtllagincius exostosis. Its periphery waa 
overywhcrc covered by e layer of tihro-cartilaginous material, 
varying in thickness from a line to more tlian half an inch, till- 
ing up its ftnfractuosities, and giving it a much luore iiuiform 
appearance than it lias at present alter maceration. It is now 
exceedingly irregular in outline, covered by rounded knobs and 
cragg}', stalactiforni prnjeclious. The coudyle*, it will be seen, 
participate in the alteralioii. The weight of the tuumr, when 
recent, was thirteen pounds. The soil parts, ooveriiig the bony 
maBBj were to all appearance perfectly hcaltJiy, with the oxc 




CARTILAGIXOCS TUMOBS. 



227 



tion of the alteration oonsequcnt upon the pressure of tlio tu- 
mor, and thuir dianuc of pui^ilion. The nervous trunliB, |jar- 
"tJcnlarly tho popliteal and pemncal proUiiigjUioiia of tlio sciatic, 
TTore oWtvccI to be thicker than natiiral, and hatl oviilently, by 
"iheir elougation, been subjected to very considerable Btretch- 
ing." 

In July, 1 84{l, some signs of a return of tlic diBeaae began 
manifest themaelvee, in the shape of pain in tlic stomp and 
cuUrgement of tlio aawefl end of the bone. These slowly 
intTeaeed, his health began to fail, and on the Slst of March, 
L850, it was deemed best to endeavor to n-rnovc tlio whole dis- 
bv anipulatioQ at the hip-joint. This was done by Dr. 
Tan Knren, by tlio method of the anterior and jjosterior flajis. 
Tlie patient nuido a most natisfactory recovery. 

"The sj)C<'iinon, prcvions to dissection, was Bueceasfidly in- 
jected by my friend Dr. Isaacs, to whose kindness I am indebt- 
ed for its preparation. It will be perceived tliat the ftppe;iranco 
■^ the disease correitponda with tho desL-ription given already 
-^ the tumor firbt reuioveij. It i;; of a uuifonn bony h.irdiie6S, 
«uid very irreKular outline, involving the lower end of the bone, 
•aBDtl extending upward toward the trochanter. One fipienlar 
^roloii^tioii, projecling toward the joint, on its anlenin- fur- 
nace, was jfi-azed by the knife in cutting out tlie anterior flap ; 
Tiad this flap been half an uich longer, the knife would have 
"been (.■aught behind this bony project ion, .ind the opendlon 
Tuiavoidably delayed. Tlii* <hingor was partially recognized 
licforehand. As this specimen has been preserved in the wet 
state, the hiyer of the filiro-cartiliiKe ou the surface of the lw>ne 
can be reco^ized. In removing tho layer of mnaclcs coveiing 
the disease, it was nollccd that the sart<irius and rectus, and 
meet of tlie adductor group, were closely fittju*be*l, by their cut 
extremities, to the enlarged hone ; the lirst-mentioned muscle 
raa, in feet, inserted by a well-marked tendon, and was noticed 
fore the openftion to act strongly as a flexor of the stump. 
The muselcs had preserved their volume fairly, although they 
had evidently undergone some degree of fatty atrophy. The 
femoral arterj- waa ]>erviou6, and apparently of full size, up to 
a point about two inches fironi the extroniity of the bone, where 
It became transfonued Into a lihrous cord. The sciatic nen*e 



288 



nWOBS OF BOXE. 



■was eonaideratly enlarged, particularly at its ertremity, wlierc 
it U oloselv adliereut to ihu purfac^ of the boae — occu]>ymg, as 
it were, a vulley between tvro [irojecting crags of boue, by the 
growth of* whifli it was constantly eubjectetl to increasing prcd»- 
iirc. TltiR watt tho spot upon the Htmnp to which most of the 
pain M-aa attributed." 

The patient, after his recovery from the ampntition, re- 
turned to the country, where he enjoyed csccllont health for 
about two years. lie then began to sutler pain iu the stumpy 
which increased for ecvcral month^^ and tinally brought bim to 
town .1^'ain for advice. Dr. Van Uuren recognized a return of 
t]iu Iwiiy growth in the os innoniinatum, of fhc eidc fVom which 
tho lowLT extremity had buuti reniovLHl, invuh'ing tlie aeeUbo- 
liun and tho neighboring parts. This continued slowly to in- 
crease, pausing pnin similar in character to that fonnerly cxpcri- 
ence<I. Finally ftyniptonis indicating pressure upon the rcctnni 
and bladder gradually appeared, and increased in severity nntil 
death followed, at the eud of five years fram the date of the last 
o])eralIuu, fh>in intestinal obstruction, resulting fivm pressure 
of the intra-pelvic growth u|ion the rectum. The parts were 
removed nrter deiith, and sent to the city for in8]jcetir»n. " The 
whulc OS innoniinatum wa« invnlred in an cndnmma outgrowih 
similar in character to those already described, presenting no 
new appcarmces which could he recognized as malignant.^ 
The physician who made the .intojisy reported that there were 
no evidences of disease in any otiier organs of the body, tho 
imniediato cause of death being peritonitis. 

Tliii! case offers a guod example of th.it sotni-malignant 
behavior in which, though no proper cancerous eharactfir is 
nssumi'd by the growth, and though no evidence is dtseovered 
of generalization of the disease, yet, by its recurrence and ex- 
tensive invasion of vital parts, it finally produces death, and 
this after what seems to be the most complete removal. Fig. 
do shows the appeamnce of both portions of the femur aQtfk 
maceratiun. ^| 

Auollier quite interesting, and not verj' uncommon, form 
of osteo-cartilaginouB giv>«ih is that which nflbcts the hist ph«- 
Iimx of tho gre.it-too. It springs from the dorsal surface of the 
phalauy, under the nnil. As it grows — and the growth ttcema 



CABTILAGINOCS TCUOBS. 



230 



^ 

N 



to be by cnrtilage which ossifies as it grows — it is pxished for- 
mrd by the re^iiBtancu of tho nail, nrnl in.tkca its appearancu 
jttst tiniler the free |K>rtiDa of tho nail, as a hard, wart-like 
growth, insensihlo to the touch, aiul usually jKiiiiless, when not 
^ffonod upon, but gtvuig rise to 
a great de.U of pain and tender- 
neM when pre&goj upi^u by tho 
shue ill wUkiiig. 

The first case of thiti <niriouB 
Affoction tb.it I »iw was in the 
New York Hospital, in tho ser- 
Tice of my fi-iond and preceptor, 
Dr. Buck. I give it in his owu 
VDrds: 

"■ William Jewell, ajpjJ twen- 
ty, Norway, was adrnittoil into 
ihe New York Hospital, 8tJ]>- 
tember 2.', 1 839. Fourteen 
months ago, first felt pain in the 
,^r63t-toe of the right foot under 
the nail. Had walked about 
with a ]>air of uow boola, whieh 
were rather small. Upon exami- 
nation found a amall, Imril lump 
growing under the free edge of 
the nail ; this he kept pared 
close with ids razor, whidi of- 
ten eaosed it to bleed freely. 
Eight months ago it was par- 
tially reuioved with a (Kirtion 
of tho nail, but soon after the 
wouikI boated it grt-w out again. 
September 25th it prcw-nted 
the following appearances : The 
edge of tho nail was pareil 
diort, 60 tliat a email tumor pro- 
tmdod antcriur to it, of about the size of a pplit pea, cf a pray- 
uh roee-color, tough and dense, though not having the fci'ling 
an osseous growth, free from pain. He always took the pre- 




Fw. a— (From V«i Burra'a foll**tim.) 



330 



TTMOBS OF BOXB. 



two II 



cflTition to wear an easy boot, othci-wise lie felt nnentiinces. 
From its apparent tiituatiun, aiitcnur to lliu nail, I aimed to 
save the uui), and i>asfied u bibtuurv duwn ibroiigb the nail,, 
little behind ilu middle, in a tninsvunnj direutiun, to the bui 
then directed its edge forward, ^crazing the bone eo hb to 
move the tumor at it^i origin, where it wafl evidently of aii 
ens diaraeter, requiring much force to cut througli it. 
incii«ion, I found, split down through the middle of the esci 
ccnce. 1 therefore determined to remove the entire nail ; anr 
ill the uaiue manner as above, couimcucetl a new incision, two 
liiiee posterior to the union uf the nail and cuticle, g^''>? <^^^ 
to the bone, nnd grazing it* tipiK-r bnrfaco as Iwforo, where 
tniiior gi-ew fi-oni the hone. I pared away the surface as elosei 
]>06sible. The hmmorrbnge was trifling, color of bone hualtliy. 
The rcBistflnce of the nail had given a direction forward to the 
oxcrcsccui^c, and thus deceived me as to its point of origi n, n 
which WAS beneath the middle of the nail. Sunplc dressing^l 
to the wound. ^^ 

** October 2l»f. — The «ouud gradually cicatrized imder tli^ 
a])p)icatiou uf light dre»sings, with the oceatiiuual ap]ilicati< 
of nitrate of Bilver to repress the cxnbcrant granuhitione, 
hud diminished to the aizc of n ajdit pea, witlnjiit any ap 
ance of reproduction, when at his urgent wquest he was dis- 
charged. A small portion of nail grew out of the postei 
comer, which had e&caped t3ie hiiife." 

Some years after, another case presented itself to me, 
jirivate practice, which I had the opportunity of watching aft 
the cure. Mr. Geoi^ 11. P.. aged about thirty, showed mo 
December, 1S55, a sninll corn-like projet^tion, under the uail 
the great-toe of his left font, wldi-h liad made its appeamnce 
some five months previously, ntter having worn fur a)nie lime 
n boot which was too short for his foot. It had given him a 
good deal of trouble whenever be walked for, and ]>artieularly 
if he wore a boot in the least degree too tight; and whencvt^^ 
he stubbed bis toe, or received any blow upon it, the pain ^^"1^1 
e.\ce*faive. The projection was a little to the inside of the 
median line of the toe, and was only iwirtly covered by tlie nai^^ 
from under whirfi it pi-otruded, :ind by which it waa ovident^^^ 
coinpressod. On feeling it, I recognized a hardness about the 



ati<^ 
poi^ 



CABTlLAGINOrS TUMORS. 



2»1 



biae of the little tumor, which, talvca in counertion with ita 
tmt ami hifltorr, induoed ino to regard it as a 8iil)ungnal exos- 
lo^is. Uiiwilliiig tu iittlii^ an operatiun I'ur so t^li^ht an att'ec- 
thn, I tried for some weeks the etfcTt of remo\'infr all pressure 
tpf the Loot, and at the same time 1 destroyed, with liquor 
ipotAfiSje, the thickened, wart-like cuticle which covered the 
;r-seated tumor of the bono. As the flakes of altered 
Cuticle separate<l, and were drawn out from under the nail, 
some temporary relief would be obtained, from tho pressnre 
beiii^, by 60 ninch, diminishod. Tlioy formed a^in rapidly, 
liowuvi*r, and, as tlie tinnor it-ielf wms all the time slowly hicreas- 
ing and becoming more aeneltivf, it was deemed beat to remove 
it. The operation was pertbnned on tho 22d of March, 1856. 
An incisiou was made around the whole nail, about a line dis- 
tant fr*>m ita margina, takinj; care to go far onf»ujjh back to 
iiielude tlio whole tnatrix, and fiir enough forward to inchide 
tlie tniiior. By this incision, the whole nail and the aotl parta 
Hader it were raisicd from the upper surface of tho phalanx, and 
tlic tumor of course fully exposed. It was found to spring 
^roni the bone near its extremity, aiul HuQicient sound bone ii^ 
X3uiincil to warrant lue tu cuttin<; oil' the antt-'rior lialf of the 
^Kilanx only. This was easily douo hy llie bone-nippers. A 
Sr}> wns thuB left which was a Httlc lon^r than wbs uecessniy 
^o cover the tTid of tho bone. This tlap was i^imply drawn a 
little up toward the top of the phalanx, and rhe gap thus left 
'^ras allowei! to heal hy grnnnhitiou. The hcah'ng process went 
^jii most favorably, aurl was entirely completed at the end of 
fuur weeks, leaving a shortened but very good-looking and 
'Rueful toe, with plenty of soft part« covering the end of the 
Ijone. On examination, the tumor was found to consist of bf>ne 
in three fourtha of it« e.\teiit, tho ythur fourth being formed of 
v^artilagu which oorercd its most euperlicial surfaue. It had a 
«lecided neck, considerably nan-owcr than the prominent j>or- 
'ftifin of the tumor. Tho adjoining bono seemed sound. Tlie 
'Auraor was about aa large as a uiedium-nizod pea. 

This gentleman baa boon under my observation up to the 
2>re«eut time. Of course, there hits been no return of the dis- 
^ue. His toe has been perfectly well, and useful in every 
^respect. One slight drawback to liis entire comfort, however, 



233 



TUMORS OF BOKB. 



exists in the fict tliat at one corner of the wound a sinaTl,^ 
irregular frronth of nnil exists — the evidence that some portion 
of the matrix escaped the knife. This, it will he oh*ervetl, 
occurred olt^o m Dr. Buck's c-ase^ though we both took much 
pains to avoid it. The aceident arises troin the fact that the 
Corners of the nail are 6oini>tiine6 longer, and tavre deeplv im- 
planted in their matrix, than the central portions, aiiU that, Jl 
therefore, tJie root of the nail haa a etraight ed^^j teninnatinp in 
riglit anjjles with the sides. Any incifeion, therefore, whidi is to 
remove the matrix entire, mnst not curve round the root offl 
the nail, but mnst extend straight across the dorsum of tho 
finger or toe, at least a ]inc beyond the lateral edges, and fullj 
two lines back of the apparent root. This is a matter of raucl 
importanee, for a growth of nail from a. einatl remaining portioi 
of matrix Is usually a defonned and irreguhir gr«..\vth, and giveft' 
as much trouble, wheu it gets long, as the disease for which the 
operation was jM-Hbrmed. In Mr. F.'s case he waa eo much 
annoyed by the growth, while the cicatrix was still recent and 
tender, that I pi-oposcd to destroy the remaining matrix with 
nitric acid. As, however, tho cicatrix got firm, and ho lenmcd,^ 
loo, how to trim the nail-growth with a sharp knife, it bccam( 
less troublesonic, and he liaa never had any thing d<«no for It 
removal. 

Anotlier well-marked ease of this exostosis occarred to mo 
in the pureon of ifitw E., nged nineteen, who sliowed me in 
July, 18tI6, a hard eweltini; niuler tUo nail of the rij^ht big-toe. 
This had been growing gradustlly for aevend montlii*, and sho 
could attribute it to no evident cause. At first it gave her no 
pain or ineouvenieTipe, but as it grew more pi"omincnt it gave 
rise to pain in walking, pfiiticularly ■n-ith a new or tight shoe. 
About two months before I saw it she had showed it to a sur- 
geon, who called it an eueyated tmnor, and performed au op 
tion for its relief. This operation must have been merely 
paring otf of the auj)eiiieiul portion of the tumor, for it 
followed by no benefit. 

The nail was found to bo Tftiscd by a firm, solid tumor, 
dcntly springing fruni the bone. The superficial jwirtion which 
projoctGfl from under the nail waa covered by a flftky, horaj 
epidcmiis like that covering an ordinary corn. It projected to 



I 

e«V 

be 
ch 
id 
Lth 

m 





CARTILAGIXOnS TUMORS. 



S83 



Cm. M^(!J T- «0»- 



<iQe ei^e of the median line of the nail, and, m tlie uail had 
m cut AWftT on one side to relieve the pressure, the whole 
?velopment toward the sujtaeo had taken place ([xiho on the 
aide of the uitil. Mr. Paget stated that this iti the usual fnet 
-with refpird to these tumors, and that tliey rarelv grow from 
exactly the middle of the dorsum of the i>halanx. Fceline tlie 
-tumor deeply and iirtnly, It-tl no doubt that it was an exostosis. 
Removal being the only reme^ly I had to pro- 
jose, the operation was done on the ITth. T 
^nwcoedcd as in tho last case, being caretid to 
Jcmorc tlw whole matrix, in whicli, this time, 
I snct-eeded. The &tnmp healed Boumltv aii<l 
^jiiiclily, leaving a very comfortable though some- 
rbat Hhurtened toe. 

The bone reinovcil ehowcd the usual osseous 
ie,with verj' little cartiliigiiwus tip. This was 
^ioHhtlcsa due to the operation whifh had preceded mine. The 
^Tfliole exiistftsis was ahout the size of a Inrjfc jiea, .ind, having a 
^mewhnt narrow base, and an expnded, flattened top, pre- 
VKQtcd a decided mushroom shape (Fig. TiO). 

The seat of cartilaginous tumors is, by preference, in or 
^^pon the bones. Many, however, are found in other tissues, 
<3as the tnamnia, the testicle, and some of the internal organs, 
"irliere they seem to have no relation whatever to any bone. 
Tlio parotid region is a favuritc seat of these growths; indeed, 
Mr. Paget remarlis th;it the greater j."art of tlie solid timiors 
of this pcginn liave more or less cartilage in their composition. 
Wlien originating from bone, the tumor may gi-ow either ujion 
mid apiMircntly from the surfat-e, or it may hv developed witliiu 
the cavities of the bone, which in its growth it exf anda. Mr. 
^Stanley thinks that this diflerence is connet-tcd with the size of 
the bone; thus he says: "In the instances of its occurrence in 
any of tlio larger Ijones, as the humerus, femur, or tibia, it usu- 
.'Uly gnfws from the outside of the bone, rarely within it. But 
in the instances of its occurrence in any of the smaller bones, 
nally of the hand or foot, it usubIIv originates within tlie 
iKJiie." Tlie explanation of this peculiarity lie di.>es not g^ve, 
^nd probably, in tlie present state of our knowledge, it cannot 
gpvcii. As a pathological law, however, it is not without 



234 



TC3I0RS OF BONE. 



its practical importmice, and would certainli? havo a bearing on 
tliu docisiun of tlm qiicBtiuu of ampotatiug tlie limb or r«uio^ 
lag the tumur. lilr. Stanley al»j tiiinlitj that tlio urjgiu of tlic 
tumors cnn bo diBcrimiuatwl by th« eUurac-ter of tlic external 
surface. lip says: •• When the cartilaginous tumor ori^iniu 
within a mctacar^m) or <ligiral Inme, the morbid deiK)fiit cot 
mencing in the cancelloiid texture is in some cases diU'iiscd. 
through it, nnacconipnuied by jMiin or any change in the cover- 
ings of thti bone iadieative of the disease within it. At length, 
in oiiQ part, and it may be on one Bide only, or in tho entire 
drcuinference nf tho bone, its walls ex]>and into a globular tu- 
mor, con&i!?li[ig uf a thin, ot^seous 8heil, enclosing the cartilugi- 
noufl substani-e. The tumur in some iutitances reniauis kuiuII, 
in olbors it incrcasea to the Bize of an orange. But, however 
large tho tumor may be, it retains the ossscous shell, which 
grows with tlie increase of the cartilage within it; and, even 
when of largest size, the tumor ia unaccompanied by pain or 
change in the eurrouuduig tissues." 



M 



Fu. Sle-(ftiKa OomQ tail Ruvlar.) 

"In the instances of the cartilaginous tumors growing fro 
the outride of a bone, the exterior of the tumor is usually nti: 
nled, it9 cartilaginous substance is disposed iu lobes united. 



:s 



236 



VUaiOBS m BONE. 




/ 




nffoetcd with tlicse growtlie, they usnally originate within the 
bone. 

A favorite eeat of tho cartiltgiiiotig tumor U the hand, and 
less conuuoiily thu fuut (Figs. 57, o% J9). On thu liami, they 
often nlibc-t several fingure, tho tumors not all upiwaring; 
once, but following one another ut longer or shorter interva_ 
Here, as elsewhere, the growth is very slow and painless, an 
the tnmors arc trouhlcsome mainly from their bulk iiiieiforing 
with the use uf the fingers. They usually show thentselvcs 
first in early i^hildhuod, though occasioutil cases are uotiin^L 
where they have begun in advanced lifo. The rate of growt' * 

usinilly slow, is sometimes qui 
rapid, and the rate of increase 
not hy any means the same 
cvenr' tumor of the same h.ind ; i 
deed, it is most ollen seen that 
or more tumors, where tlierc are 
Ttiany, take the preecnience and go 
on rapidly iniTcraxing in size, and 
perhaps may pass through the stages 
of ulcei-atiou and destruction ; wliilo 
otheiTS of the same hand, perhaps 
on the Bflme finger, quietly inaia- 
tain themselves without iucrea^e or 
otiicr apivarent cliauee. In tJiese 
' tumors, as well as m tlioso deveU 
oped in tho hir^r long hones, it is often observed that 

growth Ilts commen*-cd both within and without the h , 

and t]iat tho two masses of cartiUige thus growing have eo- 
croached upon tho bono both fi-oni within and from withou 
until it lias been eutiroly absorbed, and the exteraal and int« 
nal tmuors have coalesced into one, (he eonthiuity of the bon_ 
bemg entirely intei-rupted at its middle portion. In this eoti- 
dition a slight cause will produce a fracture, and the de^itnio- 
tion of the bono occasiouatly advances so far that only tracea 
of its central portion can be discovered in the mass, while .___ 
articular ends retain their integrity. This disappearance of tho 
original bone is soinclitncs ean-iod still further, as iu the case 
of single tumor of liaud above alluded to. This case was in 



CARTILAG1.V0CS TUMORSl 



237 



the first phalanx of the miiKlle finger of a p&ticnt in Bellevue 
Hospital — John SliaiinoD, aged sixtv, an Irish Inborer, who 
ttras athuittetl tje])teinhur :iy, ISOtf. Tiiu tuniur hnd been grow- 
LiBg nbout three months, aiul, va he thought, hnd uri^Inated 
frivm a hlow againet a mantel-pipco ahoiit three weeks before 
the ap]ieAr:ini;e of the tumor. The tiunor wns soft, and gave 
«nch cridenc-ea of fluctuation that on the 2d of October an ex- 
ploratory inciaion was made about three inches long, A cav- 
ity was opened containing a tmft, puini-fluid niass, wliifh easily 
broke d<iwn under handling. This was mingled with portiune 
which wore firmer in coneiiitencc, and in particnlar the portion 
Ht the end of the phalmx was distinct in its nppcanmpo and 
pre«ented a siut of canlilluwer growth 
of tolerable finnncss. Tlw metacarpo- 
phal.tijp.-al joint was encroached on. 
Tlie tingiT waft amputated at this joint, 
and the wound did well. Tlie tumor, 
examined mit-rosw pit-ally, ehowtsd all 
the elements of enchonJroma. Pret- 
ty rapidly the tumor grew ngnin, now 
involving the metacarpal bone, and 
eooD rc<u>hing a size preater tlian be- 
fore. On the 12th of November the 
hand W96 aniputaterl. Tlio wound ei.-a- 
trizcd without accident, and the nmn 
Trae discharged well, November L'Oth. 

Dr. Duhttleld makes the foUowinj? 
report <m tlie tnnior: "The carjMl 
snd mctacnrpal bonea are almost en- 
tirely replaced by a tnraor. Tlua tn- 
Dior i* enclosed by the skin, exrept on 

the Iwek of the hand, near the base of ^^ tf«.-^f rum cuwii uuj iiaiivict.j 

the middle linger, which had been re- 

loved. When the tumor is cut into^ it is found to consist of 

sofY, partly-gelatinoiiis, grayish, Eemi-tranfihinent Bubstance, 

*"ruTcrseil in dlflerent directions by fibrous bands. Microaropi- 

*^ny examined, it con&Ista of bnnds of fibrous tissue, mixed 

"^^itii small, round, and fiwifomi cells running in various diroc- 

*Xoiia. Enclosed and separated by those btrnds are more trB&»- 



fi38 



TUVOBS OF BOXK 



parent portions? of tissue. These portionB consist of a basement* 
substanc-e, either homogeneous or finely gramiLar, or fiiintly 
fibrillated. Embedded in tiiis bsscment eiibstance, in some 
pLtccs are wcll-furuicd cartlliige-cells; in other places the cells 
are of more irregular 8lia]je, are mixed with small, round, aud 
I'ueiiurm eeUs, imd are iu sueli uumbers as almost entirely to 
obficure tlie basemen t-suli stance. In other places uotliiug but 
small, round eeli& can be seen, and here the basemcnt-^ubfitanco 
is distiiictlT fibrous, and is aiTanp^d in small, regular alveoli. 
In other places the basement-substance is faintly fibrillated, 
Contains only a few oval and fusiform cells, and resembles mn- 
C0U8 tissue. ■* 

In casca where tlie growth is from the outside only of the 
bone, there aeema to be less tendency to its destmction (Fig. 
60). 



CHAPTER n. 



L 



OSBEOUB TUUOBB, 

Tumors, composed entirely of bone, are found almost exclu- 
sively in or upon the bones, though some rare cases are ropi»rt«l 
of ])erft'ct tiimora of this sort being found in the sofl parts en- 
tirely discuiineeted with any bone. In no ease of growth, from 
«iy part of the body, is the hnuiokigy of the new funnation 
more absolute than it h in many of these tumors; they pre- 
senting, in most cases, not only an exact identity in intimate 
microscopical structure with true bone, hut bcjng arranged into 
compact anil cauecllous tissue with ftii much regidnrity and per* 
fectioa as are the original bones of the skeleton. What is true 
of the structure of these tumors is also tiiie of tbeJr chemical 
composition, whit-h by numerous observers has been shown to 
bo precisely that of uornial boue, and most of the varintinns 
which the chemical ramposition of these tumors present are 
not greater than those ■which we find in the orifpnal bones, 
under tlie varying conditions of age, sct, and disease. Of the 
mode of (levelopnicnt of tlieso pert'ect osseous timiors, It ia 
perhaps difficult to speak positively, because it fi-equently ]i&]>- 




OaSEEODB TCUORS. 



380 



pens that no trace of any oartilfipnoiw or fihrotis matrix is 
Auod in any part of the tumor; but the analogy is so clear 
auil Bu strong, with tJio development of owUnarv btme, and is 
burae out so <lifrtinctly by those tuinui-s when we do trace the 
(Mufic process in its i)rogretiS, tliat there can hardly be any rea- 
sonable doubt that they arc funiiud in a soil matrix, wLit'h i& 
Bomctimcd cartilaginous and sometimes lihrone, in this obeying, 
pnibably. tlic ^aIllc j»oiieral laws aa those which dutcnnine this 
(JifFerence in the oriyhial dovolopnient t>f tiie skeleton. 

Ogseons tnmora present tliemselvcs under two forms, ao- 
iwrding aa the cancellous or cmnpact ti^-sne prevaiU Jn their 
8«b*tance. By far the larger niinilHT present n well-formed 
otncellone arrangement in their int«riur, and an equally well- 
formed, c«>mpaet shell surrounding them on the outside. In 
9ome, however, very little if any cancellous substance is found 
to exist, the whole tnmor being formed of solid, very dense, 
oomp-ict enhstaneo;, giving it much the appearance and the 
weight of ivory. Hence we have tlic dietim-tinii iiitri the ordi- 
nary cancellous bony (nmor, and the ivory-like tumor, two 
das-ics which differ nnt merely in the facts above recited as to 
Jheir structure, but also in many points of their history, aa well 
of their prflclical rclationa. These two classes, therefore, 
TBiiy advantageously ho studied separately ; and first for the more 
common, the cancellous class. 

The cancellous btmy toraors ocxrnr in almost, every iJOfisible 
ntoation, sometimes witlnn and sometimes upon the surface of 
the bones. Their history is usually that of a slow, painless 
growth, though sometimes, when they appear to Imve been pro- 
ruked by an injury, some pain and soreness accompnny their 
early development. When they grow fmm within a bone, the 
ettema! shell of the bone is usually distended by the growing 
tumor, and moat commonly itself forms the outer shell of the 
tumor. Indeed, it should be remarked that, in those casea, as 
TC'l! as in those which grow from the surface, the line of dis- 
tinction between the tumor and the original bone is not clear, 
■nd perliaps most commonly the tissnes of the original Imno are 
limply continuous with the tissues of the new growth, so that 
they belong to the class which Mr. Paget has denominated out- 
gtvwtba. So strilcingly is tliis the case, that, if a section bo made 



£40 



TUHOBS OP DOXR 



of some of tliese wliich o^owfrom the outside of the 1ongbone«, 
for instance, a coiitinnitv will be found, not only of the ooter 
fibrcis of compact tissue, but also of the cancellous interior 
which will communicate with, and be coutiuuous with, the can- 
cellous interior uf the bone npon M'liich the iuiuor is developed. 
These tumore are usually round or oval in shape, and present i 
emooth, even Bnrface ; in exceptional cobcs they are irre^ulai 
lobcd. Those whicli spring up from the sar&ce of a bone. 



r-r-r" 



•^ 



Pin. 31.— <f>oin BUInHL) 

which (he tenn exostosis is more properly applied, liavc uBua 
H nnrrow neck by whicli they are attnchcd to the iMine trim 
which thoy grow (Fig. 61). and Mr. Stanley makes the eta 
mcnt that In the increase of the tumors this neck dn« ri 
enlarge, all the growth taking place Id the body ut the inni' 



bej'OBd llie neck. Mi 



(HBEOUS TITJCORS. 



lley 



S4I 



ir. at.i[ilcj (luce not give the obscrmtions 

iJpnn which this ideii is founded, and it can, thert-forc, not be 

■oc-epted fts pro^'wi ; but, even if it be a fact of eomniun occurs 

nince. it wi>iild have some vidnable pi-aetic-al bearings on the 

IQcetiuns uf the time for, and the mode of, eflWting the re- 

•nonl of the tuuior. Sotae of these exostosce, however, hnvo 

not the narrow noek, but are themsulveB flat, and attatdipii by a 

bixMd surface to the bone from whicb thoy gr'ow. And here it 

is often difficult U> decide as to the rcjil nature of the disease ; 

wlicther it is a proper tumor, or whether it is a thickening of 

the origimd bone-tissues, by inflammation of tlie buue, or its 

periosteal covering, ilappily. the dLijfiioeis is not of ]>ractica] 

izmportaiiee, for the tpichtiou of removal if; not ollen entertained, 

wlicre tlie large base uf atlachment makes the removal of the 

irliolc morbid mass nncertiin and difficult. 

Vitli r^rd to the seat of the cancellouft exostoaea, scarcely 
wiybone in the skeleton is entirely exempt from them. Per- 
hn{M the most frequent scat in in the cpiphysary endtt of the 
lony bonct), wliere of course development is ^oiri^ on nmst ac- 
tively^ nnd where, in young por&one, tliey miiy bo consIJcrud aa 




*P to a morbid excess of formntivo activity. Next to these 
•wJ^'iiU in frequency arc thn jawbones, both npper and lower. 
ft- 62, Ijiken from Ilcjith, in a good example of the cancellous 
•^Mtoaisof the npper jaw. It ori^nated in the luft 8ui>erior 
^Scinn, projected douniwflrd. dieplating an<I deforming the 
^'or jaw, and largely encroaching on the mouth. 
1$ 



342 



TrUOKS OF BONE. 



I have now n lady tmdcr my care wlio has an exostoflls, of 
tlie 8]inj>e anJ size of a email c)ierrv, projecting iato llie nioutU, 
and jjTowiug fVom about the middle of tLe under surliice of Uie 
l>ony palate. It has beeii growing slowly tor about twelve 
jcflcs. It is covered with bcaltLy mucous mcuibraiie, ii> without 
pain^ Hnd pvee no trotiblti e.u'ept from iU inecliaiiicul prc&cnee. 
It has a narrow nei-k, and wjuld be very easily removed. 

I have Been recently, with my friend Dr. E. Krakowitzer, 
of this city, a young Indy in whom a tumor is slowly growing 
on the riglit parietal bono, and has now rcache^l a aixe of about 
an inch and a quarter in its long diameter. It appeared, with- 
out caiise, about ten years previous, at the age of elei-eii. It 
has the shape of a section of the blunt end of an egg, and rises 
about h&[f an inch from the level of the surrounding bone. 
It seems to bo immovably fixed to the bone, though owagionally 
we thought some movement could be developed in it by very 
atrong pi'cssurc from eiilc to siclc, as if to elide it on the parietal 
bone. A needle passed down to ita sar&co indicates tliat ie ia 




entirely bone. It is pninlesH and free from any tendomcsd^ ^^^ 
the scalp over it Is perfectly healthy. Wo advised tliat fo'^" the 
present no opcratinn should be thought of. Fig. 6-1 repre^^*'iti 
h scries of smalltr growths of this kind scattered over th-^ 
fiu» of the cranium. 



OeSEOITS TTMORS. 



349 



I 



An interesting variety of exostositf is that which has its seat 
b the larger tendons jnst at their point of attaeUment into the 
bone. These arc qnlte commnn, ami soarccly a museum can be 
foaiid -u'liich tias not one or more of the^e ^ovcthi^ They seem 
to he developed in the tendinous titune, with which the growth 
18 SO intimately confoiindcd that it is diffiwilt to decide whether 
the bony growth has taken place in the tendon-suhstance as a 
matrix, or whether it has replaced the tendon by absoryition of 
itft fibres. They usually have a base of attachment to the bone 
no larger than that occupied by the tendoiL, and Hoinetinies ex- 
tend a considerable diEtaneo up into the mnscakr substance, 
diret^tion of whose fibres the inorca&c of tumor always fol- 
(Fig. tW.) According to Tny observation, these exoetwes 
are always found in strong, well-developeil men, in whom the 
muBcles and tendons are hirge and vigorous, and the bony pro- 
eeuc« of attachment largely developed ; and, if this be so, it may 
he &ir to consider these also as a result of an excess of forma- 
tive power irregularly excrciseii, rather than properly a disease. 
A fine Rjiccimen of this exists in the cabinet of the Xew York 
nos]>ital, which was found growing from the femui' of an athlcl le 
negro, "in whom it had caused no syuiptunia, and about tlie 
origin of winch nothing was known. It consists of a niat^ of 
bone, six inches long, springing by a large pyramidal base from 
llie shflrt Ijclow the troclianter minor, and pairing downward as 
a slender, tapering process, ]Miralle] with the femur. The whole 
rewmblcB very much in shape a snipe's licad and bill, the head 
representing the base, and the bill the prolongation down- 
ward." Fig, 65 shows a flat exostosis on the anterior surface 
of the tibia, 

The osseoHB tumor usually gives rise to no sviiiptoms ex- 
cepting snch as may be due to its i^ize, or to its pressure ujion 
neighboring organs. Tliiia Mr. Stanley speaks of a ciiso wliere 
a nwn had an exostosis growing from the posterior surface of 

I the clavicle, in whom no pain was experienced while the arm 
W.1S at rest, "but directly it wag moved lie hutVi'ii-d acute [lain 
in the direction of the axillarj- plexus of ner\'es and its branch- 
i 



I 



ea 



and also of another "in whom an aneurism was snpposcd 
to have arisen from the subclavian artery ; but, upon more eare- 
fnl cxarninatioD, an exostosis was discovered growing fram tlie 




Flo. an — (UiMouni offvat^ot nj»i^ "**• 

UdBBntMOk) 

bnchia!, radial, and nlnnr arteries no pulsalion conld he 
Mr. STjinley aUci refers t« several other cnriniis Ior.iliti< 
whifh exostoses have been found. Thna ho alludes to 
whore the rewiphaffufl vtm coiiiprci^st'd hy an cxosto?is pro'**''' 
from the "body of cue wf the Tertcbnu. Another is reco*"^* 



OeSSOCS TUMORS. 



34S 



I 



rw. «u-<N. \ 



*iiere a conical cxostoeis, prowing from the posterior part of 
'be odontoid process of tlic second cemuil vertebm, caused fntal 
Compression und sofleniiig of tlic epiiml cord. He inontioiis 
^ao a case where an exostosis grew from the ob pubis and i*oin- 
pt'^ssod the nock of the bkdder, bo that a catheter could not be 
itttruduce<l ; and nnotlicr very curiou* 
ca«o in which " M. Jules Cloquct, ia 
«Kaminius tlie body of an aged fi-male, 
fonnd the symphysia pubis ossified, and. 
a bony growth projecting from its jioato- 
rii)r aiirfdce into the cavity of the blad- 
der. The prcasure of the tumor had 
(Sased the abttorptioii of the cuat» of 
till) bladiler; hence, oti opening it« car- 
ily, the bony tumor w.i6 seen projecting 
iutu Jt, covered only by ft tliiri Uyei" of 
fibro-cellttlar tissnc, which, at the base 
of the tumor, was eontinuons with the 
mucous niembmiie of the bladder." Fig. 0(5 sliowa a very com- 
moa form of exostosis springing from the eawed end of a femur 
lifter amputation. 

The exostoses which grow from the inner surface of the dnra 
mater, and from the internal surface of the cranium, are ?ome- 
tiioea the cause ot various cerebral Byniptonis, and gometimea 
their presence has not been suspected, from any sign of their 
existenoe dnring life. Thus, Me have one in the New York 
IIoBpital Miisouni, which is developed in the fiilx cerebri, and 
liao attained a size and thicknciw Buffirient to make a very de- 
cided depression in the cerebral Mibstiinec, agninst whirh it by, 
and yet the patient, who was a man of about one hundred yeiira 
of age, never had shown any sign or nmrlc of perobral dishirlv 
anec. On the othor hand, Mr. Stanley alludes to the fasc of a 
boy who was "admitted into St. Tliomas'e Hospital nn account 
of epileptic fits," in whom " a spot was dismvered where prcssnre 
{WVf much nneasiiiess. Here tlie trephine was apidiod. At the 
mstant of raising the cirelet of bonci lie had a sharp epileptic 
fit ; but this was the Inst. From the inner table of the portion 
of bone removed, a siiionbim a quarter of an inch long pro- 
jected, pressing upon the dura mater." "ffTiv this dilferenee 



Kjcctt 



246 



TTMORS OF BOVR 



stould cxi»t between tnmors vhicli seem to Lave prcctaelT the 
Bfime physical relntions to the cerebral snbetance, Las not, as far 
att I know, b<.-eu particulsrly iuvestigated. 

A feature of inucli interest in theMj 
ounccIlouB oxostoscs is tlmt, eomctimca, 
tlicy ara (\nit» uumcruiiK, atrccthig a 
number oi" boiion of the skeleton (Fig. 
6"). Instances of tbia kind arc re- 
lated by wjvenil authors. Ono pro- 
Bented itiself at tUo clitiiquo of tUo 
Coll^:e of Physicians ant) Sur^fco 
in wbiuli at least twenty of thtee bon 
tuinurs existed at vaiiouB points, and 
nsually tlio seat of the tumor corre- 
fipondwl on tliotwo sides of the boflv. 
Thug there was one on each clavicle, 
ono on the up|)cr end of oaoli ulna, 
one oti eacli ac-rouiion precebs of the 
Bt-apuln. ono on each internal ninll 
Ins, besides several others in whi 
the correspondence waa not quite 




F». t,t-(rna BUlruUi.) 




Fu. «— (FmbiU««i&.) 



perfect. They were of a dizo varying from that, of a pea 
that of a wiiliiut, were without paiu, aud had givwn &lowl y^ 
without jiesignahie cause. 1 

An inter&?tin,if vuriety of exnstoRis is that which we occo^'l 
sionnlly find developed from the fangs of teeth, and which co 
siftts entirply of hypertrophy of the osseons tiasne (eementum^ 
of the tooth. Fi^. 68, fnnn llcntli, frfvos a view of one of tJii 
etostoflps attached to the nide of a molar tooth. It waa as b 
as a pigeon's egg, and came away with the tootU wlion it w; 



OBBEOI 



lOBa 



247 



eitrapted. "Under tlic microfwopc the specimen was seen to 
|. contain no dentine, bat to ooiisist exclusircl^ of osseous ti^uo 
[cenientiiio)." 

Tlje second form of exostosis, in which the growth consists 
3riucifHill,y, «rid somotimes ontiruly, vf coniimt-'t Wne-Bub stance, 
ifi tt niUL-h niuru niru, but a mudi inuru fonuidublu diHeasv. It 
vsuall; aeeutiics the fonu of a siii^Iu tumor, nnd its favorite 
eeat is in the bones of the face nnd skull. It Bometimea pre- 
seots a. narrow pedii/lc or base, but this Ib rare; tfic iiioRt coin- 
3au>n mode of devclopmf^nt beinjo: between the layers composing 
■»lie bone, as in the di]0(»5 of the siipra-cilifiry ridge, a point 
•vhich these tumors very commonly ntfect. In its growth the 
tumor diaimrt* the two layers of bone, which are extended over 
it at firisi, and afterward disap^war, ur are t'oufounded with the 
growth which g^radinlly j>u»hes its eiicroachnieuts in all diree- 
tions, pressing upon the cavities of the orbit, or the nose, or the 
jnth, cxtrudinjr the eyu, disjilncin;; the brain-substance, and 
inally producing death after the inoet fenrlul ^iifferin^, and 
"M-ith the moat ropulsivo fenturcs of defomn'ty. Cases are also 
iBoraetimcs observed where no dietinct tnnior can he trarcd at 
any lime, but a sh^w cnlai^mcnt or hypertrophy of the affect- 
ed bones takes place, wliich gradually develop themselves into a 
liard^ irregular mass, wliich, in its ftilly-fomied condition, cau- 
nol well bo diatingiiiahed from the tnmor proper. These hyper- 
trophic growths are principally ftmiid in the superior maxillary 
bones, but the di^catm hsi» n disposition to spread to luljncent 
bonee., pushing its eucroachmeiits in every possible dire(!tion. 
Mr. Paget gives an account of a 8[>eci!nen in tJie ransenm of the 
College of Surgeons, in which ** two large inasscs of bone, of 
almost exactly nymmetrical form and arrangement, project from 
the upper jaw and orbits, and have partially coalesced in the 
Ijuedian tine. They are ronnded, deeply-lobed, and uodiJar; 
learly as hard and a8 hea^-y as ivory ; perforated with numerous 
fftpertaree, apparently for blood-vyssuls. They project more 
than three inches in front of the face, and an inch on each aide 
^beyond the malar bones ; they lill hoth orbits, the nasiil cavi- 
*ties, and pn>hably the antra, and they extend backward to the 
pterygoid plates. Part of the septum of tlio nose, and the 
alveolar border of the jaw, arc almost the only remaining indi- 



U6 



f OXOBS OF BOKB. 



ctttion of ft iacc. Tito ditwnsc appears to have bcgnn in tho 
giil»crior maxillaiy bones, and tlioiu'c to have spread over the 
bouL'9 of tUe tauu; similar disease, in a loss dc-jjixe, exUtiiig m_ 
the bones wijaRcat to tlio chief outgruwUiB. The jiatiL-nt, wl 
was «ixly vcnra old, behcved thu disease bjid been L*ighteul 
years In progress, aad a^i-rihod it to repeated blow^ ou the face 

ITe snitered much pain in the faM 
eves, and head. Ilia eyca projec*t< 
fruni the orbits : the right, at'ter su] 
punition and sloughing uf the com( 
phrivelled ; the left was accidentally 
burst by a blow. During the last 
two years of his life he occasionally 
showed sjiinptonis of iii^iuiity. and at 
last he died with apoplexy of tlie cero- 
brill naembranes." (l*"ig fi!).) 

In fill these rases, however, th^H 
chief fealurt', and the ono of moaft^ 
practiii-al itnix.rt, is the gi-aduiil in- 
crease of the osseous lu&e^, until, by 
its sheer intnision upon thesurnjnnd- 
ing organs, it produces etj much injury niul disturbance as finally, 
after long months of Biiflering, to destroy the patient. And 
this tendencv to st^'ody iiuToasc eccms to be charitci eristic 01 



Fuk «.— (rrtn Bvath > 



m 



this fonn of bony growth. It is a well-known fact tliat thi 
cauceltcius exostosis is apt, after it has reached a cert;tiu size, to 
increase very ulowly, or to i-eniain stationary during indcfinlto 
periods, perlmps for lUe. These ivory exostoses, on the ci_tn- 
trary, seem to Iiavc an inherent tendency to increase, which 
nothing can arrest, savu the death of the swfTcror. 

The anatomical character of these ivory exostoses is gener^y 
ally that of pure and perfect, but very hard, bone-tissue. Th<^| 
harde-st parts of these tumors prci;ent sonietiiues an iri'egular 
distribution of^ and sometimes an absence of, tliu usual anatomi- 
cal elcnienta of bone, as in the rase Mr. Paget alludes to in the 
musenm of thii University of Cambridge. It is also oircasion- 
nlly noticed that the elements of lioiie are not aminged iu the 
usual orderly manner, but are irregularly distributed abont 
the mass, varying ecmewhat in their arrangement at various 



OSSEOUS TnilOBS. 



U9 



points of the same tumor. TJBually, however, the bono-tissnc 

is pcrfeft iu every respet-t, and cnunot by tlic microncope be 

dist itiguislicd frx»m hone of original forniaiion. M^iay of thetse 

tiiinors contain nothing hut thy hard, ivory-like boue-tit>eue, hut 

ill many again it i<j mingled at points «-ith eoiiie cancellous 

tissue, and some tunioi-s are rucorded whleU present a thick 

outtside shell of hard bone, onchtsing cancellous tissue within, 

of perl'ect fonnation. 

Their scat is most commonly the bones of the skull and 
foce, and, as stated ahove, a predilecllon h ebown fur the urbital 
'^gi»">n, in or about which a large proportion of these growths 
origiuate. Fig. 70 gives a scctiou of u cranium where one of 



iV 



"^>- 



•"*•'' 



Fin. TOi^l^tHii P^ci-i.) 



th 



**<is^ tuinore^ appnrently developed in the Biipra-ciliaiy region, 



Iu 



^* grown to an immense size, displacing nil tlio honca of the 
^*^» and projecting backwnrd into the cranial cavity. TIio 



**^^'inicn is in the muBcinn of tbo University of Cambridge, 

,j^^ Mr, Paget, from whoso work the plate is copied, says of it: 

^~^ is the largest and best specimen of the kind I have ever 

v^***^. and ita osseous structure is distinet; only, as Prof. Clark 

- ^ informed me, it is irreguLir; in tho hardest parts tliere are 

' tlier Havcrftijin winnla nor lacnnn? ; in the less hani parts tlio 

J ***lfl are very large, and the Incimre* are not arranged iu eirclcs 

^^^■*Jt them; and cverj'Avbcro tlie lacunaj are of irregular or 



850 



Tl'StORB OF BOKE. 



distorted forms." They are oewiMionally found in other ptrts 
of the skull liud face, and Bometiiue&, tlmiigh rarely, there u 
more thBn one, as in the specimen in tlie Mue^ Dujiuyiren, 
alluded to by Follin, and of whicli he pvcA a drawing. Uare 
two distinct osseonB masses existed, one on the anterior and 
one on the postonor part of the vault of the cranium, eacii 
projecting about equally froito the outer and inner swftos 
of the bone, the inner projection l;»r^ly encroaching upon 
the cerebral cavity. These tuiuutu ai-e occauoaally devel- 
oped in the lower jaw, and very rarely in other benci It 
is curious to observe that, sometimcfi, the hypertropluf out- 
growth tliat we iind as the result of periosteal indaaumli'^n 
puts on tliie ivory-Hho charaptcr, and fiometimee vies id soliditT 
with the hawlcst of the tuniore. Thus, in a specimen in tliB 
New Yorh IIoEpititl Museum, which pi"eaenta nn enlargemeot 
of the anterior hnlf of the tibia, evidently from periosteal irn- 
tJition. the new material whicIi hns been deposited, to the tiiifi^' 
neas of more than hsih' an inoh, is shown by the section to be 
of the hardest and most Bolid kind of bone, in which no md> 
celli and no vasculur canaU can be wjcn by the naked e.ve, ni* 
iuimcuiie weight of the bone confinns its solidity. ThisepKi- 
men seerns tu mark the dividing line between the ivory tumon 
proper and those enlargements, above alluded to, which ut w 
general, and involve in their progress bo large a part of tie 
attected bono that thoy more naturally suggest the idea wf W 
hypertrophy than of a simple tnmor. 

Of the cases in which the tumor character is tlie Bi<*t 
marked, a number of examples are on record. One daaacil 
caite is given by Mr. lleath, which was under the caro td Six 
William Fergusson, iik King*!} College Ilospital. The patlait 
was twenty-cne years of age, and the tumor had appeared 
twelve years before. It was the size of an apple, and occupied 
the eitualion of tlie orbit fnnu which it projei^tcd, carrying vat 
with it the eyeball. The tumor, after removal, was found to 
eonaist, " in all its anterior part, of nodulated bone as hard u 
ivory, and posteriorly of very dense ordinar}* bone, mixed with 
ft Bmall amount of cartilage. The tnmor sprang appanmtly, M 
in the former case, from the upper pirts of the maxilla, and bad 
invaded the antrum, orbit, and nostril." , 




OBSnniS TTTSOBS. 



251 



Hr. Heath aleo alludes to Michou's casC} in wliicli the tuoior 
occupied the cHvitv uf l!ie antrum, upriiigin^ fnim itB upper or 
orbiral wnll, and tiiBteruliiig it in till dtirctiuns. ''It weighed 
eighteen hundred grains, and waa deejily lobulated, particularly 
on its posterior aspect. A gcction showed concentric niarkinga 
upon a fturfat-c of ivorj-, and mieroacopic examination demon- 
strated the lacunse and canaliculi of true bone." 

Dr. Buka's c^se (''Pathological Society lieports-," vol. xvii.) 
wu still moi-e remarkalile, "and occurred in a female native of 
Bengal, aged twenty-six, on the right &ido of the lace, wliieh 
W8B not much deformed. There was a di8<,*liarge tVoni tlie right 
Doetril, which was obstructed, and on ercaniiriatioi] a hard tumor 
was found within it, wkidt wax movabley but could not be ex- 
tracted, and which had existed six years." It was removed 
trith mnch difficulty, and the Bpeciiiien is in St. George's 
Hospital Museum. *'It has an oblong shape, and is not unlike 
a middle-fcized potato, with depi'eseiouB and eIe%'atioua pas&iug 
irregularly over it. The upper part, which h believed to have 
been in eontact with the cribrifonu plate of the ethmoid hone, 
exhibits corregponding delieate depressiona, with other deeper 
sulci in front, hohrnd, and on tlie side, prohahly for the passage 
of blood-vessels. . . . The whole bony mill's weighs one thou- 
sand and sixty grains; ita long diameter is nearly tliree inchee, 
tlie short one an inch and two linoa, and the longest circum- 
■fereuce seven inches. There are no distinct Iliiveiisi.in ftystems, 
Xnt abundance of lacunee an'anged around vascular canals. In 
some parts of the tumor the characters are very much like those 
•of simple ossified cartilage." 

Fig. 71, from Heath, is a good example of the ivory exos- 
toeiB growing from the auglo of the lower jaw. The tumor 
-pMJects both diiwuward and on each side of the jaw, and 
measures nearly tliree inches in its longest diameter. It is 
composed throughout of bone, uniform in texture, and as hard 
and heavy as ivory. 

Two accidents are apt to happen to these tumors, which 
present sotne points of ]iat!io1i>gical interest. I allude to necro- 
sis and firactupe. In several instances it has been noticed that 
inflammation bos attacked these growths, and that after its 
subsidence abscess has been formed, communicating with and 



S53 



TrMons OP Boyt 



cstpoeing the surface of the bone, wliich has gradually fkUen 
into the condition of a stHiiit'strutu, whifh wijiie&irum has finally 
eepanited from the surrouudmg bone, and become detached, 
luaving a granulating crnvity, which in wveral recoitled ii 
Btant-efl has perfectly healed. 1ji Mr. Ililton^s case, tlie pi 



# ^, 



no, Tl.— (Frtui llMil.-) 



of aepnmtioa was going on for six years before it was finally 
completed. Aeting npnn this liint, Sir Aetley Coo[K'r ma( 
the snggcstion thiit an indsicm should be made down npo| 
such ft tumor, cx]K>8ing its eurfacc, and detflching it from 
surrounding eoft parts, in the hope tliat, by such esjwsure, ne- 
cToais would take place, and a fipontimcous Kcparation occnr. 
Whether any sucli expectation liati u^er boon rcahzed, I am nut 
informed. 

With regard to fracture, the only instance that 1 know of h 
which the ivory exostosis has been sei^arated in this way t* Dr. 
Dukft'fl case, before uientionod, in which tlie tumor growing i^ 
the antnnn had separated fmm its bony ottachments, and wi 
lying loose in tliti caviry. The c'anccnnii& exostoses, liowcvi 
and partienlarly where they have acquired a narrow base of at- 
tm-hraeut, nre not unfrequently broken oft* Several examples 
are recorded of tliis accident, and the suggestion has been made 
to break them off, with a view to arrest their growth, as, in tlio 



OSSEOtTS TUHORS. 



253 



instances known, no growtli haB oreurrcd after tlie base of 
attac-litnent lias buen bmketi thnttigli. 

In »11 these diil'erent funtis uf tninors eituated on bones, the 
qoestion of operative interference ia linble to present itfielf. It 
may be :u»ei'tcd as a ji^ncral fAct that, in any case in vhie'h the 
tumor «in be completely removed, the operation will be likely 
to be encce*eful. It must be remembered, however, tliat In only 
a stnall proportion of bone-tnmoi's ig the baex) so dititUiet and bo 
small that the eurgcon's naw or cliitK-l uiii reaoli the whule of 
ito att^ehnient witli easu and eurtaiuty ; and that, therefore, in 
4heee caaee the removal m apt to be imperfect and partial. I do 
xiot mean to say that, in all cnses in which llie whole diseased 
tissne is not removed, a reeurrouee will talco place, but that in- 
complete removal leaves a dispos^ition to rcenrrence I suppose 
no surgeon will deny, find that, therefore, the possibility of 
con]plete removal becomes an impoi-tant element in deciding 
ijpon the propriety of an oporatiun, lu many exostoses M-hi^b 
lure a narrow nnd accessible neck, the mere removal of the 
xnasa by incision tliraii|;b this neek is eiiffieient, for, as abovo 
stateil, the stump thus left shows very little inclination to grow; 
l>ul, in many otlicrK, when flie base of attachment is large, and 
the tumor situated deeply, the operation of removal is among 
tlie most difficult, tedious, and troublesome, in gnrgery. These 
difficulties were experienced in the fidlest degree by my col- 
league. Dr. John Wsttson, in a ctiH.> of exostosis of the middle 
of the femur, which he was engaged in removing. The depth 
«f the wound, though a liberal one, and the unyielding nature 
of the tendinous and aponcujtitic tissues near thi* lione, pre- 
■vented very seriously the ubli<]uo applicatii»n of the ciuBels and 
ibrceps. which was neeessnry tn get at the base, and which 
Tronld have been so easy, eould the soft parts have been re- 
moved. After a long and laborious operation, conducted with 
inucli pftticnoe, in hia nsnal thorough manner, he suecccdod in 
removing the whole growth, nnd the wound was brought 
together. Severe, deep-seated inflammation followed rapidly, 
and spi-ead up and down the thigh, tc-riuinating in unhealthy 
suppuration, and bringing the patient rd rapidly down that lie 
sank and die<l about a week fmni the operation. It seemed as 
if the violence done to the tissues about the tumor, by the no- 



SSi 



TITUORS OP BOm. 



ceaaary m«nipulation, had provoked an mflnmnuition whidi the 
injnred pHrts vrevo nut able to resist, aii<l heuce the fatftl extcn* 
Bion of its ruvagcs. 

Nevertheless, if the tumor be growinp; rapidly; if it involve 
|Mirts where its pressure miiy become d«ngcron«, or painfhl, or 
even inconvenient; if it be Bitnntwl where it ie n dotbrmity; in 
fihort, if there be any good reason for de«iping it* removal, the 
operation may be undertaken with a good prospect of perfect 
sueoess; if, as above etaied, the mechanical conditionB of the 
tumor and iU eurroundings be euch m will permit of its easy 
and complete removal. As to the mode of accompliehinj^ the 
rftuiovnl, eo much will depend on tlto nature and seat of the 
gruwtli that specific rulo« can lianlly be laid down. The firet 
Btcp will bo to expose the liimor by an incieion, which should 
be a liberal one, aufi in deep tumore, in fleshy parts, Mr. Stan- 
ley g^ves direction to cut the muscular tibrcs transversely, both 
because it cxposea the seat of disease more thoroughly, by the 
retraction of the fibrw, an.1 becauRe it leaves the wound Iwtter 
open for the discharge of matter during the healing process. 
The bone is to bo attacked by sawa, clnsele, or bone-fnrcopB^ ao- 
conling to tiircuitiBtancus and the fvhule ilificaacd tiseiio, with a 
liberal portion of the tmrronnding ttound bone, shonld be re- 
moved, if it can with liafety be done. In ray own hands, the 
chisel (and particularly a moderute-Bizcd gouge with ronnded 
cutting edge) is the most effective and most genernlly useful 
instrument I employ. It is, however, in the ivoiy exotitosis, 
about the face and bead, thnt the most formidable operative 
djfficultie« present Ihcmselves. In the following ease the 
manijmlationa arc not stated to have been ditHciilt : 

Dr. Alexander B. Mott, of this city, was the operator, and 
the patient, a Seutchnian, thirty-throe years of age, of good 
eouBtitntion and health, had noticiMl for Bcven years nn enlarge- 
ment about the inner canthus of the left eye. It commenced 
without obvious cause, and graduaEly became the seat of g;r€at 
pain as it grow larger. Its growth, at first, was toward the 
nasal cavities, ami afterward t^iwanl the orbit, projecting alao 
from the surilice of the check find siiio of the no«e. Ij»telv an 
abscess had fonne<l and dieeharged near the inner canthus. On 
pae«iug a probe through the opening of thia ftbsceos, bnro bone 



OSSEOUS TUMORS. 



93S 



■ fonld bo felt. The deformity wns still furtlier incTeaeeil by tho 
letl eye being prt-*sed by ibe tiuuor very jjiiich frtmi its proper 
[Kwition, a euudeiiueiiuy of whidi pressuru wiis u very prcat iiii- 
painiicnt of vieiun, amciuuting tinally ulniost to a totnl loss. 
L)r. Mutt oxpoae<l the fiiirfac^ nf the tiiiiKir bv niakirijf i'onr 
Sajja, and dissecting thern up from (heir uitaelimcnts. "This 
being (lone, I found the bony tumor waa firmly impacted in the 
orbit and nasal cavity. I conaequently eeiwrat&J the nasal bone 
of the left side from its fellow of the opposite side by nienua of 
* strong pair of Liston's bonc-forcepe, and, with a Jine, straight, 
flexible saw, detaclicd it from its frontal attachment, liy a 
little manipulation I wa* tluia enabled to remove the poilion 
I represented in Tig. 72, and, ou accomplishing this, I next, by 




l\-^ 



no. 13.— (Ftuin Or. A. fi. Mott'i ColleotlABO 



of a delicate chisel and Iiaminer, gradually detached tho 
bony niii88 fi-om the orbital plate of tlie frontal bone, and 
also from the orbital [>iat« of tho superior iimxillury. Tlio us 
nngiiis was bo thoroughly ineorporated with tho tumor that I 
wafi obligeil to remove it ali-ng with the mass ; and the wholo 
being now goinewhat niovablej I made slight traction by menus 
of a pair of strong fctrc-eps. A few nioro cuta of the chiael en- 
abled run to wilhdraw it." The tumor vrfit* fruind to be of dense 
osseous siruetiire, atid is represented in the idnteol' natural size. 
Xt6 ircight was three ounces and ouo drachm. The patient 



S5fi 



TTMORa OF DOSE. 



made a very good recovery, and has since remained entirely 
free from any symptom of return of the afl'ection, a period 
about tliirtcen years. 

Sir William Forgiiasou, M. Michou, Dr. Buka, H. Dt 
quay, and otliere, have piiMislied full account* of their opei 
tions on Uiese tumors, and, tlmugli the number of operation* 
too few to be of any statistical value, tlio general result sooc 
to be, for so serious an operation, quite encouraging. Sir AVil- 
liam FcrgnsaonV cane (\'uni, tint ilic three other surgeons nnm( 
above were successful in curing their patients. 



CHAPTER in. 



FIBBO US TD MOBB. 

The pure fibrous tumor ia not rare in the boues; 
eouimonl}' wiimected with tht? periuateum, of which, as in some 
forms of epulis, it seems to be an outgrowth ; but aometirai 
found — as in tlio uppt-r and lower jaws — developed in the sni 
stance of the bone itself. These tumore an? puiniuinily typit 
epceimens of their class, being eomposed entirely of the wliite 
fibrous tissue, containing scarcely any other clement, and with 
no trace of stroma or baseiuent-substance, in which the fibres are 
embedded. Some differences in structure, however, are found. 
Thus, some are harder and drier, others softer and more juicy ; 
some show tlie fibres cleanly dclined and distinct, others show 
merely a gctioral fibrous character, tu which it is not always 
quite easy to di^tingitieh, and quite impossible to isolate, sepa- 
rate fibres. Some show a distinct basement-substance, hard, 
firm, and wliitc, almost like cartilage, in which fibres are vari- 
onsly interlaced, Romotimes in comparatively sm»Il numbers; 
others, again, pai-ticnlarly the Imi-der specimens, are so com- 
pact and condensed in their structui'e that nothing but careftd 
micro&co]>tcal examination will reveal the fact that they are 
composed of nothing but fibres. Kliistic fibres are i^omotimea 
BcattGPcd through the turnnr in considerable abundance, thongfa 
in a large proportion of cases they arc entirely ab-wnt. Nuclei 



FIBItors TL'UORa 



S97 



arc also found in young fibroiie tiimors, and in tljose which aro 
growing ni]>iflly, while in the older and more slntiuiiary cxain- 
pl«s they may be entirely absent. Again, carlilage and bone are 
not iinfre<pieTitly met with in a|>])arent)y accidental as,sodation 
with tlie fibrous tissiio, though tnie bone is not otlten found in 
Urge amount in tins form of tumor. It i^ true that there in a 
change in many of them, wherein, by a process of slow degen- 
eration, the chemical elements of bone are bo largely infiltrated 
' through tlio tumor that it finally bceonie^s a hard, solid masR, as 
I heavy and as solid as bone, wliioli to the naked eye it Runetiiues 
resembles; but this is (^»kit!i-Ation, not ugsitimtion, and the elo- 
I ments are seen, under the niicroscope, nut to have asmimed 
, any of the eharacters of tnie bone. Cysts also aro developed 
^H in fibrous tumorn, sometimes many bcin^^ scattered thr<^ugh 
^^ their siihfttance, while it soinetinics happens that ono large cyst 
so displaces and replrtces the orij,nnaI structure that its char- 
acter aa a primary fibrous growth is diflicnlt or impossible to 
recognize. 

The external features of tbetie tumors are somewhat con- 
stant. They have a distinct and usually smooth Injutidary-line, 
whicli 6i']iarates them from the s^irmuiiding tiivsues, from wldeh 

ttliey can, by enucleation, be readily removed. This is true of 
those portions whereby they come in contact with parts other 
than the bone or periosteum, from whit-li they spring. In their 
mode of connection with these latter, considerable dill'erencea 
present themselves. Thus, from the perioeteura they often 
have the ('haraeter of outgrowths, in wlueh iio boundary-lino 
ejcists between the tumor and the tissue from which it is devel- 
oped, and in some cases not even (he microscope can discrimi- 
^B^Ate between the new growth and its parent-t issue. In other 
^R**«e5 a line of separation can be traced throngh the whole con- 
totiT of the new growth, and even in some instances the tumor 
^^^f* tio contact with the fibrous stnictures ne.ir which Jt grows, 
^*t is at every point sepni-ated from them by a loose areolar iu- 
.^'■ftpBct*. This is occasionally noticed in fibrous tumors grow- 
^'^f? almut the melatiirsua and metacttrpns. The external anr- 



fa 



*^ of these tumors is usually rnundod and smooth, sometimes 



*-*"«<J, rarely bosselatcd or botryoidal. Their consistence is 
^^^ hard ; their specific gravity, as a class, greater tlian any 
17 



S68 



rUMORS OF BOKE. 



other but ibe osseous. Their rascularity is generally slight, 
though Eome of the softer forms receive a large nniuber of 

They are, in the ttoncs, nsitally single, thetr growth Is very 
slow and ]»!iinless, nnd they sometiinee attain a very great size. 
With regiii'd to tlieir constitutional character they are, by geu- 
cral consent, considereJ to be uniformly benign. Their ten- 
dency, however, to local reproduction, particularly if imper- 
fectly removed, is well marked, and in operating must uot be 
loBt sight of. The malignant hii>tor}' of some " fibroid tumors " 
inu£t not lead us to the unjust imputation of evil character to 
nny of those which, under tho microBcopo as well as to the 
naked eye, dcners'e the naiiio of " fibrous tumors." In eliort, 
it inny be stated, as the cx])re8Biun of a general law, to which 
there are very few exeeptionB, that the benignity of these tn- 
niors ifl in direct proportion to the perfection which tho tibrtms 
element has Attained — those which rejiresent perfect fibrous 
tissue being absolutely benign, and those which present it 
in a lets jfcrfect state, and jiarticularly in its embryonal form, 
are always to be looked upon with a certain amount of sus- 
picion. 

The scat of these tumors ts sometimes on the surface of ibe 
bone, and then they may fairly be supposed to orifpnate in the 
periosteum, with which they are commonly contiuuuus, or it 
is in the central parts tluit they are developed, and then they 
usually distend, in their gruwtb, the compact outer sliell of the 
bone, which oflen, even in tumors of the largest size, fomis 
a thin, imilbnn covering, sometimes not thicker than an egg- 
shell, whidi gives them, on a slight touch, tho fool of a Iwny 
tumor, but which, by firmer pressure, yields, and sotnelimes 
crackles under the finger like a broken egg-shell. They have 
been found in or upon most of the larger bones, nsnally near 
their cancellous rather then the compact |>ortions. They have 
been noticed of very large size in the femur, himienw, and 
scaiuila. We have one very marked example of one of these 
tumors in the museum of the New York Hospital, devel* 
oped in the lower part of the femur, which had been six years 
growing, and which, at the time of amputation, measured thir- 
ty-seven inches in eircumfcronec. Mr. Stanley speaks of one, 



FIBROtrS TUMORS. 



B60 



fa the museum of St. Bartholomew's, -which grew from the hu- 
Qcnig, aud which monsured three teet in cirLMimfcrence. Oth- 
ers of very large size !iave been recordetl in the ewipula. It is, 
Lftwover, in tho maxillff', both upper and lower, tliat the fibrous 
tmnors aro most commonly ibunO, and have been most carefully 
tludied. For many reasons the tumors of the jswa can be most 
j»nveniemly eonflidcred together, and I therefore ]>(>Bt|»ftn(.( any 
more p«rtictilar account of fibrous tumors of the bone, till we 
come to the chapter devoted to the study of the varions tumors 
whicli affect tlie jaws. 

BPtKDLE-CELLED FIBEOU)9. 

A roneiderable number of bone-tumors present themsolvea, 

of which tlio liislological character is given, by tho presence of 

({>tndte-sluii>e<l or oat-i^hapod ccUr, whitih compose the innss of 

the tumor, often U> the exdiision nf any other element. From 

the distinctneea of their anatomical characters, and the facility 

with which these characters may be recog;nized, these tumors 

fcftve long been known, and have been described by nil modem 

Wrritere. But, some controversy liaving arisen with regard to 

their histogenesis, different names have been given to them by 

tiitTLTent observers, in accordance with their different views, as 

to the aignifit'ation of tho microscopical elements of which tJiey 

are composed, 

Ldiert first drew attention to them aa a class worthv of 

*«pftratc consideration, and, as ho adopted very confidently the 

2<ieA that the elongated cellfi, of which they were comp<>9ed, 

f^B^rere nothhig more than ■fihro-rclls arrested in a certain stage 

f development, he named them, very appropriately* if his view 

,-ere correct, fibro-plastlc tumors. Billruth, Virchow, and oth- 

^^ira of the modem Gcnuau school, have protested against this 

L_^*^iow, and have shown that in the fumiation of fibrous tissue in 

^^^Sie embryo there is no stage or condition which presents tho 

^^fc'j>indIe-sliapod cells, and tluit, therefore, Tjobcrt's view boiiig 

■^ »icorrect, tho name ho uses is inappropriate. Billroth insists 

"*-liat, if thefie peculiar cells represent a stage of incomplete de* 

'^''^lopment of any tissue, it is the miiscnlar fibre, and not the 

*i'br"us tissue, to which they belong, and that therefore they 

"ught to be ttichided under the myomata, or tumors composed 



seo 



TtrilOBS 0? BONK. 



of muscular 6bres, ratlier than under tbe fibromata, with which 
tliey Iiave no proved relation. Virchow prononncos the spin- 
dle-shaped cells, whinh arc often found in utortnc iihniid, aa 
iui]ierfe(rtlj--dcveloped inuRclc-ccllB, and given these tumors the 
iiuriie of ^^ myoma lanv celhdiU'e" In t-oniparing the views of 
the best microscopisis, it socniB donbtliit whetlior white fibrona 
tissue is ever developed from t-ella at all, and even Virehow^ 
the great advocate o/ the doctrine " omni<i «r eellufa," acknowl- 
edges that in the formation of tibrons tissue it is the intercel- 
lular substance and not the cells which are concerned in its 
development. The yellow elastic tisBue, it ie true, sccma to b« 
developed from cells, but this element is comparativelj" nneom- 
uion in fibrous tumors, and has, therefore, but Utile signification 
as fnr as histogenesis is conccriicd. It is not without reason, 
therefore, that pathologists have rejected Lebert's term, "fibro- 
plastic," H9 coni-eying an incorrect idea ; but still it is necossuy 
to remember tluit, thoufth his theory of formation is unsound, 
and his nomenclature therefore faulty, his observations are nev- 
erthelcfif) clear and admirable, and that from his labors, and 
from tlie contributions made by numerous other observers, wo 
have H fHir ground fur including in one class all those tumors 
that are mainly composed of these peculiar and easily-rccog- 
nized cells. This class would include all tliose cases so well 
doficribrd by Lcbert, as well as those described by Mr. Paget 
under the title of recurring fibroid tumors, those called by 
Billroth spindle-shaped sarcomata, and those which Virdiow 
donominatps i>arcomata with fusiform colls. It will pcrha]>B be 
convenient forns to denominate them the ttpitulU-ceUed jibroitU^ 
as an appellation which erabr.-»cc8 the facts in the case, without 
the snggt'stiiin of any theory. 

Thct^e tiituors, as their name imports, have a nearer resem* 
blancc, in their naked-eye diaracteristics, to the fibrous than to 
any other tumors. Indeed, the firmer specimens cannot in any 
way be disiinpiiahcd fmm the fibrous growth, except by tlie 
aid of the microscope. Tliey are usually tolerably firm, of % 
whitish homogeneous section, fmm which but little juice can 
be acrnped, not very liberally eupplicd with blood-vessel*, and 
usually unifunu in their appearance thro\ighont their whole 
Eubstance. 'When they recur alter removal, their appeajBoce 




FIBRODB TUUOII& 



S61 



ii often much chanf<;ed to tho naked eyo ; thoj arc softer, like 
(he fleeh of fisb ; tlit-y ft'c more juicy ami more vascular, in 
CBch roeiirrcace departing more widely from the iibrous nppcnr- 
ince, but allowing under the microscope the same pccniiar &na> 
tomical constituents. In gliape these p-owths affect the Bphori- 
ral, but in or upon tho bones they arc of course much influenced 
by the pre&surc which they encounter, aa they spread ; where- 
ever, however, they escape into the K»ftcr tissues, they uwnally 
show a rotinded niasa which is limited by a pretty firai eapiiule, 
and which, Lke the Iibrous tumors, can be easily eniu-Lentcd 
from the bed in which it liea. After several recurrences, they 
ire apt to involve more cxtcnfiivcly tho surroundin|^' parts, pene- 
, (rating- between tlie miiwloe, adhering to the buries, and depui-t- 
H ing ihemeolvcs nmro and more like a iiialigimnt m»BS each time 
^1 they return. Whether this form of tumor ever reatly invndoB 
^P and involves in ita liuhstHnce the tissues with H*hich it is in 
p tontact, I do not know, but that the contrary is generally tho 
fiict, ia well illustrated by one of Symc*s caries, in which a large 
tumor on the chcfit, which waa the last of five or eix recur- 
rences in iccOy lay, at the time of death, among the muscles so 
loosely attached that it ml^ht have been removed Mithout di- 
viding any impurtaut part, "ati a couimuu futty tumor might 
Pibe." 
The microscopic characters of these tumors arc those of 
■Very el oBcIy -packed, spindle-shaped colls, often without any, 
and sometimes with a considerable amount of homogeneous, 
transparent, intercellular substance (Fig. 73). The colls con- 
ji tain, a nucleus, which is situated at the thickest or bulging pon- 
^Rion of the cell, and they terminate at each extremity in an 
elongated i>oint, soiuclimes branched, which varies verj- much 
%n its length and tenuity. Tliese cells are most coiitmuuly 
rrangcd willi some regard to order, so that in well-developed 
c^pectiueiis a liiruinated or fasciculated tissue results, the lines 
^^Tunning parallel witli the suriace of the tumor, thus increasing 
^Blts likeness to the structure of a proper Iibrous tumor. Vir- 
^?how also notices the rcsembliince to epithelial growth which 
is assumed by some of these tumors where tlie cells are large, 
^nd where the intercellular substance is absent or in very small 
^nantity. With the elements thus enumerated, we have often 



202 



TUMORS OF OOXE. 



X, 



Fu. m— (rrom BUlratb.) 



a number of free iiucloi scattered through tho tissue. Of 
isolated nuclei, wneidcred by many as an original and esam 
eleiiierit of the formatiuu, Vircbow speaks very emphnticftlly, 

in denying to them any Iiisto- 
genetic value, he considering 
them iu all eases as the r<>sult 
of de^truirtiou of the original cell 
with libtirstiun of the nucleus, 
most comiiiouly oci^^iouud by 
the riolence done in the prejw- 
ration for tho microacope. In 
many of these tninors we have 
also, associated with the Rpecific 
cell-formation, a certain amount 
of well -formed connective tis- 
Bue, and this is usually arranged 
80 as to form a caii^ule covering 
the mnss, and partitions within 
separating it into lobiM or lob- 
ules more or less dititinet, or at 
least forming compartments in 
the internal arrangement of the 
growth, the contents of which compartments soraclimca dilfer 
coDsidcnibly from one another in their naked-eye and micro- 
acopii; charactora. 

In the bonc-s, thoso tumors are found almost exclusively in 
the face and licjid. Of the largo uuinbt-r uf cases collected 
by Lebcrt, only thirteen were on the bones, and, of these, 
one was developed, in the cranium, four in the superior maxil- 
lary bone, two in the inferior ranxillary bono, and five were 
connected with the alveolar portion of theiie bones in the shape 
of epulis. He gives no case developed In any other bone of 
the skeleton — which is aUo true of several of the principal 
writers on this subject — from which the fair inference is that 
they are, iu a very largo degree, confined to tlic bones abovo 
mentioned. Some exceptions, however, do present thcmsolvo^H 
to this geuenil bw. I shM give, farther on, two cases, in one ci¥^ 
which the diseaso commenced in the malleoli, and another in 
which the growth sprang from tho transverse process of A 





FIBROUS TUHOBS. 



S63 



cal rertebra. In their general characters, as to mode of growth, 
ppogreBs, and changes, much tlmt has been aaiil uC fibroiifi tumors 
mi^t bo repotted, and their histories ui> to a certain point, are 
not markedly ditferent. Fig. 74 gi%-ei a very good idei of the 
external app*;:irancG3 of one of thuse tumors developed io tUo 
lower jawbone. The case waa under the care of Mr. Heath, 
l>oui whose work the figure is copied. It was of slow growth 
in a man aged thirty-two, and made a fungous protrusion iuto 






Fw. Ti^Fraui llmtli ) 

the moulh and also through the intejrnmentB externally. It was 
removed l)y Mr. Heath, but the patient died exlinimted on the 
sixth day. The weight of the mae» was four pounds six ountres. 
lilr. Heath givofl an elabornto account of the miniife stnietiiro 
of the tumor, whtyh terminatea with thia Btatement: '"Tliy gen- 
eral strncture of the tnmor in that tutually deambcd under the 
head of ost go- sarcoma, and it belongs evidently to the group of 
simple fibro-plastic tnmorp, but differs from the myeloid fibro- 
plaatics in the equal proportion oxititiug between the cellular 
and fibrous elements." 

But, in their tinal tcndeni^ies, the tumors helongin<:; to this 
clara pri^sent a very much l(»s satisfactory history than that 



364 



TTHORS OF BOKB. 






WG have given of tbc fibrous tumor. Their evil diepoeitiooB 
are mimifeatt'd in three wjiys: 1. In u teudencv to reproduiv 
tion in hco, after the most thorough extirpation. :i. In a diapo^ 
sitioD to reappear in neighboring ports. 3. In gencmlization 
the disefise, allowing of its exteni<iim to other and distant par 
alW tbo UJuEit maUgnant Ct;ghioa of true cancer. 

Of tho firet two facts in the Uietory of these tumors, viz., 
disposition to rucurreiice, both in tlie origiiml sptjt ntid in its 
neighborhood, but little needs to be said. They are the striking 
factH which iirst drew attention to the Kcmi-malignitr, as it is 
called, of this cldss of diseases, and tlic^y are illustrated, most 
nnhappily, in every collection of cases which are reported. 
"W^ith regard to the third evil feature sometimes obaerved in 
tbcBu tumors, vix., their generaUiation, it is happily exceptional 
and nire. Paget ispeaks of no cape; Virchow describes three 
very hitercsting and well-raarked examples; and Lebcrt men- 
tions seven as having been eccn by hluiBelf and by others, but 
of theao only two were tumors of bono. In these cases we 
have, either after the removal of the original growth, or during , 
its progress, new tumors appearing at a distance from the pH)^| 
mary tumor, winch may multiply at various jxiints and in 
variuufl organs ; these second-try or metiiatatic growths a8-_ 
Burriiug tho prominent imi«)rtaiice, and finally destroying tl 
patient by the extent of their involvement of organs neeesaar 
to life. TlieBu metnstatic growths sometimes take place alor 
tho course of tho absorbent vessels, involving the glands in 
their progress, but somDtimcs, also, they appear in distant 
organs, when we can conceive of hut one mode of infcctioi 
via., through the blood. It is very remarkabie that in alin( 
every cas« in whicli an autopsy has been made, where any 
temal organ has been found infected, tlie lungs have been eithc 
the occlusive or the principal scat of the morbid deposit One 
example, taken from Virchow, will be a sufficient illustration of 
the diwistruuu imd malignant behavior which occasionally chi 
actcrizes this disease : 

A morocco nianufaoturer, aged thirty-one, shortly after m 
severe attack of pleurisy, observed, growing on the dorsum of 
his left foot, a tumor which appeared Ut be connected only witli 
the fibrous structures of that rcirlou, and soon al\cr a second 



1^ 
arS 
>n^ 
. in 
jint 
ion^^ 



FIBROCS TCTHOBS. 



ses 



^mor developed itself on the extonial miilleoIuB of tUo Bame 
"fooL These tiuiiors gruw ntpidly, and about two mouths afl«r 
Ifadr ttppcarance another attud: of plauriBy caino on, aitcndu<L 
■with Qxtroino oppivssion of brcathiiif;, without cough or expec- 
toration, and wliioh rapidly proved fatjvl. The tumora of the 
foot were found to involve tlio malleolus, nnd Bomc of the Ixmcs 
of the tarsus, in some of which acarcely any tiling remained of 
I the original hone but the periosteum and cartilage. The tumors 
showed a very ioft, almost dilfiueut ooneistcnc-e, much like en- 
cepluiloid, in some points of a brownish-gi-cen color, in othera 
xKldifih from intillration of blood. Externally they showed 
unmcroiis lobes, more or lei^a dii^ttmrtly Pie|)amlod. Tri tlic pop- 
liteal &j>ace was funnd a gland, eiiliirged and nit-dull.iry in ap- 
])earancCf and tlic same wiis true of seveml of the lo%ver chain 
of inguinal glands. In the anterior mcdinstinimi was found a 
scries of inniora of the same medullary appearauec. The right 
pleura contained a lai^e ganguinolent cMmion, and over its 
whole surface, sot^, very deli^-ate, atid very vasculur growths 
were seen, which formed ahuo»l a complete layer, covuriug it 
entirely. The same apjiearanee in a less degree presented itself 
in the lefl pleara. In the lung itself, several medullary nodules 
of a gelatinous conBi&tencc were found, mostly near the baeo 
of the left lung, wtiilo near its Bummtt was a single tumor, the 
Bize of an apple, and efisily enucleable from die tissues in which 
it lay. The right lung was simply compressed by tiie pleuritic 
eflRuion. All these masses had the snme microscopic structure. 
They were ever\'w]iere coniiwBed of the spindle-celU of small 
9Lce, with an intereelluhir subsitance, showing very little trace 
of fibres, and of great numbers and. very large vessels. The 
arrangement of the eolU was fasciculated. 

The statement, thus presented, of the malignant behavior of 
toome of tbese tnmors, is not by any means to he received as 
their nsoal history. The fnct is — and it is in lliis fact, now 
well ascertained, that the importance of the anatoniicfd distinc- 
tion consists — tliiittb© larger part of these spindle-cellcd tumors 
do not show any evil dispositions, and, if removed early and 
thoroughly, do not return, either in their original seat, or in 
any otlier part of the body. This brings these, like tlie myeloid 
tumors, fairly into tbe class of betiigu atlcctions; and, while wo 



360 



TUMORS OF BONE 



recoj^izc the fact Uiat rame oxccptionnl io&tanccs may occur, in 
wliicli a ficiuL-uialignant or even a malignant history iiiay be 
realized, wo may, with good warrant, hold out to our patieu^^i 
the hope and expoctatioD that a thorough exttrpatioa will B^l 
followed by a perfect and pcnniinent cure. Evc-n the local ro^ 
eurrcnco ia not necesi^nrily utti:i'ly ditw^uraging. Iktany cases 
arc on record where several operations were required for soo- 
cessive retunie of the disease, and where finally the disposition 
to the recurrence of the di^eaeo eeemed to be exhaustedt 
the patients Imve maintained fur many years perfect healUi. 
one singular case uf Mr. Stanky's, mentioned by Mr. Paget, 
after four extirpations by Mr. istauley, a tilUi Cuntor appeal 
and frrcw to a certain size, and then remained stationary, iJ 
whieh condition U had rcmaiup<l at the time of the report, "^ 
long time without in any way interfering with tlio |Mitienl 
health." Another rcrj' striking case is reported by Mr. Pa 
as occurring under the care of Dr. Douglas Mrtclagan, in whit 
"alter four recurrences and fuur operations, the patient has 
uiained five years well, and, at the present time (Xoveiiiber, 
1862, thirty yeiirs after the removal of the first tumor), she is 
in perfect health, and daily follows her avocation as a laundress. 
Since 1857 there has been no rcenrrcneo of the tnmor." 8imi- 
lar wises are recorded by other observers. 

The following case of spindleHjelled fibroid, attached to tl 
transverse process of the fourth cervical vertebra, illustrat 
many of the points to which we have referred, and is in itself 
so wonderi'iil a surgical story, and terminated in such a com- 
plete and surprifiiug success, that I feol warranted iu giving U t 
in full detail : bH 

Mrs. I. N. E., then about the ago of twenty-three, coaaiilt^^^ 
mo first, March :^0, ISGG, about a tumor on the right aide of her 
neck, which luid been growing for several months, and whic 
■was attended by a great deal of neuralgic jKiin. The tnmor wa« ' 
about the size of a large hirkorj'-nut, pretty firm to the feci, 
situated about the middle of the neck, a little behiud the stemo* 
cloido-raastoid muscle, by the posterior fibres of wbiub it seemed 
to be overlapped. It had gi'own slowly, and without apparenj 
cause, and, although there was no history of auy other glondt 
enlargement in auy other part of the neck, I felt no he«itatic 



FIBBOUS TUUOBa 



207 



in pronouncing it an hypertrcphied lymphatic gland, and to 

>muieudiug its remoraL TUo patient's gcueral health and 

litiuu were perfefl. 

Tlie opcratiun was perlbrmed May 1, 1800. The tumor 
presented it«clf with a smooth, enucleahle surface, on all hut its 
deepest parts, and there it waa attai^hcd no cloflcly to the trans- 
Ttfse proceea of the fourth ccrvifai vcrti-bm that, in tr}'ing to 
separate it» it broke and discliargud a whitish-yellow^ checay, 
semifluid substance, leaving a pretty thit'b but not very t<.nigh 
6ac atill ailaehcd to the bone from which it appeared to grow. 
Thi» sac was, as thoroughly as possible, 8nip]XKl with tho scia- 
sors, or disseeted with the knife, from at:! attachments, and the 
clteesy matter carefully wiped trom the wound. Things did 
not go well after this operation. The wound iuiiamed, and 
matter foniied, buiTowing down the neck toward the elnvicle. 
Tlie whole region becaino extremely sensitive, and tho fiiihject 
of aererc, apparently uehralgic paint;. She lost eourage as well 
aa strength, and nothing seemed to bring her up until she went 
into the country, when the wound healed, and she regained 
iome of her former excellent health. 

Microscopic examination of the tumor waa reported by Dr. 
Belafield, as follows : " Tumor was broken during the opera- 
tion, and a quantity of thin lliiid escaped. The fragiiieut^ con* 
sisted of a gniyibhtis^ue, re3cmbling that of a lymphatic gland, 
and of |»ortiona of cheesy material, Tlie firmer portions consist 
of fnaiform cells and oval nuclei packed closely together in hands. 
Here and tlicrc are groups of rounded, nncleolatcd cells, some 
resembling giand-cells, and fourtlnics as large. In other places, 
round cells were mixed with Urge fusiform cells. There waa 
hardly any stroma. The cheesy portions consisted of the same 
elements, degenerated." 

After her return from the oonutiy, she still complained of 
a great deal of {tain in the neck, about the scsr, and nlVeeling 
all the muscles of the region. She was partieiihirly ditilre^ed 
at night, and after steeping found it exeeedingly painful to move 
the head. Some fulness renifLined about thu scar, slowly in- 
creasing} so that within a few months it seemed as if the tumor 
were fornn'ng again. Hoping tliat it might be merely a tume- 
&ction of the scar, we applied leeches, and used all aorta of dis- 



368 



TUMOllS or BOXK. 



cutient npplieatrons, but witliont effect. It grew graduallr, tin- 
til, in the siiriugof ]8fl9,it Boemwl as Urge ns, if not larger than, 
before. In April, 18G7, about a year after the first operatioo^^ 
site liad borue a healthy, vigorous cliild, bor first, and had boed^| 
very well, except the locnl complaiats about tlie uei'k, during 
all her gcvtatioii aiid in her recovery from elitldbtMl. During 
a great ])art of the in(er\'al, as well as fur months bclbre the 
first oporation, she had used iodine wry largely, both locally 
and internally, wiliiout any perceptible effect. 

During the ]iitl<?r part of the winter, and in tlie spring of , 
1869, Bho oomplaincd of numbness of the right arm nnd ^ide^| 
Trithont any marked impairment of motion, and this aecmcd t(^^ 
be slightly on the increase up to the time of the second opera- 
tion, which was performed on the lOth of April, 1809. In this 
operation, which exposed a tumorvery eiintlar in size and shape 
to the one ]>reviously removed, we experienced more difiiculty 
in dytac-hing the deepest parts uf the mass from Che tmneTOise 
process. Indeed, the morbid growth seemed to penetrate be- 
tween the transverso proccsaes of the two adjacent vertebrEp, 
where we folliiwed it as thoronglily as we dared. The sae had 
broken as before, and in so dtnip a wound it was very difficult 
to distingtiiah the morbid from the healthy tissue, and still more 
difficult to remove it. Great pains were taken to remove every 
thing that eeenied disensed. but it wns impossible not to feel 
that some might have been left behind. The actual rautery so 
near the spinal cord was not to be thought of. From this opera- 
tion she recovered rapidly, and without accident. The numb- 
ness of the arm disapixsarcd, and she felt freer from pain, and 
mora hopeful of entire recovery tlian she had been at any 
since the first ap])(!arance of the disease. 

The microsc-opic report of the tmmor was: **It wascom 
of a floftj gelatinous material, with some cheesy portions enclosed 
in a fibrous capsule. It was brolccn in its remov.-il. The softer 
portion consisted of a gelatinous, finely-granular basement- 
substance, in which were embedded large numbers of round 
and oval nuclei." 

In the fall of 1809 she began to notice s return of the old 
nuitibncss, now in both hands, and in the right foot. This 
slowly increased until she found slie was obliged to ^ve up 



I, and I 
timWH 

pose^l 




FIBROUS TCMORS. 



369 



nwing altogether. In JaDuary, iSTO, slie conld no longer nr- 
nago lier own hair. In March her BecontI cliild wiis bom, after 
an easy and rapid labor. Bt thia time she had bouomc very 
bdpleaa, bat improved a little &a she recovered from her con- 
finement. Still, she was very Huinsy in handling the baby, 
though through the summer she managed to mirsc it, and 
maintained her health in a remarkable degree. She aufforcd, 
however, a great deftl from a fiesure of the anu8, which a very 
cofltive habit tended much to increafie. Until September, sho 
ms still able to walk about, though with some ditfieulty, cspo- 
oally in the right log and foot, and she could use her hands in 
Beiring bursclf at table, the riglit better than the left. Early 
in September she had, without apparent csusc, au attack of se- 
vere paiu iu the moscles of the neck, with great difficulty in 
moving the head. Thia pain eontiniiod more or lesw at intor- 
vals for several weoks. Coincident with tbeae increasoiJ pains, 
the paralysis inerc-iscd more rapidly. By the latter part of No- 
vember she had lost entirely the power of walking, and sootJ 
the power of supporting hereelf upriglit, even for a few mo- 
mettta. ller hulplessnew now beunme eoniplote, and by the 
middle of (Taniiary she was entirely jmralyxed In all part^ of the 
body below the neck. Ity the time of the last operation, the 
only movements she could make were, to raise the right hand 
a few inches in the direction of flexion, and to rnisc the legs a 
similar distance by dnwing up the thighs. These movement.'* 
were executed very slowly and p.ainfully. Every movement of 
the body, in lifting lior from her l>od or mh, or even in slightly 
changing her position, gave her great pain, With the paralysis 
of motion there was a paralysiti of sensation, which could be 
recognized by the dividers over the whole body, but more mark- 
edly in the hands tlian in the feet. Tlie bowels now became 
more obatinately costive than ever, and, as alio had entirely lost 
the ooiitml of the sphincter, the o|ierfLtion of medicine was at- 
tended with great trouble and inconvenience, so th:it we finally 
foil into the way of gi\'iag her a dose of castor-oil once a week. 
In the mean time her appetite had oontimied pretty good, and 
the gcncml nutrition not so much impaired as might have been 
anticipated. She was, however, very despondent about horaolf, 
and lite was a weary burden. By this time tlio tumor had again 



ilo 



TTHOBS OF BOSK. 






slowly developed, and was nearly aa prominent, and presented 
very much the same feci that it had done previous to the last 
operation. ^y 

Dr. Wm. H. Van Buren now saw her in consultatioa witi^^ 
me, and the question presentod itself, Could anything he done 
to relieve her hy another operation? The evidences of preasr^ 
lire on the cord, probably produood hy an extcn&ion of the di< 
caae within the spinal ranal, were so unini«tabah!o; the pro! 
abilities, deriv-cd from the fact that the left side was mc 
affected, that the pressure ws« from a growth which had de^'el- 
oped itself most on the lefl side, were so great, tliat I myvelf 
felt hopelces of any good result from an operation. In view, 
however, of a partial relief being possible from a partial re- 
tnoval of the compressing cause, and taking into consideratioil^B 
the utter hopelessness of her present state, it was. alter muctt^ 
hesitation, decided to try what could be done hy another at- 
tempt at removal. 

The third operation was performed on the 2.'ith of Janunt 
1871, Pi*. Van Tluren and Dr. IT. B. Sands assisting me. Wd 
had deteruiiued that it would be justifiable to remove as muc 
of the transvorso pritcess, and the edge of the lamina of th^ 
vertebne, as wuuhl give at-cess to the point of preseore, in ease 
this point seemed at all accessible, and for this I was prepared. 
A longer incision wns made tluin on former occasions, parallel 
to the Rtcrno-rnnstoid miiKcle. The surface of the tumor ws 
exposed, and then, to gain more freedom in the deeper manipi 
lations, .mother incision was made directly bacfcwanl, at ngfaf 
angles to the first, commencing at about il« middle point. The 
more aHi»erficifll portions of the tumor presented very much the 
same ap]»earftuce8 as ou fonncr occasions, and were quite readily 
separable by enucleation from tlie surrounding parts. We were, 
of course, extremely anxious not to hi-eak the sac if it could be 
heljied, and succeeded in keeping it whole, until wo arrived at 
its deep&it parts, which we found to dip down by a sort of ped- 
icle, between the transverse processes, and to reach quite down 
to the foramen of exit of the cervical nen-c. No trace of that 
nerve could be discovered coming out alongside of the pedicle 
of the tumor, nor any sign of the vertebral artery, whose track 
from one transverse process to another we had now crossed. 



at- 







nenous tthors. 



271 



All this space was pretty closely filled by the root of the tumor, 
whicli, as wc carefully isolntcd it from Biiiroundirig parts, eoiild 
be difitinctly soen to enter tlie spinal canal. At this moment 
the tnmor broke, and its soft contents were eracimted, makmg 
it, of course, more difficult to identify its outline, and to dis- 
eriminate betweeu the morbid growth and the uonnal tissues. 
Proceeding very cftrefully, however, we found that the bony 

i-canal hud been much enbirgcd by absorption, from the pressure 
of the tumor, and it soon berjinie evident that thi-oui^h this open- 
ing, as large as would easily admit the end of the finger, the 
external tnmor communicfltcd with a growth within which lay 
m contact with, and pressed upon, the spinal ditra m.iter. As 
for as could be reached, the growth, which was of a soft, giumny 

j^eonsistence, easily friable in the forceps, was removed piece- 
meal as thoroughly ns ]><>st»ible. Al\er all was got away that 
eould be reached, the surfnce of the dura mnter of the cord was 
left bare and clean, and not nsibiy deprcssc<i hclow its proper 
level. We conld still percc-fve, under the odgo of the bony 
opening, that some of Ihe rnurbld material existed, hni it was 
impoftsiblo to remove any more through the opening in the 
bone, and the great depth of the wonnd seemed to malce any 
enlargement of the bony opening an undcrtiiking so formidable 
that we slirtmk firom undertaking it. We had, moreover, good 
gromid for believing that the great mass of the tuinor had been 
removed, and that the thin rem.iining edge which lay under 
the bone was so mudi lacerated and contused by the forecps, 
that it would probably lie destroyed by the suppuration. The 
Wound was therefore cloned by fine sutures, leaving a small por- 
tion at the junction of the two hicisions open; into this a tent 
of silk thread was passed fairly down to the bone, with tho viiiw 
of keeping this part of the wound open. This was done partly 
to give free exit to any fluids forming in the wound, bnt mainly 
to give a chance to any new gro>rth, th;U might form, to develop, 
itecU' toward the smrfaco ratlier than into the spinal canal. 

The micro8co}>ie report of the tumor is : " It has the same 
gross flppctirancea as at the first oecurreucre. The basement- 
membrane is still soft and hyaline, but contnins blood-vessels. 
The nuclei arc hirgcr and more numerous, and tho stnicturo ia 
liiat of a mvxo-sarcoma." 



979 



TTTMOM OP BOKE. 



Janxtanj 26/A. — Had tolcraWy good rest during the Dighl 
but CDinplHins of severe Itendaclie. It slioiiM have Ix^i 
tioiitid tliut bufbro the operation she suflered troiu Ecvero paiii8, 
qnite iri-egular in their recurrence, in the thi^lis, nnd logs, and 
bnck, eoTTictimes very severe, and eometiiiiCB eli^ht, The*e 
paiiiB were, at iilglit, acodmpnniod otlen with Budden and vio- 
lent contrnt'tiong of the muBftoH, flexing tip tbo thiglis on tho 
body, and tho legs on the thighi^, tho Rpasm of the luuflck-i^ very 
Bevorely iricreaeing the psiin, and often entirely depriving her 
of sleep. She comphined this dny of increased pain on the 
uutriide of the left thigh, nnd in the right leg. Xo eontraction^H 
of miiwles. She was sensible of greater power over the whol^l 
body* and found she could movo the toce a little, and slightly 
raiBe the right hand. 

Jantiart/ 'i~dh. — Severe pain in lefl arm, and distrossing 
headache. Improvement in the use of limbe; can raise lcl\ 
arm. 

January 28M. — Good night's rest, nnd haa very Kttle pain. 
She begins to feel hungry. Toward evening complained of 
numbness nil over the body, wlih increase of pain in the left 
thigh. No contractions of limbs. 

January '29th. — Sleepless night. Complains of dark objecta 
flitting before her eyes, find Bcems to hen^elf to be carrying oi^| 
both eidtis of a convereation. llus severe headarhc and buruin^^ 
sensation in the eyes. Pulse slightly accclerntod, shiu nnturah 
She feeli^ her body very hot while the foot are oold. Gave a 
full doKc of morphine at bedtime. ^^ 

January 3twA. — Not mudi rcliof from anodyne. Grea^| 
pain to-day down tho spino and left leg. Any bending of the 
Bpiue in changing her pilluw or jxisitiun givea dreadful |>ain, 
if the bark were being biNjkon. In making any diange 
position tho hips and head must be raised on the same lev* 
Wound doing well; has healed mainly by the first Jnteutioi 
the c'cntral portion discharging a watery pus. By tlrawing 
her knees, she finds that eho can raise her hips from the bed for 
tlie first time in nhmit four months. Towai-d evening, sevej 
pain in side and bat-k, from changing her position, coniiuuii 
most of the night. 

JamMxrij Z\sl. — Chloral substituted for morphine, but with" 



HBttOUS TDMORa 



273 



out prodncing anj aatiB&ctory sleep. She is much reduced in 
llobb, pulse feeble, imd about 100. The ekin Bomcliincs hot 
and dry, and BometimeB rclnxed ; the feet generally cold. The 
thin dUchargc fyom the wound is in great abundance, and, on 
examination, i» found to be a pure, white, trans]iarent water, 
which trickles from the opening in such quantities as to soak 
tlirough the sheets and pillows, and to keep her bed constantly 
wet. This can only be the cerebro-spiiial fluid, and its point 
of exit must be the prolong-^tion of the dura ni^tcr which cov- 
ered the spinal nerve as it letl the caual, aud which sheath must 
have been 0[>ened in the u]ieratiun. It is probably iucruHscd in 
quantity by the spinal nieuingitis, froiu which she is evidently 

[nffcring. She suit'crg greatly &om pain, constant in the head, 
mij^ratory in tlic trunk and limbs, and also from threat aorcnesa 
and sensitiveness of the suilJice, sometimes in one region and 
lometjmes in another, which makes it verj- painful and difficult 
for ber to move, or to be moved. She was now kept systemati- 
cally under the full influence of i[ior[ihiiie, of whicJi slic took, 

lliowever, only a moderate quantity, say fivu to ten droits every 
four hours. 

/•'ei/ruary 2rf. — Still Bufl'ering greatly. C^miplains of a eon- 
BtantseneAtinn of fatigue; rsnnol. iKuir any light or noise. Tliia 
evening, in consequence of changing her position, violent eon- 
tractions of the left leg, with excessive pain, were produced, 
recurring at intervals during the night. The watery discharge 
very abundant, 

^«bruary 4th, — A Ijctter night, and general improvement. 
Can uae all her limbs more freely, and can almost turn over in 
1}ed alone. Cannot raise the bead and shoulders, by bending the 
q>ine, without giving severe pain in left leg. From this time 
improvement went on ateadily for a few days, and was then 
intemipted by a severe attack of headache, and pain in the 
back and limbs, with some fever. This subsided in a few days, 
and similar attacks recurred several times, at intervals of sk week 
or ten days, each attack becoming lees severe, and in the inter- 
val a greater improvcTnent being attained. The ccrcbro- spinal 

'fluid continued to trickle away till toward, the end of I'ebru- 
ftrr, when it ceas^cd for a few days, to begiu again as freely aa 

r«rer. About the lir&t of March it ceased agaiu, aud Anally. 

le 



7li 



TCUORS or BOSK. 



Ko apparent connection could bo traced 1>otwccn tbe flow and 
any ot" lier Bvinptcims. 

By tiiB lirst of Miirch the paralysis Imd pretty oiDub disap- 
peared in every part of the body. There was still some stiff- 
nesa in muving the fingcra, and boqic want of precision in 
taking hold of (tmnll ubJc*ci.B, but banHy more than eonld be 
ancountcd for by the long disuBe of the mnatOcs. On tlic llth 
of March she was carried down-stains to dinner, and on the IRth 
took a diive of thrce-^juartcrs of an hour. Slie is quite tbin, 
but free from pain, cats well, and deeps with the help of • 
grain-pill of opium. 

JUay }»t. — Mrs. E. called at my office to say that tjie wount^^ 
had entirely healed over the tent, which on examination I foun^| 
to be the case. There is no swelling or tenderness about the 
cicatrix, and I advised tbnt the tent be leH' undisturbed, bh^^ 
ia perfectly well, fining flesh and appearance, no symptom o^| 
paralysis remnininrj, excepting tliHt the limbs get aelccp more 
easily than in health. She walks, rides, sews, and docs every 
thing tliat she over did with a rapidly-increasing tacility and 
perfection. Menstruation is regular, as also the action of the 
bowels. The old symptoms of fissure give her bat Uttle incoz 
venience. ApjMjtite and digestion perfect. 

Jamiaiy, 1872. — Mrs. E. continues perfectly well. 

The proportion of cases in which recurrence tak^a pli 
after operation has been carefully studied by Lebert He gives 
an account of elxty-tbree cases, situated in all parts of the body, 
in which operation had been performed, of which thirteen cases 
were followed by one or more recurrences. Of these thirtocot 
six were instances in which tlie operation had been imjierfeti^B 
iVoni the situation of tlic tumor, or from its extent, and i^™ 
which, therefore, it might bo inferred that the return of the 
growth was only a continuation of Its former existence, rather 
than a now formation. Of the remainder, two were somewh 
mixed in their ehflractcr, or doubtfiil as to their nature ; Icivin. 
out of sixty-three cases operated on, only ilve frank, oncqaiv 
cal relapses after complete ablation of the original tumo: 
None of these five, however, were tumors of the bone. Of 
course, such statistics as these can be of httle value in settling 
the actwil proportion of recurrences to permanent cures, be- 






er 

I 




FIBBOrS TUMOBS. 



S7S 



csnse the element of time is necessarily imporfcctlj Btatod in 
tbe alcnlation. How manj of these patienta would have had 
a return of the disease, if long;er time had been given to the 
observation, cannot of course be ascertained. But, nevertho- 
lefts, the statement is of interest, as giving n general idea of 
how frequent recurrence is within a few yoara of the time of 
operation, and it is fair to iio^w that a relapwj so long delayed 
indicates a permanent cure in a good proportion of cases — tliis 
hope strengthening with every year of freedom from the signs 
of return. Kouie of LelicTt'ii I'ascs had boon under observation 
for a long periuJ after operation. Three ])atient8 lie speaks of 
whom he had watched for periods varying from twelve to fifteen 
years. He also gives tlic duration of thirty-five cases where 
the disease had been observed from its beginning to its termi- 
Bation, either in operation or death, which he thus tabulatt»: 

Existing from 1 to S yean in S enaea. 

" 2 10 8 " iQ " 

" " 8 to ■* " in B *' 

" * to 6 *' in 4 " 

» " S 10 a *« to 4 " 

" for e Toara In I osM. 

" " 10 " in 8 COM*. 

" " 12 " hi 1 raso, 

" •* 16 " in 2 cttM^ 

' " " 18 " lO I CMC. 

" " 20 " in 8 CUM. 

" ovtr 20 " in 1 aiw. 

as 

VTith regard to the comparfltive frequency of generalization 
of the disease, he does not attempt any ttatisticul statement, and 
I have met with none in any other writer, lie simply states tliat 
be has known of seven cases, of which he gives mure ur less 
ftill details, from his own obsenation, and tlmt of others. Of 
thete aeven, only two were hone-tumors, one of the bones of the 
knee^ and one cf the hones of the tarsus. 



216 



TCUORS OF BOXE. 



CHAPTER IT. 



VTBLOID TUUORS. 



TwB name of mycloiil (marrow-like) was given by Mr, Pa? 
get to a class of tuiuorB which present as their principal ana- 
tomical constituents the elements of the medulla or mantiw of 
the bones. The English writt-rs generally accept this name for 
a claes of diseivses wliich has a most nneqnivocal chamcter, and 
which seems to be as well marked and as distinctire as the car- 
tilaginous or the bony class uf tumore. The French writere, 
followiiig M. EngLMie Nelaton, prefer the clumsy tenu of <w- 
meur mt/ehpl^ixu/ue, or funieur d mt/eloplaxes. To Kobln 
aeems to be due the credit of baring fir&t made the distinction 
of a certain claM of tumors wliose principal elements cousin 
of the elements of the normal medulla. In the Comptea 
dii6 of the Soci6t^ de Biolo^ie for October, IS49, M. Robing 
after giving an account of certain anatomical elementfl of 
normal medulla, goes on to state that these elements arc some- 
times fonnd to be the sole constituents of certain tumors; of 
which tumora he then proceeds to give some description, am 
ends his communication by again calling attention to the 
that these tumorg are comjwsed ee&ontially of an aj^egatioi 
of these peculiar elements of the marrow, which he now 
the first time brings to the notice of the society. M. l^bert 
had already noticed that certain tumors, heretofore deemed 
canccroufl, did not show the clinical history of cancer, and 
these he had placed in a new ckss, calling tbom, from their 
histological elements, fibro-plastic t«mor«. Among these were 
many which had the peculiar marrow-like cells in great abun- 
diince, but these Lobi-'rt does not allude to as distinctive ; and it 
was nut till Uuhin dt>sc-ribed them as the c-ouelitucnt elements 
of the normal niiirrow, that their significance was understood. 
Robin immediately recognized these new elements as the aame 
found ia the tumors which be and Lehert, it would seem, bad 
seen together; and to him, therefore, and not at all to Lebci 
behmgs tlie credit of the discovery. Some confusion lias thi 
arisen, and a proper discrimination has not always been mads 



MTTLOID TTHORS. 



«» 



ktwecn the two classes of disDaaoB, vir_, the tumors composed 
of fibro-plastie cp\h, and those roniposed of marrow-like coIIb. 
Mr. Paget, usually m accuraU', has tiillen somewhat into tliia 
confusion, and describes the myeloid tumor and the fibro-plastic 
as if they were one, while tbe fact is, they are as different in 
their anatomical contttitutiun as boue and cartilage or any other 
two claseee of tumors. It ib true that the fihro-plastic clcmciitt 
are Bometiroea mingled with the true myeloid, hut this is true 
of all other clashes of tumors, and docs not forbid a discrimina- 
tion where one or otlier element very greatly prudominateB. 

And here, |H*rha])8, Uie intert'Bt whit-li at the present time 
attaches to the etthject may jutttify a Bketeh of the normal c-on- 
BtJtuent of the marrow, the presence of which, in ^catcr or leas 
abundance, gives the character to the clnss of tumors which we 
are dcBcribing. I know of no deficriptioTi bo minute and com- 
plete aa that of M. E. Kelaton, who has publiJihed an elaborate 
thesis on this subject, founded on tlie careful observation and 
study of forty-seven caij<es, nine of which came under his own 
eye. He says, in sjjeaking of the normal marrow-celle (myclo- 
plaxcs), that tlicy exist in all the vertebrata and at all ages; but 
they form only a small part of the wholo medullary snbelanee. 
They are found more eafiily in the fwtiis, and in very young 
snbjccte, because they are not obscured by the adipose develop- 
ment which predomijiatos in later years. Their favorite situa- 
tion is close to the bone-siirfaces rather than in the midst of the 
marrow, and they are also sometimes seen in the Haversian 
canab. Their form is variable. They may be round, oval, tri- 
angular, elongated, hour-glass-ehaped, or cun"ed on theineelves. 
Their almost imifomi tendency is to be flat ; so much so as 
to give theni the character of plates {plmpte^) rather than of 
masses. Their (limeneionB aro as variable as tlieir fitrms, ex- 
tending from 0'" '" 03 to 0'" '" 08 or 0"' '" 10. Their thiek- 
nesB is from ono-<piartcr to nne-Iialf their breadtli, and some 
are seen no larger tluin blood-globules. Their color is grayish, 
iomctimes a little yellowish. 

^Vith regard to dieir structure, they seem to be composed 
of a homogeneous maea without color, uniformly pervaded by 
very fine grayish granules, soluble in acetic acid, and mingled 
wmetimes with granules of a yellow tint In the thickness of 



878 



TtlliORS 01 



tLU stroma exista a number of naclci, ovoid and transparenl 
and containing one and sometimes two nucleoli. The number 
of nuclei varies from five to fii^een ordinarily, in exceptional 
cflses from one to aixty. They are irregularly distribnte«l 
through the maae of tho plate, but are nsually acctunolated *l^m 
or near the centre. ^| 

A second variety of tlicse medullary bodies differs from 
that described, in eeveral particulrtrs. They are smaller, more 
regular in size and shape, not flat, but round or oval. They 
have one or two and aoinotinics no nuclei, which, when they 
exiaij are ovoid in ehapc, and have a diatinet nudcolus. They 
are usually leas numeroiia than the larger llat plates, and, being 
amaller, are leaa easily found. In other respects their atracturo 
eorresponda witli the lar^ platea. 

These anatomical elements had been seen by acvoral ob- 
servers in certain tumors which tliey were engaged in studying, 
but their character was mieinterpreted, simply because the key 
to (heir explanation had not been supplied, ae it afterward was 
by Robin's discovery of these ]>cculiar bodie*} as nomial ele- 
ments of the marrow. Thus M. Lebert, seeing these myelo- 
plaxcs scattered through some of the tumors he had named 
fibro-plastic, enihraccd tho notion that they wore parent-cells 
out of which were generated the fibro-plastic cells of which the 
tumor was eesentinlly composed. UntJer this view he gave 
them tho name of fbro-plattk inotfier-c^Is, thus ranging them 
very easily uuder his favorite theory of the formation of the 
fibro-plnstic elements. 8ucb erroneous views of the significance 
of these bodies are now happily corrected by M. Robin's dis- 
covery, and all the authorities agree in accepting it as the satijs- 
factory solution of the vexed problem. It will readily be per- 
ceived how much importance this study of the microscopic 
characters of these tumors has in settling the important ques- 
tion of their homologous or heterologous chnractcr; and it is 
eminently satisfactory to find that, in tumors of a manifestly 
benign character, the elements which heretofore have been con- 
sidered at least doubtful, have now been ranged positively un- 
der the head of the normal constituouts of the body. Still 
further, it seems very much in accordance with the rt^ihirit^^| 
of true science that this discovery completes our catalogue o^^ 




MTELOID TUMORSL 



979 



'"tlie homologous bone-diaoa«c8, giving m the tumors composed 
■of the t'lenienta of cartilage, of bone, of tlio tibrous tissue of 
tihe perii->stemn, and of the modullft, all of which we might ex- 

B2>6ct to belong, and all of which we find to belong, to the class 
of benign nlleL-tioQS. 

On this point, which, after aD, is the most interesting and 

Bamportant one coiinoctod witli tlio Btudy of the diB&ise, the 

^BMtimony of the best obsci-vcr^ is iinKei;itating and iiniform. 

^^Sr. Paget's whole cliaptL-r oo Mj,'floid Tumoi-a is devoted to 
show that, as a general rule, they are benign in. tlioir nature, 
and that, if thoronghly removed, tlie likelihood of their return 
is extremely sniaU. N61aton says: "The 'tumours 4 myulo- 
plaxes' (efipccially tliose of the typical variety) deserve, in 
■virtue of their habitual localization, and almost to tlie same 
degree ae the hix>ma8, the tibri>mas, and the cu chondromas, to 
b© classed among the benign tumore.*' Virchow, while ho is 
not willing to acknowledge the myeloid as generally benignant, 
gives no case of hia own in which well-marked myeloid disease 
iiOB been accompanied with generalization, and says in diseusa- 
ing the value of the diflercnt anflhmucal elements of sarcoma: 
"The SIM of the cells is not without importance. All the 
sarcomata with small cells are more dungeroua than those with 

(large cells. The soft sarcomata with the gigantic multinuclear 
cells g;ive even a prognostic comparatively very favorahle." If 
'to this be added his avowal of the almost uniform benignity of 
the myeloid epulis, and of the tumors of the jaws in general, 
"we may aeeept him as an unwilling but a strong witnosa to the 
^^neral ]>atliologii>al law that myeloid tumors are ossoatially 
■ l)cnignauL Billroth says: *^ Central osteo-t^arcDinata (myeloid 
tninorsi are usually solitary, very rari'ly gcueraily infections.*' 
Cornil and Rativier say: "Among the uiyeloid sarcomata those 
■which resemble absolutely the marrow of the bonca are more 
l>enign than thofic in which wo find parts representing the tis- 
sue of the enccpbaloid or faaciculnled sarcoma. It is ci^scntial 
H to note these complications and their value in prognosis, which 
■vrill exphiin why, for example, the tumors, which some authors 
etUl call 'tumour a myeloplaxes,' may not be always regarded 
cw benign." 

Tbe occasional malignity of myeloid growths has been 




280 



■nmoBs OP DoxR 



«nP 



frankly admitted, both by Mr. Pn^et and Eugftuc TfiUat 
and it is unfortunately illustrated in the experience of ev« 
Burgeon who dealfl with many of the»o interesting tuinai 
N^Uton fteeraa to be the special apologist for bcnigiiity of the 
myeloid dieeafee, while VircUow, though hardly acknowledgiug 
the fact of its usual benignity, allude* to several examples in 
which the diisc-ase ha« terminated life, with all the malignant 
characters whieli we generally regard as characterizing the 
worst forms of cnucer. He gives no case of his own, however. 
One of the earliest cases reported in New York was one of a 
tumor of the lower end of the humerus, in which the microHoop- 
ical appearnnces were carefully ob9er\-etl by Dr. IT. B. Snndfl, 
and were unequivocally myeloid. This patient wa* amputated 
by 1^1'. Sands, and made a very satisfiictory and appareni 
perfect cure. He rcuiaiued well for at Itast two yean, ai 
then a return of the affection tfccurred, of which he finally died. 
I rcgi-et tliiit I am not ahio to get any particulars of the relapse. 
Mr. J*agct recounts two cases, one by Mr. Stanley, and one by 
Mr. Ijiurencc, in which after removal the disease returned in 
(lislant parta, and jiroved fatal. Mr. Mitchill Henr}-, Mr. Coop«r 
Foster, Drs. Cock and Wilkes, have each given a record of one 
or more casca in which fatil metastasis has occurred after rfr 
moval, and in which the recurrent tumor has been shown ^| 
the micruecopG to be of the same nature as the ori^al growto? 
If to thi^se cases we add those in whinh, after eomplcto eatir wfc- 
tion, the disease is reproduced in ?ow, wo are forced to ackno^H 
wlge tlmt the myijUiid tumor shows, in certain ca^oa, « character 
of iiiveteriicy and malignancy which must always be taken into 
the account in making our prognosis. Nevertheless, we ^M 
warranted, from the more kindly behavior of the grent jiropor- 
tion of the canes, in regarding the myeloid as an cascntially be- 
nignant affection — one in which, aa stated above, a thorongh 
extirpation, if performed early, gives a good hope of a perfect 
cure, and one In wliich the evil course and malignant termina- 
tion are rare and exceptional, tliu» bringing, by the bad bo- 
liavior of a few members, a certain amount of discredit on 
Othorwifio well-behaved and reputable family. 

A feet which Boema to stand alone in connection with 
tnmors is their occasional spontaneous disappearance. Mr. Pi- 






HTELon) TtnioRa 



261 



get, in giving an account of one of Mr. Stanley's caeea, mentions 
that the patient, from whom tlio right upper Jaw was removed 
for mjeloiU liieeiitie, hiid u siuiilar ttiionr on the left jaw iitid on 
the parietal bones. He Bays: ''The patient recovered perfectly 
from the ctJ'ects of the operation; and, to even,' one's surprifie, 
the tumor on the left iipjicr jaw, wliich had been in all rcspccta 
like that removed fhtin the right eide, gnulually ilitiappeared. 
It underwent no change of textnre, but simply aubeided. The 

rVn'dlings on the pariftal bones, also, the nature of which wag 
)t aecortained, cleared awaj- ; and when the patient wft» last 
seen, a few months ago, she appeared completely well, and no 
swelling could be obBerved." This dis:ippearance, by spouta- 
neous Kub6idence, lins been occaEionally observed in tumors of 
lie soft parts ; and even cancerous di&en&c h&e, in rare instances, 
m apparently absorbed and removed, a& illnetrated in a cnse 
alluded to under the nialignant diKeai^cs of bone ; but this dis- 
appearance of tumors fonnod in the bones is, I believe, ex* 

^tremely nncommon. 

The myeloid tumors, like the oki^cous and cartilaginou*, most 
Commonly affect the bones, yet, like them, occasionally are 
found growing independent of them, Tlie alveoJ.ir portions of 
the upper and lower jaw aeem to be their favorite avat, but they 
also occur in tlio head of the tibia, in the condyles of the femur, 
ul more rarely in other bones which contain a largo pn»por- 
Mon of inedullari,' or cancellous tissue, fig. 75 is taken from 
?aget, and represents a myeloid tumor of which he gives n very 
interesting history. It showa the growth of the rnaas both ex- 
ternally and internally from the bones of the vault of the crani- 
nn. It produced death by pressure on the brain. They some- 
times grow from the surface, often from the interior of the Iwnea, 
not onfrequently in the medullary canal itself, when it isome- 
titnes happens that the line of demarcation between the sound 
medulla and the morbid growth cannot lie at first sight recog- 
nized. These tumors arc naually single, ocoasionally multiple 
OB the same bone, with a smootli, rounded anrface, projecting 
equally in all directions from t!ieir base of attai^bmcnt, when 
tliey grow from the surface of the bone. Their Bidwtanco varies 
from a iirm, almost cartilaginous consistence, down to a softncsB 

^4qtul to that of fresh granulations. Their color is remarkable. 



88S 



TDUOBS OF BONB. 



Somotimcs the wliolo cut surface proscnts a deep, ruddy li 
often eveu a diirkisli brown. PerhapK more commonly a piiikif 
or a grecnUh tint pcn'adea the whulo mass, though varying in 
dopth at ditTeront points. Int«rspersed through the tunior arc 
spots or blotdtes of deep red or brown color, liK)king as if 



irK)r:: 



r - 



tmvasntion of blood Had taken jilaco from email mptnrcd r»- 
Bcla. These colorations of the tumor are the most utrijcing and 
cliaraeteristic features to the naked eye, but the microscopiod 
examination gives still more distinfitive characters. ^M 

Tims we find tbe whole tumor made up of tho elemenlH 
irhieh normally oxist in the mednlta. Mr. Paget thus dcEcribca 
them: 1. "Cells of oval, lanceoUte, or angular chapes, or eloaoy 
gated and dttonnatod like fibre-cells, or caudate cells, having" 
djmly-flnitcd contents, with single nuclei or nucleoli. 2. Frr:^ 
nuclei, ench as may hare escaped from the celts; and amoi^| 
these somo tliat appear enlarged and elliptical, or Torions^^ 
angular, or are elongated t-nvard the same sbapcs as the lance^^ 
late and canclate cells, and seem as If they were assuiuiug ^^M 
charaetcrs of cells. 3. The most peculiar form : large, roun^^ 
oval, or flask-shaped, or irrp^dar cells and cctl-like niaasea or 
thin disks, of clear or dimly-granular Rnbutance, meaanring from 
■s4ir *o tAt of an inch in dinmeter, and contnining from two to 
ten or more oval, clear, and nucleolated nuclei. Corpuscles sudi 
as these, irregularly, and in diverse proportions, embedded in i 



HTXLOID TUMORS. 



SB8 



dimty-granular substance, make up the m&sa of a mjeloid tnmor. 
They may t>c mingled with mulccuhir, (aity matter ; ur the mass 
ihey compose may be traversed with filaments, or with bnndlca 
ot coonectivo tiasue and blood-resaclB ; but their csscntini fea- 
tnres (and espotially tliose of the many-nuslcated corpiweles) are 
rarely obdcitred." Figa. 76, 77 show the appearance ol these 
nrious cells. 

M. E. N^laton, in describing the inicroBcopic characters of 
,liieae tumors, says they are composud — " 1. Of a great (quantity 



'«£»> 



f*. 



^'. ,; 



r^.o 



fta. m— <nMi Cornll «iiil BauTicr, *fldr Tlnboi*,) 

'•iiyeloplaxcs, the fundamental elements which, by their pre- 

. ,**^"'™cc, characterize the ikmc. 3. Of certain acceasory 

[j^**icnt*, such as fibrmis or tihrn-pkati(! cells, nmorpbona mat- 

ioT-' '**^^'*^^'' grannlea, fatty granules, free nncloi, eomo mednl- 

^^l«,sonie L-apillary blood-vessels; besides these the micro- 

"^pecan distinguish in the preparation a certain number of 

■ "^^lod-globulcB, fiometimcs coloring-mtittor in a free state, and 




no. n.— (^^<™ ('o"!^ "^ BBfiw^ 

It wonld 6ccm as if there exi?tecl a pretiy well-marinll 
tion betwci>n the var>-in^ proportion of tUcse elements tnfl ' 
pTiysical qnalit3<>B of tlio tnmnr. Thus, in thoBc spopimcnK wbcrt 
t>ie fihroiis or fibro-pkstir eleirientfl ahonnd, the parencliTin* 
of the tnmor is firmer; where the marr(iw-<'«IlB are grefttlTprf- 
dominaTit, the tnmor ic fmfter ; wi soft as eometimea to be alniort 
ft diffluent pulp. In tlio «anie way the color seems, from tbf 
ohsen-atioiie of EniK'iie N^-laton, to depend npon the pro(>ortiflii 
of the marrow-cells to the other constituents; these nuuro'- 



MTELOID TUVORSl 



380 



eellB, accordiop: to him, possessing the peculiar intrinsic color 
firhich marks tliese tumors, and this entirely independent of 
^Wood cither contained in the vesiicla, or extra vftsa ted. 

The history of myeloid tumors is generally one of slow and 

painle^^ growth. Most commonly originating from no apprecia- 

■ ble caaec, their increase is regulated souiowhal by their situa- 
tion, those within tlie bones developing more slowly, those on 
' the Burlaco, tike the myeloid epulis, having a more rapid course. 
They are tar more coniinou in youth and erirly life tlian after 
middle age. They show comparatively little disposition to 
niceratc, even when injured, or when vcrj' large. The most 
interesting feature in tlicir histor}* is their almost uniform bo- 
nignancj. It is true, several cases have been observed of tu- 

■ mom in which myeloid elements have cxistod, sometimes pretty 
lai^ly, which have proved fatal, and many have occun-ed in 
which the myeloid and cancerous elements have been found 
intenningled in the same tumor. It is also true, as stateil at 
page 280, that some inst^mces have been observed, in whic-h b 
true metastasis and generalization of myeloid disease have taken 
place; but the general pathological fact remains incontestable, 
that myeloid tumors, as a class, have uaiuilly none of the L-harac- 
teristica of malignancy, and that, when completely removed, wo 
may with confidence pronounce that they will not rctnni. A 
partial or imperfect removal is certain to be followed by a repro- 
duction of the disease, and hence it becomes a study of much 
importance to ascertain the physical relation of these tumors to 
the parts within which or upon which they gnriw. Unfortu- 
nately, it is found, by cartifiil uxamiiiation, tliat tlieso growths 
have a great propenaity to puah themselves in every direction, and 
oAen, by prolongations, bo slender as to eseape notice, to invade 
the surrounding areolar hone-apacca, or ca>'ities, stretching thera- 
idves lilce rootA, aomc distance from the original mass. Tliis is 
markedly the case with those developed in the alveolar tissno 
of the jaws, where several successive alveoli have been found to 
contain small outgrowths troia a tumor, whose general mass waa 
apparently cutircly indepciulcnt of and at some distance from 
them. AgaiUf small outlying tumora have been noticed imme- 
diately iu the neighborhood of the principal nmss, some so small 
: as scarcely to be identified, certain to bo overlooked during on 



986 



TCMOES OF B0N8. 



operation, and onl^f to bo found by a careful Anatomical exnarji- 
nation. Once more : though these tumors have gcnerallj an 
outline eo distinct, and a 6urfa<^ 6o lightly adherent to the sor- 
rounding parts, that they are in fact readily enucleable, yet ce^ 
tain 0)108 aru so diiweniinRtcd through tlie tistiuo in vhieh (hey 
form that thoy might almost be olasstHl among the infilfnitiMis, 
rather tlian as tumors properly bo called, and therefore bare id 
outline which cannot be accurately followed by the eve, niucli 
less by the knife of the operator. AH these are consideralioM 
which, while Uioy do not aftcet the real benignity of the distttt, 
make it a matter of prime importance that no operation ahmW 
be undertaken, or deemed satisfactory, which does not ahwlntelj" 
secnre the entire ablation of the disease. 

The development of cysta in these tumors ig a fact so fre- 
quently notit-ed as to entitle it to belong to the hietorj- of tlie 
diseaae. ThiB fenture is most prominently brought tonrtrd 
by Mr. Henry Gray, In bis paper on "Myeloid and Myciorrstic 
Tumors of Bone," in the tliirty-nintb volume of the "MeJiw- 
Chinir^ical Trnnsnctions ;" but NiSlaton, and indeed all Ih* 
write™, acknowledge their very great ftequenc^. TheeccritB 
are of vanous forms and sizes, Bometimcs as large as a hen's^i 
with very distinct, smooth, polished wails, as if lined by stiwib 
membrane; often bo small as ecarecly to be discerned bT tfie 
naked eye. Somctimca they have no clcnrly-marked wall,bnt 
seem to be mere cavities, hollowed out in t3ie substance of iIm 
tumor, and all conditions intermediate between theee havebwn 
Bcun in tho eamc growth. Their contents are usually redcUA 
or brownish Bcniin, Konietimes transparent, often muddy, SoA 
Butnetinies mere fluid or semifluid blood, and this pnrticululT 
in those irrt^gnlar and i!l-<iefiucd cnvities whieh Imrdly ought I* 
be called cyBtts, and yet which form a very important featowrf 
the discjise. 

There secmB to be no Tcry marked tendency in these 
toward ossification, and yet a certain amonnt of bone is 
produced in the progress of their g:rowth. This bone is •odM' 
times found in irregular plates of various sizes, but not nnftfr 
qucutly it pen-ades the mass, with some uniformity, in the shApe 
of a delicate framework, more or lens perfect, giving a corUin 
feeling of firmness and solidity (o the tumor when lightly 



irrxLoiD TCHORa 



SB? 



died, but giving wsy with a. peculiar crackling feci when firmer 
pressure h made. The abcU of thiu bone, in which these tu- 
mors are often enclosed, belongs entirely to the original bone, 
and ha& no other rcktiou to the tumor than that of cnelotting it. 

Ai An illastration of the luAtorj', but}i piithological and clini- 
cal, of the«o tumors, I know of none more compliCte And more 
carctbUy observed than the following, which I condense from 
Kelatoo's paper : 

Pierre liossuge, aged twenty, camo nndor M. N(51aton'8 car« 
in April, 1856. lie had uuticed, about Boven inuntlis previous, 
a small, indolent tumor, deeply Hitiuited on the face, just at the 
side of the nose. This had j^adually inereoscd, prcsaing upward 
toward the orbit, and inward toward tho nasal cavity. At the 
time of admission, the tumor had gft.ine<l the size of a pigeon's 
egg, hard at it« base, which was evidently in the substance of 
the lower jaw, and more yielding at its more prominent sur- 
I iaco. It had beou punctured with a lancet some time previous, 
but only ft few drops of blood had iluwed out. The integumeuts 
sod surrounding tissues wera sound, and tho man was iu & good 
condition of general health. 

M. N6kton operated oti tho tumor on the S-ld. Ho made 
an inciflioD into lliu tumor throng the mouth, and then broke 
ap and removed piecemeal all of the diseased mass which he 
could get away in this manner; and then with the liot iron 
burned very thoroughly in every direction the cavity which he 
had thus left. A moderate suppuration followed, and a gradual 
healing, so that the cure appeared to bo complete. On tho 20th 
of November, however, the man again prcacutod himself with 
a reproduction of tho tumor, which liad iiuw attained a greater 
size tlian before. It pressed far in upon the nostril, and ex- 
tended back 60 as to be felt in the fauces. The tumor also now 
for the first time gave him some pnin. 

On the .Id of December, the whole superior msxillflry bone 
'was removed on the left side, embracing, as was thought, every 
portion of the tumor. The case went on favorably, and he was 
discharged cured early in January. 

Tho examlnatLon of the pieces removed in the first opera- 
tion ahowod A reddish, friable substance, much like the sab- 
stanoe of the kidney or like a lung in a state of red hepatisa- 



888 



TUMORS OF BOHR 



tion. M. Robin mndo the inicrosf>opic examination, and found 
it almost entirely formed of mvcloplaxes, with some amorphous 
granular matter, some fibroplastic cells, and a very aligbt 
fibroiu net-work, witli a few blood-vessels. Tlie tomor exam* 
ined, aflier the reuiovat of the jaw, was about tlie size of a large 
ben's 0^. It was situated in the subtstanee of the jaw, ea- 
croaching npon and alnioEt obliterating the antram. A section 
displayed a iimi clastic substance, rceombling the tissue of the 
heart, or of the foetal liver, or of a kidney in a Etatc of active 
congestion. Its color, therefore, was a reddish brown, pretty 
uniform in all of its parts. In making the section, the scalpel 
eucouiitei-ed some slender osseous fibres penetrating the nusa 
in various directions. Several email cysts were scattered 
through its substance, containing only bloody scrum. The 
mtcroscopicul constitution of the diseased tis6ue was again 
studied by M. Robin. Ue found it "au exaggerated multipli- 
cation t)f the special elements of the marrow of the bones, tliat 
is to say, plates with many nuclei, i. e., myeloplaxcs bound to- 
gether by very delicate fibroplastic elements, a few laminated 
fibres, a cci-tain amoont of amorphous matter, and some eapil* 
lary vessels ; these last clcracnta appeared in rather larger pro- 
portion than in the first piev^es examined. The vascular ele- 
ment, however, plays evidently a very secondary part, for it is 
less developed tlum in certain whitish or slightly rose-tinted 
tumors, conBidercd as types of cncephaloid, which were exam- 
ined by way of com]mrison." The cure Hfter tliia second oi>era- 
tion was rapid and satisfactory. More than three years after, 
the patient was seeu and examined by M. Nelatou, and found_ 
free from any suspicion of a return of the malady. 



CHAPTER V. 

TVUXTKQ TUMORS OV BOKZ. 



A nisTraCT pulsation is noticed in some tumors of bone, 
the cause of wliich is, in difFcrent cases, to bo traced to differ—^ 
ent pathological conditions. Thus some of these pulsating^ 
tumors lie in such relations to a lai^ artery that its polaatioi 



nnsATiKa tttmorb op bonbl 



98fl 



are communldUad to the tumor. In other caacb there Is either 

such an ftbwtidant or eudi a jieciiliftr vAscular iirranfjenicnt 
through the sultstanue of a lumur, tliat its own circulutiuii givea 
■ il «n evident and sensible pulsation. It ia clear, thcrctbro, 
tliat the mere fact of pulsation existing in n tnraor cannot give 
it any Bpeeitie anatomical oliai-arter, or really entitle it to be 
considered as belonging to a cht» of ita own. The symptom is 
to atiilciug, however, it« discriniinntion so importnnt, and its 
bearing upon ]>nicticc eo direct, tbat mot^t writcra on the eubjoct 
bare given tlie tumors which are cUarRL-terised by It a f)C[)arato 
place iu Elidr caLilogue. It Eccitis strange that &u atrihing a 
feature bad not earlier attracted attention, but the tirat distinct 
occcmnt of n pulsating tumor of bone was one publiahod by 

r Pearson, of London, in 1790, Since attention hii3 been called 
to it-, numerous caws have been published, and wo are now quite 
familiar with the general facts which characterize these pulsating 
growlhg, 
H There arc three conditions recognized && producing pulsa- 
|V tion in bune-lumors. These are: I. The proximity uf a large 
artery which imparts its own pulsation to the swelling; 2. The 
Uisproportinnato development and activity of the vessels of the 
tumor it^eU"; 3. A peculiar arrangement of blood-cavitioa or 
B blood-spaces in the tumor, which comniunicate M-ith the vessels, 
and wbicli give the structure a close resemblance to the natural 
structure of the corpus cavemosum penis. 

Of the fii-st variety, numerous instances are recorded. Mr. 
iley gives the following : " A man, aged sixty-eight, suffered 
severe fiills upon the shoulder. Subsequently .in eulurgo- 
ment of the jmrt ensued, with pulsation in it. The tumor was 
considered lo be an ancuriflin, and the subclavian artery was 
tied. Three weeks after the ojicnition the paliciit wiiik. Tlio 
tnmur was found to he a mass of medullary substance, t-<j which 
the axillary nrtery firmly adhered, the vessel itseU' being per- 
fectly sounil.'' Mr. Stanley alludes to six other cases which 
had come to Ms knowledge. Of those six eases two were ia 
the upper part of the luimcnis. one in the h>wcr part of the 
femur, one in the head of the tibia, and two in the lower ex- 
treniity of the tibia. In all the disease had been supposed to 
be aneurism. 





< 



TTVORS or BOXE. 



Of the eccrond form, thoee in which the pulsation is depend* 
ont u|>oii unusual development of vcseuU in the ii^irt, wc luive 
perhaps the be«t examples in the very vascular cncephalaid tu- 
moFK which are Bometiines de\'Gloped on or in ilic s]iod^v ex- 
tremities of the long Ix^vea. Other forms of soil and rapidly- 
growing tnmors may be accompanied vrith pnlmtion, but no 
class of tumors is so nbnndantly supplied with vessels as the 
onccplialoid, find none so often present this particular sj-mptom. 
Indeed, ro decided is this afwieiation, that pulsation in a bone- 
tamor has come to be looked upon with uiach suspicion, as being 
extremely likely to depend upon the existence of eneephaloid 
disease. Mr. Paget romarkE: ^*1 think that, in many of the 
cases which iiave gnined for erccllle tumors their ill repute, a 
clearer cxHmiiiatioii would liavo proved tlmt tliey were, from 
the beginning, very vascular nie<lullary cancers, or else medul- 
lary caneora in which blood-cysts were abundimtly formod." 
The vesRolfl in those cases are sometimes eice?*iive, mcrelv in 
number and nixe, ncit in other respects diifcring from the healthy 
formation ; while in others they arc enlarged irregularly, torta- 
ous, varicottc, thinned in their coats, or thickened at points ; in 
short, they may be in vanuus ways auJ degrees dlecaGed, as 
well ttB excessively developed. The amount and diatlnetneeB 
of the pulsation will of counw depend upon thcao anatomical 
fHindttions of the vessels. If they l>e merely increased in nnm> 
her and size, utill continuing healthy in their stmctnre, I can 
harvjly suppose that the pulsation can ever V more than an in- 
crease of the ordinary arterial throbbing, tlial can be ubsen-ed 
in every very vascular part, when it ia comi)rc88ed slightly bv 
the hand. If, on the other hand, the vessels be very nuiirfa 
dilated in the tumor, over the cnlibro of the [wirent trunk iK>m 
which its circulation is derived, and particularly if tliis dilatation 
be irregular and i>oijch-Uko at mnuy jwiuis, then wo have, in 
obedience tc) w«ll-kn»wn hydraulic Lhws, the conditions of a 
pulsation, which is sometimes so distinct and so povrcrfnl as 
very naturally to lend to the auspicion that our bone-tumor is 
an aneurism — n. mistake which has been made in a number of 
instances by excellent and careful surgeons. 

The third form of pulsating timior of bone, viz., that in 
which something like a true, cavernous, erectile tissue is formed 



PULSATING TUMOBS OF BONE. 



'291 



ttirongb the mass of the gruwth, iis much more rare. MM. Corail 

and Kanrier, in their admirable Manuel tT Jlititoiogie J^atlt^o- 

jr*y«#, give the Ibllowing description of thisftinnation : "Thelis- 

sne 18 lioUowwl out into Jilvcoli, cominunicaiing in a very Irregu- 
llar nmnDer with each other, very mncb in the same way A9 do 
Ittie alvi-'oli of cftrt-iiioma. The hlood eirculAtcfl in this cavernous 

System, which ot-eupiee the jilaoe of the capillary Byetein, sitn- 

&t(3<l m it is between the arteries and the veins. The drt-ulation 
through the«? cAvitie« ie extremely active." Tliey fiirtlier de- 
Bifibe the walls of the alveoH at; (•i)ni|«ino(.i of ft wi*ll-iuiirkcd 
flbmiu tliteiue, mid lined iutenially by a pavement epitbeEinm, 
eimilsr to tbftt which linos the veinB. A curious fact is also 
noted by these observers — that tbo blood in tlwso cavcmous 
spuces conUia^ very few of the colorless blood-glohulee. As 
these are knoi^Ti, by their adhesivenciiB to the walls of the ves- 
•ela, to present a cerLiiu amount of tnipefLinient to the natural 
circnlation of the Wood, it ifl ar^ied that their comparative fow- 
ftess makes the cimilatioii more active, and the pulsation there- 
fcro more mnrked than it would 
'» under the ordinnry circum- 
*t*»nce8 of the uircidation. Tho 
•^asooiog eeema pood, if the foets 
'i^ decorate; and that they are 
** would seem very probable 
"^^\ llie mode which these gen- 
lIcKucQ adopted in their invi-sti- 

|8*ti«n. Tho mass after removal 

'^^a« immcdintely plaoeil in alco- 

'^"*I, by which all the blood in 

*oe tamor was coagul;ite<l. It 

:^*8 then cut into thin slieeB 
"id hniiihcd over with cainriinOj 

**>5cJi adheres to tho white bnt 

"•^t to the red grlobulee, nnd then 
"'iked in glycerine. This ren- 
^•^ it rery easy to connt tho 
*'rnber of white plohiiles, wliipli 

[■^ae done, with the result above etatcd. BHIroth gives ahnost 
ly the same anatomical description of this form of tumor 









293 



TTMORS OF BONE. 



as tliAt presented hy tlio French writors quoted. Fig. TS, taken 
fttitn Eric1i!i«n, is a representation of wlmt he calls anctirUm hj 
anastomoaU of the parietal bone. It corresponda tolerablywell 
with the description of the diseasD here given. 

Tlic clinical history of thew; different forms of pulsating tn- 
inora of bone, of eonrso, depends upon the nature of tlic tumor 
itwlf. They fire mostly found in the extremities of the long 
bones, the position in which all hone-growtlia are most likely 
to appear. The pulsation is BDmulliuca an early and cuuBtAnt, 
gomutiiiics a late, and o^TaBionally an intennittunt syniptoni. 
It may be aeconipanied with a thrill, soraetimea with a distinct 
hn/it de eouffict, and is Bonictinies so distinctly and strongly ox- 
paiiitive as to puzzle tlio most carcfnl and experienced examiner. 
The diagnosis, however, can ustmlly be made from proper aneu- 
rism, by tlic location of the tumor, by its evident connection 
with aud cuutiuuity with the bone from which it grows, by its 
usually preiienting at some peiiod a thin shell of hone on ita 
Burfacti, and most commonly by the fecblenee« and want of es- 
pan&ivunesa of the pulsation. 

The fallowing caae, for which I am indebted to my friend 
Dr. Chjirles D. Smith, and which I aaw with him on several 
occiisions, illustrntes extremely well some of the uaual clinical 
fenturoa of the disease. I take the account of the case &om the 
report published in the iVW York Journal (if JCedioine for 
March, 1S53: 

"Mias C, twenty-four years of ago, unmarried^ of nerroiu 
tcuiperamcnt, and of pronons good health, came under ist 
care in the month of March last for a [luiiifid swoUing of tlto 
left ankle, which cnme on without any apparent cause a month 
or two before. The Bltin was reddened, and painfiil to thfi 
touch, particularly over the internal malleolus. There w.is alao 
a creaking scuRation about the joint when handled. 6he walked 
with difficulty, increasing thereby the pain and tension. Tli 
paiu woidd occasionally leave her, and the swelling subside 
It had the complexion of a scrofuluuti diseat<c of the joint, btL 
there being no ^vldence of struma in the system, I was at a lo 
to what to attribute it. Local means as well as com^titntion- 
remedica were rcsort,cd to without avail. ThetHsea-w remain 
about the same until the month of May, when I detected son:s^ 



PTTLSATIXO ■nmORS OF BOXE. 



398 



thing like fluctuation over the interual nialleolue, which in two 
veekfi became distinct. The skin was not chan^d in color, 
neither did it hiive the feci nor present the appearances of nn 
nbeccss. 

"In the early part, of June I noticed in this ^iliintion a pul- 
sation which, from diiy to day, Ijecflme more evident, and was 
(tynchronous with the arterial pulse. Pressure on the iroatcrior 
tibial artery arrested the pulsation in the tumor. At this time 
Dr. Van Bureu waa called in consultation, who contirnied my 
diagnosis, viz., aueurism of the ])oBtyrior tibial arter}-, and at 
the same time sofrgcgted that possibly the bone might he iu- 
Tolvod. She readily tron&cntod to our proposition, to tie the 
J posterior tibial ; and, with a view of cutting off tlie recurrent 
^ft circulation, it was aUo deemed advigable to put a ligature upon 
^" the anterior tibial, where it passes ovor the dorsum of the foot. 
I On the ad of July the posicrior tihini fii-st was tied, about an 
^m inch and a half above the tumor. The pulsation, ceased only 
^^ for a short time, and the uize of the tumor was not at all dimin- 
ished. Tlie same result followed dehgation of the anterior tibial. 
On vbtting my patient the morning fullowiug the operation, 
the pulsation luid returned with full furce, an(l was plainl}" felt 
tLrou<;h the bandages. During the mimth of July the disease 
steadily increased. The skin in the neighborhood assumed a 
transpnrrnt appearance. The tumor grew larger, more firm 

Pftnd resisting to the touch, and the puL^tion became decided. 
Pressure upon the femoral as well as jwpliteal arteiy arrested 
it. Its true character was detcrmiiieJ by the crackling sensa- 
tion, and breaking down of something like an osseous shell, un- 
der the lingers. The wound from the operation did not heal 
landly. It was seven wi^oks before fiho recovered, yet lior gen- 
^_ eral healtli was not materially injured, either by the progress 
^Hof the disease or her long confinement. Abont the middle of 
July^ Dr. Mott was called in to decide the question of anipuia- 
^_t)on. llis opinion was that, inasmuch as pressure over the 
^P&uioral artery completely controlled the pulsation in the tu- 
ftiur, deligation of timt artery might be tried. He was also of 
Opinion that the ligature was prcfornble to compression in this 
J>articuUr case. 

"On the 23d of August, Miss C, having entirely recovered 



9«4 



TOMORS OF BONE. 



from the first operation, in the prescnco of Drs. Uott, Van Bn- 
ren, Stone, anj otherfi, I placed a lignture around tlie fcnicral 
artery, immediately Ijeiow Poupart's ligament, and aboTe iIk 
profunda. Pulsation in the tumor instantly ceased, but h iHil 
nut oo)lat>ee, as in ortlinary anuurifims, neither did it dimiuitli 
in size. From this operation my patient rapidly rccorenxl. 
without any nnplcnsant Bymptoma. The ligatare came awij 
on the twenty-Bocond day, and the wound h&iied readily, V» 
tumor subsided about half an inch in the course of tbeiroek 
following the operation^ but it soon increased to ita fonwr ^ 
dinieneions. ^H 

" On the 12th of September I felt a gentle pulaation in tlt^^ 
femoral arter}* in Scarpa's space, and at tbe same time in the 
tumor, eince which period it hiui been noticed only occasic*- 
ally, and then exceedingly feeble. Suffice it to say the diten 
steadily pra^fresscd. The tibia expanding, strctclied the tot* 
rior tibial nerro, causing great pain. Her health, too, b«^ 
to feel the influence of rlie dineaae, and rendered amputatJM 
neceseary. Another consultation was held. She waa adriKd 
to lose the leg, to which she unhesitatingly consented, tnd oa 
the 20th of November I removed it at the place of dectioi. 
A day or two atler it« removal, my friend Dr. C. E. IsUQ ia- 
jected the limb, through the posterior tibial artery, with i 
propitrfttiou of chromate of lead dissolved in ether. The »kb 
and fatiL'ia were tlien removed, and cx[io6ed the periosteum 
thickened. The shell of bono under it was broken down, wi 
in some points partly absorbed. When cut into, thwo wia pifr 
Bcntcd a ttolY, brain-Hke hiam, of a rcddif>h-bTown color, minxt 
with the injecting material. Upon turning this out, it w»diB- 
covered that the lower end of the tibia was absorbed foraboal 
half an inch. The cirtllage lining the aarfaoe articulating witK 
the astragalus was preserved. The bone was expanded into t 
thin tthell, the caucelLtted structure guue, and its place occapic*! 
by the matter deacribed. ^o resscU were found entering tfio 
tumor, although the bono and neighboring parte were esstttA- 
ingly vaiM-ular. The other tissues were healthy." 

Another case was under the care of my friend and collcafm 
Dr. Willard Parker, about the same time, and waa published itt 
the same journal in the nnmber for May, l$o3, Itgiru m 




\ 

I 



loaDy featttrea of interetit in (lie hietoir and progress of the dis- 
ease that I give it almost entire, as relatod by the pntieut hua- 
K\t, Trho was an intelligent |)hv»ii-iaii : 

"In the siiniiiior of 1842, while jiim])ing for recreation, I 
Btmck mj Icll heel uj>on a round stick about nn inch in diame- 
ter ; it i^va me severe pain at the time, which, however, laatcd 
bnt a few minutes, and I thought no more of it. Several days 
after, u|X)n rising from ray bod in the morning, I experienced 
a sharp pain dnrting through my hc^el, which quickly pushed ofT, 
bat rocuiTcd again on the following moniing in the »amc niau- 
ngr. This transiait pain continiiod to rotuni every morning on 
aaenniing the vrect [K»5ition, until tlit; Bunitner of 1H47, withoni 
the occurrence of iitiy other sjinptom, euch .is swelling or tcn- 
tlemcaa, to indicate the nature or scat of tlio ditticulty. This 
pain invBriahly reiumrd on rising to my feet, after resting aonio 
time in the horizontal posit i.jii, but never continued to exceed 
one or two minutes. During tltis period, my heel gavo mo no 
uneatinees, my general health was good, with the exception of 
eomc dygpeptic sym])ti»iis for two or three yeai-s after the in- 
jury, which 1 attributed to sedentary habits, being then a stu- 
dent, and which |ia(i8ed off after engaging in practii-e. 

" In the summer of 1847 I began, for the tirst time, to ex- 
perience a tenderness about the heel whenever it cnme in con- 
taet with Bolid fiub&tances with more tluin onlinary force, as in 
fitamping or making a false step. This tcndenie^ gmdually 
increased, until I began to suffer some pain in walking at my 
usual |iaee, nulcRfi I was careful to elide my foot along without 
raising it much from the ground. There was no appreeiablo 
Bwelling until December of that year, when, upon drawing on 
my boot one morning, X suffered so much pain that I wa^ obliged 
tA withdraw it immediately. During the day the heel dwelled 
considerably, and, being hot and painful at night-, I 6caritied it 
deeply, and held it in hot water to lavor the bleeding. On the 
following day I was disapiwintud at finding my foc»t still worse, 
and was obliged to use a cnitcli in walking. Leeches imd poul- 
tices wore applied, and subsequently iodine and other medicinal 
applications wcro employed, but without even ]>alliating the 
Bymptoms. Xotliing bnt cold water and snow gave me even 
temjK>rary relief; these were very grateful, and I resorted to 



S06 



TtmOES OF Bosa 



them often, as the relief thc.v afforded enabled me to attend to 
Tiiy l>«8iiies6, thiin^h I siiftbrtMl mnch pain ni^it and day. 

'* I continued to tp-ow pradually woi'bc until Bomo time 
Febrnar)*, 1S48, when I determined to consult l>r. Parlcer. 
this tiinc there seemed to be thickening of all the tissnes about 
the OA calcift, with a deep-seated, constant pain, as if tlie fibrous 
tisime was put upon the stretch ; occasionally the pain was lau- 
cinating. ^H 

" Dr. Parker ndvieed an incision down to the bone, whiii^* 
he accordingly made, dividing the periosteum of the oa calciA_ 
about an inch and a half on its inferior Burface ; tlie n-oni 
bled freely, and gave a little relief to the severity of the paii 
but of short duration. I kept the wound dischai^ng four or 
five weeks, but, finding no material benefit, allowed it to heal. 
Soon after this I applied moxas, by the advice of Dr. Tiekuor, 
U. S. Kavy, but with no benefit. The pain continucil to in- 
crease in severity, being worse nt night than during the day. 
I rofiorted to large doaea of morphine to obtain elocp, and otV-n 
two gmina at a doito would produce only a short nap, from 
which I would be awakened by the most excruciating Unci* 
nating pains in the heel. I finally began the use of quinine in 
the fiunmier of 1848, as I was beginning to emaeiate and t^^_ 
lose my appetito, taking eight grains a day, with cold applici^l 
tions to the atfi-ctcd i>art. Under this treatment my npjiotite 
and gericnil heidtU improved, and also the local difficulty; the 
pain was much less severe, and in a short time I threw aside 
my crutch, still continuing my praptice, and got around very 
comfortably with a cane. This improvement lasted until D( 
cember, 1848, when I had an attack of acute brondiitis, ft 
which I was bled, and took antimony, and of course oniitt 
the (^{uinine. I wns confined to my bed about ten days, and 
this time the puin in my Ituet became worse. On getting u| 
I discovered, for the first time, a tumor on the outer aspect 
the heel, just below tlio external malleolus, which had a spoi 
elastic, and pulsating feci, and was painful on pre*suro ; 
veins were mnch enlarged about the heel. I again resorted 
the quiihinc, from which I had derived so mnch benefit, but 
now gave me no relief. 

"I grew worse so rapidly that I again visited Kew York with 



PFLSATINO TUUORS OF BOXE. 



26V 



the intention of submitting to amputation, if this course was 
deemed ndvisable. I had cumu to tliu conclusion tlint I could 
DuL much longer survive buiUi indescrib»ble agony (I will nut 
call it by so sot^ a name as jiain). l>r. I*arker advised imme- 
diate amputation, to whieh I chccrtnlly aesonted. lie per- 
formed the operation on tbe 24tli of January, 1849, after ad- 
minialeriug a mixture of chlorofonn and eth^r. I resumed the 
practice of my profeaaion about three months after the opera- 
tion, and have continiiwd .letlvvly enga^d since, in tlie enjoy- 
ment of good licjdtb. I have supplied my deficient extremity 
with an artificial limb, which answers ita puri»06e admii-ably." 

On examination, it was found *' the bone c\)>aniK'd into a 
thin shell, Ihu eauL-cllated etructuro absorbed, and in its lAoica 
a matcrinl answering the character of carcinoma." 

Koth these eases seem to have been instances of the softer 
variety either of cartiiaginouB or myeloid or possibly of the 
spindle-celled growth, which, from the excessive development 
of their veeselg, received the pulsating chawcter. Their gen- 
eral appearance was that of eaccplialoid disease, hut that they 
were not truly cancerous affections is proved by their after-his- 
tory. Tlie last ease, the tumor of the heel, wa* alive and well 
four years after the amputation, and Dr. Smith b.is i-ceeully in- 
formed me that his patient waa entirely free from any symptom 
of recurrence of her malady two years ago, being about sixteen 
yean after her limb was removed. 

Practically speaking, the main interest which attaches to 
theee tumors is the quet^tion of treatment. The pulsation, par- 
ticularly where it is well marked, very naturally anggcsta itself 
u a prime factor in the problem, and the question of cutting 
off the circnlation by ligature almost necessarily presents itself 
to the mind. It has been put to the te^t of experiment in quite 
■ number of instances. Dr. Smith, in the paper above quoted, 
refers to Dopuytren as the first surgeon who tried the ligature. 
" Ilis case occurred just below the knee, at the inner side of the 
tibia, in a man aged thirty-two. He tied the femoral, the pul- 
sation ceaB©<l, and the tumor disappeared. Seven years after, 
it returned and acquired a largo size ; ho amputated, and the 
patient recovered. It proved to be composed of uumert^us 
cysts, 6ome filled with gelatinous matter, and others with co- 



298 



TUMORS OF BONS. 



-•V 



agulated blood. A fioti membrane lineil these ojiti), 
which vesselu were seen distributed in the tbiin of u d 
vrork." This ecema to bo the most satis&ctory rosuU that has 
been Attained. I<alluma]id, Roux^ Velpeau, Gutlirie, Luke, 
Har^rcavcB, and Tuftlu, liave OHuh operated by ligature, with a 
partial or negative result ; in the best cascK the pxjwth of the 
tiimor being arretted only for a few weeks or mouths, the dia- 
easc then rcftuming it« ori^nal rate of progre&s, until death or 
amputAtion relieved the patient of his su^erioir^ 

A certain and B«)mctimc8 very ^eat mitigation of pain is oo- 
casioniilly gained by cutting off the circ-uLition in tho&e tumors, 
evidently by relieving the tension of tlie growing mass un tfa^J 
unyielding titisues by wLieh it iB imprisoned. This I have exp^H 
lienccd in two cases of malignant disease of BUpcrior maxitbu^ 
bone, where the discAso had extended so far as to proclnde any 
idea of extirimtion. In one of tliene casee I applie<l a Hgaton 
to the common carotid, in hope of arresting the progress of 
nudady. The patient died a few days alter the operation. 
800U to judge of any eftect on the growth uf the mtuss, but 
too soon to demonstrato that the operation had bntught imme- 
diate and complete relief to the exccesivo pain wliitrb he Itad 
boon sutlering. In tlte other niee, for a eiinilnr hut mora de^^ 
(>era(e condition of tlie autxirior maxillary, makr, and tempor^H 
bones, in the hope of alleviating dreadful and constant pAin^^ 
and perhaps arresting somewhat the progress of the growth, I 
tied the common and internal carotids ; the former halt' an 
ind) below, and the ]»tt<>r half an inch above, tho hifurcatiofl^H 
I did thiit with a view of more c-utnpletely contmlling the rs^ 
current circulation tluvagfa the common carotid trotn the other 
side, which so quiekly roi'stablishes itself tltrough the circle of 
AViJlis. The man, who vkoa old and feeble, dioil about a wt 
ailer the operation, but during that time wag entirely fr 
from pain, so as not even to require an anoilyne to priMMi 
sleep at night. In 1834, Ur. John Xeill, of PhiladelphiA, i 
botli occipitals for the cure of a large pulsating tnmor of 
occij'ital bone. It had been growing slowly for many years, 
bat more recently its increa^ had been more rapid. **It liad 
a pulsation distinctly |mreeptiblo btith to the eye ami touch, »o- 
coinpanied by a nuurked aneurismal bruit. The pul&^ilton wa« 




PUL8ATIS0 TTJHORS OF BOXB. 



290 



not a fiimpio ritdng and falling of tlic tntnor, but an oxpansion 
111 all directions. The riglit owipital artery could be felt beat- 
ing etrongl^v, and witli a distinct tUriil. Pressure upuu it seD> 
iibiy dmunislied the pulsation of the tumor, and pi-essure upon 
boUi oceipiUiIs almofit entirely dcstruycd pulKition." The ctiioct 
of tlie ligature ol' ttiuse arteriirij whs tu check iu uuiue degree 
tiie progresB of the diseiitie. The patient lived four or five 
months after the operation, no ehan>^ takinj^ place in the tn- 
mor, except a diminution of pul&ution and bruit. Pmt-mortem 
examination showed the tumor to bo of an cnoophaloid nature, 
and entroaching Isrgely on the cerebral cavity. 

Dr. E. D. Mapother reported to the Surgical Society of 
Ireland, January !)l!d, ISGS^ a case of pnleating tumor on the 
let\ tibia, iu which, after trytug a variety of remedies, be 
finally determined to use the actual eauterr. There did not 
fieein to be much encouragement to attempt the ligature, ns ho 
found tliat prcfisuro upon the femoral did not control the pulsa- 
tion. He says, in hie report in tho Dublin hVee J^f&nt, Febru- 
ary 4, 18(13 : " We resolved to try the offcet of actual cautery, 
aud having dilorofomiized the patient, we pressed an iron but- 
ton of the diameter of a ghilling, heated to a white hciit, deep 
into the tumor; a good deal of bn>morrhage followed, but wa« 
repressed by murintcd tincture of iron. In seven days the alougfa 
separated in Araall gritty pici'es, and then was diftcloscd a mass 
of hai-d, pul&atuig HubstuDce, of the &bapu of large gnmulations, 
but of a pale color. Seeing that it was necessary to reapply 
the cautery, we did it tliis time with a sharp conical iron, which 
was tlinist five tiincfi into the tumor, and thna it burnt ita way 
for an inch and a lialf from tlie surface of the tibia. In tea 
day^ a thick and aomi>what conical slough came away, leaving a 
cavity tilled ^vitli Buiall, lietiltliy grunuliitiong at its si«les, but 
with B small spot of rough bone at the bottom. This gradually 
became ctjvered in, and the ulcer Hssumcil the lieiUthiest cliaroo- 
ter," At the end of two months, Dr. Mapother reports tlie 
ulcers healed, and the tumor entirely removed. At the end of 
a year the patient was still perfectly well. 

Of eourve, if the tumor be favorably eituated, there may be 

in which extirpation can bo performed by the gouge and 

flair. Here the result ^vill depend on the nature of the tumor; 



90O 



TciioRs OF uoym. 



bat, as fnr as I know, tlio mcra fiict of tho vascular charnctcr 
the tumor need not disconrage tho resort to the usual operi 
tions in «iiniUr non-pulsating growths. In the limba, amput 
tion has been, la bv far the larger number of Cftse«, the only^ 
method of ridding the patient of hia al&miing and veiy com- 
muul^- latal di^oaee. 



CHAPTER VL 



TUK0B8 or TTTE JAWS. 



TiiR enlargements arid tumors wlucb we encounter on 
jawbones present so many fentureti whieh are peculiar to the 
bones in wUifih thcj occur, that it is convenient, in stndyi 
thcise atfcctions, to place thorn under one head, and tUn^^ brin 
together many |iointft whicli arc, in otlier jjarU of tlie i^keleto 
differently cliisaificd. This arises partly from tho anntomical 
peculiarities of the jawa, such as the large mucous cavity of the 
ttntrnra, lite spongy enbstjinoe of the alveoli, the itnpLiiit:»tiim 
of the teeth, the close connection of the gingival membraud 
witb the bone, the largo proportion of the bune which is cov- 
ered by mucous membrane; and partly certain imtlnilogicnl pe- 
culiarities, Biich as thu fact that cystic disease of bone ie almost 
exclusively Ibutid in this regiou, aiid that the myeloid tumor is 
so habitually fitnud in these liuncs, rather than in the other. 
bones of the skeleton, that its whole history might be wri 
from its dcvclopraent in this part alone. Besides, the very 
perfieial position of both upper and lower ja\rg makes so 
important modification in tho facility and completeness of the 
diagnosis of their diseases, while their accessibility gives pe- 
culiar advantages to the surgeon in seeking their cure or extir- 
pation. Most of the writers on diaeasea of tho bones liavc 
found it convenient, for these reasons, to discuss tho ailections 
of the jaws under a division by themselves. I ahull follow 
good an example, and present what I have to say on this di 
ion of the subject under the following beada ; 



1 



ther 
om^l 




TCltORfl OK THE JAWS. 



301 



1. luflftmrnatory distentioa of antram. 

2. Cyeto and cystic growtlia in the jawa. 

3. TumorB connDctcc! vcixh the gums. 

4. Sulid tumors of tlie jawbonea. 

INFLAUMATOBY DUTENTION OF A^TrBClI. 

Inflammation, attacking the luucous membrane lining tho 
latnun, may, by ruteiition of tlic inlJanimittory products, from 
a cIo6iirti of t-lie small opening into the nostril, raitsc a diMon- 
tion of the cavity, which even in acute cases may rench a con- 
sidoraMc size, and in tho chronic fonn may pre rise to donbts 
and mistakofi an to tho natnre of the swelling which is thua 
produced. Inftanimntion of tills cavity may bo an extonftion of 
catarrhal disease from the nasal cavity, or it may orijjiinate from 
some diseased condition of the roots of llie first and second 
molar teeth which project iiiion its floor, sometimes slightly, 
and sometimes quite considerably. E.xtemal injury, particularly 
that of extraction of the molar tooth, is a frcciuent cause of this 
affcftion. The symptoms can nsually be easily recognized by 
the <hil1, aching pnlu localized in tho centre of tlie upper jaw, 
and, after a very short time, the genenil iuflammator\* swelling 
of the face is seen to be connected with an enlargement of tho 
jawbone itself, which, in the region of the antrum, is extreme- 
ly sensitive to the touch. As the distention increases, the suf- 
ferings of the patient become more severe, and tho deformity 
of the face more and more marked. The bony wall of tho an- 
trum, ns it yields to the accumulating fluids within, becomes 
thinned, and gives tlio yielding, crackling, broken egg-shell sen- 
sation, so characteristic of distended bone. If the attack be 
TCiy aeute, the matter finds its way pretty early through the 
nostril, or under the cheek anteriorly, or through the floor of 
the antrum, into the mouth. If a tooth has been recently ex- 
tracted, its socket often aflbrds n ready outlet for the matter, 
and suggests the most direct mode of reaching it with the sur- 
geon's trocar. 

If, however, as is perhaps more commonly the case, the 
acut« symptoms abate, and a subacute or cJirouic course is aa- 
Bomed by the disease, then the oxtonml evidences of inflamma- 
tion gradually subside, while the distention of the antrum aa 



»a 



TCKORS OF BONE. 



gradually incroasce, and the aflertion often pre§en(s itself in 
a shnpfl diat leaves it veiT doubtful whether the tumor is ono 
deiiending upon accumulation ot' puB, or whether it l>u a evetic 
growth in the antrum. Indeed, it is recorded that surgeons 
have undertaken the removal of the upper jaw, under sneh cir- 
cumstances, and have not discovered their mistake until their 
handa have been covered with pus fiwm the ruptured absccsa, 
LiBton and 8tauley both niontiou Biwh ortcurronceB; and the 
facility witli which even a jjjood sur^'on mijfht fall into sueli an 
error will perhaps be appreciated, when we remember that, in 
many of these cascH, the early history of inflammation han b«en 
unnoticed or forgotten, and that, in those instances where tlie 
actionii are very slow and deliberate, a thickening and indura- 
tion of the di&tending wall of the antrum take place, instead 
of a tliiuning of It, which thiokoning coneeflls the fact <tf tlie 
existence of a fluid wlihhi, and thereby makes the diagnosisj 
sometimes extremely difficult. 

The ronscquencca of these inflammatory diatcntions of tho 
antrum are of>cn flerious. Xecroftiri of the bone if) i?ometinies 
produced, a« in a case related by Hr. Christopher Heath, where 
*' the front part of the floor of the orbit, the upjHir eheek-jiortion 
of the t>uperi*>r niaxiUa, and the infru -orbital, and a la:^ plate of 
bone from the inner (nasal) wall of the antrum," were involve 
and Tcniovcft aa Beqneslrn. In this case, the eyeball Iiad been en-1 
omaclKHi upon by the swelling, and, from the pressure, the sight 
had been utterly destroyed. Otiicr instances are recorded 
where amaurosis fallowed this disease, and one in which con- 
vuUions and deflth in sixteen days were produced by it. At 
all times it ia, in its acute form, a painful and deforming dis- 
ease, in which the assifitaiice of art should be invoked as foon aS] 
possible. An opening may be made into the antrum in one of ■ 
two w.iy8 : Either the socket of the first motar tooth may ha\ 
perforated by a trocar, or the lower part of the anterior wall 
of the antrum, jnst above the gum, may easily he penetrated, 
and a portion of the thin shell removed sufficient to allow 
free and permanent opening into the antral cavity. If the! 
molar tooth be sound, the second will probably be the best 
niethnd. Of roiiree, after such an inflammation, the cavity 
does not immediately return to a healthy condition, its mucous 



rmioBS OF TUB JAwa 



MS 



lenibrune continuing for an indefinite time to eecretc rauco-pna, 
■«*hieh, U* the opening, made by the surgeon, lie mA kept. fa'O, 
-will accnmnlatc and give rise to a return of piiin, nn<l purliupti 
A renewal of the inflammatory disease. The opening through 
Ifthc bone, In wbichever ^itnation it is made, ahould be free, and 
^t wUi, in most cages, bo necessary to dilate it at stated, inter- 
-val^, to prevent its eoutractton. In doing this, I prefer a coni- 
■tel steel boitgie, iutrodu<'ed and allowed tg remain a few min- 
utes, at apjirojiriate iiitervalti., aa giving less jiain aud being leea 
liable to do iniBcliief than the sivotige-teut. Tlie cavity nhould 
also be fre4|uei)tiy injected with warm water or eome sHghtly 

Kitniilating or corrective lotion, bik'Ii as aulphatc of zine, ear- 
olic Bcid, or ehlnride of Roda, or, what I like better than all, a 
weak solution of common salt. I have nnder my care a gen- 
tleman, aged thirty-eix, who notified about six years fi^ a pain- 
less swelling, just above the root of the right first molar tooth. 
It gradiiaUy grew larger uud larger, And boou began to make a 
decided prominence of the fbeek. It watt then it (^iino \mder 

»my notice. 1 found the anterior wall of the antrum bulged 
forward into a proniinent tumor, wliich was eovered by the 
Ihinneil boDe, and crackled under the finger, giving a distinct 
feeling of tluctnatlon. The swelling was now somewhat tender 
and iMiiuful, and wits gradually becoming more so. I recom- 
mended that the first mol;ir, which be guapccted was the cause 
of the tTOuble, should be removed, and as it was drawn from 
it« socket) matter flowed freely, and the tumor partly colkpsed. 
1 This was about two years from the time when he first noticed 
■the swelling. Since the opening, the cavity has been kept free 
I by injections of water or salt and water, i>r a KoluLioii of sul- 
phate of zinc. Occasionally I have introduced a probe, or a 
conical bougie. If this is neglecte<l, and uccumulation is al- 
lowed, be immediately begins to sutfer pain, and the whole jaw 
feels inflamed. By constant caro of this kind, the antral cavity 
has now shrtmk bo as to contain much less injected fluid than it 
formerly did; it discharges but little, the prominence i& no 
longer visible ; in short, it is gradually and very slowly regnin- 

ting a healthy, uataral condition. 
Some rciuarkuhle cases of extreme distention are on record 
from the accumulation of ilnide within the antrum. A very 




S04 



fi a 

I 



Btriking caae is spoken of by Mr. Heath as havinjc occnrrcd to 
Sir William KergURBon, the preparation from which is preserved 
in the King's College Museum: "It was taken, uiaiiy jitjar^i 
Ago^ from a Bohject in the dissecting-room, and from the pci^o^l 
of an old woman. The tmuor, w]iic.*h was of" very largo siz^i 
had buret shortly before deuth, leavin*; the remarkable deforiD- 
ity, Bhown in Vi^. 79, which is due to the complete absorption 
of the front wall of tlie antinim, and its follapse, hy which a 
prominent liorizontal ridge of hone, formed by the upper w 
of the antrum, has been left imniediaU'Iy below the orbit. T 
preparation ahowg great distentiun of the autrnm, the diamet 

of whiuh varies in dill'eront pa 
from two to two and a half 
inches, nnc] Ixmy vniW bo thiano^H 
out as to rejicinblc parclnncnfP^ 
The gums are edentulous. There 
is no cuinmuuicatiuu hetwefl^H 
the nose or mouth and the caTi^^ 
ty, whii'h h. lined by a nicmbnmc 
eovt-reiJ with laminated dep 
Whether this was originally 
case of eystio growth or a ehronl 
ftbscees, it is impossible now to 
decide ; but it is, eo tiir as I ai 
awnro, a unique post-morte 
spetinien of this distention." 

Besides this case of 6im|il? 
distention of the antrum by tli^i 
accumulation of fluids within it^ there are other raws in wbi^^| 
a true eystie formation ocrurs within this cnvity. Sometimes ^* 
single cyst is found growing in the autruui, to somo part of , 
whose mTiccus memhrane it is attached. These have been de- 
tected in all stages of their growth, from the smallest noticcabl 
size up to the point of completely filling and distending 
antrum. Their walls are usually thin, and their contents 
deRcrihetl as most commonly of a transparent viscid charact 
but in the older tumors becoming flaky from Ihe prepeueo 
eholestcrinc, and occasionally thick and opaqoe like butter or 
caseous fluid found in sebaceous cysts. Sometimes, instead 



Pis. Te^Fpom Hratli.) 



TtJSIORS or THE JAW3. 



305 



being^ single, tlicre arc sovfiral cysts, aiui Mr. Henth gives one 

» instance, iHken from M. (iiraKU's's prize cs^kiv uti this subject, 
where tlie whole of hoth atitra were pac-lied. full of cysts of 
Ttrying size, but of great numbers, nnd in every stage of devol- 
(>]»incnt. Tbe*c cases, of course, during life, preuent no features 
by wliich tli«y oiii be dibtluguishcd from the other foniis of 
chronic antral diitteutiou. An to their mausgement, particu- 
brlr where many of them exitit, it is evident tbut an opemtion, 
mure thorough and more estenaivo than mere puncture, would 
: necessary for their perfect removal. 



CTSTO Um CT8TT0 OSmVTHB Dt THE JAWS, 

Cysts may occur in the substaneo of either jawbone, and 

[»rtsent themselves soinctimea in connection with the teeth, and 

jnietimes entirely indejveiidenr of them. Of tho^e connected 

rith the teeth, some are attached to the fangs of jverfcctly de- 

'■Telopcd tcelh, and other« are found to l>c connected with teeth 

either impc-rfectlv developed or abnonnflUy placed in the jaw, 

which wrongly-developed teeth are commonly considered to be 

the cause of the foruiation of the cystic tumor, by reauou of the 

local irritation which tlicy produce. 

■ Of cysts connected with the roots of sound and welWevel- 

Hoped teeth, Mr. llcnth gives three examjdes as coming under 

HSkis obsen'niion. They are Ktatcd to bo quite aniall, am), judging 

from the drawings, not larger than a pea, except one of them, 

which is the the of a hazel-nnt. One of them has quite ft long 

pi'diclc by which it is attached to the end of the fang. They 

KuAy, however, grow to a largo size, and several cases are on 

record where they have intruded into tlie antrum, which cavity 

»they liave more or less completely occupied. Of course, the 
discrimination between such a ease and one originating in tho 
tntrnni could hardly he made, except by a careful disEsection of 
i^the parts atler death or rcuioval. 

Of cysts connected with undeveloped or itiiaplaced teeth, 

tdcntigerous cvsts, examples have now been recorded by many 

)bsorvor8. Most commonly it is the permanent tocih whicli,by 

sir abnormal condition, give rise to tho cystic growth, but it 

been occasionally found in connection with tlie temporary 

SO 



30« 



TUWORS OF BONE. 



tectli. Jind, ill at least one instance, with ft supcntumcraty tooth. 
Tbe explanation of the mode in which these cysta are formed 
abont the impiiL'ted tootli is given by Mr. Salter as follows: 
" When a tooth is thns situated, its fang in enc]i>«ed in a bony 
socket, lined by penosleum, as in ordinary circunietanceft, while 
the crown of the tooth is free in a little bony lociUus, lined by 
that whieh was the eo-called * enamel-pulp.' This structure it 
clothed with a wri of epithcltuiu, which ie apt to aseoiue iJio 
futiL-EioR of secreting fluid. AHer the enamel is completely 
forme<l, the soil membrane, which rests upon the surface of the 
erown of tiio tooth, freiiuently ecpamtes from it, the intor\-al 
being occnpiecl by a snrt of serum. This is generally the rcsnit 
of some irritation or difficulty in tooth-cutting; and where the 
irritation rune on to acute inflammation, as in some cases of 
tedious eruption of wisdom-teeth, the secretion may 'become 
purulent. In the deep-seated casee of impaction of teeth, the 
action is, I hclievc, always slow, and the secretion almost always 
sorons." 

Mr. Salter gives two instances of his own, one of which I 
will relate, as a type of this class of cases: "A girl, eighteen 
years of age, had an clastic fluid-eontjiining tumor in llie siib- 
stauce of the incisive bone, extending np to the base of the 
nose on the left aide. She bad been seen by two or thitre sur- 
geonfi, hut tlio nature of the malady was not asceilainod. She 
had tlie normiil tiuniber of teeth in the jaw, though the char- 
acter of one of thorn was abnorntal for her age. When the 
patient wna sent to me for my opinion, I perceived that the left 
ccntml incisor was n temporary tootli j and this eircuinstance 
was ft key to the correct diagnosis of the case Tlic left tem- 
porary central incisor occu]ucd a position which its pcrmaacnt 
Bucce&sor should have held ; the absence of the tooth, under 
Bueh circumstances, suggested the almost Inevitable position 
which it must occupy above and behind its temi^rary prede- 
cessor, that is, in the axis of the serous cyst. The temporary 
tooth was removed, and the cyst ex]ilon.Hi, to discover the suc- 
ceeding tooth. The permanent central ineieor was found deep 
in the bone, in an upright and natural direction j its crown hare 
within the cyst; but, upon its removal, it was observtMl that 
the feng was ahoi-ted, and had only grown to one-fittb of its 



TTMORS OP THE JAWS. 



807 



Batoral Icn^h. This cireum stance it waa whidi had prevented 
its extmding its temporary predecessor, and cstabtisliing itself 
in lis uormal poeltion. The retentiijn of the tootli in its 
epitlielioid eau fumii>hud the anatoniical gruuiidii from which, 
mder favorinj; eircumstanees of irritntion, the serous secretion 
aroeo, and the bone-expansion followed." 

Fig. 80, taken from Mr. Heatli's work, represents a lower 
j»w distended by a cyetic growth, in tiie lowest jwrt of wliich 
is seen a canine tooth, the irritation of whose presence probably 
li&d given riiao to the developiueut of the cystic dUease. 



Fib. HI.— (Kroiu H<sUl) 



Yta. M.— iKrou ll«»lh.) 



^he affection is stated lo be more common in the upper jaw 

uii»^ in tlie lower, hut all the teeth in either jaw seem to be 

liar»l^ to ^ve rise to tlic diacnac The symptonis of tliia form 

^' tvinior can be no different from those of other expansions of 

jawbone by cyetic formations, but a very reasonable ground 

*' ^xispicion that the caae is one of dentijjcrona cyrt may some- 

tiiii^5^ be found in the fact that the teeth are not nomial in 

Jii^Viber or in character. Thie point is not one of mere patho- 

"fficral curiosity, for it has a direct and most important bearing 

^^ treatment, as it must be evident that, if the diseaee depends 

t^P*^>"n the presence of a misplaced tooth, it will not be eflet-to- 

"^"y curt'd until that tooth js fonnd nnd removed- 



soa 



TUMORS OF BOXE. 



Cvstto growtlifl not directly connectod with the teeth are 
not iini-'oinuKin iu botli iipjvur and lower jaws; thonghf firom 
Mr. Ilcalh's account o( tlicm, I infer that Uiey are more iVe- 
qiieut in the lower. They may be spontauwus in their origin, 
ftA in one case reported by Mr. Coote, where the di50!i;3e wa« 
congenital ; or they may have their origin in some injury of the 
alveolar eubstance; or, as is perhaps most commonly the Cftsc, 
they tuay originate frinn the irritation of dofcotive tcctli, or 
fttuitipA, which are allowed to remain in sockets which, perhaps 
for yoarsy have h'ocu more or less oonstantly in an ioflamed con- 
dition. Tliey may be unilocular, whirh is by far the most oom- 
moit form (Fig. 31); or they niay be lunUiloL'iilar, and oecasioD' 
ally proliferous. This was the iact in Mr. Coote's oonjircnitat 
ease, and on opening the tumor it was fonnil to '* be tUlwl with a 
regular ncj^t of cysU, one placed within the other." Another 
case, of Dr. Robert Adams, ijiiotcd by Heath, wag composed of 
numerous small cysts arranged side by side: "The mucous' 
membrane covering it was here and there raised into rounded 
emiueuces of the size of pL>as, though some were lai^r, and of 
a purple color. The tumor was composed of bony cells, of a 
texture as fine es the ethmoid bone. The cells generally were 
of sneh a size tlmt each might ho capable of receiving within 
it a garden-pea. Tliey romnmnicated with each other, and 
amonntod to no loss than twenty-six in number. They were 
all lined by n pulpy, very red, vaacular membrane, and con- 
tained an albtuninoua fluid tinged of a reddish color, apparently 
from blood dissolved in it." 

Tliia polycystic fonn of growth is well illustrated in Fig. 8ji>t 
which is given by Heath Irom a case of M. Girald^ iH 

These cysts sometimes attain a very great size, e?c]V)ndmj; 
tlio whole hone into a great tninor, which is a mere bonv flhcll 
with fluid contents. In many cases, particidarly in the multi- 
loL'iilar form, tlio disease exttrids to the ramus of the lower jaw, 
quite lip to the condyle, and even into the coronoid procea. 
The fluid is commonly a glairy, transparent^ albuminous rnato- 
rial, sometimes so thick as to flow with difflcully, sometitiies a 
serous fluid, containing floccuH of fibrinous umtter, and occt^ 
sbually some blood. Thuir growth is usually slow and pain* 
lese, and patients are apt to be urged to apply for relief more 



TUHons or the JAwa 



800 



«x acconnt of the growing defomiit^, than from increasing suf- 
fering. 

The treatment of all these fomiB of cystic development in 
the jawbones is nearly tho &ainc. The cy&t ninst be evacimttnl, 
and tho cavity kept npun, and then by tents or pings of liiil, or 
by stimulating injwtionis a hctiltby action must be promoted in 



. .-^■. 



FW- Sl-Hrrom II«M}i ) 



the lining of the wall of tho ryKt. This, happlh% onn generally 
be acfoinplisheil, and when aided by the crushing together of 
the expanded bony fihell, so as to obliterate, ns far as may be, 
the abnormal cavity, very perfect restoration of the shape of 

Lthe deformed bono mjiy be hoped for. Some writers, as Mr. 
tutcher, of Dublin, rccorauiend the free removal of liii; ante- 
rior bony wall, and the ecooping out of all tlie contents of the 
cavity ; bul; most of the later operators have foimd that they 
Becurc success qnite aa snroly by a more moderate pmeedure. 
X>r. John Mason Warren, of Boston, very strongly advocates 
th'iB less severe treatment of these cases, and I winnot better 
ijlustrate what seeni& to be the received opinion on this point, 
'than by relating one of hi^ cases : " A young woman, aged 
twenty-five, with light Iiiiir and blue eyes, and delichte skin, 
applied to me in the spring of 180i, on account of a large tu- 
xnor involving tho whole right sido of tho lower jaw above Its 

mgle. Tlie tumor was of a globular shape, extended back 
ider the lobe of the car, forward so as to encroach upuit the 

cavity of the mouth, and upward so as to press upon and eome- 



310 



TUMORS OP BONB. 



wliflt to overlap tlic zygoma. The external surface of the ta- 
mor WHS sinootli ami sliniing, Klifjlitly uidematouB, and she snt- 
fcrcd from it« pressure upon the mirrounding organs. It had 
connncneed, some years before, bj a swelling at the root of the 
wi»dom-tooth of the right aide; and the inconveniences caused 
by the pressure had beconio so great aa to lead her to take 
ineasurue fur Its reinuval. 

■' Upuii conaultatiou, it was decided that a portion of tlie jaw 
would require removal ; the tumor having been tirst exposed 
by an inciaion inado inside of tho mouth, to verify its character. 
TIio following operation w.is perfi)rnied under tlie infiuence of 
ether. An incision was nia<le in the most prominent part of 
the tumor in the mouth, upon which a large quantity of gUiry 
fluid escaped. Upon passing the finger into the opening, it 
was foiuid that the whole jaw at tliis point, with the articulating 
and coronoid proceeseK, was expanded into a mere shell, at some 
parts as thin as parchment, and destitute of o^coua substance. 
It was without solid contents. Under these circumstancca, and 
couhidisririg the good liealth anil youth of the jtaiicnt, it ivas de- 
tcnnined to make tho attempt to save the jaw. A portion was 
therefore i-cmovcd from the sac; and with the fingers the sides 
of tlio cavity were made to collapse, so as to come in coniaot 
with each other. Id order to exdte alill farther irritation, a bit 
of cotton cloth was forced into the interior, and the end left pro- 
jecting into the mouth. A moderate degree of irritation fol- 
lowed ; and at the ond of a day or two tho pledget was removed, 
suppuration having coniniencud in tho sac. Tlie aperture w.is 
diluted from time to time, by the introduction either of tliu fin- 
ger or of a bougie, and the sac injected with tincture of iofline. 
At the end of two or three weeks slie loft the hospital with the 
tumor reduced to about one-half its original size. From tlmt 
time until the present, she has occAsion.illy visited me at mj 
house, and by keeping the external opening free, and occaaon- 
ally irritating tho interior of the sac, a solid maas of bune haa 
been deposited anew, and the jaw has resumed somewhat of ita 
original iiha|iu. 

" In ^s'ovcmber, 1S63, 1 again saw the patient, who came to 
consult me, not about herself, but about a friend. All signs of 
the tumor had disapjteared, and the jaw had regained almost its 



TUirOBS OK THE JAVTS. 



811 



natural eliape; but a anmll aperture still cxiBtcd, at the site of 
the former opening into the mouth ; and a glairy fluid was oc- 
CAftionnllj discharged from it. She "was quite ttell, and all tho 
functions of llie jaw were perfectly performed." 

In oixler to secure the more perfect oWitcration of the cyst, 
preesnre by jmds acting externally by tlic force of springs, as in 
the ordinary truds, has been found to be occasionally of gi'cat 
stance. It need liardly be repeuted tli:it, in all cn&cs which 
juti upon the irritation of misplaced tcctli, the ott'ondtng 
cauBe must be carefully searched lor and removed. 



TOIOBS OOSSBCTED Wmi THE DUMB. 

Tliese tumora Lare commonly been all included under one 
Lead, and described by the name of epulis, Irom two Greek 
word&T signifying ttpon the gum. Much ditference exists among 
IheBe tumors, however, both in their aeat and nature. Thus, 
some of tbcm are mere hyi)ertru]iliica (>f the gum-membrane, 
and reach a formidable size, spreading above the teeth, which 
somctimca tbey almost entirely conceal, projecting from the 
mouth, very vascular, liable to ulceration, and ])n)ducing nil the 
inconvenience and di*tre&8 of the most malignant fonn of dis- 
ease. One such case i* described by l>r. Gross in his ** System 
of Surgery," and ariother, quite tiiiiiilar, is fully described by Dr. 
Salter, iu his article on "Diseuhcs connected with the Teeth," 
before rcfcrrctl to. These cases seem to have been simple hyper- 
trophy of the tifisuo of the gum of both jaws, and ulso, iu some 
degree, of the alveoli, which it covers. The mucous membrane 
participated very largely in the hypertrophic changes, both 
papilla and epithelium becoming enormously exaggerated in 
their anatomical characters. 

Again, some of these growths are poIy])oid in their form. 
Theae of\ea spring from the gum at the side of or between two 
carious teeth, and grow quite large, with a pedicle which is often 
entirely concealed by the niushroom-shaije of the growth. Sev- 
eral of these projections are sometimes f(»und iu the same iiidi- 
vidtul, all depending upon one cause, namely, an irritated con- 
dition of tbe gums, mostly connected with defective or neglected 
teeth. 



S12 



TUUORS OF BOyC 



all il i-^ 

itfac^H 
legre^ 



Feu. ».— (Krwu ilixiUi.) 




The true epulis (Fig- 83) is a firni fibrous tumor, de^c 
in tlie Riihstancc of tlit- gum, upujilly Bjirinpn^ from 
of tlio membrane which is close to or UotWL-oii the twith. It^ 

grows elowly, wiUiout pnin, an^H 
often, in its earliest stagt-s, wiihitu^H 
IcnOemesR, and it extends in all ili-_ 
ix'ftions nearly equally, so Uial> 
it [trojucts fi-om the mucous iurtac 
it cxteniifi in u nearly equal dt 
on that surface. The memhrBne 
covering it is of a natural appenC^M^ 
ance, and rarely bccomoa the sea^^ 
of ulceration. As the epulis cu- 
Itti^es it commonly disphwes one 
more of the teeth, and eomotimes grows 6o as to fill up and oblf 
erate the Boekcts of the teeth that have thus Wuii n-tiKivi 
After a time the bone begins to participate in the action, 
coming vascularizeci, epc»ngy, and Bonding ]>rolongfltion9, in tl 
shape of dulimto spiuuhe, into the fibrous eub^tince of the ta> 
mor. In tlie older and larger Bpecimens, some detached mafises 
of bone arc occasionally found through the growth, but ncvi 
in Hiich a d{^cc as to give a true bony eoiiaistenee or cbaract 
to the tumor. The course seems rather, that the tutnor inv 
and displnces tlio bone, than that bony fomiation pervades tb« 
softer growth. Their naked-eye futures viiry according to the 
consistcneo of the gi-owth. In the harder varieties we have the 
firm, glii^tening, pwirly-whitc apiKiarance of the onlinary fibroi^H 
tuntor, while in the softer forms we have the raddy, brown, o^^ 
greenish yellow of the myeloid tissue. Tlie microscopical ap- 
pearaneos correspond to the outwnrd features, and in the firm 
varieties wo have in general tho simple fibrous tissue, more or 
less purfectly funned, while in the softer forms we have an abun- 
dance of those peculiar elements which so distinctly cIiaracterij^B 
the myeloid growth. Mr. Salter says: "Epulis tnniors ai^^ 
always, I believe, a form of 'iibro-pbstic;' a combination of 
fibrous tissue and myeloid cells, the proportion of the two con- 
BtitucDts Tarying indofinitoly. In general, the main bulk of the 
tumor consists of fibmus tissue ; but sometimes the mveloid-cel] 
element preponderates, and may form the major part of 
growth." 



ifises 

ictoS 
adS 




TUfOKS or THE JAWS. 



ais 



In their clinical Listoo' these tumors present the coano 

which tliL-ir liistulti^icjtl ulLanic'ture would indicate. They are 
never rnali^iuint in the true sense of the word, und yet jiertina- 
dously recurrent under partial extirpntion. They are tliereforo 
regarded by all as iti their nature benign. Kven Virphow, while 
he iniiists upon absorbing tlict>e cuiiiore) all in his immense class 
of *'sareoma,'' does not deny tbat, as a genera] faet, epulis does 
noeosetune any mali^ant features. 

As s general rule, tbese tumors are single ; tbey affect the 
upper jaw rather more IJequently tkiin the lovrvr; they never 
occur in jaws whieh have uo teeth, or in parts of jaws where 
the teeth luivo loi^r been removed. Mr. Salter (>^ves a cnso 
which, at first sight, seemed an exception to thiia rule: " One 
ftbc most Bcvure examples of this itialady whieli I lisive seeti, 

leisted of a bilobular mass, the »ize of a lar^ walnut, extend- 
ing on tbc left side of the lower jaw from the dens Bjipientiie 
to the cnnine teeth, the fonr intermediate teeth liaving boon ro- 
moved. The excision of the tumor bad been repeatedly per- 
formed, but it always returned. It* removal, on this occauion, 
diaclosed the remains of one 6ing of the first molar tooth iu its 
very axis ; this was e.\tracted, and the disease did uot agaia 
make ita appearam-e." 

The treatment is extirpfition, as thorou^rh and as early as 
posgibtcv If removed while smjill, the operation may he efibe- 
tivc without touching the bone ; thougli, in all eases, the teeth 
immediately involved slitmld be extraeted. !£, however, the 
disease baa been of Ion/? standing, and has therefore involved 
the underlying bore, then any thing short of a thorough ro- 
wioval, not only of the tumor, but of the altered bone which 
forms part of the growth, will be attended with (lisap])uintment. 
WiUi the gouge, or the giiawinfj-foroups, or the aliarp curved 
buno-iLip[>oni, tlie whole of the sofl, spongy, alveolar hone, which 
it implicated, can easily be removed, without leaving any de- 
formity which the dentist's art cannot repair, and witbout at all 
^iminisliing tlie strength of the jawbone. 



SOLID TTMORS OK THE JAWBONES. 

All the forma of hone-tumor which are found in any part of 
tlie sltelcton are found in the jaws. Some, however, such as the 



8U 



TTMOna OF DOSE. 






Cflrtilaginoua, and the eanccllous oxostosis, occur no mora 
quently in this situation than in other parts of the slcelelun 
wliile others, sach as the £bruu8 tumor, the myeloid tumor, au< 
the ivory uxotttobiis, aru rarely fuimd lu any other bones. Thi 
tumors mny develop tlienisulves by growth into the aiitnim, 
their baee spriiifring from its wnlls, or they may orij^nntu in tho^ 
bone outride of tho antrum, wh){:h by their growth ia more (mH 
loss (t>in]>Icti.'1y ubliteratud. In all these cases, if the tumor 
grow from withiu the bone, the striking fealure ii*, that the 
outer compact tissue of the jaw, both upper and lower, u di^ 
tended by the increasing growth, and forms a thin uhell wlucli, 
during all the early poriodd of the tumor, entirely encloses it, 
and j^vcB rise, if the tumor withiu be tolerably i>ol^, to the son- 
sation of crackling when pressed upon by the linger, which wo 
have seen to be so chanictcrlstie of tlic distention of the antrui^H 
by fluid aw'umulation. TIiia thin, yielding shell of bime is ra^| 
tained to a late stagi* in the growth of benign tumors, though 
somctimoa, it' the increase be rapid, the bony covenng is pierced 
by the gi-owth, and the peculiar feiiturc is thenceforward lost. 
Tliisi symptom is sometimes only discernible at one or more 
points, the shell at other places being still so thick aa not 
yield to ordinary pressure. In a case 1 have recently fie«n 
the Straiigi;rs' IIo»pita.l, of myeloid tumor of both up^ier jawi 
I found the crac-kting at only two points, viz., just above 
rootci of tlie mular teeth on both aides in the upper jaw. 

Many of the growEhB into tho cavity (rf the antrum 
from a comparatively small base, and distend without other-* 
wise implicating its walls. This peculiarity sometimes enables .„ 
the snrgeon to remove completely and thoroughly, by a ^^i^^w 
simple operation, tumors which, from lh«ir fomiidablo size 
and extensive encroach tnents, seemed to dem.ind the removal 
of tho whole of the atFected jaw. Sir William FcrgOBeon, in 
his lato volume on the " Progress of Anatomy and Surgerr,^B 
insists very strongly on thin |>oint. In speaking of it ho savs^' 
"In operations on this bone, as on the lower jaw, and as with 
bones in other parts of tho body, I take the liberty to protest 
against the doctrine that the whole bone must be taken away 
when there is tumor present. Indeed, it is largely in conse- 
quence of what I have seen In tlio maxillie, that I have come to 





TmORS OF THE JAWS. 



819 



the practical cod elusion, tluit total excuilon is not always nced- 
fiil in the case of tumors." 

The encroaehment of these tumors upon tho fsurroimding 
r^uns is an mtereuting foiUurc, both aa to diagnositt nnd ns to 
the necessities and tndicntions of operative interlercnce. Moat 
conuiiouly the tendency of growth ecems to be principally in one 
dlreetion. Thus, we have the tumor expnndinp the anterior 
wall of tho bone, and appearing prominent cm the face. Tliia 
is the direction most frciptently noticed, and in many inBtanced 
the extension is only in that direction. In othcra tlie tumor 
invades the nasal cavities, eomctimea the orbit, sometimes tho 
roof of the month, and soinetimcs the poaterior fauces; very 
rarely all are successively and nearly eijnally encroached on. 
The case above alhided to, of double tumor of both upper jaw- 
boucB, is a striking cxamplo of this uniform distention. The tu< 



^VA^ 



t! 



..lb.) 



mor malies a moderate projection forward on the face, it biilgca 
down the paliitiac platu on both sides into the mouth, it hag 
begun to push up the eye, and can be felt deep in the orbit, 
and, by i^fl.isin^ tlie finfjor behind the velum, a rounded edge of 
the growth can be felt very distinctly pressing into tho poste- 



310 



TUMORS OF BO.VE. 




rior fauces, Tliese encroaclitneDt* take place to a very dUt 
ing extent ns the tumor iiicreftsei;, and tlie incouvunicuce they 
cause is uftcn the warrant for operation, while the tumor itself 
is pcrhapB neither painful nor cxtcmallv Uefomiing in any very 
urgent dc^oc. Tlie cncronnhniont upon the orhit is of course 
mainly important in regard to tlu^ implication nf the eye. which 
by the pressure is dlslot*nte<l, and otten (lisorgBui7.ei.l, after re- 
peated and distresaing attacks of inflammation ; nnd yet some 
remarkable instancea are repoited of very great digjdacement 
cauaiug frightful deformity, without loss of sight. In one 
Mr. Fergussou's eases the eyeball was thrust forward more 
8U inch from its natural position iu the orbit, and yet the sigl 
remained unatiectcd. In most elites the eight is lost very carlj 
The projection into tlio mouth la very di^tre^ing, by interfciini 
witlii tlie !i(;ti<in of ni8t)tic:aiiun, and indeed by preventing th( 
comfortable introduction of any kind of food. Whun to the 
mere bnik is added the (act of excoriation, and in some instanco^f 
severe and painfiil ulceration, with bleeding on the slightest 
injury, then, indeed, we have in some of these jaw-tumors, grow- 
ing priacipally into the mouth, the most distressing and dx^f 
haunting of ail the growths M-hich are not es&entially of a malig- 
nant eharaetur. The eucroaduuenta on the ua£al cavity and 
On the posterior fauces are, en the whole, less serious in their 
consoqiienccs. 

Of the general characters of the fibrous tumors of bono w< 
have already given an account at page 256. In the jaws, whei 
these Mimors are mo&t cominonly sitnated, they may ho fmmiT 
growing cither from the outside of the bone, and then they are 
usually confounded with the periosteum, from which, rather 
than the bone, they Eeem to be an outgroM-tli, or, in other cues, 
the growth ia from tlie central part of the bone outward, and 
in the increase of the tumor the outer compact shell of the 
bone Is often distended to an cnnnnons extent over the masB. 
The practical difterencc between these two methods of gi-owth 
seems to be that^ in the periosteal outgrowtli, the diacnscd maas 
cannot bo cleanly sqiaratcd from the bone, which ia gmdnally 
more and more implieated in the tumor; while, in the 
from within, the bone covering the tumor is merely in eontac 
with it, and the msss can readily be enucleated irom its bouj 



ml 




TUMOnS OF THE JAWS. 



317 



connectiunSf except at the puiiit from which it Bpniigs. This 
unatoiiiinil dilTercnte is illuslnitcd in Figs. 83 aad 80, taken 
ixvm Mr. P.igct'u " Surgical I'atliolo^'v." 

Fig. ail from Ileatli, gives the t^xtcnial Appeamnce of the 
bone as itts wall^ yield betore the growth of these tumon;. 

Of all the tuiiiore, however, wiiifh affect the jaws, the mye- 
loid LB that wlitcb haa attracted must the btteution of receut 



n*. n^-{rioni nv*t> 



Pi«. H^rrom P*ff*t) 



Biirgicnl writers. Though occasionally found in other boncB,yet 
it itt so much more common in the jiiws as to entitle it to bo 
coneidereil the pocnliar tumor of this region. We have already, 
in a prcvioua chapter, given the general histor}- of ihis form of 
tamor; there only remains to say a few words of some of its 
features as affecting the jaws. First, they almost nniformly 
grow from the inner parts of the bone, either the cancellous 
tUsne or the antrum, and beo<^c they are almost invariably cov- 
ered with the thin shell of bona so often alluded to. It is true 
that some even very large uiyehiid tumors are connected with 
the gums, and secondarily involve the jaw. The history of 
these cases clears tip their nature, and shows that they have 
commenced as true epulis. Their growth in tlie jaws is very 
dow, sometimes occupying years in their development — con- 
trasting, I think, somewhat with their more rapid career in 
other bones. A very striking exception to this general fact 
occurred lu a case recently treated by my friend Dr. Henry B. 
Sands, tlio notes of which he has kindly placed at my disposal : 
^^ AvffiiH 14, 1870. — Operated to-day on Emma K., aged 
fhirtcoa, for the removal of a tumor of the right superior max- 



318 



T1TH0R3 OF BOKB. 



nia, which wns first noticed two months ago, and was then mte- 
taicen by the parenta for a jrum-boiL Wlien examincil a shor 
Ume aAurwfird, by Dr. Sflmfuu-in, it vau thought to be confint 
to the alreolar procca^, and involved the socketa of the 
and i><econd molar teeth, which, though stjtmd, were loo!;en< 
Dr. Sampson extracted the teeth, and excise^l the tiimoi 
Shortly after this operation, the growth reappeared, and 
attempt wan made to remove the diseased parts by means o( 
the knite and actual cautery. The second operation, pertuniied 
8 fortnight ago, doca not appear to have checked the growtli, 
and it is probable that in neither operation waa cxtirixition 
thoroughly ar(V>mpliidicd. \\licn the patient cnme to me, a fe^^ 
dnyft since, I discerned a soft, elastic, flenhj-looking nwel1in^^| 
occupying the right half of the roof of the month, and evi<lcntly 
involving the alveolar proceaa of the upper jaw. Its surfice wag 
convex And slightly ulcerated. It extended from tlie curve of 
the dental arcli inward nearly to the median line, and back^f 
wan) as far as tlie posterior edge of the palate process of th^^ 
maxillary bone, Whether it occupied the antrum I conld nnt 
determine previons to the operation, which I performed this 
morning.'' 

The operation eonsistfld in the careful and thorough removal 
of all tisauc that appeared diseased, leaving the orbital plate. 
Tlie cptiration sliowud that the mass sprung from the alverdsBM 
floor of the antrum, into which it had ]>rotrudcd without nnj^l 
attachment to its sides or roof. It wus, thcrctbro, cssonttally 
alveolar in tt& origin, and pretty certainly epuloid in its earliest 
stages. Posteriorly the limits of the tumor were ill de&ied; 
it was followed back to the pterygoid process of the sphenoid 
hone. 

"No cnuse could be assigned for the disease. The patient 
is a healthy-looking country girl, and inherits no morbid ten- 
dencies. Her parents are alive and well, and have nine living 
children." Three months ailer the operation she was h 
from, quite welL 

Dr. Delafid'l makes the fallowing report of the microsoopt 
characters of the tumor: "The tumor has a peculiar loo84>' 
spongy conaistence. It consists of a basement stroma, partly 
flbroiiB, but mostly composed of small, round cells. In the 



vmg 



w Tira JAI 



81« 



stroma are numerous alveoli, either rounded or oval. The 
alveoli are single, or a number of ihcin arc found cloao togctlior 
like the 8e«;tion of a racemofto gland. They are filled with 
email polygonal cells." These represent the myeloid element, 
and are present in great numbers. "Most of them aUo cuii- 
tain large hjitliue bodies of globular sha{>e. These bodies, 
when isolated, consist of a homogeneous hyaline substance, 
sometimes wrinkled, sometimes on a pedido of the same ma- 
terial, sometimes strung together on n. broad hand of the same 
materiaL" Most of tJic hyaline bodies in the specimen shown 
to me were oval instead of round. 

Another case, which I saw at various times with Dr. Sands, 
iTlustratcs the more common course of this disease, and its very 
^reat tendency to be reproduced in loco. I coiidensQ from Dr. 
Hinds's notes: 

Aaa Ilill, aged thirty-eight, presented Iiimsell", December 12, 

1S63, with a tumor of the superior maxilla whipli had been 

growing for about eigliteen monttis. The right cheek sliowed 

a wcll-mHrked prominence over the body of the superior maxil- 

isrj' bone. On looking into the month a large tumor is seen 

projecting into \U cavity, occupying the whole of the jaw, and 

extending a little beyond the median line. Tumor firm, clastic, 

Hot tender, not ulcerated, Hight nostril somewhat obstructed. 

3Vo pressure into orbit. The upper jaw was entirely removed 

liy r*r. W. Parker, and the jmtient made a gtjod recovery. 

Matf 17, 18G6.— The disease hits returned, occupying tho 
"Sfvalls of the cavity from whi<"h it had been removed, filling the 
Tjostril, and involving the pti-rygoid plate of the sphenoid. It 
"Waa again removed as far as it could be reached, and, to the 
Jxiinis where the knife could not safely be cfliTiod, the actual 
^rautery was freely a|)plied. The wounds liealed kindly. 

Januartj 27, 1870. — Tho disease, doubtless imperfectly re- 
' amoved in the last operation, has returned, and now involvea 
the letY antnim, while a large projecting ma-its presses down 
into the phnri'nx, and seriiniHly interferes with deglutition. It 
iTivolvcs the entire lefY snperior maxilla. It has also invaded 
the right tonsil. The whole left superior maxilla was removed, 
%Qd every particle of the diseased tissue was e.-5tirpaled as far 
as could be reached, and, as before, the actual cautery was thor> 



320 



nnioi 






oughly applied on all doubtful spots. lie rocovored 
severe operallctn, tliougli tlio woumU in the mouth we 
henlod when he died of puuumonia on the 23d of July, 1870. 
Htu lieahh utUil hi^ la^t attack had been very well maintained. 

The uiicroscopical cxaiuinatiou of the last tumor rcmovod 
was miide by Dr. DelaticUl: "The portion of tlic tnmor which , 
wu examined waji of uniform consistenco, of a white eolo^^| 
mottled witli brown (after preservation in alcohol). Theniinut^* 
structure of the tumor U a fibrous stroma containing colls. The 
stroma fonus in scjmo places a very doli&ito not-work, in utli< 
thick bamU of fibnjus tissue. The cells which are eiubeddt 
in the stroma are round, oval, fiiatlbrm, and slellate conne 
tjve-i8sae cella, with great numbers of tlio large^ irreffular, 
finely-^-anuInr mosaes, filled witti nudeij usually called myt 
plaxos." 

Many years ago, while curator of the New York Ilospit 
Museum, we received a donation of a spet-imen of upper ja^ 
which had been removed several years bclWe, and which w( 
presented to us by the operator, i>r. A. H. Steven^ then oi 
of the sur^i'UB of the hoiipital. He had removed it from A 
private p.atient, and had preserved it in his own cabinet until 
the formation of the hospital oollocUon began, when bis waa 
one of the first contributionfi. It in No. 4K in the cat!iIoj3:ue. 
Mr. G., the gentleman from whom it was taken, was a man in 
the prime of life, about thirty-tliree ycare of age, one of our 
most prominent la^'yers, active in his habtls, ."^iid in other 
respects perlectly healthy. He consulted Dr. Stevens in Au- 
gust, 18:23, "on, account of n swelling and a livid redness of the 
glim from the root of the first left incisor tooth to the ponull 
mate molar of tlic nppor jaw. The membrane lining the ro( 
of the mouth between thcee same points exhibited the sat 
appearances. Externally, the clieek, under the orbit of tlie eye, 
wa* projected foi-ward, so ns to fill up the an-rlo between the 
nose and the check." The tumor, with a considerable portion 
of the jaw, was removed August 14, IS23. The operation In 
an historical interest, as being the first one of its kind perform* 
hi this city, and one of the first anywhere attempted. Dr. 
son's operation, which is recognized, as the first, liuving 
performed in 1820. Dr. David L. Kodgers's o}>oration, whi( 



the , 




TCMORS OF THE JAWS. 



321 



ras more extensive Uian cither, involving nearly the whole of 
'both upjior jawB, m'ss done in 18ii4. The oj>cr.itiun was done 
mainlv with a tine saw made out of a waU-h-t^jiring, and did not 
embrace the orhital plate of the m&xilltiry bono. " The cxnmt- 
Dation of the removed jaw showed a ftingous tnnior occupying 

^ho whole Antrum, aud arising by a broad ba!>e t!rom the luwer 

Hportiou of it." 

Mr. (t. recoTcrod withoat any drawback from the operation, 
and an iujfouioas dentist of that day fitted to the gup in the 
jawbone an ivor}' plate, with the proper teeth^ which answered 
a very go<jd puriiose, entirely eomiealing the deformity. I be- 
came aapiiuutud with !Mr. Q. in 18-18, and, though much with 
bun, I never suspected that he had lost any portion of Uie bones 
of his face until he told me of the fact, and allowed mo the scat 
of tbc operation, which presented a perfectly sound and healthy 
appearance, lie died of pnenmonia in ISoO, then npproachiug 
fixty years of age. lie lived, therefore, twenty-seven ycara 

—entirely free from any symptom of recurrence of tlio disease. 

^ Dr. Delafield made a careful examination of the tnmor after 
it bad lain iu the museum of Br. Stevens's private coUuctioa, 
and allerward in that of the New York lloapital for forty- 
ecven yeurti. ilis report of bU examiuntion, imide in 1870, ia 
as follows : 

K *' Atlenoma of tha Antrum. I7ew York JTonj/ltul Jfimeum,, 

fZPo. 4S. — A tnmor IIIIb the antrum, and replnceg the superior 
waxilta and hard palate; the orbital plate is absent from the 
specimen. Tlic incisor teeth remain in placa The superior 
maxilla retjiina its normal shape, but the bone is replaced by 
the new growUu The tumor, after preservation in alcohol for 
many years, is mostly of a loose, spongy eongiatence, though 
soiue parts aro hard and fibrous. A few spicule of bone are 
scattered irregularly through it. The minute structure is tliat 
of follicles, which api>eAr n^und, oval, or long^ iu dilferent seo- 
tioiis. These follicles are, for the most part, very regular in 
sbapo and arrangement, reaembling the sectioa of a racemose 
gland. The walla of the follicles aro of fibrous tiSBuc. Tlie 
ioIHcIpri are filled with an amori^hons mass, probably epithelial 

■hells destroyed by the long prescn'ation of the s{)ecimen. In 
Bomc places, however^ these follicles do not have the same 
21 



S2S 



TtJMORB 07 BOXK. 



regular ehnpe and arrangeniont, but are found %'ery large, or 
email and isnlated in fibrous ti?ane." 

Tliiu case seems to me a very interesting example of an «. 
tremely rare affertion. Adenoma is unknown in the bonca, and 
ita existence is only rendered possible in the jan-s by tbetrn- 
tensive connection witb the mueous membrane, in the nomorou 
glands of which it seems quite reasonable to eappose It tu; 
have had its ori^n. The microscopical appearances are, it moit 
be acknowledged, somewhat obscured by the lengthened ai»t» 
ation of thiB [ipecimcn, but enough remains to make itsdli^ 
actere unmistakable. The regular alvpoH, encloaed witli mil- 
formed fihrous titt^ue^ can Imiiily be mistaken for any tboii; 
but the alveoli of epithelial cancer, and this idea of its rattn 
eeems to be rduted by the manifest and well-proved Iwnignilr 
of ita course. This \-ery benignity, attested by twentr-aeTW 
ycarft of non-recurreneo, coincides very accurately with ihoie- 
knowledgcd good character of the adenomatous tumors wiff- 
ever found. 

The operations necessary for the removal of these solid 'I^ 
mors of the jaws are of two kinds, viz., those whidi invol« » 
partinl, and those which deinnnd an entire, resection of tl^ 
bone. In a considerable number of cases, porlicuhirly irhtft 
the tumor h mninly confined to the alveolar arch or to the tn- 
trum, a partial roHcction is all that is required to secnre tke 
final conditions of success. Tliis partial operation, involvfeg 
only such parts of the bone aa are manifestly diseased, is aliray! 
to be preferred to the more severe and extensive resection rf 
the whole jaw, not merely because it is a less eerioiu surgbsl 
operation, though tliat coni«ideration should have great weij^N 
but because the resulting defonuity is so much lees; ui<ltbr 
inconveniences of the loss of support to the fauces aud veium, 
aa well as of the wide exposure of the diifcront mucooii c*n- 
tics, are not eo disagreeably experienced by the patient. Tbc 
dentist's art has readied bo great perfection that he isaWcW 
Bupply extensive deficiencies, if only he has a bnsc to woA 
upon ; hut the mutilation caused by the removal of the wl»l» 
of the upper or lower jaw la a pcrious evil to which the patiea't 
if he recover, is condemned for life, and for which the nta^ 
skilful dental mechanist can offer bat an imperfect compfno* 



TtmOSS OF TOE JAWB. 



383 



tion. It bocomcs, therefore, the duty of the surgeon to meas- 
ure with great care the amouut of deatniction he inflicts on 
the bone dieeaeed, and limit, with Bcrupulons precision, this 
destnictioQ to the degree ucce&earv to secure liiiu against leav- 
ing behind any portiua of the disensud growth. 

To this point the enipliatic cautions of Kir AVilliam FergiiB- 
ton Etrongly tend, and 1 tliink it hns been in this direction ttiat 
the mind of the best sargeons has inclined, ever ainco the opcr- 
atiou of excision of the jnwa has been introduced. Most of 
the operations, of which I hnvc had any knowledge during the 
past few years, have been of this partial character. Sir William 
Fergnswn's advice is, in all cases, to begin the oporatton by at- 
ticking the tnmor nt its central point*, extending the area of 
excision as the parts mrty be found diseased ; and iu this way 
*e have proceeded at the New York IIo»pital with very Kitis- 
lactory Biicceet;, in a nainber of inBtances. Wliat diflercnee 
there may be in the ultimate result of partial and entire exsoo- 
tion, only cxteneivo and careful BtatiBtical compflrison can dis- 
cover, but it seems to mo that only the aaccrtaincil fuct, lliat re- 
eurrcncea in loco are more common after well-conducted partial 
than after complete removals, would jnstifv us in inflicting the 
greater injury, provided there seems good evidence that in the 
leeser operation we have entirely removed the disease. It can 
only be in reference to the benign class of tumorv that this 
qneetion has any interest, for it is well understood that many 
of this claaa have that local inveteracy by which, if any portion 
he left behind, they are fluro to bo rcpr<^)duccd ; assuming thuB 
a character of semi -malignancy, as some oxprose it, or local ma- 
lignancy, as I think it ia better deticribed, which makes the 
point of complete renio\*al one of prime importance. In the 
tnio cancorouB affections, any operation short of complete re- 
moval would rarely be JHslifiablc. 

Utit, while we give full weight to theec considerations, the 
other side of the question must not be overlooked. Modem 
patiiology e.\pIainB the growth of some tumors by an infection 
uf the fiurrounding parts with the Juices of the original diseased 
mass, in such n way that there is Biippotsed to be, at all times, 
in the immediate neighborhood of the morbid growth, a zone 
or district of tisBue which, while not yet manifestly altered in 



324 



TUMORS OF BO.VE. 



its physical appearances, is alrcadj poisoned by tlie infecting 
fluids which issae from the growing tumor. This view is pretty 
certainly coirect for some cancers, and it eeems reasonable auJ 
even probable for some other tntuora not so essentially malig- 
nant in their nature. If this be so, it mniit bo ackuou'ledgetl 
tliat the risk of reproduution lA very contuderably dinnui&hed^ 
by taking away tlie whole limb or organ containing the foci^H 
of diecaee, and nioiiem clinical obsorvution hus abundantly 
proved Uie fact. In operating, therefore, upon some cases of 
donbtfiil ufttnrc, it is the unrgcoir s duty to consider whether 
anxiety to save the patient from the more extensive mutilati< 
of the removal of the whole jawbone may not lead him to ««( 
rifice the prospect of a perfect ultimate recovery ; for it ini 
not be forgotten that a morbid growth, which has reappeared 
after a partial rumoval of either the np]>er or lower jaw, does 
not present bo ensy or so favorable a subject for complete cxtir^ 
pation as did the original tumor. ^M 

Again, it must be home in mind that some tnniors, partict^^ 
larly the myeloid, often extend thcniselvefl by minute prolon- 
gations, or even detached nodules, so small as not easily to b6 
detected by the aargeon at the moment of operation, and yet 
sufficient to insure a reproduction of the mischief, even before 
the vonndt made by the partial excision have entirely faealud. 
This insidious encroachment of the myeloid tnraor on eurroiind- 
iug healthy part& has already been mentioned in tlie chapter de- 
voted to the general study of these growths, and it is nowhere 
mure strikingly illustrated than iu tlie spongy and alvciohir 
atructuro of the jawbones, where fre<iuent]y the area of real 
disease is found to be much greater than the apparent tumor 
indicated. In all such cases it sccma very certain that the only 
safety for the patient must consist in a very thorough operation, 
if not in a couiplete amputation of the whole infected bone. No 
general rule, therefore, as it seems to me, cau be laid down im 
this point of the extent of ojieration which shall bo pcrformt 
Each case must be judged of by itself; but I think no judidoi 
surgeon will venture to decide on his course without csrofbllj 
considering both the views of the question which hare beca^ 
Above presented. 

The details of the operation will necessarily vary with the 



TUHORS OP TUB JAUS. 



335 



cue. TliU i» hardly tbo occttaion to enter into the various 
modifications of proeednrc which have been adopted, or which 
may be neceesary. I confine myself, therefore, to a few BUnjjea- 
tioos of general practical interest. And first, with regard to 
incisions. Many of the partial operatinna ean be conveuiently 
and eaeily a(.-complishe<L without any incision of the skin. The 
tissue of the Up is so extensible, that with proper assistants, and 
iiith suitable spatulie, very exlcneive excisions, and, even in 
Btnall toraors, eomplete extirpation of the upper jaw might be 
accompli ahed. If incisions are re(iuired, then, in the upper jaw, 
the most useful and 1ea»t deforming is one i-ommencing in the 
median line of the upper Up, extending round the ala of the 
Doe^ and up along its side to the inner ranthus of the eye, 
Mr. Feignsson strongly roeoninieuds ttiis incision. He says: 
" By these incifiions throiigii the lip, up the side of the nose, 
and aiong the lower eyelid as far out as may be useful, say 
even to the zygoma, all the room required for the ri>moval of a 
large tumor may be sccnrcd, and tlic most conspiouous jwrt of 
the cheek left untouched. Another great advantage which I 
claim for these incisions is, that tlie chief vessels of tlie surface 
arc all divided at their uArroweet points, and thus hemorrhage 
is Ic^ severe than when the facial arti-ry is divideti in the mid- 
dle of the cheeh, as in the common incision." Of course, it 
will hnppcn, in particnljir inatauccii, that more extensive or 
differently-planned ineirfions may better answer the surge«m's 
purpose; but there must bo very few cases in which the in- 
(ision given by Sir William Fergusson will not be the best, 
both as regards convenience of operating and subsequent do- 
fonnitv. "Wlien the flap thus marked out is carefully raised 
&om the bone, the next step in llie oj^eratioii, if the entire 
maxilla is to be removed, is to sepiirate the median uttachrnenta 
of the two boucs tit the line of junction along the palate. This 
is beet sarompliBhed by a fine saw, which is patted intx> the nos- 
tril, and by it tlie luu^:l palate is dividc<I from above downward 
as far back as the jmlate-bone. Much is not said by writers on 
this operation, about saving the piilato-bone, thereby leaving a 
ipport for the velum, and preserving the sliape and nscfiilncsfl 
the isthmus fauciiim. In persons past middle life it cannot 
easily be done, as the palate processes of the superior ma.\illary 



526 



TUUOBS OF BONB. 



i 

in- 

I 



3 



and palatc-bonc am so firmly welded together as not to be easily 
sepsratod; but in }'oung pdoplc, if the nnttiro of the tumor wi 
admit of hj the attempt should l>o nmde^ »iid will otlen be 6 
dcssful. This incision had better be complete with the SA 
and will be much facilitjited by the previons removal of the in- 
cisor tootli. The mahir bone is next to be cut through, and thi 
is portiaps best accompliiihcd hy cutting the compact tissue 
the surface with the saw, and completing the section^ across 
tlie anterior end of the spheno-maxilhtry fissure, b^ the stron 
eutting-furcepa. Then, hy the same forceps, i)af»cd into tlie 
nostril and orbit, tliu iianal procct^ of the maxillary bone is 
divided, and we liave only remaining the attachmciitH to th^^ 
palato-bouc, and tlirough it to the sphenoid behind, and to th^| 
lower edge of ethmoid in the orbit. These attachments aro 
easily broken by a slight rocking motion of the nearly-severe 
jaw, and this can very conveniently be imparted to it by seiztt 
it with the double-toothed " lion-forceps," first suggested 
Sir William Fergusaon for this purpose. These motions should 
be cuuttoua and gentle at tirst, so as to secure, if possible, a 
loosening at the natural junctions, and afterward more forcible 
and extensive, as may be nccci^sary to detach the mass. Tho 
soft parts which hold It muttt he severed with the scalpel, or 
strong curved acisaors, care being taken not to wander awat 
ftijm the surfaces of the bone which is being remove<l. lest im? 
portant nerves and vessels be unnecessarily injured. The intra- 
orbital nerve should be treated with especial consideration, an^f 
no violent tractions shoidd bo made upon it before it is cut. 
This caution as to the early carcfal movement of the loosening 
mass is of special interest where it is desired to save the palato- 
bono H'om coining away with tho maxillary. 

Commonly, no largo vessels are wounded, if the surgeon 
have been careful in hugging the hone while using bis scisatjrs. 
The space left by the removal is so large and open that the ves- 
sels can easily be secured. I liavc once seen the trunk of the 
internal maxillary opened jniit as the jaw was about to be 
tached from its bed. The bleeding was profuse, but it ws 
easily controlled by the sponge, and without much trouble safti 
secured by tlic ligature. I have never seen the carotid ligatured 
before the operation, nor has it ever seemed to we to be at aU 



ful^ 



Trmons op tde JAwa 



397 



The wid&^pcn character of the wound makes it 
easy to apply tho actual cautery with precision to any points 

L which may have a doubtful look at\«r tho main disease is re- 
moved ; and with us it has been a common practice to resort to 
It freely. 
The removal of both upper jaws has now been several times 
perfumi*xl with success, and with less detbrmity than might bo 
expected from so extenaivo a mutilation. Dr. David L. Uogers, 
of this city, was the tirst gurgeon to attempt thifi operation} 
piich lie did in 1824. His case is recorded in a volume of 
Riirgii>»I essays, published by himself, in 1S49. It was a man, 
aged thirty-four, who came to Dr. liogers witli a tumor occu- 
pying all the front of the upper jawbone, and extending into 
the right nostril, with the loss of all tho upper incisors. It was 
Rowing rapidly, and had only existed about six M'eeks. His 
operation was perlormed May 10, 1824, and was published in 
tlio third volume of the Phynico- Metlwal Jour/ial of that year. 
J^rom his own book, piihlishod flilocn years afterward, T take 
the following account of the opemtive procedure : " An in- 
ojdion was made first through the filtrum of tlio upper lip, 
■*vhich was dissected fW>m the tumor and ala; of the nose, so as 
to turn both portions of the Up over upou the cheek. The seo 
oad incision was to detach the caililagliious portion of the scp- 
Intti nariuui fi-om the top of the tumor. After extnit'ttiig tho 
Urst two molar teeth on each side, a fine aaw was used which 
^Kfe>eadily divided the superior maxilhiry bono including the pala- 
tine process, tho two incisions nicoting at the palatine suture. 
^A-fter sawing through the principil bones, the tumor was easily 
*^moved, althongh it extended much farther back than was at 
■first aaticipatod. It was found necessary, during the operation, 

»to remove the two inferior turbinated hunes, a part of the sep- 
tum narium, the vomer, and a part of the right antrum." The 
man recovered well, with a moderate amount of deformity. 
The record of tho ojicratitm is lucking in anatomical precision^ 
and the extent of the excision is left somewhat doubtful. It 
can hardly claim, however, to have been a complete extirpation 
of both upper jaws, while to it must nevertheless be accorded 
the honor of being .1 pioneer effort in the field, since so happily 
cultivated, and deserving of all the credit to which its bold* 



ssd 



• TTHOnS OF DONB. 




nesB, originalitT, and bucc^m are, in all fairnese, entitled. 
In operating ou the lower jaw, much may bo done witboDt 
any external iuci^iun. biiudl portioiu, and iudeed tiiu until 
lialf of tlic l>onc, can be excii>ed tltrougfa the mouth with 
cutting the lij). llj however, tlie tumor be Urge, and partk 
larly if it involve the ramua, a» in some inKtanfes uf cy? 
growth, then external incision in indispensable. The incision 
usually practi&e<l is one parallel with the base of the bone, and 
thrown back us much as jxisfeihlc, that the ecar may be out of 
sight. Tliis incision, by being prolonged on the cheek, gives 
ample room even for the removal of tht* entire bone[ and some 
writers rccmnmend to incise tho lower lip, in the median line, 
aa fer as the vermilion border, if more room is required. Th^, 
simple vertical incision of the lower lip, prolonged well bod^| 



ward, ia said to give all 



llltJlAKH' 






./ 



the space neceosary for any of tbede 
operations, tiiongfa 1 have not nse^i 
it nor seen it employed. At\or ac||^| 
arating tlie hone carefully trom th^^ 
mil pHrtB at tlte diin, both befor 
and behind, and extracting a eenti 
incisor of the side on whit-h the did 
Ciaee exists, a clmin-saw (Fig. 37) maj 
bo passed round tho bone, and its 
division aeconiplishtHl at or near the 
symphysis. Then, with a sharp an^^ 
strong scalpel, closely hugging tb^| 




Fm. ST. 



bono, the attachments arc lo be df- 
Ti-ided, an assistant at the same time 
managing the loosening bone, so as 
to keep the rcin.iining attachments 
in a state of tension. This part of 
the propeduro is sufficiently simple 
and easy, but becomes diiiinult as we approach the eondvie 
where from the depth of the part it is not easy tn sever the 
ItgaineiilH of the joint. This diflficulty become* perions vh 
the ramus and eoronoid process are duitended by tho mor 
growth, and it sometitiies h simply impossible to finish the 
moval without cutting off the mass as near the joint as possib! 
and iLcQ witli sharp, curved forceps, and the rengeur, removing 



ate 

1 

bl^ 



TCUOBS OP THR JAWS. 



329 



le dptached condyle piefemen!. Ferf^sson's lioTi-forcepH (Fig. 
ie rlie Ik'SI instrument for tlus purpow, giving the holder 
fees control of the movcmentg of tlio fmgnient, and enabling 
im to change tJ*e tcnuion of the attAclimenta to meet the opera- 
)r'8 knife. The facial artery is the priacipal vc«8cl UBiinll; cut 



Tte»'- 



>i» 



C3^ 



Fm. & 



nn this openition, and this ih cut and tied nt the time of making 
Itiie first incision. When the entire jaw is to he removed, it is 
\woll to ftccttro the tongue from falling back into thcphsrynx 
||md choking the patient, as in Severn! of the earlier reconled 
fCpemtionB it threatened to do. This is easily at-eomplished by 
fpft«sing a strong double silk thrcnd through the Buhstance of 
[the tongue abont an inch from the tip, which is given to a 
[careful assistant, who&e duty it is to watch fur this ["articular 
[dangor and obviate it hy drawing the tongue firmly forward. 
^fUter the wonnd is bmught together, and the nniecles have 
[become aeeui'tamcd to the loee of balanced action, there is but 
uittle danger from the swallowing of the t^mgne. 
\ The wounds made in tlieee operations should bo hglitly 
puffed with soft, well-picked lint, and the incised integument 

roiight togctlicrwith the moat careful accumcy. Some eur- 
ma prefer the silver sutures. We have, at the New York 

oflpital, used the fine annealed iron wire with great satififac- 
(tlon ; but, in my later oper^itions on the face, T have been much 
toleaeed with the very fine silk suture, made with an ordinary 
ronnd cambric needle. From its extreme pliability, the eilk 
pdapta the edges more perfectly to each oilier than nny metallic 
Vfro can do, and the cambric needle, though not quite eo easily 
t tlirough the skin, nuikea Icse of a wound than the ordJ- 



330 



TUMORS OF SOKE. 



nary surgical needles, and leaves much less of a acar. If the 
fltips are loose, and not well sujiportcd by the parts beneath, 
lliL-u Uic harelip pins, at intenals among the other sutures, 
maintain the parts more perfuutly in coapUttiou, and steady the 
whole Uue of suture, ^o adheiiive plusterfi are usually uecoa- 
aary. 

OonRJdering the magnitude of these opcrationa, and the ex- 
tent and inii>ortance of the iiarts involved, thoy are very suo- 
cossful in their result. In the Medical TiiMg and Gae^tts 
for Septetitber 13, 1859, is found a table of eeventeea caaea of 
resection of the upper jaw for various diseases, and by various 
operatore, and of the sovcutcen only three died. The rest re- 
covered entirely from the operation, though scrcral suffered of 
course from a retiini of the malignant disease whieh had 
dcred an upm-atiun neeessar^', I tluuk our. own operations 
A'ow York would sliow a not less satisfactory result. A similar i 
table in the satne journal shows a mortality of three in elevei^H 
cases of the lower jaw operated on in several of the London^ 
hospitals. These tables of coui-se do not claim to represent the 
exact mortality alter tliese operations. Thoy are suffiuieut, how- 
ever, to indicate that, under favorable circumstances, the opera^H 
tiun is a safe and suucL'ssful uue. ^H 

The following ease I saw with much interest with my friend i 
Dr. Goodwillic, and I give it in his own worda. It is an inter- 
esting account of a very neat and sueccssful openilion, and at 
the same time a good, and I Chink quite a rare, example of the 
hard foi-m of osseous growth of tlie cancellous variety In the 
alveolar border of the superior maxillary bone. The micro- 
scopical appearances, of wliicli a drawing is given^ were reported 
by Dr. J. W. S. Arnold : 

'* Mra. It., aged forty-four years, has always enjoyed very 
health. Some six years ago she first noticed tlut the alveolus 
of the right superior maxillary began to enlarge, and liae gradu- 
ally increatsed to the jireBcnt time. 

"She has e.\pcriei)ced no pain, and desired to have it re- 
moved, m from its large size it has become a source of great 
annoyance to her. In size and shape it very much reaombles 
a ben's egg, the large end presenting posteriorly. It extends 
autero-positerlorly Irom the right superior cauiuo to the internal 



TCMORS OF THE JAWS. 



aai 



^terjgoid process ; IftterflUy from near tlie irentre of the palate to 
lie maxillo-malftr fo&sa forward to the caniue fotm. Tiic duur of 
ie antrum of llighiiiurt! w&n uuvniauhud vu to a tdiglil clugree. 
The macouB membrane over the &urlaL-e of tho tumor appeurod 
a little lighter in culor than is cumuion to the alvcohis ; tins 
|3rms no doubt due to the tension on it b_y tlio parts below; 
mhcrwi^ it viaa in a normal condition. In tlie surface of tho 
tumor could be fteen the fangs of the first and second molars. 
The canine and bicuspids were not decayed. Canine and first 
bicuspid retained tlieir nomial jweition in the jaw. All the 
crown of the latter was buried in the tmnor, except the cuspa. 
The crown of the Hucond bieuspid could all be seen, but the 
rhole tooth was niised out of ita nurmitl position, and tlu'owa 
iward about one-half of an inch (Fig. 89). 




y 



ftfl. m.-^Tnn Dr. D. H. Qooiirtiaet CWImUod.) 



"There boin^r no pain or discharge from the month or nose 
doring the lonj? period of its growth — its apparent firm texture 
witli no crepitation — tofFether with tlie excellent health the 
patient has alwiiys enjoyed, there appeared no doubt of its 
benign character. 



8S2 



TTMOSS OP Boya 



*' The following cut (Fig. 90) represent* sn orsl saw tliat I 
devised to be used in opevatiuni* on tlio maxillary bones. 

'*To a Uaudlti (a) ia Hiiul.v ^bteucd a U ciliituk (6) to tab in 
tlie check or Hj), and thus do away with making extenul iod- 
siuns. On the otlier extremity ot* tlie riluink ie a squaro lockrt 
to whicli arc titled saws (or knires) of ditfurent eizcs, these king 
firmly ftfttene*! by a thumb-screw (c). The eot-ket being equare^ 
allows the saw (or knife) to be turned and worked in foitri 
rettions. It is uiily nec-es&anr' to unBcrow the fnsteningasbo 
dititauce, to turn iha saw in the desired direction. 



e.TiEMARN&ea. 

e 



" The BRw, being in direct lino with the handle, can be 
easily guided. The bat^ka of the saws aqe ihin, while the teith 
are broad, thna giving free action. 

"On June 20, 1871, the {Kiticnt war placod in an operniing- 
chair, and, when she was fully under the aiweetlietii.*, the IkhJ 
WHS thrown back, and the mouth kept open bj a gag betwMO 
tlie molar teeth of the opposite side. Taking my ^loeitton to 
haek and over the head of (he jmtient, I pincod m sponge cat I 
completely fill up the jjaseago to the tJiroat, and Iwld in ]ioeitio 
on the Boft palate hy a sporgo-lu)lder to prcrvont the blood 
iiig into the throat during the first part of the operation. 
patient waa only allowed to breath througli tlie nose, «liicli 
ponld very well do. No external inciBion of the lace wasoad 
The two intemnl incisions were made from Iwhind on the; 
tenor protniuenee of the tumor, one-half inch on each 
of the flings nf the molars forwanl to the left central incis 
The hone was now hid bare by stripping tlio soft parts 
pertostoal denuders; the latter part of this o|>enition WM *" 
tear the piilntal mtisiles from the posterior part of the It»> 
palate withftiit injuring the piilntal veaaels and nerve that jasK* 
over on to tlic hard palate at this point. There being no faiOus 



TUUORS OF THE JAHTS. 



888 



nsc for tlic sponge on tlio soft. (Uilate, it wnsi removed. Tlie right 
lateral incisur was now cxtriL'tcd, nnJ, by its socket through a 

I little to the right of tho centre of the hard palate, so aa to savo 

I the vomer, a section wns made with tlie onil saw, thus dividing 
the superior inaxillArv boues. This saw whs iiuw reuiovod from 
the socket and i-epUced b,v another one, half us lung (one auU 

la half inch), tho teeth of wliifh were clmogeil to a difierent 
aiiglOr M nt) to allow the check to go into tlie ll-sliank, nnd let 
the saw play frcelj. This section w»s made iip between tlio 
tumor and the inleriial ptert-guid pi-ccess to the malar bone, 
then forwiird tluough the canine fossMi, dividing also the utferiur 
turbinated bone, to meet the other section at tho right ahi Q:isi. 
AJlor clio saw Imd cntcrc<1 the antntm, tho handle of the saw 

■waa more nipidly advanced Ih n the point; tliis prevented tlio 



m 



Ito. n.^Onerau tamaT tVnm Dr. n. II <1nni|iiTlt1l«i. innirnlflail SM dUtnMn*.) 
UrftWD bj- J. W. S. Aroobl, M. I). 



point of tho Bftw from piercing the vomer which I desired to 
■ave. By these two sections the tumor with the adjacent bone 
was removed clean. After hivmorrhage had stopped, the soft 
parts were closed by seven eilk sutures. On the fifth day four 
of the sutures were removed, and tlie remainder on the follow- 




334 



TUIIORS OP nOKE. 



iiig d«y, the wound having healed by first intention. Four 
uiuntlis after the tiperation, there appears every indication of 
a new formation of bone. 

*' Pathological examination of the tumor shows it to be o«m>* 
otui. On making a section of tlie tumor through the line 
the teeth, the following waa observed : 

" At the apex of the root of the second molar tooth there 
was a 8m»l), liult i-yet containing pus, and fur a short distance 
Kurrounditig this bone Hp[ieared iiuite eancellated, but the rest 
of the tumor was quite dense. The pulps of the canine and first 
bicuspid teeth had still Bome vitality, but that of the second 
bicuspid waa dead. The pulp^ianxbcrs were decreased In size 
by a deposit of osteo-dentine to their walls. The cementnm on 
tlie fangs of the teeth was hyportrophied. A Urge nerv© en- 
tdi'cd the tumor on its buccal side. 

"■Microsooptcal CJuxracUr. — Composed of cancellated liesue 
almost entirely; the outer rim or cidge of a thin layer of 
more compact bony tissue; iu the spongy part a small amount 
of soft marrow, containing the usuaI constituents of fecial : 
row, that \%y niedullo cells and niyeloplaxes, \^-ith uil-globult 
(Fig. 91.) 



PART III. 



MiLlGiXANT DISEASES OF BO^JTE. 



ts the liglit of rwpnt mirmscnpical find rliniral BfrndicB, it is 
■not o:ifiy cvartly to define the intoning nf tlic torm malignant 
KB applied to morbid growths. The difficulty does not ftrisc so 
much from any waut of precision in the term itself, or any want 
of appropriateu088 when applied to tj-pical and well-marked cases, 
u it dues from tlie varying degree in which the qualities it ox- 
preseea arc manifested in the dilfurcnt tumors in whicdi we study 
it, and the want of constant correspondence between their ana- 
tomical structure and their clinical history. It is pretty well 
aprccd among pathnlogistfi that the chief clinical features of 
mnligrnity arc: 1. A tendenry to Bofton and nli'cmte. 9. \ 
tendency to return after extirpation, even the mnst complete. 
Z. A disposition to appear in many places successively in the 
utne individual, invading many tisanes in the region originally 
affected, and developing itself in many distant organs, where it 
seems to have no connection with the origiual disease. These 
clinical features have been sought to be associated with certain 
physical forms, whitrh pathologists liave hoped would prove 
charactortiftic. This hope has not boon ftilly rpalized. Xo ana- 
tflmii-al fonn has yet been fouml, wliich, of itaelf, is distinctive 
of cancer, and without «'liicb malignancy cannot exist. No as- 
sociation or grouping of histological elements can he said to be 
ahsohitclv charactcri-ti ic of malignancy ; and much as has been 
done by Vin-how, Weljor, "Waldc-yer, Hcftle, and TTuxley, in un- 
ravelling the laws of histogenesis, no mode of development, 
whether as to source, fomis, rate, progress, or Irregularities, can 



830 

be invoked to solvo tlit 



DISEASE^ OF 



question of the clinical Iiistijry of DVCTy 
morbid growth. There will still remain some obsttnattj exce[>- 
tions, where structure and history do not correspond, exceptiona 
which at present wo must accept as indieatinfj to us how superfi- 
cial is our knowledge of the deepest laws of vital organization. 

With this acloiowledjrment, enough remains upon whioli wc 
may build our cla&aifli^atton with sufficient precii^ion for many 
practii-al purposes; and as we may accept those above given as 
the most striking and constant features of what we call maUg- 
nancy, so we liave certain histological and bistogenetic charao- 
ters which comnionty accf>mpany these eiiuical OQO8, which wo 
may with pradii-al utility and safety consider as the physical 
oouditioii with which they are commonly associated, and. upon 
which they usually depend. Thus malij^ant growths arc usually 
unlike tlie tiasuca from which they spring, and many present 
featnrcfl which arc unlike ihofto of any tissue found in the noi 
mal gtnictiires of the body. Again, malignant growths have] 
usually tlmir elements scattered through and iatermLced witb 
the normal tissues, so as to entangle these normal tiasuca with 
tliein in their ])rugrcKS, and to involve them in the dt-strliction 
to which tliey are so certainly hjistcning. These two features, 
heterology and infiltration, are well mnrkcd and characteriBtif 
in a vast proportion of casoe of malignant disease, and thoL*efora^ 
may bo considered the general anatomical features of ihcsc affe^ ' 
tions. Accepting them as simply the general characters of the 
disease, wc may, for moro particular study, divide the great 
class of malignant, or cjinceroua, or carcinoinatoua diseases, for^ 
these terms are generally received aa evnonymons, into the sul 
classes of scirrhous, medullary, epithelial, colloid, and melanoid. 
8ome other suhdiviiriona are eometimee made, but, in relerencQ' 
to tho bones, I believe these will be sufficlcut. 



CHAPTER I. 

SCTREnCS, OR TtAttH OANCEK OF "niK BO!fm. 

Asa primary diEeaao of the bones, scirrhus is extremely rare. 
Several authors allude to tho possibility of its occnrronce; but 
I have not myself seen, nor have I met in any published ac- 



SCIRREIUS, on HARD CANCER OF THE BOVTS. 



337 



leoQnt, any such details of an uncquivoctl case as would warmnt 

my presenting it as an example. As » scL\)ii<laiy develupuicut, 
^^it i* not (jo iincoinnion. It usually has been Ibuud in persona 
Bia vhora the cnncerous cachexia 18 far advanced; in ninny in- 
H »l;incei^ the patieiitH have been bedridden. In ono rase '\rhich 
" uceiUTud a few yuure a^o in tliis t-it^-, the patient, an old lady, 

dying slowly from the disease, primarily developeti in the brcaat, 

had been confined for noinc time to ber bed, 

when, on one wcasion, on nttempting to tuiii 

or to raiae heraelf in bed, one of her thigh 

I bones fT'ivD way, and eonic days after, ou a 
similar trifling exertion, the other al^w broke. 
In her I'ittie the ekeleton wna very extenBivcly 
infiltrated with tnie acirrluins cancer. The 
femorji, the ribs, the Intineri, the pelvic bones, 
and I boliovo all of the bonee which were ex- 
amined, gliDwcd tmces, more or leea consider- 
able, of the disease, in sonic more advanced 
than in others. The spet-inieus were present- 
Bed to thb Pathol ogif-al Society, and, in particu- 
lar, I rcmeinber tlmt the ribs were so soft jis 
to be flexible, and capable of being cut by a 
Bcal|>el. In tliip case, as in the other repoilcd 
cases, the morbid nniturial has all tho a])pc.'ti- 
ancee of the dittcaso when it is developed in 
Itlie soft parts, both to the naked eye and un- 
idcrthe nucrosco[>e. It h pometimcs seen in 
more or lees ronnded tumors, as in Mr. 
t'a ca«e, delineated l-'ig. 92, but more fre- 
quently. BB in the specimens I saw, dissenii- 
»nBted in small nodulos tlirongh the cnncclloiia 
tissue, artt-r the manner of an infiltration. 
The bono-aulMtance becomes gradually dis- f,c u-j-niam p»rL) 
placed, or nither, probably absorbed, so that 
fracture from slight canseB is extremely likely to occur; and, 
indeed, it has been noticed, in certain rare instances, that the 
whole bone has disappeared, Iciiving the pcrinstcum unchanged 
,in size or form, but tilled with rjinceroue material instead of the 
[original osseous tissue. Hr. Paget speaks of a case in M-hidi 
S3 




338 



DISEASES or BOVEL 



"a caucerons fetnur wag broken eight monlliR before dcatli, and 
the now bone with whic-h it whb ropairod was itiSltratcU wi 
cancer as well as the oripfiiial textures." 

To the naked eye the morbid mateiia! preacnta, on scctio' 
the nsnal bhiish-white, pearly, shining, scmi-trannparcnt appear? 
anoe of hard c-anter elsewhere. T'nder the microecope, the cells 
preeent the eame appearances wlii».-h ,ire chamcteristic of the di 
ease in other parts. Their irregnlarity of form, their dim, pel- 
ludd cell-wall, their large nuclei, eonnnonly single, with large, 
distinct nucleoli, are features well marked ; while tlte semi-fluid 
Bubstancc in which these cells lie enclosed, as in a strong, can 
be sq^ueezod out or scrR]>ed out iu considentblu abtiudunce. 
There is aonie dillerence of view among pnthologiats aa to 
whether the fibrous element, so commonly fonnd in this form 
of cancer, be one of new Ibmiatiou, or whether it be only the 
original tissues, distended by, and enclosed in, the growing ca: 
eerous mass. This question, it seems to me, receives some lighi 
from the fact that this fibrons structure is sometimes uUuu 
completely absent in liard cancer of the bones. In some of t 
firmest and most tibroii^-looking of these cases there t& no 
librous tissue to be discovered. 

I>r. Dclafield made a careful e.xamination of snmo of the 
bones removed after death trom a patient of Dr. S]irngne, of 
i'ordhani, who had died of cancer of the broflst of the scirrho 
form. "All the long bones were diseased; had become 
during life, especialh* one femur. Specimens are femur, fi 
and tibia, last afteeted. Femnr is mnch bent, and tibia n 
Periosteum and cartilages not involved. Kearly the entire bo 
and nietlulla chtingwl into a firm, white, lardaceous sub«tance; 
a little of bone of i^haft and eaucellous tiseiue left. Xew tissue 
eoneists of dense bands of M'tnte, iibrous tissue, crossing and in- 
terlacing and foi-ming round and oval interspaces. These 8j>a 
are mostly empty, hut, in the youngest part of tissue, arc fill 
with polygonal, mu-leated cells. The manrnm was a Btuail, con- 
tracted, hurft lump. Only librous itesae could be found; 
cells." 

In another case, brought into Bellevue Hospital Xovemb' 
25, 18fi7, fmcture had ocenrre^l of the right femur by a full in 
the street the day before her admission. The patient was 




sciRRinrs, OR bard cancer of Tire bones. 



339 



very old woioad, eigbtj'-eeveu j-eitrs of age. and had an ulcera- 
ting carciiioma of the bruast of unknown dumtion. An attempt 
was made to treat the broken luub, but idic rapidly failed, nud 
diwl December 8th. 

Atit^jMy. — " Body verymurh emaciated. The ripht mamTna 
is the seat of a large ulcer, with indurated edge* ; tlio axillary 
glands are mnch enlarged ; several small tubers in the skin near 
the nicer. lUad. — In tlie vault of the t-niniuin are three round- 
ed places wliere the bone is replaced by u sti-ucture resembling 
fibrous tissue; the periosteum and dura mater are adherent to 
these plaees, but tliero is no tumor. In the bone surrounding 
these placet;, the dipIo3 is iilled wllh new tisBue, and the buiies 
thinned. All the bones of the sknll are eoftcr than natiiml. 
Brain is normal. Lungs. — There are a few old adlicRiona over 
Wh lungs. Both Itinga are more tlian usnally pigmented. The 
upper lobe of tlic right Inng is hepatized. The liver has hardly 
any left lobe. There are gall-stones in the bladder and ductus 
comnumis; the latter is dilated so as tu admit my linger up to 
one quarter uf an inch of the intestine, where it is obstructed. 
Spleen small. A few nodules in the capsule. Peritonteum 
throughout studded with small white tumors. Kidneys, in both 
pelves and calyces, dilated and containing pus, especially the 
left. Tjirge intestine, its w.alls containing many small tumors, 
over which the epithelium has ulcerated. Bones. — The right 
femur is fractured at its middle, the ft-actured ends much dis- 
placed, and bathed in pus. At the ^>oint of fi-aeture the shaft 
of the bone is thinned, and the medullar}* cavity tilled with a 
new grofl-tli. The left fcinur, both tibiie, both humeri, the aa- 
crum, and one os innominatum, contain similar deposits of now 
tiseuG in their nicdulljiry cavities. The scnpulfe, ulum, radii, 
clBTicles, and metneHr|iHl bimc^, contain no such deposit. 

*^ Jfinnt^ JSramiiuUion. — The ncwtiasuo in the mamma and 
in the tubers in the skin presents the same appearance, viz., 
polygonal, nucleated, qiithelinl cells, .018 to .0*35 in diameter, 
contained iu round and oval alveoli, the proportion between cells 

frameM'ork varying in different parts. The tumors in tUo 
itouffium diOer from thete in their greater number of cells. 
In the long bones, the tumors are situated either nest to the 
shaft of the bone or in the cancellous tissue, and aro surrounded 




340 



VAUGVAXT DTSKAfnSS OP BOXB. 



hy rod, indurated umdulUi. This red tuedulla is com[ 
lai^ely of 'nicdulloirellcs.' The now tissnc consUU of a preM 
detisc fibrous fminework, fumiing alveoli wliii'li cvntatu cclla. 
The cells are the same as those found in the hreast. There ai 
also fonnd nnmbera of nnclci ndhcring together and sarronndc 
by protoplisma, not myeloplaxcs. In iwnie places only colU at 
seen. In the cranium the cells are the same, but their arranj 
Uietit is somcwliat ditVcreut. The fibrous titsuo id more abun- 
dant, and the alveoli small; liumu ualy coutiiiuliig two or three 
i-ells, others much larger; und these small alveoli may be close 
ti>getlicr, BO tliat it looks lilcc libro-ojirtilago. The charactor ofj 
tlie cells and the examination of a sufficient number of s( 
mens dcatroy the possibility of this." 



CHAPTER n. 



srai>TIT.IJ.BT, OR SOFT OANOER OF THE BOKE». 

By far the most common form of cjinperous disease of boneft 
is the medullar)-, or soft cancer. Indeed, of all the casea of medul- 
larj- cancer» the bones furnish a very coneidcrablc fraction. Mr. 
Pa^'t gives a table of 103 case* of extenial metlulbry cancer, 
omittiug those of the uterus and other int^nial organs, and of 
these '21 were in the bonoB. I-cbcrt gives a table of 44" can- 
cers, of all kinds, of ivlildi 35 were in the bones. M. Taiichon's 
extt'Dsive tables, embracing 9,118 cases of all kinds, give only^i 
38 to the bones. This small fraction miglit probably bo iii^| 
creased sooocwhat by adding eomctbingfor those case* which 
he includes under the head of thigh, shoulder, leg, arm, etc., 
some of which were doubtless affections of the bones, Mr. 
Sibley's tables give, of 530 cases, l.'i of the bones, and Mr. Baker,| 
in oW) cases, records 23 as occurring in the bones. None oi 
these arc to be relied on as giving an accurate fitatcmotit of thf 
relative frecjuency of cancer in bones, but they may serve t< 
convey some gencml idea on the subject; und, whcJi wc take^ 
into account the fact that by tar the larger proportion of all aro 
medullary, we have arrived at some rough estimate of tho pro- 



■EDDLU&y. OB SOFT CANCBB OP THE BONES. 



341 



portion in which eatrh furm pretseuts hselt' in tho hones as com- 
pared with the soft part^. 

These statistical Btnteracnts liave reference to cancer in all 
ita forms and all itti conditions. Ae a primary dteeaee, liuw- 
cvcr, cflncer In tlie bones is, almost without exception, of the 
soft varietji'. Tho primary tumora present themselves in iiU 
parts of thu skt-letou — Mr. Paget tliiuks most lre((ucntly iti tho 
(high-bone — Hnd nsuiUly ailect the cHnc-ellous tissue in tlic first 
instance; often, imwuver, extending their encroach mints to the 
oompBCt Bubstjinco, which is gradually ineorpfn-atcd with the 
growing mass, losing always its compact character, and hecom- 
ing either altogether absorbed, or spread ont into a sj>ongj* 
maw, pervading the new growth, in which finally no trace of 
the oi-iginal compact structure can be discovered. This is j>ar- 
ticularty the case with the unu and thigh bones, and it is in 
cancer in tticsc situations that we most often have fniL-turcs oe- 
curring from the most trivitil degrees of violence. Most com- 
monly tlic primary cancer is single, and in tho elui])o of a 
rounded tumor, which dislends before it the outer shell of tho 
bone, which shell, growing thinner and thinner, as tho tnmor 
enlarges, it sometimes retains until it lias attained a great size, 
when finally the cancerous mass breaks through its covering, 
and soon all traces of it disappear. The tumor may cither be 
an isolated maps of mcdiillary substance displacing tho surround- 
ing boue-tissues, or, as is most frequently tho case, it is an in- 
filtration from the first; and grows as such, gradually ajipro- 
priating to itself, nnd enclosing within its growing mass, what- 
ever bony material, whether compact or cancclloua, it comes in 
contact with. 

In this way tlie most various shapes nre assmned, and the 
most ^Tirioufl conditions of the growth itself are fuuud. Tho 
tumor usually projects from tho surface of the bone on one siilo ; 
sometimes it projects unequally on both sides, as iu tlie cniuiul 
>nc8. Sometimes, as in the licads of the long bones, tho 
rhole spongy extremity expands nearly eqnnlly, and otYen 
reaclte* an immense size, with a somewhat syminetrieal form 
(Figs. 93, 9i). 0\\ the cranium these tumors very commonly pro- 
ject from tlie surfai-e <if tlie vault in the form of evenly-roimded 
domes or hemispberee, and where several are growing close to 



S43 



MAUOSAXT DISEASES OP BO.VB. 



one another tlie 1iead prceenU a most exti'aonliaar^' appoarsnce. 
Tlie Hguri's HI> and 100 art- tul;cn from pntienta who died of tlio 
disease developing iteell' iiiternallv, wliile the tiunors seeu oa 
■the head were slowly increasiug. 



rie. er— (From DOIroth.) 

The cut surface of these growths presents a whilishf poarty 
Beetioti, in whidi an armngouicnt into lubules can bo more nr 
lo-aH difitiuL'tty seen ; the lubiilei) varying inncb in size, and still 
more in consistence and color ; some are quite hard and wliitCi 
others are softer, and reddish or bi-ownish in color. Others are 
BO ftoft as to flicker ahnost like jolly, and have a deep-ivd or 
raodena color, as if stained deeply with blood. In other poiata 
actual extrnvawitions of blood, some apparently contained within 
cyst-walls of a sort ol' fibrtms tissue, are found, giving the ap- 
pearances which wei'e formerly spoken of as fungus hffiniat<Klo8. 
The tumor is naualiy contained within a capsule formed from 
the periosteum, otT;en much thifkened, which cafKiule is, dnring 
the earlier periods of the growth of the tumor, fortified, as men- 





MEDCLI^Rr, on SOFT CANCER OF THE BONK. 

tioncil above, with the thin shell of compact bone upon which 
Uie periustcum lies, the two lavers at first expsudiug together ; 
then, as The tumor increases, the bony shell giving way firat ; and 
kltcrwarr], m the niaes softens and ulcerates, the imriostuum 
disappearing at the point of greatest prominence : and the soft 
growing mass, now released from the support of its hitherto 



r'^V^S 



r^m 



Fm- M.— (From BtllroUt.) 



Ff*. 9&>— <Fratti BlUraih.) 



firm envelope, sprouts without restraint iu whatever direction 
it is least opposed by BiUTounding tissues. If the tumor have 
not yet raiched the suriacc, when it h-i^ escaped from its fibrons 
incaeement, then we find it invading and appi-opriating to 
itMfll' all the sorter material* which it encounters, which, becom- 
ing iueor])orated with the gro-nnng mass, lose all identity; or, 
pushing itself iu and among the variotiis interspaces where press- 
ure is the Icnst, it reaches out its fingerdike ]>ruce««e«, extending 
(►ftcn much deeper and mueh farther than its external appeiir- 
anco would lead one to expect. At the same tune it often 
flecms limited by eneonntering a firm aponeurotic layer, against 
which it spreads Ifttcrally, and adheres to it witliout involving 



844 



3UU0NANT DEBASES OF BOXE. 



it, ttt leaet far a considerable period If, on tbe other liand, the 
masa bos reached the surface when the fihruiu eiivch^pi! gi%-o6 
way, tiieu we Itnvu Ihu [>ixti>er fuu^tis character itesumi.-*!, with 
the ra]>id growth, and Blmogt as rapid dcetritctiDU of the pro- 
tniditi^; c-aiiceroua mntcrial. ^m 

The rclationi! of tlio original 'hone to the growing cnncc^l 
have ah'cady hciii alhuled to. Here the processes are invari- 
ably those of <k'«tnn:ti(ni nnd disjippearanw, more or leas com- 
plete, (if both mncelloim and c»ii]{iai-t bone-ti^nnc. Tlii^ dUap- 
penrance is irregular, however — at some points being further 
advanced than in otliers, so that at different parte of the tumor 
we may ha%'e either niucli or verj' h'llle of iho disappc.iriii^^ 
original bonu remaining. ItVith the^e irreguhir rcnuiias of tl^H 
fheleton of the part we Imve n certain nmuunt of lli^po^ition on 
tlie part of the tumor itself to gencmtc new bone. I think tl 
ii rarely observed to any gi'cat extent in the mcdulliiry cancel 
of the hmg bonce, but in thoBC (iffeeting the elciill it ia of 
verj- market]. In the in:ifi'ratittn of tbe liead, I-'ig. 100, 
found, on elenring olf the Eoft part^ nnd dri*ing the bones, 
most extraordinary and beantitul framework of dclit-nte spicular 
bone (tpriiiging froni the surface of tlie inknll, which Wfi« it£cl^^ 
erodefl and partially absorbed wherever the tnnior had grow^H 
from its surface. These slender epieulje and thin laniinrcr of newly- 
foniK'd bone were, ahiio«t all, at right angles with ihe aurfui'e 
of the bone from which tlicy gi"ow, and from tlieir deh'catc for- 
mation, varying funn, :ind beautiful feather)' temiluatioQB, mac 
a most beautiful prcjiaration. This we Uept, caitJidly protoi-tt 
nnder glass, in tJie Xrw York Hospital ('abinct for some year 
btit it gmdually di.*integratcd and fell tn pieces, so that now 
none bnt tbe rougher and stronger foundations remain of the 
light nnd delicate structure, ahowiiig by it» destruction how 
imperfcL't and feeble it was iu its organization. Tliis furni 
mdiating skeleton, iis found in the K>tt caui'er of tlie nkull, il 
epoken of by several wi'iterti, but nothing tto marked is of\( 
fonnd in other bonce. In eomo rare casDs an tnercaee of bone 
Bidwtance ifi foimd fiinn the beginning of the disease, giving i 
hardness to the grnwlli wliicii makes it i}uite ditlii-uU lo pi 
nonncc, without microseopic-il examination, whether we hst,\ 
to deal with a cancer or an exostosis. 



MEDTTLLARy, OR SOFT CANCER OF THE BONX^. 



34fi 



The Tflscularity of these cancers h uuually very gtcat, and 
aew vesscU are tbnnc<l witli Burprising rajiidity. Thwtu vesaela 
are pjnerally vory lar^ in size, thin iu their walls, tortuous 
and otU'n varicose in their course, and in such abuudance as to 
be out of hII pro[)ortiou to tlicir amoinil in any nnrmal tissue. 
It is on account of this (lispro[K>rtioiintti dcvelopnicut of ve^^h^ 
large and small, arterial and venous, thfit we bfive, in many 
of thei«e tumors, eo active a circulation that the pnlsation of the 
arterial vessels ofteu gives rise to the suspicion of anenri3m — 
a suspicion which is sometimes strengthened by the fact tbat 
thoy do diuiiiiihh in (:izc when prcBsnrc is mndo upon the maiu 
trunk above the tunioi*. Tbig diminution, so much like the 
enbt<idcnce of an aueurii^mal ewelliufr, under the fiamc manipu- 
lation, 18 atmply due to tho fact that tlic bulk of the tumor is so 
largely made up of vessels tbat a dimiuutiou in the amount of 
1>lijod they contain ia siitficicnt to pn.dupe .in evident decrease 
in tho fiize of the tumor itself. Hence, also, we have the fre- 
quent extravflsationtj of blood into the ^ubstauce of the medul- 
lary ma^s, and, when uh-erttion has taken place, tbe same abun- 
flaufce of lai^ and thiu-walled veesels txplains tho facility with 
'which hiemorrluiire occurs, and the alanniiig extent to which it 
aometimes roaches. 

In tho softer cancers, a largo qnantity of juice can he scraped 
or 8qucezr*<l from the cut Btirface, ami indeed, by modpratc and 
repeated squeczinps, the wlmle sulid mass of the tumor may be 
emptied of its l!uid and semilluid contents, and then appeai-s as 
a flaccid, wliitish, shreddy, wet, tow-like mass, which bears a 
surprisingly small proportion to its origiual size. This largo 
prop<^rtiou of £uid matter, retained id the meshes of a com- 
paratively small amount of weakly solid stroma, explains very 
readily tho deceptive feeling of fluctuation which medullary 
cancers In the soft parts so often present, and which feeling is 
not by any nieims rare iii the ailvaucod stages of the disease as 
it occurs tn the bones. 

The microscopical study of these tumora pves ns nothing 
different from their well-known features In other paits of the 
body. Of cells, we have the characteristic multilbrraity. Thus, 
we have the ordinary cell, with its single, rarely double nu- 
cleus, and bright, »rmetimca multiple nucleolus ; these cells 



S46 



MALtCXAyT DISEASES OF BONE. 






presenting every variety of rfiape, eonietimes round, sometiniea 
llatteuec], H«MUL'(imes cUm^tcd into proce&see of tuo^t irreguli 
outline. Tliei-u urc mingled with a Urge ]>rojM>ruou ul* wbi 
arc considered as freti nuclei, tbongb Mr. lieale's rceeardioe 
wouM lead us to rc>rar4l tbea^c as eoUa as maeli m the other 
fonns, ihetyG free nncdei having shtipes at; varione as the celh^_ 
and often presenting a dose approximation to the gpindle^| 
shnpcd (^fll, of wUioh we have seen that tho hulk of some non- 
malignant twnoi-s is comjwscd. The true elongated, spindlc- 
ekaped eell, with nucleue and uneleolu^ in not uQCuituuon^ but 
never, to far as I know, mnkes up any considerable portion of 
the niaee. CclU also occur iu wliich uo nuclei can he econ, and 
sometiiiicfl we have the large eclle with many uiielci, resem- 
bling tlio peruliar cell of tliL- myeloid gt-owth. The interi-elluli 
fliib^Ianee itn Botler than in the cai^e of si-irrlius, and a good dm 
of the cell-growth seenia to take plat'e in a substance which 13 
nearly fluid. Here, however, much <litf"erencc prevails in dif- 
ferent speciinens, the intereoUulflr substance in some examples 
being qiiilo tirm, and in extremely email amount, whereas ia 
others it furnia the bulk of the growtli, is aknost liqui<l, and has 
the cell); lloating in it, much an ]fUii-i^-e1lg float in the liquor pu- 
rJB. It is somewhat characiteristic of tlua form of disease, that 
all these varieties, both of eell-formanon and of intercellular 
pubstancc, are constantly found In tbo same tumor, and often 
in the same lobule. ^j 

!Miich has been said, of late years, of the fibrous stroma o^| 
framework in which the ciucei-ous material proper is coutiLined. 
The alveol-ir character has been considert'd by many able ob- 
servers as the one characteristic anatomical feature of cancer, 
by which a ground of distinction iVom all other tumors may 
iiinintained. I da not feel prepared to accept this as a unive 
Stilly applicable anatomical distinction, yet it has much evidcn< 
in its fiivor. Rokitanaky, as long ago as 18'<2, published a de- 
scription of the development of tho stroma or skeleton of can- 
cers, accompanied with beautiful plates, giving bis ideas with 
great distinctness and minuteness. lie describes tho Btroina 
of eant-eras composed of two distinct elements; one somewli 
of a fibrous character, and the other made up of colls rloscl 
packed without any distinct fibrillar nrrangemcnt, Tlicse ti 



1 



HEDULLAJtY, OR SOFT CUN'OER OP THE BOXES. 



347 






ml>gtaiice9 are arraiigod iu the form of bands of a tolerably 
ri;gular she, which iDterlAce among theiu«e1ve^ leaving spaces 
ut' '\'nrioue sizes and shttpes, in wLieli are contained the true 
cancerous cells, and tlieir proper iuterceUiUar substance. This 
.roma he conBidcrs iia the real basis-substance uf tliu cancer, 
ss much fl part of it an the ccLltt tbeniBcIvc^ nnd, pervading all 
parta of the diMaeed mass like a skeleton, is one of Ua e«3en- 
tial analomiail fuatui'es (Fig. &6). Many of the moet eminent 




cal anatomista siueo Rokitansky have given a descrip- 

tiOTi of an alveolar arrangement ol' tlio fitroma of cancer varj-- 

ing somcwliat trom, but in the main confinnatory of, his views. 

08, in Comil and Kanvier'a manual, carcinoma is defined to 

Imj "a tumor composed of a fibrons stroma arranged in alveoli, 

which form, by their communication, a cavernous syatem; these 

veoli are filled with free ceils contiiincd in a liquid more or 

ftbimtlant." Billroth entertains vicw^, ivith regard to the 

ors which ehould bo inclnded under the tenn cancer, in 

which he differs somewhat from otlier recent writers, but he 

videutly recogniJiea as an anatomical fact the alveolar diarae- 

ter of the cancerous turners wliich he describes, ns hia plate, of 

which Fig. ^7 is a eopy, very evidently ehowa. Uo does not, 



pTh 

Iw 
^whii 



848 



UAUGXAKT DISEASES OF BO.VE. 



hovercr, eoem disposed to admit the fllvcoUr arrangemeDt 
an alwoluttly cliaract«mtic feature uf (.'anctT. 

Tiic cliuieal liUtury of soft (.-uucer of bones preeenta uuuij[l 
variatidtit from a trpical caae. Most frequently tlio diseai 
coniitiuni^es witliont any or with very little pain, and wlcbont 



^ 



fW. VT.— (Fram BCDrotb.) 



any very evident assipiable cause. "Without being confined to 
any age, it is most cuuinion at a mueli earlier jferiod of life 
than cither the BcirrhouB ur epithelial form of the diecaec. In 
my obajrvation, most of tlie very rapid-jimwing cases have 
been in younc acinlts. In one very rciunrkable case which oc- 
curred in the Kew York Itospitfll, and of which we have the 
epecimen in the pathologicftl cabinet, a cancerona tumor of tho 
clavii'le atid su-apuk proved fatal in eix weeks fi-om the day of 
its first apiJt'iuTtnce, by which time it had attained a size of ono 
foot in diunjL'tcr. This tumor occurred in a young man of 
eighteen years of age. Another enormous and verv rapidly- 
developed tumor was the one preeented in Fig. i'S. This waft 
devclf'i>ed from thu clavicle in a girl aged fourte«i. and reached 
its gigantic siie within a few months. It wu? of the softer 
medullary character, and to the last showed but little tcudcnej 



KESULLaRT, or soft CANCKR ok the BOWES. 



340 



to ulcerate. Sbe died, worn out by tlio diecnse, and caiiwruua 
deposits of a siinilnr t-Imracter to tlioso of the lar^ tumor were 
fuund in the lung's. Slio had ahu, as bccii iu the woodcut, a 
very singidar-ItKiking redinidaii- 

ley of the skin, with hypertrophy 
;»!* Its ti»iuc, on the right Hrm, 
ig fl hanging «ort of bag of 
tliickeued, Oiscolorod skiu, with 
numerous etrong Ufiirs gri>witi<; 
npuu it. It wui for t\nn curious 

|Jomifltion, which had hven grow- 
ling for several yeare, that 1 ppc- 

'ient4^ ber to the Pathologii-nl 

[Bociety, about a year ticforc her 

'^deatli, wbt-n tJie tumor of the 
d»\-iclc had Bcarcely begun to 

Ithuw itself. The tumors shown 
in Figa. 90 and 100 were both 
yoaii^ men, one eighteen, the 

[other nineteen years old. 

The oaurto of thoao growths 

icnnnot gcni-rally be ascertained. 

times an injury, as a blow, h the starting-point of the dis- 

'rtse, and one esse iti nurfullection ftilhnved a fracture. No. 107 
itia picture of this ease, wUich was briufly this; A man, tweiity- 
two years old, hro1;e his arm in the act of throwing a eiiowhnJl. 
"No union took plafH*, and at the end of eix months lie entered 
the hospital, where the limb was removed at the eliouWcr-joint ; 

[»n encepbaloid deposit having meanwhile talicn place upon tlie 
fratrtured Immenin, bo abundnnt as to form a largo ftisiforai 
swelling, jn%-olvIng the greater part of the ann, and measur- 
ing at Ica^it twenty inches in ciroumfercnce." Sf»me eases are 
«poken of %vhere encephaloid disease Ims attacked carious joints, 
where the products of old inHamnialiou may be supposed to 
liave lieen iho nidna in wliiiili tliu caiifer originated. In by fnr 

[the lai^er number of casea, however, no distinct cause can be 

tained. As the tumor gro\rs, the jvattents suffer jmin from 

'distention of and pressure upon the !*urronnding soft parts, 

itlie tumor ituelf remaining free from j>ain or tenderness. In 




no. n^x. T. iiMptai HUHB.) 



350 



HAUOXAKT D1SE.WES OF BOSE, 



some exceptional caae» great pain la experienced from tbe ear- 
liest to tlie Litest stage*. The teiidener to ulceration does not 
eeem to be ao mtirkod in medullary cancer of the bunes as it is 
in canpera of other parts and of other forms. Mimy of the lar^cet 
tumors I have eocn were not ul^-cmtcd at all, and those which 
wcrtf o^ien at any-p^unt of their mirfaco soemod to havo 1)600010 
ao from ftome abrasion, or pressure, or tome other accident 
■wliicli had determined an ulceration where it wonhl not other- 
wise have occurred. The great tumor of the shoulder had a 
V6r/ small »ni'face of ulcerttion. u[>on its summit, which only 
appeared in the last weeke of life. The tendency of most of 
these tumors is rather tuwaixi rapid prolitemtion of the cell- 
growths, of which they are composed, than to ulcjrative dcstnio- 
tion. This ulceratiitn, however, docs occur in some easos, usnallr 
preceded by a bulging of the tumor at urio or more points, which 
become very vascular in their external appearance, and often 
very tender to the tondi na the ulceriition is about to take place. 
This bulging and apparent inflammation is the accompaniment 
of a proccas of rapid softening which is going on at that point; 
and, when the surface does give way, we have an ulceration tV»l- 
luwed by fungous eprouting forth of enormous, soft, ejKmgy 
gmuiUalions, rapidly tucreasuig in siice and prominence, bleed- 
ing iicrcely on the liUghtettt injury, and discharging a copious, 
thin, bloiidy ichor, which very mpidly exiuiust the remaining 
powers of life. The condition which precedes tliis ulceration, 
viz., the sntY, bulgina;, very vascular prominence of a certain 
part of the surface of the growth, very closely simulates tbe 
process of suppuration in its external features; and, when com- 
bined with the fact that a pretty rapid and 4uite considerable 
Boftening of the mass occurs at the protruding point, it is not 
wutiderful that many goud surgeons have been deceived, and 
have plimged a bistoury into the Biispected spot, expecting s 
fi-ee csi'iipe of matter to follow their incision. The feeling of 
fluctuation is so perfect in these cA-tes that I know not bow to 
dismniinatc between it and the fluctuation of real pna. Tlie 
niirttAke ia an unfortunate one, for ulceration and ftingus are verv 
apt to follow the incision ; and yet, in several instances, I lun-e 
known such a cut to heal as quickly and as soundly as if it had 
been made in a perfectly healthy part. 



UEDCLLART, OR SOFT CAN'CZR OF THE ROXES. 



SRI 



During all the earlier part of this disease, partk-ularlr if tlie 
patient du not suQ'ur muuli [Xilii, tlie coustituUmi ilws nut Bcein 
to expiTiuncL' imifh deteriuration. Some of these patieuta, with 
mpidly-growinp; and Inrgc tumors on the arm or leg, will keep 
ab<m( tlieir ordimiry avoealiimp, and, among the lower classes, 
seem sometimes to feel very lirtU- anxiety about their diaeasc. 
Odc of the Inrgest tiunors of tliis kitid that I liavc ever seen, 
occupying two-thirds of the whole thigh-hone, and of enornious 
diameter, walked to oar college clmjquc, and np to the third 
story, with ao more ineouvenieace than was occasioned by the 
cxcoB8i\''c weight she had to carry. In the later stnges, after 
eodeoing begins, and particularly after fungus has protruded, 
the sjelem gives way nijiidly, .nnd the true cancertuis cachexia 
occurs, if the patient live long enough for ile peeuliur fentures to 
be developed. Secondnry depoaits, of the same nature as the 
original tumor, are found in the livor, the lungs, and various 
other internal organs, sometimes in immense massess, and some- 
times very extensively diftused over various organs and regions 
of the body. Spec-Imens No. r>57 and 558, in our collection, are 
inBtnncc'B of secondary cancerous Jevelopniente iu the lungs and 
pleuni, in a man from whom llie thigh had been removed a few 
months before for a large medullary tumor. About three montlis 
aJlcr the amputation he began to sutler from pectoral syniptoms, 
of which he finally died. " A growth of fungus htmntodcs was 
found to have involved a large portion of the lung, while, be- 
tween the lower surface of that organ and the upper surface of 
the diaphragm, which is pu9ho<l down, a cavity was found con- 
taining nearly a gallou of brownish-i-ed serous fluid, with coagula 
and ehreds uf lymph floating through it." This cavity was that 
of the plcuni, whose surface was studded all over with " numerous 
rounded and flattened maizes, soft, and of a white color," which 
were evidently of the same nature as the tumor originally re- 
moved from the thigh. No. 55(i is an itunieriBc secondary umdul- 
lary Inmor, developed in the mediastinum, and comprcRsing the 
lungs and other thoracic organs into a very small space. This 
Bpecimcn was also taken from a man who, about a year before 
bis death, bad had his thigh amputated for a large cncr-phnloid 
tumor of the femur. Secondary deposits of all the forms of 
cancer arc quite common in tiic bones. 



ftss 



uauoxakt diseases op bone. 



It 18 well known that all of the forms of cancer arc capable, 
under ccrtaua cii-cumstaiicei», of uudcrgoinj^ a change for the 
hettfir. This cluinge may be ehuwn by the tumor, liurL'tuforu 
progi-Gssivc, remaining 8tationnry; tho bulk of the tumor, in 
otliur casts, may actually dlminiiih, even Eonictimcs to tlic ex- 
tont of thc'<IiA:i|>)H!araiiL-cnf all ugna of the disease; Lhettiirface, 
ppevjoiwly deejily nlcemted, may fill np with healthy granula- 
tiontt, and cicatrize ; or, lastly, these fuvoniblo changes mnr be 
conscf|nent upon a process of inflannnntion and ulougliing, 
whereby, the whole tumor being destroyed, a »ound cicatrix 
inSy be secured. Thetse llnttering ["bases of caiiceroiig life are 
perhaps best and certainly nitwit ij-e^ueutly seen in the furiu uf 
the di^aso we are now stndyin|; ; bnt, it has ^ happened, that 
I have never &oeii any good exemplification of it in any form 
of cancer of the bones. It doubtlees docs sometimes occur in 
medullary tutnura of the bones; but I must believe U to be 
more rare than in any of the forms of cancer aftbcling the soft 
parta. A Tory slow growth of the tumor is sometimes seen, as, 
in one instance, whei-e a woman presented herself at the New 
York Hospital, Aritli a large txmior of tlie tibia, which, 6he 
assured no, Imd not gn»wii at all for twenty years, and whtch^ 
only within a bhort time, had given her any uneafciness. The 
limb WH5 amputated, and the tumor, which K]>rang from the 
anterior lace of the tibia, gave the most unmistakable evidence 
of cnecplialoid cancer. 

Tlio fiillowiiig eases illustrate bo well the chief plinicsl fca- 
tnrcfi rif the discjise we have been considering as to justify mo 
in introducing here a brief outline of their history. The firfet 
case was under my care as resident surgeon of the Xew York 
Hospital, Dr. Om-dou, Buck having the responsible maiingc- 
ment of it ns attending Eurgeun, and, from his very Ihtl nnd 
careful notes, dictated at the time, I draw my material: 

Albert Milderberger, a btwitman, iiged nineteen, was admitted 
into the 'Sew York ]If»ji|iifal, DeccuiUer 14, 1839, with a tumor 
of the size of a large orange covering tho parietal and temiK>ra] 
regions. "In the month of May last preceding, while at work 
oa board a vessel, he struck his head uguiiist the boom, as he 
was in the act of liflinga store; but, having en a fur cap at 
the time, he perceived no unpleasant effects from the blow, aud 



■EDCLLART, OB SOFT CANCER OF THE BOXES. 



353 



continueil his wurk. Tiic mme evening he noticed a soft tumor, 
nnder the scalp, oi* the size of a walnut, on l.he spot where he 
Jifld rcceivwl the blow. In a lovtnight it incrcnacd to the size 
of a ifadeira-iiut, and was pronounced a wen by a physician 
who exainineil it. In July it wan as Inrge as a hen's egg, and, 
00 being punctured, it discharged a I'int of florid blood in a jet 
Uiat was easily nrrcs^tcd. The puncture heated in two days, 
and the fiizu of the tiitiior wm diminished. The lots of blood 
relieved a headache from wliich lie v.'s» eatleriiig at the time. 
Prc&snre was now applied, dHrin<j four or five weeks, by uieaua 
of a piece of lead, but had no other effect than to ilnttcn the 
shape of the tiinior, which continued inci"easing in size. For 
four weeks preceding his adniission, very powerful presHure was 
kept up by means of a piece of lead, weighing two ponnda, 
flattened out aitd adapted to its surface, and bound fimdy to 
tlie bead. This caused the tumor to apread at its base, particu- 
larly along tlie lower side, toward the orbit and xygoma. l-'ive 
daye before admission it was punctured a second time, and a 
pint of brigh(-rud blood flowed rapidly in a jet, without diinin- 
iahing ita aize. The blood was easily arrested, and the puncture 
healcKl kindly. 

" At the time of his admission, the tumor had attained a for- 
midablo size, and presented the following characters (Fig. 99): 
It rose two inches above the surface of the craniiun, standing 
off in an oblique direction ijutward. its base wae of an oblong 
form, and extended upward to within two fingers' breadtli of 
tlie median line; backward to tliu Umbdotdal suture; down- 
ward to withui an inch of the ear, and foriMird.to within three 
tingera' breadth of the outer mai^n of the orbit. Its limits 
were abrupt and well defined, except about one fourth of ita 
circumference thnt expanded out over the temple in a 8U]>erfl- 
cial soft swelling that was gradually lost near the outer cauthus, 
and along the zygoma. This portion appeared alter pressure 
was applied the second time. The tumor measured, in an ob- 
litpie direction, fonvard aud downward over the summit, seven 
inched ami a half. The t<urface was of the color of the rest of 
the scalp, and sparsely covered with hair. Numerous veins 
raraific4l under the skin, and, when presanro whs mndc on the 
internal jugular rein, they became swollen and prominent. A 
83 



8S4 



MAUGXAyr DISEASES OP BOyE. 



small congeries of pnrple arborescent cftpillaiy reasela existed 
at one point on tlio gurlai'O. There was a eutlcaed ejiot, of the 
size of a Bjilit-pea, and of a dirtjt'-yollowigli color, nt tlio point 
where tlic last punctoro had been made, apparently from tho 
formation of a Buperiicial abscess. The tnmor was tense and 
elastic in every point, rather softer and more supple in iVont 



i 



Tia. 09-— <Froiii K. Y. ll(i«[i^ul HuMtun.) 

tlinn elsewhere. No fluctuation conld be felt, nor oould nnv 
dirninutiDn of its size be prodiu-cd by pressure. Tlie puliation 
of the bmucihos of tlie tenipond and occipital arteries was per- 
ceptible on applying the hand, but there was no pulsation of 
tho mass. On applying tho cheek, however, I thought I ix-r- 
ceived a slight movement of elevation and subsidence. A dis- 
tinct hruU de souJJfH and thrill could bo penrwix'od lu the tempo- 
ral artery above the Jtyi:jomii. A eolid, roundish lump was icit 
within tho tumor at its posterior part ; tho patient himself bad 
noticed it, and Bomettmes bad noticed two lumps. Tliat por- 
tion of the tumor that epread njion the tempio, after pressure 
was applied tho second time, was soft and dnuehy, except at its 
anterior part, where tlierc was a cirpumBcribed portion of almost 
bony barrlncfis tlmt seonied movable on the craninm, and con- 
veyed to tho touch a Beusation of crcj>itn8. Pressure on the 



MEDHLLART, OR SOFT CANCER Or THB B0SB8. 



g&9 



carotid bad no other effect tlian to stop the pulsation in the 
lirant'lics of the temporal and occipit-a! (irterii*8. Patient had 
no |tain in the tnmor itself, but had been subject to pain acroto 
the forehead for six years previous, whit-h cnmo on at interrala.'* 
His general condition was good ; pulse sixty-eight ; nppetite 
good, and IxiwcU regular. 

From the evident vagcnUrity of this tumor, it was ihonght 
beet to try the effect of cutting off its arterial supply. Thia 
was done hy Dr. Buck, on the yut of Dceenibcr, by applying 
a ligature to the common carotid artery, and afterward, by 
circumscribing the tumor, by an incision through tlie scalp, 
about an inch from its base, which encircled the whole tumor 
eocccpt about two inches in the temporal region. The vessels 
had of course ceaacd to pnlsat© when the carotid was tied, but 
Cftch was carefully ligatured as the incision was made. The 
ligature came away from the carotid on the 13th day, and the 
incision round the tnmor rapidly cicatrized. No change was 
produced in the tuin<:»r, by this thorough operation, c?LCL-pt the 
arrest of all pulsation. 

Jan^MTy 4, 1840. — " The tumor was again punctured ; Wood 
flowed freely, and a prolw paft,«ed in moved easily aboitt in the 
sulwtAnce of the tumor, as if its substance were of the wuisist- 
enc8 of brain. An attack of erysipelatous inflammation fol- 
lowed Ihi^ manipulation, and the wound reiriaiued open, dis- 
charging bloody fluid-" 

January lliA. — "The punctured opening has taken on a 
circular fonii of the size of a s])lif-pea. I*ressure around it doss 
not force out any discharge. The anterior half of the lunior is 
eoftcr, Aud its covering thinner, having much the feel of an 
ahsoc^s near the surlace ; it has subsidetl and is less prominent." 
The last two punctures were open and discharging, and a probe 
CDold be passed from one to the other. A bisfoury was there- 
fore passed, and the communicating sinus laid open, thus hrgely 
exposing Uie centre of the tumor. Tliid exposure of the mass 
of the tumor was followed by a gradual softening and disin- 
tegration of the ex]>o6ed jKirtion, pieces aumetimcs coming 
away as putrid sloughs. This process gradually destroyed the 
more prominent part of the tumor, but it nevertheless extended 
at its hose until it became cfinvci'tcd into an immense promi- 



390 



MALIGNANT DESEAEES OF BONE 



uent, but not fungoufi, canccraus ulecr, tUo lovd of wliich 
nut more tliini an im-li nbovo tlic surlaco of tin' Bkull. At one 
or two |ioiiit9 tlie bone was exposed. Clr«nxiktioiis covered the 
enrface* and st times hcalthy-Iookin^; pus was discharged from 
it. Occasion Jilly, severe hiDmorrhage now began to be p: 
duccd \>y sliglit cnusca, whidi, with severe epistaxiii now aui 
then occurring, reduced liift strength rapidly. 

Til iUy be left the hospital, and went to reside at his ais- 
ter'o house in the city. The disease continued lo siiread over 
n greater area, but did not assume at any time tho fungo 
character. ITo died, worn ont by fi-oquenl liseniorrhage, in No- 
vember, 1840. 

Post-mortem esaitiination showed that *'thc tumor extend- 
ed from the middle of tho superciliary aifh to within two fin- 
^ra' breadth of the median line, in ttic occipiral region^ and 
trom the sagittal suture above to the ang]e of the jaw below, 
so as to bide the right ear, the cheek, and outer LaU'of the eye, 
the lids being drawn down with it. Tho margin uf tho tomor, 
along tho sagittal suture ami as far furw-ard as the orbit, prc- 
aenlii an irregular bony ridge, aa though the oxtemal table wei 
pushed outward. The suppurating surface of tho tumor wnr 
coated with dry pus. At tho up]>er part, a mass of dry lint, 
imjipognateii with blood, adbei-od to tho surface, where it had 
been applied several months since to arrc«t luemorrhagc, and 
had not been removed for fear of its return. The circmnier- 
ence of the tnmor measured twenty-five inches. Bony spiculn 
could be felt in the tubstauce of the tumoi". Tho inner table 
of the crouiuiB, as well as the outer, was very extensively ab- 
sorbed, and tho tumor lutd pushed before it the dura mater, so 
as til encroach very much on the brain. A prolongation of tho 
diseaaud mass extended into the Bphenold fissnrc and zygomatic 
fossa. The surface in oontnct with the dura mater was of ft 
grayish color, and of a finn, jcUy-Ulte consistence. Tltc margia 
of the opening in the inner table was thin and *Jisrp, and not 
pushed inward, while that of tho outer table was elevatod and 
nrii-ven. Besides the aponeurosis that invested it, the tumor 
seumcd to ho coutained in a strong, tibi-uus envelope, titat di- 
vided it into lobea. These consifited of » substance of iinn, 
flealiy consistence, and of various colors— iwrtions resembling 



MEDDLLJlBT, or soft OANCKR op TEH BONBS. 



337 



congnlated blood, whilo otliera wero of a grayinh color. Tho 
dura niat«r and otber inembraneis as well as the braiu itself, 
were apfareutly healthy. 

"Till! lcl\ kkliiey was six times larger than llie right, and 
formed an irregular uodulalud mass vi' the same morbid struct- 
nro aB the tumor. The ontliae of the org;iD could he recog- 
nized upon the anterior sariace of the mass, the morbid chaugL's 
having mostly invaded the posterior half of the kidney." 

Both Bpeeimens arc preserved in the h^ispital eahitiet. The 
microscopical appeni-ances are not noted in the recor<L 

The next case was that of a man, nineteen years of age, who 
waa admitted into the New York Hospital in June, 1S56, with 
an enormous tumor of tho thigh, which had been grtiwing nbont 
four monClw. It occupied the lower lialf of the femur, and the 
limb, at its largest part, rac&fiured. twenty-six inches in tircmn- 
fercnra. The thi<|;h was amputated on the 31th (ff June, and 
the tumor fonad to be enccphaloid caincor. Ho did well after 
the operation, and the stump healed slnwly. On the "ifith of 
December follriwin^', a Bndden attach of ntdenia of tho faw 
called attention to a soft lump on the side of the head, at the 
jnnction of the frontal and parietal bones, near the sagittal su- 
tnre. Stated that he had notiewl it about three weeks before, 
bQt, aa it jtftve Mm no pain, ho said nothing about it. It is of 
the Eize of the fist, has n soft, fluctuating feel, and is not mo\-n- 
ble on the skull. Has also a email tumor on the right clavi- 
cle, which gives him bomc burning pain, and U tender to the 
touch. Haa a good dmd of headache, especially on the left side 
of the head. The wdema of the face soon suht^idud, und he 
Beemed ns well as usual. Small periosteal swcUinga were noted 
on the third and fourth ribs, on tho right side, near their 
middle. 

January 4, 1857. — The swelling on the clavicle has disaj^ 
pearod. Tho large tumor of the head is also Biilwiding, and his 
headache is much relieved. Tie has been taking iodidu of po- 
tassa in iuiTcasing do^es since December 2Sth. In the latter 
part of January another attack of oedema of the face eame on, 
without chill or fever, and witliout any evident cause, and jwissed 
away as before in a few days. 

i/onwwy 24?A. — The tumors are beginning to gix>w again, 



858 



MALIGNANT DISEASES OF BONE. 



tlioTigh ho is taking eighty- grains of pota.48a tkilf . The medl- 
dne ficcnicd to diiorder his stomach, and was i%dacod to fire 
grains three timc8 a day. 

F^fuanj aoM, — Another tumor lias spmng np over the 
occij'Ut. The original tumors are increasing. About the let 
of March another tumor showed itself on the right side, over 
the parietal bono. He has been using cod^liver oil, and a gen- 
eral tunic and inviguratiug regiuieu. Ho now sufl'ers great 
piiin rnnning down the lull arm, requiring large anodynes for 
its relief. In April a swelling without distinct tumor appeared 
over rij^ht lower jawbone. The tumors of the head are gain- 
ing a fonniiiabic size. That on the clavidc at one time again 
ahnn.sc entirely (nsap]K>iireil, whioh was also the case ^ritli the 
BvrclUngs on the ribs. The tumors on the head, after their first 
partial subsidence, steadily but slowly incrcMsed- 

Zlay 1 -Ith. — Tumor of jaw diminishing, From this time 
guuerul L-auceroUK i-aehuxia made pretty rapid progress. 

June 32//.^lle is noted as delirious, and his eyesight fail- 
ing; still his ap|>ctitc is wonderful, lie gradually wasted away, 
and died, July 27th, witli no other cerebral symjitouis than 
0(?c.isional delirium and gradual but not complete loss of 
sight. 

Avtopgy. — Tho weight of the hcnd was 21 J pounds. Its 
circumleLX'uce, moaouring horizontally round the meet promi- 
nent points, was 2Ti inches. The periieudicuLir promineuee 
of tlic largest tumor trom the surface of the ekuli was about S 
inches C^ig. KKi). Tlic tumors, of varying heights, but mostly 
of a rounded, dome-like form, covered nearly the whole surface 
of the vault of the cranium, several of them merging at tlieir 
bases, into one another. All gave the feeling of fluctuation, 
and when cut open wore soft, brain-like, very vascuhir, with 
bony epiculfe and solid bone-masses scattered about tluvugfa 
the growth. The skull was perforated, and the tumors pressed 
down upon the brain. The lungs and pleurm were studded 
with firm, white, tunior-liko masses, varying from the size of a 
hazcl-tiut to that of a walnut. An euccphaloid mass, as laigo 
as a child's head, wns fouml in tho right Uiae fossa, developed 
ii'om the bone upward into the pelria, and downward so as to 
surround tho head and neck of the amputated femur in a sort 



860 



UALIOXAKT D1SE.VSES OF BOVB. 



CHAPTER in. 



SPimSUAL CAXCKB. OF DONE. 



Much less cummon than tho mc(liillun,% and considerably 
more so thau the scirrhous taucerg, the epitheliomaUi of bone 
occur biiflit-'icutly often to huve buoii carul'ully obisen-ud by feev- 
eral writera. As a primary aflertion it ia rare; I have novor 
encoiiutered one which wae rew^izcil. The most cloarly- 
tnnrkcd case I Jind recorded ia one which was admitted into 
Guy*8 Hospital, under the caro of" Mr. Cock, in May, 1858. 
Tlic patient was a man forty-five years old, ]ialc and cachectio 
looking, but his general health was good an<i his habita regnlAf. 
"Twenty-six years ago he noticed a swelling in tlie right knc«, 
which coulinued io increase fur eome thnc, till at laiit be wbs 
unHble to M'alk. This swelling then buret, and he was ranch 
relieved. The wound, however, never healed, and was fiotne- 
times worse than at others. About two years aj^ he fell down 
and Btruck the part; tlio wound tlien become rapidly larger, the 
bono diwl, and at last ho came to tliis hospital. Wlien admit* 
ted, the ri^ht Ic^ presented over the Bnrface of the tibia a large, 
sprouting, opithflial growth, involving nearly the whole bone ; 
in the centre was a deep hollow, which excavated the bone, 
and at the bottom some darlc, carious, and necrosed bone was 
visible." 

Jlir. Cock amputated the limb, through the lower third of 
thii tliigh. and soon allcr tho man left tlie hospital cured. 

*'<)n cxanuning tho litnb, it was cleai' that both the tibia 
and the iulc^imeiit over it were involved in one mass of cpi- 
tlieltJil disease. Tlie bone was for the most ]mrt dead, and iji- 
fihrated witli the elements which characterize epithelial cancer, 
or epithelioma. The sprouting eauliflower-growtha from ihc 
integament presented the same eliaractcristica ; but tho cells in 
the bono wore very well inarkod, and proved remarkably bcan- 
tjful microscopical objects.'' 

Another ca^c is ^ven by Mv. Bryant, of the same hospital, 
of a man who had au epithelial cancer in his heel, involving tlio 



EnriTELUL CANCER OP BONB. 



aei 



00 cfllcis. It seems Tcrr probable, liowerer, thut ia this case, 
the disease begnn in the sear of an old injury of tlic intojfn- 
meuU of tbe heel, and only spread secondarily to the bone. 
The samo suspicion, it must be confessed, attaches to Mr. Cock's 
cafi^ though nothing is said about auy dovclopmont of the dis- 
ease in tlie skin before the bone boeamo attoct«d. Billroth, who 
nukes all careinomata to cuusist of epithelial elouientt>, says: 
** Acronlin;j to my whole lii9ti.>gunetic view, I must reifurd it as 
impoi>sibIe for an epithelial cancer to occur primarily in a bono 
or Irmphatlc gland. The observations that I know, to this 
ctfect (in tlio lower jaw, on tlio anterior surface of the tibia, in 
the lymphatic glands of the neck), do not seem to uie sutttcicnt 
proof, because the skin and mncoua membrane are so near ; 
there may liave been an, indigniti(.-nnt carcinomatous disease of 
the skin or mucous membrane as a startiug-poiut of the disease, 
without its Imnnj; been noticed." 

Seeimdary developments of this form of cancer in the bonca 
are not extremely rare. T.cbert says, without t^pecifyini? as to 
the primary or B6e<indary character of the disease, that, in iiine- 
(y ctsca of oanccrotis disease of bones, he found it sis times of 
the epithelial variety. ()f these, four were in the lower jaw, 
probably soc-onrlary after cancer of the lip, one was ui the upper 
jaw, and one Wfts in the oa cald^. 

The anatomical characters of Uio disoftse are well inarkoiL 
Uicroseo pleat ly they eonsitit cf^scntially of e[>ithelial celts in 
varying conditions of iH-rfectioii, and very variously arranged 
in their relations to one another. Sometimes the epithelium is 
contained in tubes and rnuiided cavities, on the internal sur- 
fiices of which it makes a distinct, well-arningcd layer, bo regular 
and orderly in its appearance as to make it difficult to be sure 
we are not flefllingwith tnie gland-structure (Fi;;. lUl.) At 
Other times, the e^'ithelial elements are massed confusedly with- 
out any apparent onler, and for no useful end. OtH-u they are 
rolled upon IhemselvuB into ruimdish masses, in which the suc- 
ceseive Layers of flattened epithelium are arrnoged eomewhat 
like the layers of an onion (Fig. It'-). In short, evorj- possible 
variety of arrangement and diairrangcmeiit of the«e cells may 
be found, and u|>on these varietiea some writers have founded 
numerous subdivisions of the disease. It is sufficient for us, as 



862 



VALlGHlASr DISEASES OP DON'S. 



Btndeuts of boue-patholof^y, to be aware of the great variety of 
fbnns iato wbich the cpidielial elemcnta are in difforent cuei 
amngcA. 

BciitdeA these ^ical cells, many other cells are often 
found which are differently described by ditl'erciit anthors. 
Paget Bpe^ilis of tlioni aa free nuclei. Ho gays : **2sudei, either 
free, or embedded in a dimly molecular or granular bn^id, are 



y . 



4 



tii. 






Fn. lOI^Fram BIDradii.) 



commonly found mingled with the (epithelial) cells. I believe 
they occnr in the greatest abundance in the mo«t acnte cages. 
Tliey may be juiit like tlio nuclei of the colls ; but usually, among 
those that are Iree, many are larger than those in the celiti ; and 
these, reaching a diameter of more than xoVir of an inch, at the 
same time that tlicy appenr more vesicular, and have larger and 
brighter mich^oli, approximate very closely to the ehamrtprs of 
the nuclei of scirrhous and meiliillary cancer-cellfi." Rillrulh 
Bays: "But we must here state that, in canoer-tumonj, beside* 
the epitheliums, there are usually numcrona young, small, 
round cells which, infiltrated iti the conneclive-tisano portion 
of the tumor, furui an important part of it This small-celled, 



8M 



UAUGXiST DISEASES OF BOXE. 



The stroma of epitlieliAl growths docs not e^em to bo con- 
etaut or ahvavs well "kBiieJ. la many eases, au«] I tbiak alwavs 
in buue, DO j>ru|>(5r alvt.'olar stroma, bucIi an luia bct.ii described 
in coDDectiou with medullary cancer, exists. The ti&sQCS arc 
merely dispbced for the reception of the new deposit, and what 
fibrous structurea wc find traversing the morbid mass nrc prob- 
ably derived from modifications of ]irei5xistent nonnal tisenos. 
Tir the tiibuliir and foUit-nlar fomis. the substance of the tube or 
follicle, which is lined by epithelium, may be supposed to be a 
direct derivative from the normal tissue, of which it is mnally 
ouly an exaggeration. 

These tumors are permeated with a certain amount of fluid, 
"cancer-juice,'' ns it is called; and, as the cells have but little 
cohesion ani(m<.r themselves, there is easily Ecraped otl', from the 
cut furfnee, a milky fluid, which is made so by cimtaiuing ^oat 
uuuitH'rs of the epitlielial cells Hoating through it, suspended, att 
in an emulsion. 

The clinical features of epitbelioina, wherever situated, are 
mainly those of nlcci-ation. Most epithelial cancers are really 
cancerous ulcers from their commencement. In and abont the 
base of these ulcers, the cancerous deposit ts constantly talcing 
place, eo that, as the ulcer gi'ows, the cancer increases ; and it i& 
mther uncommon for an epithelioma to gain any great size as a 
tumor, on account of its constant teudcncy to ulcerative destruo- 
tioii. In the bones tbo^e feiitures uro somewhat modified, ac- 
conling as the deposit reaches the osseous tissue from an ulcere 
atod CTitaneous sui-tacc, or by infection from a distant tumor. 
Of cases travelling subcutaneous) y, and infecting bones doep- 
eeaCed and distant from the focus of disease, Virchow give* one 
inst.ince, in a man aged fifty-nine, who had an nleemling epithe- 
lial cancer of the letl bi'east. On the t-th uf Febniarj-, 1S53, 
the left broaat and several enlarged axillary glauda were re- 
moved by opemtion. The man died with symptoms of pyirmia, 
Fcbruai"}' 21st. At the autopsy, marked lesions, characleristio 
of pywmia, wore found. The ribs, from the thii-d to the sixth 
on the riglit side, were inliltralerl with e])itliclial cancer. Tho 
vertebral end of the first rib on llic left side was also simQady 
infiltrated. lu the npper part of the left medi-nstinum were 
found several small nodules of epithelial growth. There seemed 



EPmiELIAL CANCER OP BONE. 



305 



to be no direct eominuiiicatioa between tlie tumor of the breast 
and the axilliin' glnmiti. ur with the iiiiillrateil ribs. In such 
casea us this thui-c could be no chance for ulcemtion, and I take 
It for gi-antcd these tumors, if the man had lived, would have 
compoi'ted themselves much as other decp-«efttcd cancers do. 

In by fer the larger proportion of case*, the epithelial dis- 
ease is merely an extension of a similar affection from the mu- 
coua membrane or ekiu which coverg it, and hence, aa far as the 
bone-diseaae is concerned, it may be eaid to eoiiimeiice as an id- 
cemlioD, in the same gense that tiih i^tateniuut may be made uf 
enpcHiciiil cpithetiotnii ekewhere. Mr. Sl^iiiley, in his admirable 
book on " Diseases of Bunea," gives a number of case* which 
he caIIs instances of pluigedenic ulceration of bone. These 
casee, Tcry jirraphically described, nri> {■Imracterizcd ''bysiicceft- 
sive abscesses and ulcerations of the soft partj; f>preading to the 
periosteum, and thence the ulceration extended through the 
bone. Hard, wart-like grnuulations arut^o from the uk-erated 
Eurfacce of the sott parts and uf the bone, but Xhfse granulations 
had no dihimsitJon to cicatrize, and they diacharged very ]>ro- 
fiisely a thin, fetid fluid. In this alJito I have known tlie dis- 
ease to continue many yeais without the slightest eflbrt of rep- 
Rration." His cases were all in the tibia, and followed some 
injury which had produced abscess or ulcer over the bone. 

I cannot help thiukiag that these ca^es were in reality epithe- 
lial in their character, and I am the more Etrougly let! to that 
belief from the following case, whieh I watx;hcd with great in- 
terest, and which, in all its clinical ftiatnros, correeponded very 
accurately with hia de8crii>tiuns : 

John O'lirien, aged thirty-two, was admitted into tlic New- 
Tork Hospital, Sci'temlKT 10, ]8.'>4, with an nkcr on the fwnt 
of the tibia, connected with enlargement and disease of the 
bone. At the age of twelve years he had received a severe, 
contused, and lacerated woimd of the leg, by the fall upon it of 
a heavy piece of machinery. The laceration was mostly on the 
front part of the leg, and never healed entirely, but contract- 
ed down to a small ulcer, whicli gave him little trouble. Sev- 
eral times, during the twenty years of its existence, the ulcer 
had become enlarged, and covered with proud flesh, and given 
him a gresit deal of pain, particularly in sof^ weather and at 



«*s 



MiXlGNAJTT DISBAEBS OF BOXB. 



niglit. After such an outbreal;, it has slowly returned to ite 
Urtiial ijiiict fdiuHlion. Tlie last of these attai'ks, ntidcr which he 
wad Hiifleriug when admitted to the hospital, began alwut twelve 
weeka ago. While thaa enlarged and tilcerating, it liiw often 
bled freely. No bone has been diiwhnrgod, and he denies ever 
having bad RvpliiUa. The ulcer was upon the middle of the 
tibia, which was much thicVcncd above and below, as was aleo 
the lower part of the fibula. The surface of the ulcer, half the 
size of tlie palm of the hand, irregular and prominent, was 
fonned of large, Iiard, wart-likc granulations, giving issue to a 
thin, fetid, walorv fluid. The jirobe, on beiug pressed down 
uniung these granulations, entered at several points half an indi 
into the substauco of the bone, and eneountered rough RpicuUe, 
pnrttcuiarly round the mar^n of the sore, where there seemed 
to be a border of sharp, irrcgularly-uleeratcd bone, fituo 'whidi 
the granulations sprouted. There was no great tenderness or 
inflamrnatory appearance about the limb, and hie general con- 
dition was good. On the 'J.'ld of September, finding no im- 
provcuient under treatment, Dr. Buck cut down and expoeed 
the wliole surface of the libia, and found that the wart-like 
gi-anulations sprang from tlio bone, which was hy[Hirtr((phied 
abovo and below. With a chisel, the wlirde ulcerated portion 
was gouged out to the depth of about half an inch, leaving 
epongj- and hypcrtrophied bone below, which, however, seemed 
olherwise sound. At one point the gouge opened the niedul- 
laiy artery, which bled very freely, and which was only arrest- 
ed by pressing a plug of wax against the bleeding orifice. Tlio 
wmind was left open and drejjeeU lightly. JVotwnAer SWA. — 
No iniprtwcment followed the operation. The wound did not 
assume a hctiliiig actirpn, but produced anew the peculiar wart- 
like gnmuktitjiift, bicixling freely from (ho slightest injury. 
Several largo pieces of bone cauio away, and the ulcerative ac- 
tions were prop^rcssive in the centre of (he sore. His general 
condition was npidly deteriorating, and, at his own request, the 
]eg was amputated Just below the knee. 

On examination, the lower two-thirds of both l>one8 were 
found veiy- greatly hypertrophie'l. At the point of ulcer there 
was a lo5d of stibst.iucc tif llie bone ocjnal to mora ttian one- 
third of its diameter. This oxcnvation was oovci*ed and {Mftly 



EPITHELUL CAXCER OF BON-fi. 



367 



filled up with canliflower-like grarmlfttionB contftining no "bone, 
TUo bone-substauce ecfemed to bo irregularly excavated, nnd 
wonii-eaten, but without any repnrativo formatiuu of uew bone. 
The po6tcriur HuHhce of the tibia &howe<l tliat the diseased 
action was penetnitiTi<» throughout its whole structure. It was 
jiromineiitf with irrcgulai' uodules of bony deposit on its surface, 
and the substance of tlio bone gave the idea of being intiltratixl 
throughout with the uiiine material as that coni|H>sliig the granu- 
lations. The same substance seemed to form tlie basis of tho 
ikin-granulation, and was, in several places, infiltrated into the 
muscles. My friend Dr. John T. Metcalfe made the micro- 
Bcopic examination of the tumor for me, and found the mass 
compogcd mainly of cells. In the fluid pressed from the bone- 
g;ranulations these cells were of various ckiraeters. There were 
many small, round ccIU, witli well-marked, t^omelimcs double, 
nuclei ; othere birger, with branching proecjides; otiicra spindlo- 
sbflped, but among them a considerable proportion of large, flat, 
single nucleated cells which were mauifestly cpithcliid. 

The patient made a ;jood recovery, and when the stump was 
Ii&ilcd ho left the hospital ; but already some enlarged lym- 
phatics in the groin looked suspicions. On the 1 Ith of Ifarch I 
was sent for to see him, and found him greatly changed. The 
swellings in the glands of the groin had grown to be immense 
tumoKi, which had broken rmt into foul and funyvniH ulceration, 
which were rapidly deiitn.tying their surlact', while their base was 
being as rapi<ny increased. The pain, and discharge of matter 
and blood, were rapidly bringing on true cancerous caclicsia. I 
beard fr^'ni him ocfasionally till his death, which took place a 
few weeks after I aaw him. I heard tliat the autojisy showed 
lar^ cancerous maescs developed in the pelvis, and in some of 
the intenial organs, but I got no aothenlic report of the ap- 
pearances. 

i£r. Stanley considers the disease as a local malady, and I 
am not prepared to deny that it is so in some cases. He docs 
not give, however, the after-history of any of his pationte, but 
I think there is good ground for believing that the inalignnnfc 
history of my case was rcjKJatcl in at least «iine of his. 

Dr. Delafield gives me the following acconnt of a knee-joint, 
which was the seat of a large tiunor which had been growing' 



86B 



MAUGSANT DISEASES OF BONKL 



for Boine years, the knee linving boon in a condition of diseaao 
for hIkhiI Bixtuen j'eara. Tim liirili was rL^inoveil by Dr. Jnmes 
K. Wood. ''Tbe articulating extremities of tbe feninr and 
tibia, the patclln, and tho soft tissues around tlie joint, ore 
eoftcnpd, ulwmted, and psTtly replaced by new tlsiiue. Thyre 
are eevcral fi-ituloiis openings into tbe joint. Tlie new tianie 
coneists of celU of VRrions size and shape, mostly of an epithe- 
lial character. Eonnd and polygonal uucleatetl t-elU, and large, 
tiat, pavement epithelial cells prwlouainate." &.aciiehdlen "are 
also found in considerable numbers. The cliaract^rietio mark of 
the tiK8tie is the neets of epithelial ccUd ]ia(-l<ed together. The 
cancroid Btrueturc is most complcio in tbe tissue replacing the 
bone, Icnst eo in the tendons. In the latter are found portions 
consisting of round granulation-ecUs." 



CHAPTER IT. 



MEI-AKOID CASCEB IX BONP. 

Patholoobts are hardly yet agreed a« to whether this form 
of cancer can lay claim to any other anatomical peculiarity than 
the existence of the black pigment tlirough tlic etriicturca of 
%-hich it is eoniposod. Mr. Paget is very cinpliatic on this point. 
He says: "I have not seen or read of any example of melano- 
sis, or melanotic tumor in the bnman Bubject, wbich might not 
be regarded as n medullary rancor with black pigment. In tho 
horse and dog, I believe, black tumors occur which have no 
cancerous character; but none sncb are recorded in hnraan 
pfltholog)'." In the main, this view prevaiU with the best 
writers ou the subject, who generally agree that melanotic 
ttmiors an*, in tlic human subject, medullary cancers into wliicli 
tbe melanotic niatcriiil liaa been introduced^ without in any 
other way altering tlio anatomical features of the atmcturoa in 
which it is found. It exists mainly in tho phape of black or 
brnwn granules winch are sometimes found in the colls, some- 
times in the nucleus, and, often enough, entirely independent 
of cells or fibres, merely disseminated thi-ough the uitercellular 



UELAXOID CANCER IK BONE. 



360 



aulistance of the tissne. In tliia distribution it is extremely 
irregulai*, eumftiiiies afl'ectinj^ 6m<,'le cells, and not thuir ticigh- 
hoTiy gvuc-rallv iixure abuuUant in Koiiiti culls thim in otlierB, 
ofkeu found plcntiiully Jiililtruted through one lobule, while 
Uioau artmnd it may be of a natural eolor, sonietiuics all in ibc 
colls, and sometimes mainly outside of tlicin, aud not iiufi'e- 
qucntly affecting one oi" more tumors In a verj' marked d^ree, 
■while several others may be entirely free from it. What the 
fioiirec of the black material may be, whether it be Cfwcutlal 
black pigment, like that of the clioroid or lungs, or whether it be 
altered hematoidin, i« nvt by any iiieanB positively ascertained, 
but thi» niucli ii certain, that in the eye and in the iategumcnts 
it is more common than iu regions which naturally contain no 
pigment, or but email (juantitie* of it. The diseafic itt^clf is one 
of the rarer foi-ms of cancer. Ifr. Paget gives a tabic in which 
he found, out of 33r) oat^ea of cancer of all kiuds, 2o were of 
the melanoid ^■aricty; of these 14 were in the skin, in the 
eye and orbit, 1 in the testicle, and 1 in the vagina. He alludea 
to none in the bones. 

In the bones it is mostly found as a secondary deposit, and 
in this respect the disease shows one feature wliich may bo said 
to be, at lea^t in its extent, peculiar. I mean the very remark- 
able disposition it has to generalization ; so marked that in tiome 
instances no tissue — almost no organ, and suarccly a single bone 
in the whole body — can be found which does not show some 
trace of the black deposit. And here a question snggcsta itself, 
whether, with nil this confitltntional jiropcnsity to the formation 
and deposit of the motanotic liiibst-inf-e, it may nut sometime? 
be found accumnlatcd in the healthy tissnes independent of any 
cancerous fomiation whatever. This f|UC8tioii I cflunot answer, 
but, from analogy in the inferior animal^ from the extremely 
general and abundant manner in which it is otlen distributed 
over all ]>arte of the human body, and from the absence of all 
appearance of any other change, as far as the naked eye can 
discern, of many of the spolj', as soon particularly in the can- 
cellous structure of bone, I am disposed to exjiect tliat the 
microscope will show us that the^c eeconiiarj' black -pigment in- 
filtrations are sometimes projected into tissues otherwise per- 
fectly normal, and entirely independent of any canceroua fonna- 



570 



(AXT DISBASKS OF BONB. 



tion. These views were suggested to me, and, I think, con- 
firmed to a great extent, b}' the obBcrvation of tlic I'ollowiiig 
caae, which, pcrhiips, will atford us a study of the iiioft iuijior- 
tant clinical f«irtires of melanoid dtsease : 

Peter Hies, aged thirty-three years, applied at the German 
l>ifipen«ar}- of thia city, April 2T, 1869, on account of several 
black tumors on different part* of the eurface of hi« body. Tlie 
patient stated that he had had, from his earliest childhood, a 
pigucuttiry uicviis of tlie size of a small be^n, situated over the 
angle of the left scapula, which, without any known cause, be- 
gan to grow larger about two nionthe before, and had then 
attained the size of an egg. The first melanotic tumors dcvel- 
o^wd in the immediate vicinity of this mole. From the tirat tlay 
when he applied for treatment, up to the very last day of his 
being under observation (a period of about eight months), not a 
day passed without new tumors being discovered, either on the 
suifac-e of the body or inside of the cavities of the moutli, brynx, 
or var. From eloee observittiuti of huudrods of these nietitnotie 
tumors of the gkin, Dr. Simrock, under whose care the patient 
was during ahnont the entire roursc of the disease, states that 
they all took tlieir origin from the subcutaneona tissue, and en- 
croached upon the cutis only a1\er they had attained a certain 
size, nntil finally they reached the surface of the skin, by tliin- 
ning its elements by prese>ure from below. As soon as the 
growths reached the snrtxce, they began to undergo marked 
retrogressive metamorphosis, and, shrivelling up and decaying, 
tlicy gradually disappeared, and letl only a black mark as indi< 
eating their former ]>rc&once. In some cnseB even this la^t (hirk 
pigment-ary diwohjration was tibsorved to fade away, leaving 
the skin only of a eoniewhat darker hue tlian in the surruimd- 
ing parts. 

In 3ome instances the surface of the tumors became ulcer- 
ated, and a scab fonncd over them which finally desquamated, 
leaving only a discolored surface beneath. A few tumors were 
obser\'ed, which showed no pigmentation. About two months 
after he first cam© under observntion, he began to complain of 
his eyesight, and especially of soreness of the left eye, when 
the exietom^ of a melanotic tuinur of the size of a large pinV 
head was detected in the inuer and upper half of the iris. In 




MELAXOID CANCER IK BONK. 



8^1 



a very short lime — about fourteen days — the intic tTimor devel- 
oped to its utmost eize, about the diameter of a large pea, and 
then, in about the same length of time, it rsn through its retro- 
greeeive coar&c, until finally' uuly somo extremely slight diseol- 
oration of the affeutwd sjwt foiild be observed. Vision was at 
first blightly interlercd with, but, upon the 6uhi;idcncc of the 
tumor, it became normal. A similar growth appeared in the 
right eye, with moeh more Revere impairment of vision. 

Tlie patient's general condition underwent no marked 
change for the worse, until some large tumors devt-lnpod in 
tlic tongue, the painfiil condition of which materially interfered 
^th mastication and deglutition, and this began to tell upon his 
nutririon. Up to the latter hall" of Ot-tober the man eontinned 
to work at his trade, and had not lost a single day. About tliat 
time he had a slight attack of varioloid, from which lie recov- 
ered without any imtoward aj-mptom, but he Btcadily failed in 
Btrcngth afterward. One of tlie melanotic tumors, on the right 
eidc of the tongue near its root, waa very deeply ukeiiitcd, and 
BO jMiinful tlmt it was ditficult for him to swhUow. The surface 
of the body was covered with innumerable black tumors, vary- 
ing in fli/c from that of & smflll ahot to that of a hii-kdrv-imt. 
He continued to fail In (strength, and died, exhausted, January 
13, 1870. 

Dr. Simroek says: "The diagnosis of the eharacter of all 
these metastjitic tuniora wits baeod upon the niicroBcuiiica] ex- 
itDiination of the primary one, and of several others which were 
taken out for the purpose. The prinmry tumor from the back 
proved to be true aaroomii, in the funnation of which tlic fusi- 
fnnn and round cells equally participated. Pigmentary parti- 
cles I was not able to see in any of the sarcomatous cells. The 
pigmentar)' part of the tumor was entirely iutercelluhir, and 
appeared in the form of irregularly-shaped partitles and cakes 
of different tinges, from blood red to deep bbick, in the fonna- 
lion of which the extnivasitted and stagnated blood may have 
had ita part. One small tumor, the size of a bean, wns extir- 
pated frtim the inner side of the left, hmnenis, and showed the 
same aarcomatous olcments »*> the primary one, with jiignien- 
tary interapereion as the chief characteristic pnrt of its conatitu- 
eaite. Five particles were removed from tumors wliich after- 



MALIGNANT DISEASES OF BOKT 






tt»l 



ward disflppcarecl almost entirely, leaving only a discolorntion 
of tho ekitt, and in. both the Bain« eliaracteri^tic elements 

sarcoma were unduubtwily prev; 
lent Klato uiicrtwoopieal uxumi- 
n»tions (rorroborate my diiign 
of tnie Barcttnia, then tta &})on 
neons disappcarauee ttUI prove 
precious expericncfc to tlie patU 
ogist. Viichow remnrks, in 
biti>l^ on tumors, Ihut * ti{i to t 
time be knowa of nu well-proved 
cmc of sarcoma h»vuig Bpontan&- 
oiisly disappeared. ' 

** On post'Tnort^nn examination, 
blaek tnuiors were iVmnd Leru and 
there un the membranes, and in 
tho substance of ttio brain. Tbo 
jiloiinr, both pariotid and visceral, 
and also the pericardium, were 
Rtudded with small black maasea. 
External eurface of heart covered 
with pigmout-epots, some projeel- 
iii^. uthers nut. In tbe BiibHtau(.*c 
of tbe beart, the pigment accm 
to follow tlio course of tbo m 
cidar fibre*. The colnmnre 
neip, as well a« all tbe internal 
smfnce of tlie or^cau, were mottled 
with similar massce. Both Innga 
were iuliltratod with pigmcnt-ni 
tcr throughout. Mucous Biirfa 
of larger bronchial tubes contain- 
ing Rpots of pigment. Bronchial 
gl.iiids ealargc<l and black. T 
diaphragm containol uielauo 
tumors OD both surfaces and 
its substance^ as ilid also tbe pe 
lompura, both visceral and pa 
tal, tho omentum, the stomach, tho intestines, largo and small, 



nice 
[no^H 

dl 

-iial^ 
led 
'^ 



■•:^i 



':^- 




Tji<.. 






COLLOID CAXTSa OP BONE. 



873 



u 



the pancreas, the mesenteric fi^lftiids, the liver, the spleen, the 
kidnevfs the ui-ethral mueous Borlkce, the bladder, the prustatu, 
the i-orjwra careruosa, the testicles, and the cord. The luiiscIeB 
overywhero were infiltrated with the same black pigment, whicli 
followed iu a marked maiiuur the cuiinto uf the musculiir fihre*." 
Dr. Delaticld tnude » careful examiuatiun of many of the lucali- 
ties meutioiH'd, and his observatioua are of nmph interest. In 
all the situations where distinct tumora existed, the pigmentary 
matter vrns contained cither in round or oval cells, or in thfir 
intert'enular substance, in granules line and coarse, or ititillrated 
into the neighboring tissuce, thne forming, as it were, the out- 
ekirta or borders uf the snrcomaloos nodule. In several sitna- 
tions, however, it was distinctly made out tliat the deposit liad 
taken place in the Kubistauce of, and in the interstices between, 
the elements of perfectly nornial and unchanged original titn- 
8UC. This was particularly the case in the bronchial miicone 
monibrano, in the kidneys, in sonio parts of the skin, and in a 
portion of t!m fibrons stnictnro of the dura inater. ThcM ob- 
BCrrations were made with much care ; nnd iu reference to this 
Tcry point, aa to whether, in the human subject, pigmentary 
accumulations ever tiikc place independent of cancerous disease, 
iu any of the gituationa where pigment 'is not normally found. 
They seem to me qnite conehisivo. 

Several of tlie bonea were marked by black epota, and when 
sawed thmngh the cancellous tissue presented numerous black 
dots, an<l irregularly -shaped spots, due to the iutiltnition of tlie 
melanoid matter hito tissue otherwise pcrfortly healthy. Fig. 
103 represents a section of the lower portion of the femur, 
irhich exhibits <iuito a number of the peculiar black spots. 



CHAPTER V. 



COLLOID CA>'CEK OF BONE. 



That form of cancerous disease which is characterized by 
numerous ftlvcoH, containing a ghie-Hke maten.il, is occasionally 
Been in the bones. Mr. Stanley gives a ver}' well-marked ex- 
ample, occurring in the phahingeal bone of a finger. The case 



334 



KALIGNAXT DISEASES OF BONE. 



wfu under the care of Mr. Lawrcncei in St. BartliolomcV» 
Ilyspilal. " A mau, aixty-tive ^ears old, liad been healthy from 
birth, iiitd both kiii jjiti'euU Imd been huiilthy and luag-Uvcd. 
Bather uiore thnn a yuar 14;^, he noticod a gwcUing in tlio first 
pliolanx of the right fore-tingcr; it was moderately firm, gavi 
him little pain, hut gradually increased. Six moutUa ngo m 
lancet was thni&t iiitu it, and some blood, with a watery fiiitd, 
was discharged, and ulceration of the oj)ening ensued. A eeton 
was ailerwurd passed through the swelling, and immediately 
afterward it rapidly increased. The hand was amputated at 
the wrist-joint, and, in the examination of the diaeased partd, 
the following particulars were observed ; The tumor was of a 
globular form, sott and ekstie, and about two inches and a half 
in diameter. It enveloped tlio fin>t, with part of tlie second 
phalanx of the fure-finger; its interior coni^latml of a semifluid, 
jelly-like substance, contained within cells formed by dense, 
wliite, fibrous bands. The tumor closely snrromided the bone, 
which waa rough in one situation, while, in another, part of it* 
wall hiul diitappeared. Within the bone, gelatinous substance 
WHS deposited, like that of which the tumor coaalated. Mr. 
F:iget submitted thia substauee to microscopic examiuation, and 
found tluit it jHJfisessed none of the diaraclcre of cartilage, but ^^ 
apparently consisted of a structureless, viscid jelly." He alao^^l 
remarks that there is in the museum of St. Bartholomew' s Hos- 
pital an example of this same form of tumor growing fr4)m a rib. 
In the museum of the New York Hospital there is a cast 
(No. i7\ of the head of a patient with a huge tinnor, iuvol\-ing 
one side of the face, which is stated to have sprung apparently 
from the antnim, and to have extended from that point iu all 
directions, so a« to fill the inouth and pharynx, pressing upward 
into the orbit, and causing Rb&orption of the septum narium, 
extending up through the sphenoid bone to the base of the 
brain, and forming externally a large tumor U|Hin the lateral 
and lower parts of the letl side of the face (Fig. 104). The 
tumor was surrounded by an imperfect capsnic, and consiMcd 
chiefly of cells filled with an amber-colored gelatinous fluid. 
The bones upon the outer parts of the growth were softened, 
and very much thinned by pressure, but did not seem to be in- 
filtrated with any foreign, material. The brain was not uivolvcd. 



OOLLOU) CANCER OF BOKt 



875 



The patient wae a man thirty-five yeare old, who had long Buf- 
fered fi?om gjiTnptcims reBcnihling thoRC of oza'utt, but the ta- 
mor was not discovered in the fuuees until within fi yonr v( bis 
death, which took place chiefly from exhaxietion, Iroiu tuutinued 
ptyaliem, and inability to swallow food. 



X 



PS 



Flu. laL-Hf- T. nuptial UoMom.) 



Dr. llouift Bauer laid before the New York Pathological 
Society, at its meeting in Jftniiarv, 18"i7> a tinnor of the site of 
ft man's fiat, which ho had removed from the aiirfacu of the leJt 
femur ju^tt behind the great trochanter, which presented all the 
apjieaniucea of colloid disease. Tlic tumor had been growing 
jibout two years. At one time, an abecess had formoii, dis- 
fliarging a viscid substanco with the pus. Be bad suffered 
much pain, and wns greatly reduced by the disease. About six 
months previous to the time of presenting the spoeimcn, Dr. 
Bauer had removed the tumor. After tlie portion presented 
had been taken away, the femur was fcmud to bo e.\tensively 
carious. All dtbeaaed bone, as far as could be reaelicO, was 
gouged off. but the whole of the tumor could not bo got away. 
The wound healed, however, and, at the time of reporting, the 
man remained well. 

Lcbcrt gives the history of a case which was under the cans 



8T0 



llALICN'ANT DlSF^iKES OF BONE. 



of Itous in 1S46. A izmn, agwl thirty-eight, had two moderate* 
eizcd tumora of the upper end of tin; tibia, one on eithur side 
of the ktieo-jnint. The^' hod been groning about three months 
•without i>aiu, and followed a atrain. Tlioro was no heat nor red- 
netif) nboiit them, and no other feeling but a growing weakness 
of the limb. There w*rs a slight pulaatiun felt on liivuig the 
hand gently over the surlat-e of either Bwellmg. Snppoaing 
them to be of a vasenlar nature, Koux tied the femoral iirtc 
Secoudnry hemorrhage occurred ; a second ligature was applit 
higher up; but the man died from pyfeinia. Ko change had 
been produced in the tumors by the operation. The upper part 
of tlio tibia wae found occupied by an cncophaloid ni.ii^, pro- 
jec-tiug on either side into the two tumora noticed during life. 
This niasB contained, in all parlt*, unnierous gelatinous points. 
The bone-subatanee was difiplaced by the tumor, and had nt tliat 
point entirely disappeared. lu the inside of the mass the mor- 
bid deposit WR8 of a yellowish, pale-rose color. "By micro- 
scopic examination, as well as by the naked eye, tlie colloid 
nature of the cancer can be e«en, which is besides very vasculur. 
There in everywhere a very abuudxmt transparent Eubstunt 
in which are a few fine, rare, divergent fibres. Tliis Bub^tnnt 
everywhere eontains futilbnn rancerous elements, having 
length of yi^r of a millimetre. Some of these were ]X)iiited, an< 
some rounded at their ends. Tlie nuclei are round or elliptii 
and from bV to iV '^*'* millimetre in di.imeter. Some are fr 
Tlie nucleoli arc shout ^in of a millimetre in diameter. There 
are almost no fatty elements in the cancer." 

Cruveillii^jr figiirea a very beautiful case of alveolar onn< 
wliich grew in the bones of ihe face of a woman who died of 
at tlic age of filly-two. It occupied the o1hmoid> na.s:il, unc 
fruntnl hones, made: a liugc projection on the anterior and upper 
part of tlie face, and cncroaf^hod back into the laueea, filling up 
tlicnasfll cavities, and preseing backward upon the brain. It 
had grown slowly for about ten years, with great pain, tliough 
the patient, who wiu a painter of some merit, had continued at 
her work almost to the end. On section, the whole masa [jre- 
aented the peculiar alveolar arrangement which char.U'tertzes 
colloid. The alveoli were large, and, though of dilferent si«o, 
wei-e nearly uniform in every part of the tumor. The pecu ~ 



OSTOm CANCER. 



377 



arity of the ease was, that tlieao nlvooli, instcnd of l)cinp fillwj,. 
witli a transparent, ji;]ly-Hkc material, contained a wliitwh-yelto*''' 
Bubfitance, wliic'h Cruveilluer, in one place, likens to concrel* 
paa, and in another speaks of as consisting of caseum. No can- 
cerous disease was found in any other part of tlio body. 

Tbcsc cases all are instances of the primary form of tbo col- 
kiid disuitsc, and of thi^ tlicy pret<eat a tolerable pictun:. From 
what we know of the tendency to generalization of this disease 
in Uic softer ]>arts of the bod}', we can v.\A\ suppose that it may 
sometimes appear as n secondary deposit in the bones; I tliink, 
however, it mnet in this form be rather rare. I have never 
eeen an instance, nor have I encountered any statement of one, 
in any of the authors wlio^e works I have had an opj>ortuaity 
of consnlting. 



CHAPTER VI. 



oeroiD CANCER. 

Several writers have insisted npon giving this name to a 
form of cancer containing a very large proportionate amount 
of bone; and yet iti other parla and in other rcsjKiirta pre^^nt- 
ing all the ehanicteristit'ii of true cancer. Thef>e ostnid cancers 
arc found most often in the lower end of the femur, and most 
commonly aft'ect equally the inside and the outside of the 
bone. The sot^er porta of the growth do not exactly correspond 
cither with The scirrhous or encephnlold nrntcrial. Mr. Paget 
describes the snbsrance us " nsually excfiodingly dense, tirni, and 
tough, and may bo incompressibly hard ; its cut suriUce uprises 
like tliat »f an iuton*ertebral cartilage, or that of one of the 
toughest fibrous tumors of tho uterus. It is pak- grayish, or 
with a slight yellow or pink tint, marked with irregular short 
bars of a clearer white ; rarely intersected as if lobed, but some- 
times aj'pcaring handed with fibres set vertically on the bone," 

The bony portion of the mass is still more peculiar. He 
gays : '• In the central jiarts it is, in the best-marked spci-iniens, 
extremely compact, scarcely showing even any pores, white and 
dry. To cut it is nearly as hard as ivorj', yet, like hard clwlk, 



id 



MALIGKAST DISEASES OF BOKE. 



A 



**. 



[it may bo rubbwl or 8cra]>ed into fine drj* powder. At the 

'l>ei-il>bery it is arranged in a knubbed and tiiberou» fomi, tbu 

knubd btiug olleu foruied of close, thin, gray, or wbite Iitniellv, 

wlioee presuutiug edges give tlu-iii a 
fibrous look, exactly like tliat of 
puniiee-Btoiie. In tills psrt, al«>, the 
bone is very brittle, flaky, and pul- 
vcndent. In ftome specimene, ibe 
whole of tlie bone Lae tliitt deltcute 
lamellar and brittle texture ; but, more 
^nerally, && I liave said, tbe central 
part is very hard, nnd this, ocyupying 
the walls and canccUoua tissue of the 
shaft, equally with the snrrt»nnding 
part of tbo tumor, makes of the whole 
suL-h a conijjAot, white, chalky ma&s a» 
the f^kctiJi here represents." Fig. 105 
is the picture Hr. Fagct gives of the 
disease thus de»i'ribed. 

Whatever may be thought of the 
expediency of erecting tbi» forai of 
dbea«o luto a Bepnrate class of can- 
cers, ita well-marked featured evi- 
dently ontitio it to a position aa an 
important variely. Ii has already 
been remarked that, with most of the cancers of bone, tho 
osseona tissue is displftt-ed by the cancerous growth, and that 
very little and often uo new growth of bone accompanies the 
destruction of the old bonc-subatance, at the expense of which 
the morbid growth is constantly increasing. Even in those 
cases where something like a hony skeleton is fnrmcd in the 
canraroiia ma^ this skeleton is usunllj* composed of exceed- 
ingly slender spicula, and thin and delicate lamina;, which holdj 
a very small proportion to the wholo mass, and which are usu- 
ally so impertect in their construction, and so fragile in tlicii 
consistence, that, when mftcerated and dried, it is exceedingly 
difficult to prciierve them from falling to piecea almost by theil 
own wciglit. To all this a very strong contrast is presenlt 
by the tumors now under cunadcration, whose must strikii 



pm, loa.— (rmiii fv"') 



OSTOID CANCER. 



379 



feature is a very great deposit of new bone as a basis of the 
growth — a deposit which seems to be ft cotutant accompaniinent 
of that growth, and to increase ^/■£jw«#« with its increase, so 
tliat, iu tiomo of the Largest tumora of thia kind which have been 
detiCTibcd, the proportion of bone in the growth wad quite 06 
great as iu the snialletit. 

Another feature, cqtmliy striking and. oquallj important as 
elcarly marking the truo cancerous cliaractor of the disoatw, is 
found in tlic tendency to generalization whitth thcRe tutnori; so 
niarkally diiiplay, in wliich the moRt distant and most nnex* 
pected organs are sometimes iinpliostod. The secondary de- 
posits prcserre the character of the origiiml growth, and hence 
we have the lymphatic glands, the nterns, the blood-vesseU, and 
even the thoracic duct, filled up or inliltratod with bony sub- 
Btauoe 80 completely &!t iu soum instances to become unrecog- 
nizable. 

!Bir. Stanley gives three cases of this disease which ho terms 
malignant osseous tnmor of Ih>iic : " A man, agod thirty, was 
a<hniited into St. Hartlioloniew's Itosjiital under the care of 
Mr. LawTencc, with a swollen and painfnl state of the right 
kncc-juint, consequent on a fall, for the removal of which anti- 
phlogistic treatment was successfully employed ; but, shortly 
aA«rward, a painful swelling arose immediately above the knee, 
and gradually extended around the lower tliird of tho thigh. 
A sotU'uing of the swelling iit one point being discovered, an 
incision was node into it, from which arterial blood (lowed 
freely. Pulhutioii w.ns now discovered in the swelliug, and at 
the same time it was observed that the leg had become oHlema- 
tous, and that tho toes were colder than in tho opposite limb. 
The temoral artery was then tied. Pulsatiun in the tumor 
cease<], and its size gradually diminished ; but after some time 
it again enlarged, sloughingof the skin and central substance 
of the tumor ensued, but unaccompanied by hsemorrhage. The 
man gradually sank from exhaustiuu. 

"On exniuiniug tho liiub, I found thu tumor to consist of a 
compound, sutl, fibr^ms, and dense osseous substance, the tatter 
extending completely round the femur. Tho whole aeries of 
femoral, inguinal, and lumbar absorbent glands, wore couvertfld 
into ossoous tumors. Tho femoral and popliteal voxels were 



3S0 



ualig.vant dise.^ses of boke. 



wand. Id tliu caw the tiunor of the femur, and the tumoit 
uf the iibsorbent ^liinde, were identical in Ktruclure, both being 
composed almost wholly of a solid, duU-white, chalk-like, oeeo-j 
OUH Eiibtitjinco, which, in the femur, wne continuous with a ei 
ilar dc|K)sit in the mcdiillary anil canoellone tisduo ut* all that 
jiart of ilie bone which was Biirroiimled bj the tumor.'* 

As a general rule, this form of cancer is rapid in its pro; 
re?&, and Mr. Haf»el reckons them about equal to the mcdu 
in the length of lite they allow to the patient. Some caaes 
ejtoken of in M'hich life was prolon^'d for many years. Thiu> 
Mr. Stanley mentions one where the disease was in progress for 
eighteen years. Mr. Paget alludes to two cases whore death 
did not occur until in one instance tweuty-four, and In another 
twuuty-five years, had elapsed troiu the time of the first appoar- 
ance of the ailection. On the other band, some caeca are 
corded in which the di.4ca.4c has nm a course af. ntpidly dei^tmi 
tire as tlic most rapid medullary cancers. Mr. Paget gives one 
CAse of this rapid progress of ostoid cancer in a girl of fiftee 
who was admitted into St. Bartboloinew'a Hospital " with geu' 
eral feeblcueaa and pains in ber limba, which had existed for 
two or three weeks. They had hecu ascribed to delayed men- 
stmntion, till the pain, becoming more severe, socmc4l tu bo 
concentrated about the lower [lart of the back and the left hip. 
A hard, deep-seated tumor was now felt, connected with the ala 
of the left ilium. Thia gradually increased, with eon»lant an 
more wearing |i«in ; it extended toward the pelvic and abdomi 
nal cavities; the patient became rapidly weaker and thinner; 
the left leg swelled ; sloughing ensued over the right hip; no 
she died, cadictie and exhausted, only three and a half mouthi 
trom her first notice of the swelling. 

" A lianl, lobulatud ma^ was Ibund, completely filling thi 
cavity of the pelvis, and extending across the lower part of the 
abddiuinal cavity. It wns fimdy connected with the sacmm, 
both isc'hia, and the left ilium ; it held, as in one ma«s, all the 
pelvic organs; and the uterus was so embedded In it, and so in- 
filtrated with a similar material, that it could scarcely be rucog- 
nized. The general suHiicu of this growth was unequal and 
nodular. It was composed of a puarly-whitu and cxcoalingly 
hard slmcture, in which points of yellow bony substance W9« 




TREATUEST OP HALlCyAST DISEASE OF BONE. 



S81 



Ided, and wliicti had the cliflractere of oatoid cam'er per- 
fecrTy marked, llie ilium, where tlio lumor wa* cuiiiiDcted 
witU it, liad the same li.iU-fibrou^ liaU-boiiy structure as tbo 
tumor iteclf. T)iu L-uuiinon iltac veins, tbeir mniii divisions, 
and (jtliers lending into them, passed through tUc tuiiiflr, and 
were all disttinded with hard substance like the aut^ aruuiid 
them. From the common iliac veins, a continuous growth of 
the same suhfitaucc extended into the inferior rava. whifli, for 
nearly live inches, was distended and completely obstructed by 
a cylindrical muM of frimilar tibrons and osseous sabstance one 
and a quarter inch in diameter. At the upper jiart this niasd, 
tapering. cAiim to an end near the liver. The lower lobe of the 
right lung was hollowed out into a large sac, containing green- 
ish pus, and travei-«ed by hard, coral-like hands, wliich proved 
to he branches of the pnlmonanr" artery plugged with lirni white 
suhstaiice, intenninglcd ■n'ith softer canccraus matter, and re- 
sembling the great mass of disenRo in the pcIviB. " The reet of 
the lung was hcnitliy. wilIi ihe exception of some scattered 
grayish tubcnlca ; and so was the left lung, except in that there 
were a few small abitcetifioit near it^ surface, with hard, bone-like 
maases in their ccutres, like those iti the hrandies of the right 
pulmouarv artery. The skull, bmin, pericardium, heart, and 
all tiie abdtuninai organs, were healthy." 

In the other aspects of its general pathology, the oatoid can- 
cer diilers in no mati-riiil rt'spcft from other forma, except per- 
haps in the fact that it shows no particular teudenty, under 
ordinary eircuniRtanccs. toward ulceration, or any other form 
of rapid destniction. It is a<-knowlcdged, however, by those 
who have best studied the disease, that materials for the full 
stoiy of it3 life and tenninatlons have as yet hardly been accu- 
mtilatcd. 



CHAPTER VU. 

TBEATME»T OF >UUOXANT DUKASB OF BOXIC. 

Thf cancerous tumors of bone present, aa a matter of coitrse, 
nothing more encouraging, &» far as their treatment is con- 
cerned, than caueerons tnmors in other parts. A large share 



382 



ICALTGVANT DISRASE3 OF BONE. 



of the success which Bome of the older surgeons elaiined 8s the 
result of their several raethmls of treatment wc can now ex- 
plain, with great plausibility, hy their want of accurate diftgno^ 
•ii; while the few iuetancee in which the cure is tinequivi. 
we are disposed to refer to the coincidence of a spontaneoi 
or natural retrogression, rather tliau to the result" of the remc 
diee empluyed. It is suniewhat disheartoniug tu find tliat, 
our knowledge of these prowlhe advances, our conviction 
their utterlv intractable nature grows deeper ; and that Burgcoi 
of the present day, with all their incrcflBcd light, and with the 
grcntly-iniprrived mcaim of diagnosis, are \eae. Euinguinc and It 
confident, m to the therapeutics of cancer, than were the mew' 
of lialf a century ago. Tlie hopes which have been excited by 
the vainous reroedie« lauded as curative of cancer have one bj^H 
one been sadly disappointed, the exiwctfttions roused by th^^ 
vaunted |)0wer8 of cornpressiun, electricity, canst ic^tfc/(^, gal- 
vano-cautcry, acetic acid, etc., have sobered down to tltu i^mple 
question, not whether thcBc reraedie« are curative, but whether 
they are in any degree beneficial to the euft'erer. Indeed, I tliinfc 
it would not be too itiuch to say t]iAt,tin the minds of the best 
men who are now occupying themselves with this study, the 
qncBh'on of cure has very much given place to the question of 
palli.ition ; and that the labor? and hopes of such men cc»]tT^| 
more upon alleviating sntTering, and prolonging conifortabls^^ 
life, than they do upon Utopian projects for the fundamenta l 
cure of the disease. Much may be done short of n cure, fo^l 
the great benefit of onr cancerous pationts, and it seeuie vorjj^^ 
clenr to me that it is in thia direction that onr therai>euticol 
labors arc likely to bo most fruitful, and our elTorts on behalf 
of onr pHtictits most beucficial. ^m 

I nm far from wishing to nndervnhie or to deny tlie nseful^^ 
neas of certain internal romcdie», from some of which I think 
I liftve myself derived benefit. Tudeed, T consider the subject 
is worthy of our most serioiie attention. 

The most recent statements I have seen on this subject are 
those of Mr. T. "NVeeden Ci.mke, whoso long experience as sur- 
guDu of the Canct-r Hospital in London frizes git-iU weight to. 
his opinion. In his work on " Cancer, and its Alliee and Com 
tertcits," he devotes much 8|iacc to the subject of trcstment||1 




TRGATUENT OF VALIGNANT DISEASE OF BOXB. 



SB3 



and passes in review the various intemAl remedies wlitcli liave 
been most used in the hope of curing (.-ancer. liis venlict tipou 
all of them IB iiiigpiiriiig and decisive. He hag found ao benefit 
from their uso which is worth nauiinj>, and he dismiBaufi them 
all as unworthy of ronfidcni?e, as having any apceilic inl]ucn(*e 
on the CDUi'so' or tenninatiou of the disea^. Nevertlielees, he 
[ cue of the most hopeful and cnfoumging of niodeni writcre 
on tlic trealnuMit of cancer. Viewing the diaea«e aB one in 
which the perverted cell-growth depends upon want of tone in 
the system, and believing that this tone can, in a certain degree, 
be imjNiried by appropiitite treatment, he asserts moat confi- 
dently that, by the judicioiiB uee of certain nutritive tonics, 
with proper local applications, much may be done in arresting 
the progi'css, relieving the sufiering, and actually cnring the 
disease. The intcnial remetjiee which he reliea ujmn with most. 
eonfideuce arc cod-livor oil, iron, hydrochloric acid, and cin- 
chona-bark. The tirat two are the principal remedies he era- 
ploy*, the latter nuxiliaricB, to which he Bometinies adds other 
tonies according to the condition of the digestive .ind nervous 
system*. Of the oil he saye : '' There is only one other medi- 
cine M'bich baa any large clauu upon our attention, cither aa an 
auislaiit anil rectifier of the digestive process, or as a direct 
alterative and tonic to the blood. In my handu eod-liver oil, 
administered in tho occult Btage of a ecirrhus of the hreaat, baa 
more nearly approached the charnctcr of a »pecifi« than any 
other agent. It flceins to fupply that aliment to the cells of 
new formntioTip, for the want of which they droop from their 
rotund form, and lose the power of creating nomial tissues." 
The reaulta of his treatment are encouraging and auifrising, 
for he gives an outline of fifteen cases in which manifest hcuetit 
wna derived from the course adopted, of whii^'h cases, all under 
his personal observation, he eaya: ** These are a few instances 
of aiTofit of sciiThus of the mamma by eonslitntional mcjins, 
for ten, twelve, even sixteen years, and Iho jmtientfi are still 
living evidences of the conservative powera of Nature, when 
properly 9upi)orted by art, to stem thu destructive influences of 
this malignant disease, and reduce it to a mere inert mass." 

It will, however, be more in accordance with my plan to 
glance at a fow of the local Temedies, which have gained most 



S84 



MAUGKA!rr DI3EJLSES OP BOXE. 



fiivor witli tbe profession, as farorablv modifying the progress 
aad result of cancer developed in the bonce. Of tUeee, fi 
are of chief interest: 1. Rc|ieatod local depletion hj leet' 
i'. Svtttciiuttic compression ; 3. Ga]vano-<?Icctridt>' ; 4. IJgaturo 
of artery leading to tumor; .'>. Ablation. 

1. Iie/<e-cU^l Local De^^etion htj Leeches. — This melliod of 
treating cancer is one of tlie oldest tnown. In former times, 
when almost every Hwclling was re;*nrded aa a modified tV)nn 
of infiamination, tLc idea very natumlly suggested it«elf 
treat tbe cancerons form of inBammatton by local abstrocti 
of blood. Something was found to bo gained by this practice^ 
and it has maintained ita jmpularity perlinps more &tofidily 
dowii to the present day tlian any other remedy on the list 
Tlie explanation of \\» good etfect^s aeconling to our present 
view, must be billed upon its influence In akiting local con 
tions, and atvidental inllammatious in the tumor, to whieh lo< 
aotiouH modem pnthology nsi-ribcs a ccrtnin considerable 
in the doBtruftive agencies which arc at work in sny cancero 
growth. That any thing can be gained in modifying what may 
be called the normal nutritive processes of such a tumor, by 
remedy which, Uke leeching, cau only have an occabioiial nppi 
cation, does not seem to be Hkely ; but that, by relieving Eiiln 
and averting or curing intlanimation, it may do good iu discn, 
where the worst influences in opcmtion are acknowledged 
"be those of the inflainmatorj' oharaeter, is, it seems U* me, 
reasonable expectation. On this ])oint Walshe, after allndi 
to the ]ong-continned popularitj' of the trcntment, sav 
"Hodem experience lias established the degree of utility 
local Hb»traction of blood. Iu the earliest stages of diseased 
indwration tbe application of leeches is strongly advi*iable; even 
as a giiido to the diagnosis of tumors of h d'MibtfuI character, 
it ia nseftil. The progress of growth of nndoubtedly rarciiioma- 
itywn nature may be thus rctanled, anil in(-td<>ntal inflainniAt^t 
symptoms in the adjoining tiwiuos Buceesftfnlly eonibated ; b 
beyond this Mpillnrj- depletion lias no power. The nuinber 
leeches apyilicd must bo regulated by the size of the tumor; 
should vary between twelve and six ; h smaller number cau; 
an afflux of fluids to the part Mithout emptying the vi 
sufiieiontlv. Mlicn the tumor is adherent to the skin, there \t 






TltEATMESTT OF MJIUCXAKT DISEASE OF BOSE. 



36S 



in coiititmiiig the practice, as tliu bites have &L>queutly 
'been known to piisa iuto jiersieteut nlt-eraiioiis." 

"Wliatcvcr may be tbe decision of a more rigorous etatistioal 
inquiry into the retarding influence of occauoiial leeclitnga, 
tliere can be no doubt tliat in certain instances tliey do netom- 
plish frome good b^- the relief of paiu. Much of the euffcrlug 
infUeted bjr thc^ di-eadful diseases is caused by or aggravated 
bj acvideulal intlamuialioii£, \^'llieh are under the eontrul of 
well-regulated local de]iletioii ; tind, it ia u wonderful fact, 
re<.*ognb!ed by all who have much employed the remedy, that 
in Bome itietaneea the iininuuity from pain.proctired by a hIu- 
gle application of leecbea will last much longer than can be ex- 
pLiined by the relief of a simple attack of iuHaitinintion. It 
would set^m as if the sedative ettect of loKs*of hWwi sometimca 
remained artcr tbe immediate depressing etfect had been appar- 
ently recovered from, and tbe vital actions of the atlected, parta 
ueeiu to be modidod for a certain iiidotiuite period by a cau« 
which we ordinarily considt-r Iv bo of teiujKirarj' and generally 
of brief inliucnire. This relief of puin, and its nccompunyiug 
sorcncee and tcndemosB, is an immense benefit to the siiU'ercrs 
wIUi cancer ; and wo can hardly help associating with the means 
of procuring alleviation, the id&a of at least a tendency toward 
ft cure. The testimony of many writers is favorable to the use 
of this remedy, although it must be acltuywledged that those 
who have ii]>ukeu niu«t eulogist ically of its etfects have been 
Uuwe who upheld most earnestly the intUtmmatory nature of iiU 
eaneerous disease. 

^liich caution should bo exercised tn the uae of this means, 
which is |)Owcri"ul for evil if used too freely. By too fi-eipient 
or too liberal an em]iluynient of local depletion, it is very evi- 
dent wo may so reduce the vital power of tbe part ailccted as 
to Civor rather tban to check morbi<I action, and thus, by weak- 
ening the power of resistance, we may incrcoiic the evil tenden- 
cies of the diM»se by the very means we employ ro relieve it. 
Again, ba Sfr. Stanley remarks, care should be used in applying 
leeches over a tumor which is ali-e:idy Mdhereut to the ekin, the 
leech-bites becoming sometimes the starting-point of ulceration} 
which miglit [Kirliiitis have been long poetpouod had the skin 
remained unwouudcd. 
25 



886 



lULtGN'AXT DISEASES OP BOXE. 



2. Sfjatematio Compremon. — This is not a new remedj 
cancer. It waa first brouslit to notice by Dr. Toiing in 
earlier jwira of tins century, and was tried very fully at 
Middleticx TTosjutAl in 1816, w-ith so unBatii^factory results tt 
but little raore was hoard of it till M. Riii-amior i-ovivod its wi 
and nnnonnccd souio wundertiil suocuisea. Unfortunately, 
entlmaiastic Gxfterimcntcr dainiod a great deal too much 
his pet plan, And accordingly the profession froncrnlly has dis- 
credited his resultg. Ue says: '^CM* one hundred paticnU, »ix- 
tcon appeared to bo ineurable, and underwent only a palliative^ 
treatinont ; thirty were coniplctoly cured by fompressiou aloi 
and twcniy-one derived, eoniiidcmble benefit from it ; fifl( 
were nii'ed by extirpation alone, or diieily by e.\tir])Hiiun and 
pre^urc eouibined, and Btx by compression and cantcrizatjc 
in the twelve remaining caswi, the dlsMsasG resisted all the ineii 
omplaycd." Even the high character of M. Ktjcainier 
hardly give currency to eucb magnificent statcmcnt«, and 
something must have been realizwi by the treiitment to ha^ 
formed a bafeis for 8ucli exaj^rated praise. TVHwt tUi$ lujuie- 
thing was, wo can gleiin from the reports of other, jferluipe more 
candid, experiuientera with the same niothod. 

In theyejir 1S.19, my late venerable and esteemed friend 
J. P. Raii'lioldor published, in the New Y^ork Jmtrnal- ofM^ 
rjtif, an account of hla experience in the treatment of varioj 
att'ectir.nft by ]irc«8vn-e applied by compressed sponge. Amoo 
other things, bo had tried the elfect of the remedy in a number 
of cases of cauccrous and other morbid growtiis, and the rcsul 
he obtained are well worthy of attention. No one wlm kni 
him could doubt the truthfulness of his statements, certainly 
the honealy of his convii-tions, Itis explanation of tlie mtjdi 
operandi of his plan ho thus states : " The pressure occasii 'U( 
by the expansion of the compressed sponge distnrba the cancer- 
cells, and fort'cs them nut of plaw ; affects tlicir consistency, and 
oanscs thcui to be dissolved ; and the tutnor, thuK freed of 
malignant ingredients, may be more readily removc^l by al 
tion, if the process be continued, or, if not absolutely remove 
it may be so divf-stod of il.^ malignity as to remain harmlose filj 
year;*, as happened in a case whicli will bo n-Iated. Does \\ 
preseiire, as the doctrine teachcsj deprive the ca'ncer-ccUs of thoir 



TREATMEST OF ilALIQNANT DISEASE OF BOXE. 



S87 



power to contaminflte other parts, or the B/stem in geuorsl t 
The cancer-cell, like tho pu&-globu1e, is die^ulved, and, belii^ 
thus changed iu its uutury, is more rendil,v al>s<>rbud, and of 
course, outers the circulatiun, nut as a niali^^iant, but a& an in- 
nociious Bubetanue j and, inBtead of wintaminatinff tbc system, 
is eliminated therefrom, as are other disintegrations of tispncs 
and strartuTOB, witliont hnnuing any part. Canecrons atfee- 
tions, Kieally considered, seem to derive their nntrinient from 
mrronndin^ parts by a sort of imbibition or endoerooeis, and 
not from any direct vascular medium. Tbe 6j>o!ige, by its pecid- 
iar mode of preetfure on the diseased part, either deetruvB iU 
texture, or prevents its being nourished, and continues to do so 
until its agency h fully reeiBtcd by the circumjacent part^ wluch 
are in a healthy condition." Id support of his views, ho then 
goes on to relate a number of cases in which groat benefit was 
gained by tbe nse of tbe sponge; iu one of them tlio tumor eu- 
tirely disappearing in leaa tbnn two months from the commenoe- 
ment of tbc treatment. Sonic of the cases were treated in pri- 
rate practice, and some in licUovue Ilosjiital, and all of tlicm 
were watched more or leaa carefully by eome of our best aur- 
geoiia. I g^ivu the full biatory of one which is most to our pur- 
potic, iuasnuich as the diiieae>e was seated iu a bone : 

"A lad, about eigbt or ten years old, fruni New Jersey, was 
brongbt by bis motlicr to Ur. Mott'a cliniqne, in 1847 or 1848, 
with a fungous tumor pr<itniditig iVom the Inwer jaw, sitimled 
in the space fomierlv occupied by tbo iirat and «econd molar 
teeth, on the left side. Tliie morbid growth Iiad made its ap- 
jMsaraoce srtme months before, loosening the teeth, pi-otruding 
on each side of them, and pushing away or involving (he gums, 
previous to Iiis coming to the elini<)uc. The teeth liad hcett 
extracted, and tbc tumor, witli, I believe, a portitui of the alveo- 
lar pmc'C!*, renaovcd by a siii^geon in the boy's inimcdiate vicin- 
ity, wliicli operation was now repeated by Dr. Mott In a few 
weeks, tbe little fellow was brought again to the clinbpie, the 
disease having returned. Tnahle to lay my hand on tbc notes 
of the case, I have indeed forgotten, as well as Dr. Alott him- 
self, whether another operation was pei-formed. AVbetlier it 
was, or was not, is c^nitc ininialerial to our purpose. The dis- 
ease had returned ; and at my suggestion tlie compressed sponge 



S88 



^[AUGN'AXT DISKA8B8 OF CONE. 



was to be tried ; and Le was ftMignwl by Dr. Mott t* my care 
nnd mnna^ment. I look biiu, with bis motlitT, to my offic 
and cut two or tbrco piccee of tbarowglily compressyd epon 
siiffletontly largo to cover tbe whole tumor, and indeed extend 
beyond it on the outer and inner sides of tbe alvcobir process, 
nnd rising biglier than the upper siirfacoe of tlio adjatrcnt teeth 
bcture and beliind it; sad then bound the lower maxilla lirmly 
to (he npper by menns of n roller, leaving the pieces of sponge 
to expand by the imbibition of mltva. The mother wits snp^^ 
plied with several pieces of oomprcased sponge, and dirci-ted t^^J 
apply them hi tbe same manner once or twice a day. Shu was 
told by Dr. Mott that the disease was of a malign-int chamctcr, 
and would be very likely to destroy her son — certainly, if not 
properly and failtifully attended to. Tho doctor's faith in a 
fevorable result was obviously not very strong; nur was any- 
body's else, except my own. Notwithstanding, in the course 
of tive ur six weeks tbe mother and lad agnin ftp|M?arcd at Dr. 
Mott's cliniqnc, not to ask adncc, but to show the result, that 
the boy was perfectly cured. Tlie remedy had been entirely 
Bueccssful. Tbe location of the disease bad been £ivorable to 
tbe application and action of tho s^ionge. Tbe result in this 
caeu WHS analogous to wliat I b»d wituesbed in others." 

The du[;tor then alludes to one other case in which a similar 
tumor, situsted on tlie lower jaw of a lady between fifty and 
sixty yenns of age, was treated by tho compressed sponge wi 
an oipially pcrfe<!t result. 

The theorcticjil \*iew9 cxpres.'ied by tbe ndvocatea of 
mode of practice are ingenious, and not improbable. That c 
life and growth may bo modified and destroyed by p: 
seems entirely likely, as the mere result of the action of 
chanical force ; tliat it is actually aceompJiaheU is deraonstra 
by tbe cases published. Thus much is practically certain, i1 
tumors, even malignant tumors, can be eniirely removed, un- 
der favorable frircumstances, by tho mere action of carcfuU; 
regulati'd pressure; and this clinical fact adds just so much 
our means of contending with cancerous disease. That t 
method Ii:is imy power of raodifving the local cancerous acii 
on the 8un-oniidirig parts, or on the geueml system, is not only 
not proved, but not rendered probable by any of the &ct8 which 
iiuve .IS yet been made public. 



m< 



TlteATMEXT OF MALIGNANT DISEASE OK BONE. 



389 



3, Gatvano-Electru-rit'j. — This ngeut lias been einpli)yc<l lu 
tlie treatment of cancerous disoaaes in two modes iiiiite dis- 
tinct fivm <»no anothfT. One of these nietliods is tluit in wliitib 
the eircuit through which the elcclHcity passes is bo arranged 
that, at a certain point, tlie condticting tnaterinl bocnmcs in- 
tensely heated, and this liwited portion, being in contact with 
the point of disease on which it w de«irod to act, prodiure* the 
cauteiizing effect of intense heat, nud destroys the part ex- 
posed to its influence. Tliis is an oxcwjdiiigly convenient 
iQotliod of employing electricity to produce the effect of the 
actuid cautury, but it must be eridcnt that the action is ein^ply 
that of a ciiHstic, nnt, so far nti apftcara, specially mollified by 
the fiict of electricity having been used !<i produce the lieat. 
There is tio breach of contact, and therefore no passage of the 
cLictrio tinid tlirongli any part of the tissues; and, tlierefore, 
any specific effect of electricity, as such, in modifying the mop- 
bid actions in the part« tlu^iugU wluch the conductor paii^ses, 
may, I think, bo pn.>purly left niit of condderatiou, and thin 
form of electrical upplicatiou may he considered, &% it \& com- 
monly named, a mere gntvano-cantery. 

The other method is one in which the electrical current is 
Cflttsod to pass through the jinrt to be acted ujTOn — the mode 
cf ii8 passage, and the extent of its action npon the tissues, 
varying very mudi according to the manner of its employ- 
ment. Eitlier the Faradaic or tlie direct ctureut may be used, 
and either may be applied externally on the unbroken eltin, 
or either may Ik; caused to act upon the deeper tissues through 
needles thriiht int<i their tiubstance. Tlie use of electricity by 
exteruiil up[ilicntiou is much the oldest method, but much the 
leaist effective; indeed, the testimony we have of its usefuinesa, 
in the discussiim of tumors of any kind, is confined to so few 
well-authenticflted Instanccf*, that not many snrgeons now em- 
ploy it. The method which has of lute attracted most attention 
!£ that in which the power of the current is so great tiiat, M-hon 
introduced into the tissues by proi>erly-pi-epared needles, a de- 
composition of siuiiu of the textural elements takes place, by 
vhich such alteration in the mass is set up that absorption or 
alteration of the tumor ib the immediate or ultimate conse- 
quence. "Wluit is the precise extent of this decomposition, and 



s«o 



UAUGNAirr DRBASBS OF BOaTB. 



how precieely it aflWta tlie clcmeiits of the tisijuca, are jKiinta 
wliicL fire nut yet fully cxptniiieil. Tbe luctUoil itacll', from the 
decomposition wliicli acpoinpanics it, is called clcctrolvftia. 

Elcetrolysis lins now been used in quite a large nnmber of 
tumors of all kinds, and with a degree of euccese which leada 
us to hope titat it is to bo » positive addition to our uionas of 
dcaliufr with the£« intractablo and nnpromiaing dclbrinitiefi. ] 
do uut know that any thing has yet been m-hicved in the direc- 
tiuii of i-untruUiitg the mulignant fejitures uf theeo di^eiise^ but, 
merely spcuking of them as tumoit^ nnieh has certainly been 
accomiilirfhetl. I cnnnot better present the main features of 
tikis tnotliiid of ti-eiting tumors tliHU by giving an outline of A 
caae recortlo<l by Dr. R. P. lancoln, in tho Medieal Uncord of 
this city, for December 15, 1S70: 

A gentleman, aged thirty-three, wag tbo «nbject of a soft 
tnmor in tho Kupra-clavjctilar e^>ace of tlie left side. It bad 
appearL'd, without known CiUise, about eighteen months before, 
and with shght iuterniptioni; hod pretty steadily inereaAcd np 
to the time of hia coming under Dr. Lincoln's care. Tho tu- 
mor was; now the size of a large gtmsJe'M'gg, niovwl to a certain 
degree with the tmchea, was nmndwl in shape, two iiiehes in 
diameter, and rising about tive-cighllia of an inch from the 
natural Burfiicc of the neck. Tlie tumor was soft and conipreft- 
eible, but elastie, and when prcstiiire wait removed reiiunie<l its 
Ufiuul 6ha]>e. There was no puleation, but it grew turgid when 
the breath was held, or any etraining eflbrt made. Under ejc- 
citemctil, &A from public speaking, this turgid condition of tlio 
tnrnur wuuld become coubtant, and was eomctimca attended 
with very alanning (symptoms of fiulfocation. TIio diitgiioMS 
wa5 venous erectile tuuiur, and electrolysis waa applied, Sep- 
tombor ;ii), 1870. 

" The patient having been chloroform ized, I introduced four 
gilded steel needles, insulatofi to one-half or three-fourths of an 
iudi frt'ui tlieir points, into the fonr quarters of the tumor, the 
two upper being one and one-fourth inch apart, and one inch 
above the lower, which were one inch aj^art. ITie two inner 
needles were connected with the subdivided anode, and ihe 
outer two with tlie subdivided eatliode, and ten elements of (lie 
battery, which waa working with a weak current, vounci'ted 



: 



TREATKENT OF UAUGNANT DCWjISE OF BO\B. 



3»1 



witliin n feu* moments, and f^aduAllv llie power of tlie battery 
iras increased to its niaiciiiiuni, and the number uf elements in* 
creased to fifteen. At tlic expiration of tiftecu minutes, the 
two lower needles were disengnged from tlie current, thn« con- 
centrating the whole force upon the two upper ; at the expira- 
tion of fifteen minutes more, the uccdlos were removed. Dur- 
in;; the operution all the prominences of the tumor disappeared, 
and a delicate exnniiuiition detec-Lud a hard matss in its place. 
Not a drop of blood escaped on the removal of the needles. 
The skin over the tumor presented a bright flush, and the tra- 
chea had returned toward its nomml position. 

" Odohi^f [\Hh. — Patient presented himsolf for cxarainntion. 
There was no tendency to a reappeannce of the tumor; on the 
contrary, the induration in the neck wag steadily diminishing 
in size. 

** Octt^r 22d. — The following is an extract from a letter 
&om the patient, M'ho had already made scvcr.il public address- 
ee: < I urn feeling very well, and there is nothing to indicato 
any thing like a rocun-cneo of my malady.* " 

It is tniG that tbia case is probably one of an erectile tumor, 
and as sucli would he likely to be inure easily all'cctod by such 
local action as that of intense doooniposing eleetricity than 
almost any other form of growtb. It is nevertheless a fact of 
great interest as it stands on tlie record, and perhniK> will bo 
more cneoiiraging when we reflect how large a portion of tu- 
mors, and particularly of malignant tumors, are made up of a 
very abuudant roueulation of vessels. 

Rut electrolysis has been trieil on malignant tumors. Alt- 
haus. Von liriins, and Gherinl, Iiavu used it each in a immher 
uf eases. Allhaus reports that be has gained some advantages 
in the treatment both of scirrhus and enccphaloid, and pariicu- 
Urly spealis of the relief which ho has obtained from tlie severe 
lancinating pains which are so distressing a feature of many 
cases of cancer. Ton TJnms is not so sanguijie, and says that 
electrolysis rarely, if ever, disperses or even uiatcrially dimin- 
ishes a malignant tumor. 

Tliu most st)r]irising ease on record, however, is one puh- 
liahed by l>r. AVilliam B. Neilel, of this city, in the Medical 
Reoord of September 1, lS(!d. It is substantially as follows : 



898 



blSEABES OF BONE. 



A gentleman, fift.jt--eiglit years old, liad a tnmor of llie left 
mftmina, wltlc-h hv ii^'vural good sui^eoiiB wns pruiiounucd can- 
cerona. It was Bucccssfhlly removed by the knife, and tho 
wound healed favorably. The axillary glands of that side 
1>cgan to calai^ soon a£tcT the healing of the wonnd, and 
formed a lai^ tumor whicli also vns successtully removed. 
This wound healed slowly, and npon it* cicatrix a new tumor 
grew, whit'b soon attained the eizc of an orange. The general 
eyat^u) had by thia time beoouie aorioii&ly impaired. To tlita 
tJiird tutnor electrolyeis was apiilied by Dr. Xeftd, at three 
aittingH, on Iho 2Tth of April, and on the 4ih and 7th uf May, 
1809. lie used the "large appamtuB of Kriigcr iind Ilir&cb- 
maon, with elements of Siemens, anbdividing, at the second 
and third ojieratinn, the cnthmic into tlircc or four branobes, 
contiected with the needles by scrres-fines. The latest improve- 
ments of the flpparatns attorded the possibility of gradnally 
increastng tho quantity of the current without interrupt iiijr the 
circuit, and of dim iu lulling it iu the same way, so that Ute cir- 
cuit was broken only by tho extraction of the last ueedle. Kot 
a drcfp of blooil escaped. The first operation Instfjd two min- 
utes, using ten elements; the second live minutes, with twenty 
elcmonta; and tho third ten minutes, with thirty elements. 
AtXor tho oporntioii ttio tumor increased considonibly iu aize, 
but became softer and more clastic No febrile or other local 
or const itutional symptoms followed. On the contrary, tbe 
patient, who before was weak, ansemic, and cacbectit-, began to 
gain llc!>h und strcngtli, tho tumor at the same tiuiedimiuitiluug 
slowly but conttaiitly. A month after the first sitting ths 
tumor was found a great deal s<^>fter and smaller: at the end 
of the Boooiid nioutli It had almost di&appe-ar«d, and n fortniglit 
later no ti-ace of it remained. Tlie general condition of the 
patient is now in all respects excellent, and new deposits can 
nowhere be detected. In his last letter he writes to me as fol- 
lows: *IaTOnot able to discover any new deposit* anywhere, 
nor would the tumor in the right breast be detected by any 
oi-diniiry observer.' " A year and a half after tbis date Dr. 
UelU'l reports this gentleiunn oa doing well. 

It ia of course unsatisfactory, certainly unwiaOf to attempt 
to generalize &om a single case like the above. We must wait 



TREATHEXT OP MALIGSAAT DLSEASB OF DOSR 



Sfi3 



for more lifiht. When we remember the natuml tcmloncj to 
retrc^jjcssion of some cancers — h tendency which, un<3er im- 
proved general and \n<til manageinent, liag been certainly very 
mncb more prominently recognized during tlie Inst few years; 
when we recollect that nnder all reasonable modes of treatinetil 
eomo caaea have appeared to bo beuotitcd ; and when, still 
further, we make allowance for tho natural disposition for utl 
men to believe wliat they wisli to "bu true^we shall, I tliink, bo 
disposed to receive these confident and sanjfuinc Btatcments 
with some grains of hesitation, and, instead of neccpling them 
defisive of any therapcuti^^'al result, we shall be disjioscd to 
»y them away for fiitnrc tomparison with other fact^ which are 
yet to be acciimulated ; fyitisficd with the encouraging hope that 
tlioy are |iointing us in. the right direction. 

4. Lig<iture <^ Ariancs. — In a previous chapter some allu- 
sion has been made to the cutting oJT the ^iiscular supply as a 
means of modifying the gT^^wth of certain very vasctular or 
erectile benign tumors. The same idea Itos l)een applied to 
malignant growths, and j)articalarly those in which groat vascu- 
larity of the timior la a prnminent feature. The idea of slamng 
malignant tnmora by cntting oft' their circulation has been a 
popular one with sm^ons, and coiitideut hopes linve been en- 
tertained that it wonid prove to be a valuable rc«oarcc. Theo- 
retically it has &onte coneiiderable plaubibilily. Though all 
pathologists recognizes certain independent life, and indepen- 
dent Ainction in all forms of cell, yet it is equnlly recognized 
that the cutilimmnco of this life, and the perfection of the func- 
tion, duj^iend dirt'L-tly uixin the Bupj)ly of appnii>riiile material 
from the Wood. The absolute etoppngu of this supply involves 
death, the diminution of it certaitdy modifici activity: why 
may not this diminution, carried to a point extreme, but not 
fatal to the tissue involved, act 00 as to change the morbid 
actions, either by slopping them altogother, or reducing them 
within the limits of health? For tho answer to this question 
we must of coureo tmru to experience; and I think I may say 
that expenence is ready with an answer — -I'l-obably not a tinal 
and decisive answer, but one which I think will enable us, in 
some good degree, to appreciate tlie true value of the remedy 
proposed. 



894 



VAUONAST DISEASES OF BONE. 



The Advocates of the opomtion claim for it tlireo disdai 
poiuU of benefit to the patients: 1. A relief of pain; 3. A 
arix-fet of i>rugre*s; 3. A perfwt cure. Of the first point, tli 
of relief from pnin, tbo claim aot-nis to bu pretty well eufltaiD< 
a very lar^u ituijority of all tbe cawi-s operate"! on expresait 
thcm&elves very greatly beiietitc^l, ais far us relief from eiiHu 
ing is conccrued. With it^rd tu tbu Bceoud ]>oiut, that of 
aiTcst of pru<»ret«, it must ho homo in luiiid that wc hnvo here 
a prohic'iii iiiiK'h iiuiro. unferuiin in ita clement^ than the mere 
existence or non-existence of pain. What the rote of progrcM 
was before operation, and what it would have been if no oper 
tiou had been perlormKl, are ipicstions which we cannot aiiswf 
M'ith preci»iou ; and heuce it comes that we are very liable 
be deeeivud in our etitimate of M-hat has been accomplipUed 
tlic H<^tiirc iu diminiahing a rate of progroes, wUidi nite 
hare not the means of Tory acrurntely determining. Still, ^ 
olwervcrs have, in so many instances, felt waiTante*! in rocor 
fug eiii-Ii arretst of growth (\a one uf the cointnun results of (1 
application of a ligature, that we are constrained to accept it a^ 
a faet. Of the third point — a pcrieet cure — the record U of 
eourae by no means promising. I muBt here, however, cxpli 
what is meant by peifect aire, as used in this connection. C\ 
tiiiiily it dues not mean that a i^rfeet removal of lood cancerot 
growth lias been fnllowed by an evident cradi<>ation of cane 
Otis cliatliei^ii;. and a restoratiun of the patient tu perfuirt anund- 
ness, botli local and i-unstltutioual. Indeed, so far as I uiider- 
6tand the views of the reporters, it ia not intended to itD]iIy 
tliiit imdcr this treatment there is noeeaearily any better ehancQ 
of escaping secondary tumors, gcnei-aJiziition, cnehcxia, at 
death, limn in caeca where other mciiis of removal arc 
ployed. Some enthusiastic admirers of the ligature, encoi 
aged by their theoretical views of its action, do evidfeutly 
to persuade thcmeelvea that thcao bright hopes are to be 
iiod ill the ca&cs they give; but no higli authorities tliat I bav 
had access to chiim any thing more than a local cure, Icavii 
the question of tinnl result unsettled, either by their opinions 
or by the facts iviiich they present. With tliia nudei-ttiandinj 
then, of the meaning of the words wc nse, wc may say that, in 
a very sranll proportion of the reported caaes, a perfect cure 



TREATIIEST OF lUUOSAXT DISEASE OF DONE. 



805 



liaa resulted. I have not myself been so forttinntc as to *eo 
one of tliese itcrlect cures, nor, indeed, Lave I met wiUi anj 
j)ublij>ht>d cane nitli full details. I give two i-usus, one ul'M'liicU 
I saw orteu with the pcntieman who reports it, nud the other 
otiunrrcd in the practice of one of my friends, though I am not 
Bare tlmt I over taw the iwtient, Tliese isses are not cures, 
but will ])Grhnp6 represent the averago bcnotit which results 
fnmi the opemtion, and thcrefure are tnier elinical examples 
than if they were more perfect in their results. 

Madelaine Xieliola, aged fifly-four, a inan-ied. woman, was 
adiiiilted to the Xew York Iluspital, March 30, 1855, under 
the care of Dr. UuUted, with a lat^ tiunor of the antrum on 
the right side, the history of which slic gave as follows : *' Two 
years a^ was lirst attacked witli pain iu the upper jaw uf 
right !oUlfx', the [lain con^taut and lancinating iu cliaiTictcr. 
During the next two months a swelling of the jnw showed 
itself, gradually incrc-ising, projecting not only upon the exter- 
nal surtiicc, but also upon the roof of the mouth, aud in its 
groTi'tli pu^ihing out the last two molar teeth. AWut two 
months before admission, the tuuior having iu the tnenn titus 
greatly lncrt.>a8ed iu size, it begnu to uk-cratc, aud, since it luu 
pi-eseuted an open sore, fre<picnt hicmoiThagce have taken 
pkce. Mastit^tion of food is diUicult, and deglutition much 
embamissed. Since ulceration comnicncoJ, the imToasc of the 
tumor has been much more rapid. The general condition of 
the patient is pretty good. 

" Mmxh rtOM. — An attack of htemorrhage came on, in wliicli 
she lost about lour ounces of blood. During the toUowiug 
night she lost about the same amount. 

" April 2d. — On consultation it was determined, with a view 
of arresting tempomrily the growth of tiic tumor, and prevent- 
ing the fretjucnt and exhausting hfvmorrhage, tcj ligature tho 

imon carotid artpry. This was accordingly done by Dr. 
falsted, jiiijt below the point whcru tho artery is crossed by tho 
omo-hyoid mnsclc. The first efl'ect of the operation was to pro- 
duce some giddiness, with dinmesa of vision in right eye. This 
made us feci some anxiety for tho brain ; but in a few days this 
passed away, and, with the exception of an attack of erysipelas, 
every thing went on favorably. 



3M 



MALIGSAXT m?EASES OP BON*E. 



"AprU fith. — The wound has not lienled by first intentioa 
and ia commencitis to snppurute. She has Und no hipiuorrl 
since the operation, and there has been n vr«ibIo decrease itfcl 
the size of the tumor. Deglutition is moro easy. 

" Maif 3rf. — The lignture came sway to-Jfly. The tumor la 
now about one-quarter of its ori^uai size." From this point 
the improvement continued. She lelt the hospital on the 8lli 
of May, Uie tumor conttuuiiL<* to diminish in size, uutU it ia 
statevl iit ttiu uutcs to have ahnost disappeared. The putient 
regained her general health and ap|tearaucu, aud remained well 
fur eeven months, when the tnmor agnin bt^n to grow. She 
died Fehmary, 1856, unwilling to submit hcrseli'to any further 
Burgieal trciitment. 

The other case occurred in Rdlcvnc Hospital, under care 
of my friend Dr. Stephen Smith. 

Alice Griffiths, aged fifty-thrco, a widow, of good luibit;s, 
was udiiiittud to tlie wards of IJellevue on the 13th Otiwber, 
18jt(. She had a tumor uf the left upper jaw, which had come 
on about seven months prenously. She had bad some slough- 
ing of this tumor, leaving an upon sore, which gave great di£ 
tress on attempting to eat, and from which fli>wed a large and^ 
offensive discharge. She was then nmch broken down from 
Buflfcriug, and inability to masticnte her focM). She did not re- 
main long in the hoepital at that time, but was readmitted 
January 23, 1S57. "The cheek was now much enlarge^l from 
the growth of the tumor. The fissure fi-om the slough bad 
nearly filled from now growth. The tumor now extended 
buck shmg the inei^ian line as far as the soft palate (jiart uf 
which had sloughed away), and both within aud without the 
jaw, from the second incisor of the left side to the lant mohir. 
She had great difficulty in ftwnllowing, owing to the size of the 
tumor, which was now as large ns a hcnVegg, and also from 
the tenderness. There was a constant ooring of matter into 
the mouth, rendering her stomach very irritable, and als«i oozing 
of blood from time to tmie, on her attempting to masticate any 
food of unusiuil lianlucss. IK-r health had rapidly failed during 
the time she was out. The left naris was so pertectly occluded 
that she was unable to force air througli it in blowing. 

"ApTil 2ith. — The tumor, instead of diminishing by the 



TREATMKST OF SJLTQNAST DISEASE OP BONB, 



397 



treatmetit wliicli had been adoptod, lias increased. Tho dis- 
charge into the month and t'rotn the loft naris ih extremely 
offensive; her hearing is so iniieh imjiaired on tlie letY Hide, 
that it u with great ditliculty that any couvereiition ean he had, 
or the patient nuulc to iinderstund nny thing. There is ex- 
treme tenderness in the root' of the mouth, and hlccding almost 
cverj" time the patient attempts to take any food of grcflter con- 
sistency than fluids. TTer general health is rapidly failing; tho 
tumor now extends across the luc^ian line, hack to tlie soil 
palate, and is of t1ic ^ize of a medium-sized lemon. The pains 

of a kncluating eliaractcr, and almost constint ; the integu- 
lenLs over the tumor ai'e ten&e, shining, and painfull tu tho 
touch. The patient is willing to guhniit to any operation that 
will afford her even tempomrj' relief from the jwin. The 
hiemorrhage avcmgea fi-ora one ounce to two ouncea per day 
from the roof of the mouth, which is bo sengitlve that the 
patient is unwilling to take her wlne^ from the pain it pro- 
duces; the erygi|>clatous attacks have become more frequent ; 
the hroiithing in so mueh interfered with that the patient is 
obligotl to keep the luouth open in respiration ; she is rapidly 
failing from n-jteated losses of blood.'' 

In this eondiiion the earntid was tied by Dr. Smith, April 
24, 1857, in the usual situation, 8he boro the oju-ration well. 
No e\nl consequences followed. The ligature cjime away on 
the 2<)tli (Uy, being the I-tth of May. 

" JTay 29tA. — The wound is almost entirely healed ; a small 
point remains where the ligature was removed, which is pro- 
gressing fjivprahly. The tumor remains about tlie same eizej 
tho integuments are much pater; tho pain has almost disap- 
]>ejired; the iutt'gumetitfl oan be enrnignted witliout c<jmplaiut 
on the part of the pHtieiit ; the liardneM still remains; there 
has been no hicmorrhage from the month sinec the operation, 
except that mentioned as oceurring on tho second day, and that 
followefl the attempt at vomiting. The breatliing h still inter- 
fei'od with ; patient unable to force air tlirough the right naris ; 
slight dis'-harge from tlio n a res and mouth continues; she has 
improved in health and strtrngth ; the pain has been alleviated ; 
the com&rt slie has enjoyed since the operation, from the nn-est 
of the disease, and improvement of tlio general health, arc daily 
remarked by the patient." 



866 



MAUGNA.VT DJSBA8BS OF DONE. 



The historr taVeii from the records of the Ixospital goes no 
fiirtlicr, Inil Dr. Smitli lias recontly iiifrtrineU mc that tlii.'i inv- 
provcmeiit Intttcfl only a few inoDtht^ wlicn the disease ogHUi 
began to itmhe progreas, and soon detttruvcd her life. 

In both these cases the arrest of the discaae was manifest, 
and in both so great an improvement took place in the luteal 
and gcnerjil ronditions, from the time of the npplirjitiun of 
the lipaturc, that we are justified in regiirding the remedy aa 
having sliown gi-eat power in moditying and retardiui^ the pro- 
irressive development of the cancerous affection. This same re- 
Edlt, sometimes more and Bometimee less pronounced, is stated 
to have oceurrod in quite a largo proportion of the oaam whidi 
are recorded. 

In the July number of the JVew York Journal qf Jfadidn^^ 
for 1857, Dr. .Timiee R. Wood has collected all the caiics he 
could iind of ligature of the common carotid artery l>y Ameri- 
can surgeons. Of these cases, seventeen were performed for 
the relief of cfincerouB tumors, mostlyof the jawbones. Of the 
seventeen, four are stated to have resulteti in the apparent cure 
of the diireai^e ; ten were dc^'idedty bene]ite<l, the growth of tho 
tumor being for thu time arrested ; two died ; one not noted. 
Loiilving at the operation merely as n palliative procedure, and 
it ia only in this light that we have any warrant fnr regarding 
it, this certainly is an evcocilingly wtisfactory exhibit. To 
these gtatcments I might add the recollections of Dr. Mott, eon- 
tained in a letter to Dr. Wood, and published as [xurt of tlut! 
pajwr above referred to. 

Dr. Hott siys: "The conclusions I have come to are the 
following : that in malignant diseatie of tJie o&res, antrum, 
sides of the he.td, posterior faueo»t, and orbit, the ligature of the 
conmion carotid of the aide affected is, not only a wife, bnt 
proper operation. If the diaease is not arrested by the tying 
of one carntid, the other ought also to be tied, as soon as the in- 
crease of the disease ia in the slightest degree manifcsteil. In 
several of each of these classes of cases, I have operated mvself, 
and have seen it done by otliers, and never without manifest 
advnnt.igcs to the patient, provided a recover)' from the opera- 
tion ha« fnllowed. It is well known that Bomeliave only lived 
three to five davs after tvin;; the Urst carotid. 



IRKATIIKyT OF MALIGNANT DISEASE OF BOKE. 



300 



"I have 6ecn a cnsc htcly, a malignant tumor in the poste- 
rior fances, orighiiiting prolmbly from the periosteum and bodiea 
of two or more of the cervical vertebrffi, u-losinjt ouc eidu of tho 
posterior xiarea, obliterating the Euatachitin tubes, and impeding 
deglntitiun, wliiflt was greatlv btmuiitcd by tying the carotid 
of thnt side. The tumor obviously diminished in size, and all 
tho unpleat^iitt symptoms were assmiged. A\Tien be loft for 
home, lie pifuntsted to return and have tho artery on the other 
side tied, a^ wvon as tlierc was a return of his siitVering. In tho 
first case of this frighttid affection, in which tho artery wfla tied, 
the tnmor actually sloughed. In four instances of thi« disease 
which we had previuuely met with, and in which the artery was 
not tied, they all lingered out a most painful and dietresfting 
existence. 

"1 liavo ficcn and Icnown more than one year elapse l>eforo 
it was deemed nei'i-ffary tt> tie the eecoiid artery. During nil 
this lime tlic dificase wa-s not arrested, but atrophy wns going 
jn constantly; and, njwn tying this second artery, the tumor, 
jongii malignant, has entirely disappeared. Two instancoa of 
tlufi kind I can now refer to, in which the individuals have en- 
joyed g«x>d hcaltli for years without a vestige of the diseaw 



It may fairly be deduced from the al>ove Rtatements, that 
ligature cf the itrtery leading to the region nffectod hy a cancer- 
ous growth doetn. in a i-ertain quite largo proporlimi of cases, 
favorably modify that growth in all the three ways claimed by 
ita advocat!?3. Ilut tho otlior eido of the question is still to bo 
conjiidcrcd : In how many cnsca does the operation involve the 
dc-tth of the patient i The answer to this question depends 
upon many inquiries, and the most important, perhapB, are as 
to the disease for which, and the artery on which the operation 
is performed. By far the largest number of cases have been 
growths about the Jafre and head, and in ttie«e the cnrotid artery 
boB been tied. The femoral and brachial have also been several 
times operated on for growthB of the lower portion of each ex- 
trcinify. Tlie largi^r trunlis have \cry rarely been Bubjeetcd to 
ligature for ctnccrous discise, Tho qucRtion, therefore, might 
bo narrowed down to these three arteries, and even to tho 
carotiii aloue, for I think few sui^eons would be willing to risk 



400 



MAUGXAyr DISE.\SBS OF BONB. 



the dangers of applying a ligature to the great truukis, where 
tbu expc'f.-tAtioii unii only ho one of ]>H]tiation and toiiipunirr 
benefit. It U not easy to get at tlie diingerb of ihcho n|it.*rations» 
as scpanited from the diseases and injuries for wUidt they were 
pcrfurined. 

Dr. 0. Pilz, ftsaistant to the Physiological Institute of Bre&> 
Ian, bait publiithed, in Langcnbeck's " Archivca of Clinical Siti^ 
gory " for 1 SfiS, a rnrisr elaborate and valiuhle table of all the casefl 
in which the carotid artery was tied for all caa&cs, in all L-oimtries, 
and by all surgeons. This wondcdiil specimen of Oenuan in- 
dustry and tlKinrngluioss contains &dO rascsi, and givra eonie 
details of the o{M.'rution, tiie disease, and the reanlt. Of coarBe, 
iu Bueh a vast table, the details must be veiy slight, and it 
is, then-fore, only geuwml results wliich cnn be obtained from 
its study. He gived 14'J cases in wbieh tlie artery wna tied 
for tumors of all kinda, and of these he reports 87 cures, -19 
deaths, and 13 not stated. The cases embrace all form* of 
tumors, erectile, malignant, etc., and it is evident that the term 
cure I'cfcrs only to i-ecovcry from tlie oi>erfltion, and not at all 
to recovery from discAse. Uovr much the condition uf disease 
had to do with death eannot be educed fvom this table ; but tlus 
very striking fact appears: tliat, while in the eases where the 
ligature was applied for lutniurrhagu, for anourisni, for tumors, 
the mortality was from forty to filly per cent,, when wc eome 
to operations performed for epilepsy and for neuralgia, wo hare 
the surprising statement that, out of 34 oiJcrations, in 33 the 
patient recovered, and In only one was doath the result. Still 
further, Dr. Pilz refers to some tables published on this very 
p(Mnt by Velpeau, of Paris, and Xorn's, of Philadelphia, iu 
which a better result still is given, viz., eight cases by Norris, 
in which tlie carotid was tied for the cure of sonic airoction 
of the nerve centres, all of which recovered; and Velpeau, 
three cases and three recoveries. This statement is all the 
more remartiitble when we reflect that out of cverj' hundred 
cases in which tlic carotid is ligatured for hmmorrhage, for 
aneurism, and for the cure of tumors, twenty-two j>atienl8 die 
of eerehnil symptoms, siiperveuiog utler the operation, and 
manifestly depending on it as a cause. That this should be 
the testimony of statistics on so large a scale, aud coUrtrted by 



THEATHEXT OP HALIOSANT DISEASE OF DONE 



401 



three indopenilcnt and reliable obserrcrs, soems ctiough to con- 
Tince ns that tlie ligature nf tho carotid arterv in itsH-lf h nlmost 
&ee from danger, and yet the statcmeitt 'n &o eurprit^ing, and eo 
couir&ry to all our prec-ouceived uotionft, ttiat I am sure siu^ 
geous will hv bIuw to accept it without qualitication. Tlio fact 
etandti ou tiic rccui-d, however^ aud wo are bouud uot tu over- 
look it; but, at tlio bame time, the careful Biirg^eou will uot be 
witlin^^ to nt't, in any ^ivun case, u& it' lie loicw tluU the ligiilurc 
he was about to apply to the carotid artery could never bo pro- 
ditctirc of injury. The same elatistica (but show that tbo liga- 
ture of th(' camtiil, in one elaas of oaeei*, is never fi>llowod by 
■ deatli, show as clearly that, in another class, including the one 
i|n which we are now R]>eoially intei-o«tc<i, the mortality alYer 
ligature U somewhere in the neighborhood of thirty-tlircc [>er 
cent. It is but jiist to innke one claga of cases rcctity the results 
of the other ; and to deduce our practical rules, not fnjui the con- 
Bideratiun of one, but from a fair coiupariHon of both, aud an 
honest recognition of the value of each. My own feeling in the 
matter U llmt, in nil Biiltablo cases where the canccmns digco&o 
IB Hwkiug rapid pro^eas, or is attended by excessively painful, 
or dangerous, or exhausting com pi icfi lions, the patient !uia a 
right to expect from us the inlligatioii of aulferitig, the rescue 
fiv>m immediate danger, and the hope of prolonged life, which 
we may with intelligent cuntid«uce promise liiin as the pi-uba- 
ble result of the ligature of the artery from which the morbid 
growth derives its sustenance. The patient should be fairly 
infonnnd that death may bo the effect of the operation to which 
he bitbuiiti^; but it in our privilege to say to tiiuL that he has a 
chance of a ]>crfect cnre, and a much bcll-cr clianco of an im- 
provement in his condition, audi us will fully warrant tiie risk 
he runs. 

5. AUation. — It can Iiardly be appropriate for me to discuw 
in this plaoo the general subject of ilio priipriety of operation 
in cancer. The views of surgeons on this point are gradually 
a«euming so much of positivenoss in the light of recent studicfl, 
both in diagnosis and iu the statistics of treatment; we know 
so nearly just what to expect, aud just what we may promise ; 
the result of our proeuduro is bo nearly uniform in each clnee 
of case*— tlmt it would seem as if the canon law of Burgcry 
26 



"|jM| VALIOKANT DIHEASES OF BONE. 

might almost now be recorded on thin eubjoc*, with the hope 
that future rcvelirtiong would not materially affect it« provisioos. 
Certain things seem to be definitely ft«cei't<iiiied with regnixi to 
the eiFoct of removing cancerous tuuiorv: 1. No degree of 
tlioroughiiess or promjititude ia operatiou will, in any given 
clus^ of caneers, bec-ure an iDiiniiiiil}' from reouiTenL'e. This 
statement 18 one which most surgeons find it hard to accept. 
The idea that cancer its in its earliest stagee, mci-cly a local 
di>«cs«c whidi begins to iiflcct the system only after iC liaa 
gained a certain dcvt^lopment, and the feeling that, if operated 
on at this period, it. will he eradicated from the syptcni, and 
that, therefore, the early extirpation should be insisted on with 
the hope of permanent core, are so plausible, bo much in flualogj 
with many other ]):)thologieal actions in our eyatem, that even 
such men aa Mr. Ericbsen and Sir "William Fergusson, fully 
informed as they are of all that has been done of late yenre in 
giving ua precise information on this subject, cannot avoid 
clinging to it as one of tlic grounds upon which they ltai=e their 
advice for early operation. That nothing ie to be gained by 
early ns compared with late operations, I would not be under- 
stood to say. On the contrary, it seems quite certain that the 
local disease ii^, at all times, a centre of contnmination, both to 
the neighboring paru and to the general system, a contamina- 
tion some of the effects of which can undoubtedly be obviated 
by early operation. What I mean to assert is, that there is uo 
period in tlio history of oanoer whore it is 60 nneqiiivocaily a 
local disease that its ablation will protect the system against its 
rcappearaneo. I believe this to be, if not positively proved by 
tbe statistics of Mr. Sibley nnd Mr. Paget, so fairly dedncible 
from tlicir researches, that it may safely ho accepted as a patho- 
logical far-t, and that u[ion it we may wisely base our concep- 
tions of the value of treatment. 

2. Want of completeness in an operation for cancer, whereby 
any poillon of the diseased ma^ is left behind, is iujurJous in 
its effect u|5on the progress of the disease, usually exciting it to 
a inoro rapid growth, and hurrying the disease more quickly 
through its worst and most distressing phases to an eiLrlier 
death than would have occurred had it been left entirely nn- 
touclied. 



TRKATMENT OV MALIGNANT DISEASE OF DON'K. 



403 



This proposition is so clearly dcmonstrntcd, both l>y reason- 
ing Bnd experience, that I think it will hardly be denied. Even 
in those recurrent tumors which have no other quality of ma- 
lignancy thaa their tendency to return in loco, wo have ample 
eviduuce of the evil cfl'ect of partial or itiiperfeKt opuratiuns, iu 
provoking a more rapid derelopineut of the disease ; and, iu 
the most benipi form of tumor, a portion of the growth, left 
behind, in nhiioet ^nre to reprodiim, in aggravated form, the 
oH^nal difficulty. The exceptions I Iwve seen to this patho- 
logical law have been mainly in those softlah fibrous polypi of 
the utenis where, atTtcr ligature, the stump left behind shriuka 
away and disappears; and in one instance of fatty growth, 
whore no line of demarcation could be traced between Uio 
original and the morbid tissues, the operation whereby a largo 
portion, but eWdently not the wliole of tlie mass, was romoved, 
was followed by a purfoft cure. The^e are so manifestly excep- 
tional instancea, tliat they do not invalidate the general law, 
applicable to all morbid growths of the tumor character, and 
specially and emphatically true of those belonging to the es- 
sentially malignant clas«. 

3. The operation itself is an element of danger to tlie life 
of the patient 8o important, that it must not be overlooked. 
It i« extremely difficult to tieparate this olumetit entirely from 
the others which go to make up the problem of the value of 
life in these eases, taken as a class, and still more difficult to es- 
timate its vahic in stndying any single case ; but it is not diffi- 
cult to perceive that death, as a conaoqucnce of the operarinn, is 
ButHciently common to modify very seriously any statistical re- 
sults wc may wish to arrive at, and to be an import-iut matter 
of consideration in eMimating the prujn-icty of operation in any 
individual case. Taking, however, the statistics of Mr. tSibley, 
wc find that, of 8i.Tty-threo operations for cancer of the breast, 
Bixty recovered from the operation, and three died ; giving a 
mortality of about five per cent, dno to the operation itself. 
Mr. Paget states that out of two hundred and thirty-tive opera- 
tions which he collated, without selection, twenty-three dicfl — 
a mortality of ten per cent., which he is willing to accept aa 
probably not too high, at least for hospit.il cases. Of the op- 
erations likely to be required iu cancer of the bones, we have 



404 



HAUOXAyr DISEASES OF BO>X 



extirpalioa of tbc jaws and amputntion of the limbs. The 
murtttlity, after reuiuval of the upper jaw, taking IIutchiuson'B 
nntl Ksmoud'H euUticliuus tugutliur, isy uut uf thirt^'-lhreu cn&Gtt, 
six ileattis. The average luoilality of the larger ainputiLtiuns, 
wlicn porformoci for disease, ii sixteen and one-hnll' per cent. 
Theae statement*), though not elaimiiiK to present the daugor 
of the openitiou itself, sejMiratal from iho elfeots of the dis< 
for which it \a performed, show very clearly that the risk to the 
life of the patient, trom the opcrsttion itself, most enter as 
large and a very important factor in tlie siiui of the eoaaidc 
tions airaiuijt the operation^ when dutdding as to its performaaco 
in any given case. 

These three considerntions: 1. That operation does not core, 
but merely palliates ; it. That incomplule operation Iiastens the 
fat-al terniinatiuii ; 'A. That the u].)eraiion itself adds largely to 
the dangers of the eunditlun, eeem to me to embrace the strong' 
est points that can be made against an attempt at removal of a 
cnnporous tnmor. Let us look now at what iihoiUd be aaid on 
the other side: 

1. A certain number — veiTr' email, it ia true— of those oj>er- 
ated on do recover, and retain their health for such a number 
of yeara so perfectly, ko far att euneeruus symptoms are con- 
cemed, as almost to entitle them to lie considered perfect cnrea. 
Mof;t i)f the practical writers on this discafic have noted exaxorj 
pics of thit; nnojcpceted suoceRs. Vclpeau speaks of cases where 
fifteen and twenty yenn of health have followed an, operation 
for cancer. Sir Kenjamin Brodie apeaks of two caaes, one of 
thirteen years' and one of fuurtecu years' immunity from the 
disease after extirpation. Mr. Weeden Cooke gives a very ia- 
tere^iting cjise of scirrhous breast removed eixteen years previous 
to lus report, by Mr. Lawrence. It reniaineti well for ten year& 
The diBeasc reappenred, and was treated on two occaalons by 
caufitif, and three times afterward by extirpation^ one of the 
operations embracing two enlarged axillanr' glands. At the time 
of the report, the patient was in good health; and, though the 
arm had become within a few months cedcmatous, tJiere was no 
certain cndcncc of the reappeai-ance of the original diisorder. 
Mr. Cooke says that be baa met with four instances in which, 
after operation, the patients have remained free fmm the discotfo 



TEEATiTENT OF MaLIONAKT DISEASE OF BOIfE. 



40S 



for a period of ten years. Mr. Paget alludes to a case where a 
patient died of cancer of the pelvis, twelve y<^rs aftep the re- 
moval of a cancerouR ttsticle; and tiaally, Mr. Baker, in hia 
statistical paper, gives a ca^e in. whieb a ch{mncy-«n-ecp had a 
Boot-«mcer removed from hia Bcrotum, and remained well for 
thirt^*-(ivc Tears, when the disease rcappcareil as an epithelial 
growth on the finger and hand. All authorities agree in eon- 
sidering these as only exceplions to a general law, but the prac- 
tical surgeon, in estimating the ehanecs of lifo in any given eaee, 
is fairly entitled lo all thu encouragement wliieh can bo derived 
from the knowledge that hia pHticnt inay be one of the fortu- 
nate ones where, by the operation, life i« prolonged almost in- 
defiiiitciy. 

2. All the statistics which have been published on this snb- 
jcct go to show that some prolongation of life is gained by a 
complete extirpation of a cani-erous tumor. The principal Eng- 
lish writers, who have given their attention to tho t-oinparing 
of large uumbei-s of cases of oanccr, are Mr. S. W. Sildey, of 
the Middlesex Hoapital, T^mdon, and Mr. William M. Baker, 
ct St. Bartholomew's. TLeso gentlemen, worldng each in a 
Bppanitc field, have eollatod more than one thousand cases of 
all forms of cancer — Mr. Sibley five hundred and twenty cases, 
oil treated in the Middle-sex, and about half of them oliscrvcd 
by himself, and Mr. Haker five hundred «»sc's, all of which wero 
seen and dijignoHlicatcd by Mr. Paget, about two-titllifc of them 
having occurred in St. Bartholomew's Hospital, and thrce-fifilis 
in privato i>nictice. These numbers are sufficiently largo to 
give value to the deductions made from them, and they bear 
interna] evideuec of having been earefiilly and eonseientiously 
studied, besides Itaviug r^-ceived the approval and indoi-sement 
of the higliest surgical authorities. Mr. Baker's ca«a arc the 
must valuable to us, as they were all external cancers, or sneh 
as come luider the rare of the surgeon, while Mr. Sibley's ta- 
bles embrace both exlenial and internal ; the latter, however, 
in a very small prn^portion. 

Both wTitcrs give special attention to the question we are 
now considering, viz., the length of life of the eancer- patient 
from the commencement to the tcnnination of tho disease, and 
the effect of extirpation of the cancer npon the duration of the 



409 



lIAL10N'A>"r D13E.ISE3 OF BOSE. 



dUeadc. Hr. Sibley gives for tlie average duration of Itfe 
for pciiTlious a[i(] jueJullnr.v cancer SSJ- months, and of cpithe- 
luti caii<-'ur 53 luuntlis. Tliu^u liu cunsidurs the avoragu (imuii 
of diinitiun when no upomtion has hvmi )K>rforintid, tho dia- 
caae dicing allowed to run ita course without any bur^cal 
treiUinent other Uian palliativo. Of tiic wholo nuntber thcra 
were 03 operations, and no oiteratlon ia admitted into this 
tabic, or into Mr. Balcer'a, wLifh whs not sii[>posed to be a 
complete one. Of the 63 operations, thi'ce died and 00 recov- 
ered &uta the eH'octa of tlie operation — 'S'i of tliese cases were 
kept in view, and the rest lost eight of. Of the 33, 27 had ro- 
curreneQ of the discaflc, iu periods varying trom a tew days up 
to 108 niunthB, which was the longctst ]>criod to which tlie local 
return was in any I'asu delayed; bl\ cat^u8 remained under ol>- 
BorvaUon, boiug as yet (coo from the ditjcaae, the time aiuco tho 
operation extending in four of thorn to 7, 29, 36, and 6i months 
respoctivoly. Tho average period of recurrence, in those where 
it was l^nown to have reappeared, was about 15 months. 

Mr. Baker'a residt« ate f<>uudcd on 111 cacK:s in which opera- 
tion was perfonutid. lie gives the avorago time of rcciuroace 
in scirrhous about 14 months, in medullary 7^ months, in epithe- 
lial tive months, some of thoiu rotuniing in a few d-'iys, othera 
being delayed to 4d, 94, and ono to 110 luonths. The vciy 
small number of m'cdidlary and epithelial, as compared with 
the large number of scirrhous cases, would raise the general 
average very nearly to the rate given for scirrhous, the result u 
staled by the two writers not diflering more than ono or two 
mouths. 

Xow, comparing the length of life from the beginning to 
the end of the disease, in thoso nut operated on, and in those 
on whom one or more operations had been performed, Mr. 
Sihley says: "Taking the period at which death took pUce 
after tlio operation, it is found to vary from five to 72 months, 
the average duration of life, atler operation, being 30j mouths. 
It is thus seen that the patients operated on lived 53 moalhs, 
while those Hp<Hi whom no operation was poilonned lived only 
3^ months, sliowing thai the eases operated on lived 21 montlis 
longer than those Icfl alone." In this cetimato the three that 
died from tho immediate effects of tlio operation are inclnded. 



TRRAT«E.VT OP B1A1JGXJJ.T DISKASE OF BOSEL 



407 



If they liail been Ictl out, tlic average Icnj^tb of life in tlioso 
opt-'rateil on would have Btood at 5f!A montlis. 

Mr. Baker i» rcsnUs nre not vorj- ditfercnt from Mr. SiWejV 
Uo gives the average duration from the b^pnning to the end 
of the disease, for those not operated on, &8, in acirrhus, 43 
months, in medulkr}' cancer ^0 moiitlie, and ia upithdial can- 
cer :^7 monthsi; while, iu lliose wlio have undei-g(jne extlrptL- 
tiou, tlm lentil vi Hfu it> stated to bivo been in Kiirrhtis 55^ 
fuouths, in medullary mucer 3.*^ months, and in the epithelial 
fonu ^7^ montlis. lie makes the average Icn^i^h of life in all 
casefi not opomtcd on ha ^0 month);, tn those operated on 48 
months. Mr. Baker still further shows that the period at which 
the oiieration ia perfonned makes a difference in the result 
which i» quite far from what waa eommonlv supposed, and that 
late o|)er.itions usually give late i-ecurrcntes, and a longer aver- 
age life than whe]*e the cancer is extirpateiL early. This, how- 
ever, he explains by the tact that lato operations arc uaually 
npon chronic canecrs, whi^'h maintain after operation the same 
slow progix-ss wliieh diaracterized tliom bt^Ibre, ami he doea 
Dot seem to coneider that his statietical result militates in any 
way agiiin.st the propriety of an early operation. 

In applying the results obtained from the^ tables to cancer 
of the hones, we can only do so upon general principles. The 
ntunbcr of ca^eii tif bonc-canccr is so Bcnall that no reliable 
rcfiiilt^fiin be obtjuiied fwin their t'omparieou. It seoms pretty 
certain, however, tlrnt life ia much more rapidly dei>troycd by 
priuiar}- caneer in the bones than by any other extenmt or but- 
gienl fiirm. Tims Mr. Sibley gives the dnrattun of life in cnneer 
of bre.i.st as 32^ months, of the Btomach 8J months, of the bono 
10 montlis; and M. Lebcrt gives vory nearly the same view of 
their com]>;iratively rapid totality, though he places the duration 
of life in cimecr of hreabt at 42 months, and in cancer of the 
bones at 27 months. Due allowance being made for this more 
rapid mortality, there seems to be no good reason wliy the gen- 
eral reaiiltA, obtained from tlie study of this largu number of 
ciises oct'urririg iu the soft parts, may not aafely be applied to 
the bones. Tlie sources of fallncy in such tAhlea become more 
evident the nmre they are studied, and yet, making all abate- 
menta from their authority which the most fastidious may 



408 



ilAMfljrAXT DI8BASBS OF BOKEL 



require, tliere remains euough to indicate very clearly, if not 
to ]>rovc* tlielairt, tliat, as a ^neral law, "ijKjrat.ioiis on cancerous 
tumors, if perlunued in snitahlc ctt^s, iinil tlior(>u<;lily antl faith- 
fully done, promise, even ini'luding the risk to life of' the oponi- 
tion itself, a |)rolonf|;ation of life, wfiieh, it i» nint'h to he hoped, 
impmvcd mothods of cout^titulioiial and hx-nl nianagcnient, and 
a hotter Icnowled^ of tlio appropriate hygiene of the Liinecr- 
patient, will very* matcriidly mcrcaac. 

3. M'hcn, nrter removal, the diseaw returns, it does so, either 
entirely or niaiuly, in the internal organs, and the i»atient6 gen- 
erally die from the j^adual exhaustiim of the cachexia aecom- 
panyiof? Bccondarv eanocr, rather than from the direct and 
dreadftil eJFect of local cliswise. Tluit thie is a iKwilive advan- 
tflg© <m the side of npcratiim, f\iw will doubt «'lio have carried 
a case of cxteniai cancel' throngh all its fcurfxU stajjea of ulc^ira- 
tion, slong-hinjf, lia>morrhHi;c, jwin, and sickening' fetor, to the 
wejiry and distrcfisinj; end, and have compareil this dreadful 
prrigrefis with the more quiet, more giipportable, and infinitely 
lew offensive features which clmracterize ihe equally unreleut- 
ing advaitws of cancer nf thL' luugB, or of the livet. 

In making the stjitement thiit the return of the disease is 
apt to he in the iutcnial or^ns, rather than in the original 
spot, I wish to he understood ns confining the remark to medul- 
lary eancer, which is the class to which almost all the cancers 
of the bone belong. How it may he in other forms I <io not 
know, nor am I prepared to snpjiort the point by statisties, for 
I know of none which bear on it that are fcutfitiently extensive 
to bi' reliable. I give it merely from the recollection* of my 
own 04*68, many of them not reeorded, a few typical examples 
of each kind having left a strong impression on my memory. 
Among the internal organs I include the lymphntic glands, 
pnrticularly those within the pelvis, where recurrent cancer 
of the bones of the lower limbs is apt to expend its iprcatest 
force. 

4. If the patient recover from the operation, he has an in- 
tcvvnl nf perfect freedom from the disease, varying, aceording 
to the charflctor of the casf, from a few weeks to many monthft. 
In estimating th(? hleiit<ing which this complete respite confers 
upon one who has been long a sutlcrer under the steady &d> 



TREATMEXT OF MALIGXAST DISEASE OF BOSB. 



409 



ranco of cancerous dUeaso, wc ought to t»ik& into uiir account 
the effect on the miiul as well as on the boily. This effect is 
one uf elation, of hope, of eontidcnco — a Btnte of mind wliich, 
apart from the happiness wbieh it confers, mnst nccpssarilv tjc 
more lavorahle as to the pi-o^jroM of the constitutional disorrlcr 
than tho Kiiiie nnmher (if mmitlie imsswl Iti tho ghioni and anx- 
iety of eleaflily prtigix-ssivc lowil disease. Few jMitienta, who 
find tlieinst'Ives perfcLi-ly well after the Temoval of a cancer, can 
resist the feeling that they are permanently well. Their juOg^ 
mdiit may nut tell tbein eu, and probably the most intelligent 
of them would not be willing to acknowledge it to themselves, 
but there ie a certain feeling, which I think I have often recog- 
nized, which givci^ as luuch coinfurt, in curtain dispositionB, ns 
if their own judgment and that of their t^urgeon combined to 
ndsiiru lliem that their cure was as certain and as [)cnnanent as 
it Would he artcr tlie removal uf a cystic or a futty tumor. Of 
these patients Mr. Paget very jii&tly remarlcs: "Wlicn they are 
no longer ecnsible of their discftse, there are few oani.'erons 
patients who will not enterUin and enjoy the hope of long 
iimimnitv, though It be most unreasLiuablo, and not encour- 
aged." 

In connection with this point, and in strong contrast, as far 
as the mental eondilion is concerned, lot us remember that a 
refusal to upornte i^ often a deadly bhtw not only to the hopa«, 
but to the coui"iigc and endurance of the unfortanate patient. 
Many of them have only gradually brought their minds to con- 
eider the poasibilily of an oi»eration, ami have finally nerved 
themselves up to the tK>int of couecut. M;uiy perhaps have 
come in this frame of mind from a dist:ince, with much persimal 
tliscomfort and pecnnifirv sacrifice, to consult a surgeon, ready 
to snlnnit to any thing which ho may deem necessary for their 
relief. After careful exaiiiln.ition and mature deliberation, the 
refusnl of an ojicnition id to them the vcnhL-t of tho jury, and 
the sentence of the judge, in tho some breath, condemning 
them tn death. It must sometimes be our painful duty to pro- 
nounce this fi^artul doom; tho circumstances of the cawj, the 
condition of the disease, may require us not only to discourage, 
but absolutely to forbid any attempt at removal ; but wo should 
nercr forget chat iu so doing wu are talilng awuy tho lust hnnmn 



410 



JIAUG\Ainr DIBBASES OF BONE. 



Lope, and leaving uur patient to tLo darkness and hopelessno 
of desijalr. 

I luLve tims laid down, hs fairly and as candidly as I am able, 
the considerations upon wliich we must base our advice^ as to 
the propriety of an operation, in any given case. But nn gen- 
eral application of those con^iderntiouB cnn be made in dealing 
with individuala; each case must bo studied by itself; and I 
know no more difficult prubleuia, in all the pi-actice vt surgery, 
than sume of tlte^c ca^cs present; and no more delicate <iiiefr' 
lion than tu decide liuw earneatly we may persuade our |>atieut 
to, or di&^iiade liim truni the upcnition, wliich lie eitlicr regards 
with terror, or looks to as Uia only limiian hope, Neverihelees, 
as onr knowledge has assninod more precision, so may our ad* 
vice become more unheriitntiiigand more jioaitivc. Let ushepo 
it is becoming more valurtblo as it becomes more empliatic 

Acting npou the principles we have now considered, I would 
refuse to o{>erate : 

1. In iiny case in which there was not a reaeiunable certainty 
that the whole of tlie diiieueed tissue could be removed. 

i£. In any case where there wait clear evidence that secondary 
cancer had taken place. This r*-'in'fe8 some uHMliHcation. The 
mere fact of internal cancer having begnn to show itJclf might 
not, in all cases, forhid an operation. If the local diacaao pre- 
sented nnuiiunlly distre^ing or threatening appearances, we 
might sometimes be wan'anted in relieviog the jKitiunt, by oper* 
ation, of his immediate suficrings and dangers, though wo might 
be Huro that no prolongatiuii of life could bo gained by the oikt- 
atioii. As a general ndc, however, no operation ahould be jier- 
formed where secondary disease has already developed itaclf. 

:i. In any case in wliich cancerous cachexia was already well 
marked. It is to be pre.'^umcd, in this case, that the general 6y»- 
tern is already poisoned by the disease, and that the po^vera of 
re]mration are materially i-educed. If the removal of the local 
cause could be relied on as a removal uf the whole disorder, 
then we might hope, as in other cages in surgery, tiint tlie con* 
Btitiitionsl disturbance would abate on the removal of the source 
of irrit'itioit ; but this is not to bo expected In cancer. The 
constitutional impairment is not the mere reflection of a central 
irritation with which all parts suffer, but it ia the effect, and at 



TBEATMENT OF MAUGNANT DISEASE OF DONE. 



411 



tlie sAine time tlie sign, of a cLange hi the actions of the whole 
economy, which is us much n part of the di5e:i»c m the uk'crated 
tumor it«elf, and whii-h will not be an-estfil in ita progi-esa hy 
tho moat eunccsefiil extirpatioD of tho primary diaoase. 

4, In any L-ase whcrt* tho operation re^inlrfd was so formi- 
dable in ita extent or charaL'ter aa to add tniitmally tu the 
daugera of the patient's condition. We would not hesitate to 
amputate a forcann, where we might refuse to cxarticnlate at 
the hip-joint, and generally a tiiiliiig and safe operation would 
be more readily resorted to by the siu-geon than one of great 
majniitude and danger. Om- hopes of benefit do not warrant 
the mnning of greatly increased risk of life. 

5. Where tho patient was very old, and tho cancer chronic 
in its course. Tho slow progreea of tho disfase is likely to eon- 
tiune if it is leil alone ; the operation would be very likely to 
hasten a fatal termination in advanced age. 

G. "Where the patient was not a good subject for any opera- 
tion by reason of bad habits, excessive fat, great feebleness, or 
any organic disease impairing nutrition or reparative power. 
I ihiiih, too, tliut imcou<|ucrtible fear of an ojKratiou, or unrea- 
sonable di-ead of its consequences, should be a contraindication 
not to bo overlooked. 

On tin; other hand, I would adviFo an operation : 

1. In all cases where the disease could be easily and entirely 
removed, and particularly if, as in the case of amputating a can- 
cerous tone, I could be sure of removing, not only the diiiease, 
but the whole organ affected ty it. This, I think, is a very im- 
portant practical point; and I believe that the cases in which 
any other operation than amputation ehould be perlbrmed on 
one of the long bones allcctod with cancer must ho very rare 
indeed. 

2. Where there was no suspicion of any secondai-y disease 
in any intemal organ, and no extensive aflection of the lym- 
phatic gljinda. Tlie mere enlargement of a few of theae glanda 
by loc^l infection is no contraindication of an operation, etatis* 
ties not ehowuig that this condition adds materially to the 
tmfavorablo prognosis, particularly if they admit of complete 
removal. 

3. Where the true cancerous cachexia was not as vet dcv(J- 



41S 



ILatOKANT DDEiBEB OF DONE. 



ojied in any mflrkwl dfgrcc. It in not alwnys possible to d». 
criminate between the constitntional effects of cancer, as snch, 
au<i those depending on tlic ordinary caitsea of £nUng bcaltb 
and BtrcngtU, such as pain, biiMnorrbage, excessive OiBcbargc, 
and tbu like. In many i-ae«s, bowevi-r, it can be arrived at, 
and, wliere there ecenis to lie no failing of the powers of lile 
but what ran he aficoiinted for hy the efi'ccts of the local actions, 
wo have a right to i'(H>nniiiiend an operation, in the hope that, 
for this form of constitutional irnpainnent, the removal of tho 
local eaii«e will prove a remedy. 

4. If the operation rts-]uirod for the thorough removal of 
the disease be not one seriously imperilling life. Li cancer of 
the bones thiis question is brought down to the comparison of ft 
very few operations ; mainly, amputations and excision of the 
upper or lower jaws. All these are Bcrious operations, and 
Bhould not bo lightly dcterminetl upon ; but, fur most of them, 
the precise gmde of danger is almost mathematically proved by 
reliable atattstics ; and, inasmuch fis in tlicsc operations wc are 
cutting through perfectly sound parts, we may almost say that 
wo can annonnce the pre<-ifte amonnt of risk we are recom* 
mending our patient to assume, in underg^dng any given am- 
putatiuu. Of fouree this risk will be modifieti by the condi- 
tion of the jmtient in other respcctg tlian the wim-er for which 
the operation is to be perfLiniied, but this condition presents 
nothing whirh wc are not awut-tomcd to deal with in tJie ordi- 
nary problems of surgery, and is to he apprccuited in accord- 
ance with its well-known laws. 

5. If the cancer be of slow growth, and the patient not old, 
wo have very good reason for helieving that tho recurrence wCU'i 
l>e long delayed, and tho period of exemption from the di»e»M 
will be a long, purliH])!] a very long one. It Is from this cla^s 
of cases that most of the w-called cures are derived, and, though 
I cannot apscrt that statistics pi-ove the fact, yet I think their 
reeultB reiulcr it highly probable, that tho slower a canccn^oa 
growth is in passing through Its earlier stages, the longer is it 
dckyed after operation, and the slower its progress when it 
does rctuni. Very iicutc cancers are generally nn&vorable 
cases for operation. 

6. The good general healtli of the patient ta a strong point 




TBEATHENT OF UALIONANT DISEASE OF BONE. 418 

in favor of an operation, deemed proper for other reasons, as 
well as an earnest of its success. I cannot help feeling, too, 
that in all cases a strong desire for the operation, and strong 
conviction that it will be successful, on the part of the patient, 
may be accepted bj the surgeon, not only as a good omen, but, 
BO far as it goes, a positive indication. 

Lastly : though it may not flatter our scientific vanity, yet 
it is but honest to confess that the uncertainty of our diagnosis 
may give some encouragement to operation, as, in removing 
what we believe to be a cancer, we may perhaps be extirpating 
a perfectly benign growth, and, instead of giving oor patient a 
brief respite &om death, oor mistake may secure for him an 
uncontaminatcd and a healthy life. 



INDEX. 



AlLAnon of roalixnant dlMawt, 4DI. 
AtMceu, 87: Ireaimont vt, 81 ; chronb 

sinuaoi, ay ; liibcrculDiw, DO. 
AtnlptiT, liS. 

Bioilie, Sir B., trcntiuviit of abMOw of 
bone, 81. 

Cimoer, colloid, »7.1 ; cpiUioISkl, 340 ; 

eclrrhus, »;!A ; iiiiMiulkrr. 840 ; oslold, 

»;7; m-lMinW, aftH. 
Cuica, Mi luciiiiul t-lian^o in, 10O; 

prVKOOgl^ of, lOll; Ircullnulit of, 101; 

CftrtiUgtiioiu Liiinnr^. 2l7i mallgniincv, 

521 ; cfaaiign into Lotie, 224 ; »t-at of, 

233. 
Chrtmlo slnuoni abec^es, 3t3 ; diaglUHtti 

of, II ; IrcaUueol of, 43. 
CloaciD. 130. 
Colloifl MDccr, r.73. 
CooiprMiion In ugalij^ant diioftM of 

bone, 384. 
CraniuUbo, 99. 

I>liru!t« luppuralioD, 4S. 
I><>Driiioii In riokeis, 49. 

Ealiir^ein«nt of bon«, S4. 

Ejiirtii-lUl cMicer, 3D'D : tecoadkrjr, 8A1 ; 
rckTOfcoplval cl»tK«ura, 3A1 ; uloen.- 
ti'in in, S64. 

Kpiili*, 311. 

Bxri'liutwo, IB1. 

EiliaustioB from aecposb, IflO. 

Eioglciiv, :il<): intracranial, 2(11: mul- 
tiply. SHfl ; of fi»njn of trtth, 2*8 ; can- 
celloiu, a."?!* ; ivury, 247. 

Exiectioa of bonea, 1 Itf. 

Fibro-pliMtic tumon, Stfi. 

FndHiv or rorrix fmnom during Reid'a 

iiuiiu|iulat!un, 19. 
Fn^taa uadluni, 82. 



On]*aDfr43ectricItj in malSgnuit disMM 

of bone, 899. 
QencnillulioD of mall^ant diseuc, 849. 
CiroKMOe, MUBioiU ol, i!2^. 

HviDorrhat!^ '■> Qecnwb, ISO. 
Hypoiirophy, IC. 

InflaintTinlloD of bone, 19 ; iMUOkt 

otiangn in, 21. 
InrnlucTiiin, fomiikiloii of, 132. 
Ivor; cxoiLOcia, 16. 

L&cuDil chaagcv! in caries, 100; In in- 

ilamrd bon«, 2). 
Ligatura of nnerini In innllgniiiit dlnesM 

of bone; 893 ; In pulwtUag tnmora of 

bono, X97. 

lUheoaWon, 74 ; abipe of iralris tflflr, 

7fi. 
M«llKnanC diMMSM of bonp, 3^^; Irtat- 

HMHtof. 381. 
ML''Iul]ary caDcer of bone, 340; IbIoio< 

iicopi*^ chnnu^rs of, ft46: flU-otnu of, 

84tl ; ductuslion in, 8110 ; accundarj, 

Sfil. 
Ueluioid rancer of bonD, 3611 ; gcui-rali- 

ution of, 8<>i'. 
Mercury in iMbciliK, 110. 
UollIlli» ostjiuiu, 71. 
Ujeloil lUAora, Hit. 

NccvoMi, llf); cau«pa of, 1St;«cKt ot, 
ISA; patbul(t(i;ii:id trondition? of, 129; 
•OuroMofnvw boEie ID, iS'A; oxtnuioB 
of SMiUMtnim In, 1H7 : nymptnins at, 
188; bioniurr1)AK>! bi, 143; icitirc* of 
lumDorrb>K« in, M.l ; troauiivnt of 
b»ai9n-baRu bt, I4S : giiperflci&L, I&3 ; 
In beads of bonuA, \iS; of short bonn, 
IS.*!; of vraulul Lioiii.'*, 19* ; irnuinniio 
of cranial bonce, IftC ; irMtincni of 
cranial, 140 ; of JafrboiUM from «ru|i* 



^^^^^^ll^^^^^^^^^^^^^DTDES. ^^^^^^^^^^^^^^^B 


^^^^^B tive fcrem, IQfl; pbMph<>nu> uecrwla, 


Trcatintnt of [nflaniRiaiion of booc, SA ; V 


^^^^^1 170; rv|Hiraliuii nlUr pbospLoruf, ITU; 


of Hhac«f«, 31 ; ot (Mlco-mji'litif, SI ; ^^H 


^^^^^1 prOgnotU of phokpliorua, ITS ; tmt- 


of rii'kctn, 7y ;cf vorins 1<»7; ufiurm-^^H 


^^^^^1 Bieot of [iliwph(ini& 119: o]ii.-nUon> 


Orrlium- in iwitosit, 1 Ifi ; of pbonplionM ^^H 


^^^^H k pfaMphoniN, INU; rccurrcoaeorplioa- 


&ceri»i«, 179; ol nmutiU, 2W ; of ^^B 


^^^^^B phgriMilAS; |ilitMiihuraa in upper ja<r. 


pal*aliii|; luiiiun of bun*', 297; ofniA. 1 


^^^^H 183; ii\w frai-tuTw, IM; in tliuplw 


lipianc (liaeasva of bnw, Ml. ^^H 


^^^^^1 IVttQtutc, lt*lt ; trratiiiL'iit of, nder Irac- 


Ttimon of boDC, ilb. ^^H 


^^^^^1 lUKA, M ; ftnituirai inrolucrum, IKH ; 


oartila^noitt. J17 ; cauMw of, 2S0;^B 


^^^^^H kAot RtDpiilntiuu, IV3; ftpUuatioD of, 


aiiHtumr of, ?1S; nrlaiMna 10 


^^^^H 191; willioul itup^QruUou. 2«X> ; villi- 


luatiKU^CT. i£l; aUu ul, 2tS; 


^^^^B out exrulUtioB. 'I'ti : trcnUnvut oC 3t>t ; 


cbangca In, iiZ; aonmuv of. 


^^^^^H reuiuTtl lit in-»\ut^lvu\n it), !fi)6 ; evl> 


ass. 


^^^^^H deuces uf luofit^aiti); uf Kvqiurtlruiu in. 


oaMoua, SK8 ; ratimllo«iB,3aO: Mat 


^^^^H 207 ; apcTutUins for rcmcival of BeqiiL's- 


of,«l; irory, 2*7; acoi oi;«l»; 


^^^^H trum in, ^'>S ; IiMtruiMtita OmcI in op- 


opcratioiu un, S&D, 


^^^^H entiona for, 21U; ccMulition of Ltotic 


fibtTHw, 200 ; MMt «f, 238, 


^^^B ftfter, in. 


. Dpiiidli--c«Il(Kl libcold, Mw ; auUf^ 




nancj, 2<Vt ; Tccuri«nc« of, il-k i 


^^^^H OllUf's rk-wa on rcproiluction of bonc^ 


dunilion of, 27S. 


^^^ 


njrvload, 37A ; anatuwical dcDWOk^H 


^^B Obbcqiu InmoK, S38. 


0(277. 383; naBKHUcv ot X79 Jj^^B 


^^B Oatco.o)}FeUtu, -4S ; oumii of, (H) ] tmt- 


■pontanrnna iliMppcaranoe o^^' 


^^H EDvnt u^ SI. 


iSO ; (wlor of, m ; m«I. of, 381 ; 


^^M Oatoul cuicer, 877. 


ojaia in, i9t. 




• polaatinic. 2«S ; cauau of piiUatioB 


^^B Pelvia dcfornxd bj- rick«M, 68 ; bj mftl»- 


In, 2S8 ; rrcciile siriM-tuic of, 2hl ; 


^^H cnstrun, 7S. 


C. V. SiuiUi'. ■:«»* gf, SW ; W. 


^^H Pboi:>pliUTUiii'ecrosli, 170. 


rarker's oftte of, 2M ; tnatoMnt 


^^M PulBftUng unnor of bone, itSS ; ligature of 


of, Till lieaiiire of nrtcrica in, 
2ftV ; uftuA cautenr in, 199 ; ex- 


^^B artcrica b, SV7. 




'tirpaltno of, 299. 


^^H QuqmIdd of operation in malignant db- 


of llic jawii, 3U0 ; tnflntnmAlorj div 


^^L^ cue, 408. 


ti-niinn of antnim in, :ti>l ; 'cTBla 




■ml I'VHtir I'ruwIliH (n.-tOll; l'''B*(*^^^| 


^^^^H Ucketa, U \ ermptoma of. CIS ; analy;d£ 


mciit of cTtin in. .'^rtt ; 04miicct«4^^^B 


^^^^^1 of bone in, OS ; •tlmpc of pAtit in, 6i ; 


with pamf,, Kll : aaliij, BIsT^^B 


^^^^^H fflliipa i>{ liiiiil m. lilt ; iJiiipr nt' Uiarav 


fibrouK, ;<IA; tnT<>iriid, 317; Bdt- ^M 


^^^^^B in, OS ; uuu»ua of, 72 ; Ui-aiuivat of, 78. 


Domi, S2<>; tniiinivnt ut, SXll^^fl 




t'emoTnl of ii|>pi:r Jaw for, 81tS),^^^B 
rnnovnl of ]owi>r Ja*' Ibr, Sxd^^^^B 


^^^^^F Setrrhiia of bone, 830 ; primary, 838 ; t«o- 


^ ondary, 837. 


riTntdval of traib tqipor jatia lor, ^^H 


^^H fieilillnt'* oiKtralicin for cari<«, 1 18. 


227. ■ 


^^H Bequcnlriiiii, I'.'S; MpiLrulian of^ ISO. 


1 


^^H Hub'P^rioot^Ml tv*eelii>nK, IJ7. 


1 


^^H Siipirticial iii.'cr«»is i^^ 


rppcr jaw, pbojiplmniB nectoida in, 18S| 1 


^^B BujipiiTaiiim in bonr^ 27 ; diRHac, 49. 


nriDOval of both, 827. H 


^H m^ 


EXB. ^^^H 



C AT A LO G U E 

OF 

MEDICAL WORKS. 



ANSTIR 

IN CUrslglS., and ZHaeoies lehich rrMmble it. 
Bj- FBAKCIS E. ANSTIE, M. D., F. R. C. P., 

ntD*t«tllii*plUISi.b<xil: BudPlij'loiBti lu t?>c Bi!lt:ravr tlurpltal lurCl.ildmi - Bittcni 
Of "Tba Practltloavr" (Londnu). i^ui. 

I TDl., ISnw. Ctotb, %tM. 

"It If ■ vilnktiti; coiilrlbmloii luicleDlHi^ tnl.■^lkltK^"— T*< Z«nw[ flenrfon). 

"Hli wortt upon Nearalcl*!* one o( Uie mofi IntrrMlInc, Iniritiictttr. anri prMllr«l. 
wo liMvc lecQ far a long time. Mfr Iiitf (.-Im) It urpfa) nMiUnx >"<l ihiiui;hin)i •indj. 
■ad, lork tnitiii* or ltB»ls«, wo ar* rr«» |i> mr ilui w-p lMt« oirTvr nmi oat lljilgtrM 
B>un pncllc^ intunnalloD and i> fuIlcT ur usi-rul MiesirslivDa.*'— JtaMcvf Staard. 

BAKKER. 

On Sea-sickness. 

Br FORDVOE BARKER, M. D., 

dtalnl Pnkttot at HUjkXUtj tnA »te Dlnran'v of Woenea In the BcUdtm BoaplUl 
ModlcAi Citllrac me. 

1 Tol., Mnw. H pp. TlMdbU Cloth, TO otnu. 

RepHnted tmm the Siw YokK Uiuk^hl Juuxbai. Bj nviau of tbBK'*<'^''"'Mnil 
Ibr thi iinmlHir af that Jourtial coiiiBlnltift tfio paper. It !■ cciit prnifntml In Imoh form, 
wlib taeh pr«Mcr1i)tlin* addnl an trio auUiur lia* tound lUcrul la rcllcriBX Ui« •uiTGrtim 
tnm ■ca-alclcnuiB. 

BARNES. 
Obstetric Operations, mdndisig tM 'iVeatnmu 

of UventorrUii'je. 

By ROBERT BARXES, M. D.. F. R. C. P., Losdoji. 

Ohalrtiie Pb^ilrUn tnuul Lpclnn-r on Mldvlfnn nnd flu- TtUcasR* «f Wncnrn snil niD- 
dfvn at HI. Ti)Crtiia>'K I](»iitliil: EistntiiOF od Hlilwlfurv loihi' no;>al OoDee* ol rh*. 
atdana aixl to tbe Itniil Cullen of 8tircn>n*^ Ibnnnm (Ibitntric Pbyalaan to At 
LoQdon UocpltDl, and uu I'liTrietu (o l£e Euuni 1>Jt|*Icii of Uit tWf»\ Halmllf 
CbarltT. 

WITH ADDinOXa, by BENJAiTIN F. DAWSOS, M. D., 

Lite LarlnnT on Pleflne PafWocj In tlif Mndlcal Dnparlmml of thn tlii1»'n!tr iiT Haw 
Vork : .\aiUlanl lu llic Cltulcal Pr»f(H>si>r of DlMaaa* of Clilldren la tr^e <:uIJfe« of 
Plj.viirliiii* anil Sn r|[piili' , Nnir Y'irk ; riijatclau tat tlic I)la(-A>r« it l.'lilMrrii rn Iha 
NcW Turk mtmnMry; Hnaibrr of die- .New Torfc Obilotrtcal SavlKlj.iir iliv Jliidleal 
Socletf oftbo Cunm; of Sew TorK, dig., «ie. 

eaeonS &m«riMB EdiUon, 1 Tol., Bto, 509 pp. Clath, t4.B0, 

To tbd unidenl and praRUtloner tbi* work will pri<r«ot llie ifmlcfll nvlne. brlDC. at I( 
U, a oKMi pnffrct inii-lwcdt on "Ob*lMf1e Opttatkinii." bj one wbo boa iWlrly earoad lb« 
Jtjtbt to amms Ibc poatttoa ofa icacliet. 

" Rnc'l a Tork a> I>r. B*ra>»i'* waa eTnttl* nw^n), ll 1> i^r-iilalMl In *]«Tit* Iba 
pncUc« (tt ib« obstetric art )d thi* coaBtrf. \ni kj b« of ereat Htvici tu lb« praciiUoaQt.*' 



>. Aiy)kton cS Co.'s Mediaal PuhUcatioM, 



Bellevue and Charity Hospital Reports. 

Th^ volume tifHeiUvue and Charity MotpittU Reporta 

for 1S70, CQTtlainintf valuable contributions from 

ISAAC E. TAYLOR, IL D., WILLIAM A. DAMMOND, XL D^ 

AUSTIN FLINT, M. D., T. GAILLAKD THOMAS, M. I>^ 

LEWIS A. SAYRE, M. D., FRANK 11. HAMILTON, M. D, 

and otlicra. 

1 voL, 8T0. Clotb, tlOO. 

"Time IntiliutloM an tbe mwt iiii|iortaat, u r«^rd* BcconunoiUlioQS for 
fwiteato ud tbHui; of cuw tmtod, of nay cm ibu DootiacU, BOd sn) suraaaicd 
by but few In the world. The gcntlniuf a connccwd witta tbcm &t« acknowltdeed 
to be ainODg the firat in Ibelr prorisiiloii, tni Uic vo1utD« is wa tai{iortuil aJditiao 
to lb* proi«Miounl literature of ihU oouati/."— />/cAit/cyica/ Jounvd. 



BENNET 

Winter and Spring on the Shores of 

tfte Mediterranean; or, tlte Rimera^ Mentone, Ttati/y 
Corsica^ Sicily^ Algeria^ Sjpain^ and Biarritz^ eu Win- 
ter Climates. 

Dj J. UESKY HKNWKT, M. D., 

UtDitMir ol the HoyMl Colkirr (4 PliroinUna, Lmidoo: Ul* Pti;atclftn-Aooa«ch«- to tl>o 
Itujnl I'rneniMpkUil; Uocbir nl MutllHnc uj tlio Inivunlty of Pkrie: rocmailj BmI- 
■lunt Pbyvlciui to ttu Part* JluBplula (vs InimiD dot HOpluax d« Patift, etc 

Tbli work omhodlc* the vtpcrlcncc vf ((.-u wlnltin aud •prtiii;* pkM»d b; Dr. B««aM 
caUii>sliorc« of th« McdttcTnuitBD, wul Kiatklo aujcli vklaablu loFomttU'D [ui pbjit- 
dao* In tcUUdd lo the bealUt.' nelurluj; cticuip or lUc tu-,-iuiia iii'«cilb*l. 

L ToL, 12mo. SSI pp. CloUi. MJiO. 

" KieMdInjTir i««dU>l«, ftpurt Irom tu epccltl purpocM. ini] well IIIaMnted."— Am- 

"(t lit»a mure iDb*iiiitiiiI vnluo fTIU:' I'tijilclnn. pn-hap*, than fnr auj^oilxrcUMOr 
pmrfaiiun. . . . Wa cainiuctid lliio Uiuk l<i.>ur nink^rv an it iiiliiiiif I'ttMlitlkit IwO 

capllal qiuUilca.Uou«— It k« ut oucm uiiviViUiiu^kiid iii«inicli>i>.' ^iV, 1'. ViiJinu JininMrf. 

On the Treatment of Pulmonary Con- 

sumption, by Hyffiene, Climatf, ami Medicine^ in its 
Connection teith Minlcrn Doctrtnts. 

By JAWS HENRY BENNET, M. D., 

Mambn of tho Rojal CoUqt* itf Pbjiklnnii, LnDdnn; Dnclor ai M«dtcUu oflks Unlf«nUy 
of P«iij, etc., otc 

1 vol., tun »To. ZM.\ %l.W. 

An loT'Ttvttltie ari'l luntriiL-llvu wori. wrliien In th« >trnB|[, ckartawl Inrld — iw 
Wbld) tppoan tn all Ujo cuuul'iuUoDS ol Ur. BcDDct 10 medical ur gam nl lll«r*iur*. 

••Wq cortlallToniEnniitl thl* ixxik to ihe atHtilloB of all. for li« pr^'ik-KxiBinHio- 
ten'c vif wii of tiia tialiiN nod inrattucut of Ihc acout];* 0( iJl tuaptnala ulliuaUM. pal>A» 
nan nNMOtupllcm."— -QiMnMt ftnlnv v M*ititn0. 



D. Appieton t£ Co.V ^edieai P\ihttecUion*. 



BILLROTH. 

General Surgical Patholog}^ and The- 

rajjevtiesj in J^'^fty Lectures, A Text-look for Students 
and jRAysicians. 

By Dr. TITEOTJOB BrLLROTH, 
FnitaMr of Siumr In V kiUA. 

Tniulftt«d ttom tb* FoarUi CIsn&as Edlticn, with tbe atAcl&I permlul«n 
of Um Autbor, by 

CnAELES E. EAOKLEY, A. M.. ii. D^ 

flnqMB 10 (be Sow Tutfc Ef » aod Est lunruunr; PbjtMni l« (Iw Nnr York B«fp(UI ; FiUvw 
«r Uie !>«« Vark UtOtaij at UodldBu, eb^ 

1 ToL, 8to. 676 pp., and 162 Voodenti. CloUi, 8&.00. 

Professor Thcodor Cillrolb, one of the most noted autliorities no 
Snrgicftl Patbolof$y, ffivM io tbis Tolome a complete ritumi of the exist- 
bug eialt of lutowlii(l|,'i3 in this branch of medieal Kieoofl. Tlie face of 
Ihifl publicution going through four editioiu in Gcnn&ny, and baring 
b»ea troDsluLei] into Freucb, Itallau, HassioEi, aoil Uniigiirkii, should b« 
MUM goariiolee for Its st&mJlDg, 

tncatMH or awrnunon. 



"The want of a book in tin- E[i;:1U)i UD(riaR«. prvMDtisR in a coiidw (bra the 
rlewB of the OcTTnan p»0io1opi«lji, hne long htca Toll ; aod ire venture to saj na 
book flould moTv iicrfcvtlT tupnlr thut «nnt than th<! prcM'Tit vAtiimc. .... 
We troabl iiroDicly reoommend it to all oho take any loterecl ia ibe progroM of 
lluNi(Al and obaerratton in Mn^ca) pathology and targery." — ThtZaiutL 
"A grut addition to oar lilcntur&" — JV. T. Mt^ad JitimA 
" Vi't ran BMiare our tvadert that th^y will roDiidcr DcllbR money waited la 
it« purchaae, nor time In JU peruaaL"— 7»< Medieai JmmtifitOor. 



p. AppUton <6 (7o.V Medical PtAUtxUiom. 



COMBE. 

The Management of Infancy, Phyfi6U>ifi- 

col and Morai. Intended chicly for th« Cw €f 
ParenU. 

By ANDREW OOMBE, M. D. 

BEVISBD AND SOZTSD 

Bj Sm JAMES CLARK. K. 0. B., M, D., F. R. a, 

Fhj:aldui*lD-«n]lnu7 to tbtQuMO. 

Zlnt Amerinn liroin th» Tttitb £«Dd«n Editloii, I toL, ISbw. SOS pp. 

Clolb, %IM. 

"In the following ps^ea I buT« a<li]reM«4l inrself chieflj topArenla 
and to thfl youugur monitors of tho nicdicul proft.-s«iuu ; bnt it U not to 
them alone tlint the anbjoet onght to prove uttrftettre. The rt^dj of in- 
fancj, coDfridered «v«n as sa clmirnt fn the hirtor/ htkI pIiilosoptiT' of 
man, nbonnda in Iniereet, and Is TerUIe 1» troths of tlie lii^iiMt practical 
Taino and importdnoe." — Eitraetfn>m Authar't Pr^ae*. 

" TliU cicallcni little book iUoulJ be in tUc linml of ctcit mulfacr of a TMiaQj ; 
Atid If some of oiir Uity fHcDda would miLSler Its ^aotenu, and ellltcr bring up 
thtili cljildreo by llie IikIiI- ot i<a Icai-ibm^s, or coiQiiiijiiii-at« Ibe Irutlu it coitlaloa 
to tho poor bf irhum titer are inrmunilnd, wo kro convinced ttvat thef "ouli] ef> 
feut LilUiitvly mure ^ood ibiui br tbe ili^irlbuijuii of niiy number of tnoti what* 
eref .... Wa consider this work lo be one of the faw popukr riHii-'aI trcatJMa 
thnt *ny prnctitionct nkftj iv«o(nini;iiil 10 hin palivnt;! ; ami, Iboii^b. if its precept* 
are I'olluwtd, lie will prubiblj luM a few Ruineu, be nUI uol bruradsv thvo if 
be sea bis rrleodB* cbildrcn grow up beiutb;, active, BUoDg, and both mcDtaBx 
■Dd phjaicixllj eapAble." — T'Ae Zarud. 

DAVIS. 

Conservative Surgery, aa exhibited in r^twdying 
80ine of the MechanMjl Causes that operate injuri' 
ously Iroth in SealtK and Disease. With lUusirakimt, 
Hj HENRY O. DAVIS, M. D., 

] veL, Bvo. SIS pp. Cloth, $S.Oa 

The Author has Gqjoyod rare fiicitttiea for ihe ntwlj' and treatment 
of certain ctaasea of diaoaao, and the records hero prei^ntei] to tlie pn> 
feasion are the gradual accumulation of over ibirty jreara' Investl^attoo. 

"Dr. Bsvis, bringlDg, u be di»9 to ti« «pFcialtj, ■ gmt apthnde for the 
BolutioQ of DK^L-batiiual probleios, lakes a hicb rank as aa orthopedic mrgeoo, 
and t\a tutj practical eontflbutSoti to Ihe lilrralnrf of tbe subjeet \a both vain* 
able and opportune. We deem Et worthy of a place in tierj phrKietan't Itbra^, 
The stjle 1> nnpretMiding, but tr^ndinoi, ^npbic, and, betl of all, quite iuloli^ 



2>, Appteton tt Co.*s Medical PuMicationt. 



FLINT. 

The Physiology of Man. Detignedtortp- 
resent the JExisling StaU of Physidoffieal Scie7ica as 
applied to tha JF'unctioiu of tha Uunuin Body. 

Bjr AUSTIN FLINT, Jit., M. D., 

PnAMnr of rhyiMccr nd KKreumiT 1" U» OiHImH Hupltal H»dlMl OdUn ud la %k» 

long Itlutd C^Urco iI«^U«l; F«llbw«r Uinltaw T«A Academj oTMcdldMi lUcnMM|M 
to BaOmiM UMl^laL 

Id FIto Tolomea. 6t9. Ttnt«d P«p«r. 

TolameL— 7';p^<5 y?/o(wf; Ciradation ; Beapiraiioji. 

aro. 602 pp. Clotb, t4.S0. 

■l^B-IH r^ err IL1.1T»TKAnCm. 



Duet* Md Adnl of tb» tfuniBiry Orixii*. 

"If th« nmalntn); portloos of ihU w^rk ere cqtut>n«d wlih the wmOMraand 
ftoearac/, the vholc ranir rl« with &ny of itioso that h>T« of Jate nikM been ptth 
duccd ib our own i>r id foreign UnguAgca." — HrUUh and forttyn MnSa^CSiriayi- 
ad Rrviru. 

" Aa a tMMk (if KPncral infonnnttnn it wilt tut found. iKvful to Lb9 practitioner, 
and, u a book of rcfervnue, ius-uluhbb iu ilic liunila of itao uiutoiuiH kdiI phjri- 
olo^jil." — Luliliit QitarUrlft Jourtini of Mtaient Srimet, 

"The cO'mfilde work will prore a ?aliutble additlOD to our sfMetnatic trcatiaw 
on fautoan [ill 7 MO logy," — Thr ijiurrt, 

" To thoie wliu duairci to ^et in one to1uui« a cy>nci»e and dar, aai at ibit 
nMi« lime suffioivntly full rfvimJ of 'the exiftinK ttatn of pbyuoloii^l e']]eDC«(' 
we can beanllf rraommmrl Dr. Flini's vork. HorcoTcr, nn a work of typogmphi- 
oal art K AeMrvet n prominent plnce tijioii our librarT.«helf(«. Hcaara. Ap|il«ton 
k Co. deeeire the thnnt>i of Hip jirofeniwi for the v*tt dandnorae Btylo In whieli 
they icsuo tiiclii'iil iroi-k*- Tlicj tisw >jk hop* vT a lirwu "hm it will bo verj 
pencrallj bclieveJ b; publlsbcra that pbftioiuu' tjrt are worth MriDf" — Mtdt* 
tat (hutile. 



D, Appieton A Co.^a Medt'cat Pithtieations. 



Flint's Physiology. Volume Tl. — AUmtnta- 
tionj I>ujcstiott; Alieorpiion; Lymph and Chyle. 

8to. fiftfi pp. Cloth, •4.90. 

" Th« Becood Initalmcnt of thli wurk Tulfib all ilic cipccUtioDs nlwd bj tlw 
perunnl of tho fim. . . . Th« auihor'a cipUiiAtuma and dnluctlona bear 
ertdeDoeof much cnrorul rcflrctiDH und stiidr. , , . The mtiT« work i« OM 
of nit iiiter«sL TU- aultiur'n el]-le i* lu dnar auj co&cEm m fail atetliod b 
Bladioui, ctrcful, and elabonitG." — I'Mladiifikia Inquirer. 

" Wt rcgud th« two tratifiM aliwdj i^ucd is thv rcrj bwt oo hiaun pliTii- 
doBj which th« EneUjb or u}* otbcr LngunKC ntfonlft, uid t« recoauBcnd than 
Vila thonmeh ooDMenoe to atudcniA, pnctliiouera, and UTmai, h models of 
Ijtcnrj and Hwntific ability."— jV. Y. ifniUal JoKmal. 

" W<i have found lh« rtjle Miy, I^ieiil, and at th« muki tiin« ten*. Tbt {>»«- 
tical and posltlro raaulia of pli}>iolvi;icid ini<.>«tiKa('Da are ■neelBCtlf »tai«d. 
wi^out, it woold scan, extended dlKuaiioD of diEputed poloia.** — BiuUm JVaKtw 
and Suryiml Joumol. 

"It Ia ft Tolntno Tfhich irill be welcome to the odronoed Bladcat, and u a 
work of roferenca"— 73* Laiuxl. 

" The leading subjecta ttvatrd of an preamtod b dttUtWt parts, «ach of wlkirii 
ia doali^^iied to be aa cxb&UEtlve cffny on thst to wbioh it nfeni."^ Wnttm Jomr. 
tat of MtdititK. 

Volume IIL — Secretion; Ercreiion; Ductless Glamh; Nu- 
trltum; Anivtal Heat; Movements ; Voice and iS^cK 

•vo. M6]ip. Clotb, t4.90, 

" Dr. Jibit'a reputation Ea guflidcot to rIvo a dimeter to the book among the 
profMrion, where U will chit^ ctrtulat«, and mAn; of Ike facts eivtn hare b«<a 
Tirilirtl bT tli« autUor in his uibontorjt uid in pulilic Ai:ia(milr*Utiab.^^CSieaga 
Co»rirr. 

" T1i« author bestows jiidluionsi varo aod labor. Facta ara ee1«et«d with dl*. 
criicinaiioD, ili«oriiw criiicnilj eiiuaincd, and ccDolortoDS enimdatod with cocn- 
tDCii<ijblo clC'l>^n•^3E and prooipion/' — Annencwi Journal »f Iht Mtdieai Seuwtt, 

"Ths work is calculated to attract other Ibnn profcfrional readora, and ia 
wriLtim with Runicieiit ctcnrniiiB and fretMlom fiou li-ctmical pedantry to be pct> 
frctly tntpUigihle to anj w«l1 -informed laao."- — Lt/tui'm fiitHrJay linntie. 

" From the vileut of ilie author's iDTC9tJRi.tLoii9 into the be^l thmrj and pno- 
lice of thd prcKUt dAjr, tho wodd orer, and the candor aod jnxid JTid),'ujeut which 
he bringd to \tt&t upon the diaeuaaitm of each nul^ect, we aie justl&ed in Ttiganfing 
his Ireutisea as »lAtidiird and autlwrlUtlre, ao fkr aa io thit diifoted aubjeol 
authoritj ia admitMble.— JVop y<>rit Timn, 

Volume IV. — The Nervous Sysiem. 

This Tolumo la now rend;. It la ft work of gntt Interest, and, ta 
coi^uuction wicli tile " Truat'iHQ on Diiw&aei of the Nurvout Synlwin/' hj 
Dr. Wm. A. Uaiumoud, couaii tutus il cumpLuto work on "Tbel'lijdoloior 
and Patholog; of the Nervoas SjstemJ* 

VolnmB V. — Generation. {In press.) 



D. ApplHon <C Co.''* Almfifal Pulilictxtiont, 



FLINT. 
Manual of Chemical Examination of 

tAe Urine in DUeaw, With Brief Directions for the 
£xamintUicn qf the ino»t Common Varieties of Uri- 
nary Caievli. 

By AUSTIN FLIXT, Jt, M. D^ 

Pn*MOrof rhjlMlffruut IdkKMH^ h U>« BtDcrDC HmMUI MtdMlCftlhf*: r«1l4lrorih« 
Xmt T«fc Acadanr af UadhHiw; Ueulur of tlie Uallol 9«Mr of Oie Cauct; of 3r«w 
TMk; BMidM(lIaittbe«rthBlo^»ttii>or )r»iunll[in«y UiUMClt]r<ffN«iT V»rk,N£. 

Third Edition, nvlicd aad corrteUd. 1 Tvl., ISnig. TT pp. Clotb, tl.OO. 

The cliiff aim of this little ^oi'k i« to i^nablo the bns^ praciitioncr to 

nisk« for liimself, rapidly anil ixwily, iill rtrilinary Msminiition* <>( Criiw; 

to givo litui ttitf luDotit of itio autbor's eit>wriviic« Id elimiantiiu; littlv 

difSoiiUI^ in the nia&l{>tiInlionfi, nml in mdiu-iot: procesaea of oniiljrsia 

Co tlie utiDOiil simpliciLj tliat ia boasialeQl with tLccoraej. 

" We 'in nni linow of •n* work in Englinh «o complete ■nd h«ndj »• the 
Manital uow i>niTriul to ibn pnifoiiilnn bj Dr. rlint, and thi; ki^li luiEiiUSt! nrjmln- 
UoD of Um author Is a euAlLilcut K'lamiiiee of ihc acoursi:]' ofvJI the dJrccilo&s 
gWcn." — Jotinj^ »f Ajyitied ChfViufry. 

"Wo can unhaHltttbtglf reeoaiinonil this MwiuM." — Piyefmlo^iu^ JvunaL 

*• Emin*Ti(ty pftcttcfcl"— Urtpwtt Snkm of UfdiHnt. 

On the Physiological Effects of Severe 

and Protractcl Muscular Exerciw. With S/fciiil Hef- 
ercncc to its fnfiuenM vjwn the Excretion qf Nitrogen. 
By ACSTIN FLINT, Ja., M.I>., 

rra&mn of Ptiydcilijejr la Ilia n*U«*iin Tloaplul MwlUal CiiDngi^ Stir Torh, alo^ Me^ 

1 T«l., «v«. 91 pp. Clotb, %%!», 

This monc>i:ra|>h on the rdations of TTrus to Excrciso is tho result of 
fl thoro\];'h and carc-fal tnrojitigaliun nijulo in the caiA of Mr. Edward 
l*ty8oa WvetDii, tho tvlobntt*.-!.! [K-dvstriiin. The cbviuiciil siinlyHM wers 
made uoiUt tho dlrcetloo of K. 0. Dor«inii8, M. D., Profi^sior of Choia- 
Istry ontl Toxicology in the lt<>llcviiB I[o»pit«l Medical Co!i*ge, by 
Mr. Onrrtr Loiw, Ma ssjtiiitiuit. Tli« observation* were made with th« 
cooperation of J. C. Dallon, M. D., Profewor of PbyBioloKj In the Col- 
let of Pbyaicianfl nnd Surireona; Ak-sanJtT B. Molt, M. D., Profeaaor 
of Sargic^ AnatoTny; W. \\. Van linrcn, M, I>.. Profowor of Principle* 
of 8urg«ry; Aii«tiu Flint, M, D., ProfwMor of tho Prim-ijilwt anJ Pr»o- 
dceof Medloioe; W. A. HnmnioiKl, M. I)., Professor of t'beases of ch« 
Mini] and \ervoiui tiystom — all of ttio Ilelkvue Hospital Medical Colle)C«. 

"Thin irnrk trill be found inl«rv«iing to eTCry phyiiii^inn. A nntnbor of fia- 
pOrUut naulu weru abtaiuet] valitible tu Uie pbjF*iolugut."^Oi>v. iUi. Rt ptt M' f . 



2>. Appkttm A Co.''* Medicot Publication*, 



HAMMOND. 

A Treatise on Diseases of the Nervous 

System. 

Bj-WaUAM A. HAMMOyD, M.D., 

rmfrMaraTDbMtaiDttlivMlBjHiilJirrrcauerXpni. »a\ at OlBfaal M»JMn*. la m Bel»T— 
HnaplUI UhII«I t«lii«* : ri]rilrliu)-laH?lilef lu I1h> Smr Tort Slat* UiMfilU] tK OlMMW 

•aoiKio XDtnoH, aBruto ma eoKRiteTta». 

Vlth Tortj-flve Ulutratiou, 1 v»l., Svo. 750 pp. CloUi, Sft.OO. 

The tri'JiliM dmbnicra bh inlrodm-torj' ihapter, which rtlaityi lo tbs 
hmtrnmoaU and aj^piirfttiu eroplojcd in the dia^ons tod treatmefit of 
(itseasM of tho nen-oaa system, and fire aeotioDB. Of theaa, tbo ftnt 
treats of ilUeue* of the brnin; tJ>« second, d:>on*ea of th« Rpinid cord; 
the third, oortibro-Hplnal dUeases; tlie fourth, dUeaies of oerTe-oellk; 
and the flfth, diaoaaea of the peripheral nerrea. One featnro tvbirh may 
hv clAitawl for thd work is, that it roata, to & gr««t est«Dt, upon th« per^ 
Bonul olisorvatloa sod exparieuce of tUo author, and u therefore >o vatn 
eompilatloD. 



" The aulhor'i clear nnd tonsc atylu or diction rondtrt the book exce«<Jlo^7 
reftdable, and ihe cium niiorte-d uid oltcd add much to the InierMt of ibo Mn. 
. . . There Is to diulIi iLal i« oiitoruining in the iceDtal utd other naairwit*- 
tlonfi of DOTTOoo dUnnlvr, ripcci^tf nhcti |it4-jcnU<rI u lb«7 >T« b«r«, th*t & work 
of this kinJ will And tuuij rcAdera ont«l(Ie tlie profeuion ; wad, (t ma; be hoped, 
iHll serve not ouly to Intercit tni amuM. hut to iQ<3ace a closer obHCTuee of 
those tirgienlc laws nnon irhcMe rintnii&n ta^aj of tlio aUmcnts here tneled ef 
d'gpmiJ." — A'cM Forft iMk^ JvumaL 

" The ^ork ig rcpkte irilh ii»cliil knoirWgf, and ererj phrtidan «rbo expeela 
to be cilli'd on, a» on nupcrt, l» tciiltry in canrii oX HuppoMea inwnItT, sAer Um 
cuiiiiiiiitHiuu or crimes, should give Uio hooka lUoroutEii penusL"— ^oMMMpttlt 

" Tbnt a tresllse bj Prof. Haiamocd wouM be one of ■ blRb order wu wbat 
we antlcipuiod, anA it nlfordn ai< plcnsiirc to stAte ihst oar aotlelpaUonS bete 
bpto fcnli^cd," — Cineinnati Mcdital Hrperlari/, 

" It afTorde a Taat amount of iDfonaailoo, Is oaptlratlns. anit nonb rrediog ** 
— Cincinnati Ijanai and Obtrtver. 

"Tbia U unqacsilonablj the itmil campl«to treatise on the diseaaes lo wbkb 
It is derolcd that baa jot appeared in iho Eii;;IUIl lanf^a;^; and ill tbIim la 
Diuob moreaeed by tb« fact that Dr. IlamTno'nd has inaioly ba*ed It on Ui own 
experience and praetloo, which, tre need Imcdly rcmiad our itedera, hare beca 
tery oxtoosirc." — Landon Utdical Titnrt amt OazdU. 

" Free from useless Torblaite nticl obscurity, it ti eridenlly tbe work of ft 
man wlio kivowa wliat be is writing ahout^ end knowi how to write about U.**-^ 
CJtiro^ Mtdieal JottmaL 



/>. Aftphton (ft Co.V -Verficfl/ Publicatiom. 



HOLLAND. 

Recollections of Past Life, 



Vj SIR nE>ntT nOLLA.!n>, Ikn., M. D.,7. R.8^K.CLB^«tc^ 
Pmldnit of tb« Boyil ImiIiMIod ar finAt nriialn, Phjritcln>4D.Otdliiar7 u (b« Qomn, 

«IC^ etc 

1 ToL. ISmo, Ul pp. Frlo^ Clotb, i2.00. 

A ««r7 *iil«rlalntnK *fA Inntrociln lumlLr*. parUklnj »ninowhit of llift imlnr* of 
Kitotiiosmilij and r*t dttUact ftum IL In llilr. Hut IM chWt object, •• >11>Fi|r(l b; Uw 
WMtnr, )• itot ^n much to recoanl lh« «veat« ot lit* awn 111^ u to perknn ibe vOlce of 
chtonlcht All othar* wltli whaai be came Id mttoct mod waa loag «Nod»l«d. 

Tha '- Llfo at Sir nsorr Dolltnd " U ono to 'bo rocoUaclad. Ud ba haa not onwl In gtr- 
lag an aiiiJInc ul U la ilw public"— 7tt« L^feu. 

"Mia iDemorjp wiu — I*, wii nu^ur. for br la xllll allvp aud In ]Hi«««*il«it of all tila 
(kciillUi«— akirfil wtlh iwcollecUna* of Ihn iiM*t nnilnFtit tattt anil woni>eD of Ihla ccn- 
Inr*. ... A life *il*'«dliii" \vn^t a p'^ritft of ^IsM* f"nr yi-an, ani] pa^^^d In l!i« cioat 
ni'iln rattnticr. lu tha mldat ot the liul iDdrtjr, ntilrh tint wuriil baa toolTi-r. inn<t titt*r- 
a*rlly I14 rull Dfairijiilir intaiwl; aaj| Sir H'-nrj Itollanil hn* fiwivnalolT nut wilri-d aiiill 
hi* inrmnrr l«a lla InakaMt b«ftii« ractlllcu euue or Uia tBcUDKU In i\."—'t%d Aw 



HOWE. 

Emergencies, and Howto Treat Them. 

The Eihhgy, Puthoio-j*/, and Treatment of Aceidmt*, 
I>i*easfs, and Cd-fra of Poiaoning, tefiich demand 
Prompt AUititinn. Deaigmd for Students and Prae- 
lUionera of Me'iicine. 

Br J08SI>il W. HOWK. K. D., 

TiBHIsxSiirrwataClMrtlillMpttAl: Lecturer on Snnrerrhi lh«H(4lalD«puUkaBtflf 
Iha CnlToraltj of New York, eto. 

1 vol, 6n. S64 pp. Clet^ «3.00. 



ThU Totnms l« 4e>l^ed aa a ptdo In ttis trMtnwDt ofcMn oromsrifnicy occarrtDg la 
mwUcAl, aiU'EiC't, or ntjatftrloal iiracdr& I( oombJiiea a1! the Inkpartuit iuljrrl*. Kl*1>i|t 
a|i«1al pmmt'imioi- lo piiliiti vT iirsrllcNl tutori'tl In pnrrmio* ta llwonilul rtmiliivni- 
tlon*, anil nnliliie, irlih tlio rvaulta of panoiiAl olMurrnilOD, iba IMmi vWin «f Snropcaji 
bmI Anericaii ftuUivhltea. . 

"Ths •Ijlr !■ cnnrNr, jwT'plrnima, and >lr1Inlle Eacli ardcleb srlltBDUl 
tianlriiUr l■ln^■^.1■Il^^ w-p.-fi: ptv.-^ni; ihi're 1" ii'i WMtr of won!*, nnr tl 
rani«'ili<reAr<l<'>ul)i(iil afita'-j. Thi-nnlrWnit (wK-niii i:tii1lliil>. n>)jti\ila,i_ 
hi^mU, Hio panl'ulBrlr •Icar tuil iiravUcal, uhI ftiriJali all Um liifonMilno nqalraVli tki 
nunasoia rnt ufthotr ur^cnl caiea. ' 

"It will \w fonii'l liivuliiaMi! Til atu'lpnia and votmit pfnclltloBin. to tupplytoff tbfBI 
Willi an «pliotncor B»c(al knriwlniljri>(>li[alnnli)<> (rom no ntlitrr vliuWworlc: shite 10 ib* 
«Mer tna-nhur* ot iho pn>fv*luu It wiH wrvo aa a »Bll«b]« aud • ewdy raniemhnacar.' "— 
TfH Mtitk^ Utters 



A 



2>. ApjitftoH tt Co.^8 Medical Pu6tteatiMi$. 



HUXLEY AND YOUMAKS. 
The Elements of Physiology and 

Jlygiene. With Kvmerous Illustrations, 

By THOMAS H. nUXLKT. LL. P., F.n.3., sod 

WILLIAit JAY YOUiLVXS, iC.i>. 

1 TOL, ISno. 430 pp. fl.Tft. 

A toxt-book fcr i.-duoatioaiil iattUutiuDs, and s Tslnible elementtnj 
work fur etndcnU of mediclnv. T)io gre«1cr [Mirllon l» from Uie pen of 
Profosur UniloT, lulaptcd 1t]r Dr. Yoanuns to the drcomatanrca ond 
r<.-quireinenls of Ani«ri»in eituc.ilion, 

" A Tnlnnlilo contribution to anatomical and phvridloglnl ici9Di3ii.''—JUijtomM 
Ttinnipr. 

"A clnr tad n-dl-amnf^ irork, cmbraoiiig tbu blcal dijicoTcrHS and u^ 
eeptcil thforiM.*"— flm/rt/rt l.'<ttnmrrtial, 

'' Trcmiiii; with inrormuliun cuncvming Ukp bumwi pb}'>ical ecMKHOy."— 

HT7ZLET. 
The Anatomy of Vertcbrated Animals, 

Ity THOMAS HCXRY BCXLEY, LL D., F. R. S., 

Aiitltur ct "Haii'a nac>.> In Nalnii'." "On Itic Origin nt t^iicclm," " L*j ScnnonB and 

Aililn Ml-"," 111!-. 

1 TOl., iSmo. ClMb.<S.OO. 

Th« former work* of I'rof. Husky leave no nvm for doubt « 1i> tb« linpar- 

taiuw and vnJue of hi* tuf^ vnlamc. It ia one which will b« Tvrjt aco«pUibIe to all 

who are int«reit«d in th« •ubjort of wbioh it trvats. 

mrmctxMx op n^irarKiTnmiL 



""m* Innz-rxpectcd nmrk will lie cnMifllir wdcamFd iij nM MnArM»tmi Itarbafaof 
Conpa'atlTO Aiiatomj >■ a ciinipnDdtnua. rrlUlOf. nuA. i>l>Iu tihilaiidliii; lu (Oiall llllWII 

Sloiw. nrwMi coint>r«tii-ii>j»^ mii'li! on llir »DliJ<r(-i "'ut*. TontalHoi lo iTlit- 

CiM lilt work of ■!) nrroirpli^Iiml a nrninr nf li\' ' iite woutil ln> oqnally OBI nt 

place. Il ir (■iii.>(u:!j lit «av Uia( tl rmlliR*. In a r>': i-^i-ir. iN^anlkfpailoD* wlilch 

utTa been fimni'il "I 11^ nml >hnt il [it»*iM:iI* an uiLrdi>.iiiiia[7 oomliluitlMi at wida, sra- 
cral Tirw*. »<ith til- cWr. sManlo, and laMlncI •UiecMDt of a prodictou* nuabtrat 
tii'll*l<toal hci*."— A'i»fifr». 



/). Appltton <ft Co?* Mtdieal Publication*. 

JOHNSON. 
The Chemistry of Common Life. 

Illu«traUd -with numerous Wood En^ramngt. 

By JAMES F. JOHNSON, M. A., F. R. S., F. Q. S., rrc., bto., 
&atb«r •r*'LwtarM oa AfilMltnial C^mUirr mi R«>ti>«r,'* -A flWrMim of Acrtouluint 

fl Tdt., ISus. Olttli, tS-OO. 
It haa be«n the abject of the antfaor io Uiu work to exhibit tlie 
preMDt cooditioQ of chemical kiiowlei3g», ao«l <if toalured voientifio 
uiiioioD, nptm tlio soVJects to wliicb it ia dcvotwl. Tlie raxler will not 
be anrprlsed, tberefort, should h« find In it wtno ihioga irbicb diff«r 
from wlioi la tu b« found in otlier popular worlu olreadjr.in bia bauds or 
on Ibe shelve* of biu libror;. 

LETTERMAN. 

Medical Recollections of the Army of 

Hy JONATHAN LETTERMAN, M- P., 

lAtoSwToon 0. S. A, Md U<«llad DIpMtorof iLs Anajt of Uio Potoi^n 

iTvL, iTo. 194 PF Clotk, tl.OO. 

**Thu afeanot at tlie medico] department of the Artnr of tbe Poto* 

mAC Iiaa been prepared, mnid pr«asmg «agag«n)ODt«, in the hope thai 

the labors of tbe tacxlical o(&c«re of that tmaj may be kouwa to wi ia- 

lelligoitt people, vith vbom to know is to approciate ; uid m ao affbo 

tionata tribute to many, long my z^alotig iin<l rflici«nt oolleagii>4i, who, 

ia days of triul ocd danger, wUcli liaro pa«od, lut ua hop* nerer to r*- 

turn, evini'cd Ibeir devotion to their country and to the eoaae of ha- 

tnaoity, witboat Iiopo of promotion or espectation of rtvard." — Prtfae*. 



" Wo veoLun to asoert ibat Init fcir who open thU rolamc cf nedtcal i 
pr^ant m ihcy trv viih inntructJoa, will care to do otherwise tiian llniah tkca* 
al • littiiif^" — ifaitcal Jittord. 

" A grarofat nnd affvctiomato ttlbats."— il'; Y. JMieat /ownw^ 

LET^TES. 

The Physiology of Common Life. 

Uy GEORGE HENRY LEWKS, 

S nU., ttmo. Cbtli, %iM. 

Tlie object of this work difien from tli.it (>r »]I other* OQ popnlar 

tcieoce In it* nlteinpt to meet the want* of the ttuilcnt, wliilo moedofr 

thoso of the ^neral reader, who is STipposetl to be wholly muuvioainted 

with aaatomy and pbyBiology. 



J}. Appleion it Co't Medic<ti JhiiftiaUton*. 



MAtTDSLET. 

The Physiology and Pathology of the 
Mind. 

By UENKY MAUDSLEY, M. D.. Lo:;»o3i. 

nyibkB U Uin Wnl tMntiHi Hnitill*!; Hniimry Mvuiticr or lh> Mnlkrj J*nf)idtatlnISod*4r 
at Ptrtt; bromlj Ev<iI>JeSI riijucluu uf IIm >lufu.-!>i*Ivr lU'tiJ Liiimar lliMI'tUl, •!« 

1 Tol,. two, 442 pp. Clotb, 13.50. 

This work ahus, iu the first plaee, to treat of tuciiUil plicnoRiena from 
■ [iliTHiulo^ctd ratiier than from a inctaplijEioal point of view; md. 
neoondty, to hring tliv innnifuld in»trui4ive iiiHl.tni'M jirc-Miittcil l)jr tiio 
nntound luind to haw upoa the ijiterpretfttic>» of ttie obscur« probWim 
of mental 9cieac<>, 

"Dr. Maiiiisley tiKfl hod llic courngv to nnJ«rlalic, nntl the iiklll iq esMiitc, 
Mtmt i>, Kl Icut ID Eojliiii, ui origiiu] «iil«l|i(iw." — Loiutvn Sittiniay fyvine, 

" ti U (o Tull of ecndble nfiecLlcnu ind wnod tratbfi ibat lliuir tri<l« iU«mcdI- 
lutiou could hut l>iit Itt or benefit loolUliinkingpcnoiit."— Ay^ofi^rrofJiHinM/. 

'■ rni^DMUotuihlj- one of Iho «M«st Mil nio*i important work* on the lubJMt 
of vh'KU it treata ihat liaa t-ver appuu-ed, und dwai credit to tils ]iliUo«apbic<d 
ACUinvn and aceiirali; obBCrralion." — ^I/i/k*' JiKftfd. 

"Vie lav down thr book with adreiirallon, atnl w« cotimiffid it molt earnc^ttf 
to our rvailcr* u & work of cxtraordtnar;' mrrit uid origiiulity— ono of these 
productions tbat are eTolvcd cnlr oci-iiflioniilly la tJie lafM of ftsra, and that 
Mm» to mark acluul aiid Tur; ilucidwl kdranccs in knowtedg* uid ■c[<bou."^. 
J)^. Y. Mtdifaf Jaui-nrtl. 

Body and Mind: An In^inj into t/mr C<m- 
n&:tU)'n and Mutual Infim-nce^ speciaUy in reference 
to 2fe}tt<tl Difordfrs ^ heing the Gnh(<tnian JLtfAurtn 
Jqt 1870, delivered Vefore the Jiojful Coliege i>f 
I'/tysioiane. M'iiA Apj>endix. 

Bj- HENRY MACDSLEY, M. D^ Lokoos. 



Ibv Uxltni-IV (hotvlod SwMjr of IHHi. of Oia l<ir[>Briiit SmMr of PIirBlrfaiM «f Mi 
»Dil or tlw SodMv tor tb« f*rant«ii<»i of F^reblalrr ud Foraiile rtyehotocr «f Via 
tjnii>d]> KoMont PliyiidMi nf Uie Minrhftrr ItojJ Luttrtlo Ay Imm <te, <tfc 

1 -nl., ISmo. 1&5 pp. Clotb. 91.00. 

Tiie ffen^m] plnn of lliii work iiciy lie d<'Ai-ni)«<l an lK>ii)g to bring 

man, botli ia his pbyfiicnl anil mcDtoL relations, ab idqcL as poadbl* vlt^ 

is thCKOpe of Bcientitio inquiry. 

"A ropmcntativo work, whicli vrt^ej one nnrX Mudy who dcdrM to koor 
wlial in duuiK in (tie wav oi rml progTMa, ftod i>at mvrv chatter, afcotU nnita] 
plitaloloi;; »nd patliology." — Tht Latuwl. 

" Ii dkilnctlf tuuka a sicp !n (he prognm of tcSroti/t« pnyckoktgy." — ?%• 
PradiiioHtr. 



>. Applcton <ft Co.*i Medical Publications, 



MARKOE. 

A Treatise on Diseases of the Bones. 

B; TB031AS M. UARKOC, U. 0., 
PtalWKirafSwsorj In tba Oalle|[o of PfayMlduu end SorccuD*, Mew Tor1c,eU. 

WITH NCXCROL'S I LLC BTUATIOK 8. 

1 vol. Sto. Clotli. 81.$0. 

BrBoiaiH or iLi,r«TiATt««i. 



TUs valuable irork \a » treallse oa Diwaui of llie Boom, cnibradng tlieli 
•trucluntl cliwigM um affv'ctcd by disease, their dinieil ItUtory nnil ii«uiiaenl, is- 
clodla^ ttUo &u kooovnt oE iht T&riom tumon mh'wh grow in or upon ilmm. 
Kono of the injuric* of bom aro inclnilcd m lU 8«ipc, and do ^Vni di*««>e«, ci- 
cepiing ifbcn the conditiOD of thu bona b a prime factor In llii: |>tDbl«a of 
disease. As th« vortc of an emfncnc e^irj^ca cdT bt^ and raried espcrioncc, II 
ma? b« regarded aa ths t>«3t on the subject, aad a valuable conuibution to raeii- 
tai literature 

"TtiA book nblcli I DOW ofTer to my praCpMloiia] bfwIhMti oontalo* tho RnbiUtic* of 
■be Icemrct wblcb I hira tlellTcniil dnHDi! lh« patt TPoKe jenra al Uie cxillcct. ... I 
liaio fiiltowcJ Ihe IcMiiiit* or rojr iiwn •luillm ami o^>crrmlkln■, dwelling moto ao UMiae 
braoclm vbi?n> I IulI «i>aii anil atildlod moat, uid p«itapi loo mndi oo^lrftlDS utbora 
wbcre m; oim eipcrleoee vai mora (Mnvn. aod ibcrvlurv to me IcM Jottrvdlsu. I baro 
•ndcuTornt, howrTor. tQina)(«np lh«deOdencicao(my an hnoKt«tl;tc br theOveuaeof 
Ike matcriBli iwaiii-ris] *u ridiljr tUroa^h our ijvriodlctti lltcntow, whkli leallvml 
Umvra It i* lb« rU:lit and Iho iluij ol tlie ■Tvtnulk writer to eoUrct and m vmbody Id 
atij •ccniini ^r nuj ofcr of Ui« itat« of a KileDce at aaj- gH^ea period,"— Aclrwt /m^ 



D. Appl^oii S Co.''* Maiical PuMicatiom, 



MEYER 

Electricity in its Relations to Practical 



Mfiticine. 



Bj Ob. MORITZ MEYER, 



TgmilaUd from Um Tlilrd Otrmm SdiUon. with HoIm uid AddiUoas, 
A N««r knd HttTla«d Sdltlon, 

B/ WILLIAM A. HAMMOND, M. I>., 

ProbuwafDlMHMar Ib'MlnduK] Nwnnii flnUnn, ud of Cltatail UtdlvUM lit U>* B*B»*«* 
MmdM UrUmI CoUck", VU-.-l-W*ldtHl or Ibe JUadcfflir of UtDUl (xttntM. SukMl 
IukIiuI* of JjMtn, Arb, aiiil ^IrnrM ; Ibm !^iir|[«un-G«DirnJ V. S. A^ Me, 

I vol., «T0. «97 pp. ClBtb, MJO. 

" It U tJie (Inly of evoT/ jiliysiHiiD to *tudj- tlio ai^tion of elwtrlcitr, 
lo beoouiv uequuiutcil wilb Kb ruJu« iu ttiurnpvutu-ii, uad to t'oilow tli« 
haprov«ni«DU that ar« betns maale in the ftf>pftratnB for iU applicatioQ La 
mwUeiD*, tliat Ito ma; b« alilfl ta ofaoo«o Cb« (<d« bust adnpied to tb« 
trestment of mdiridanl cues, and to ttrflt a r«n)cO; fairly anil withnnt 
prdudioe, wlilcli already, espectully Id ocrvuiis diiensei^ han beeo uB«d 
wltli tJtfl beat results, and whicli ]iroini»ca to yii-M an abonduit barreit 
ia ■ etiU broaJiT doiuain." — /V-om AttUipr'a I'r^vM, 



%\ 



Baitdn-EtaBEbmM Jlptwctm. 

"IVtoe wb» do not rmd Oprmnti are iind«r grMt abll^tkwfl to WiQiaiB A. 
BatnmDad, who baa givem thcni tint tinlr an exrell^ail tr«n«lBtii>n of a imsI rt- 
Mllent work, bnt hu piTcn W9 much vshiablc tnfoftnation owl many Wfisutiotw 
from hin oira jvtitonal Mp*rini€e." — Mrditat tUwrd. 

" Br. Moriti Meyer, of Ilcriin, hi.i bM* fOT more ihnn twnrty yean a kboriotn 
and coD«dcTitioii» »it)d(Til of Uib applicntion of rfcrtricity lo practioal mtdlrin^ 
and the rexuilu of bis lubore ht« ^ritt in thi> valiuiM!. Or. Ilaiuinond, in maldBg 
a tmniJalinn of th* third Gcrmnn tiHiion, ban done a real »ciTioc to IbeptrfWrioa 
of this ooiiBtry and of firrnt Brilain. risinly and conAdy writlciv, aBd almiily 
and dearly ammpwl, U conlslni jiwl what Ih* physician wanla to know OB ihe 
■object,"— .V. r. Jfn/ffnf^(wn'a'. 

" It ta destined to C11 a want long felt bT physicians la this EOHDtry."— /wt^ol 
9/ dttttriei!. 



Appkton A Co.*B Medical J^iblicationt. 



NIEMEYER. 
A Text-Book of Practical Medicine. 

Wil/i Partictilar li^fereiice to Vhyilolotjij and Patho- 
logical An'itofny, 

By the Uio Dr. FEUX VOIf NIEMEYER, 

Vnttttm of PkUiOkisr aM TliM«p««tk«: DIiwuit at Hut llwlkkl CItnte of dw ITnlTenUjr of 

TTSiuIat«d CroTQ tta« Bi^^Ui Q%rmKa Edition, by Bpeelal permUalOii of 

tb« Autbor, 

By GEOKQE D. nUMPHREYS, M- D., 

LaU OM ef tbe Flir«lclnD4 to Ube QaiMa «tf IKdlcil iM OOf^m Brtlvf M Mhrra* Ilg«|itW tor 

tba Oui-iloar I'uir ; Fdluw a( tW If vw Tnk AeMouif oT UedUus, iW^ 

and 
CUABLES E. H^VCKLEY. IT. D., 

Uii.' of Ui* ni*>tdaiui t» tliB Kiir Tork I{oa|>ltd : onr oT tlia Snnraon* (a lh« TI<ir Tack ^« 
■uil 1^ lJii:niuu7: I'aUovrof UmSdw Tork JLtoacmj- of MnUdiin, «U. 

BaTlMd £diUon. S »!■., Sro. l,ftM pp. Clotb, 49.00 ; Sbetp, tltOO. 

The autlor otidortakca, first, to ^v« & pictnre of d)wu« irhicli sLall 
be Oft lifelike and fiuthl'ul to Duture on poMiblo, Uutvnd of being a mera 
theontUcal scbouic; su«oaOIy, ao to utilizo the more roc«ot adriuiccs 
of pathoIo}(ical anatomy, phyaiolngy, ami physiolofrical cbciulatry, oa to 
furnUli u cl«arvr inHigtit into tli« xnt-iuuH iiToeutwfit ul* dUoiuo. 

Tbo work hua met with the most fiattoriux rc««|>tioD uiJ donrTsd 
■n«c«M; lifls b«eii adopted as a toxt-book in many of the ra»lical colleifea 
buUi ia tbii cuuutry and ia Kumpe; and baa received tb« very bigliosb 
enootniuiaa from the medical and Bficiilor pre^. 

" It b fli)t»prob«nal*e ind concise, aad ii cfaaraelcrised by deancn and 
OripDtSty." — Dtiitlin Qitarlerljf Jantital of MaHeine, 

" lU anthor i* loamcJ in ineiliuil lilcmture ; be !»■ ■rrangi.t] bii niat<rUlt 
with oare and lodgmenl, and hag tlwu^t orrr i\wia."—Th* jUinert. 

"Aa a fiiU, fl*ateinatic^ and thonnuEtily pracUcul giiidc for iho etodent and 
pbyatdaD, It la not ezoeUod by any dmSar Ireatlaa la any laii£ua(^" — Appteumt' 

" The author i* an aocompliidicd patholoj^t and prneUcal phjMcisn ; ha ia iMt 
only OBpable of appreciating the n«w discoveriiM, wliivh daiinx tbo latt toi Tear* 
hara been tmueaally nnmcrcna and imponant b Kiditilic and pmotloaJ loedLciaa, 
but, by hia clinical expcrienoa, be can put theiw ncir tickh to a praotical tat, and 
gl«a judgment repudlng litma."^£i!inlivroh Aft^ical JanmaJ. 

" From lU geaerol eioeUence, -"e nro dUpoaed lo think that it wtkl siKin uk« 
iti placa among the recogaiaail test-booka."— ..djiwrinin Quarltrt^ Jounml o/ 

"The flfti inquiry in thia cwintry rcfrf rdSn^ a Ocrman book geonally h, ' U 
it aworicof practlcn] value? " Without mopping to canal dor the JuMotes of th« 
Amerioan M«a of thu ' praciicul,' we can unbti&ttiitliiKiy answer, 'It ii 1 ' " — yaa 
York M»iUalJoumnl 

" Tbo author lina the povcr of silling lh« tarca from the vbent— a matter of 
llw gmlcft iuiportance in a t«st-bQok for atudvnU.*'— ^VuA Jl/tduut Jmimal. 

"Whatever c.tati«d opinion oar (xmntrynwa may have of the autbor'a talrata 
of oboerratiun aiid his practical good sense, bis text-book will not diMppoint 
them, while thoao who are ao wnrortunate as to know him ouly by name, hatre in 
ttore a rich ttMt."— ^*u Kvi-Jt MtJint Rttvrd. 



J>. Apptdon tb Co*a Medical Publicationt. 



NEUMANN. 

Hand-Rook of Skin Diseases. 

By J>ii. i;?inon sErMAXN', 

L«ctnr«rM>8khiDlK<ua<iii ilic B>>)aI Calvtnltf of Viniiu. 

Traiulated from ulviuiood «b«eta of Uta sooond edition, fUznUhod lor Ui« 
Autboir ; wiUi HotM, 

Bj LUCIUS P. UULKLET, A. M, M. D.. 

am lo lIiQ '^hln critilf '-f itic CoVire or Piiyflclani ind Suiswuw, Hen Yunk; M«gB> 
bcr DfUiv Nvw Vort Di-raiaiatqg1cal Soclttj. etc.. rtc. 

1 vol., tTo. A^3nt aSD psget &nd 66 WoidoaU. OloUi. S4.00. 

trwcuttit <jr n-kOiTiurioK'. 



■^^iv 



:— -rf 



ShUoo qf tkiD rrom a iMid bold. 

Prot Naanann ranln ■Pctni') nntjr lo n«)iK. wIi'i^p iftlptant be mm tor m%af ft»n, 
tnilhl* wot): niAjr bn cntii'lili^rril la it fair<'ipnncnt cj Iha GcnDiin pnrltMOf IMniWtOW- 
$f. Tlie book U abniidiitilly ItluolrtlLil with iiUlui nV thu hlploluv'T ■iicl iMlboloKr ^f ^^ 
•klD. Ttaelran«1alor liM tiudn«riir«4,b; oiH<ri«iiriiiiI«iifroi>i Frrucli. Gii-.-'I'b.mnd AoMrl* 
«stoiaeM.:o nuke lite work niublcioUioitadeiituwutlulu tbe pnciiilmicr. 

>* II 1* a work wbleh I Bhall h nartlly nwoniinrad ta ra; cUm of «tiid>»Dta at Ihe Xitiinr- 
(llT of Pan n< lira nil, and ana irhkli 1 twl unro Will do moch (owBrd cotlgbiiialiig ihe pro 
(cmIuu on ilil» n\'}i!i:L,"—iMtilt A. AiA/fim. 

"I know It lubs n uond txiolc. jiiid 1 am nra that ll !■ ir«11 (rxn^Utod; and llUtnt«>r> 
MtlarwBndllUJiutmcil b; rc/cr«iieu la tLa nana ot c^labonnla iheawieflaJd."— 
Xnaavf WIlMm. 

*' B« cmnplet* u to rmdorlt Bmaft ii*rfii1boofeorK>ntriRiee.~— 1*. JfcClaff .iMd/nm. 

"Thonl cirrialnljr la iin nark i-tTaiit iitili:]! tionU ao Ihtirnucklj writb Ibe falhalofkal 
Aliiali>tii7 t>t ihA SIcIn a- •kx* ihlH bniirl ln>L>lc. " --.V. r. itattMi ittcora. 

"Ttia orislnal notr^ by Dr. llulUlry iud rnrr riMrilml. nnit arc an Important odjoncl 10 
IhoCcxt . . . Iaiiik)|Ml«rorlt B^*ldocltcnlali<J1]."-Alf.lf funUt. BnMi. 

" I linrv alnatlj Iwioc piurvcMd Dtj bmnibtL- ci|iinloii of the book 111 pHiiL, and an 
£lftj| (hai It 1» gitfu lo ibD piiDlk at lawt."—J-vni^ C. H'fiitf, Be^'vn. 

•• iir.rr- tttin liTii vrar* tie" w« iiolk^d Dr. Ni'univiti> Bdiulr«)il« work In Ua oit^lBal 
•hap*; ■ni) ""* »'" HiPTvlVirv (.Imolvi^ from inr ticv^iitT of (aj-lng Kiam Ibaa to npcal 
Mt itfODf rowiUBiEtiilarioD o[ li to BnflUta rcadan."— i^iwUMwr. 



"«*«_ 



NEFTEL. 
Galvano -Therapeutics. n^Physhiofficaimd 

T/terapeuiKol Action of tJie (riUvania Current upon 
the Acomtki Oj/ttCf Sy/iij>atAe/ic, and Pneumoga^trio 
Xfemea. 

By WILLIAM B. NEFTEL. 

1 TOL, ISao. 161 pp. Clath, tlM. 

Tliia book has been publishod at the req^uest of several aural aurgeotu 
and otber professiona] geutlenien, and is a va]nabl« treBtlsa oa the aub- 
Jecta of n'hicb it tre-at«. Ila author, formerly visiting phygtcian to th« 
Iftrgc-at liospitsi of St. Poteraburg, boa bftd th« very best facUitks for !□• 
TeBtigntion. 

" ThU Mitle work ahow*, u br &i It gooN, tall knowledge of wlist bu been 
dons on tli« •ulij(s:U IntatcH or, and tbo author's pmotlul avquabtaDoe with 
tl)«n),"^.Vcu York Mtdieat Jo*irtLol, 

" Thoao vho us» tlectrioUj' ihoiild get this work, ud those who do &oi 
•hould peruso it to lesm thkt there i« od« rooro tbcmp^ulloal sgcnl that ihey 
eouU and should possess." — 7%* Jfa&mJ InvtMigabtr. 



NiaHTINGALE. 
Notes on Nursing : Mltat it «, and what it ianot. 

By FLORESOE yiGnTINGALE. 

1 rA, ISmfr, 140 pp. Cleth, 7A eents. 

Ercry ilay sanitary kuowlcdgu, or tb« kiiowltdjfi; of nnrsin^, or, in 
Dth«r wordii, of hov to pnt tho constitution in sach n ntnte nft that Ic will 
hav« no disoa^ft or thnt it can r«corer from rlise^we, tuk<>« a higher plac*. 
It Is rec»^iz«d a-s Ibe knowlod^ which ev^rv gne oiii;lit to bnv« — dls- 
tioct from luudicul knonludge, which only a profoision oau bavu. 



D. Appleti>n A Co.*« Medical JPUbltcations. 



PEASLEK 

A Treatise on Ovarian Tumors. Their 

Patfiotogy^ liiaffnoai*, and Trtatment^ ycith r^trtnct 
especiaUtf to Ovariotomy. 

Bj EDMI7XD R. PEASLEE, M. D.. M.. T>., 

FmrSMnror Bhpaica of Wmneti. In DiiimnnOt CVilloii*: ODfor ItieOnPMWPMBa^pM W 
Ki lll« N. r. SikIC WQKUiri-* ll'>IiltBl; famCTir ProfMHW of ObaUtriM UH OtHMH 
i>r Wamn). In Iho N, T. MuiUcftJ Collect: Oarrtnpoitdlug Umubor of Um (HMtetrtEaJ 
6oei«tr urB«rllu, etn. 

In. o&e loxcn TOL, 8vo.. wiUi lUustntUona. 

ananxn or n-irtnurioxiL 



^» 



8thx<i> ros ExruiMTiaK or Otakiax Cms. 

^tathMUitM'IacbM Im^: A RHilfil tolw. B InnhM tonf- uiil A I" iV I'h'Ii t** dlunrlar, 
with bMdUjMLnt ; S. sitnll&r tutw. 4K tochcs Innn : (7, raUHT Wttf^ to he UUcbcd to tnil 
«, Iijr which U* fluid, drawii fraa uio q^st tbroush ii\ la (wmA oat. T^ *tQ|hvoika « tf 
Mil It' H« boib ttiowo la doiod. 

This T&luAblo worlc, embracing the rcsulu of nmc; jean of succMBfiil ex> 
perlpnc«, b ihu dopanmcnt of which fi trcab, will proTD ttott aeccpialil* to th« 
cuUre prDfcjilon; while tlii high standing of tlio snthor uid lib knowledge o( 
tlia aiil^eot combine to nuke the book the bof^t in the UnffingKi U is ilWidcd 
into twD pttrtd: tli« lirat, Inuting of Orariiin Tiimoni, thnir snntoroy, p>tbolog3r, 
diDgnosiii, and trCHtnient, cscc|>t by extlrpalion ; the Mcond, of Orarlotamj, Its 
hialory sud vtntixtics, mi of the operation. Full; illustrated, and sboUDdlng with 
infonnaliOD the tmuU of a prolmignci »tailT ol the subject, the wofk sbouhl h* 
1& the haoJs of every {riijuiclsn in the coantry: 



D. Appltton tfc Co^t Medical I*ut^i<ations. 



STROUD. 

The Physical Cause of the Death of 

Christ, and Us Hdaliona to tlte Principles and Prac- 
tice of Christianity, 

By WILLIAM STROUD. M. D., 

With ft I.«tUt OD tb« Sut^ooU 

Br Sm JAKES T. SIUTSOS*, Bait., U. D. 

1 VOL, IfiJBO. 482 pp. Clolb, f8.C0. 

TlitB Imporiant and ri:maTkabl4 book ia, Id its D*ni |>Incc, & mutetiHitce, ud 
mill he comUereii as a stimdiLrd vork for maoy yonn tu cam& 

Til* principal polat tovlitvd npon I*. Ibat lti« tinatit of Oiriat itm nqacd bj ntplnr* 
or bMrallon oT tD« ti»n. 8lr Jkioei i. S<iup»iMu wbo had rpwl tba ftntbur's tnaiUe 
and ■■riuun cinumimia nii li. x-ipreMri Mratvlf yerf pcwltl*ely ia fliTor of the ftewi 
inftliiulacd br Dr. atroad."— AyaAfiktf'faa' inMnwr. 

SWETT. 

A Treatise on the Diseases of the Chest. 

Seing a Course of Lectures deliwred at //«■ jtVcw 
York Hospitiit. 

By JOHN A. SWKTT, M. D, 

PrAmoi ff ll'p IrniItiitM ■nd PracHci- or Mrftdne Id Hie N*w York Unherrltj: Pbril- 

otUtochD New VMfcUcopluli HouitMforitioNew York f^llii.U>£iQi] Socletj. 

1 Tol., evo. B87 pp. sa.BO. 

Embodied In thU volume of Iccturot U tli« exjwrtnK'O of ten ytut \a hospiul 
and priTttt« prao^co. 

SAYRE. 

A Practical Manual on the Treatment 

of Club- Fool. 

By LEWI.S A. SATBK, M. I>.. 

PNtMMTof Ortbupedic SnnrcTT InBcllerDvilnrpltnl Mnlieni Oollece; Hnrscoo to Bdl*> 
Tur uii CbarElf Boi|)IUl*. otc. 

t vol., tSmo. Ot pp. Cloth, tl.OO. 

" T1i« iibj«ct of (hi* work in to conrcr, In u roocl^e a nxKn^er a> poulb1e^ fell 
thit praclioal informnlinn nnd instruction jinve^taTy io eiuililc the general pnie- 
tiHonOT to apply thai plan of treatment wbloli his beta bo luccoisftil in my owd 
baads.** 

"Tlw tiooh Brill T#r» w»Il Miliir* ill* want* of the nialorltr 0/ ir>>Q<init prKtltlotnrk 
te wkOM iu«, M ftttwl. It It tnioDdnl."— AVu IV* JMktf /mtuL 



i). Affpteton <fc Co.*« Medical Pttbtt'caii^ng. 



SIMPSON. 

The Posthumous Works of Sir James 

Yoiuiff Simpton^ Bart., M. I). Jn Thrx VoluuioA. 

ITolume T. — Sdlaeted Ohtietrieal and Qynaeotoffieal Worka of 
sir JMse* Y. Kmpaoa, Burl, U. D., D. C. L., iala VnSemot of ICidwifer; hi 
(hv Unlrvrvtj of KJiribuHh. Cocitaiauig tti« tutncanM of bb LKtom 40 
ICdwirBrj. EJilvJ by J. War Blicc, JLM., ILB., VcmtMrvf tbc KojftI 
CoUogs of PliyskiBc?, Louilatt; FbjTHciftn-Aooouelwur to Chuing Croa 
HoepiUl, LoDdoa ; aod Li]<:tun:r od MiilwiAry ud Dtow — <rf Wcbimb ud 
CbUdrcn b Uie HosplUl Sobool of Mediciuo. 

1 ToL, 8to. 8&S p]>. (notb, •a.oo. 

Thii VAlume contNUis all the njoro importdst of thft contrihntioaa of 
Sir Jamed V. bioiptoa to tli« atudj of obstetriea ud dbeases of women, 
with tha oxcc[>tian of Inn dinioal lectures on tJia latter sntyect, which 
will shortljr appear in a separate Tolame. This first rolumc ooolAins 
uuLDjr of the paper§ rc[irinteil from hi* Olwtetrio Umiioint aiiil Qimtri- 
^utiQiu, Bad aUo bis L«ctur« N'tft«a, ocv pabli^«(L for the first tim«, 
containing the Buhataac« of the prncticA] part of liiflcoorte of midwlfsrjr. 
It lA a voluine of j^reat iotereitt to the pruf««aioa, and n fitting nemurlaJ 
of ita renovaed ood taleDtod author. 

" To niuiy or our rAudf n, douhtkH, i.h« chit^ of U)« pAp«n it oonuini %n 
fiuutUar, To otbera, ilihcuith probubly ihoy loav be airare (hi*. Sir Jnnca Simp- 
kh tau written oa ths BubjecU, tlie pftp«r* tlionuielvca rill be new koA tttn. 
To ths 8m clttM, wo woiilil ro^omrnenil thiii edition ol' Sir JanuM Sintpsnn'a worlu, 
ts & v^unbli! volutin? of rvrereUL-L- ; to tlie Utt«r, u a ooUcctlou of tli» works nf ■ 

Kat lUAgtDr and iioprover ofhU art, the atiulyof «hlcb chuooI fail to make th«tn 
[ur pnparvd to muvt and ovsroouc lu OUSculLiet."— JMieo/ 7'tnwi ainl AmM. 

Volume 11. — Anofsthesia, hospitalism^ <te. Edited by Str 
WAi.Tni BiMMOM, Bui. 

1 vol., 8va, fi60 pp. Cloth, »3.0D. 

"WVMf oflbid, as of the flm Tolumo, that it fhould find % plaoooa tfa«ut>l« 
eferflr^ prtcliliooar ; for, tiiougb H Is pati;hwurk, mcIi pioco majr be piok«l out 
ud atiidioJ (ritb pintturfl ud proGt."— 7'i^r LancH {Ijantion). 

Volume m. — 77t« DUtaxts of Womm, Edited by Albx. Swr* 
■ox, U. D., ProfMBor of Uidwlferj in llit> Dureraitx of Ediobar^. 

1 ToL, Rvo., Clotb, sa.00. 

(>n« nf lh« b««t worki on (he aDbjsc't extant. Of iDeatiinable value lO«Ttl7 



I>. Applcton Jb CoJ'a Medical Publications. 



TILT. 
A Hand-Book of Uterine Therapeu- 

tics and of Uiseuses of Women. 

By EI)W.VRD JOIIN TILT, M.I*, 

IMBbv of th* BonL Colitn of Fb}4ettu; Conmlllnt Fbrtfdu to Ih* nfriBcdon Gra«M 
Dtmuarjr: raCowar UwBoTalMadkkluid <3Unv|lcal Soolrtjr, uiloT wntd BrlUahiiad 

1 vol., Bvo. S4& pp. CloUi, tS.SO. 

Becand Amsrioiui edition, Uiuroitghly revised and amended. 

Xbe main poinU developed in this work &re : 

1. TI18 pammvant Ijiipttrluiico of Uygluno fur tbe rcliof itiiO cure of 
diaeAMS of womun. 

S, Tbo CDustittitlusal uaturo of aiaiiy dist^OKL-H of women, ttiid Uit 
tmpoembilStj of curing thtm without con&titutiunaS remotiifs, 

3. The iaiinlfi.-8t rt'octioa uf nturioe dixt-nM* on tlio feiDivlu lyjiteai, 
and the impossiLilily of cniing moDj' uterine cornplainta, without snr^ 
oat in«iisur«a. 

4. Tlio crcAt Tftlue of thtrapctitici; to ss.<tcnge and cure dii^^AMA of 
womeo, 80U tlie belief ia the valac of those remt'dial m«afinr«9 that are 
Q» old na meditiue lu«:-lf, «ucIl aa TODC»i.-cti{>D, emetics, and caustics. 

" In giring the n-iull of hit Inbon to iht profcMioD IImi niilhor hai don« t 
Brc*t wurk. Our ri'ailei* wlU find iU pag«> Ti^r^ IntvmtliiK, artit, at llic end of 
uelr \*ek, wtU foel gratvOi] to the author for niany very Talaablc aiigg^eUms u 
to the trnitment ef nterine diMuea." — ITu LmvM. 

" Ilr. Till'* * llaad>book or Uterint TlKfrHpriitic^ ' inippliv* a want <rbti:h hai 
often lieeu fell, ... It way, tlinrerure, ht reail iial outy with pleasure aoii 
Inttraclion, but will al«o be fouoil Terj uwAil a* a book of r*fprpnoc." — Tfu 
MnH^ Mirror. 

" Seconil to oodq on tbe thcfafionttcB of al«rin« &\tNM."—Jotimal 0/ 0^ 
^ftria. 

VAN BTTKEK. 
Lectures upon Diseases of the Rectum. 

Dtlivtred at t/ia JBeilevu^ MofpiUil Medical CciUg«. 
Hesuon of lS69-'70. 

Bj-TT. H.TAN BTTREN, M.D., 

pteftmar «r th« Friadpl«« of Sonm' «lih PImbm* v1 th« Gt^to-Urtein Oima. fte.. to Um 
BvUbtuc llcapJUl MnUol CoDrfa: oua of tho CmunlHiiK Suranoni of Itw Now Twk fli» 
pllal, «t tbi BeLMrue llMpHal; Member of Um K«w lark ini&tarf «( lMMD«k o( Iba 
hUiekfkal SudMy or Now Ytiri.ctc,ctr. 

1 TttL, Ifimo. IU pp. Oloth 91.60. 

Lecture I. — Pruritua Anl, Hjomorrliolds, eto. 11. — Internal ITiumor- 
rhoids. III. — Polypus. IV, — Fistula in Ano, V. — I'lssnre, or Irritable 
Ulcer. VI.— Stricture of the Kectum. VII. — Cancer. VIIl.— Diagno- 
eis, et«. 

" Ii netmi hantlr n^ccaaatr to tnor<> llian mention the name of Ihc author of 
this adiiiinbic liule vulume in order to insure the <Jiara<;t«r of hiJ book. No 
ona in thii country hu eiuojed creatfr adTaQtag>r#, and had a trore cxicDsive 
field ef abxcnratioQ in thti Bpcetiutv, Uian Dr. Van lltircn. and no one ha* ;>aid 
the tame amount of attention to the iitit>jt:ct. . . . Here in the experii^ooe 
of j«an aumiofd up and giten to tbe proraMlonal woild id a plain anil pntctical 
manner." — P^hoi^ir^ JtmrHol, 




VOGEL. 
A Practical Treatise on the Diseases 

((f Childreti. Second American from th« I-mirtA 
German £i2tium. lUwtraUd hy Six Lkhoffraphia 

By ALFRED VOGEL, M. D., 
rof CUcLlnl MadklM tn the Unlvonhjr vl Do(f«t, 1 

-nUKBLATID AXD XOITSD BT 

H. RAPHAEL, M. D.. 

«r C&Uilraa, au^ etc 
1 TOL, 8T0, 611 pjf. Clatb, M.W. 

The Torlc is well up to the present state of patholo^ral knowl«)ge; 
oomp1«te without tmovcviWAr}- iir&lixitr; its symptomatolopy scoumte, 
evideatly tbo result of careAil observation or a compeU'Jit aa<l experi- 
enced clinleol prnrtitioner. The din^oaU iid'1 dilTerMitiul rcl:itions of 
diaeuM to enoh oilier are accurately described, and Uio therapcottca 
JotUdotu aod dlseriniiiiatiDg. All polyp hnrroaejr la discarded, and only 
Ui« r«in«ltea whiir^h appeared useful to the author coinineoded. 

This work of Vogol's contuins rnticb that must gain for It the merited 
praise of all iuiporlSal Judges, and proro it to be an invaluable text-boolt 
for the student and practitioner, and a %ife and aeefnl fuide tn the diffi> 
cnlt bat alI>iitip»rlA»t department of PRdiatrii^n. 

"lUpUly pawing to a fourth «lll1oD In GcnDany, and Iraodated inte ihr«e 
etker lannnf;**, Anpiici now hu the crodit of pi«««nt!nf; the tlrBi Kn^livh *rr- 
■lon of a DO<?k wkidi niti«t uk« a pramltiwt, if not tto Imdine, posilioa unoog 
worka devoted t« ihia class of dlBeasc." — y. T. XtiKeal Jwiw. 

" Tb« profcMion of Ibis eotiolry are oodcr nony obGsattooa to I>r. RaphMl 
fbr bringtiig, as he bu dcm«, this truly valuable work to their noHee^"— JTm/iai/ 

"Tba Irnndntor boa been mora tliao ordinarily lucceMful, and bis labors 
bsTo resulted In what. In every Bens«, is a valuable cootributloQ to medicai 
telenceL" — PtyfMogieai Journal, 

"Wo do not knav' of a compact text-book on the dlseasee of ebildreti aore 
tompletc, mofc comprclK-niiTc, moiti rtnltie with prsdieal remtrks and selenllSe 
fact*, mon> in kci^inf; tritli i)ic dpTdopment of modern nedicoM, and man 
worthy of lh< alieini'^n of ihp |irore««ion, than ib»l which has beco the fful^joct 
of our remarks." — Jm'mal o/ Of'rt*trin. 



NEW MEDICAL WORKS IN PRESS. 



On Puerperal Diseases, cunicai ixvture* cfo- 

livtred at Btilevue Ilvtpiiat, 

By FORDTCE BARKER, M. D., 

CUsiaJ ProlVMor ol Mldirtlcry irad CHkmm of Wmwd Id Uie ftcUcTae Biwplta) ll«4ksl 
L'ull<M.-«: Obetdrlc riij«icUa to B«llrni«HOfptUI; C<inii;lilni;l'&7iikUa lolboN. T. 
!•(•;« Wociui'* II<M{>IUl. Rnd to iIih N, y. Slat* HoxplI*! tut 1)I*mw» ol IL« Nortotu 
SfiMn I Hnncni? Vomtwr o( Um BdUtniUKli ObM«trtc«l Socletr, Me,, etc 

A marso of lectures Tnlnntile alike to the stodoDt aod the practitioner. 

Hand-Book of the Histology and His- 

to-Chemhtr>/ o/Mttn. 

3y Or. HEINRICH FKEY, 
of Ko rich. 

lUnBCntod wltb 600 Woodcmta. 

A Treatise on Obstetrics, wiva an introduction 

9n the Pathology of Rngnanfy and C/tUJbirth. 

By Dr. KARL SOHROEDER, 
or tbc tialrerfltf of BrUngco, Bavarin. 

On Surgical Diseases of the Male Gen- 

ito- Uritiartf Orj/ana, inciudmg Syp/titis. 
By W. H. VAX BURKN, M.D., and EDW. L. EETES, M.D. 



A New Work on the Anatomy, Pathol- 

o^y, and Thatment ofJ>isfatci of the Ovaries. 

By T. SPENCER WELLS, M. D., 

ftnECon-lD'CMlDmjTtallef MAjwtT'i lloiuvbold; Bar^vm to tlio Sanuttao Botpttol to* 
Womm ; Ifeniber of the Itoiftl Intllinilona. eio., mo. 



Chemical Technology. 



By EL'DOLF WAGNER. 

Truulited by WU. CROOEES, F.K.& 




SAM*