Part 14

In external necrosis, or death of the outer lamella, reparation is chiefly made by the subjacent parts; and this species of necrosis occurs most frequently in the flat bones. In necrosis involving a greater thickness of the bone, the new matter is also furnished by the subjacent parts, which, however, are materially assisted in the process by the living bone, which forms the margins of the void caused by the absorbent process for the detachment of the dead portion. The bony matter is deposited with great activity, and frequently columns of the new deposit cross over the sequestrum, binding it firmly down, and rendering it almost immovable, although it may be completely detached from the living parts.

It has already been stated, that those vessels which ramify within the substance of the periosteum have no share in the reproduction of bone, but plastic matter is effused by the ramifications extending from the membrane to the bone: this effusion becomes organised, and greatly assists in forming the substitute.

It has been formerly remarked, that a limited, and, on after examination, an apparently trifling necrosis of the cancellated structure, may produce the most violent local symptoms; the painful feelings, the discharge, and the thickening of the bone, continue, as long as the cancellated sequestrum remains; severe symptomatic fever is induced, endangering the life of the patient, and often rendering removal of the limb absolutely necessary.

Occasionally abscesses form at a considerable distance from the necrosed part, and terminate in sinuses, which communicate with the diseased bone, and are consequently long and tortuous, so that examination by the probe is rendered difficult. When necrosis is extensive, there is a risk of fracture occurring, if motion of the limb be permitted before a sufficient quantity of matter has been effused, before nature has had sufficient time for the consolidation of her substitute, and consequently before the new bone has come to resemble the old in thickness and cohesion.

Violent inflammatory fever attends the incited action of the vessels of the bone and periosteum which precedes necrosis. But after the abscesses have given way the painful symptoms subside, and the health seldom suffers to any great extent, the system becoming gradually accustomed, as it were, to the new condition of the parts. Hectic supervenes only when the disease is very extensive, and joints become involved. Frequently fresh collections of matter form as each piece of bone approaches the surface. When the effusion of new bone has extended to the neighbourhood of a joint, its motion may be very much impeded, and, from the limb being kept in a state of rest for the cure of the necrosis, anchylosis may even occur.

Treatment.—The means of preventing inflammatory action from running high and ending in death of bone have been already alluded to—abstraction of blood, rest, purgatives, and antimonials. When necrosis has occurred, no interference with the bone is allowable, unless the sequestrum is quite loose, or unless the patient’s health is suffering severely under the discharge and irritation. When the sequestrum can be readily moved about, or when, projecting through the external opening, it can be laid hold of by the fingers or forceps, attempts must be made to remove it. The surgeon ought not, however, to allow it to approach the surface, and project externally, for the natural discharge of the sequestrum is a much more tedious process than the removal of it by art, and by the irritation produced during its spontaneous ejection the inflammatory action is continued, and may prove alarming. Long before it has appeared externally, it must have been completely separated from the living parts, so as to admit of ready extraction by the proper means. When it has been ascertained that the sequestrum is separated, it ought to be laid hold of by forceps, and moved freely upward and downward, so that any slight attachments by which it is connected to the neighbouring parts may be destroyed, whether these be minute filaments which still in some degree retain their vitality, or small portions of newly deposited bone, which are so situated as to prevent the free movement of the sequestrum. In general, no impediment of this nature exists, and the dead bone is easily removed. Before extraction can be accomplished, it is generally necessary to enlarge freely the external opening, in all cases where the dead portion of bone is of considerable size. If, on thus exposing the parts, the sequestrum be found detached, but still firmly bound down by the substitute bone, deposited over it either in one continuous sheet, or in irregular columns, this must be divided by a trephine, a small saw, or cutting pliers, before the sequestrum can be extracted. When a dead portion of bone, of considerable length, is exposed at its centre, whilst its extremities are entangled by the old or substitute bone, the division of the exposed part of sequestrum, by means of the cutting pliers, will often be sufficient for its removal, the cut ends being seized by the forceps, and one half removed after the other; thus the perforation or removal of any portion of the substitute will be rendered unnecessary. The instruments, and especially those for extraction, ought to be very powerful, and suited to the purpose; for in the employment of inefficient means there is much folly and cruelty. Incisions into a necrosed limb are attended with profuse hemorrhage from the enlarged and excited vessels; and in some cases it is with difficulty arrested, in consequence of retraction of the cut ends of the vessels not taking place within the condensed and indurated parts. Pressure, and an elevated position of the part, will generally be found to answer. When necrosis has been extensive, the limb must be carefully supported by the application of splints and bandage, till the process of reparation be completed, in order to prevent fracture of the recently formed substitute. This proceeding is seldom, however, necessary.

The treatment may be summed up in a very few words. Prevent the necrosis, if possible; open abscesses whenever they appear; encourage the patient to move the neighbouring joints; support the strength; remove sequestra when loose, but do not interfere till they are ascertained to be so; give the limb proper support and rest, when a large sequestrum is formed. When fracture has taken place, when the health has been undermined, or when neighbouring joints have become diseased, amputate, in order to save the life, if it be impossible to save the limb.

It is almost superfluous to remark, that leeching and blistering are worse than useless after necrosis has occurred, however useful they may be in preventing it; and that the adoption of measures to promote the dissolution and absorption of the sequestra are glaringly absurd.

Necrosis, after amputation, was formerly frequent; but in the present improved state of this operation it is so rare as scarcely to demand separate consideration.

Such specimens as here depicted are common enough in the collections of those who have practised the old round-about operation; in fact, it is only by this painful and tedious interference of nature that a tolerable stump is formed in many of these cases. Death of a small portion will sometimes, though very rarely, follow even a very well performed amputation, if through any mischance the recovery is slow, and wasting discharge takes place with emaciation. It happens sometimes, as when secondary hemorrhage (that is to say, bleeding after the fourth day) has taken place, that the flaps are separated by the coagula, and it may be impossible to bring the parts together and give them due support; then the muscles, wasted and shrunk, may leave the bone a little, but the exfoliation is but very trifling.

The inner shell of bone, as may be seen in the above sketch, perishes more extensively than the outer; and this arises probably from inflammation of the medullary membrane, in consequence of exposure, or, perhaps, from its being sometimes injured by the operator or assistants seizing the bone rudely to steady the stump, in order to facilitate the ligature of the vessels. In experiments on animals, the disturbance and injury of the medullary membrane is followed by internal necrosis, thickening of the outer living shell, and effusion betwixt the periosteum and bone. New bone is also furnished from the medullary canal, as is also shown in the sketch.

FRAGILITAS OSSIUM

Occurs chiefly in old people, whose bones contain an undue proportion of earthy matter, are endowed with little vascularity, and filled with an oleaginous fluid. They contain an undue quantity of phosphate of lime compared to the gelatin; and the liability to fracture is further increased by the interstitial absorption of the outer shell. They are in an atrophied state, and this is often in part attributable to disuse of the limbs. This state of the osseous system very often follows upon an attack of rheumatic fever, and is met with in patients who have laboured under cancerous affections.

The bones, when in this condition, often break from the slightest force applied; as from the action of the muscles when the patient turns himself in bed, whilst walking across the room, or when endeavouring to attain the erect posture when seated on a chair. After fracture the process of reunion is extremely slow, and it does not take place at all in patients very old and of worn-out constitution. With a view to prevent the occurrence of fracture when the bones are in this condition, for it is impossible by any treatment to prevent the change in the texture of the bones, the only rational indications seem to be to keep the patient on a generous diet, and to prohibit him from making any great muscular exertion—to avoid, in fact, all circumstances likely to produce a sudden action of any particular set of muscles.

OF MOLLITIES OSSIUM, RACHITIS, ETC.

These affections differ only in this, that in the latter the earthy matter is not deposited originally, whilst in the former it is absorbed after having been deposited; in both the result is the same. The latter is peculiar to the very young, the former to those of an advanced age.

Rickets and mollities ossium seem to differ also in this. In the latter there is seldom, if ever, any reparative action. The diseased process of deposit continues in the bone, the softening increases, and the patient ultimately perishes. Whereas, in rickets, the softened and yielding state of the bones is only temporary: after a time earthy matter is deposited in due quantity, and the bones become compact, firm, and solid, capable of supporting the weight of the body, though necessarily permanently bent and deformed, if proper means have not been employed during the softened condition. The thickness of the rickety bone, as Mr. Stanley has shown, takes place on the concavity, which is the situation where the greatest strength may be added with the least expense of new matter. In the same way the reparation of fractures not accurately adjusted goes on most actively in the concavity formed by their displacement.

Softening of the bones is met with at all ages, and in different degrees. It seems sometimes to be congenital, and combined with hydrocephalus. It often follows dentition, measles, hooping-cough, or other infantile diseases inducing debility. In females it seems to be produced, or at least often accompanied, by the debilitating effects of leucorrhœa, miscarriages, and floodings. Loss of blood, in any way, predisposes to it. Mercury, given in immoderate quantities, produces a softening of the bones; and, in some most remarkable instances on record, the free use of common salt was the only cause assigned. When the disease affects children, all the bones generally suffer, those of the extremities as well as those of the trunk; the limbs become bent in an extraordinary manner, and the heads of the bones are swollen, and appear to be much more so in consequence of the wasted and flabby state of the muscles. The child walks with difficulty, and in many cases the legs are utterly incapable of supporting the weight of the body, so that he cannot remain in the erect position. The chest and pelvis become deformed, breathing is oppressed, the digestive organs are deranged, and the belly is tumid. The bones of the limbs become flattened as well as bent, and in their concavities, as remarked in the preceding cut, new bone is effused, in order that the column of support may be thereby strengthened. The new deposit is of extremely dense consistence, and is effused in greater or less quantity, according to the degree of curvature.

The bones of rickety subjects are soft, cellular, and of a brown colour, contain a dark fluid, and are very deficient in earthy matter. As a simple proof of the latter circumstance, it may be mentioned that distortions of the pelvis can be, and often are, accurately imitated by soaking the bones for some time in acid, whereby the earthy matter is extracted. In many instances this component of the bones is almost entirely removed, and soft matter deposited instead; they then consist merely of an extremely thin external osseous shell, covered by thickened periosteum, and containing a pulpy substance resembling fatty matter. During the progress of the disease, the urine deposits, often in great quantity, a white sediment, which, on analysis, is found to be the phosphate of lime. In rickets the head is generally enlarged to a greater or less degree, and the bones of the cranium are thickened and spongy; not unfrequently the intellectual faculties remain acute. In adolescents and adults the limbs seldom become affected; the bones composing the spinal column are the seat of the disease, and, along with the distortion of the spine, the position of the ribs is necessarily altered. Certain rare cases have occurred, in which all the bones of the adult were softened to a very great degree. In one remarkable instance, the patient complained of an annoying sense of tightness in the limb most affected, and, on examination, the softened bone was found greatly depressed at that point, as if a strong ligature had been drawn tightly round it. Mr. Howship, who attended the patient, was so kind as to present me some years ago with a portion of the altered femur, which consists of a fatty-looking substance, and appears to contain little or no earthy matter.

Though incurvation of the spine occurs in boys, and even in adults, still it is most frequently met with in young females; and in them it is often induced by their having assumed a bad habit by sitting long in one constrained and awkward posture, as in writing or drawing, without, perhaps, the bones being unnaturally soft in the first instance. It often follows affections of the lower limbs, as of the knee or hip-joint; and is also caused by shortening of a limb, which has been negligently or ineffectually treated after fracture during childhood, or by the patient being allowed to continue a custom of standing awkwardly on one leg. In a very remarkable specimen in my possession, the curvature seems to have resulted from the tremendous enlargement and consequent weight of the head. The whole skeleton (head, thorax, pelvis, and extremities) is deformed, flattened, and twisted. This may have arisen more readily in consequence of the atrophy of the bones, and retardation of their growth, produced by the long confinement to bed. The number of ossa triquetra in the lambdoidal suture was unusually great. The patient attained the age of twenty-five. The affection commenced from birth.

At first, during slight curvature from such causes, the spine can be brought into its original straight position by the voluntary action of its muscles. After some time, however, the curve cannot be remedied by any effort; interstitial absorption of the bodies of the vertebræ towards the concavity of the curve occurs; they become changed in form, and accommodated to their altered position, as shown in the accompanying sketch; the muscles also accommodate themselves to the new position, as do also the various ligaments connected with the spinal column. When the curvature is seated in the dorsal vertebræ it is generally to the right side; this shoulder is raised, and the chest is protruded, whilst the opposite side is depressed and flattened. The clothes hang loose, or fall off on the left side—the patient rests the weight of his body chiefly on the left leg—on stooping the right scapula projects, and, on examination, is found to be nearer to the spinous processes of the vertebræ than the left. The left cavity of the chest is diminished, and the ribs press upon the heart and lungs, causing difficulty of breathing. To preserve the balance of the body, a curvature occurs below the former, and in the opposite direction; and not unfrequently there is a third incurvation situated above the primary one.

The bones of the pelvis become distorted, and are twisted to one side; or, when the softening is great, and the patient confined to the recumbent position, the introitus of the cavity becomes diminished in the antero-posterior diameter; and, if the patient walk about, the ossa pubis are squeezed together, in consequence of the pressure of the ossa femora against the acetabula. The crests of the ilia are often bent inwards, in consequence of the pressure of steel apparatus injudiciously applied with a view of removing deformity. When the bones become consolidated after such distortion, they present most serious obstacles to parturition; and, most unfortunately, crooked and deformed women possess, it is said, “great aptitude for conception.” When, in such females, the untoward circumstance of pregnancy has occurred, it has been necessary, in some, to have recourse to the Cæsarean operation, and others have been delivered with the greatest difficulty and danger; notwithstanding which, many of these latter have, after recovering from a long and tedious illness, again become pregnant.

In some cases the softened ribs not only compress the organs of the chest, but are also pressed down upon the abdominal viscera, or even into the pelvis. The symptoms arising from such displacement are at first urgent, as can readily be imagined, and are often treated as inflammatory, to the detriment of the patient.

After some time, as the state of the patient’s health improves, the bones in some degree regain their original firmness, and the curvatures are rendered permanent. New bone is deposited in the concavity of the curve, at first in irregular masses, but afterwards becoming condensed, and assuming a more regular form, the column is thereby supported and strengthened.

Bending of the spine backward, with depression of the spinous processes, is extremely rare. But curvature forward, with projection of these processes, is by no means uncommon, and is generally supposed to be caused by caries of the bodies of the vertebræ; in many instances, however, it arises from interstitial absorption only.

Curvature from caries of the vertebræ, though not so frequent as the curvature from other causes, is met with pretty often. In adults, the curvature from ulcerative absorption is more common than that from softening of the bones. It is attended with the formation of purulent matter, which presents in the loins, at the top of the thigh, or near the anus; the bones may become affected secondarily, though much less frequently, in consequence of the formation and accumulation of purulent matter in their neighbourhood. There is pain in the loins; the patient walks in a stooping posture, and often complains of pain in the knee or thigh. The lower limbs sometimes become paralytic, as also the sphincters and extremities of the hollow viscera; this, however, may arise, without curvature, from softening of, or effusion on, the chord, or diseased thickening of its membranes. In some cases the palsy supervenes slowly; at first the patient has an awkward gait; he lifts his feet high to avoid stumbling, and afterwards puts them down clumsily and suddenly; the foot, in some cases, is extended, so that the patient is unable to plant the sole on the ground. Retention of urine occurs, and is followed by incontinence, with copious deposits.

In the treatment of Rachitis, the chief indication to be fulfilled is to support and increase the powers of the system; and this may be accomplished by affording the patient a generous diet, keeping the bowels in good order, enjoining gentle exercise and exposure to pure air, by the assiduous use of frictions, and by supporting the softened bones by properly applied and light machinery. Much mischief may be done by clumsy and heavy apparatus which confine the movements of the patient; the muscles are wasted, consequently the spinal column is weakened, the general health is impaired, and the disease is aggravated. Some have recommended the internal administration of the phosphate and muriate of lime, but their efficacy is extremely doubtful. Preparations of iron seem to answer much better in the greater number of cases. In cases of curved spine, apparently arising from bad habit, the patient should be in no degree confined at writing, or drawing, or music; her posture while at work or play ought to be attended to, as well as her mode of walking or standing; and, if awkward, prohibited. Gymnastic exercises of the more gentle kinds ought to be enjoined, such as those with poles and light wooden clubs, the turning of a wheel, the exercise with balls, &c. Carrying weights on the head can only be applicable in certain cases. The shoulders, in some instances, ought to be kept back by means of a light back-board; and in aggravated cases the weight of the shoulders, and sometimes also of the head, must be taken off the spine by a light and well-contrived apparatus. Sea-bathing, good air, out-of-door exercise, and attention to diet, are of material importance. Frequently advantage will result from the patient’s sleeping on a hard mattress; and, in bad cases, from lying down, when tired, on an inclined plane.

In great softening, it will be necessary to confine the patient entirely to the recumbent position, and to support the head and shoulders by a light and firm machine. The causes, symptoms, appearances, and treatment of caries of the spine, in its different regions, with or without curvature, will be afterwards considered.