UNIVERSITY OF CALIFORNIA CALIFORNIA COLLEGE OF MEDICINE LIBRARY AUG 1 5 1972 IRVINE, CALIFORNIA 92664 A TREATISE Off DISEASES OF THE BONES. BY THOMAS M. MAKKOE, M. D., PROFESSOR OF SUBSERT IN THE COLLEGE OF PHYSICIANS AND 8TIKGEOKS. SURGEON OF THE XEW TOBK HOSPITAL. SURGEON OP BKLLKYUE HOSPTTAL, STTBGKOX OF THE ROOSE- VELT HOSPITAL, coNsutrnra SURGEON OF THE MOTTNT SINAI HOSPITAL, OF THB STRANGERS' HOSPITAL, OF THE STATE WOMAN'S HOSPITAL, AMD OF THE NUBSEBT AJO) CHILD'S HOSPITAL, ETC., ETC. NEW YORK: D. APPLETON & COMPANY, 549 & 551 BBOADTTAY. 1872. ENTERED, according to Act of Congress, in the year 1872, BY D. APPLETON & CO., In the Office of the Librarian of Congress, at Washington. DEDICATION. TO ]\fij colleagues in the SURGICAL DEPAETMEST or THE YORK HOSPITAL, I dedicate this volume in grateful recog- nition of twenty years' professional association, illustrated by a thousand tokens of friendship and confidence, and unmarred by a single cloud of estrangement, unbroken by a single hour of distrust. PREFACE. THE book which I now offer to my professional brethren contains the substance of the lectures which I have delivered during the past twelve years at the College of Physicians and Surgeons of this city. It does not claim to be a com- plete compendium of all that is known on the subjects of which it treats; for so much has been learned in bone- pathology since Stanley's work was published, now nearly a quarter of a century ago, that I have not had the leisure, and certainly not the ability, to write such a treatise. I have, therefore, in the arrangement of the different parts of my work, followed rather the leadings of my own studies and observations, dwelling more on those branches where I had seen and studied most, and perhaps too much neglect- ing others where my own experience was more barren, and therefore to me less interesting. I have endeavored, how- ever, to make up the deficiencies of my own knowledge by the free use of the materials scattered so richly through our periodical literature, which scattered leaves it is- the right and the duty of the systematic writer to collect and to em- body in any account he may offer of the state of our science at any given period. In all cases where I have thus made use of the labors of others, I have given credit in the text to the authors from 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 v i PREFACE. have been ample. I can only regret now that these excel- lent advantages have not been turned to better account, and that my industry and perseverance have been so far below my privileges. For this, my apology, not my excuse, must be, a life somewhat actively devoted to the practice of my profession and to its public teaching, leaving me less time to devote to scientific studies, than those studies, for their successful prosecution, imperatively demand. In illustrating the work, I have not hesitated to borrow largely from my friends. By the kind permission of the publishers, I have availed myself of a large number of admi- rable woodcuts from Paget's work on Surgical Pathology, and from Billroth's work on the same subject, translated by Hackley. All the original illustrations, mainly taken from specimens in the cabinet of the New York Hospital, were made for me by Mr. Joseph Harley, of this city, and are, 1 think, remarkably fine examples of his beautiful art. The photographs, on which so much of the success of a woodcut depends, were made by Mr. O. G. Mason, the accomplished photographer of Bellevue Hospital. I cannot too warmly express my thanks to my profes- sional friends, who have in every possible way encouraged and assisted me in my work. I can only say that, if there be any merit in the book, it is largely the result of their kind and active cooperation, and that a good share of the most valuable observations have been contributed by their generous friendship. If the reading of my book should afford as much profit as the preparing of it has given me pleasure, I shall have reason to be abundantly satisfied with what I have done. NEW YORK, March 6, 1872. CONTENTS, PAGE INTRODUCTION . . . . . . . . . . . 1 PAKT I. DISEASES OF BONE. CHAP. I. HYPERTROPHY AND ATKOPHY OF BONE .... 13 II. INFLAMMATION OF BONE 19 III. SUPPURATION IN BONE 27 IV. CHEONIO SINUOUS ABSCESS OF BONE .... 33 V. DIFFUSE SUPPURATION. OSTEO-MYELITIS .... 45 VI. EIOKETS 54 VII. MOLLITIES OSSIUM MALACOSTEON 74 VIII. FBAGILITAS OSSIUM 82 IX. TUBERCULAR DISEASE OF BONE 85 X. CABIES 94 XI. ISTECROSIS . 119 PAET H. TUMORS OF BONE. CHAP. I. CARTILAGINOUS TUMOES 217 II. OSSEOUS TUMORS 238 III. FIBEOUS AND FIBROID TUMORS 256 IV. MYELOID TUMORS 276 V. PULSATING TUMOES OF BONE 288 VI. TUMORS OF THE JAWS . . 300 viii CONTENTS. PART III. MALIGNANT DISEASES OF BONE. PACK CHAP. I. SCERHHUS, OR HAED CANCER OF THE BONES . . . 336 II. MEDTTLLA.RY, OR SOFT CANCER OF THE BONES . . 340 III. EPITHELIAL CANCER OF BONE 360 IV. MELANOID CANCER IN BONE 368 V. COLLOID CANCER OF BONE 373 YI. OSTOID CANCER 377 VII. TREATMENT OF MALIGNANT DISEASE OF BONE . 381 DISEASES OF THE BONES. INTRODUCTION. THE office of the skeleton in the animal economy may be said to be threefold, viz. : 1. To afford that support to the softer tissues that is needful to maintain the shape of the individual ; 2. To give the protection to some of the more important organs which the delicacy of their structure de- mands; and, 3. To supply the necessary levers by which locomotion is to be accomplished. In the lowest classes of animals, whose functions are simple and few, and whose vital activities are moderate, the skeleton seems to be designed sometimes for mere support, and sometimes mainly for pro- tection : in the higher and more complex animal, where the tissues are beginning to arrange themselves into distinct or- gans with specific functions, we need both support and pro- tection ; while, in the highest classes, including man, the increasing diversity of organs and functions requiring varied and precise movements, we have the skeleton divided into many distinct parts, articulated with one another in such a way as to be capable of an infinite variety of movements, upon the strength and precision of which the perfection of the varied functions depends, while the offices of support and pro- tection have become secondary ones, almost lost sight of in the more prominent and more important relations of the skeleton to locomotion. Thus, the coral animal supports its position on the rock on 1 2 DISEASES OF THE BOXES. which it grows by slowly calcifying its oldest and deepest layers until they become part of the stony structure itself, while its younger and softer parts are sprouting and growing, to repeat, in their turn, the same process of solidification, till reefs, and islands, and continents, are upreared by their mar- vellous multiplication. Thus, too, in some of the other of the lowest zoophytes, whose whole body is little more than a mass of jelly, and whose almost only function is nutrition of the simplest and most direct character, we can only regard its silicious or calcareous covering as bestowed upon it for pro- tection against the rude agencies to which, in the ever-moving waters of the ocean, it is constantly exposed, and without which protection even its incalculable fertility might not be able to save its species from extinction. In the higher classes of the Radiata, when distinct digestive, respiratory, and gen- erative systems begin to show themselves with some definite powers of locomotion, we find a framework which is designed not merely for protection, but evidently also for preserving form, and for giving effectiveness to the limited movements which the animal is capable of making. In the Mollusca, where the vegetative or organic is developed so greatly in excess of the animal or locomotive system, we find the shell serving the purpose almost exclusively of protection, neither support nor locomotion depending on it in any very marked degree ; while in the Articulata, which as a class present a preponderating development of the locomotive system, we find their hard cal- careous or horny casing BO arranged as not only to preserve their perfect shape, but to give variety and power to the com- plicated movements by which they are characterized, and upon which their vital functions in a great measure depend. In the Mammalia, some of the more delicate organs, as the brain and lungs, require the protection of a bony envelope like the skull and the thorax ; all parts require the support neces- sary to maintain their shape ; and the same support is neces- sary for the action of the muscles on the unyielding levers sup- plied by the bones. The mechanical necessities of the case, then, are threefold : 1. Firmness of tissue sufficient to afford the requisite support and protection ; 2. Mobility of one part upon another, such as INTRODUCTION. 3 to permit the movements of which the muscular system is ca- pable ; and 3. A power of increase and change which will adapt it to the increasing size or changing shape of the animal. These mechanical requirements are, in the lowest classes of animals, easily answered by a silicious or calcareous covering, which increases in extent as the animal inhabiting it increases in dimensions. This increase, however, it must be noted, is one merely of superaddition to the edges or surfaces of the original shell, which, once hardened, is no longer under the in- fluence of vital action in any such sense that it can undergo any change either in its consistence or in its size. It must be evident, however, that such an arrangement can only be effi- cient in the simplest shapes that animal life assumes, and that the moment complexity of form is assumed, and variety of locomotive action exhibited, a new element is added to the problem of the skeleton, and that this new element is the power, not merely to increase, but to change its form, in obe- dience to the changes which each part of the more complex animal is liable to present, as each part grows to a greater size, and usually to a greater power. Thus, in the cell-like protozoa, already alluded to, we can readily conceive that the rounded or elongated form, partly roofed in by a rounded or elongated shell, may, as it increases in size, be still covered by a simple increase of size of its protecting case, and the diffi- culty is not much increased in the Radiata, whose form is merely a repetition of simple elements round a common centre. But, among the Articulata, as the Crustacea and the Insecta, the growth of the animal in all the segments of its body, and in all the complex subdivisions of limbs and antennae, must be accommodated by a provision for something more than a mere superaddition at the edges of the original-simple formed shell. This part of the problem is differently solved in different classes of animals. In the gasteropod Mollusca, for example, it is evaded rather than solved. As the animal grows it leaves the narrow quarters of its original dwelling, and finds better accommodation in the larger segment of shell which, as it grows, it adds to the old homestead, from which it usually shuts itself off by a partition-wall, which completely isolates the 4 DISEASES OF THE BONES. old chambers from the new. In this way many of our most beautiful shells are produced, their form and size depending on the successive additions and alterations which the increas- ing size, and often the changing form, of the animal has obliged it to make to its original construction. In the oyster, each degree of growth of the animal is provided for by an entire new layer of shell-growth, which, being internal and larger than the preceding one, takes its place ; and thus we have produced the peculiar lamination and the very thick, heavy shell by which these valuable animals are protected. In many of the Crustacea, some of whom, as the crab and the lobster, are entirely encased in a calcareous envelope, the difficulty is met by a process of throwing off the skeleton entirely, and providing a new and larger one, proportionate to the increase in size of the animal. A similar action is ob- served in some of the changes which take place, during the development of several species of the Insecta. This process of the periodical shedding of the shell is a very curious and interesting one, and it may enable us to appreciate somewhat better the difficulty of the problem we are now studying, to watch the tedious, difficult, and one would think painful ex- ertions which these animals have to undergo, in order to free themselves from a covering which has simply become too small for them, and has by this clumsy process to be got rid of, to make way for a larger one. The imperfection, if we may so speak, of the mode is still more strikingly shown by the un- protected and helpless condition in which the unhappy animal is left after casting off its old coat, and before the new one is firm enough to be available. In some of these species, and also in some of the Yertebrata, which have a partial external skeleton, another arrangement is sometimes found, by which the growth of the excrementi- tious skeleton is provided for. It is composed of numerous plates, fitting more or less closely together, but separated from one another by a portion of the foundation membrane of the shell, which is not calcified, and which therefore allows a cer- tain degree of mobility among the plates. This provides, to some extent, for the increasing size of the animal, but the change is still further accompanied by an actual increase in INTRODUCTION. 5 size of each separate piece, by deposition at its edges. By this method form is maintained, and mobility secured, without the necessity of the uncomfortable and expensive process of shed- ding. In the Yertebrata, where great complexity of structure and function demanded great variety and precision of muscular movement, and where the importance of the life of external relation required something more sensitive than a calcareous shell, the skeleton becomes more complex in its form, greatly multiplied in the number of its pieces, and either mainly or entirely internal in its position. And now we find, in obe- dience to its higher requirements, that the skeleton is no longer a mere dead, uechanging, excrementitious substance, entirely removed from the actions of the living organism, and incapa- ble, except by bare addition 1 to its mass, of changing with the changing necessities of the body. It has now become a living part of a living body; it is capable, by its own nutritive capacities, of growing and changing with the increasing size or varying necessities of the part which it supports. In short, it is endowed with all the powers of adaptation which the most favored tissues possess, and exhibits in a high degree the pres- ence and action of that formative force and nutritive energy by which the integrity of all parts of the living body tends to be preserved, both under the demands of health and the press- ure of disease. And here the vital problem is superadded to the mechani- cal. How to endow with all the attributes of life a tissue that shall be hard enough, and therefore strong enough, to answer the mechanical purposes of an internal skeleton, was the ques- tion to be answered, and most admirably has it been solved. The unabsorbing and impenetrable bone-tissue forbade the im- bibition of the nutritive juices into its substance, by which imbibition, indeed, the very strength of the structure must necessarily be compromised, and therefore we find its nutrition carried on on a plan entirely peculiar to itself. ~Not only are the vessels introduced into every part even of the hardest bone, but its tissue is studded everywhere with minute centres of cell-life in the form of the bone-corpuscles, which are, in fact, nothing more than bone-spaces containing cells. These spaces 6 DISEASES OF THE BONES. are far too numerous, and much too minute, to have any direct relation to the bone-capillaries, but they are brought into such relation by a series of fine tubes, or canaliculi, which permeate all the interspace between the bone-cells and the capillaries, opening a communication between them, by which the plasma of the blood, exuded from its vessels, finds its way easily and abundantly to the most distant bonercorpuscles, and thus per- meates the bone to its minutest elemental particle. This beautiful and perfect system of pores, traversing all the terri- tories between the Haversian canal and the bone-corpuscle, secures all the advantages to the bone which imbibition gives in the nutrition of the softer tissues, and yet, by the fineness of its arrangement, it does not interfere with the solidity and strength of the hard and intractable substance for whose nu- trition it so perfectly provides. By these peculiar and admirable arrangements of its nu- tritive supply, bone becomes endowed with a grade of vitality equal to that of the most favored tissues of the body. It is not only a living part, capable of growing with the growth and changing with the change of the growing and changing frame, but it is endowed with all the highest attributes of vitality, not only in its power, first, of Growth, but second, of Develop- ment third, of Regeneration / fourth, of Repair y and, fifth, of Disease. 1. Of Growth. The increase of size of the shell of the oyster or of the crab is, as we have seen, one of mere super- addition to parts already formed, and which in themselves are incapable of any other change. Bone grows by an inherent vital power, by which it accommodates itself to the increasing size of the animal to which it belongs, and this by a series of interstitial changes in its particles as complete as, though prob- ably much less rapid than, those with which we are familiar in the soft parts. This growth, of course, is mostly observed in the younger and softer bone, which is in the process of attain- ing its final and adult size ; but it is, nevertheless, true, that the process of true interstitial growth can be demonstrated on the mature and firmly-ossified bone of young adults ; and it is altogether probable that, even in the most solid and mature INTRODUCTION. 7 bones of later life, the interstitial and molecular changes, which we know to characterize the life of the softer tissues, are the constant conditions of the life of the bone. 2. Development. No phases of development are more beautiful or more interesting in their study than those of the skeleton from its first rudimentary trace up to its perfect form. None aiford better opportunities for observation, and none better illustrate the laws which regulate the process. But, besides this original development, by which the properties of mature bone are assumed, after its passage through many inter- mediate, less perfect, and gradually improving stages, we have the fact daily verified that the mature adult skeleton will de- velop itself not merely in general robustness, but in the actual increase of its bony processes, by virtue of the law that every part grows in size and strength by increased exercise of its function. Exercise and labor will develop the bones just in the same manner, and precisely for the same reason, that they develop the muscles themselves ; and, moreover, though it may be a slower result, yet, if the increased exercise be maintained sufficiently long, the development of the bones will be precisely proportioned to the increase in size and power of the muscles which move them. 3. Regeneration. M. Oilier, of Lyons, and others who, with him, have been engaged in showing how large a share the periosteum takes in the formation of bone, have, in the course of their numerous experiments, fully demonstrated how com- plete is the regenerating power of bone if only care have been taken to leave the periosteum uninjured, and that, under favor- able circumstances, the periosteum, thus left, will generate a new bone almost as perfect as the one which has been removed. Bat, still further, when the whole bone, periosteum included, has been removed, a certain amount of regenerative power remains, and instances are on record where the lower jaw, the clavicle, the ulna, and several other bones, have been removed by operation in the human subject, with the result of a repro- duction, imperfect, it is true, but, nevertheless, a regeneration of the removed bone, sufficient to maintain in part the shape, 8 DISEASES OF THE BONES. and in some degree to supply the loss of the original. Simi- lar partial regenerations have been observed in animals when, in experimental operations, entire bones, with their periosteum, have been removed. 4. Repair. Each of these processes of growth, develop- ment, and regeneration, is abundantly provided for in the skeletons of those lower animals to which allusion has been made in former paragraphs. Of repair, however, in the proper sense of the term, they are not capable. A fractured coral stem is a hopeless severance ; a crushed shell, in that portion from which the animal has retired, is an unchangeable injury. Even in that part which it still inhabits, no proper repair of the injury to the shell takes place, though the animal protects its body from the effects of exposure by forming a new calca- reous layer opposite the damaged spot, by which the mischief is rather compensated for than healed. The same is true of the Crustacea. In a lobster whose claw had evidently been broken by contact with some sharp, hard edge, I recently ob- served the mode by which the serious wound was closed. The injury was evidently an old one, and still remained a gash, as it were, in the upper edge of one of the large claws, nearly an inch in depth. ^The opening was thoroughly and neatly closed by calcareous matter, which had been deposited by the vascu- lar membrane which secretes the shell, and the injured part was thus separated from its old relations to the surface of the animal. No deposit was found on the broken edges, but by time, through the attrition against the gravelly or stony bottoms in which they live, the sharpness of the edge was smoothed oif so perfectly that it was only by examining some- what carefully that the scar could be distinguished from that left by a proper healing of the tissue. In all such cases, and in similar instances among the Insecta, the absence of repair does not at all depend on the want of reparative power in the animal, but simply on the excrementitious nature of the skele- ton, which is, in that sense, no longer a living part of the body, and cannot, therefore, in its injuries, profit by the im- mense reparative capacities of the animal. The same animal, and by a law evidently of compensation, which cannot repair INTRODUCTION. 9 a compound fracture of its shell, can reproduce, it may be, the entire limb, if the injury happen to be severe enough to tear it from its body. Contrasted with these imperfect efforts in the lower ani- mals, we find in the higher Mammalia, and particularly in man, that the repair of injured bone is among the most beauti- ful and perfect of all the reparative actions : 1. Its most strik- ing feature is that it is intrinsic ; that is, it depends for its per- fection on the perfect life and high vital organization of the bone-structure itself. 2. It is reliable. Under all circumstances of age and condition, and under all degrees of injury which do not compromise the life of the injured part, it may be so surely counted on, that occasional failures excite our surprise, and can in most instances be explained by some mechanical inter- ference with the process, rather than by any want of inherent power of repair. 3. The repair is economical. Xo more ma- terial is employed than necessary, and this material is so per- fectly transformed into bone-tissue, that the microscope cannot distinguish between the old and the new formation. 4. The repair is complete. Although, in the highest Yertebrata, the repairing 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 healing process is perfected, a fracture would be more likely to occur at some other point than at the seat of the perfectly- mended original break. Finally, the process is so arranged that its result is shapely. !N"o deformity is left beyond what is the necessary result of the displacement of the broken frag- ments. The uniting medium is so proportioned, and so ar- ranged between the parts it is intended to heal, that, after the process is completed, no superabundance remains, and, if the broken ends have been maintained in perfect apposition, so shapely and so perfect is the result, that it is oftentimes diffi- cult to decide that a bone has been broken, when it is ex- amined long after the injury, or, if the fact of fracture is known, to point out the precise spot at which the fracture was situated. It is true that, in some of the Yertebrata below man, the union of broken bones is accompanied by a superabundance of 10 DISEASES OF THE BONES. the ossific material of repair, and that hence the union in these animals is accomplished with a deforming prominence of the callus at the seat of the fracture. But this apparent imperfec- tion in the process is so evidently in obedience to certain mechanical conditions of the injured part, connected with the impossibility of securing its absolute rest, that it should rather be regarded as an admirable illustration of adaptability to cir- cumstances of the reparative force, than any impugnment of the power and perfection of that force itself. 5. Disease. I have classed the liability to disease as one of the evidences of the high vital endowments of bone-tissue ; and while I am not prepared to maintain that there is in the capacity for varied and serious disease any direct indication of high organization, yet it must be acknowledged that, under our present dispensation of sorrow, such liability is in fact al- ways associated with those tissues, and, indeed, with those animals who hold the highest place in the scale of complex organization and varied function. Comparative pathology has not yet been studied so carefully as its importance in illustrat- ing human disease would seem to warrant, but enough has been learned to give us some valuable hints. Thus, as a general law, I think it may be stated that the reparative power in- creases as perfection and complexity of organization diminish. I know that this law is riot by any means uniform in its appli- cation to the different classes into which we divide the animal kingdom, but, for our present purpose, it is quite safe to accept it as a general fact that reparative power increases as we de- scend in the animal series, and that, while in the higher animals moderate injuries are often followed by fatal consequences, in the Mollusca and the Articulata we find species in which whole limbs may be reformed after detachment, and, in the Radiata, some that can reproduce an entire and perfect body out of each of the fragments to which accident or design may have re- duced it. This reparative force, thus readily called forth by injury, we may be pretty sure, I think, is also ever present as an antagonist to disease ; and that, by the ever-present virtue of this powerful controlling agency, disease in many of the lowest animals is either altogether prevented or is only allowed INTRODUCTION. 11 to assume its lowest, simplest, and least dangerous manifes- tations. Tims, I believe it might be maintained that the proneness to disease is in an inverse ratio to the reparative power, and that therefore the animals highest in the scale are those most likely to show varieties of severe and complicated disorder. The same principle seems to me applicable to the relative liability of the different tissues of the same individual. Those, for example, of the lowest class, enjoying a mere vegetative life, as tendon, aponenrosis, and cartilage, we find but rarely the subjects of disease, and, when diseased, their affections are commonly of the simplest character. Disintegration from the effects of inflammation is almost the only morbid process we know of in the tendon, and ulceration in its varied forms is the chief disease of cartilage. It is in the higher, more vascular, more actively living tissues, that the most varied, the most frequent, the most interesting, and in all respects the most important, morbid changes are observed to take place, the care- ful study of the minuter shades of which is the difficult and laborious task of the modern student of pathology. Among these higher tissues, bone, as we have seen, holds, by right of its elaborate vital provisions, a very high position, and this position it abundantly vindicates by the immense variety of the shades of its morbid actions, as well as the fre- quency and severity of its diseases. We shall find no morbid condition of the soft parts of which a counterpart may not be found in the bones, and few of the tissues present so large and varied a catalogue of diseases as this same apparently insensi- ble, and, to the careless eye, lowly-organized, bone-substance. It is liable to every form of nutritive change, as in hypertrophy and atrophy ; it is subject to its own peculiar constitutional disorders, as in rickets and malacosteon. It is prone to inflam- mation in all its forms, and illustrates most admirably its every variety and every grade, and at the same time sympathizes so keenly with every constitutional taint that a large chapter in the history of syphilis and scrofula must be taken from the behavior of these poisons toward the bones. Its softer por- tions are invaded by caries and tubercle, while every part is liable to the insidious 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 B O K" E CHAPTER I. HYPERTROPHY AND ATROPHY OF BONE. BONES, like the soft parts, are liable to hypertrophy from two classes of causes : 1. Those which are morbid in their action ; 2. Those which are unconnected with any appreci- able diseased condition. Of the morbid conditions of bone, terminating in an increase of their dimensions, we shall have very frequent occasion to speak hereafter, and we shall find it to be one of the commonest results of long-continued inflam- matory disease in all its forms ; so much so, that an expe- rienced eye can pronounce, with much accuracy, that chronic inflammation has existed in a bone, from an inspection only of its enlarged size an enlargement which, in the hypertrophy from disease, is usually accompanied with more or less distor- tion and deformity. 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 femur or the tibia, which, by its undue growth, makes such a disproportion between the length of the limbs that serious lameness is sometimes thus produced ; and it is always well for surgeons to take into account the possi- bility of such a condition in measuring the length of the two limbs, to clear up doubtful points of diagnosis. Such embar- rassment in the study of obscure cases is spoken of by several authors ; and in the New York Hospital an instance presented 14 DISEASES OF BONE. itself, where only the history of a previous elongation of the femur explained a discrepancy in the symptoms which we could not otherwise comprehend. Mr. Stanley speaks of several of these cases of simple hy- pertrophy where the affected bones had be- come curved, and Mr. Paget gives a curious instance from St. Bartholomew's Hospital Museum, where, the tibia having become hypertrophied while the fibula remained unchanged, the tibia had become curved outward in order to accommodate its in- crease to the unaltered fibula, to which it was tied by its ligamentous attachments above and below. Fig. 1, taken from Mr. Paget's work on " Surgical Pathology," gives a very good idea of the deformity. Hypertrophy of bone may, however, be the result of increase in the duty which a given bone is called on to perform. Of this compensatory hypertrophy the best example with which I am acquainted is shown in a specimen in the museum of the College of Physicians and Surgeons. The young lad from whom it was taken suffered from an acute necrosis of one of his tibiae, involv- ing almost the whole length of the shaft. For some reason, the reparative actions were very imperfect, and almost no involucrum was formed, so that, when the sequestrum became loose and was removed, no new bone replaced the loss ; and, though the wound healed, and he was able to go about, yet the tibia was represented, for several inches, by a mere fibrous band, in which but little bone-deposit could be de- tected, and which gave no support whatever to the limb. Under these circumstances, he was advised to use the limb as much as possible, which he did, and gradually found that it began to be stronger, so that before his death, which took place within two years of the operation, he could bear con- siderable weight upon it. The bones of both legs are pre- Fio. 1. (From Paget.) HYPERTROPHY AND ATROPHY OF BONE. 15 served, and show' the tibia of the diseased side replaced in its middle portion by a mere fibrous cord, with some nodules of bone continuous with the sound bone above and below, but not fused together in the middle ; so that the supporting power FIG. 2. (From New York Hospital Museum.) of the tibia is as completely abrogated as if it had suffered a fracture which had not united. The fibula of that side, how- ever, has undergone hypertrophy, most marked opposite the deficiency in the tibia, and so considerable that, on comparing it with its fellow of the opposite side, it is at least three times its superior in thickness and strength. A more perfect illus- tration of simple compensatory hypertrophy, and a more beau- tiful manifestation of the intelligent action of the laws of nu- tritive reparation, can hardly be found. (Fig. 2.) 16 DISEASES OF BOXE. Another form of hypertrophy of bone is that which affects the bones of the face, and is commonly spoken of as the ivory exostosis. It consists of a very dense and solid growth, which slowly involves the bones of one side of the face, more com- monly in the neighborhood of the orbit, and which gradually converts them into a tumor of great size, which projects from the surface of the face, and which encroaches on the cavi- ties of the nose, eye, antrum, and mouth, in such a way as to produce the most serious and sometimes the most dangerous deformity. A large number of cases of this curious form of hypertrophy have been collected by Mr. Heath, in his admi- rable essay on the " Injuries and Diseases of the Jaws." The disease is usually painless throughout its entire course, except where it inflicts pain by its encroachment, and it is unaccom- panied by any evidences of inflammatory action. It seems to affect adults of middle age, and is not traceable to any injury or connected 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 so much allied to the tumors which affect the bones of the face, that its more particular description may be conveniently reserved for a future chapter. Atrophy of bone most commonly presents itself as the consequence of long - continued disuse ; but several other causes sometimes produce it. Thus, Mr. Curling has shown that, in certain cases of fracture, where the injury involves the trunk of the nutritious artery, the fragment of bone which is deprived of its vascular supply from that source will some- times undergo a process of atrophy, and that in this way non- union is sometimes produced. Atrophy of bone is likewise seen in those cases of localized paralysis under which the whole limb wastes away, and in young children never attains its proper development. Disuse, however, may, I think, be said to be by far the most common cause of atrophy of bone ; and, inasmuch as a certain amount of diminished activity accom- panies the action of all other causes, it is difficult to prove that any one of them is sufficient to produce the condition without the assistance of some degree of diminished functional activity. Two forms of atrophy present themselves: one in which HYPERTROPHY AND ATROPHY OF BONE. 17 there is simply a diminution in the amount of bone mate- rial ; and one in which there is at the same time an exces- sive development of fat. These two forms correspond to the two conditions of atrophy met with in the soft parts ; and, while it is not possible to define precisely the circumstances under which each occurs, yet I think it would be correct to say that, generally, the simple atrophy is best seen in cases where the change takes place very gradually, and from simple disuse, while the fatty degeneration is most striking where the affection is somewhat acute in character, particularly if it be associated with some inflammatory action about the part dis- eased. Thus, the most striking example of simple atrophy that I have seen, is in a stump of a tibia, where the end of the limb below the knee had not been used for support for many years. Here the bone is rarefied, its cavities enlarged, its walls thinned ; but, in other respects, it is normal. On the other hand, the most marked instance of fatty change is in the bones of the leg of a lad upon whom Dr. Stevens performed exsection and wiring of the fragments of an ununited com- pound fracture. After giving the poor boy a long and faithful trial, the limb was amputated. The bones are small and light, and almost pliable, but they are so much imbued with fat that, though the specimen has been in the cabinet of the New York Hospital for about twenty-five years, it still, in warm weather, distils oil enough each season to destroy the varnish, and run down on the stand upon which the specimen is placed. The occurrence of atrophy from disuse has some important practical relations. First, a bone in a condition of progressive atrophy must be very liable to undergo other changes, in obe- dience to mechanical influences acting upon it. I have now under my care a lady who had rigidity and a vicious position of abduction of the hip-joint, following a delivery, accompanied by convulsions. 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 bone has taken place to a very marked extent. Similar changes we see in old luxations ; and in atrophied limbs, where unfavorable positions have been assumed, we see the bone be- 2 18 DISEASES OF BONE. coming absorbed under the influence of the pressure, or bent by the gradual action of the force exerted, to a degree which we would not expect in sound, healthy bone. But perhaps the most important practical deduction from the history of atrophy is that which inculcates extreme care in manipulations with bones which have long been disused. The fact that disuse for a few months, or even for a few weeks, will reduce the resisting power of bone, should never be forgotten, and was impressed upon my recollection, in the most emphatic but unpleasant manner, by the following case : Patrick Barry, aged forty-two, was admitted to the Xew York Hospital, October 23, 1854, with a dislocation of left femur, of seven weeks' standing. The symptoms were unequivocal, and the head of the bone could be felt on the dorsum of the ilium. The man was of good muscular development, but the limb was flabby and wasted from inaction. Attempts were made to re- duce it by Reid's method of manipulation, and, being unsuc- cessful, were abandoned for the ordinary method of Sir Astley Cooper. Extension was made by pulleys, and, while a strong movement of adduction was being made by my own hand, a crack was heard, and it immediately became evident that the neck of the femur had broken. On taking off the pulleys, the crepitus, the form, and all the symptoms, made the diagnosis clear. In the original minute of the case, the remark is made : " With regard to the fracture of the cervix, we were all sur- prised at the slight amount of force which was competent to produce such a mortifying accident." A similar accident oc- curred to one of my colleagues in attempting to reduce an old dislocation of the elbow-joint. While making extension, and at the same time trying to flex the forearm on the arm, the humerus gave way, and a very oblique fracture was found to have occurred about a hand's breadth above the joint. These unfortunate occurrences (and most surgeons have had a similar experience) should lead to the greatest care in using bones, which have long been disused, as levers in reducing displace- ments, remembering that great power is developed by the lever- action, and that the bone-tissue is not so strong to resist as it is in an unchanged bone. INFLAMMATION OF BONE. 19 CHAPTER II. INFLAMMATION OF BONE. THE process of inflammation in bone presents many modifi- cations, due to the peculiar structure in which it occurs. Its essential character is the same, however, and the laws which govern it in the soft parts are those which regulate it in the bones, due allowance being made for the density and intracta- bility of the tissue involved. As in the softer tissues, so in the bones, we may conveniently arrange our study of inflam- mation into divisions embracing the various effects of the morbid process, as shown at each stage of its progress ; for, while it is well understood that no absolute line separates one stage from another, and that one stage is constantly mingled with another during its progress, yet, for practical purposes, we shall recognize that each case assumes its importance from the prominence of one or more features which give it its in- dividual character, which features are those of some particular stage or effect of inflammation. Thus we may include under one head all those inflammations of bone which are attended with organization of the exuded products. A second class may embrace those in which the exudation goes on to purulent formation. A third will include all those cases in which ul- ceration and destruction of tissue by molecular disintegration take place, embracing most of the cases called caries ; and a last will embrace that large class in which death of tissue is the consequence of the inflammation, as in necrosis. Inflammation of Bone with Organization of the Inflam- matory Products. The cases coming under this head are, almost uniformly, of a chronic character, and of a moderate degree. Their causes are habitual exposure to wet and cold, injuries of moderate severity, and sometimes a constitutional vice, either acquired, as syphilis or scurvy, or original, as scrofula and its numerous allied taints of the blood. Their pathological anatomy seems to be a low grade of inflammation pervading a certain part or the whole of a bone, and which, 20 DISEASES OF BONE. after it has been fully developed, presents microscopical char- acters which have now been pretty thoroughly investigated. To the unaided eye, the bone is of distinctly pinkish or ruddy hue, usually in patches of irregular extent and shape, and dif- fering among themselves in depth of color. The compact tissue, as well as the spongy, shows this inflammatory redness, though, of course, in a less degree, and, when thus reddened by inflam- mation, has usually lost some of its apparent density. The periosteum and the medulla usually participate, in a marked degree, in this vascular change, as they do in all the morbid actions of bone. Indeed, writers are generally agreed that they are both of them intrinsic parts of bone, and that the study of their diseases cannot be and ought not to be dissociated from the diseases of the bone-tissue itself. Sometimes, it is true, the inflammatory actions are mainly confined to the periosteum, and more rarely to the medulla, but the neighbor- ing bone is always more or less implicated, and must necessa- rily be so, because its vessels are derived from, and form part of, the circulation of the membranes by which it is covered. After the inflammation has existed for some time, the bone begins to be enlarged, showing the addition of new bony mat- ter to its original substance. This enlargement shows itself in two principal ways : first, by increase of size, and, secondly, by increase of density two conditions which, though usually associated, are not by any means constantly so ; and hence, among the numerous specimens of inflamed bone which encum- ber every pathological museum, we find some which are merely enlarged, in all their dimensions, about the seat of inflamma- tion, without any manifest consolidation of tissue, and others where the bulk has not undergone any marked change, 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 Haversian canals. This takes place in obedi- ence to the requirements of the increasing vessels, for in a con- dition of health the canal is so nearly filled by the vessel which traverses it, that little or no enlargement of the latter can take place without some yielding of the former. So true is this, that it is believed by most pathologists that this impossibility, in INFLAMMATION OF BONE. 21 bone, of yielding to the pressure of a suddenly-increasing cir- culation, is one principal reason why acute inflammation of bone is so liable to produce necrosis. In more chronic and moderate attacks, there is time afforded for the bony canals to enlarge by absorption, and thus allow the gradual expansion of capillary vessels ; and hence there is usually little or no lia- bility to necrosis where the inflammatory process assumes this deliberate and sometimes extremely tedious course. Besides this enlargement of the Haversian canals, the lacunae also undergo a change both in size and shape, and the same is ob- served in the canaliculi. Mr. Barwell, in his admirable ac- count of these changes, says : " The lacunae have increased still more in size and breadth ; even those of the Haversian sys- tems are very broad, oval, or are rudely circular ; their interior, instead of remaining dark, has, as it were, opened out into a light space, marked by light-colored round spots, surrounded by dark lines, or vice versa^ according to the focus and direction of the light. Some of them are very granular ; others, more rare, are crowded with round, cell-like bodies, -forming a mul- berry mass, which appears to stand out above the bone-surface. The canaliculi, remaining large in number, have increased in size chiefly at their commencement in the lacuna, so that they appear to open into that space by a broad mouth like an estu- ary. They are throughout more marked than the normal tube ; they branch also in many instances into three or four channels, and, sometimes, at the spot whence these branches diverge, a considerable enlargement in the main trunk is perceptible, as if at that point a new lacuna were being formed. While these changes are going on in the lacunae and canaliculi, a change is also noticeable in the granular sub- stance of the bone-tissue itself. The granular character becomes more distinctly marked, as if a partial disintegra- tion were about to take place, and the bone were about to break up into its original particles. What is the precise mean, ing of this change, has not been, so far as I know, positively determined, but Mr. Follin does not hesitate to attribute the general granular appearance of an inflamed bone to an en- largement of the orifices of the canaliculi, such as has been above described, which, when the bone is macerated, gives a 22 DISEASES OF BONE. dotted or granular appearance of the surfaces on which they open. The further microscopical changes in inflamed bone are merely the more advanced stages of what has already been described; the bone-structure gradually disintegrates and dis- solves away, and this to an extent and in a manner which vary considerably, according to the characters of the inflam- mation and the tendency which it develops. Consequent, how- ever upon these merely destructive actions, we soon begin to see some attempts at reparation, and, in the moderate form of inflammation we are now studying, these actions soon assume the prominence. Into the natural cavities of the bone now enlarged by the processes we have been studying, we soon have poured out the plastic exudations which are the results of the inflammation, and which begin to show organization. This organization leads by a strong and almost unvarying ten- dency to the development into bone, so that we soon begin to find new bone deposited in all the vacancies and porosities of the old. By means of these two processes, the first one of ab- sorption, and the second one of deposit, 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 are 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. "When, on the other hand, the destruction is more than compensated by the deposit of new bone, then we have an expansion with consolidation of the inflamed bone, so that it becomes harder and heavier than natural. The enlargement of bone, with expansion or rarefaction of tissue, is the rarer of the two, though Mr. Stanley says, " I have learned that the simple swelling of bone, from expansion of its tissue, is one of the most frequent alterations to which it is liable." We have, in the cabinet of the ]STew York Hospital, a specimen which shows this condition in a remarkable degree. It consists of the bones 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 which the external lamina, the plates of the cancelli, indeed every INFLAMMATION OF BONE. 23 separate layer of bone, has become reduced down to the thin- nest possible dimensions ; so that, while every thing seems to be present that originally constituted the bone, yet it is so refined and so rarefied as to look as if some process of corrosion had been adopted which had begun to act upon the surfaces of the bone, but had been arrested before any lamina had been com- pletely destroyed. The weight of these bones cannot much exceed half of what it originally was. Some degree of this expansion is very commonly seen in the neighborhood of caries, and I suspect most often in those cases which depend on scrof- ula. FIG. 3. (From Billroth.) FIG. 4. s implicated. The other organs enumerated are less frequently the seat of this peculiar change. The pathological state seems to be one in which an infiltration of what Dr. Jenner calls an albuminoid exudation, throughout the substance of the organ, slowly takes place, much after the manner of infiltrated tubercle, which so RICKETS. 71 thoroughly incorporates itself with the substance of the affected tissue that its original texture is entirely lost, it assumes a fatty or waxy appearance, and loses, more or less completely, its functional power. After stating that the lymphatic glands thus affected are considerably enlarged, Dr. Jenner thus de- scribes their appearance : " The cut surface of the glands is singularly pale and transparent, compact, smooth, tolerably moist, and, to the unaided eye, uniform in appearance. The substance is tough, and the gland heavy in proportion to its size. In rare cases, instead of being pale, the glands may be purplish in color." Of the spleen he says: "It is increased in size : the increase may be either trifling or extreme. Thus I have seen it little larger than in health, and I have seen it measure as much as eight inches from above downward over its convex surface, and four inches from side to side. It is never adherent to the parts adjacent, as a spleen containing tubercles often is, and its capsule generally is scarcely, if at all, thickened. Its anterior border is pretty sharp ; it is firm to the touch, and smooth on the surface ; its weight, regard being had to its size, strikes one as considerable. The substance is tough but elastic, and the thinnest sections can be cut with facility. The cut surface is remarkably smooth and transparent. It is not unlike what one might suppose would be its appear- ance if the whole organ were infiltrated with glue. Only a little pale blood can be expressed from the cut surface. Usually, the organ is pale red, but occasionally it is dark purple. The more transparent any given part is, the paler it is ; the most transparent parts are almost colorless. The splenic corpuscles are sometimes more readily seen than in a healthy spleen ; they may be mistaken for gray tubercles. I have never seen in the spleen of rickety children the sago-like little masses, so often present in the spleens of those who die of phthisis." With this anatomical change in these organs, and very much in proportion to its extent, we have the constitutional cachexia becoming more marked and more distinctly progres- sive. Emaciation is sometimes extreme, muscular power grows gradually less and less, the derangements of digestion become more and more constant, and the little patient either wastes gradually away, or succumbs to the attack of bronchial or in- 72 DISEASES OF BONE. testinal inflammation, whose effects his weakened organization is not able to contend with. Dr. Jenner thinks that the most common cause of death in rickets is acute bronchitis, and explains its fatality by the imperfect action of the soft and yielding walls of the thorax. He also says what seems very astonishing, that to rickets is due, in London, directly or indi- rectly, a larger percentage of infantile mortality than can be credited to any other single disease. "With regard to the causes of rickets, nothing very positive has been ascertained. It is very certain that it prevails prin- cipally among the poor, though it is sometimes seen in the children of the rich. Its prevalence is certainly favored by bad hygienic surroundings, but the same may be said of every diathetic disease ; and why these unfavorable conditions should produce in one region rickets, and in another scrofula, as a preponderating disease among the infantile population, does not seem clear. It has been pretty distinctly shown that it is not hereditary, and yet, when one child in a family has the disease, those born afterward are extremely apt to show traces of it. Dr. Jenner thinks that the state of health of the mother has much to do with the occurrence of rickets in the children ; if she be feeble, delicate, ill nourished, and ill cared for, she will be much more likely to have rickets in her children than if she were strong and robust in her own health. Phthisis and rickets have no necessary connection. Statistics show that phthisical parents are no more liable to have rickety offspring than those who are not phthisical ; and it appears that scrofula, the twin-sister of tuberculosis, is not by any means commonly associated with rickets in the same individual. Bad food, bad air, bad clothing, bad habits of life, and exposure in short, all those circumstances which are generally combined in the miserable, crowded, filthy habitations of the poor, and which so manifestly affect the general mortality of the districts where these habitations are crowded together all these have an un- doubted influence in producing the disease ; and this is more practically interesting because it is in this direction that we must look for our principal means of controlling and curing it. In fact, the treatment of rickets, as such, is entirely unsatisfac- tory ; and the very natural idea, that, by supplying an excess RICKETS. 73 of earthy matter to the stomach, we should cure a disease char- acterized mainly by its deficiency, has not proved in practice to be well founded. Not only is there no specific for rickets, but there is no specific treatment. Every case must be studied by itself, and managed on the general principles of constitu- tional treatment. The first cares are hygienic. Improve as far as may be the home and the habits ; and, of these, none are so important as the habits with regard to food. The children of the poor are always fed improperly. Even with those who are industrious and thriving, and who, therefore, have the means of supplying a sufficiency of good food to their families, we constantly find the younger children, particularly the infants of from one to two years of age, fed on food too stimulating for their stomachs. There seems to be in the minds of these people a kind of pride in seeing their babies sitting at the table with them, and, even before they are weaned, partaking of the strong food which makes their parents' ordinary fare. It requires some time, much care, and some trouble, to prepare the milk-food which should be the principal food of every child under two years of age. From these two considerations arises the habit, almost universal, of giving the children what- ever they like to eat, and rather letting them feed themselves, than taking any pains to provide or prepare for them food such as shall be suitable for the digestive power of their tender stomachs. This is undoubtedly a common cause of disease among the poor. The strong bear it, while the feeble die under it. In rickets there is so marked a tendency to de- rangement of the digestive organs, that it would seem that the regulation of the food was a point of even more than usual importance, and its proper quantity and quality a prime sub- ject for the watchfulness of the physician. After the care of the food comes that of the air, the exercise, the clothing, the cleanliness, and the hundred other things which go toward the making of good blood and strong muscle. In the regulation of many of these points much can be done, for it must be remembered that a large proportion of the errors committed in these respects arise much more from ignorance and inatten- tion than from actual poverty. In regard to medication, the main indication is to improve 74 DISEASES OF BONE. nutrition. Tonics, such as iron, and cod-liver oil, are most commonly useful, and spoliative and depressing treatment, such as is usually called the antiphlogistic, is badly borne. Particular caution is required in managing the acute affections, which so frequently supervene in the course of rickets, that too much reduction of the powers of life be not produced by the very remedies we use to save it. Mercury and bloodlet- ting are both reprobated as dangerous by the best authorities, and the care of the practitioner should be to accomplish his ends with the mildest means compatible with success. Each case and each complication must be judged by itself, and treated both hygienically and medicinally, according to its own indications; but, in all, the one main fact must be constantly kept in view, that we are dealing with a diathetic disease, and one whose tendencies are all toward a feeble reaction, and a diminished reparative power. CHAPTER VII. MOLLITIES OSSIUM MALACOSTEON. A CERTAIN number of cases present themselves in the adult, in which a softening of the bones takes place somewhat like the softening of rickets, but in which the accompanying features do not warrant us in placing the disorder in that class. These cases are quite rare, and are scattered over the records as indi- vidual cases by single observers, few writers having had an opportunity of observing any number of them, and none, there- fore, having had that kind of experience which can only arise from a comparison of many examples of a givqn disease. From these recorded cases the general history of the disease may be gleaned, and yet, so considerable are the diversities of charac- ter among the individual cases, that it is difficult to present a clear picture of the affection, such as can be recognized by its own characteristics, and distinguished easily from other disor- ders to which it is closely related. The cases thus far observed have occurred in young or MOLLITIES OSSIUM MALACOSTEON. 75 middle-aged adults, a little more frequently among females than among males, and so often in connection with the puer- peral state as to warrant the opinion that this state is at least a strong predisposing cause of the disease. In a few instances it has seemed to be transmitted from parent to child. With these exceptions very little is known of the cause of the dis- ease. The changes that take place in the bone seem to vary con- siderably, both in their nature and in their extent, in different cases. In all, however, a gradual diminution, and in some an entire disappearance of the earthy salts of .the bone, takes place ; a change upon which, of course, the main features of the dis- ease depend. This change takes place gradually, and invades more or less completely all the bones of the skeleton. In some cases this loss of the earthy constituents seems to be almost the only change which takes place, the remaining animal sub- stance not having undergone any very marked alteration. In other, and much the larger number of instances, marked de- generation of all the component elements of the bone-tissue is found. Thus the original structures 'are often replaced by fat or free oil, and this is so common a feature that Mr. Paget is inclined to regard the affection as essentially a fatty degenera- tion. This fatty change involves the whole bony substance, and, when excessive, converts the bone into a bag of soft, oily substance, enclosed in the periosteum, which itself may not be materially altered from the healthy condition. That it is not a fatty degeneration in all cases, however, is shown by certain examples where the replacing material is of a gelatinous nature and presents few or no traces of fat, and certain others where the amount of fat in the bone does not vary from its normal proportion. The change in the bone sometimes involves the compact and the .cancellous structures equally in its progress, and when this is the case there is a gradual diminution of the firmness of its texture, which permits it to bend instead of sus- taining mechanical force. This flexile condition of bone is sometimes found to the most marvellous degree, and in all the bones of the skeleton, and it seems to depend for its produc- tion upon the evenness of the process in all parts of the bone at once. Sometimes, however, it happens that the central can- 76 DISEASES OF BONE. cellous portions are far advanced in the degenerative changes, while the external compact shell, yielding more slowly, is only thinned and weakened, but not yet disorganized. In this con- dition the bone does not bend so readily as it breaks, and we have produced sometimes one and sometimes many fractures, arising from so slight a force as almost to seem spontaneous. The microscopic study of the altered bone shows so very different appearances in different cases that it can hardly be said that any thing distinctive has been discovered which char- acterizes osteomalacia as contrasted with rickets. Still the general features of this disease, as displayed by the microscope, are not the same as those of rickets. Follin says : " The alter- ations in this case are very different from those which are es- tablished as belonging to the rickets of children. Thus, in the osseous layers of recent formation, we find an alteration in the bone-corpuscles, which have become elongated, fusiform, and without regular borders, and have taken on the character of the elements of fibrous tissue. More deeply we observe bone- cells which have become irregular, enlarged, with shining out- line, and with a disappearance of their canaliculi ; they con- tain sometimes small drops of oil, and sometimes granulations grouped together. The fundamental substance of the bone presents an infiltration of fatty granulations, which impairs its transparency and gradually invades the surrounding parts. The Haversian canals are also infiltrated. Thus, when we examine by the microscope a section of one of these Haversian canals, we see in the centre a darkish part formed by a mass of blood- globules, and around this mass a cavity with distinct borders, filled with little drops of oil, with fatty granulations, and with marrow-cells in process of formation. In the medullary tissue we find hypertrophy of the marrow-cells and an increase in their number, as is also the case with the fatty cells." Mr. Dalrymple, in a case which he examined, found some peculiar caudate cells, which induced him to regard the disease as ma- lignant in its essential characters, and other observers have given accounts varying in many points from those given above. It would seem, therefore, that the microscopical appearances vary with the other peculiarities of each case, and that thus far no features can be said to be absolutely characteristic. MOLLITIES OSSIUM MALACOSTEON. 77 The symptoms of this disease seem to be more uniform than the pathological appearances. In the earlier stages, the pa- tients complain of vague, wandering pains, at first not severe, increased very much by exercise, and accompanied by a distressing sense of weariness, which is but little relieved by rest. These pains are sometimes periodical, and often accom- panied, particularly after exercise, with severe cramps. Writers speak also of a tenderness and soreness to the touch which much aggravates the sufferings of the patient. As these symp- toms advance, the general state of the patient deteriorates. He becomes feeble, emaciates, and begins to have irregular fever, followed by very copious and exhausting sweats. The digestive power begins to fail, a change very much hastened by the condition of the teeth, which soon become so loose in their sockets, from the softening of the alveolar processes, that they either drop out, or give infinite inconvenience and dis- comfort in the attempt to masticate. Of course, when the softening of the thorax has reached an extreme degree, the function of respiration must be imperfectly performed, and an- other serious embarrassment is added to the load already press- ing so heavily on the powers of life. The termination of much the largest number of cases is fatal, after a longer or shorter course of suffering ; but a certain number of recoveries are re- ported by various authors, and in particular Naegele cites a case in which the Caesarean section was performed on a woman whose pelvis was so deformed by an attack of osteomalacia that natural delivery was impossible. Other recoveries are also spoken of, in which the deformities produced by the softened state of the bone remained permanently impressed upon them. During the course of this disease, the most striking symptoms are due to the mechanical results of the yielding of the soft- ened bones. The lower extremities are bent and twisted in the most remarkable manner, and, after the patients are bedrid, the upper extremities, upon which they now have to depend for movements of all kinds, begin also to be distorted. The cranial vault sometimes undergoes a change, being either flat- tened by compression, or rounded by the weight of the brain ; but these changes are pronounced to be very rare. The spine is deformed mainly by an increase of its natural curves, and 78 DISEASES OF BONE. the changes in the thorax are clue mainly to the position of the patient in the bed. If he lie constantly on his back, the an- tero-posterior diameters are diminished, and the chest-cavity becomes broader laterally and shallower from before backward. If, on the other hand, he lie habitually on his side, the change in the form of the chest becomes marked by an antero-poste- rior increase, and a lateral diminution in diameters, together with such other deformity as the twisted position of the spine may impress upon it. In the pelvis, these changes are very marked, and have been particularly studied. We have al- ready seen how the form of the pelvis is affected by rickets. In malacosteon, the deformity presents features so different that writers contend that the disease can be distinguished by the deformity ; rickets exercising its effects mainly by a dimi- nution of the antero-posterior diameters, while osteomalacia usually produces a contraction of the pelvic circles in a lateral direction. This distinction, however, is not to be relied on too implicitly, for several authors speak of cases in which rickets produced a lateral deformity precisely similar to that ordinarily resulting from osteomalacia. The general fact, however, re- mains, that in malacosteon the deformity is produced by the yielding of the sides of the pelvis. Dr. Tyler Smith thus sums up these changes : " The general effects produced in malacos- teon are : narrowing of all the diameters of the pelvis, but es- pecially of the transverse, whether of the brim, cavity, or out- let. The antero-posterior diameter of the brim, or rather, the distance from the promontory of the sacrum 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 ; the tuberosities of the ischia are approximated ; the sacrum is very much incurvated, and the acetabula are much closer together than in the normal pel- vis ; 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 oblique furrow, running from above downward." Dr. Matthews Duncan, in a paper published in the Edinburgh Monthly Journal for April, 1855, has very carefully compared these deformities with one another, and gives a series of in- genious diagrams, by which he illustrates, by accurate measure- MOLLITIES OSSIUM MALACOSTEON. 79 ment, the difference produced on the absolute and relative diameters by the two diseases. His demonstrations are very full and clear, and minutely establish the difference in the effect of the two diseases on the form of the pelvis a difference, the general features of which are sufficiently expressed in the state- ments made above. The urine, in malacosteon, has sometimes presented marked alterations in quality and appearance, and several of the ear- liest writers have recorded cases where it deposited a copious sediment of a white, chalk-like substance, sometimes described as a mortar-like material on cooling, or after evaporation. Later and more thorough observations have shown this sub- stance to be mainly phosphate of lime, and the idea was natu- rally suggested that this might, therefore, throw some light on the pathology of the disease ; the waste of the bone-earths through the kidneys explaining very satisfactorily their disap- pearance from the bones where they properly belong. This renal view of the pathology of malacosteon, though so promis- ing, has not borne the test of larger experience; and it is found that, in a certain proportion of the cases, there is at no time any change in the urine which will in anyway correspond to the changes in the bones ; in fact, that there is, in some cases, no deviation whatever from the healthy constitution and ap- pearance of the renal secretion. Still, though the urine may not have supplied a key to the real pathology of malacosteon, its changes in this disease are certainly worthy of careful con- sideration, and we can hardly regard as merely accidental, phenomena which present themselves in certainly the larger proportion of cases thus far recorded. Besides the more nu- merous cases in which an excess of phosphates has been found in the urine, there are some where other substances have been discovered which did not belong to its healthy condition. Thus Mr. Dalrymple reports a case on which Dr. Bence Jones made some observations in the " Philosophical Transactions," vol. Ixvi., in which he shows that the peculiar matter in the urine which Mr. Dalrymple had described was, in fact, a deutoxide of albumen, combined with water so as to form a hydrate. Dr. Jones says : " There was as much of this peculiar albuminous substance in the urine as there is of ordinary albumen in the 80 DISEASES OF BONE. blood. So far, then, as the albumen is concerned, each ounce of urine passed was equivalent to an ounce of blood lost. The peculiar characteristic of this hydrated deutoxide of albumen was its solubility in boiling water, and the precipitate with nitric acid being dissolved by heat, and reformed when cold, by this reaction, a similar substance in small quantities may be detected in pus, and in the secretion from the vesiculae semi- nales. This substance must be again looked for in acute cases of mollities ossium. The reddening of the urine on the addi- tion of nitric acid might, perhaps, lead to the rediscovery of it. When found, the presence of chlorine in the urine (of which there was a suspicion in the above case) should be a special sub- ject of investigation, as it may lead not only to the explanation of the formation of this substance, but to the comprehension of the nature of the disease which affects the bones." Mr. Erichsen refers to the analysis of the urine, in a case of Dr. Mclntyre's, published in the " Medico-Chirurgical Transac- tions," vol. xxxiii., in which an animal substance, differing in most of its chemical reactions from albumen, was found in the urine in great abundance. In illustration of the general features and course of this singular disease, I add a sketch of the famous case of Madame Supiot, one of the most remarkable, and probably the best known, of any on record : Elizabeth Querian afterward Supiot came under obser- vation in the year 1752. She was then thirty-six years of age. She had had three children and one miscarriage, without any serious accident. She had twice had falls, which produced more than usual swelling and lameness of the limb injured, but no fracture. She had had, however, much aching pain in her extremities, and of late had not been able to sustain her- self on her feet without suffering. She had now been bedrid from this cause about two years. About a year before that is, in 1751 she had commenced to observe a milky sediment in the urine, and about the same time the bones began to show some evidences of softening, and the legs to assume a distorted position from the retraction of the muscles. This was accompanied by a very great increase of the pains in the limbs, which at times were intolerable. At first sight, the MOLLITIES OSSIUM MALACOSTEON. Rl woman, as she lay in bed, seemed to have neither feet nor legs nor hands. It seemed that the body terminated at the pubis. The thigh-bone had curved so as to allow the foot and the leg to turn up by the side of the body, so that the left leg inclined to be under the back, and she could on this side lay her head on her foot. The right thigh-bone was similarly bent, and the whole extremity drawn forcibly against the right side of the body. The patient could not move herself in bed. Defecation and urination were not interfered with. This violent separa- tion and twisting of the thighs, however, caused sufficient pressure on the crural vessels to interfere in some degree with their free circulation of the blood, and consequently some oedematous swelling of both limbs existed. The thorax, sink- ing down at certain points upon the lungs, interfered with res- piration, and at times she spat some blood. The upper part of the sternum was prominent, the lower part sunken in. The clavicles were more than usually prominent at their sternal ex- tremity. The humerus was curved about its middle from with- in outward, as well as the forearm, so that the middle part of the right arm was habitually applied against the internal mal- leolus of that side, while the middle of the left arm rested on the upper part of the tibia, just below the patella. She could make 110 use whatever of her limbs, being able to move only her head and the left arm. She could also separate some of her fingers 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 gums swollen and ulcerated. When an attack of pain 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 very distress- ing itching. Her menstruation was regular, but was exceed- ingly apt to be accompanied by very serious exaggeration of her other disorders and sufferings. 82 DISEASES OF BONE. CHAPTEK VIII. FRAGILITA8 OSSITTM. A WEAKENING of the texture of the bones, rendering them more than usually liable to be broken from slight causes, is found to occur in the course of several very different diseases of the bone-tissue. Thus we have seen that certain conditions of malacosteon present great fragility of the bones, while it is well known that carcinomatous infiltration will sometimes so weaken them that fracture occurs on the slightest possible prov- ocation. Several instances are recorded where, both in mala- costeon, and in cancer, the thigh-bone has snapped asunder from turning in bed, and the arm-bone from an attempt to raise the body in bed on the elbow. But, besides these cases, there are certain individuals in whom, with all the evidences of good health, we have a degree of brittleness of the bones which exposes them in a remarkable degree to the occurrence of fracture, and in whom fractures take place from the most trivial causes. I had under my care, some years ago, a gentle- man, then in middle life, who had from various accidents seven times fractured one or both bones of the forearm, and on one of these occasions the fracture was produced by somewhat too cordial a shake of the hand. This gentleman was rather slender in his formation, with small hands and feet, and delicate limbs, but was always a healthy and active man, and the father of a large family of well-formed children, none of whom pre- sented any trace of this peculiarity of their parent. A gentle- man of our profession, who has practised many years in this city, has twice fractured his leg by a slight stumble in passing along the street. He also has the slight frame and delicate formation which characterize the female, bat Ii3 was, at the time of receiving his injuries, in excellent health. He has since suffered severely from rheumatism. Mr. Stanley alludes to a case under the care of Mr. Arnott, in the Middlesex Hos- pital, where, " in a female, aged fourteen, the first fracture -occurred at the age of three years ; altogether there were FRAGILITAS OSSIUM. 83 thirty-one fractures in different bones, and in some of them the fracture was many times repeated. Many of the fractures occurred from the slightest effort, and there was no difficulty in obtaining their union. In a sister of this patient, six years of age, there was the same condition of the bones, favoring the occurrence of fractures. She had suffered nine fractures since the age of eight months." Other writers speak of this peculiarity as belonging to several members of the same family, and there are certain cases in which its hereditary character is unquestionable. An instance is mentioned by Dr. Pauli, of Leipsic, in which, for three generations, certain individuals of a family have suffered from extraordinary fragility of the bones. These cases are such as appear to be unconnected with any disease of the bone, or any constitutional disorder, the patient enjoying a good degree of health, and capable, ordinarily, of fulfilling the duties of life in a satisfactory manner. There are others, however, in which some symptoms precede the con- dition of fragility, and these symptoms are generally rather vaguely spoken of as chronic rheumatism. Thus Mr. Stanley reports the case of a woman, aged twenty-six, who was admit- ted into St. Bartholomew's Hospital, with a fracture of the left femur. " She stated that she had suffered rheumatism in this limb, and that, three days previously, the fracture occurred as she was crossing a road. She was placed on her back, with a straight splint on the outside of the limb. When she had been in the hospital about two months, while lying perfectly quiet in bed, she suddenly cried out that she felt a severe pain in the other thigh, and that the bone had broken. The house-surgeon happening to be in the ward, found the right femur fractured in its centre. At subsequent and distant periods, while con- fined in bed, a second fracture of the left femur occurred, a little above the knee, and fractures of both tibiae, immediately below their tuberosities. She remained in the hospital above two years, during which every effort was made to obtain the union of the fractures. Throughout her general health was unimpaired, the appetite good, bowels regular, and the urine perfectly natural. At the expiration of two years from the occurrence of the first fracture, the patient left the hospital, 84 DISEASES OF BONE. both lower limbs being powerless, and, when moved, severely painful. None of the fractures had united, arid both limbs were shortened to the extent of several inches, with consider- able distortion." In another case mentioned by Mr. Stanley, the symptoms were very similar, excepting that the patient's health gradually broke down, and she suffered constantly witli general weariness and aching in the bones. She died about four months after the first fracture. " A portion of the re- cently-fractured femur exhibits a thinning of its walls from the absorption of its inner laminae, but without softening of its texture ; it retains the hardness of healthy bone." A man was received into the New York Hospital a few years ago who had received a fracture of the clavicle from a very trivial cause. He told us that he had been suffering for some weeks with rheumatic pain, and great tenderness about the bone, for which he could give no explanation. His general health was good, and he had no syphilitic history. The bone was found broken near its middle, and was exceedingly sensitive to the touch. This was not confined to the point of fracture, but extended along the whole clavicle, which was manifestly thickened through all its middle portions. The limb was dressed in the usual way, and the only uncommon feature noticed during the progress of the cure was that an unusual amount of bony matter seemed to be thrown out, forming apparently a thick ferule of callus around the fractured ends. He was put upon the use of full doses of the iodide of potassium, and, when he left the hospital, the fracture was united, but the bone re- mained considerably enlarged, and, very tender upon pressure. "With regard to the result of fracture in these cases of fra- gility of the bones, it seems to be different in the two classes of cases. In those where no disease exists, and where, there- fore, the pathology of the case may be considered to be a mere delicacy and slenderness of construction of the bone, it seems to be generally conceded that we may hope 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 patients being reported as having much less suf- fering and trouble during the union of their fractures than oc- cur in ordinary cases. In many of the cases, however, when TUBERCULAR DISEASE OF BONE. 85 the rheumatic pains, showing diseased action about the bones, had existed in a marked degree and for a considerable period of time, the sufferings inflicted by the fracture were very great, and the union slow or imperfect, sometimes failing alto- gether, and in some instances inducing so much constitutional irritation as finally to wear out the powers of life. The prog- nosis, therefore, seems to depend more upon the sound condi- tion of the bone at the time of fracture, than upon the degree of mere fragility. With regard to treatment, it would hardly seem probable that what may be regarded as a mere peculiarity, such as ob- tains in simple fragility, could be influenced in any important degree by medicines or regimen. Still, I can conceive, in cases where the peculiarity shows itself in early life, that, by a robust regimen, and careful attention to all the details of hygiene, something may be done to strengthen slender bones as well as to improve a slender constitution. In those cases where some inflammatory action has given rise to the pains called rheu- matic, of which some of these patients complain for a long period before the first fracture, I am in hopes the iodide of potassium may prove of benefit ; though my own experience is limited to the case mentioned above, and in that the result was not very definite. Finally, I fear there are a number of cases where the disease is general, where it is severe, and par- ticularly where it has been long continued, in which nothing can be accomplished but the palliation of suffering. CHAPTEE IX. TUBERCULAR DISEASE OF BONE. THAT true tubercle may exist in bone, I believe is denied by few pathologists ; that it is a common affection of bone, is denied by many of the most eminent. In the earlier days of the revival of pathological anatomy, before the microscope had revealed its immense multitude of facts, leading us to recon- sider and to change all our generalizations on the nature of 86 DISEASES OF BONE. morbid products, pathologists easily found tubercle in bone, and gave it a prominent position in bone pathology. Nelaton took the lead in this department of study, and his chapters on tubercle in bone were among the earliest, and have ever since been recognized as among the best of the publications on this subject. He accepts and describes every form of tubercle from the minute gray granulation up to the most ^extensive infiltra- tion of crude yellow tubercle, and has no hesitation in bring- ing them all under the tubercular category. Later writers, among whom is Mr. Barwell, whose careful and conscientious studies entitle his opinions to great weight, have been disposed to limit very much the use of the term tubercle to those in- stances in which the normal history of tubercle can be dis- tinctly made out in all its stages, and to exclude from the list a large number of those aifections 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 soft parts of the body, where the difficult problems of structure are so much more easily unrav- elled than they can be in the hard and unmanageable tissue of the bones, we can easily find reason for being particularly cautious in pronouncing a judgment on changes which we can- not always satisfactorily appreciate, a judgment which there- fore we are apt to found upon imperfect analogies rather than upon careful observations. It is acknowledged by all that there is here a debatable land, in which it is impossible to decide on each individual instance as belonging either to one category or the other, and it is therefore eminently wise not by any violent generalization to throw all cases under either head, reserving opinions as to the tuberculous or non-tuberculous nature of the various deposits, until our knowledge shall be more extensive, or at least more accurate. "With these reservations we may say that tubercle in bone presents itself under the two forms usually described, of gray granulation 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 unequivocal, and there- fore, in settling the question of tubercle in bone, it has been TUBERCULAR DISEASE OF BOXE. 87 sought for with particular anxiety. It is in this search that the hardness of the bone-substance interposes such great diffi- culties, and it is only by the most tedious and careful dissection that we can arrive at any clear view of the pathological condi- tions we are studying. Nelaton, however, persevering in his investigations, claims to have several times succeeded in de- monstrating the presence of the gray granulation. He says, in describing one of his dissections : " In the centre of the spongy tissue which occupies the base of the great trochanter was found a mass, of six or seven lines in extent in all directions, formed by the aggregation of small pearly granulations, of a half a line in diameter, and of an opaline-white color. Many of these granulations, and particularly those M r hich were placed near the periphery, were surrounded by a little osseous shell, so thin and transparent that at first sight it could not be recog- nized ; in fact, its presence could only be demonstrated by the resistance it offered to any attempt to pierce it with the point of a needle. Some of these granulations presented, in their centre, a yellow opaque point, evidently the indication of com- mencing transformation." This seems a distinct observation of the gray granulation, and there are several others on record. The crude form of tubercle, or that in which larger masses of the opaque yellow material are found variously disseminated through the bone, is not only more easily recognizable, but is much the more common form of the deposit in the bone-tissue. Both these forms of tubercle are usually found in masses more or less isolated ; often so distinctly separated from the surround- ing tissues that some authors have described them as encysted. Both forms are recognized in the soft parts, and particularly in the lungs, as sometimes assuming the character of infiltrations, and undoubtedly the same is true in bone ; but it must be ac- knowledged that, for the gray, transparent form, the demon- stration in bone must be difficult and uncertain. Nelaton, with his usual careful minuteness, describes this infiltration, and gives a case most particularly and thoroughly studied out, in which this infiltration existed at a number of points in the sacrum and pubis. The case seems a clear one, but the want of microscopic examinations must always cause it to be received with some doubt as to its real nature. 88 DISEASES OF BONE. The crude yellow tubercle is not uncommonly infiltrated through the spongy substance of the bone. The normal tissue does not seem to be displaced by the deposit ; simply its inter- stices are occupied by it, and its cavities filled up by it. Some- times the deposit is firm and solid, sometimes softer and cheesy in its consistence, and sometimes it is not easy to pronounce whether we have under view an infiltration of soft tubercle, or of inspissated lymph. In its microscopic characters, the tuber- cle of bone has no different features from those of tubercle elsewhere, and, in its behavior after it is deposited in the tis- sues, it obeys the same laws and goes through the same trans- formations as in the lungs or in the lymphatic glands. Clini- cally, these changes have some peculiarities impressed upon them by the peculiarities of the tissue in which they are devel- oped, but, in all essential particulars, tubercle in bone presents the same history as tubercle in the soft parts. The first change noticed is that by which the gray tubercle changes to the yel- low. This change commences in the central parts of the tu- bercle, and gradually proceeds until the whole is transformed. While this process is going on, we usually have an increase in number and size of the deposits, so that, when the change is completed, we have large crude tubercles replacing what were at first small and scattered gray granulations. That this change does occur, most of the best authorities agree ; but, that it is the invariable law of progress, is more than doubtful. That some gray granulations, by aggregation and the yellow change, become crude yellow tubercle, may be considered as certain ; but it is equally certain that many, and perhaps most, of the crude tubercles we encounter, have never had 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 softening (Fig. 10). This change also commences in the centre, and spreads to the circumference. While it is going on, in- flammatory action begins to be developed in the surround- ing soft parts, the products of which, mingling with the soft- ening tubercle, favor its disintegration ; while, being retained, they add to the local irritation. Soon, a process of ulceration begins, and the cancellous tissue slowly breaks down, forming TUBERCULAR DISEASE OF BONE. irregular cavities, which at first contain, mingled together, the substance of the softened tubercle and the purulent results of the surrounding inflammation. The rate at which the changes go on is very vari- ous. In the circumscribed tu- bercles it is said to be more slug- gish than in the infiltrated form, and again, the harder deposits change more slowly than those originally of a softer consistence. In all cases, a wider and wider area is involved, and the disease finally makes its way to the outer compact shell, which, either by a process of necrosis, or by a con- tinuation of the process of ulcer- ation, is finally perforated, and the matter comes in contact with the soft parts surrounding the diseased region of bone. These have been already involved more or less in the inflammatory ac- tions which, for so long a time, have been going on in the bone, and they are ready to contribute their share to the mixed, semi- fluid mass which is struggling slowly toward the surface ; and thus we have formed the tubercular abscess, which finally opens on the integument, and discharges a fluid composed of softened tubercle, mingled with the pus derived from the inflamed tis- sues which have been traversed, and also the detritus of these tissues as they have yielded to ulceration and molecular disin- tegration. From this point the changes vary in different cases. Sometimes this seems to be the termination of the tubercular action, and reparative dispositions begin to show themselves as soon as the evacuation of the morbid products is completed. Healthy granulation begins, the cavities in the bone and the soft parts are gradually filled up, and a perfect cicatrization terminates the disease. This favorable behavior is, however, the rare exception, and, though ultimately we may hope, in per- FIG. 10. {From Billroth.) 90 DISEASES OF BONE. haps a large number of cases, that a cure will take place, it is not commonly realized without a period of protracted local disease, which gives to the tubercular morbid processes their peculiar character of obstinacy and of danger. These traits they well deserve, and are exemplified in two ways : First, we may have in the tissues, immediately surrounding the original focus of disease, a new deposit of tubercular matter. This is now usually of the crude yellow variety, and of the softer form. It is more commonly infiltrated in the surrounding tissues, bringing larger and larger districts under its baneful influence, and going through the same destructive processes above de- scribed, the whole series of changes being repeated indefinite- ly, until the local ravages and the constitutional cachexia to- gether bring either limb or life into a hopeless condition. Secondly, even if true tubercular deposits can no longer be found to take place, we constantly have the ulcerative actions slowly going on, forming new excavations, reaching into new regions, keeping up foul and profuse discharges, and, in short, presenting all the well-known and much-dreaded features of tubercular caries, so hopeless in treatment, and so fatal to the joint upon which it is slowly making its destructive invasion. Through all their course these changes are slow and deliberate, characterized by acute inflammation only as an occasional ac- cident, and accompanied by a condition of the general system of which the local behavior is merely the expression, and which in its turn is constantly deteriorating from the irritation re- flected upon it from the local disease. The suppuration which accompanies this process presents often some peculiar features. Sometimes the amount of pus formed is very small, never collecting into abscesses, but, re- maining infiltrated among the degenerating tissues, seems to take no further active part in the process. Thus we have not unfrequently extensive tuberculous destruction of the bodies of the vertebrae, and yet no abscess may ever make its appear- ance. 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, so rapidly that no accumulation could take place, and it is well known that these cases often go through their whole course, and arrive finally at a complete cure, without the for- TUBERCULAR DISEASE OF BONE. 91 mation (certainly without the appearance) of any abscess what- ever. But, though extensive tubercular disease may thus oc- casionally exist without the formation of distinct abscess, yet the general fact is that, some time during the course of the dis- ease, abscesses do form, and it is their course and behavior which give their peculiar character to all the later stages of the affection. Sometimes these abscesses slowly reach a certain size, and then seem to remain stationary, and even to retro- grade. Such are occasionally seen on the front of the dorsal vertebrae, where caries is arrested and a cure beginning. Some- times forming slowly, they grow out from the diseased point, and receiving from the tissues around them very firm walls, they gradually extend in various directions, and, with curious, fantastic shapes, insinuate themselves between and among the muscles and the bones and the organs, until they reach into regions perhaps far distant from their point of origin, " and hang like huge leeches," as Nelaton expresses it, " on the sides of the vertebral column." He gives a drawing of a specimen in which these bags have been dissected out from the surround- ing tissues and left hanging from their points of attachment, and their appearance as thus seen certainly justifies his simile. But again, without appropriating to itself any such distinct sac, the matter may gradually push its way, without inflamma- tion, without pain, often without any symptom marking its travels, until it comes to the surface at a^point far distant from its source. This is most familiarly illustrated in the psoas ab- scess, accompanying disease of the bodies of the dorsal verte- brae ; and there are on record numerous examples where the pus has wandered to the most wonderful distances, and showed itself in the most extraordinary situations. The ordinary course of psoas abscess is very slow and very painless, and often it happens that the matter announces its presence by a fluctuating tumor below Poupart's ligament, while its course along the sheath of the muscle has not been attended with suf- ficient inflammatory action to give rise to any pain or tender- ness that might serve as a warning of the mischief that was in progress. In these cases there seems to be a mere burrowing of the matter along the areolar interstices, almost without lim- iting inflammatory deposit, and therefore without the distinct, 92 DISEASES OF BOXE. firm, and well-developed cyst which in other cases encloses the pus, and very much restrains its distant wanderings. A somewhat similar history may be given of the abscesses which form in connection with tubercular caries of the joints. Some- times they form with ranch evidence of inflammatory activity, break early, and discharge good healthy pus, and soon put on a reparative aspect, which may result in their prompt healing. Often, however (and this is particularly the case with the hip- joint), they form slowly and travel quietly to a considerable distance along the intermuscular spaces, and then bulge out, forming a painless, cold, fluctuating tumor, whose only vital activity during months, and even years, may be displayed in a gradual and often extremely slow increase in size. This con- cealed suppuration, escaping our notice during the earlier part of the disease, sometimes adds suddenly to the gravity, both of our prognosis and of our diagnosis, and the possibility of its latent existence should always be recognized and carefully watched. After opening, these abscesses usually continue to behave as their previous demeanor would lead us to expect. The cav- ities show but little elasticity or tendency to contract, and it is only after a long time that the abscess contracts into a proper fistula, and, even when this has occurred, we are never quite sure that some deeper parts of the original cavity may not remain uncontracted, and may yet be burrowing in some new direction, to surprise us with a new opening in some distant spot. The fistulse thus formed discharge a matter which varies in its quality according to the condition of the diseased bone on which they depend. It is very apt to present the appear- ances characteristic of caries in its ordinary forms. It is thin, sometimes curdy, often acrid, excoriating to the surface over which it flows, and particularly, if the tubercular caries be in active progress, it is fetid. The further clinical history of these abscesses depends on the course of the disease of which they are symptomatic. If this be healing, the abscesses will also gradually heal, leaving deep-seamed and purple-colored scars, usually adherent to the bones over which they have been situ- ated, apt to reulcerate from trifling causes, and only after many months becoming sound and white, and free from tenderness. TUBERCULAR DISEASE OF BONE. 93 The tendency of these scars to contract in every direction was strikingly shown in the case of a young girl, who recovered from what seemed to be a case of strumous disease, probably tuberculous, of the hip-joint, during the course of which, many abscesses formed, leaving many sinuses running from the dis- eased joint, and opening at various points on the surface. After all the sores healed, and her health became reestablished, she grew fat. The scars of the healed sinuses had contracted down so firmly as to make deep fossae at the point where each of them presented at the surface, and the wall of fat round each of them gave them the appearance of a very deep umbili- cus, at the bottom of which was the scar. These, scattered, to the number of six or seven, over the buttock and hip, gave it a most extraordinary appearance. If, on the other hand, the disease of bone, on which the abscess primarily depends, be progressive or even stationary, the abscesses remain, sometimes the source of a good deal of irritation and annoyance, and sometimes so quiescent that the patient has no care for them except the daily dressing they require. As a general rule, their further history and course are intimately associated with the primary bone-disease, though occasionally it will happen that, as said above, they will show a disposition to accumulate the pus in some of their irregular cavities, which pus, thus pre- vented from a ready outflow, sometimes burrows silently and extensively into regions where we do not expect to find it. The disease thus described is most frequently found to affect the cancellous rather than the hard portion of the bones, such as the vertebral bodies, the carpus, the tarsus, and the articular extremities of the long bones. Mr. Paget makes the important observation that, " when it affects bones that are arranged in a group or series, it is usually found in many of them at once. Thus several vertebrae, or several carpal or tar- sal bones, are commonly at the same time tuberculous ; yet not often so equally but that one of them appears first and chiefly diseased ; while, in those gradually more distant from it on either side, the tuberculous deposits are gradually less abun- dant. In like manner, the parts of bones that act together in a joint are, usually, at the same time tuberculous." The treatment of tuberculous disease of the bones is, as far 94 DISEASES OF BONE. as its constitutional character is concerned, no different from the treatment of tuberculous disease elsewhere, and it seems scarcely worth while to repeat here what has been so well said by systematic writers on tuberculosis. The local management, however, presents many features of individual importance, and demands our most careful study. So much of this local treat- ment depends more on the eifects than on the nature of the affection, and so much of it is included in the history of the treatment of caries, in its various forms, that I reserve all that I have to say on the subject till we have discussed the latter disease, to which nearly all the cases of tuberculosis are so naturally related. CHAPTER X. CAKIES. CAEIES is a condition of bone in which suppuration and ulceration are combined, but in a proportion so varying that it has been found somewhat difficult to give a concise definition of the disease. Different authors, looking at the prominence of one or the other of these processes, have described it either as a suppuration or an ulceration, as one or other action seemed to them most important, and hence, perhaps, there is no disease in which there is more apparent discrepancy of view and of statement than in this. "Without attempting, therefore, to de- fine caries, I will content myself with describing it as a disease of the cancellous structure of bone, characterized by a chronic or subacute inflammation, terminating in suppuration, which is partly infiltrated, and partly collected into abscesses, the cavities of which abscesses, after they have discharged their contents, have a tendency to ulceration, whereby sometimes extensive destruction of bone-tissue results. With this there are usually to be marked some abortive attempts at reparation, such as large, flabby granulations protruding into the ulcerated cavities, and irregular and ineffectual depositions of new bone in and about the diseased parts. It is essentially chronic in CARIES. 95 its character, showing very little disposition toward healing, and it is generally associated with some constitutional cachexia, or local unfavorable condition, on which its existence, seems to depend Commencing our studies with this general description, we shall further find that caries sometimes presents itself as a dis- order arising from some slight exciting cause, and running its course without any evident connection with or dependence upon any other disease or injury ; while sometimes it is mani- festly dependent on some disease or injury of which it seems to be the consequence and effect. This seems to me to justify a distinction into primary or idiopathic and secondary or symp- tomatic caries, a distinction which I think is found in Nature, and will be useful in practice. Taking, now, a case of primary or idiopathic caries as a type of the disease, we shall find that in a young person, who has probably already presented some of the evidences of a strumous disposition, a slight swelling, with some pain and tenderness, presents itself in, we will say, a wrist- or an ankle-joint. This is at first attributed to some sprain or other injury, and then to rheumatism. The inconvenience caused by the affection at this stage may be very slight, and the patient may continue to use the limb without distress ; but soon stiffness after exercise, and more or less pain on motion, begin to show themselves, and the joint gradually grows more disabled as the disease advances. The affection becomes more and more markedly in- flammatory, involving the surrounding parts in its increase, but evidently centring its effects on the bones of the tarsus or carpus, rather than on the ankle- or wrist-joint. Gradually, and generally very slowly, the motion of the parts gets to be so painful that the limb becomes entirely disabled, and soinetimes constant pain is experienced independent of any movement, pain which is worse at night, and aggravated by damp and changeable weather. Soon the inflammatory signs begin to concentrate themselves 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, flaky pus. Little or no disposition is shown toward any healing action in the abscess, the discharge 96 DISEASES OF BONE. from which continues, generally consisting of a thin, acrid irritating, and bad-smelling pus in moderate quantities. No relief of the symptoms, but rather an exaggeration of suffering, occurs after the abscess has broken, and, if not before, now cer- tainly, constitutional sympathy begins to declare itself. Fever of a hectic character develops itself, emaciation is marked, and the patient becomes a confirmed invalid. The progress of the constitutional symptoms varies very much in different individ- uals, the general deterioration progressing very rapidly in some, and in others so slowly as scarcely to be marked, even when local destruction has made extensive progress. Of course, the size and importance of the joint, and the extent of the dis- ease will have much to do with the gravity of the general affec- tion. New abscesses now form at various points round the dis- eased centre, deformity increases, and sometimes, as in the knee, displacement of the joint -sur- faces takes place, owing to the loss of tone in the ligaments, which may proceed so far as to simulate a real luxation. These abscesses, particularly those accompanying caries of the ver- tebrae, are often of the cold variety, and extend sometimes to a great distance from the original seat of the disease. The psoas abscess is an example of this pathological fact, and we often find the matter travelling into very distant and unex- pected regions before it approaches the surface. Fig. 11, copied from Erichsen's work on Surgery, shows the extensive wanderings of an abscess originally developed on the anterior FIG. 11. (From Erichsen.) CARIES. 97 surface of the bodies of the lumbar vertebrae. The soft parts, in these confirmed conditions of caries, are extensively impli- cated, being thickened and consolidated by the inflammatory exudations, and traversed in various directions by sinuses, which lead, often indirectly, from the diseased bone to the sur- face. This condition, once established, may last for an indefi- nite period, and may have one of two terminations : It may either settle down into an inactive and unchanging condition, lasting for months, and even years, without any manifest prog- ress ; or it may go on through a process of local disorganiza- tion and general depreciation, which brings the patient to the point where both life and limb are imperilled, and where the interference of art is imperatively demanded. If, on the other hand, a favorable change is to take place, we have again one of two results to hope for : First, an improvement in all the conditions of the part, and a gradual restoration to health, with such an impairment of the joints affected as shall not entirely interfere with the usefulness of the limb ; or, secondly, in the more advanced cases, we have to hope that, if the destructive actions be arrested, a gradual consolidation shall take place, such as will permit a return of soundness to the diseased tis- sues, though at the expense of an anchylosis either partial or complete an anchylosis, the ill-effects of which mechanical ingenuity can often very much neutralize, and which in some instances surgical art can measurably improve. Symptomatic or secondary caries has, of course, no such distinct history of its own, but is developed in connection with some injury or disease of the surrounding soft parts, upon which it depends. Long-continued destructive inflammations of joints very often produce this carious condition of the bones which compose them. Thus, we often find, in white swelling of the knee, that the disease has involved the head of the tibia, and sometimes the condyles of the femur so far that the bone- disease has assumed the prominence both in prognosis and in the indications of treatment. This is sometimes particularly well marked in the conditions of joints which have been de- stroyed by inflammation following penetrating wounds. In these cases it is well known that the cartilage rapidly disap- pears under the influence of the inflammatory actions set up by 7 98 DISEASES OF BOXE. the wound, and the articular lamella is early exposed. From this the inflammation gains ready access to the cancellous tis- sue underneath, and we have infiltrated suppuration and caries as the common consequence. The symptoms indicating secondary caries are usually so mingled with those of the original disease that it is not easy to separate them. The extension of the joint swelling so as manifestly to embrace the joint ends of the bones ; the tender- ness and pain in the heads of the bones ; abscesses breaking at a distance from the joint and over enlargements such as above described, and the detection of carious bone by the probe these are the most striking and unequivocal symptoms of this form of caries ; but it may be stated that the long continuance and destructive behavior of joint-affections generally may lead to the suspicion that caries of the articular extremities of the bones has taken place. From this sketch of the clinical features of the two varie- ties of caries we may now proceed to a study of its pathologi- cal anatomy. Bsyond a doubt, the first morbid conditions which would be found in a bone which was falling into caries would be those of inflammatory excitement. Increased vascu- larity throughout the cancellous tissue is, however, a patho- logical fact sometimes difficult to verify. The violence caused by the saw leaves a surface which always seems too red to be healthy, and in young people the circulation in the heads of the long bones is so active that in the most healthy specimens we find what seem to be the evidences of great and irregular congestion. Much care, therefore, must be exercised in decid- ing upon the existence of diseased states of the circulation in these cases, and conclusions should not be too positive. The increased action is soon accompanied by exudation. This exu- dation at first a reddish serum is infiltrated through the bone, and tends very soon to be converted into pus a pus, however, which does not assume a very perfect form, and which at first seems disposed to remain disseminated rather than to collect in the form of abscesses. This imperfect sup- puration has no doubt often been mistaken for true tubercular infiltration of bone, which is certainly a rare condition, but it should be remembered that the lines between true tubercle and CARIES. 99 imperfect suppuration are not very cleanly drawn, and that, though it is extremely rare to find in bone a deposit which answers the description and obeys the laws of tubercle, yet we do often find, in this imperfectly-de- veloped suppuration, in scrofulous subjects, something which, histologi- cally and pathologically, very closely assimilates to it. As the disease pro- gresses, it takes on more and more dis- tinctly the characters of disseminated suppuration, and collections of mat- ter, gradually accumulating, begin to show themselves, at various points, forming abscesses. Some increase in activity accompanies the formation of these abscesses, and they seek the surface with some signs of acute in- flammation. They point and break, or are opened by the surgeon, and discharge a small quantity of mat- ter, which, according to the activity of the inflammation, has more or less of the character of healthy pus. Frequently it presents the thin curdy or flaky character which is consid- ered characteristic of struma. These abscesses show no tendency to heal, and yet a reparative disposition is evinced by large granulations, soft, flabby, which spring up and usually fill to a great extent the suppurating cavities. Instead of being truly re- parative, however, the presence of these granulations is not in- compatible with an ulcerative action by which the cavities are being slowly enlarged, and the cancellous tissue more and more extensively broken down. This destruction of the bone-tissue is a complicated process, and seems to be made up of two kinds of action, one where the bone-substance undergoes a change in which its earthy element is absorbed, and the other a true pro- FIG. 12. (From Billroth.) 100 DISEASES OF BONE. csss of ulcerative absorption whereby the altered bone is re- moved (Fie 1 . 12). The changes which go on in bone during this process are extremely interesting, and have been fully investigated by many recent observers. Mr. Barwell, in his work on " Diseases of the Joints," gives a very full account of his observations on this subject, which seem to have been made with great care and thoroughness. He considers the first change to be an enlargement of the lacunae and their canaliculi. The lacunae gradually lose the elongated shape and approach to circular or broad oval. The canaliculi are larger and more numerous, and seem to open into the lacunae by broad mouths. Where the canaliculi intersect each other, there seem to be new spaces formed, which assume the charac- ters of new lacunae. Thus there is a positive increase in the number as well as the size both of the lacunae and canaliculi. During this change, the bone -substance itself undergoes a transformation, which commences nearest to the llaversian canal or cancellus and spreads outward. The bony sub- stance becomes granular; that is to say, it looks as if it were composed of dark and light dots placed close together. As this change spreads from the Haversian canal or cancellus outward, the margins of the cavity lose their distinctness of outline and become very irregular ; in parts the edge is gone, the cavity is therefore on that side increased ; in other parts the spotted bone-tissue appears to mingle, or to be continuous with some granular contents of the cavity. It is quite evident that, in these places, the bone-tissue is softened ; one can trace the gradual completion of the process, from some point which is only slightly spotted, to the part next the cavity, which is a mere pultaceous granular mass, in which many of the dots have the appearance of nuclei. " Another change in the cell forms part of this softening process, viz. : that as the dotted or granular condition reaches a certain stage, so do the canaliculi disappear ; therefore, of course, from that side first, which is turned toward the cavity (Haversian or cancellar), they vanish by simple shortening, by recession from the entirely softened bone, until they are re- duced to mere little rudimentary projections on the surface of the cell. At this time the cell itself is visible, as a granulated CARIES. 101 dark bag, more or less transparent, and very highly refracting, which projects from the wall of the scarcely-resistant bone, and is of large size ; it bulges out and seems swollen, projects more and more, and at last breaks away from its attachment, and lies among the softened debris in the cavity, still retaining its dark color. In breaking away, however, it often leaves behind those of its canaliculi which were turned away from the cavity, and which may often be seen on the edge, but which soon dis- appear as softening goes on, spreading outward. Frequently several smaller cells come out of the lacuna, instead of one large one. In this way a lamina between two cancellous cavi- ties very soon disappears, from softening on both sides : in this way, also, circlet after circlet of cells around an Haversian ca- nal caves into the cavity, and thus the system melts away and leaves around the vessel only a soft granular and cellular FIG. 13. (From Billroth.) mass." Fig. 13 shows the worm-eaten appearance of carious bone under the microscope. By these processes, the bone-substance becomes gradually 102 DISEASES OF BONE. disintegrated, so that, before actual ulceration has taken place, it is so softened that the scalpel or even the probe can be read- ily pushed through it. In some points the bone-elements seem to disappear entirely ; in most, however, some of the original framework remains so as to maintain the shape of the part. Not nnfrequently, from this softened condition of the joint- ends, great deformity results from unequal yielding to press- ure a circumstance which, the vertebrae excepted, I have more frequently noticed in the knee than in any other joint, and one which, if a favorable change takes place in the origi- nal disease, leaves behind a distortion which is permanent and irremediable. As the process of ulceration goes on, some parts of the bone-substance are apt to die, giving rise to small se- questra, generally upon the ulcerated surfaces, which thus at- tract less attention, because easily cast out with the discharges. These sequestra which accompany caries, however, are occa- sionally of considerable size, and assume great importance when, as is sometimes the case, they involve the articular lamella, and fall into the joint-cavity ; thus forming a com- plication which renders the destruction of the joint almost a certainty. Where much of this necrotic action accompanies caries, the disease is spoken of as caries necrotica. While these destructive actions are going on, reparative dis- positions show themselves unequivocally, though ineffectually, in the diseased parts. We have already noticed the luxuriant granulations which fill the cavities of the abscesses ; the bone- tissue shows the same tendency. Mr. Barweil thinks he has ascertained that, in the early period of the disease, the bony lamellae become thickened and indurated, as one stage of the inflammatory process. This must be a pathological fact ex- tremely difficult to verify, but, be it as it may, it is certain that later in the disease new bony deposit is seen around the cen- tral points of carious bone, as almost a universal fact. Some- times this is only noticed to the extent of some slight surface incrustations round the diseased spots, but commonly there are considerable thickening and consolidation through the sub- stance, and often a very great amount of stalagmitic deposit on the whole of the neighboring surfaces, and sometimes ex- tending to the nearest bones, which may themselves be entirely CARIES. 103 free from other signs of disease (Fig. 14). In the caries, so common, of the bodies of the vertebrae, this deposit is often seen to be very extensive, forming bridges of bone between FIG. 14. (From Bfflroth.) FIG. 15. (From New York Hospi- tal Museum.) neighboring vertebrae, as if to strengthen the column, while the disease is still progressing ; and as favorable changes he- gin to take place in the carious parts, fresh and stronger devel- opments of new bone are observed, which finally fuse together in one solid anchylosis the vertebrae whose bodies have been more or less completely destroyed by the ulceration (Fig. 15). When a cure is about to take place in ordinary cases of caries, the ulcerative action ceases; the granulation-substance assumes a healthier and firmer character, and gradually or- ganizes itself into tissue. The suppuration ceases, and the in- flammatory congestion diminishes. New bone-deposit, formerly confined to the outskirts of the disease, now is deposited so as in part to restore the deficiencies which have occurred. Some- times this action is a prominent one, the granulations spring- ing from opposite bones coalescing and ossifying ; and in this way we have true anchylosis as one of the methods of cure in 104 DISEASES OF BONE. bones which have been long and extensively carious (Fig. 1C). A modification of this conservative action is sometimes ob- served in carious bones which have formed part of an artieula- Fia. 16. (From New York Hospital Museum.) tion ; that the opposed surfaces, from which, perhaps, cartilage has long been removed, as healthy action is resumed, become hard and smooth, so as to allow of a certain amount and freedom of motion, which tolerably preserve the usefulness of the mem- ber. This induration of the surfaces is sometimes so complete as to assume the appearance of ivory or porcelain, and hence it is often spoken of as the porcellanous or ivory-like change. Finally, in cases where the ravages of the disease have not been so extensive as to disorganize the neighboring joint, we may have a recovery so perfect as to leave no impairment of function, and no traces other than the cicatrices both in the bone and in the surrounding soft parts, which must necessarily follow the ulcerative actions which have been going on. Caries, in all its forms, is emphatically a disease of the cancellous tissue ; 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 substance in the neighborhood of active caries, whereby it is gradually changed in its structure by a process of osteopo- rosis, and then invaded by the ulcerative actions proper to caries, is not at all uncommon ; but any such action developed as a primary affection must be regarded as exceedingly rare. The bones most commonly affected by primary caries are the the bodies of the vertebrae, the tarsal and carpal bones. The joint-ends of the tibia and humerus are, among the long bones, the most frequently attacked, but no bone is entirely exempt. Fig. 17, from the New York Hospital Cabinet, shows the ex- tent to which carious destruction will sometimes proceed. The specimen here represented is from " a mulatto seaman, CARIES. 105 who suffered from excruciating pain in the left ear, with deaf- ness and swelling, for several months, at the end of which time he died comatose. Patient had nodes and other symptoms of syphilis. On examination, the disease was found to have de- stroyed almost the whole of the petrous portion of the tempo- Fio. 17. (From New York Hospital Museum.) ral bone. The dura mater had been either absorbed or decom- posed, and an immense collection of pus extended along the whole of the base of the brain. After maceration, the remain- der of the temporal and a large part of the left half of the occipital bone, extending into the foramen magnum, the left portion of the body of the sphenoid, and a part of the arch of the atlas, were found to have crumbled to pieces, thus leaving a hole admitting the closed fist." The disease is almost entirely confined to persons below the age of puberty ; though a few cases of caries occur in highly-scrofulous .young adults. The caries of the vertebrae, independent of injury, is almost unknown after puberty, while the disease in the tarsus and carpus is occasionally seen in the 106 DISEASES OF BOXE. adult. In general, it may be stated that primary caries is an affection of childhood and early maturity, while, strange to say, secondary caries is of comparatively rare occurrence in childhood, but frequent in the injuries of bone and inflamma- tions of joints which occur in adult life. It would seem as if the abundant vitality of the child protected him against secon- dary caries, as a consequence of injury ; but that that very abundant vitality, if tainted with constitutional vice, tends to crop out in primary caries and its allied diseases in early life : whilej if the individual survive these early perils, the consti- tutional taint seems often to disappear in a vigorous maturity, and with it disappear the peculiar tendencies to disease which characterized and imperilled his childhood. It need hardly be added that no bone and no age are entirely protected against secondary caries. The prognosis of caries is always bad; that is to say, wherever the disease has fully developed itself, serious conse- quences are sure to follow. These consequences may be lim- ited to some local destruction of bone -tissue, which may be repaired to such a degree that the form and usefulness of the bone may not be lost ; or they may be so severe that destruc- tion of joints and peril to life may become imminent peril from which amputation or exsection alone can extricate the sufferer; or, finally, in not a few cases, either in spite of the resources of surgical art, or because we cannot bring them to bear, death will be the result. In primary caries, every thing seems to me to depend on the condition of the constitution. If this be deeply tainted with scrofula, the case is almost hope- less from the beginning. If, on the contrary, the scrofulous manifestations are not marked ; if the system be in a tolerably vigorous condition ; if the remedies and the regimen employed have the effect to invigorate and improve the general health ; then we have a good ground for hope that the local disorder will prove tractable, and particularly if our remedies are brought to bear early in the case. Indeed, I think this an ele- ment in prognosis second only to the constitutional state ; viz., the stages at which the disease 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 CARIES. 107 hesitate to class it among the manageable affections. If they are not afforded till the destructive features of the disease are developed, we can do little to avert its consequences. Youth does not seem to modify the prognosis so favorably as in other diseases, as the strumous taint of young subjects seems to be more distinct and more disastrous than in those somewhat older ; but, nevertheless, I think it may be safely said that, other things being apparently equal, young children do better with carious disease than those in the neighborhood of puberty. One other element in prognosis should not be overlooked, viz., social condition. Those who from wealth and intelligence can command, and will use with steadiness and perseverance, all the best resources of art, have a vastly better chance in this dis- ease of securing a favorable result, than can be looked for in those whose circumstances will not permit them, and whose intelli- gence will not guide them, in the wise use of means whose care- ful application may have to be continued through long and weary months, and perhaps years, of doubtful and anxious care. That the treatment of caries is, as a general thing, ex- tremely unsatisfactory, I suppose no surgeon of any experience would be disposed to deny. And yet, most good surgeons do not hesitate to acknowledge the efficacy of certain remedies, and certain modes of management, in particular stages and in particular conditions of the disease. The study of treatment may here be advantageously divided into two stages or periods; one which represents the commencing or inflammatory stage, and the other which has to do with the consequences and effects of the inflammation. It is manifest that these periods cannot be defined with accuracy, and that they must vary in different individuals, and yet in most cases there can be dis- tinguished a period where the inflammation is going through its stages of congestion and effusion of serum, of lymph, and of pus, when the inflammation itself is the main feature of the disease, and requires to be the main object of attack in the treatment. Again, when the results of this inflammation have developed themselves into abscess, ulceration, necrosis, and ex- tended disorganization, it is no longer so much the inflamma- tion, as its results, that we have to do with, and these conse- quences now have become the main features of the case, while 108 DISEASES OF BONE. the inflammatory action itself may have ceased to be an object of special consideration. In the first stage, then, we have to deal with an inflammation which is essentially subacute, and will hardly bear active depletion. Nevertheless, a few leeches over the affected part, perhaps repeated at intervals, will certainly control tbe tenderness and pain, and seem to have a good effect in preparing the way for other remedies. I have sometimes employed this treatment in the earliest stages of hip-disease, depending on osteitis, with a good effect in quelling the noc- turnal attacks of pain, with which the first stages of this affec- tion are sometimes accompanied. Two or three leeches behind the trochanter in these cases have seemed to me to do good, particularly if repeated at intervals of ten days or two weeks. At the same time free local depletion is not allowable. The local actions are too sluggish, and too much dependent on con- stitutional causes, to be favorably modified by considerable losses of blood ; and it should always be remembered that the vital powers of the part are to be taxed heavily for many weeks and months, and it would be very poor preparation for such effort, to weaken the part by too much cr too frequent local bleeding. Blisters may also be of service in relieving pain, and it is reasonable to believe that a positive advantage may be derived from counter-irritation, particularly if perios- teal surfaces are the seat of the inflammation. "We are cau- tioned by most writers against applying blisters too near the seat of an inflammation, a caution which probably in acute synovial affections of the joints is a wise one. In cases of osteitis, which we fear will prove to be caries, however, I have never hesitated to apply my blister immediately over the affect- ed part, and have always felt that its action was useful in pro- portion to the precision with which it could be brought to bear on the threatened locality, and I have never realized any injury which seemed to me attributable to transmission of the surface irritation to the parts beneath. In the use of blisters in these, and indeed in all cases, I have the conviction that it is their primary effect which is the valuable one, and that they are very poor and very un com fort able derivatives. If any such perma- nent drain is desired, it is much better attained by an issue or seton, and I never now keep my blisters sore. CARIES. 109 The more powerful derivatives, the issue, the seton, etc., have in former times been very generally regarded with high favor in the treatment of caries ; but whether their importance has not been exaggerated, admits, I think, of a question. Mr. Brodie speaks unhesitatingly ; he says : " I much doubt whether setons and issues are ever useful, except in some cases in which the disease has its seat in the hip-joint." Mr. Barwell gives them credit for doing some good in the earlier or inflammatory stage, but denies them all value in the second or destructive condition of the bone ; while he acknowledges that their ap- plication, and particularly in the form of the actual cautery, has a marked effect in arresting the pain of the disease an arrest which he insists is always very temporary. Both from reasoning and experience, I have been disposed to accord a higher value to these remedies than is given them by these dis- tinguished writers, but every thing, I think, depends on the character of the individual case to which they are applied. In those sluggish, painless, slowly-progressing disorganizations of the bone which are found in connection with what we call white swelling of the joints, where every local action seems the expression and result of a constitutional cachexia, and when the ordinary demeanor of inflammation is entirely masked by that cachsxia, I acknowledge that little or no benefit is to be derived from this class of remedies. But in all those, perhaps more numerous cases, where the inflammatory processes show some of their normal activity, and where it is rather the appre- hension that the vital actions will be modified by strumous sluggishness, than that they actually indicate the presence of that unfortunate taint, and where great sensitiveness on motion or uss shows that more acute action 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 very obvious causes, then I conceive that we have in perma- nent derivation a very important means of controlling and often of curing the disease. In these cases the seton or issue (and I greatly prefer the issue), placed a little distance above the affected bone, and so arranged as not to interfere with the ap- paratus which is to be applied, nor with the motion which by- and-by will have to bo made, and kept running with issue-peas HO DISEASES OF BONE. until the actions begin to indicate clearly that the tendencies are toward cure, and then allowed to diminish in amount of suppuration, and gradually to dry up, is, as I believe, a very positive agent in promoting the cure. In this respect, the actual cautery holds a high position. Its primary action is so peculiar and energetic that it controls with great cer- tainty the symptoms of the disease for a time, and its result- ant issue is the best that can be made. In the most acute cases, when much pain is an early and prominent symptom, I consider it peculiarly valuable. The use of mercury in osteitis tending to caries has also been the subject of much difference of opinion among good surgeons. My own experience is unequivocal, and has im- pressed me strongly with its value in appropriate cases. And these will embrace the early stage of a large proportion of the whole ; all, indeed, excepting those of very feeble constitution and irritable fibre. Two ways of using mercury are commonly employed with entirely different indications, one as a purga- tive and the other as an alterative. The purgative action is supposed to clear the intestines of such vitiated secretions as oppose their proper action upon the alimentary mass, and in this way indirectly improve the character of the nutritive ac- tions, while the alterative effect, obtained by the continuous administration of small doses, is supposed to show itself not only in an improvement of these nutritive actions, but also and principally in a direct effect upon the course of the inflamma- tory disease which it is supposed to affect favorably. Both these modes of using mercury are useful in this disease. In the forming stage of such cases as occur in patients of tolerable vigor, and with inflammatory symptoms of some activity, mer- curial purgatives occasionally administered have the happiest effect in improving the general condition of the system, and often in directly relieving some of the most distressing of the local symptoms. Mr. Barwell very happily illustrates this ef- fect by the well-known influence of mercurial cathartics in cer- tain cases of strumous ophthalmia, where such surprising relief is often found to accompany their proper employment. The alterative method also has its value in cas^.s where the progress of inflammation seems steadily onward, increasing its CARIES. Ill area and accompanied by distressing pain and starlings at night, with fever, more or less distinctly developed, at irregular inter- vals. In these cases the careful use of calomel, combined with opium in small doses, has seemed to me in many instances to have had the happiest effect, both on the sufferings of the patient and on the progress of the disease. In more chronic, less distinctly inflammatory cases, I have much confidence in the controlling power of the bichloride, used in exceedingly small doses, say the twenty-fourth or thirty-second part of a grain twice or thrice a day, combined with tonics, and perseveringly employed for weeks or even months. I need hardly say that in all the methods of employing mercury its injurious effects should be carefully guarded against hypereatharsis on the one hand, and salivation on the other, being likely to inflict more mis- chief than the happiest influence of the drug can compensate for. In regard to the necessity for rest of the diseased part dur- ing the earlier stages of caries, all authors are agreed, and their judgment is in accordance with the instinctive feelings of the patient. Much, however, depends upon the thoroughness with which absolute rest is not only insisted on, but by appropriate arrangements secured. In the acute eases, when the disease is in the lower limbs, the bed is the only security against injuri- ous and painful motion ; and even in bed it is often necessary to apply some apparatus to the limb to secure it against in- voluntary and accidental movements. As almost all cases of caries occur in immediate proximity to joints, the treatment of the bone-disease 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 neighborhood ; and much comfort, and I am sure much ad- vantage, is secured to the patient by splints so arranged as to secure him against the painful movements to which accident or muscular spasm makes him continually liable. About these points there can be but little diversity of opinion or practice, but the more important question presents itself: How long shall absolute rest be maintained, and how soon and to what extent may use be allowed ? I believe there is no more im- portant practical point in the history of these diseases, and I 112 DISEASES OF BONE. am sure there is none requiring more careful and enlightened judgment. The importance of this point arises out of the fact that dis- use of a limb is certain to be followed by atrophy, and atrophy means degeneration. Now, where this degeneration of all the tissues of a limb has been going on through months of disuse, it seems to me to be certain that the reparative powers of the part must be depreciated in a proportional degree, and I have long been of opinion that many cases of chronic surgical dis- ease are prolonged indefinitely, and sometimes brought to an unfavorable issue, by this loss of reparative vitality, from too long-continued disuse. It is confessedly a difficult point to decide when passive motion and when active use should be allowed in these cases, and I do not feel competent to lay down distinct rules by which practice should here be guided. The general principles of action ara that, as soon as active inflam- mation has sufficiently subsided, the use of the limb will pro- mote the vital activities which have been held in abeyance by disuse ; and that, therefore, we should endeavor to seize the moment when inflammation will not be aggravated, and when, therefore, nutritive activity will be increased by appropriate exercise of the limb. In judging of this, we must be guided principally by two symptoms, viz., the heat and the tenderness of the part. If heat have steadily and permanently subsided, until the ordinary condition of the diseased part is one of natu- ral temperature, as appreciated by the hand or by the thermom- eter, and if at the same time tenderness have so far diminished that moderate pressure is no longer painful always provided that the other morbid signs have also been undergoing a favor- able change we may suppose that the time for considering the question of passive motion has arrived. And perhaps there is no bettsr way of ascertaining the fact than by cautiously mak- ing the experiment. When, therefore, circumstances seem to indicate that the proper time has come, careful and very slight movements of the joint should be made by the surgeon's own hands, for this is a thing that should never ba committed to the patient or his attendants, repeated daily or at such inter- vals as may seem best. Undoubtedly all local symptoms will be increased for the time by such a procedure, which in its CARIES. 113 performance will give the patient much pain. This need not necessarily forbid its repetition, and by no means indicates that it is not judicious, and it is only by its ulterior effect that the wisdom of the manipulation can be vindicated. One practical precept, for the clinical enforcement of which we were all in- debted to Dr. Alexander H. Stevens, then Surgeon of the !N"ew York Hospital as well as Professor of Surgery in the College of Physicians and Surgeons, seems to me a safe and useful guide in this matter, viz. : if the pain and tenderness produced by passive motion last more than twenty-four "hours, we have done too much ; if, on the other hand, how much soever pain we may give in the manipulation, its effects have entirely passed away by the same hour of the next day, we may be encouraged to proceed. Without claiming this rule to be a positive guide, I can say that I have found it a very useful assistant in my own cases, and one which has very rarely seri- ously misled me. Another and an important point is still to be decided, as to when the use of the limb may be advanta- geously permitted. This question will no doubt generally de- cide itself, as the results of passive motion are developed, but still cases present themselves where passive motion has been sometimes employed without manifest injury, and yet, where no improvement follows, and where the general atrophy of the limb is so decided as to lead to the belief that nothing but the stimulus of use will bring about a healthier reparative condi- tion. In these cases careful but courageous use, perseveringly and judiciously insisted upon, seems the only way of solving the problem a solution which is sometimes among the happi- est and most satisfactory of surgical therapeutical results. In securing the complete rest, so necessary in the earlier stages of caries, position is most carefully to be attended to. The limb will usually have assumed, if the disease have been long in existence, a position to which the patient has been in- stinctively led by finding it most comfortable. This position is usually one of moderate flexion of the joint implicated, if it be a large joint, as the knee or elbow, while the wrist or ankle will be kept nearly midway between flexion and extension, which will bs for the wrist nearly a straight position, and for the ankle about a right angle of the foot with the leg. It often 8 114 DISEASES OF BONE. happens, however, that this position has been allowed to be- come a vicious one, and one which, if maintained till a cure is accomplished, would leave the limb in a more or less deformed and useless condition. These faulty positions may be almost invariably rectified by gradual and very careful extension which may be applied by the apparatus used for securing the rest of the limb. Our instrument-makers make a very excellent light frame, well padded with soft leather, which, moving on a hinge at the situation of the joint, can be flexed or extended by a screw. This screw is moved by a key, which is retained by the surgeon or the nurse, so that in unruly children no letting up of the pressure can be accomplished without proper advice. By the steady and gradual application of a gentle force, the rectification of position can usually be accomplished without division of tendons. With some surgeons this division of ten- dons and contracted muscles is much resorted to, and much ad- vantage is reported as being gained in the treatment, in reliev- ing both the spasmodic and the permanent contraction of the muscles. My own experience does not entitle me to pronounce on its value, as I have rarely had occasion to resort to it. If the case have been under our care from the onset, then there is a mode of securing rest to the limb, the most complete and comfortable that can be attained, which prevents any pos- sibility of a faulty position, and which is attended with the very great advantage of relieving the pressure of the joint surfaces against one another, produced by the tonic contraction of the muscles surrounding the joint. I allude to what is now commonly spoken of as elastic extension. Extension is applied to the limbs by means of the adhesive bands, and the weight and pulley, as is now universal in the treatment of fractured thigh, and this, in the case of the knee or hip, is, made while the patient is lying on the back, and at other joints in varying positions according to the part involved. Somewhere between the pulley and the limb, a band of India-rubber is introduced through which all the traction passes, and this by its elasticity so equalizes the extension that it is always in uniform action, and can be borne without the least inconvenience. The advantages of this mode of managing the earliest stages of joint aifections are incontestable ; and in caries it cannot be CARIES. 115 less important, both to the comfort and to the cure of the patient. When caries, as is too often the case, proves unmanageable by all the remedies employed to check its progress, we have often presented to us a surgical problem which deals with the results of the carious disorganization, and in which the main question is, What shall be done with the hopelessly-diseased bone, and in what way can it best be prevented from inflicting injury on the surrounding healthy tissues, and on the patient's general health ? This problem embraces the destruction or the removal of the diseased bone, and must, of course, in its full decision, depend upon all the particular circumstances of situa- tion, degree, age, general condition, etc., which give individual character to the case. Some general considerations, applicable to all cases, however, will help us in the solution of each par- ticular problem. The destruction of the diseased tissue may be eifected either by the stronger escharotics, or by the actual cautery. The difficulty of limiting the action of a caustic, and the uncertainty of its effects, have been, I suppose, the reasons why they have not usually been employed for this pur- pose ; while the completeness of the destruction, and the cer- tainty with which we can calculate upon its extent, are good reasons for preferring the hot iron. The most favorable cases for the use of this method of treatment must be those where the disease is either not extensive, or is mainly situated over a surface which can be easily reached by the application. To such cases the iron is applied at a full red heat, holding it on the diseased part until its full effect is produced. Of course, a careful preparatory exposure of the bone will be made, and the soft parts drawn aside, and carefully protected against the heat. The destruction of tissue thus produced is usually not so deep as would at first sight appear, but it is perfect, and the whole 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 the application must be repeated at proper intervals as often as may be necessary. The older writers speak very highly of this method of attacking caries, but it seems to have lost credit 116 DISEASES OF BONE. with the more modern surgeons ; perhaps, because the various operations for removal of diseased bone have attracted so much of their attention, and are, after all, the only operations to be relied on when the carious disease has involved the greater part or the whole of a bone, or of several contiguous bones. The operation of exsection or excision of bone is compara- tively a modern one Mr. White, of Manchester, being com- monly regarded as the first who, by^a defined and purposed pro- cedure, undertook the removal of carious bone, he having re- moved the head of the humeras for caries in the year 1T68. Since his time, surgeons have been gradually growing to the ap- preciation of the important step thus indicated, and no operation has, during the last fifty years, commanded more universal in- terest than that of excision of carious bone, particularly in connection with the diseases and injuries of joints. The prin- ciple of the operation is founded on the fact that the caries is localized in its action, and that, when the diseased parts are removed, healthy reparative processes may De expected to begin, and the success of the operations founded upon this principle may be properly said to have inaugurated a new era in the treatment of diseased conditions of the joints. Exsection has now been practised on almost every bone in the body ; and while the value of the procedure varies much according to the locality affected, yet no doubt remains of the great value and importance of the operation itself. The operation consists in exposing the diseased bone by appropriate incisions, and then, with the saw, or the bone-for- ceps, removing all that portion which is implicated in the dis- order. As this operation is so commonly performed for caries as a part of joint disorganization, it is usually performed in such manner as to expose and remove both of the opposed joint surfaces, and it is this operation which is meant when we speak of exsection or excision of the joints. In operating thus, great care is to be taken not to interfere any further than is necessary with tendinous insertions, in order not to impair the efficiency of the muscular actions of the joint, and also not to remove any more of the bone than disease makes necessary. It is true that Nature has wonderful resources in repairing the mutilation of this procedure, and surgeons have not hesitated CARIES. 117 to remove several inches of each, bone where it has been clearly necessary, but the rule of saving all that may be saved is none the less imperative, and the success of the procedure will, in a good degree, depend upen the amount of bone which is taken away. "Where the operation is successful, one of two results is realized : first, the wounded surfaces take on a healthy action, and the bone granulates, and a uniting medium thus forms which ultimately becomes firm enough to produce an anchylo- sis between the opposing bones ; while, at the same time, all diseased action ceases, and the soft parts cicatrize soundly. This is the result most commonly aimed at, and, probably, always most desirable in the lower extremity. In the upper extremity, however, a certain amount of motion is hoped for, and quite frequently a useful degree of it is attained. The uniting medium does not completely solidif} 7 , but remains suf- ficiently yielding to imitate some of the movements of the original joint; while, if the tendinous insertions have not been too extensively disturbed, the muscles resume their power, and an amount of voluntary motion is regained which is often ex- tremely valuable in the shoulder, the elbow, and the. wrist joint. In realizing these two different results, of course, much will depend upon the management of the limb after operation. If firm anchylosis is desired, absolute rest will be most care- fully maintained during all the cure ; while, if motion is sought for, properly conducted passive motion will be the principal means of arriving at the result desired. The success of these operations has been extremely satis- factory, and, when we consider that the alternative presented is amputation, we can hardly accord too high a position to this great conservative triumph of modern surgery. Two modifica- tions of the operation of excision for caries have lately been presented to the surgical world, by men of eminent repute, both claiming superiority over the rival proposal, as well as over the old operation. These are brought forward respective- ly by M. Oilier, of Lyons, and by M. Sedillot, of Paris ; both are fortified by a considerable number of cases, and both are reasoned out with great scientific ability. M. Oilier claims that the trus method of excision is what he calls the sub-peri- osteal section ; that is, one in which the diseased bone is re- 118 DISEASES OF BONE. moved, leaving behind its periosteal covering. According to his views, which indeed are those generally received, the peri- osteum is the great bone-producer, very greatly superior in this power to any of the surrounding tissues, or even to the bone itself. If, therefore, in any exsections of bone, we leave the periosteum behind, we have the element of reproduction of the bone to help us in the reparative processes which we are anticipating; so that, if every thing proceeds favorably, we accomplish, by sub -periosteal resection, not merely the removal of the disease, but the regeneration of the bone removed, so perfectly and to such an extent as makes the result more per- fect and more complete than can in any other way be accom- plished. M. Sedillot contends that the periosteum cannot be relied upon to do its full regenerative duty in these cases, and that the only way to secure a complete reformation of the bone to be removed, is so to proceed as to leave a thin shell of bone attached to the periosteum, from which shell he says there will be the most perfect possible regeneration of the bone removed. His operation consists, therefore, in scooping out all the dis- eased bone-tissue, leaving behind a thin layer of bone, attached, of course, to the periosteum, and forming thus a thin shell which maintains the shape and size of the bone removed, thus preventing, according to M. Sedillot, the deformity which ne- cessarily follows the other operation, and which, M. Sedillot believes, will not in any material degree be prevented by M. Ollier's sub-periosteal 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 result of all the discussion 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 industriously employed on this interesting subject in every country, and the appreciation of the various operative methods bids fair to be soon practically settled. Mr. Hancock, in London, has done more than any other man to illustrate and enforce M. Sedillot's views, and very numerous experimenters in Europe and in this NECROSIS. 119 country have proved tbe value of M. Ollier's important sug- gestions. While, therefore, some features of the operation of exsection of bones may still be considered as not yet fully and finally decided upon, the general value of the operation and its estimation as a surgical resource are gaining daily, and it now ranks as one of the most valuable contributions of modern science to conservative surgery. CIIAPTEK XI. NECKOSI8. THE death of bone, so common in its occurrence, either as a primary and essential, or as a secondary and accidental cir- cumstance, is one of the most extensive and interesting sub- ' O jects which bone pathology presents. For the frequency of its occurrence two circumstances, connected with its vascular supply, present themselves in explanation : First, the perios- teum contains a larger part of the vessels whose small branches pass inward to supply the superficial or sub-periosteal layers of bone-tissue, and upon the integrity of this membrane, and upon its close adhesion to the bone, depends the continuance of this supply of blood. !Now, it so happens that the periosteum is liable to injury or inflammation, which may either destroy it in situ, or, what is more common, may cause an effusion be- tween it and the bone, which, separating it from the bone, destroys the continuity of circulation between the vessels of the periosteum and of the adjacent bone which these vessels should nourish. In this way, there is no doubt, many super- ficial necroses take place, and a considerable proportion of the thin exfoliations we so often see after slight injuries are thus produced. But, in the second place, there is, in the expansibility of bone-tissue, another and more widely operating cause of necro- sis. All the circulation in the substance of bone is through vessels traversing bony canals which they entirely fill, and which canals, therefore, compress and support the vessels on all sides. Under the first stimulus of inflammation in the soft 120 DISEASES OF BONE. parts, it is well known that the vessels are crowded with blood so as to be largely dilated in their calibre. This dilatation would seem to be a necessary mechanical result of the increased quantity of blood forced into tubes whose walls are capable of yielding, and it would also seem to be a necessary vital action whereby the yielding vessel grows more capable of transmit- ting the increased current of blood, which, without this relief, would be dammed up and stagnate in the capillaries of the part, thus arresting entirely the circulation, which, if life is to continue, should only be retarded, not stopped entirely. Of this yielding to dilating force, of course, the vessels of the bone are by their position entirely incapable. In bone inflammation, therefore, the blood, attracted by the new stimulus, crowds the unyielding capillaries so urgently that transmission of the cur- rent becomes slower and slower, the thinner parts of the blood move on, while the corpuscles become more and more jammed and packed in the channel now relatively too small to receive their increased number, until presently the current is arrested altogether, and the circulation ceases. Thus it would appear that one essential element of acute inflammation of bone is such a mechanical condition of the affected part as directly tends to the destruction of life a destruction, the certainty of which depends probably more on the acuteness of the attack than on its severity or extent. That this is so we are instructed by observing that the delib- erate actions of chronic inflammation, though extensive and severe, are very little liable to produce necrosis, whatever other disastrous accidents they may entail, apparently because the vascular movements are of such a character as to give time for the vessels and their bony canals to accommodate them- selves to changes which, in the acute inflammations, hurry on the bone to death. These considerations may also serve to explain the fact that the compact tissue of bone is more liable to necrosis than the cancellous. In the cancellous tissue a large part of the circulation is distributed through the medulla, the terminal capillaries alone entering the bony channels, and hence any increased hydraulic pressure is received, in great part, upon vessels which have the space in which to expand. In the compact tissue, on the other hand, the whole vascular NECROSIS. 121 system of the part is contained within the rigid Haversian canals, and the pressure is resisted equally by the capillaries and the vessels from which they spring. Hence, doubtless, the comparative frequency in the one and the rarity in the other tissue of an accident, which has, in its nature, no ele- ments of difference besides the mechanical one upon which we are now insisting. From the study of these intrinsic predisposing conditions, we may deduce the most important exciting cause of necrosis, namely, inflammation ; or, in other words, we may appreciate the reason of the acknowledged fact that inflammation is the great producing cause of necrosis. All those accidents and exposures which are likely to induce, and all those conditions of the system which favor, the occurrence of inflammation in any of the component tissues of the bone, may be regarded as the exciting and predisposing causes of necrosis. Of the predisposing causes, we have those that are local and those that are general or constitutional. Thus the super- ficial situation of the tibia, and its consequent exposure to the vicissitudes of temperature, are thought by some to be the ex- planation of its greater liability to necrosis ; an explanation which will certainly stand, in those cases where the -disease follows injury, to which the bone is more liable from its ex- posed situation. Again, the condition of the circulation in the lower extremities, as influenced by standing, exercise, etc., is, doubtless, often a predisposing cause of bone inflammation, and, therefore, sometimes of necrosis. But the most unequivo- cal of the predisposing causes are those which may be termed constitutional. In the scrofulous and in the syphilitic there is manifested a tendency to bone-disease; in fact, a predisposition to necrosis, which only requires a slight exciting cause for its development. Besides these, there are certain slender, deli- cate, feeble persons in whom no syphillis and no scrofula can be detected, and yet who show a proclivity to necrosis, which is evidenced by the repeated attacks, perhaps at far-distant periods, of the disease in various situations, and provoked by exciting causes so insignificant as often to leave us in doubt whether the affection might not be regarded as spontaneous. To these oufjht to be added those enfeebled conditions of the 122 DISEASES OF BONE. system which are understood to favor mortification, such as the condition induced bj long exposure, privation, and hardship, and particularly the condition following severe and exhaustive diseases, as scurvy, typhoid fevers, and such other disorders as may be presumed to diminish the power of the circulation to maintain itself against the sudden assault of inflammation. With these predispositions, both local and general, the ex- citing causes of necrosis may be enumerated as 1. Exposure to Wet and Cold. I believe this to be a very common cause of the disease. It would seem as if exposure to mere cold, while it has great influence in producing superficial mortification, did not especially compromise the bones ; while the combination of wet and cold is one of the most common causes of inflammation in the osseous structures. The modus operandi, on the bones, of this particular exposure is not more easily explained than the action of the same cause in producing catarrh, bronchitis, or rheumatism. All that can be said is, that it seems to be an analogous process in the case of the bones, intensified by the fact that the bones most liable to suffer are those most liable to direct exposure to the injurious cause, as the bones of the feet and the shaft of the tibia. It would seem, also, that the exposure must be prolonged in order to produce its effect, for we find that most patients report their attack as having come on after long tramping through snow and slush, or after bathing too long in rather cold water, or some such exposure as has been prolonged suffi- ciently to act as an exhauster of the general power of resist- ance, as well as a depressor of the local circulation of the part about to be affected. 2. Injury. In a variety of ways injury may serve as the starting-point of a bone-inflammation, which shall terminate in necrosis. Contusions, lacerations, punctures, detachments of periosteum; fractures, strains, bendings, and crushing of the bone itself; lacerations and exposures 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 constitution and the surroundings of the patient. As a direct and immediate cause of death, injury does not often act. It is, rather, by setting up of inflammatory actions, which, by un- NECROSIS. 123 favorable influences, shall be so modified as ultimately to pro- duce a fatal effect that injury acts ; and thus we may consider violence as rather the indirect and secondary, than as the direct and immediate, cause of necrosis. The inflammations which follow injury to bones are generally localized about the injured parts, and are moderate in their accession, so that it is not till suppuration has taken place, or exposure to the air has occurred, that we find, as an ultimate result, that a limited necrosis has taken place. This is well illustrated in certain compound and comminuted fractures, where the injury to the bone is about as severe as it can be, and yet where, if the frac- ture behave otherwise well, we expect no necrosis to occur; and it is only after long suppuration, and perhaps denudation of periosteum, and exposure of the bone to the air, and to the putrefying discharges of the wound, that we find a small por- tion of the end of the broken fragments has fallen into necro- sis. But besides these cases which may represent the behavior of bone after injury in a healthy condition of the system, and under favorable circumstances, there are a certain number in which a strong predisposition to bone disease existing a mod- erate injury will be the starting-point of severe and destructive inflammation, rapidly terminating in necrosis. Here the ex- citing plays so much less important a part than the predis- posing cause, that it is often difficult, as before remarked, to be sure that the injury has had any thing to do with the pro- duction of the mischief. 3. Mercury. The stomatitis resulting from the use of mer- cury sometimes involves the bones of the jaws in its progress. The action here is more frequently that of caries than of ne- crosis, mainly because the alveolar, rather than the compact tissue of the bone, is attacked. "We do, however, occasionally find that the inflammation creeps along the periosteum, sepa- rating that membrane from the bone, and producing actual necrosis, generally of a limited portion of the jaw-bones. I do not know that I have seen a general or even an extensive necrosis from this cause, the most considerable having been observed in cases where cancrum oris has existed as the pri- mary disease, whose dependence on the influence of mercury has been more than questionable. 124 DISEASES OF BOXE. 4. Phosphorus. Dr. Heyfelder, of Nuremberg, first called attention to the fact that the operatives in match-factories were liable to a peculiar form of necrosis of the lower jaw. His observations were published in 1845, and since that time the disorder has attracted the attention of surgeons in all parts of the world, and much recorded experience has accumulated, giving us a tolerably complete idea of its pathological as well as its clinical history. It is undoubtedly produced by the prevalence, in the air which the sufferers have long been breathing, of the fumes of phosphorus. These fumes are mostly in the shape of phosphorous acid, which is generated when phosphorus is burnt in atmospheric air. How this vapor acts whether by being absorbed into the system, and acting through the general circulation, or whether its action is local, producing its effects by coming in direct contact with the parts liable to be poisoned by it is a question upon which much difference of opinion has existed. It is possible that both modes of action may be combined ; but one fact, which points very strongly to the local character of the cause, is found in the statement that those operatives who have sound teeth are rarely affected with the disease, while those who have un- sound, carious teeth, or spongy gums, are extremely liable to be attacked, and, in particular, it is stated than any who are ex- posed to the phosphorus-fumes soon after the extraction of a tooth are almost certain to suffer. This would seem to render it probable ' that phosphorus, or rather, perhaps, phosphorous acid, has a direct poisonous effect upon the jaw-bones, and this poisonous effect must be much increased by the solubility of the gas in the fluids of the mouth, by which the poison is not only concentrated, but brought into easy contact with all parts of the buccal mucous membrane, acting therefore with peculiar intensity wherever the protection of the epithelium is removed by ulceration, or where any breach of surface lets the poisoned fluid into contact with the bone-tissues to which it holds so mortal an enmity. Why the Schneiderian membrane, which, in the same manner, and at least to an equal degree, is exposed to the poisonous fumes, is not liable to equal injury, it is not easy to explain. 5. Syphilis. Many of the secondary and tertiary symp- NECROSIS. 125 toms of syphilis manifest themselves on the periosteum, pro- ducing often a separation between that membrane and the bone, which is followed by a necrosis. There are also cases where, in the progress of the dreadful ulceration which syphilis sometimes produces in the facial, buccal, palatine, and nasal regions, large portions of the subjacent bone die, and are separated en masse. Still further, there is a form of syphilitic disease of the skull-bones where the action terminates in the death of a portion of the bone, and this death creeps slowly and grad- ually over such extensive districts of the skull, that in some instances almost the whole vault of the cranium is finally in- volved in the destruction. In these, and in some other less marked cases, the poison of syphilis seems to be directly re- sponsible for the destruction of the bone, and this is made more evident by the fact, hereafter to be more particularly studied, that most of these cases of syphilitic necrosis have, in their history, features which are quite different from the ordinary manifestations of the disease, and which are entirely character- istic of the action of a specific poison. 6. Fevers. It is popularly believed that fevers do frequent- ly produce necrosis, and hence one popular name of the disease, viz., fever-sore. It certainly is observed that, after an attack of fever, necrosis declares itself; and it must be acknowledged that the depressed condition of the system, which exists during and after long-continued and severe fever, is a predisposing cause strongly favoring the occurrence of the disease. I am not, however, prepared to say that it is a common result of the idiopathic or of the specific fevers. In my own experience, I have been a little surprised that I have been so rarely able to trace necrosis as a sequel to any regular form of fever, as ty- phus or scarlatina, the history of which has been distinct and unequivocal. Eather, I am inclined to believe that, in most cases, where this disease has been said to have followed a fever, it has been one affection from the beginning, and that affection has been an osteitis terminating in necrosis; the earlier stages of the disease being characterized by fever, more or less con- tinued in type, during which the local symptoms were either unusually slight, or were overlooked, and in which, the fever abating when the abscess had discharged itself, the local disease 126 DISEASES OF BONE. came to be considered as the consequence of the fever of which it was in reality the cause. That this is the case in a large majority of so-called fever-sores, I feel very confident ; that it is uniformly so, I will not positively assert. The seat of necrosis varies very greatly. Mostly confined to the compact tissue of the long bones, it may aifect the can- cellous in any part of the skeleton. Of the cases in which the cancellous tissue is the seat of proper necrosis, I think the greater part will be found to be instances in which the affec- tion has been associated with caries, and in which, therefore, the necrosis is a secondary rather than a primary feature of the disease. This is the fact with a great many cases of those ul- cerations of the bone, with necrosis, which accompany the ad- vanced stage of joint destruction, and it is sometimes observed that a small sequestrum of the cancellous tissue of the articu- lar end of a bone is a fatal element of a joint disease, which might otherwise prove manageable. There are, however, a cer- tain number of cases in which the death of the spongy tissue is the primary element of the disorder, and in which necrosis, commencing thus, presents all the pathological history of the disease as it occurs in the compact tissue. Of this, I have seen two examples in the os calcis, which I have' had an oppor- tunity to verify by operation. We have, in the New York Hospital Museum, one specimen illustrating this fact, in the upper end of the humerus, and one, a syphilitic specimen, in the lower end of the tibia. Again, it is often observed that the cancellous is involved with the compact tissue in extensive examples of the disease, as in the necrosis of the shaft of the long bones, involving some of the expanded extremity ; and, in the spreading form of necrosis of the bones of the cranium, the diploe does not seem to offer any material check to the progress of the necrosis, becoming itself affected almost as rapidly and nearly to the same extent as the external table, which seems to be the primary seat of the malady. These, however, it must be noted, are only offered as exceptional facts, and in contrast to them it should be stated that, in many cases the compact tissue dies, while the cancellous in immediate con- tact with it lives ; and thus we have produced those tubular sequestra in which the outer compact shell of the bone only NECROSIS. 127 has died, leaving a living centre or axis of cancellous tissue which has been able to maintain its vitality. This I have several times observed in those cases where necrosis declares itself after compound fracture, and I have been much discon- certed to find that, after I had removed the most superficial and accessible layer of dead bone, a similar layer surrounded the whole shaft, the extraction of which necessitated a long and difficult operation. In this way are produced the varie- ties we notice in the extent of necrosis. These varieties may be classified as 1. The superficial. 2. The internal or central. 3. The complete, where the whole thickness but not the whole length of the shaft is 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 have, according to Mr. Stanley, the tibia suffering much more frequently than any other bone. The femur is next in order, but at a great distance from the tibia. Then we have the humerus, flat cranial bones, lower jaw, last phalanx of finger, clavicle, ulna, radius, fibula, scapula, upper jaw, pelvic bones, sternum, ribs. This peculiarity of the tibia, disposing it in so eminent a degree to necrosis, seems to be most marked in its upper expanded portion, where not only do we see necrosis occurring very frequently, but many forms of inflammation and abscess, and a large proportion of the malignant as well as other tumors of the bone, find their favorite seat in this portion of the tibia. M. Oilier has thrown some light upon this subject, by the general law which he has discovered, that the extremities, both of the femur and tibia, which form the knee-joint, have in themselves a much greater amount of power of growth and development than the other extremities of these bones, which form respectively the hip- and ankle- joints. This interesting observation has many practical rela- tions, and, among others, it seems to explain how it is that the head of the tibia plays so important a part in the diseases 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 in the scale of vital activity. 128 DISEASES OF BONE. In proceeding now with the further study of necrosis, it will be convenient to take a typical example of the disease, say a case occurring in a young healthy person, in the shaft of the tibia, and of moderate extent, and make it the basis of system- atic study. In pursuance of this study we shall have to notice 1. The pathological conditions and changes which the case presents. 2. The symptoms accompanying and characterizing these conditions. 3. The treatment appropriate to each stage. 1. The Pathological Conditions. The first condition which can be recognized in a case of commencing, necrosis is, without doubt, one of inflammation, involving, we will suppose, the greater part of the shaft. I do not know of any observations which have thrown any light on this pcint in the human sub- ject, but. reasoning from what is observed in experiments upon animals, it seems probable that the whole bone partakes more or less of the inflammatory congestion, of which the central part of the shaft is to be the principal seat. This inflammatory congestion probably is manifested most distinctly by the ves- sels of the periosteum, and Try those of the medulla. "Whether any increased vascularity can be appreciated by the eye in the compact substance of the bone, I cannot affirm. In the portion which dies under this inflammatory effort, no further obvious change occurs. The circulation ceases, and the section of bone is no longer associated in any of the vital changes which go on about it. The dead portion of bone, or sequestrum, as it is called, very shortly becomes of a uniform, pale, waxy, yellow- ish-white color, differing very slightly and yet distinctly from the color of living bone ; a difference which, I think, is some- what exaggerated by maceration and drying of the bone, under which condition we most commonly see it. During all the further changes of the disease, the sequestrum undergoes no change of appearance, except that it may be accidentally tinged by exposure to the various fluids and gases developed about it. The most common of these accidental colorations of the sequestrum is the brownish black which it sometimes pre- sents, where it has long been exposed to the air, in such a way that the surface shall be alternately wet and dry. This, mainly a surface color, stops abruptly at the point where tli3 seques- trum is constantly covered over by soft parts, and is so abiding NECROSIS. 129 that prolonged maceration will scarcely remove it. What the chemical nature of the change is I do not know ; but one would naturally suspect the hydrosulphuric acid, generated in the de- composition of the pus, to be the active agent in its production. The actions which accompany this death of a portion of a bone in the surrounding living textures are more interesting, more distinct, and more important. The outline separating the dead from the living bone is extremely irregular, made so by the fact, probably, that each vascular twig does not fail to maintain itself at precisely the same level, some sustaining life a little further or a little longer than their neighbors. The unevenness of outline thus produced is rather more marked in the cancellous than in the compact substance of the bone, and gives to the extremities of the sequestrum, where they encroach upon the cancellous tissue, a particularly irregular, fissured, and branched outline. When the separation takes place through hard bone, it is sometimes quite smooth and even in its outline. The part of the bone covered by periosteum presents usually a more even and natural surface. Here the line of separation is accurately between the periosteum and the bone, so that the sequestrum is just as smooth and regular as the natural bone would have been if macerated ; while, at the points where dead and living bone have separated, it is, as stated before, extremely irregular and uneven. The action of separation is accomplished by a process of molecular death, and the removal of the particles of living tissue next in contact with those which have died. These par- ticles are removed by the vessels of the living part, by a pro- cess of absorption, which, in healthy and young subjects, goes on with considerable rapidity. Much doubt formerly existed on this subject, whether the line of separation was at the ex- pense of the living or dead bone ; a doubt that had this prac- tical importance, that it left unsettled the question as to whether the sequestrum is capable of removal by absorption. Mr. Hunter showed clearly that the action took place on living particles only, the dead taking no part in the process ; and this view, so entirely in consonance with our ideas of patholo- gical action in other tissues, is now universally accepted. Whether all the bone-matter is removed by absorption, or 9 130 DISEASES OF BONE. whether some portion of it is cast off in the discharges, is another question of some interest, perhaps more pathological than practical. Mr. Bransby Cooper's observations go to show very distinctly that pus, in the neighborhood of diseased and exfoliating bone, contains much more than its usual proportion of phosphate and carbonate of lime, leading to the inference that a portion at least of the bone-matter was thrown off by the pus. These observations of Mr. Cooper's, which have been much quoted, are not published in full detail, the paper in the Medical Gazette, for the year 1845, being merely a sketch of a lecture given by Mr. Cooper on these subjects, and are imper- fect, as far as relates to our point, in not specifying the nature of the diseases of the bones on which the observations were made. While, therefore, they prove that pus from diseased bone contains an unusual proportion of the elements of bone, there is nothing in these observations to show that exfoliation is accomplished by any other than a process of absorption. Indeed, the microscope makes it pretty clear that it is a pure act of absorption ; for all observers agree that the first step in the process is a removal of the earthy matters from the bone- tissue, which is about to be the seat of the change ; and subse- quently to that removal, while the bone is in the condition of fibrous tissue, the real ulcerative or absorptive process goes on. This being the case, it would hardly seem likely that, as the ulceration is progressing in a tissue deprived of its earthy constituents, any of those earthy constituents could be found in the discharges. The act of separation begins 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 lines in width, so that, when the process is complete and the dead bone separated, it is found to be lying loose in a space or cavity which is considerably too large for it, and in which, therefore, it can be moved about sufficiently to indicate to the surgeon, by this mobility, that it is entirely separated from its connections. The surface of the living bone, looking toward and forming the wall of the cavity in which the sequestrum lies, corresponds pretty accurately with the general outline of the dead portion ; and, probably, if the bone were macerated immediately after NECROSIS. 131 separation was accomplished, this correspondence would be still more perfect ; but, as has been remarked above, the cavity is larger than the sequestrum by all the space in which absorp- tion of tissue has proceeded. This space is not always main- tained without change ; for it is noticed in old cases that the cavity is sometimes much larger than the sequestrum, though no bone has been discharged ; and our present views forbid us to believe that the dead bone can undergo any alteration in size. It would, therefore, seem pretty certain that this en- largement is caused by absorption, provoked, probably, by the movements of the sequestrum, or by its pressure at particular points, a view which is strengthened by the fact that the en- largement is not constant nor uniform, in some cases being only at limited portions of the cavity, while the rest embraces the sequestrum so tightly as to prevent its moving freely, even in the macerated specimen. This space between the living and the dead bone is not a vacuum during life, though it appears so when the bone is dried. It is occupied, and usually pretty accurately filled, by soft, luxuriant granulations, which, springing up from the living bone on all sides, form a bed in which the sequestrum lies, and by which its injurious contact with the living bone- tissue is prevented. This layer of granulation-substance, in a healthy subject, is of a firm, ruddy appearance, and represents Nature's endeavors to repair the mischief which has occurred ; which endeavors are of course ineffectual, on account of the presence of what has now become a foreign body. Never- theless, though the main object for which they are thrown out fails to be accomplished, yet the secondary purpose of protec- tion and support to the loose sequestrum is scarcely of less im- portance for the comfort of the individual ; and it is worthy of remark, and I think of special admiration, that this admirable cushion fulfils its duties so well, that the patient may carry a large and rough sequestrum for many years, without ever being sensible of its motions, and without the least sensation of suffering from its contact with its living tissues. This arises from the fact that Nature not only provides this soft layer of protecting granulations, but makes them so firm and so callous in their endowments that they are entirely insensible to any 132 DISEASES OF BONE. painful contact, while they are sufficiently consistent to secure the immobility of the otherwise loose sequestrum. The granulations thus lining the cavity secrete a moderate quantity of pus, which finds its way out of some of the open- ings in the surrounding bone. In a healthy person this dis- charge is exceedingly small in quantity, amounting, even from a large cavity, to only a few drops in twenty-four hours. This, however, is liable to the greatest variations, both in quantity and quality. In some cases the discharge is so con- stant and profuse as to be in itself an element of danger to the patient's life ;. and there are others where, temporarily at least, it ceases altogether. It may always be accepted as a favorable sign, when this discharge is small in quantity and healthy in appearance ; and it should always excite apprehension of pro- gressive local disease \vhen it is ill-conditioned and profuse. Mingled with this pus, blood is sometimes seen, doubtless from the friction of the rough sequestrum against the granulations ; and, when it is from this source, it is usually in very moderate quantities. Large quantities of blood, issuing rapidly from a case of necrosis, indicate a different source and a much more serious danger, as will be hereafter particularly explained. While this process of separation has been going on, other changes have been taking place in the surrounding soft parts, which we must now study. Nature, as if anticipating the result which must follow the separation between the dead and living bone, summons up her reparative activities to supply that support to the limb which is about to be destroyed by her own hands ; and, long before the actual solution of continuity has taken place in the shaft of the bone, we find that the com- pensatory strengthening process has made sufficient progress to prevent any evil consequences from the break. This pro- cess consists essentially in an ossification, springing from the parts surrounding the dead bone, which, reaching from the living bone above to the living bone below, bridges over the breach, and forms a sort of ferule of new bone, which, by its abundance and perfect organization, more than supplies the wanting support. Out of this important and very interesting process grow many of the most striking features of the disease we are studying, both clinical and pathological ; and it may even NECROSIS. 133 be affirmed that most of the indications for and the success of any treatment that may be instituted for the cure of the mis- chief, must be founded on a careful consideration of this action of Nature, and that upon its perfection or imperfection will necessarily depend the future usefulness of the member. It is now generally conceded that the new bone is derived from four different sources, viz., the periosteum, the medulla, the old bone in immediate proximity, and the nearest sur- rounding; soft parts. These are all believed to contribute their share in supplying the new material, but under very varying circumstances ; and there are few questions upon which opin- ions have been more fluctuating and contradictory than upon the relative efficiency of each source of supply. From the time of Duhamel, whose first memoir was published in 1T39, the opinions of most of those who have made this a subject of study, has been unequivocal in favor of the periosteum as the principal agent in this ossification ; and more recently M. Oilier, of Lyons, has demonstrated, by a series of careful and well-con- ducted experiments, fortified by abundant observation on the human subject under various conditions of disease, that not only is the periosteum the principal source of ossific supply, where bone has been removed by disease or operation, but that, in fact, the other parts mentioned play a very subordinate and insig- nificant part in the process. M. Oilier conducted his experi- mental observations on dogs, cats, rabbits, lambs, pigeons, etc., and carefully studied to make the necessary operations in such a manner as to interfere with his results as little as pos- sible. In this, by practice, he became very skilful, and hence his operations deserve more confidence and illustrate more distinctly the points he wishes to make, than those of most of the experimenters who have preceded him. Some of the most important deductions of M. Oilier are 1. That the periosteum is the great source of reproduction of bone under all ordinary circumstances. 2. That the periosteum presents two layers, an inner and an outer one, of which the inner alone is endowed with the bone-producing power. 3. That the medulla is not, under ordinary circumstances, disposed to the formation of new bone ; but that it is, under conditions of irritation, capable, to a certain extent, of such production, but always in a much 134 DISEASES OF BONE. inferior degree to the periosteum. 4. That the bone-substance itself may also give rise to a growth of new bone, but that its powers are much more limited than those of the medulla. 5. That though in certain exceptional cases the surrounding soft parts can accomplish a partial bony reproduction, yet, practically speaking, such reproduction is not to be expected, when the whole, or a portion of a bone, with its periosteum, is removed. These views of M. Oilier are so nearly in accord- ance with the opinions of the best observers who have pre- ceded him, and are so well defended in his work, that I think they may be accepted as expressing the view most generally received on this subject, and as being as near the truth as the present state of science permits us to arrive. Nevertheless, there are not wanting those who differ from him toto coelo. Of recent observers, Marmy, of Lyons, quoted by M. Oilier, asserts that in his experiments he has succeeded better in procuring a reproduction of lost bone by removing than by preserving the periosteum ; and Hein, of Dantzic, though he does not deny the utility of the periosteum, thinks that the surrounding tis- sues may very well replace it. In the case of necrosis, which we are now studying, we will suppose that the whole of the middle portion of the shaft has perished. In such a case, the dead portion is immediately surrounded by its periosteum, and in contact above and below with the living portions of the shaft, the medulla being sup- posed to have perished with the bone. We have here, there- fore, only two sources from which the supply of new bone can be derived, viz., the periosteum and the adjacent old bone. It is observed of the periosteum that it soon begins to vascnlar- ize, and take on granulation action by its internal surface, which surface is separated by these granulations from contact with the sequestrum. "We have already seen that, at the point where the dead separates from the living bone, the sur- face of the living bone becomes also covered with a layer of granulations. It is in these, probably, that the further changes occur. It was formerly held that these granulations were the forming stage of an exudation or plasma, thrown out in a fluid state, which, coagulating, developed itself into the new bone. Yirchow has shown that, at least in many examples, such ex- NECROSIS. 135 udation does not occur, and his theory is, that there is no such thing as spontaneous organization of living forms in any ex- uded fluid, but that such actions are to be referred to a growth or proliferation, as he terms it, of germs which, already exist- ing in the tissue, assume the actions of increase and develop- ment under certain conditions of excitation. Whether Yir- chow's views are to be accepted in all their extent, or, indeed, whether they are applicable to the question before us, need not now be insisted on ; but it is somewhat interesting to observe that, after the lapse of more than a century, Duhamel's original idea, that the periosteum itself is converted into the new bone, is so nearly identical with that which the distinguished Berlin professor now so strongly and so ably advocates. The periosteum then gradually becomes thickened and vas- cularized, and on its internal aspect begin to be seen the first traces of ossification. This action, it must be remembered, begins very early in the case, and may be considered to be complete generally in the same space of time that is occupied by the separation of the dead from the living bone. Large quantities of new bone are deposited thus round the seques- trum, until finally it becomes enclosed in a casing of new bone which is in reality much more bulky and much stronger than the original bone, whose loss it is intended to replace (Fig. 18). The pus which is secreted from the granulation surface finds its way out through fistulous openings, at various points in the periosteum ; and, as new bone is not deposited at these open- ings, they remain as outlets through the bony casing by which, through fistulse reaching to the cutaneous surface, the pus finds exit. These openings are termed cloacre (Fig. 19). While this action is taking place in the periosteum, the bone-tissue, which borders on the cavity containing the seques- trum, is presenting analogous phenomena. It is becoming vas- cularized, and giving origin to granulations which have a ten- dency, when the sequestrum is removed, to be converted into bone, and thus assist in filling up the vacuity which has occurred. It is noticed, however, that this action is extremely limited, and by itself constitutes a very unreliable source of supply. In cases where the periosteum is not preserved, the amount of new growth, from the ends of the living bone, will 136 DISEASES OF BONE. not serve even to unite the extremities of the gap, much less to fill it up. In cases, again, where the periosteum is preserved and contributes its usual share to the filling up of the cavity, FIG. 18. (From Billroth.) FIG. 19. (From Erichsen.) the new bone which it deposits, and that which comes from the ends of the old bone, are so amalgamated together, that the share of each cannot be recognized, and it is only by observing those cases in which the periosteum does not enter into the reparative action, that we can distinctly see how very limited a power of producing new bone is exhibited by the old bone in its neighborhood. NECROSIS. 137 The sequestrum being thus separated, and the loss being repaired, or rather compensated for, by the growth of new- bone, the getting rid of the sequestrum is the next point which demands our attention. In those forms of necrosis where the dead portion is small and superficial, there is usually no en- closure of the sequestrum within the involucrum in such man- ner as to prevent its extrusion ; so that no mechanical obstruc- tion prevents its being cast out. We usually observe, there- fore, in such cases, that, as soon as it is entirely loose, the se- questrum begins to make its way to the surface, in obedience to a law by which foreign bodies, lodged in the tissues, find their way toward the nearest surface by which they can con- veniently be discharged. The process seems to be one in which the granulations press on it behind, and are absorbed before it FIG. 20. {From Billroth.) in such a way that it gradually works toward the surface, and finally projects at one of the fistulous openings, whence it is easily withdrawn (Figs. 20 and 21). This disposition of these small sequestra may serve to indicate to us the intentions of FIG. 21. (From Billroth.) Nature with regard to the larger ones, which we are now par- ticularly studying. The intention undoubtedly is to extrude the larger as well as the smaller sequestra, and the extrusion 138 DISEASES OF BONE. would, I doubt not, be more often accomplished if it were not for the mechanical obstacle which is presented by the unyield- ing involucrum in which the dead bone is imprisoned. Exam- ples are not unfrequent in our museums of large sequestra which are gradually liberating themselves from imprisonment, and projecting themselves toward the surface. This course is, perhaps, sometimes determined by a large and favorably-situ- uated cloaca, or possibly by a partial absence of involucrum at a certain point ; but while it may not often serve to free the patient from his encumbrance, it does certainly show that there is probably in all cases a tendency, more or less decided as it is more or less resisted, to the spontaneous extrusion of sequestra. This action, though conservative in its intention, is not with- out its dangers and inconveniences. We have, in our museum at the college, a specimen in which such a sequestrum, thus partially extruded, has eroded the popliteal artery, causing the death of the patient from haemorrhage ; and I have seen another case in which destruction of the knee-joint, with com- pete bony anchylosis, was produced by a similar cause. While, therefore, it is important to recognize the fact that there is a tendency toward the throwing off of these foreign masses, by Nature's spontaneous actions, yet it will be found that in practice not much can be expected from her efforts ; and, as a general rule, it may be stated that, where the sequestrum is enclosed in a bony involucrum, surgical assistance is required to remove the mechanical resistance to its expulsion. Where this assistance is withheld, the case will pass on for years, even for a long lifetime, without any material change either in the condition or the position of the sequestrum, which has now be- come the mere mechanical cause of the symptoms under which the patient will thus long continue to suffer. Of this imprison- ment of the sequestrum within the involucrum, Fig. 19, taken from Erichsen's surgery, is a good example, though the cloacae are commonly much smaller, and the imprisonment therefore more complete, than here exhibited. The symptoms which characterize these different stages of necrosis may be studied 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 ; NECROSIS. 139 2. The period of sequestration, during which the separation is proceeding and the involucrum being formed ; and 3. The pe- riod of retention, during which the sequestrum remains as a foreign body within the involucrum. 1. The inflammation which produces such a necrosis as we have chosen for our type of the disease is almost invariably an acute attack. At a certain period, after the action of some of the causes we have noticed above, pain and swelling attack the limb, which soon becomes the seat of severe and manifest phlegmonous inflammation. The whole limb (the leg, for ex- ample) is involved in this inflammation, which indeed often extends to the foot below, and to the thigh above. For this reason it is often difficult, in the early stages, to decide accu- rately where the effects of this violent and extensive action are to concentrate themselves. It is in this stage that most of the mistakes are 'made by practitioners of limited experience, and the disease is looked upon as erysipelas, simple phlegmon, or rheumatism, until the progress of the case throws light upon its nature. No man can with certainty pronounce a positive diagnosis, in all cases of inflammation, which are to terminate in necrosis ; but the possibility of such a chain of symptoms, depending on osteitis, leading to necrosis, being borne in mind, it is not likely that the careful observer will long be deceived. This inflammation occurring, as it does, in young and some- times vigorous subjects, passes through its stages rapidly, and soon terminates in suppuration. We have seen that the first exudations probably take place between the periosteum and the bone. It is here, also, that suppuration begins, and, sepa- rating the periosteum from the bone, distends that membrane as far as its unyielding nature will permit. This is the period which is accompanied by the most urgent symptoms of fever and pain ; and when the periosteum gives way, and the matter escapes into the surrounding soft parts, the severity of the suf- fering is somewhat relieved. Through these soft parts, which participate in the general inflammation, the matter makes its way to the surface, sometimes only after having accumulated to a very large extent. Naturally or artificially the pus is finally evacuated, and the first stage may be regarded as ter- minated. This stage is marked by very severe constitutional 140 DISEASES OF BONE. disturbance, very high inflammatory fever, and active delirium, sometimes existing during all the earlier days of the attack. This fever with delirium is often mistaken for typhoid fever the delirium masking the local complaint, so that attention is not called to the suffering limb, till inflammation has made extensive progress. When the pus is evacuated, a sensible im- provement occurs in the general symptoms, as well as in the local sufferings. The fever abates rapidly, the pains cease in a great degree, the great swelling subsides, and every thing seems rapidly returning to a condition of health. Here, again, a false hope is apt to be entertained that the cure of the ab- scess will be the cure of the disease, and the patient is flattered that he will soon be entirely well. Instead of this, however, it is found that the abscess does not heal. Fistulous openings continue to discharge pus, the limb remains swollen and ten- der, and it is liable to occasional recurrences of inflammation, which are sometimes almost as severe as the original attack, and are attended by the formation of new suppurative tracks, which at new points communicate with the cavity of the in- volucrum. On examining the limb at this time, it is found that the swelling and induration of the soft parts are gradually disappearing, while a deeper and firmer enlargement is taking their place, which is manifestly due to the gradual formation of the involucrum. This is the condition of the limb during the process of sequestration. When the sequestrum is fully detached, and after the in- volucrum is completely formed, no marked change takes place in the symptoms. The abscesses have gradually contracted down to fistulse, the orifices of which present a few large, soft, pouting granulations, which are characteristic of the presence of a foreign body at the bottom of the fistula. The soft parts have resumed their natural condition, and the deep involucral swelling has become of a bony hardness and almost insensible to pressure. The discharge continues constant, but usually small, from the fistulous 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 indefinitely with but little variation. If the fistulse show a disposition to heal, the matter accumulates and gives rise to a renewal of NECROSIS. 141 some of the old sufferings until it again finds its way to the surface. As a rule, the fistulas do not heal even for a short time, and I believe never permanently, while the sequestrum continues unremoved. I have thus presented an outline of the ordinary course of one of the most characteristic and common forms of necrosis. During the course of this disease the patient is exposed to sev- eral sources of danger which are worthy of being separately noticed. In the first place, when the death of bone has in- volved the tissues near the joints, these may become implicated directly or indirectly in the consequences of the disease. It is always noticed that, when the sequestrum is near the joint, the surrounding inflammation reaches to the fibrous structures of the joint, which gradually grows stiffer and stiffer, until the use of the joint is seriously impaired, and often till complete immobility is established. This is particularly marked in cases of necrosis of the lower end of the femur, where the knee-joint is apt to become the seat of a false anchylosis, which is often complete enough to entirely abolish its movements. This is a condition which is a necessary consequence of the proximity of the disease, and one which therefore cannot be entirely pre- vented. Something may be done, however, by encouraging the patient to practise the movements of the rigid joint sys- tematically and regularly, and thus in some degree obviate the increase of the trouble. But, the most important practical indication to be deduced from this well-known tendency to impairment of a neighboring joint is, to remove the cause of the impairment as soon as possible, by getting rid of the se- questrum. If for no other reason an operation is required, this is always a good one. I had under my care, a few years ago, a member of our medical class, who had suffered for years with necrosis of a limited extent in the lower end of his femur. For some reason he had not been advised to have it operated on, and he had submitted to its annoyances, and had attended lectures regularly, until he began to find that the knee, which had long been getting stiff, was fast becoming useless. He then consulted me, and I advised an operation, which was per- formed, and a considerable sequestrum, of the compact layer of the condyles just above the joint, was removed. The wound 142 DISEASES OF BONE. healed rapidly and perfectly, but the stiffness of the joint was no more tractable than it had been before. Under these cir- cumstances, anxious to fill a hospital appointment which his merit had secured him, and ambitious to distinguish himself in his profession, he begged me to try forced flexion of the joint. The original wound made in the operation being several months healed, and there being no evidence of any disease about the joint, I thought it a favorable case for this proceeding, which I accordingly adopted. Placing him under ether, and having arranged a couch with reference to the leverage of the leg, I made the most powerful efforts to break up the adhesions, but with only a partial success, which, though it procured him some increase in the movement of the joint, did not satisfy him. At his urgent request, and sympathizing with his brave determi- nation to fit himself for life's duties, I made, a few weeks after, another attempt, and, being better prepared with my mechani- cal arrangements, and perhaps being more determined to suc- ceed, I made more strenuous efforts to move the obstinately- rigid joint, when all at once, while I was trying to force flexion as far as I could, something gave way with a snap, and the joint yielded in the most satisfactory manner. I was shocked to find, however, that this success had been secured at the ex- pense of a considerable laceration of the integuments of the anterior aspect of the joint at a point where there had been some cicatricial adhesion of the skin to the bone, from long-past inflammation, and still more alarmed to find that this lacera- tion, of some inch and a half long, admitted the finger into the cavity of the knee-joint. I instantly closed the wound, and placed the joint at perfect rest, and had the good fortune to secure immediate union, without a bad symptom on the part of the joint, and I had the satisfaction to find that I had gained a degree of flexion which was amply sufficient for the ordinary use of the limb, and which he not only retained, but by perse- vering effort considerably improved upon. Another mode in which the joints become involved by necrosis, and fortunately a rare one, is by death of cancellous tissue reaching to the articular surface itself. When this oc- curs, there is sometimes a protective inflammation which shuts off the general cavity of the joint from the effects of the sepa- NECROSIS. 1 43 ration of and suppuration round the sequestrum, and the dead piece may be removed without really opening the synovial cav- ity ; or this protective inflammation may be wanting, or of an unhealthy character, allowing contact of the morbid fluids with the synovial cavity, and thus producing a general arthritis which is apt to be destructive in its tendencies, the more so from the constant presence of the exciting cause. Of this we had a good exemplification in a syphilitic patient in the New York Hospital, who had been long suffering from disease of the lower end of the tibia, embracing the internal malleolus. This falling into necrosis, involved the joint in acute attack of inflammation, which soon rendered amputation necessary. The specimen, when macerated, showed a considerable disk of the cartilaginous surface forming part of the sequestrum, which was almost ready to separate. Similar facts have been re- ported in many instances ; and the whole subject of the dan- ger to joints from their proximity to sequestra is most impor- tant, as suggesting the early removal of the dead portion of bone, before the evils apprehended have had time to occur. A second danger in necrosis is haemorrhage. We have seen that the sequestrum when separated has a tendency to work its way toward the surface, and that, when it is not re- sisted by the imprisoning involucrum, a large sequestrum will sometimes be thus extruded. In working its way thus among the tissues, it is liable to encounter some artery of importance which may be eroded by its pressure. In vessels of moderate size, and sometimes, doubtless, in the main trunks themselves, Nature institutes a protective process against such erosion, and the vessel is closed by fibrine before its coats are perforated, and haemorrhage is thereby prevented. Unfortunately, however, it does sometimes happen either that the protective action is im- perfect, or that the destructive effect of the sharp edge of the bone is too sudden and rapid for the calibre of the vessel to be entirely sealed, and haemorrhage takes place. This accident, as far as I have observed it, always takes place in the largest trunks, small vessels being so much more likely to be safely plugged than large ones, and this pathological fact has, I think, great practical significance ; for, if we can confidently pro- nounce that the haemorrhage, in a given case of necrosis, has 144 DISEASES OF BONE. its source in the erosion of a large trunK, ana not of a small branch, it is evident that the case from that fact assumes an importance which is immediate and pressing. And it is the more necessary that this should be fully appreciated, because these haemorrhages are sometimes exceedingly deceptive in their behavior, and some of those which first occur, even from the largest trunks, are quite trivial in amount, and are easily checked, or stop spontaneously. This is extremely apt to de- ceive the surgeon into the belief that the bleeding vessel is not large, and that the danger is not great. It may be a fatal mistake. We have, in the college museum, a beautiful preparation taken from a medical gentleman of this city, who had been suffering from necrosis of the femur for many years. On a sudden, without assignable cause, he was attacked with haem- orrhage, the blood flowing quite freely for a time from the fis- tulous openings, and then ceasing of its own accord. Once or twice bleeding recurred, always stopping in a short time spon- taneously, but nevertheless reducing him considerably by the whole amount of blood lost. Finding the bleeding so moderate and so controllable, neither he nor his medical advisers took serious alarm until a day or two after, when a rapid and pro- fuse haemorrhage brought him almost to death's door. In this unpromising state amputation was performed, but too late to save the unfortunate gentleman from a death clearly due to a non-appreciation of the pathological condition which the speci- men most sadly illustrates. It shows a large, sharp-edged se- questrum, which, having partially emerged from its bed, had worked its way down toward the popliteal space, and there, by erosion, opened the popliteal artery. By contrast, another case occurred to my colleague, Dr. Gurdon Buck, who had under his care a boy of about twelve or fourteen years of age, with a very extensive necrosis of the femur. As it was during the hot season, and, as the patient w r as much reduced by his disease, an operation was postponed, and the boy was allowed to go about, hoping that his health would improve as the cooler season arrived. In fact, he was improving very greatly, when, after a moderate walk, he found his pantaloons and shoe of the diseased side filled with blood. This bleeding stopped of itself, NECROSIS. 145 but, from its extent and rapidity, Dr. Buck believed it to be from a main trunk, and stood ready on the occasion of its re- currence, which soon took place, to amputate the limb, which he did quite high up, and the boy's life was saved. Dissection showed that the upper sharp point of the sequestrum had opened the femoral artery not far from the origin of the pro- funda. This specimen is preserved in the New York Hospital Museum. I have examined carefully, during the last twenty years, thirteen cases of necrosis in which haemorrhage occurred of sufficient severity to require surgical interference. In every one of these it was the main artery of the region which was the source of the haemorrhage, except in one case, and then it was the vertebral which had been eroded by a fragment of dead bone, from a pistol-wound, which was in a favorable state of healing when the fatal haemorrhage occurred. In each case the coats of the artery were eroded evidently by the direct contact of a sharp edge of the sequestrum, with one exception, and then, though the main artery was opened, and a sharp sequestrum was quite near, we could not pronounce positively that the hole observed in the side of the artery was actually due to the pressure of the sharp edge of bone. The number of observations is too small to decide the point that small vessels never bleed from the cause we are studying; but the testimony of these few is so nearly uniform that I think it may safely be accepted as a pathological law, and I am quite sure it affords our soundest practical indication. Precisely what that indica- tion is, must be settled by the features presented by each case ; but it is hardly necessary to say that the remedy does not con- sist in the mere removal of the cause of the mischief, that is, the sharp edge of the dead bone. "When that is removed, there remains the opened artery to be cared for, and, if my position is correct, that this opened artery is a main trunk, very little hope can be entertained that ISTature will be able to close the wounded vessel without assistance from art. Two courses present themselves to the surgeon in this seri- ous emergency : The first is, to make an attempt to reach and tie the wounded vessel ; and the second is, to amputate if the ligature cannot safely or successfully be undertaken. The 10 146 DISEASES OF BONE. point of urgent importance, however, is, in my judgment, not to delay till a sudden gush of blood places your patient be- yond the hope of benefit from any operation, be it ever so clearly indicated, or ever so skilfully performed. The two following cases, which have recently come under my observation, illustrate extremely well the points of practice I have here dwelt upon : Martin Clancy, aged twenty-four, an oysterman, was admit- ted into Bellevue Hospital, October 29, 1869. He was extremely feeble and exsanguine, and stated that he had been bleeding for five days from an ulcer in his thigh. This bleeding had occurred suddenly, without obvious cause, and had stopped spontaneously for a time. It had recurred several times in the same unprovoked manner; and by the frequency of these bleedings, some of them very large, he had been reduced to his present alarming condition. He had worn a tourniquet for many hours before his arrival at the hospital, put on by his surgical attendant out-of-doors. It was clear, from the exami- nation of his case, and from its previous history, that he had had necrosis of the lower part of the femur, dating back seven years, and several openings existed in the popliteal region, from which the blood had issued. The probe detected a large sequestrum, lying loose and quite superficial ; and the question in consultation was, "What was the vessel opened ? From the amount of blood lost, from the spontaneous character of the bleedings, and their persistent recurrence, and from the situa- tion of the sequestrum, we had no hesitation in deciding that it was the popliteal trunk that was injured, and in determining to cut down and remove the sequestrum, and, if possible, apply a ligature to the artery. The operation was performed by Dr. A. 'B. Mott, and was truly a difficult and delicate one. An incision, seven inches long, was made over the course of the artery, embracing as many of the fistulous orifices as pos- sible, and soon a large cavity was exposed, occupying most of the popliteal space above the knee, in which lay loose a large, flat, sharp-edged sequestrum, evidently formed by the death of the compact layer of the posterior surface of the femur, just above the condyles. This removed, left a bed of granulations, in which it had rested ; but no haemorrhage could, at the mo- NECROSIS. 147 ment, be induced, by which a clew to the injured artery might be gained. The operator was obliged, therefore, by a most tedious and cautious dissection, among parts consolidated by long-continued inflammation, to search for the artery, guided by a pulsation, which, in this indurated condition of parts, and in the feeble state of the circulation, was of very little assist- ance. After a long search at the upper part of the cavity, the artery was exposed, and carefully traced downward, until we arrived at a ragged opening on its side, from which, on loosen- ing the tourniquet, the blood now spurted freely. A ligature was applied above and below the opening, the two ligatures being about an inch apart. The wound was only partly closed, leaving its central portion open, and was dressed lightly. Ev- ery thing went on favorably. No haemorrhage occurred, and the man gained rapidly in appearance and in strength. The wound granulated well, and filled up so rapidly, that, by the 19th of December, it was almost healed, and on the 31st he was discharged from the hospital. He could then, about nine weeks after the operation, walk quite well, though he could not flex the foot. No pulsation in anterior or posterior tibials. His health seemed to be perfectly reestablished. The second case was not so fortunate in its results, and is a noteworthy illustration of the formidable nature of the accident we are studying, because the gravity of the situation was fully appreciated from the moment the accident occurred, and every thing that science and skill could do was done, and done promptly, without achieving the saving of the patient's life. The case occurred in the practice of my friend Dr. George A. Peters, of this city, and by his kindness I had the opportunity to study the specimens in their recent state. The patient was a gentleman about forty-five years of age, of ordinarily good health and active habits. He had had several attacks of in- flammation about his knee, the earliest one occurring in child- hood ; and on one occasion he had had a slight exfoliation of bone from the lower part of the femur. He had of late years entirely recovered from the effects of these attacks ; and, with the exception of a slight stiffness and lameness of the joint, he considered himself a well man. Dr. Peters was summoned to him at his residence, out of town, one Sunday morning in Sep- 148 DISEASES OF BONE. tember, 1869, and found that he had had that morning, while making some slight movement in bed, a severe haemorrhage, which had reduced him to an alarming point of prostration. The history given was, that about two months previously, an inflammation had declared itself in the old seat of disease in the ham, and had gone on slowly to suppuration, and had been opened by his attending surgeon in two places. The inflam- mation subsided somewhat, but the abscess did not heal ; and, though he was able to keep about his business, he suffered more or less constant inconvenience from his disease. He had only been confined to the house a few days ; and, beyond a slight increase in local suffering, no new features had devel- oped themselves when the haemorrhage took place, as above stated. The bleeding had been so severe, that, although no recur- rence had taken place, his alarming condition warranted the most extreme measures to prevent a renewal of it. The wound was therefore opened freely, and a large cavity exposed, occu- pying the popliteal space, 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 surface ex- tending several inches up the bone and downward, so as to involve the knee-joint, into which, through the ulcerated liga- mentum "Winslowi, the finger could easily be passed. A small, thin, and very sharp detached fragment of bone lay loose in the cavity. The condition of extensive disease of the femur, the opened knee-joint, with the almost certainty of the poplit- eal artery being eroded, seemed to justify and to demand am- putation of the limb, which was performed without delay, almost without loss of blood. So great was the depression of the system, that no proper reaction took place, and he died during the night following the operation. On examination immediately after the operation, the large cavity, mentioned as occupying the popliteal space, was found to extend far round the femur on each side; and into it, therefore, the whole posterior and lateral surfaces of the end of the femur formed a sort of projection. All the bone-surface thus exposed was bare, rough, irregularly eroded, presenting only here and there a granulating surface. The knee-joint was NECROSIS. 149 filled with pus, and rapidly disorganizing. The popliteal ar- tery ran along the superficial wall of this cavity, but very close to the exposed bone-surface, and, at about the centre of the popliteal space, was opened by a clean oblique cut, just such as is usually made in the operation of venesection. 'No other detached sequestrum was found. After maceration, the end of the femur was found to be light, porous, and spongy ; the medullary cavity very large, and the cancellous tissue very open. Both the posterior and lateral, and some of the anterior surfaces of the bone, were irregularly eroded, the posterior much the more deeply. Almost all the compact portion of Fio. 22. (From N. T. Hospital Museum.) FIG. 23. (From N. T. Hospital Museum.) the shaft, where it is not destroyed by erosion, has become porous as well as thin. At several points, where this compact lamina still remains undestroyed, a dull, white, opaque appear- ance of the surface indicates that it has suffered necrosis. Such a necrosed plate, separating from the posterior surface, was undoubtedly the cause of the wound in the artery. The 150 DISEASES OF BOXE. same necrosed appearance penetrated at points into the sub- stance of the cancellous tissue, which had evidently been ex- tensively infiltrated with pus. In some points small cavities existed, which doubtless had contained pus, and which did not communicate with the surface. No loose sequestra were to be found. At the point of amputation the bone has become harder than natural, with some small exostotic growths on the outskirts of the inflamed region. That the danger from haemorrhage in necrosis is a real and a formidable one, even in circumstances most favorable for prompt surgical assistance, will perhaps more clearly appear from the statement that, of eleven cases which I have met with, mostly occurring in the New York Hospital, six have died. In ten of these every thing was promising well when the haemorrhage occurred ; and in every case but that of the vertebral the injured vessel was accessible to ligature, or the limb might have been removed by amputation. These things taken into consideration, my recommendation of promptness in operation receives an emphatic indorsement. Delay in hope of saving the limb is fatal to life. Fig. 23 represents the lower end of a femur where amputa- tion was performed for haemorrhage from the popliteal artery, which had been opened by a sharp sequestrum detached from the posterior surface of the femur. The specimen is curious from the peculiar manner in which the bone is perforated by the actions going on round the bed from which the sequestrum came. It is in the New York Hospital Museum. The last danger to which I shall allude is exhaustion. In a feeble subject, with extensive necrosis, we sometimes have thrown upon the powers of Nature more than they can bear. The reparative actions, which should be promptly and health- fully excited as soon as the inflammatory stage is passed, are replaced by the continuance of inflammation in a subacute form, accompanied with a profuse secretion of pus. No proper involucruni is formed. The tissues are largely infiltrated with inflammatory products. The tenderness and pain do not dis- appear. The line of separation forms slowly and imperfectly. In short, the whole process is a morbid instead of a healthy one ; and the patient's condition corresponds, in an excited, NECROSIS. 151 irritable pulse, irregular hectic fever, want of appetite, ema- ciation, and all those numerous evidences that inflammation rather than reparation is going on about the seat of disease. Here, every thing depends upon the surroundings of the patient, and the assiduity with which wholesome and proper regimen is brought to bear upon the overtaxed powers. The best of air, the best of food, tonics, invigorants, stimulants, will, happily, in most cases, carry the patient through the period of danger ; but, if the condition do not soon improve, if the ex- haustion be gaining upon you rather than yielding to your efforts, remember that this very condition is reacting upon the local state, and making bad conditions daily worse, and it is well to be very circumspect lest, in the anxiety to save a limb, you sacrifice a life. This form of danger from exhaustion be- longs to the early stages of the disease, and depends very much upon original weakness of constitution. When once an involu- crum has formed, and the patient has recovered a partial use of his limb, the danger of exhaustion from continued drain by the suppuration, in my own observation, is confined to those in whom some other accidental complications have conspired with the original disease to depress the vital powers, and in such cases the source of danger belongs more to the complication than to the primary disorder. Having thus passed in review the principal features of a case of necrosis which has been selected as a type of the dis- ease, we must now look at some classes of cases in which im- portant deviations from this standard course present them- selves. Among these varieties of necrosis entitled to special study we have 1. Superficial necrosis or exfoliation. 2. In heads of bones near joints. 3. In cranial bones. 4. In jaw- bones. 5. After fractures. 6. After amputations. T. With- out suppuration. 8. Without exfoliation. 1. Superficial Necrosis, or Exfoliation. This simplest and most common form of necrosis differs from that we have been studying, mainly in the fact that we trace little or no evidence of any reparative or compensatory process when the separa- tion ia taking or has taken place. Hence we have no involu- crum enclosing the sequestrum, which usually lies exposed in 152 DISEASES OF BONE. the cavity of the suppurating soft parts. The granulations which form its bed, after separation is complete, push it with- out difficulty toward the surface, where it either makes its way out with the discharge, if it be small, or, if it be large, presents itself at the opening of one of the fistulse, whence it can easily be removed by the surgeon. In this way a large number of slight necroses, produced by detachments of periosteum, or after fractures, or after operations on bones, pass through their va- rious stages so easily and with so little disturbance, as scarcely to constitute a complication of the wound, or materially to re- tard its healing. There are certain cases, however, where this superficial necrosis becomes formidable from its shape and ex- tent. It sometimes happens that a considerable portion of the surface of the bone undergoes necrosis, so that the shaft of a long bone may present on all sides, and in the greater portion of its length a necrosis, which is entirely superficial, affecting only the outer compact layer. As a spontaneous disease this occurs most often in children, in whom some sudden inflamma- tion of the periosteum has produced the disease, without the bone itself being seriously implicated. This was well illus- trated in the case of a little boy who recently died in the New York Hospital. He was received in consequence of injuries from the passage of a rail-car over his right foot. About a week after, he began to complain of pain in his left tibia, which was not known to be injured. This was the 19th of July. Soon phlegmonous inflammation developed itself, occupying the whole leg, and extending above the knee and below the ankle. August VZth. The abscess was opened, giving issue to a very large amount of pus. The matter found vent at several points, and it soon became evident that the tibia was extensively diseased. The probe found dead bone at all points, the integuments were undermined, the discharge fetid, and the little fellow suffered greatly. He was rapidly sinking from his disorder, when amputation was proposed to save his life. It was refused by his friends, and he was soon reduced to a mere skeleton by his sufferings and the immense discharge from the cavities. He lingered until the 20th of September, when he died. The whole tibia was found to be diseased. The exter- nal compact shell had died almost in its whole extent, and at NECROSIS. 153 one or two points a partial exfoliation had commenced. With- in this outer dead shell the bone-tissue was in a state of in- flammation. It was congested with blood, softer than natural, extensively eroded on its epiphyseal extremities, and from several points exuberant growth of layers of new bone, still soft, showed an attempt on the part of Nature to form an in- volucrum. So soft was the bone-tissue of the head of the tibia that it broke off in removing it, and could be crushed by the fingers. The sequestrum, if removed, would have formed a thin tube, representing all the external layer of the shaft of the tibia. 2. Necrosis occurring in Heads of Bones near Joints. Here the significant feature is, the relation of the disease to the articular cavity. The sequestrum may either extend into the joint, or it may lie near it without involving the articular lamella. In the first case, the danger of destructive inflam- mation of the joint is very great, and in many instances, I think, I have seen evidence that the presence of a small se- questrum has been the cause of an unfortunate termination of a joint disease, which in other respects might have had a favorable issue. This is the result usually to be anticipated where the sequestrum reaches actually into the joint, but I have seen more than one instance where this condition ob- tained, and where, nevertheless, the integrity of the joint was not compromised. Thus, I had a young man under my care who had, over the external malleolus, a foul and ill-behaving ulcer, which was probably syphilitic in its origin. It had ex- isted for many months, and, when I saw it, had exposed a con- siderable portion of the external malleolus, which, dead and dry, formed the bottom of the ulcer. Seeing that in all prob- ability the sequestrum involved or would involve the articular surface, I feared the consequences to the joint when the separa- tion should occur. His general condition was strengthened by appropriate treatment ; the character of the sore improved, and very soon the dead piece became movable. It was not dis- turbed until it had become very loose, and then, being removed, we were agreeably surprised to find that no inflammation oc- curred in the ankle-joint, though the separated piece showed a considerable portion of the articular surface, which had been 154 DISEASES OF BOXE. applied against the outer surface of the astragalus. TVe kept the joint very still for a while, until granulation was well ad- vanced, and then carefully allowed a little movement. It was well borne, and gradually increased, until a very satisfactory amount of motion was gained, the joint all the time remaining free from any indication of inflammation. The only explana- tion of this interesting fact is, that surrounding adhesive in- flammation had closed off the general cavity of the joint from the actions which were going on round the dead bone, which was thus placed practically external to a joint of which really it formed a part. This fortunate termination must be rare. Its occasional occurrence should give us encouragement, and keep us from despairing in similar apparently hopeless cases. A much more frequent case is that in which the sequestrum does not reach to the joint-surfaces of the bone in which it is situated, but, lying very near these joint-surfaces, involves them in the inflammatory actions of which it is the centre and the cause. Of this, Mr. Stanley gives an interesting example in the case of a young girl of sixteen, who was attacked by an inflammation of the head of the tibia, which was followed by necrosis. Successive attacks of inflammation of the joint oc- curred at intervals during sixteen years. These attacks tinally grew more and more- threatening, until the knee-joint became so seriously involved as to render amputation necessary. On ex- amining the limb, there was found " a dead portion of the can- cellous tissue, about the size of a hazel-nut, firmly impacted in the interior of the head of the tibia, half an inch below its upper articular surface. . . . The several structures of the joint had undergone the usual changes consequent on long-continued inflammation ; the synovia! membrane was thick and pulpy, with lymph adhering to its free surface ; the crucial ligaments were softened, and the articular cartilages were in part ab- sorbed." But, besides these more rare cases where destructive disease of the joint is produced by the proximity of a seques- trum, there are a large number in which, by a slower process, a stiffness of the neighboring joint is produced, which very soon amounts, if the condition be not obviated, to an anchylo- sis. This is one of the serious consequences of necrosis, and NECROSIS. 155 unfortunately it is one which does not cease when the necrosis is cured ; for, by the long continuance of the anchylosis, and the consequent disuse of the joint, its constituent parts have become so adherent to one another by organized fibrine, and so changed from disuse, that but little can be done to restore its usefulness. It should be borne in mind that this implication of the neighboring joint may occur in cases where the necrosis is not in the immediate proximity of the joint, but at some lit- tle distance from. it. I have now under my care a young gen- tleman in whom necrosis of the femur took place about three years ago. I recently removed the sequestrum, which occu- pied a very large share of the shaft of the femur, but did not approach within perhaps an inch of the knee-joint, and yet the knee is hopelessly anchylosed, and has been so for many months. I think I have more frequently observed this condi- tion in the knee-joint than in any other, and more frequently as a consequence of necrosis of the lower part of the femur than of the upper part of the tibia. This tendency to the implication of neighboring joints seems to me to offer some practical suggestions in the management of the disease : 1. Where we believe the necrosis not to invade the joint-structures themselves, but merely to affect them by proximity, cannot something be done to obviate the consequences of these succes- sive attacks of inflammation, by rigorously insisting on prop- erly-conducted passive motion, after each attack subsides, and by courageously keeping up such attention to the motions of the joint as shall prevent or diminish its tendency to hopeless rigidity ? 2. Let no time be lost in performing the operation and removing the sequestrum. Every day's delay increases the risk of inflammation of the neighboring joint, ami adds to the rigidity which is rapidly making it useless. In connection with these cases, I may here allude to the fact that the cancellous tissue, in some of the short bones, as in those of the tarsus, is sometimes the seat of necrosis, pre- senting features somewhat peculiar to its situation. I had, in Bellevue Hospital, a carman, aged thirty-one, in January, 1868, who presented a diseased condition of the os cal- cis, which at first puzzled me. Ten years ago, he had injured the foot by striking on the heel in jumping from a height. In- 156 DISEASES OF BONE. flammation followed of the whole region of the heel, which, after several weeks, terminated in the opening of an abscess, and the discharge of matter from the inside of the heel. About a month afterward, a similar opening took place on the outside. The inflammation subsided, but the openings had never healed. He had been able, most of the time, to use the foot without much inconvenience. I examined the foot carefully, on the 19th of February. There was some enlargement and thicken- ing of the whole calcaneal region, and the two original open- ings remained nearly opposite one another, and communicat- ing, so that a probe could be passed through the bone, from one to the other. The probe distinctly touched dead bone. A surgeon, who had seen him some weeks previously, had passed a seton through the bone, and left it there. It had excited but little action of any kind. The history led me to suspect that it was a case of central necrosis. I proceeded, therefore, to expose the outer surface of the os calcis, and care- fully enlarged the opening which led into the substance of the bone. As soon as it was large enough to admit my little fin- ger, I discovered a loose sequestrum, which, as cautiously as possible, I extracted, not without breaking off some of its prominent points. It was of the size and somewhat the shape of a small nutmeg, and was composed of the cancellous tex- ture of the bone. It was shrivelled and apparently partly de- composed, by long exposure to the air and to the foul secretions of the part. After removing the sequestrum, the finger could be introduced into a cavity, the walls of which were covered with thick, firm, and apparently healthy granulations. The patient made a very good recovery. One other case, almost identical in its features, has occurred to me, in a lad of fifteen, in whom a similar operation was followed by a like satisfactory result. Again, it happens, but I suspect very rarely, that the whole bone dies, and remains enclosed in the bag formed by the peri- osteum. This condition presented itself in a son of the Rev. Mr. P., whom I saw in consultation with Dr. J. L. Little, in January, 1868. About five weeks previously he had noticed, about the insertion of the tendo Achillis, a swelling which had come on gradually, and which he attributed to a twist of the NECROSIS. 157 ankle received some time before. This swelling inflamed and softened, and a very large abscess soon declared itself, involv- ing the whole calcaneal region. This soon broke, and dis- charged freely from two openings. These openings, which were on the side of the os calcis, had been laid into one, thus exposing the bone to easy exploration with the finger. An abscess was found surrounding the whole of the os calcis, and the finger could be passed around so as to touch the bare and evidently dead bone on all sides. The disease was confined, as far as we could judge, to the os calcis, which was already loosened in its attachments, both to the astragalus and to the cuboi'd. There was great thickening and induration of the soft parts forming the walls of the abscess, and a very large discharge of pus. He suffered much from pain, and was rap- idly depreciating in general health. Regarding the case as one of entire necrosis of the os calcis, and believing that the destruction was confined to that bone, I heartily concurred in Dr. Little's proposal to remove the dead bone, instead of amputating the limb. It was done by Dr. Little without difficulty, by making a free opening, so as to get control of the bone ; and then, carefully separating its liga- mentous attachments, it was easily removed. As far as could be ascertained, the parts left behind were in a sound condition. No evil behavior showed itself in the healing of the wound. Granulation took place slowly, and the wound filled up with new material, the shape and size of the heel being in a good degree preserved. This, Dr. Little informed me, finally con- solidated by bone, so as to afford a very good instance of re- generation of bone from its periosteum. 3. The third variety of necrosis which I deem worthy of spe- cial study is that which occurs in the cranial bones. It is not easy to say why the disease should differ in its behavior in these bones from the course it presents elsewhere ; but that it does so is abundantly manifest. The most striking peculiari- ties of necrosis in this situation are mainly two : 1. An indis- position to the separation and casting off of the dead bone. 2. A disposition to spread slowly and gradually, so as to invade large tracts of neighboring healthy bone. These two features render this a formidable disease ; and, as they directly interfere 158 DISEASES OF BONE. with the reparative action of the diseased part, will explain why it is that necrosis of the cranial bones is so frequently a fatal disorder. It is mostly as a consequence of syphilis that this peculiar form of necrosis arises ; but I have reason to believe that in other cachectic conditions of the system, when no syphilitic history can be traced, more or less of the same pe- culiarities occasionally show themselves. I can best illustrate the disease by giving a typical case, which was undisturbed by surgical treatment. "While at Fortress Monroe, in the spring of 1862, McClellan's army then lying before Yorktown, I was asked to see an officer of the regular army, who was suffering from syphilitic rupia. I found a young gentleman covered with large crusts of rupia, and so reduced that he was obliged to keep his bed. He was unable to go on with the army, and finally was sent home, and he came under my care in New York. His case was a most difficult and distressing one, from the extent and severity of the ulceratiou following the falling of the scabs. He partly recovered under the use of liberal doses of iodide of potassium, and was able to go to his home in the country. I saw him again in the next year, greatly improved, but not well. I lost sight of him then for several years, when my old friend turned up in the wards of the New York Hospital, in June, 1868. I was shocked to see him cov- ered with sores and scabs and scars, emaciated to a skeleton, his voice altered by the destruction of part of the palate, and it was long before I could believe him to be the same man. He was in a deplorable condition ; but the most alarming fea- ture to me was the condition of his head. The scalp presented at several points large ulcerations, covering altogether one- half of its surface. The bottom of these ulcers was constituted by the bare, dead, and blackened surface of the cranium, which was manifestly in a condition of necrosis over at least one-half of the vault. Exuberant but pale granulations sur- rounded these very irregular patches of necrosis, and an abun- dant fetid discharge flowed from their surface. Some of this discharge, however, came from beneath the bone, where there O 7 7 ' were several irregular, worm-eaten looking perforations through the dead layer. On pushing back the granulations, healthy living bone could easily be brought into view, and a line NECROSIS. 159 somewhat distinct could be traced between the dead and living parts, which at some points showed a disposition to separation, so that at one or two points along this edge considerable exca- vations, of a very irregular outline and of varying depth, could be seen, some of them penetrating the skull, and giving issue to pus, which evidently came from beneath the bone. In all the rest of the line no distinct evidence could be traced of any attempt at separation of the dead from the living tissue. The bone in the immediate neighborhood of the dead tissue showed, at some points, an increased vascularity, but no other change. This condition had been brought about by a series of morbid actions, commencing a little more than a year ago. The first thing noticed was a small, painful, and tender swelling, several others showing themselves nearly at the same time. These increased, soon suppurated and ulcerated, and at a very early period presented dead bone on their floor. A great deal of pain attended these ulcerations, and made it difficult for him to place his head on his pillow without suffering. His general feebleness, and the long continuance and inveterate behavior of his disease, made his case so hopeless that nothing could be done except by a cordial and invigorating regimen, with ano- dynes in full doses, to try to rouse up his failing powers. But little was accomplished, however, and he left the hospital in the latter part of August for his home, to die a few days after he reached it, with symptoms of inflammation of the brain or its meninges. Here no surgical operation was at any time practicable, and the disease followed, therefore, an undisturbed course. In the following cases removal of the dead bone was practised, with a result which, though varying a little in different cases, is, on the whole, far from encouraging : Sarah Atwood, aged twenty-four, was admitted to the New York Hospital, June 14, 1859, with a diseased condition of the bones of the forehead. Six years before she had had syphilis, not followed by any secondary symptoms. About a year after- ward she suffered much from headache, followed by the appear- ance of painful swellings on the front part of the head, which, after about six months, softened and suppurated. New open- ings have since formed, and all have continued to discharge. 160 DISEASES OF BONE. showing no inclination to heal. Her general condition 13 good, and she has^ no other secondary manifestations. Five fistulous openings now exist on the anterior part of the os frontis, at the bottom of each of which the probe detects bare and rough bone. On the 18th of June the late Dr. John Wat- son, then in attendance, made an incision through the line of ulcers, and laid up a flap exposing the diseased surface, which occupied at least six square inches. The periosteum was so easily stripped off from the bone that it was evident it could have had no vital connection with it. The surface of the dis- eased bone was rough and irregular, and raised from its proper level by elevations and bosses, which showed that a process of thickening had been going on. Several openings presented themselves in the midst of the diseased region, from which pus flowed out, evidently from a space between the bone and the dura mater. It seemed, from the altered color and the bloodlessness of the part, that it was entirely dead ; and when the periosteum was still further stripped up, so as to expose the surrounding healthy bone, the contrast was very marked. No line of separation, however, showed itself at any point ; and this seemed the more remarkable, as there was reason to believe that the death of the bone had occurred at least three years previously. It was determined to remove all the dead bone, and this was done, after long and patient perseverance, in chiselling and gouging and gnawing the dead bone until living bone was reached. In this way the whole dead portion was removed, sometimes consisting of a superficial layer, not involving the inner table ; at other points involving the whole thickness of the skull, and leaving exposed the granulating surface of the dura mater. The behavior of the wound was very satisfactory. Granu- lations sprung up freely from the dura mater and from the gnawed surface of the bone. Toward the close of July two firm and hard swellings occurred on the parietal bone, near the wound, one of which suppurated and discharged through the wound, and the other disappeared without suppuration. No necrosis followed at this time. About the 8th of September two sequestra, of an irregular form, and together larger than a quarter of a dollar, separated from under the still-open edge NECROSIS. 161 of the wound. These pieces, on examination, proved to be from the margin of the surface left after the operation, as they showed the marks of the rongeur. This must have been, there- fore, a spread of the necrosis after the operation ; but it is well worthy of remark that Nature had been able, under the altered conditions induced by the operation, to effect a separation in a few weeks, which she had not been able to accomplish during the previous three years. No sign of cerebral disturbance showed itself after the operation at any time. November \st. All has gone on favorably ; the cavities left in the operation being filled up and nearly healed. Unfortunately, however, there is too much reason to fear that the original disease is progressing, and thus far it is not controlled by remedies. New districts of bone were being invaded by the disease when she was discharged, January 9, 1860. This was the first case of the kind I had studied, and I was much disappointed at its treacherous behavior. The first favorable progress had not led me to expect that its ravages would be resumed, even during the apparently healthful heal- ing of the wound. I was not so much surprised, therefore, when in the next case which occurred I found a similar dispo- sition. James Hughes, aged twenty-seven, was admitted into the New York Hospital, January 25, 1865, with necrosis of the bones of the cranium. He had had chancre and bubo eight years before, the bubo suppurating. No evident symptoms of secondary syphilis followed, though at various times he had suffered much fronnpains in the bones. Some months previous to his admission, he found a painful swelling on his forehead, and soon after another on the vertex, and another on the right side behind the ear. These sluggishly enlarged, and, after about six months, opened and discharged pus. The wounds have never healed. The orifices were pouting, and the probe detected dead bone over a considerable surface, covered by un- dermined integument. An operation was performed on the vertex, which was the point most extensively diseased, in the latter part of 1865. The bone was exposed, and the diseased area was found to embrace about two square inches, of an oval form. This was bare of periosteum, of a brownish color, and 11 162 DISEASES OF BONE. evidently dead. The living was separated from the dead bone by a line of demarcation, which was tolerably distinct, but which showed no evidence at any point that separation had commenced. With the rongeur the dead bone was thoroughly gnawed away, till, at all points, living, bleeding bone was reached. The wound was dressed lightly. Imperfect attempts at granulation were observed for a time, but it soon became evident that the whole surface of the wound was dead, and that the necrosis was extending. He left the hospital in De- cember, 1865, and soon after entered Bellevue Hospital. After he had been in Bellevue about a year, the disease having, in the mean time, spread very extensively, Dr. F. H. Hamilton FIG. 24. (Bellevue Hospital Museum.) performed an operation, November 26, 1866, for the removal of the dead bone, hoping that by this time, nearly two years having elapsed since the commencement of the disease, separa- tion would have taken place. To some extent his anticipations proved correct ; and one large piece, including the whole ver- tex, came away almost without difficulty. At some points, however, even of this piece, the separation was not complete, and the bone had to be broken in order to remove it. At sev- NECROSIS. 163 eral other periods similar operations were performed, removing larger or smaller pieces of partially-separated dead bone, a great part of the bone removed embracing both tables of the skull. His present condition, July, 1868, shows all the central part of the crown of the head occupied by a depressed scar, as large as the palm of the hand. Of this scar, a portion about two inches by three evidently has no bone underneath it, the whole thickness of the cranium having here been removed. The movements of the brain can be felt and seen at this point. Some irregular ossification has taken place in this central space; but, where this is found, some hair is growing, showing that at these points the integuments, and therefore probably the pericranium, had been preserved. On the right side of this central scar, which seems soundly healed, are numerous openings, which lead down to dead bone, showing that, after the lapse of four years, the progress of the disease is not arrested. His general health is good. No signs of syphilitic disease. The portions removed in the two largest pieces embrace about ten square inches, of an irregular square shape, extend- ing on either side of the median line, the sagittal suture run- ning through nearly its middle. The surfaces are irregular, as if worm-eaten, which is still more marked on the edges. The largest portion of each of these two pieces shows that the dis- ease has embraced both tables of the skull. The signs of the original gnawing operation are seen in the upper surface of the removed sequestrum, and the external surface around this point is deeply stained of a brownish-black color (Fig. 24). A third case occurred in the hospital service of Dr. Gurdon Buck. John Roberts, aged thirty-three, was admitted into the New York Hospital, January 18, 1868, with extensive necrosis of the skull. Twelve years before, he had had a chancre, fol- lowed by a non-suppurating bubo. Secondary symptoms en- sued, eruptions on the skin, sore throat, loss of uvula, and pains in the bones. About ten months before his admission, a reddish swelling commenced on his forehead, which suppurated slowly, breaking and discharging pus about eight months after its commencement. Similar sores have since appeared at inter- 164 DISEASES OF BONE. vals, scattered on the top of the head. His general health has been good. On admission there were numerous undermined ulcers scattered over the front and upper part of the head, varying in size from that of a pea to that of a dollar, and all presenting dead bone more or less exposed to view. The dis- charge was considerable, and fetid. The surface of the dead bone has not the smooth, even appearance of a bone which has died in full health, but gives evidence, by its roughness and irregular erosions, that some changes, probably inflammatory, have preceded its actual death. Some of these erosions pene- trate the thickness of the skull, and give issue to matter from beneath the bone. At these points the pulsations of the brain can be seen. On the 24th of January Dr. Buck proceeded to an operation in which he proposed to remove all of the dead bone which could be safely got away. Several of the anterior ulcers were laid into one by communicating incisions, and the flaps raised, thus exposing largely the diseased surfaces. It was found that the whole surface was dead ; but, though a line of demarca- tion could be distinctly traced, separation had taken place at but few points. The bone in the immediate neighborhood seemed perfectly healthy. With the rongeur principally, by a mixed process of breaking and cutting, the whole of the cranial por- tion of the frontal half of each parietal, and a portion of each temporal bone, were removed, exposing the dura mater over the whole of this extensive surface. This membrane was thick- ened and granulating. The posterior half of the vault of the cranium, which was found to be in the same condition, was re- served for a future operation. For a few days after the operation, all went on well, and the wound put on a healthy, reparative appearance. On the 1st of February, however, he had a chill, followed by fever. This was repeated after several days. Gradually headache and blindness came on, and soon after convulsions, coma, and death on the 18th of February. Inflammation of the meninges was found, on post-mortem examination, with numerous small abscesses scattered through the most superficial portion of the brain-substance. The ne- crosis was found even more extensive than we had supposed, occupying the whole of the cranial vault (Fig. 25). NECROSIS. 165 Several other cases of this formidable disease have occurred under my observation, but these seem sufficient to illustrate its clinical features. I have tried to trace the processes preceding death of the bone in several of these cases, but can only say that it seems to be a slow process of inflammation, in which FIG. 25. (X. T. Hospital Museum.) sometimes a mere vascularity of the bone about to die is de- tected ; in other cases the bone is thickened ; in others a deposit of a granular, pumice-like appearance takes place on the sur- face, but whether from the bone before its death or from the living tissues after death, I have not yet been able to detect. Again, erosions and ulcerations of the diseased bone are dis- covered, which must of course have taken place before actual death has occurred ; but the whole process is so gradual that it is not easy to pronounce at any moment what part of the bone is still alive and active, and what is dead and unchanging. That the peculiarities of the disease now described depend upon some constitutional vice, and not upon the pathological dispositions of the cranial bones, would seem to be clearly shown by the behavior of these same bones under other condi- 166 DISEASES OF BONE. tions. Thus simple traumatic causes produce, in the cranium, a necrosis which differs in none of its clinical features from necrosis occurring elsewhere. For example: John Murphy, aged twenty-six, in June, 1868, struck the top of his head, in rising from a stooping position, against the iron surface of some machinery he was engaged in oiling. The contused part in- flamed and formed an abscess, which, after discharging, refilled and continued to close and open several times. He came to the New York Hospital in August, about two months after the injury, with the wound still unhealed. The probe detected dead bone. Another opening formed, leaving a considerable space between the two orifices where the undermined integu- ment covered bare bone. On the 22d of September an incision was made joining the two openings, and then extended so as to expose the dead surface. It was found nearly round in shape, and about two square inches in size. A probe intro- duced under the edge of the sequestrum, which showed clear evidences of separation, loosened the whole piece, and it came away entire. The main portion of this piece was a thin plate comprising the outer table only, but at several points the whole thickness of the bone was involved at these points. In the granulating bed, from which it was removed, the pulsations of the brain could be seen. The wound healed rapidly, and the patient was discharged cured. In another case, a man was brought to the hospital, wounded by a pistol-ball at the upper and posterior part of the neck. In trying to trace the ball, it was found to have sunk down deep in the muscular mass be- tween the occiput and atlas, but we could not find it. Great inflammation and extensive suppuration followed, and, after many weeks, dead bone could be felt by the probe. In due time an operation was done by Dr. H. B. Sands, by which the occiput 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 bone in a condition of necrosis, and that the sequestrum was already loose. By careful manipulation the whole piece was extracted in shape and size much resembling the squamous portion of the temporal bone, and some of it embracing both tables of the skull. In the centre of the piece removed was found the NECROSIS. 167 opening made by the ball, which was also found lying loose in the wound. The man made a rapid recovery. Again, as illustrating another form of necrosis of the skull, a man was struck at the battle of New Orleans by a glancing ball which bruised the vertex without breaking the skin. Abscess formed at the injured point and remained unhealed. Some months after, I saw him, and, finding dead bone, made an incision and removed several pieces, embracing the whole thickness of the bone, which, from the cleanness of their edges, were undoubtedly fragments which had been broken by the original blow and had subsequently died. With regard to treatment, these simple traumatic cases are satisfactory enough; but in the constitutional form my own experience is not encouraging. None of the usual remedies employed have seemed to exert any influence on its course, and surgical interference is apparently able to eifect only the re- moval of the consequences of the disease, without arresting its progress. It is true, perhaps, that in the hopes of spontaneous separation we have wasted time and abated effort in the admin- istration of remedies ; and it is much to be hoped that some- thing may yet be discovered that will at least control the march of this obstinate and dangerous disorder ; but thus far I have no evidence that any remedy has any positive influence in arresting its fatal march. The following case I condense from Dr. Agnew's report, who kindly sent me the specimens from which the figures are taken : W. C., aged thirty-eight, had suffered with otitis media of both ears from the age of six years. He retained his hearing partially until about three years before Dr. Agnew saw him, when an acute attack of deep-seated and very severe inflammation in the right ear terminated in complete deafness, accompanied with paralysis of the portio dura of that side. " The patient came under my observation for the first time on the 16th of April, 1862, presenting evidences of great suf- fering and debility. He had suffered greatly for months from gnawing pain in the ear, insomnia, loss of appetite, and dizzi- ness. An examination of the external ear was effected with great difficulty, on account of its excessive tenderness. The concha, swollen and inflamed, was elevated by a dense inflam- 168 DISEASES OF BONE. matory tumefaction, circumscribing the external meatus, ex- tending backward over the mastoid process, and forward along the zygoma. Projecting from the meatus was a large pear-shaped polypus of a dense fibrous character, bathed by a constant flow of stinking pus. Desiring to get to the bottom of the case, I placed the patient under chloroform, and removed the polypoid mass by means of a wire snare. In attempting to push the snare to the bottom of the meatus, I encountered a solid obstacle in the region of the middle ear, which subse- quently proved to be the sequestrum, repre- sented by the accompanying woodcut. The calibre of the external meatus had been much reduced by boggy swelling of its soft parts, so that I was compelled to make as free an incision as possible to enable me to reach the sequestrum with a pair of small dressing-forceps. Having got the body in the grasp of the forceps, a slight rocking motion with traction enabled me to extract it. " It will be observed that the sequestrum includes the wreck of the labyrinth. The cochlea is shown laid open by caries, and two of the semicircular canals are seen in part. The loss of hearing and paralysis of the seventh pair were explained. Two views in fac-simile are given of the sequestrum in the woodcut, and an attempt has been made by the artist to repre- sent the eroded appearances. The remains of the anterior semicircular canal are indicated by the letter C; and the cochlea B, opened by caries, shows the lamina spiralis. The vestibule is bereft of its furniture and almost obliterated. "After the operation the patient rapidly regained his health, and by the 3d of January, 1863, the external meatus had be- come closed by cicatrization. The paralysis still remains." The patient w T as subsequently seized with an acute otitis interna of the left ear, which went on to suppuration, and proved fatal by extension of the inflammation to the brain. On post mortem the dura mater covering the petrous portion of the temporal bone was very much thickened, and a small abscess was found in the brain immediately above the diseased bone. Fig. 27 shows the appearance of each external meatus NECROSIS. 1G9 after maceration. Both of them are enlarged and irregular, from carious ulceration, and one of them almost closed by an osseous growth, as large as a pea, springing from the ulcerated margin of the meatus. Smaller exostoses of the same kind are forming at several other points round each meatus. FIG. 27. (From a specimen in Dr. Agnew's collection.) A fourth class of cases worthy of special study embraces those which occur in the jawbones. Of the cases of necrosis occurring in these bones we have a great variety, which differ in no important respect from cases of necrosis elsewhere. We have among them, however, two special classes requiring par- ticular mention, and these 1. Those occurring in consequence of the eruptive fevers. 2. Those arising from the poison of phosphorus. The cases occurring after eruptive fevers were first brought to the notice of the profession by S. I. A. Salter, in a paper published in Guy's Hospital Reports. Their de- pendence as a cause upon the eruptive disease he considers proved by their almost invariable association, and he gives the following account of the symptoms: "A little child has just recovered from one of the eruptive fevers, most probably scar- latina ; the case has been in no 'way unusual as to its severity or its course : within six weeks or two months of the passing off of the acute symptoms, tenderness of the mouth is com- plained of, and the mother notices fetor of the breath. Upon inspecting the mouth, the gum is seen to be peeling from the edge of the jaw around the neck or necks of some temporary tooth or teeth ; pus is discharging, and more or less dead bone is exposed. The denudation of bone progresses rather quickly in depth, but usually not, after the first, in lateral extent; the 170 DISEASES OF BONE. temporary teeth at the affected part become loose and often fall out. There is no swelling, and no ossifying callus is formed in the region of the necrosed bone. In a few weeks from the first of these symptoms, the sequestrum itself becomes loose, and is easily removed, leaving a large gap and a raw granu- lating surface which rapidly heals. The necrosis almost always includes the bone which constitutes the loculi containing the developing permanent teeth, as well as the alveoli of the tem- porary ; but it does not go farther, and in the lower jaw the base of the bone is very rarely affected." Mr. Salter further states that this affection occurs only after the eruptive fevers, and that it attacks children from three to eight years of age. He regards it as a self-limiting disorder, requiring only such treat- ment as local cleanliness and general supporting regimen. The resulting deformity arises principally from the loss of the teeth. The eases of necrosis of the jaws from exposure to the fumes of phosphorus make a much more interesting and a much more important class, and have during the past few years attracted a great deal of attention. They present themselves, almost ex- clusively, among the operatives in the match-manufactories, and only in those who have been long exposed to the poisonous emanations. The substance which acts as the producing cause of the mischief is undoubtedly phosphorus-vapor, usually ex- isting as phosphorous and phosphoric acid with probably some free phosphorus. It was at one time thought that arsenic was, in some degree at least, connected with the production of the necrosis, this substance being contained in some ordinary and impure specimens of phosphorus. This suspicion has not been verified, and it is now, after careful investigation, believed that the phosphorus alone is the poisonous agent. The efficient action of the cause seems to depend mainly on two things: first, a long-continued exposure to the poison ; and, secondly, some condition, either of the teeth or gums, which favors the entrance of the poison into direct contact with the tissues. In regard to the first, writers are unanimous as to the fact that it is only after very prolonged exposure that necrosis occurs, so much so that there are scarcely any cases on record in which some years have not elapsed before the disease developed itself. The dangerous exposure takes place in only two departments NECROSIS. 171 of the manufacture, viz., the dipping-room, and the counting and packing rooms. In these the patients are subjected to an atmosphere constantly impregnated with the fumes of phos- phorus, and this air is still further contaminated by the frequent catching tire of the matches, which generates a large quantity of phosphorous acid, and that, too, in the immediate neighbor- hood of the face of the patient, so that it is extremely easy for the poisonous fumes, which are quite soluble in water, to come in direct contact with the mucous membranes of the mouth and nose, and also with the bronchial mucous surface. Why the poison of phosphorus does not affect the Sclmeiderian and bronchial mucous membrane does not appear; but the fact is stated by Von Bibra and Geist, whose work on this subject is the most complete we have, that there is, among the patients thus exposed, no special tendency to bronchial or nasal catarrh, and no effects are noticed on the bone upon which parts of these membranes are spread. These effects seem to be reserved for the bones of the upper and lower jaw, and in these bones, after a prolonged exposure to the poison, the first symptoms of the disease appear. But, secondly, it would appear that something besides this exposure is necessary to produce the disease, and this something is a carious condition of the teeth, or an ulcerated condition of the gums. It was early observed that this condition of the mouth was a predisposing cause of the disease, but it was only after long observation of accumulating cases that it was shown to be a uniform and an indispensably exciting cause. None of those whose teeth were perfect, and whose gums were sound, were ever attacked, while soundness was maintained, but if caries attacked the teeth, or ulceration the gums, or, worse than all, if a tooth had been recently extracted, then the persons so affected became liable to the development of the disease. From the slow action of such a cause one would be led to anticipate that some evidence of constitutional vitiation would precede the local manifestation. This does not seem to be so, and those who suffer most are oftentimes the most vigorous and healthy of the workmen, maintaining every indication of con- stitutional soundness up to the moment when the local disease begins to infect and involve the general system. 1Y2 DISEASES OF BONE. The first symptoms of the disease, then, are strictly local. A toothache is generally the first complaint, and this may be intermittent, returning at irregular intervals, until it becomes a constant and very distressing symptom, spreading over the whole side of the face. The gums now begin to inflame and ulcerate, and the parts about the jaw become tumefied. In- flammation of the whole affected part is now active, and soon an abscess forms, usually discharging itself alongside of one of the teeth through the ulcerated alveolus. Now, retraction of the gums from the teeth, and exposure of the bone of the jaw, gradually come on until, in a great many cases, the whole dental arch projects into the cavity of the mouth bare of peri- osteum, and perfectly dead. Numerous sinuses usually form, some opening into the mouth, and some on the cutaneous sur- face, and from these escapes in large quantity a fetid pus, which, constantly flowing into the mouth, is one of the most offensive and distressing symptoms of the disease; much of it must be swallowed, and can hardly fail to add to the derange- ment of the digestive function, already impaired by the progress of the malady. As. the disease advances, involving a greater and greater portion of the jawbone, the swelling of the face becomes enormous, and the aspect of the patient, particularly if both sides be involved, is hideous and revolting. Soon the system begins to sympathize, and emaciation and hectic are slowly developed. In this respect a good deal of difference is observed, according to the irritability of the patient's constitu- tion, some being affected earlier in the disease as well as more severely. But one point has been distinctly settled, viz., that the constitutional symptoms do not show themselves until after the local disease has manifested itself; the poison, though acting extremely slowly, not appearing to influence the general health until it does so through the effect of the local ravages of the disease. The constitution, however, once affected, rapidly gives way under the constant suffering and exhausting discharges. The patients become pale and emaciated, the digestive system giving out early ; hectic fever is established, the strength fails, and the patient dies worn out by months or even years of pain- ful disease. In regard to this point, of the constitutional impairment NECROSIS. 173 not depending on the direct action of the poison upon the system, Dr. Geist is very explicit, asserting unequivocally that the health of the operatives, not affected with the local disease, is as good as, if not better than, that of operatives in other manu- factories. He goes still further, and states that, although the acid and irritating fumes of the phosphorus are so constantly inhaled, no peculiar prevalence of bronchitis or nasal catarrh has been noticed to occur. These facts, together with the facts above stated, that the disease never occurs in perfectly healthy mouths, but always requires a carious tooth or an ulcerated gum for the starting-point of the inflammation, seem to show very conclusively that the action of the poison is en- tirely local, a view which becomes more important when we address ourselves to the prophylaxis of the complaint. The swelling about the necrosed jaw feels very hard, and gives to the touch the idea of an involucrum forming about the dead bone, but, so far as I know, no proper involucrum is ever formed. There is found on dissection a great thickening and induration of the tissues about the bone, but no ossification of them. Between the separated periosteum, however, and the dead bone, there is noticed a material which I believe is not found in any other similar disease. It consists of a grayish powder}' deposit, which in varying quantities is found to adhere either to the bone or to the granulating surface of the cavity in which it lies. Sometimes this deposit adheres closely to these granulations, and, having some consistence, forms a tolerably firm layer, which seems very much like an involucrum. It will be noticed, however, that this layer is not a proper ossification of the surrounding tissues, but a mere lamina upon the surface which can, with more or less facility, be peeled off from the granulations on which it lies. On ex- amination this substance is found to possess a chemical consti- tution and a microscopical structure which is that of true bone, but differing from true bone in the completeness of its develop- ment. Yon Bibra says : " The Haversian canals exhibit in part a larger diameter than those of normal bone, and are empty. .... 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 sacs, sometimes 174 DISEASES OF BONE. contracting and ending with open mouths on the surface. These mouths are more minute in the most recent deposit, and appear larger in older layers. The bone-corpuscles are rounded off or angular, and their circumference is less decided; during the progress of the formation of the deposit they are very large, and their contour proportionally undefined. They appear tilled and dark-colored. At first they are lighter, and they have ramifications like those of normal bone, which increase in number with the age of tha deposit. . . . The matrix of the new deposit is at first very brittle ; after the deposit has been exposed to the process of absorption it shows a powdery appearance, as if sprinkled with a coarse powder." This deposit seems, therefore, evidently to represent an attempt on the part of Nature to form some new bone to take the place of that which is destroyed ; but it is also evident that this attempt falls short of the success which it usually attains in other cases of necrosis. Why this involucral effort should be so imperfect and so unsuccessful, it is not easy to say, but the pathological fact cannot be gainsaid. The following ap- pearances were noted in a case which occurred under the care of Dr. Willard Parker, at the New York Hospital, and give, perhaps, a correct idea of the usual pathological condition, with reference to this pumice-like deposit : In exposing the bone after the first incisions, " it was noticed that in some parts, par- ticularly along the base, the bone was entirely separated from the soft parts by a suppurating and granulating surface, such as is ordinarily seen between an involucrum and a sequestrum, while at other points the flap was peeled up from the bony surface by a process somewhat like that by which the dura mater is peeled from the skull-cap, or like that by which the periosteum can be peeled from the surface of an inflamed bone. This raising of the flap revealed the bone, presenting two dif- ferent conditions of its surface : one a smooth, natural, evidently dead surface ; the other a rough, granular, and irregular surface, to which the soft parts adhered as above stated, and which did not seem to be dead-bone tissue, while at the same time it was not the usual vascular-bone surface of an involucrum. The smooth dead bone was in contact with pus, the other of course NECROSIS. 175 was not. After fully exposing the bone a chain-saw was intro- duced near the symphysis, and the body of the bone was divided and raised from its bed. As with the outside, so with the inner aspect of the bone, some of it was separated from the soft parts by a suppurating surface, and some of it adhered rather strongly to the surrounding parts. So strong was the adhesion that at the upper part of the angle and neck portions of the bony deposit flaked oif and were left behind in the bed from which the bone was being removed. This had every appearance of being an involucrum at first sight, and we were in some doubt as to whether it was best to leave it. On using the handle of the scalpel, however, the soft parts were easily peeled from it, and it was enucleated and removed. The jawbone separated as usual at the joint and came away entire, and without any considerable force. The removal of the bone left a bed which was composed in part of suppurating and granulating surface, such as is usually left on the removal of a sequestrum, and in part of a whitish, rough, vascular surface, looking not unlike the surface of the dura mater recently peeled from the skull. This seemed clearly to be the inner surface of the periosteum, which had been adherent to the rough deposit on the surface of the bone, and from which, beyond a doubt, the deposit had been poured out. There was no osseous de- posit in the periosteum, and no surrounding ossification, as might be expected around so large a sequestrum ; in short, nothing but thickened tissues represented the involucrum. . . . The examination of the jaw showed the whole bone to be dead, but not much altered from its natural appearance. On the outer and inner surfaces of the jaw there was an irregular, granular, stalagmitic deposit of bone, somewhat firmly adhe- rent to the dead surface underneath, and looking better organ- ized and more osseous in its appearance than the pumice- like deposit as it is usually described. The deposit was in laminae more or less complete, and varied in thickness from a line to nearly half an inch. ... In the main this deposit was adherent to the dead surface of the bone by a sort of mechani- cal adhesion, but in some points, particularly at its edges, there was a thin membrane between them, so that, while the whole was wet, some motion could be made between the bone 176 DISEASES OF BONE. and its false involucral covering (Fig. 28). Under the micro- scope, thabony character of the deposit was unmistakable." It is agreed by all the observers of this disease that the reparation after the removal of the necrosed lower jaw is very complete, more so perhaps than in any other bone in the body. In this respect, therefore, it would seem that Nature plans her reparative work somewhat differently from the mode she else- where adopts. In all ordinary cases of necrosis, the periosteum, FIG. 23. ) to take in the cheek or lip, and thus do away with making external inci- sions. On the other extremity of the shank is a square socket to which are fitted saws (or knives) of different sizes, these being firmly fastened by a thumb-screw (c). The socket being square, allows the saw (or knife) to be turned and worked in four di- rections. It is only necessary to unscrew the fastening a short distance, to turn the saw in the desired direction. G.TIEMANN & CO. C " The saw, being in direct line with the handle, can be very easily guided. The backs of the saws are thin, while the teeth are broad, thus giving free action. "On June 20, 1871, the patient was placed in an operating- chair, and, when she was fully under the anaesthetic, the head was thrown back, and the mouth kept open by a gag between the molar teeth of the opposite side. Taking my position to the back and over the head of the patient, I placed a sponge cut to completely fill up the passage to the throat, and held in position on the soft palate by a sponge-holder to prevent the blood pass- ing into the throat during the first part of the operation. The patient was only allowed to breath through the nose, which she could very well do. No external incision of the face was made. The two internal incisions were made from behind on the pos- terior prominence of the tumor, one-half inch on each side of the fangs of the molars forward to the left central incisor. The bone was now laid bare by stripping the soft parts with periosteal denuders ; the latter part of this operation was to tear the palatal muscles from the posterior part of the hard palate without injuring the palatal vessels and nerve that passes over on to the hard palate at this point. There being no further TUMORS OF THE JAWS. 333 use for the sponge on the soft palate, it was removed. The right lateral incisor was now extracted, and, by its socket through a little to the right of the centre of the hard palate, so as to save the vomer, a section was made with the oral saw, thus dividing the superior maxillary bones. This saw was now removed from the socket and replaced by another one, half as long (one and a half inch), the teeth of which were changed to a different angle, so as to allow the cheek to go into the U-shank, and let the saw play freely. This section was made up between the tumor and the internal pterygoid process to the malar bone, then forward through the canine fossa, dividing also the inferior turbinated bone, to meet the other section at the right ala nasi. After the saw had entered the antrum, the handle of the saw was more rapidly advanced th n the point ; this prevented the FIG. 91. (Osseous tumor from Dr. D. II. Goodwillie. magnified 350 diameters.) Drawn by J. W. S. Arnold, M.D. point of the saw from piercing the vomer which I desired to save. By these two sections the tumor with the adjacent bone was removed clean. After haemorrhage had stopped, the soft parts were closed by seven silk sutures. On the fifth day four of the sutures were removed, and the remainder on the follow- 334 ' TUMORS OF BONE. ing day, the wound having healed by first intention. Four months after the operation, there appears every indication of a new formation of bone. " Pathological examination of the tumor shows it to be osse- ous. On making a section of the tumor through the line of the teeth, the following was observed : " At the apex of the root of the second molar tooth there was a small, soft cyst containing pus, and for a short distance surrounding this bone appeared quite cancellated, but the rest of the tumor was quite dense. The pulps of the canine and first bicuspid teeth had still some vitality, but that of the second bicuspid was dead. The pulp-chambers were decreased in size by a deposit of osteo-dentine to their walls. The cementum on the fangs of the teeth was hypertrophied. A large nerve en- tered the tumor on its buccal side. "Microscopical Character. Composed of cancellated tissue almost entirely; the outer rim or edge of a thin layer of more compact bony tissue ; in the spongy part a small amount of soft marrow, containing the usual constituents of foetal mar- row, that is, medullo cells and myeloplaxes, with oil-globules." (Fig. 91.) PART III. MALIGNANT DISEASES OF BONE. IN the light of recent microscopical and clinical studies, it is not easy exactly to define the meaning of the term malignant as applied to morbid growths. The difficulty does not arise so much from any want of precision in the term itself, or any want of appropriateness when applied to typical and well-marked cases, as it does from the varying degree in which the qualities it ex- presses are manifested in the different tumors in which we study it, and the want of constant correspondence between their ana- tomical structure and their clinical history. It is pretty well agreed among pathologists that the chief clinical features of malignity are: 1. A tendency to soften and ulcerate. 2. A tendency to retiirn after extirpation, even the most complete. 3. A disposition to appear in many places successively in the same individual, invading many tissues in the region originally affected, and developing itself in many distant organs, where it seems to have no connection with the original disease. These clinical features have been sought to be associated with certain physical forms, which pathologists have hoped would prove characteristic. This hope has not been fully realized. No ana- tomical form has yet been found, which, of itself, is distinctive of cancer, and without which malignancy cannot exist. No as- sociation or grouping of histological elements can be said to be absolutely characteristic of malignancy ; and much as has been done by Virchow, Weber, Waldeyer, Beale, and Huxley, in un- ravelling the laws of histogenesis, no mode of development, whether as to source, forms, rate, progress, or irregularities, can 336 MALIGNANT DISEASES OF BONE. be invoked to solve the question of the clinical history of every morbid growth. There will still remain some obstinate excep- tions, where structure and history do not correspond, exceptions which at present we must accept as indicating to us how superfi- cial is our knowledge of the deepest laws of vital organization. "With this acknowledgment, enougli remains upon which we may build our classification with sufficient precision for many practical purposes ; and as we may accept those above given as the most striking and constant features of what we call malig- nancy, so we have certain histological and histogenetic charac- ters which commonly accompany these clinical ones, which we may with practical utility and safety consider as the physical condition with which they are commonly associated, and upon which they usually depend. Thus malignant growths are usually unlike the tissues from which they spring, and many present features which are unlike those of any tissue found in the nor- mal structures of the body. Again, malignant growths have usually their elements scattered through and intermixed with the normal tissues, so as to entangle these normal tissues with them in their progress, and to involve them in the destruction to which they are so certainly hastening. These two features, heterology and infiltration, are well marked and characteristic in a vast proportion of cases of malignant disease, and therefore may be considered the general anatomical features of these affec- tions. Accepting them as simply the general characters of the disease, we may, for more particular study, divide the great class of malignant, or cancerous, or carcinomatous diseases, for these terms are generally received as synonymous, into the sub- classes of scirrhous, medullary, epithelial, colloid, and melanoid. Some other subdivisions are sometimes made, but, in reference to the bones, I believe these will be sufficient. CHAPTEK I. SCTKKHUS, OE HARD CANCER OF THE BON'ES. As a primary disease of the bones, scirrhus is extremely rare. Several authors allude to the possibility of its occurrence ; but I have not myself seen, nor have I met in any published ac- SCIRRHUS, OR HARD CANCER OF THE BONES. 337 count, any such details of an unequivocal case as would warrant my presenting it as an example. As a secondary development, it is not so uncommon. It usually lias been found in persons in whom the cancerous cachexia is far advanced ; in many in- stances, the patients have been bedridden. In one case which occurred a few years ago in this city, the patient, an old lady, dying slowly from the disease, primarily developed in the breast, had been confined for some time to her bed, when, on one occasion, on attempting to turn or to raise herself in bed, one of her thigh bones gave way, and some days after, on a similar trifling exertion, the other also broke. In her case the skeleton was very extensively infiltrated with true scirrhous cancer. The femora, the ribs, the humeri, the pelvic bones, and I believe all of the bones which were ex- amined, showed traces, more or less consider- able, of the disease, in some more advanced than in others. The specimens were present- ed to the Pathological Society, and, in particu- lar, I remember that the ribs were so soft as to be flexible, and capable of being cut by a scalpel. In this case, as in the other reported cases, the morbid material has all the appear- ances of the disease when it is developed in the soft parts, both to the naked eye and un- der the microscope. It is sometimes seen in large, more or less rounded tumors, as in Mr. Paget's case, delineated Fig. 92, but more fre- quently, as in the specimens I saw, dissemi- nated in small nodules through the cancellous tissue, after the manner of an infiltration. The bone-substance becomes gradually dis- placed, or rather, probably absorbed, so that fracture from slight causes is extremely likely to occur ; and, indeed, it has been noticed, in certain rare instances, that the whole bone has disappeared, leaving the periosteum unchanged in size or form, but filled with cancerous material instead of the original osseous tissue. Mr. Paget speaks of a case in which 22 9-2.-(From 338 MALIGNANT DISEASES OF BONE. " a cancerous femur was broken eight months before death, find the new bone with which it was repaired was infiltrated with cancer as well as the original textures." To the naked eye the morbid material presents, on section, the usual bluish-white, pearly, shining, semi-transparent appear- ance of hard cancer elsewhere. Under the microscope, the cells present the same appearances which are characteristic of the dis- ease in other parts. Their irregularity of form, their dim, pel- lucid cell-wall, their large nuclei, commonly single, with large, distinct nucleoli, are features well marked ; while the semi-fluid substance in which these cells lie enclosed, as in a stroma, can be squeezed out or scraped out in considerable abundance. There is some difference of view among pathologists as to whether the fibrous element, so commonly found in this form of cancer, be one of new formation, or whether it be only the original tissues, distended by, and enclosed in, the growing can- cerous mass. This question, it seems to me, receives some light from the fact that this fibrous structure is sometimes almost completely absent in hard cancer of the bones. In some of the firmest and most fibrous-looking of these cases there is no fibrous tissue to be discovered. Dr. Delafield made a careful examination of some of the bones removed after death from a patient of Dr. Sprague, of Fordham, who had died of cancer of the breast of the scirrhous form. "All the long bones were diseased; had become bent during life, especially one femur. Specimens are femur, first, and tibia, last affected. Femur is much bent, and tibia not. Periosteum and cartilages not involved. ^Nearly the entire bone and medulla changed into a firm, white, lardaceous substance ; a little of bone of shaft and cancellous tissue left. Xew tissue consists of dense bands of white, fibrous tissue, crossing and in- terlacing and forming round and oval interspaces. These spaces are mostly empty, but, in the youngest part of tissue, are filled with polygonal, nucleated cells. The mamma was a small, con- tracted, hard lump. Only fibrous tissue could be found; no cells." In another case, brought into Bellevue Hospital Xovember 25, 1867, fracture had occurred of the right femur by a fall in the street the day before her admission. The patient was a SCIRRHUS, OR HARD CANCER OF THE BONES. 339 very old woman, eighty-seven years of age, and had an ulcera- ting carcinoma of the breast of unknown duration. An attempt was made to treat the broken limb, but she rapidly failed, and died December 8th. Autopsy. " Body very much emaciated. The right mamma is the seat of a large ulcer, with indurated edges ; the axillary glands are much enlarged ; several small tubers in the skin near the ulcer. Head. In the vault of the cranium are three round- ed places where the bone is replaced by a structure resembling fibrous tissue ; the periosteum and dura mater are adherent to these places, but there is no tumor. In the bone surrounding these places, the diploe is filled with new tissue, and the bones thinned. All the bones of the skull are softer than natural. Brain is normal. Lungs. There are a few old adhesions over both lungs. Both lungs are more than usually pigmented. The upper lobe of the right lung is hepatized. The liver has hardly any left lobe. There are gall-stones in the bladder and ductus communis ; the latter is dilated so as to admit my finger up to one quarter of an inch of the intestine, where it is obstructed. Spleen small. A few nodules in the capsule. Peritonaeum throughout studded with small white tumors. Kidneys, in both pelves and calyces, dilated and containing pus, especially the left. Large intestine, its walls containing many small tumors, over which the epithelium has ulcerated. Bones. The right femur is fractured at its middle, the fractured ends much dis- placed, and bathed in pus. At the point of fracture the shaft of the bone is thinned, and the medullary cavity filled with a new growth. The left femur, both tibiae, both humeri, the sa- crum, and one os innominatum, contain similar deposits of new tissue in their medullary cavities. The scapulas, ulnae, radii, clavicles, and metacarpal bones, contain no such deposit. " Minute Examination. The new tissue in the mamma and in the tubers in the skin presents the same appearance, viz., potygonal, nucleated, epithelial cells, .018 to .025 in diameter, contained in round and oval alveoli, the proportion between cells and framework varying in different parts. The tumors in the peritonaeum differ from these in their greater number of cells. In the long bones, the tumors are situated either next to the shaft of the bone or in the cancellous tissue, and are surrounded 340 MALIGNANT DISEASES OF BONE. by red, indurated medulla. This red medulla is composed largely of l medullocelles.' The new tissue consists of a pretty dense fibrous framework, forming alveoli which contain cells. The cells are the same as those found in the breast. There are also found numbers of nuclei adhering together and surrounded by protoplasma, not myeloplaxes. In some places only cells are seen. In the cranium the cells are the same, but their arrange- ment is somewhat different. The fibrous tissue is more abun- dant, and the alveoli small ; some only containing two or three cells, others much larger ; and these small alveoli may be close together, so that it looks like fibro-cartilage. The character of the cells and the examination of a sufficient number of speci- mens destroy the possibility of this." CHAPTER II. MEDULLARY, OK SOFT CANCER OF THE BONES. BY far the most common form of cancerous disease of bones is the medullary, or soft cancer. Indeed, of all the cases of medul- lary cancer, the bones furnish a very considerable fraction. Mr. Paget gives a table of 103 cases of external medullary cancer, omitting those of the uterus and other internal organs, and of these 21 were in the bones. Lebert gives a table of 447 can- cers, of all kinds, of which 35 were in the bones. M. Tanchou's extensive tables, embracing 9,118 cases of all kinds, give only 38 to the bones. This small fraction might probably be in- creased somewhat by adding something for those cases 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 520 cases, 15 of the bones, and Mr. Baker, in 500 cases, records 23 as occurring in the bones. None of these are to be relied on as giving an accurate statement of the relative frequency of cancer in bones, but they may serve to convey some general idea on the subject ; and, when we take into account the fact that by far the larger proportion of all are medullary, we have arrived at some rough estimate of the pro- MEDULLARY, OR SOFT CANCER OF THE BONES. 341 portion in which each form presents itself in the bones as com- pared with the soft parts. These statistical statements have reference to cancer in all its forms and all its conditions. As a primary disease, how- ever, cancer in the bones is, almost without exception, of the soft variety. The primary tumors present themselves in all parts of the skeleton Mr. Paget thinks most frequently in the thigh-bone and usually affect the cancellous tissue in the first instance ; often, however, extending their encroachments to the compact substance, which is gradually incorporated with the growing mass, losing always its compact character, and becom- ing either altogether absorbed, or spread out into a spongy mass, pervading the new growth, in which finally no trace of the original compact structure can be discovered. This is par- ticularly the case with the arm and thigh bones, and it is in cancer in these situations that we most often have fractures oc- curring from the most trivial degrees of violence. Most com- monly the primary cancer is single, and in the shape of a rounded tumor, which distends before it the outer shell of the bone, which shell, growing thinner and thinner, as the tumor enlarges, it sometimes retains until it has attained a great size, when finally the cancerous mass breaks through its covering, and soon all traces of it disappear. The tumor may either be an isolated mass of medullary substance displacing the surround- ing bone-tissues, or, as is most frequently the case, it is an in- filtration from the first ; and grows as such, gradually appro- priating to itself, and enclosing within its growing mass, what- ever bony material, whether compact or cancellous, it comes in contact with. In this way the most various shapes are assumed, and the most various conditions of the growth itself are found. The tumor usually projects from the surface of the bone on one side ; sometimes it projects unequally on both sides, as in the cranial bones. Sometimes, as in the heads of the long bones, the whole spongy extremity expands nearly equally, and often reaches an immense size, with a somewhat symmetrical form (Figs. 93, 94). On the cranium these tumors very commonly pro- ject from the surface of the vault in the form of evenly-rounded domes or hemispheres, and where several are growing close to 342 MALIGNANT DISEASES OF BONE. one another the head presents a most extraordinary appearance. The figures 99 and 100 are taken from patients who died of the disease developing itself internally, while the tumors seen on the head were slowly increasing. FIG. 98. (From Billroth.) The cut surface of these growths presents a whitish, pearly section, in which an arrangement into lobules can be more or less distinctly seen ; the lobules varying much in size, and still more in consistence and color ; some are quite hard and white, others are softer, and reddish or brownish in color. Others are so soft as to flicker almost like jelly, and have a deep-red or modena color, as if stained deeply with blood. In other points actual extravasations of blood, some apparently contained within cyst-walls of a sort of fibrous tissue, are found, giving the ap- pearances which were formerly spoken of as fungus haematodes. The tumor is usually contained within a capsule formed from the periosteum, often much thickened, which capsule is, during the earlier periods of the growth of the tumor, fortified, as men- MEDULLARY, OR SOFT CANCER OF THE BONES. 343 tioned above, with the thin shell of compact bone upon which the periosteum lies, the two layers at first expanding together ; then, as the tumor increases, the bony shell giving way first ; and afterward, as the mass softens and ulcerates, the periosteum disappearing at the point of greatest prominence ; and the soft growing mass, now released from the support of its hitherto FIG. 94 (From Billroth.) FIG. 95. (From Billroth.) firm envelope, sprouts without restraint in whatever direction it is least opposed by surrounding tissues. If the tumor have not yet reached the surface, when it has escaped from its fibrous incasement, then we find it invading and appropriating to itself all the softer materials which it encounters, which, becom- ing incorporated with the growing mass, lose all identity ; or, pushing itself" in and among the various interspaces where press- ure is the least, it reaches out its finger-like processes, extending often much deeper and much farther than its external appear- ance would lead one to expect. At the same time it often seems limited by encountering a firm aponeurotic layer, against which it spreads laterally, and adheres to it without involving 344 MALIGNANT DISEASES OF BONE. it, at least for a considerable period. If, on the other hand, the mass has reached the surface when the fibrous envelope gives way, then we have the proper fungous character assumed, with the rapid growth, and almost as rapid destruction of the pro- truding cancerous material. The relations of the original bone to the growing cancer have already been alluded to. Here the processes are invari- ably those of destruction and disappearance, more or less com- plete, of both cancellous and compact bone-tissue. This disap- pearance is irregular, however at some points being further advanced than in others, so that at different parts of the tumor we may have either much or very little of the disappearing original bone remaining. With these irregular remains of the skeleton of the part we have a certain amount of disposition on the part of the tumor itself to generate new bone. I think this is rarely observed to any great extent in the medullary cancers of the long bones, but in those affecting the skull it is often very marked. In the maceration of the head, Fig. 100, we found, on clearing off the soft parts, and drying the bones, a most extraordinary and beautiful framework of delicate spicular bone springing from the surface of the skull, which was itself eroded and partially absorbed wherever the tumor had grown from its surface. These slender spiculae and thin lamime of newly- formed bone were, almost all, at right angles with the surface of the bone from which they grew, and from their delicate for- mation, varying form, and beautiful feathery terminations, made a most beautiful preparation. This we kept, carefully protected under glass, in the Xew York Hospital Cabinet for some years, but it gradually disintegrated and fell to pieces, so that now none but the rougher and stronger foundations remain of the light and delicate structure, showing by its destruction how imperfect and feeble it was in its organization. This form of radiating skeleton, as found in the soft cancer of the skull, is spoken of by several writers, but nothing so marked is often found in other bones. In some rare cases an increase of bone- substance is found from the beginning of the disease, giving a hardness to the growth which makes it quite difficult to pro- nounce, without microscopical examination, whether we have to deal with a cancer or an exostosis. MEDULLARY, OR SOFT CANCER OF THE BONES. 345 The vascularity of these cancers is usually very great, and new vessels are formed with surprising rapidity. These vessels are generally very large in size, thin in their walls, tortuous and often varicose in their course, and in such abundance as to be out of all proportion to their amount in any normal tissue. It is on account of this disproportionate development of vessels, large - and small, arterial and venous, that we have, in many of these tumors, so active a circulation that the pulsation of the arterial vessels often gives rise to the suspicion of aneurism a suspicion which is sometimes strengthened by the fact that they do diminish in size when pressure is made upon the main trunk above the tumor. This diminution, so much like the subsidence of an aneurismal swelling, under the same manipu- lation, is simply due to the fact that the bulk of the tumor is so largely made up of vessels that a diminution in the amount of blood they contain is sufficient to produce an evident decrease in the size of the tumor itself. Hence, also, we have the fre- quent extravasations of blood into the substance of the medul- lary mass, and, when ulceration has taken place, the same abun- dance of large and thin-walled vessels explains the facility with which haemorrhage occurs, and the alarming extent to which it sometimes reaches. In the softer cancers, a large quantity of juice can be scraped or squeezed from the cut surface, and indeed, by moderate and repeated squeezings, the whole solid mass of the tumor may be emptied of its fluid and semifluid contents, and then appears as a flaccid, whitish, shreddy, wet, tow-like mass, which bears a surprisingly small proportion to its original size. This large proportion of fluid matter, retained in the meshes of a com- paratively small amount of weakly solid stroma, explains very readily the deceptive feeling of fluctuation which medullary cancers in the soft parts so often present, and which feeling is not by any means rare in the advanced stages of the disease as it occurs in .the bones. The microscopical study of these tumors gives us nothing different from their well-known features in other parts of the body. Of cells, we have the characteristic multiformity. Thus, we have the ordinary cell, with its single, rarely double nu- cleus, and bright, sometimes multiple nucleolus ; these cells 346 MALIGNANT DISEASES OF BONE. presenting every variety of shape, sometimes round, sometimes flattened, sometimes elongated into processes of most irregular outline. These are mingled with a large proportion of what are considered as free nuclei, though Mr. Beale's researches would lead us to regard these as cells as much as the other forms, these free nuclei having shapes as various as the cells, and often presenting a close approximation to the spindle- shaped cell, of which we have seen that the bulk of some non- malignant tumors is composed. The true elongated, spindle- shaped cell, with nucleus and nucleolus, is not uncommon, but never, so far as I know, makes up any considerable portion of the mass. Cells also occur in which no nuclei can be seen, and sometimes we have the large cells with many nuclei, resem- bling the peculiar cell of the myeloid growth. The intercellular substance is softer than in the case of scirrhus, and a good deal of the cell-growth seems to take place in a substance which is nearly fluid. Here, however, much difference prevails in dif- ferent specimens, the intercellular substance in some examples being quite firm, and in extremely small amount, whereas in others it forms the bulk of the growth, is almost liquid, and has the cells floating in it, much as pus-cells float in the liquor pu- ris. It is somewhat characteristic of this form of disease, that all these varieties, both of cell-formation and of intercellular substance, are constantly found in the same tumor, and often in the same lobule. Much has been said, of late years, of the fibrous stroma or framework in which the cancerous material proper is contained. The alveolar character has been considered by many able ob- servers as the one characteristic anatomical feature of cancer, by which a ground of distinction from all other tumors may be maintained. I do not feel prepared to accept this as a univer- sally applicable anatomical distinction, yet it has much evidence in its favor. Rokitansky, as long ago as 1852, published a de- scription of the development of the stroma or skeleton of can- cers, accompanied with beautiful plates, giving his ideas with great distinctness and minuteness. He describes the stroma of cancer as composed of two distinct elements ; one somewhat of a fibrous character, and the other made up of cells closely packed without any distinct fibrillar arrangement. These two MEDULLARY, OR SOFT CANCER OF THE BOXES. 347 substances are arranged in the form of bands of a tolerably regular size, which interlace among themselves, leaving spaces of various sizes and shapes, in which are contained the true cancerous cells, and their proper intercellular substance. This stroma he considers as the real basis-substance of the cancer, as much a part of it as the cells themselves, and, pervading all parts of the diseased mass like a skeleton, is one of its essen- tial anatomical features (Fig. 96). Many of the most eminent FIG. 96. (From Paget.) pathological anatomists since Eokitansky have given a descrip- tion of an alveolar arrangement of the stroma of cancer vary- ing somewhat from, but in the main confirmatory of, his views. Thus, in Cornil and Ranvier's manual, carcinoma is defined to be " a tumor composed of a fibrous stroma arranged in alveoli, which form, by their communication, a cavernous system ; these alveoli are filled with free cells contained in a liquid more or less abundant." Billroth entertains views, with regard to the tumors wilich should be included under the term cancer, in which he differs somewhat from other recent writers, but he evidently recognizes as an anatomical fact the alveolar charac- ter of the cancerous tumors which he describes, as his plate, of which Fig. 97 is a copy, very evidently shows. He does not, 348 MALIGNANT DISEASES OF BONE. however, seem disposed to admit the alveolar arrangement as an absolutely characteristic feature of cancer. The clinical history of soft cancer of bones presents many variations from a typical case. Most frequently the disease commences without any or with very little pain, and without FIG. 97. (From Billroth.) any very evident assignable cause. Without being confined to any age, it is most common at a much earlier period of life than either the scirrhous or epithelial form of the disease. In my observation, most of the very rapid-growing cases have been in young adults. In one very remarkable case which oc- curred in the New York Hospital, and of which we have the specimen in the pathological cabinet, a cancerous tumor of the clavicle and scapula proved fatal in six weeks from the day of its first appearance, by which time it had attained a size of one foot in diameter. This tumor occurred in a young man of eighteen years of age. Another enormous and very rapidly- developed tumor was the one presented in Fig. 98. This was developed from the clavicle in a girl aged fourteen, and reached its gigantic size within a few months. It was of the softer medullary character, and to the last showed but little tendency MEDULLARY, OR SOFT CANCER OF THE BONES. 349 to ulcerate. She died, worn out by the disease, and cancerous deposits of a similar character to those of the large tumor were found in the lungs. She had also, as seen in the woodcut, a very singular-looking redundan- cy of the skin, with hypertrophy of its tissue, on the right arm, making a hanging sort of bag of thickened, discolored skin, with numerous strong hairs growing upon it. It was for this curious formation, which had been grow- ing for several years, that I pre- sented her to the Pathological O Society, about a year before her death, when the tumor of the clavicle had scarcely begun to show itself. The tumors shown in Figs. 99 and 100 were both young men, one eighteen, the other nineteen years old. The cause of these growths cannot generally be ascertained. Sometimes an injury, as a blow, is the starting-point of the dis- ease, and one case in our collection followed a fracture. No. 107 is a picture of this case, which was briefly this : A man, twenty- two years old, broke his arm in the act of throwing a snowball. " No union took place, and at the end of six months he entered the hospital, where the limb was removed at the shoulder-joint ; an encephaloid deposit having meanwhile taken place upon the fractured humerus, so abundant as to form a large fusiform swelling, involving the greater part of the arm, and measur- ing at least twenty inches in circumference." Some cases are spoken of where encephaloid disease has attacked carious joints, where the products of old inflammation may be supposed to have been the nidus in which the cancer originated. In by far the larger number of cases, however, no distinct cause can be ascertained. As the tumor grows, the patients suffer pain from its distention of and pressure upon the surrounding soft parts, the tumor itself remaining free from pain or tenderness. In FIG. 98. (N. Y. Hospital Museum.) 350 MALIGNANT DISEASES OF BONE. some exceptional cases great pain is experienced from the ear- liest to the latest stages. The tendency to ulceration does not seem to be so marked in medullary cancer of the bones as it is in cancers of other parts and of other forms. Many of the largest tumors I have seen were not ulcerated at all, and those which were open at any point of their surface seemed to have become so from some abrasion, or pressure, or some other accident which had determined an ulceration where it would not other- wise have occurred. The great tumor of the shoulder had a very small surface of ulceration upon its summit, which only appeared in the last weeks of life. The tendency of most of these tumors is rather toward rapid proliferation of the cell- growths, of which they are composed, than to ulcerative destruc- tion. This ulceration, however, does occur in some cases, usually preceded by a bulging of the tumor at one or more points, which become very vascular in their external appearance, and often very tender to the touch as the ulceration is about to take place. This bulging and apparent inflammation is the accompaniment of a process of rapid softening which is going on at that point ; and, when the surface does give way, we have an ulceration fol- lowed by fungous sprouting forth of enormous, soft, spongy granulations, rapidly increasing in size and prominence, bleed- ing fiercely on the slightest injury, and discharging a copious, thin, bloody ichor, which very rapidly exhaust the remaining powers of life. The condition which precedes this ulceration, viz., the soft, bulging, very vascular prominence of a certain part of the surface of the growth, very closely simulates the process of suppuration in its external features ; and, when com- bined with the fact that a pretty rapid and quite considerable softening of the mass occurs at the protruding point, it is not wonderful that many good surgeons have been deceived, and have plunged a bistoury into the suspected spot, expecting a free escape of matter to follow their incision. The feeling of fluctuation is so perfect in these cases that I know not how to discriminate between it and the fluctuation of real pus. The mistake is an unfortunate one, for ulceration and fungus are very apt to follow the incision ; and yet, in several instances, I have known such a cut to heal as quickly and as soundly as if it had been made in a perfectly healthy part. MEDULLARY, OR SOFT CANCER OF THE BONES. 351 During all the earlier part of this disease, particularly if the patient do not suffer much pain, the constitution does not seem to experience much deterioration. Some of these patients, with rapidly-growing and large tumors on the arm or leg, will keep about their ordinary avocations, and, among the lower classes, seem sometimes to feel very little anxiety about their disease. One of the largest tumors of this kind that I have ever seen, occupying two-thirds of the whole thigh-bone, and of enormous diameter, walked to our college clinique, and up to the third story, with no more inconvenience than was occasioned by the excessive weight she had to carry. In the later stages, after softening begins, and particularly after fungus has protruded, the system gives way rapidly, and the true cancerous cachexia occurs, if the patient live long enough for its peculiar features to be developed. Secondary deposits, of the same nature as the original tumor, are found in the liver, the lungs, and various other internal organs, sometimes in immense masses, and some- times very extensively diffused over various organs and regions of the body. Specimens No. 557 and 558, in our collection, are instances of secondary cancerous developments in the lungs and pleura, in a man from whom the thigh had been removed a few months before for a large medullary tumor. About three months after the amputation he began to suffer from pect6ral symptoms, of which he finally died. " A growth of fungus hematodes 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 pushed down, a cavity was found con- taining nearly a gallon of brownish-red serous fluid, with coagula and shreds of lymph floating through it." This cavity was that of the pleura, whose surface was studded all over with " numerous rounded and flattened masses, soft, and of a white color," which were evidently of the same nature as the tumor originally re- moved from the thigh. No. 556 is an immense secondary medul- lary tumor, developed in the mediastinum, and compressing the lungs and other thoracic organs into a very small space. This specimen was also taken from a man who, about a year before his death, had had his thigh amputated for a large encephaloid tumor of the femur. Secondary deposits of all the forms of cancer are quite common in the bones. 352 MALIGNANT DISEASES OF BONE. It is well known that all of the forms of cancer are capable, under certain circumstances, of undergoing a change for the better. This change may be shown by the tumor, heretofore progressive, remaining stationary ; the bulk of the tumor, in other cases, may actually diminish, even sometimes to the ex- tent of the disappearance of all signs of the disease ; the surface, previously deeply ulcerated, may fill up with healthy graniTla- tions, and cicatrize ; or, lastly, these favorable changes may be consequent upon a process of inflammation and sloughing, whereby, the whole tumor being destroyed, a sound cicatrix may be secured. These flattering phases of cancerous life are perhaps best and certainly most frequently seen in the form of the disease we are now studying ; but, it has so happened, that I have never seen any good exemplification of it in any form of cancer of the bones. It doubtless does sometimes occur in medullary tumors of the bones ; but I must believe it to be more rare than in any of the forms of cancer affecting the soft parts. A very slow growth of the tumor is sometimes seen, as, in one instance, where a woman presented herself at the New York Hospital, with a large tumor of the tibia, which, she assured us, had not grown at all for twenty years, and which, only within a short time, had given her any uneasiness. The limb was amputated, and the tumor, which sprang from the anterior face of the tibia, gave the most unmistakable evidence of encephaloid cancer. The following cases illustrate so well the chief clinical fea- tures of the disease we have been considering as to justify me in introducing here a brief outline of their history. The first case was under my care as resident surgeon of the New York Hospital, Dr. Gurdon Buck having the responsible manage- ment of it as attending surgeon, and, from his very full and careful notes, dictated at the time, I draw my material : Albert Milderberger, a boatman, aged nineteen, was admitted into the New York Hospital, December 14, 1839, with a tumor of the size- of a large orange covering the parietal and temporal regions. " In the month of May last preceding, while at work on board a vessel, he struck his head against the boom, as he was in the act of lifting a stove ; but, having on a fur cap at the time, he perceived no unpleasant effects from the blow, and MEDULLARY, OR SOFT CANCER OF THE BONES. 353 continued his work. The same evening he noticed a soft tumor, under the scalp, of the size of a walnut, on the spot where he had received the blow. In a fortnight it increased to the size of a Madeira-nut, and was pronounced a wen by a physician who examined it. In July it was as large as a hen's egg, and, on being punctured, it discharged a pint of florid blood in a jet that was easily arrested. The puncture healed in two days, and the size of the tumor was diminished. The loss of blood relieved a headache from which he was suffering at the time. Pressure was now applied, during four or five weeks, by means of a piece of lead, but had no other effect than to flatten the shape of the tumor, which continued increasing in size. For four weeks preceding his admission, very powerful pressure was kept up by means of a piece of lead, weighing two pounds, flattened out and adapted to its surface, and bound firmly to the head. This caused the tumor to spread at its base, particu- larly along the lower side, toward the orbit and zygoma. Five days before admission it was punctured a second time, and a pint of bright-red blood flowed rapidly in a jet, without dimin- ishing its size. The blood was easily arrested, and the puncture healed kindly. " At the time of his admission, the tumor had attained a for- midable size, and presented the following characters (Fig. 99) : It rose two inches above the surface of the cranium, standing off in an oblique direction outward. Its base was of an oblong form, and extended upward to within two fingers' breadth of the median line ; backward to the lambdoidal suture ; down- ward to within an inch of the ear, and forward to within three fingers' breadth of the outer margin of the orbit. Its limits were abrupt and well defined, except about one fourth of its circumference that expanded out over the temple in a superfi- cial soft swelling that was gradually lost near the outer canthus, and along the zygoma. This portion appeared after pressure was applied the second time. The tumor measured, in an ob- lique direction, forward and downward over the summit, seven inches and a half. The surface was of the color of the rest of the scalp, and sparsely covered with hair. Numerous veins ramified under the skin, and, when pressure was made on the internal jugular vein, they became swollen and prominent. A 23 354 MALIGNANT DISEASES OF BOXE. small congeries of purple arborescent capillary vessels existed at one point on the surface. There was a softened spot, of the size of a split-pea, and of a dirty-yellowish color, at the point where the last puncture had been made, apparently from the formation of a superficial abscess. The tumor was tense and elastic in every point, rather softer and more supple in front FIG. 99. (From N. Y. Hospital Museum.) than elsewhere. ~No fluctuation could be felt, nor could any diminution of its size be produced by pressure. The pulsation of the branches of the temporal and occipital arteries was per- ceptible on applying the hand, but there was no pulsation of the mass. On applying the cheek, however, I thought I per- ceived a slight movement of elevation and subsidence. A dis- * tinct bruit de souffiet and thrill could be perceived in the tempo- ral artery above the zygoma. A solid, roundish lump was felt within the tumor at its posterior part ; the patient himself had noticed it, and sometimes had noticed two lumps. That por- tion of the tumor that spread upon the temple, after pressure was applied the second time, was soft and doughy, except at its anterior part, where there was a circumscribed portion of almost bony hardness that seemed movable oh the cranium, and con- veyed to the touch a sensation of crepitus. Pressure on the MEDULLARY, OR SOFT CANCER OF THE BONES. 355 carotid had no other effect than to stop the pulsation in the branches of the temporal and occipital arteries. Patient had no pain in the tumor itself, but had been subject to pain across the forehead for six years previous, which came on at intervals." His general condition was good ; pulse sixty-eight ; appetite good, and bowels regular. From the evident vascularity of this tumor, it was thought best to try the effect of cutting off its arterial supply. This was done by Dr. Buck, on the 21st of December, by applying a ligature to the common carotid artery, and afterward, by circumscribing the tumor, by an incision through the scalp, about an inch from its base, which encircled the whole tumor except about two inches in the temporal region. The vessels had of course ceased to pulsate when the carotid was tied, but each was carefully ligatured as the incision was made. The ligature came away from the carotid on the 13th day, and the incision round the tumor rapidly cicatrized. No change was produced in the tumor, by this thorough operation, except the arrest of all pulsation. January 4, 1840. " The tumor was again punctured ; blood flowed freely, and a probe passed in moved easily about in the substance of the tumor, as if its substance were of the consist- ence of brain. An attack of erysipelatous inflammation fol- lowed this manipulation, and the wound remained open, dis- charging bloody fluid." January Ilth. "The punctured opening has taken on a circular form of the size of a split-pea. Pressure around it does not force out any discharge. The anterior half of the tumor is softer, and its covering thinner, having much the feel of an abscess near the surface ; it has subsided and is less prominent." The last two punctures were open and discharging, and a probe could be passed from one to the other. A bistoury was there- fore passed, and the communicating sinus laid open, thus largely exposing the centre of the tumor. This exposure of the mass of the tumor was followed by a gradual softening and disin- tegration of the exposed portion, pieces sometimes coming away as putrid sloughs. This process gradually destroyed the more prominent part of the tumor, but it nevertheless extended at its base until it became converted into an immense promi- 356 MALIGNANT DISEASES OF BONE. nent, but not fungous, cancerous ulcer, the level of which was not more than an inch above the surface of the skull. At one or two points the bone was exposed. Granulations covered the surface, and at times healthy-looking pus was discharged from it. Occasionally, severe haemorrhage now began to be pro- duced by slight causes, which, with severe epistaxis now and then occurring, reduced his strength rapidly. In May he left the hospital, and went to reside at his sis- ter's house in the city. The disease continued to spread over a greater area, but did not assume at any time the fungous character. He died, worn out by frequent haemorrhage, in No- vember, 184:0. Post-mortem examination showed that " the tumor extend- ed from the middle of the superciliary arch to within two fin- gers' breadth of the median line, in the occipital region, and from the sagittal suture above to the angle of the jaw below, so as to hide the right ear, the cheek, and outer half of the eye, the lids being drawn down with it. The margin of the tumor, along the sagittal suture and as far forward as the orbit, pre- sents an irregular bony ridge, as though the external table were pushed outward. The suppurating surface of the tumor was coated with dry pus. At the upper part, a mass of dry lint, impregnated "with blood, adhered to the surface, where it had been applied several months since to arrest haemorrhage, and had not been removed for fear of its return. The circumfer- ence of the tumor measured twenty-five inches. Bony spiculge could be felt in the substance of the tumor. The inner table of the cranium, as well as the outer, was very extensively ab- sorbed, and the tumor had pushed before it the dura mater, so as to encroach very much on the brain. A prolongation of the diseased mass extended into the sphenoid fissure and zygomatic fossa. The surface in contact with the dura mater was of a grayish color, and of a firm, jelly-like consistence. The margin of the opening in the inner table was thin and sharp, and not pushed inward, while that of the outer table was elevated and uneven. Besides the aponeurosis that invested it, the tumor seemed to be contained in a strong, fibrous envelope, that di- vided it into lobes. These consisted of a substance of firm, fleshy consistence, and of various colors portions resembling MEDULLARY, OR SOFT CANCER OF THE BONES. 357 coagulated blood, while others were of a grayish color. The dura mater and other membranes, as well as the brain itself, were apparently healthy. " The left kidney was six times larger than the right, and formed an irregular nodulated mass of the same morbid struct- ure as the tumor. The outline of the organ could be recog- nized upon the anterior surface of the mass, the morbid changes having mostly invaded the posterior half of the kidney." Both specimens are preserved in the hospital cabinet. The microscopical appearances are not noted in the record. The next case was that of a man, nineteen years of age, who was admitted into the New York Hospital in June, 1856, with an enormous tumor of the thigh, which had been growing about four months. It occupied the lower half of the femur, and the limb, at its largest part, measured twenty-six inches in circum- ference. The thigh was amputated on the 24th of June, and the tumor found to be encephaloid cancer. He did well after the operation, and the stump healed slowly. On the 26th of December following, a sudden attack of oedema of the face called attention to a soft lump on the side of the head, at the junction of the frontal and parietal bones, near the sagittal su- ture. Stated that he had noticed it about three weeks before, but, as it gave him no pain, he said nothing about it. It is of the size of the fist, has a soft, fluctuating feel, and is not mova- ble on the skull. Has also a small tumor on the right clavi- cle, which gives him some burning pain, and is tender to the touch. Has a good deal of headache, especially on the left side of the head. The oedema of the face soon subsided, and he seemed as well as usual. Small periosteal swellings were noted on the third and fourth ribs, on the right side, near their middle. January 4, 1857. The swelling on the clavicle has disap- peared. The large tumor of the head is also subsiding, and his headache is much relieved. He has been taking iodide of po- tassa in increasing doses since December 28th. In the latter part of January another attack of oedema of the face came on, without chill or fever, and without any evident cause, and passed away as before in a few days. January 24^A. The tumors are beginning to grow again, 358 MALIGNANT DISEASES OF BONE. though lie is taking eighty grains of potassa daily. The medi- cine seemed to disorder his stomach, and was reduced to five grains three times a day. February 20tA. Another tumor has sprung up over the occiput. The original tumors are increasing. About the 1st of March another tumor showed itself on the right side, over the parietal bone. He has been using cod-liver oil, and a gen- eral tonic and invigorating regimen. He now suffers great pain running down the left arm, requiring large anodynes for its relief. In April a swelling without distinct tumor appeared over right lower jawbone. The tumors of the head are gain- ing a formidable size. That on the clavicle at one time again almost entirely disappeared, which was also the case with the swellings on the ribs. The tumors on the head, after their first partial subsidence, steadily but slowly increased. JLfay 12A. Tumor of jaw diminishing. From this time general cancerous cachexia made pretty rapid progress. June 22d. He is noted as delirious, and his eyesight fail- ing; still his appetite is wonderful. He gradually wasted away, and died, July 27th, with no other cerebral symptoms than occasional delirium and gradual but not complete loss of sight. Autopsy. The weight of the head was 21 pounds. Its circumference, measuring horizontally round the most promi- nent points, was 27J inches. The perpendicular prominence of the largest tumor from the surface of the skull was about 8 inches (Fig. 100). The 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 their bases, into one another. All gave the feeling of fluctuation, and when cut open were soft, brain-like, very vascular, with bony spiculse and solid bone-masses scattered about through the growth. The skull was perforated, and the tumors pressed down upon the brain. The lungs and pleurae were studded with firm, white, tumor-like masses, varying from the size of a hazel-nut to that of a walnut. An encephaloid mass, as large as a child's head, was found in the right iliac fossa, developed from the bone upward into the pelvis, and downward so as to surround the head and neck of the amputated femur in a sort MEDULLARY, OR SOFT CANCER OF THE BOXES. 359 of cancerous capsule. The other tumors, on the clavicle and ribs, noticed before death, were found to be of the same medul- lary character, and besides these several small tubera were de- veloped upon the bodies of some of the vertebrae. FIG. 100. (X. T. Hospital Museum.) These tumors, after maceration, gave the beautiful, radi- ated, feathery skeleton of soft, friable bone-tissue, described at page 3i-i. 360 MALIGNANT DISEASES OF BONE. i CHAPTEK III. EPITHELIAL CANCEK OF BONE. MUCH less common than the medullary, and considerably more so than the scirrhous cancers, the epitheliomata of bone occur sufficiently often to have been carefully observed by sev- eral writers. As a primary affection it is rare ; I have never encountered one which was recognized. The most clearly- marked case I find recorded is one which was admitted into Guy's Hospital, under the care of Mr. Cock, in May, 1858. The patient was a man forty-five years old, pale and cachectic- looking, but his general health was good and his habits regular. " Twenty-six years ago he noticed a swelling in the right knee, which continued to increase for some time, till at last he was unable to walk. This swelling then burst, and he was much relieved. The wound, however, never healed, and was some- times worse than at others. About two years ago he fell down and struck the part ; the wound then became rapidly larger, the bone died, and at last he came to this hospital. When admit- ted, the right leg presented over the surface of the tibia a large, sprouting, epithelial growth, involving nearly the whole bone ; in the centre was a deep hollow, which excavated the bone, and at the bottom some dark, carious, and necrosed bone was visible." Mr. Cock amputated the limb, through the lower third of the thigh, and soon after the man left the hospital cured. " On examining the limb, it was clear that both the tibia and the integument over it were involved in one mass of epi- thelial disease. The bone was for the most part dead, and in- filtrated with the elements which characterize epithelial cancer, or epitheliorna. The sprouting cauliflower-growths from the integument presented the same characteristics ; but the cells in the bone were very well marked, and proved remarkably beau- tiful microscopical objects." Another case is given by Mr. Bryant, of the same hospital, of a man who had an epithelial cancer in his heel, involving the EPITHELIAL CANCER OF BONE. 361 os calcis. It seems very probable, however, that in this case, the disease began in the scar of an old injury of the integu- ments of the heel, and only spread secondarily to the bone. The same suspicion, it must be confessed, attaches to Mr. Cock's case, though nothing is said about any development of the dis- ease in the skin before the bone became aifected. Billroth, who makes all carcinomata to consist of epithelial elements, says : " According to my whole histogenetic view, I must regard it as impossible for an epithelial cancer to occur primarily in a bone or lymphatic gland. The observations that I know, to this effect (in the lower jaw, on the anterior surface of the tibia, in the lymphatic glands of the neck), do not seem to me sufficient proof, because the skin and mucous membrane are so near; there may have been an insignificant carcinomatous disease of the skin or mucous membrane as a starting-point of the disease, without its having been noticed." Secondary developments of this form of cancer in the bones are not extremely rare. Lebert says, without specifying as to the primary or secondary character of the disease, that, in nine- ty cases of cancerous disease of bones, he found it six times of the epithelial variety. Of these, four were in the lower jaw, probably secondary after cancer of the lip, one was in the upper jaw, and one was in the os calcis. The anatomical characters of the disease are well marked. Microscojjically they consist essentially of epithelial cells in varying conditions of perfection, and very variously arranged in their relations to one another. Sometimes the epithelium is contained in tubes and rounded cavities, on the internal sur- faces of which it makes a distinct, well-arranged layer, so regular and orderly in its appearance as to make it difficult to be sure we are not dealing with true gland-structure (Fig. 101.) At other times, the epithelial elements are massed confusedly with- out any apparent order, and for no useful end. Often they are rolled upon themselves into roundish masses, in which the suc- cessive layers of flattened epithelium are arranged somewhat like the layers of an onion (Fig. 102). In short, every possible variety of arrangement and disarrangement of these cells may be found, and upon these varieties some writers have founded numerous subdivisions of the disease. It is sufficient for us, as 862 MALIGNANT DISEASES OF BONE. students of bone-pathology, to be aware of the great variety of forms into which the epithelial elements are in different cases arranged. Besides these typical cells, many other cells are often found which are differently described by different authors. Paget speaks of them as free nuclei. He says : " Nuclei, either free, or embedded in a dimly molecular or granular basis, are FIG. 101. (From Billroth.) commonly found mingled with the (epithelial) cells. I believe they occur in the greatest abundance in the most acute cases. They may be just like the nuclei of the cells ; but usually, among those that are free, many are larger than those in the cells ; and these, reaching a diameter of more than -^-^-^ of an inch, at the same time that they appear more vesicular, and have larger and brighter nucleoli, approximate very closely to the characters of the nuclei of scirrhous and medullary cancer-cells." Billroth says : " But we must here state that, in cancer-tumors, besides the epitheliums, there are usually numerous young, small, round cells which, infiltrated in the connective-tissue portion of the tumor, form an important part of it. This small-celled, EPITHELIAL CANCER OF BOXE. 363 connective-tissue infiltration, which exists in varying quantities, whenever epithelial proliferations grow into the tissue, appears to be caused by a sort of reaction, and to be the result of the penetration of the epithelial new formations into the tissue, ac- cording to the number of infiltrated cells and their future fate, FIG. 102. (From Billroth.) as well as the degree of vascularity, just as, in inflammation, it sometimes leads to softening, to atrophy, and cicatricial thicken- ing of the tissue. In some cases, this small-celled infiltration is so considerable as almost entirely to hide the epithelial new formation, from .which it may be very difficult to distinguish it, if the latter be small." 364 MALIGNANT DISEASES OF BONE. The stroma of epithelial growths does not seem to be con- stant or always well denned. In many cases, and I think always in bone, no proper alveolar stroma, such as has been described in connection with medullary cancer, exists. The tissues are merely displaced for the reception of the new deposit, and what fibrous structures we find traversing the morbid mass are prob- ably derived from modifications of preexistent normal tissues. In the tubular and follicular forms, 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 usually only an exaggeration. These tumors are permeated with a certain amount of fluid, " cancer-juice," as it is called ; and, as the cells have but little cohesion among themselves, there is easily scraped off, from the cut surface, a milky fluid, which is made so by containing great numbers of the epithelial cells floating through it, suspended, as in an emulsion. The clinical features of epithelioma, wherever situated, are mainly those of ulceration. Most epithelial cancers are really cancerous ulcers from their commencement. In and about the base of these ulcers, the cancerous deposit is constantly taking place, so that, as the ulcer grows, the cancer increases ; and it is rather uncommon for an epithelioma to gain any great size as a tumor, on account of its constant tendency to ulcerative destruc- tion. In the bones these features are somewhat modified, ac- cording as the deposit reaches the osseous tissue from an ulcer- ated cutaneous surface, or by infection from a distant tumor. Of cases travelling subcutaneously, and infecting bones deep- seated and distant from the focus of disease, Yirchow gives one instance, in a man aged fifty-nine, who had an ulcerating epithe- lial cancer of the left breast. On the 5th of February, 1853, the left breast and several enlarged axillary glands were re- moved by operation. The man died with symptoms of pyaemia, February 21st. At the autopsy, marked lesions, characteristic of pyaemia, were found. The ribs, from the third to the sixth on the right side, were infiltrated with epithelial cancer. The vertebral end of the first rib on the left side was also similarly infiltrated. In the upper part of the left mediastinum were found several small nodules of epithelial growth. There seemed EPITHELIAL CANCER OF BONE. 365 to be no direct communication between the tumor of the breast and the axillary glands, or with the infiltrated ribs. In such cases as this there could be no chance for ulceration, and I take it for granted these tumors, if the man had lived, would have comported themselves much as other deep-seated cancers do. In by far the larger proportion of cases, the epithelial dis- ease is merely an extension of a 'similar affection from the mu- cous membrane or skin which covers it, and hence, as far as the bone-disease is concerned, it may be said to commence as an ul- ceration, in the same sense that this statement may be made of superficial epithelioma elsewhere. Mr. Stanley, in his admirable book on " Diseases of Bones," gives a number of cases which he calls instances of phagedenic ulceration of bone. These cases, very graphically described, are characterized " by succes- sive abscesses and ulcerations of the soft parts spreading to the periosteum, and thence the ulceration extended through the bone. Hard, wart-like granulations arose from the ulcerated surfaces of the soft parts and of the bone, but these granulations had no disposition to cicatrize, and they discharged very pro- fusely a thin, fetid fluid. In this state I have known the dis- ease to continue many years without the slightest effort of rep- aration." His cases were all in the tibia, and followed some injury which had produced abscess or ulcer over the bone. I cannot help thinking that these cases were in reality epithe- lial in their character, and I am the more strongly led to that belief from the following case, which I watched with great in- terest, and which, in all its clinical features, corresponded very accurately with his descriptions : John O'Brien, aged thirty-two, was admitted into the New- York Hospital, September 10, 1854, with an ulcer on the front 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 wound 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, which 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 great deal of pain, particularly in soft weather and at 366 MALIGNANT DISEASES OF BONE. night. After such an outbreak, it has slowly returned to its usual quiet condition. The last of these attacks, under which he was suffering when admitted to the hospital, began about twelve weeks ago. While thus enlarged and ulcerating, it has often bled freely. ~No bone has been discharged, and he denies ever having had syphilis. The ulcer was upon the middle of the tibia, which was much thickened above and below, as was also the lower part of the fibula. The surface of the ulcer, half the size of the palm of the hand, irregular and prominent, was formed of large, hard, wart-like granulations, giving issue to a thin, fetid, watery fluid. The probe, on being pressed down among these granulations, entered at several points half an inch into the substance of the bone, and encountered rough spiculae, particularly round the margin of the sore, where there seemed to be a border of sharp, irregularly-ulcerated bone, from which the granulations sprouted. There was no great tenderness or inflammatory appearance about the limb, and his general con- dition was good. On the 23d of September, finding no im- provement under treatment, Dr. Buck cut down and exposed the whole surface of the tibia, and found that the wart-like granulations sprung from the bone, which was hypertrophied above and below. With a chisel, the whole ulcerated portion was gouged out to the depth of about half an inch, leaving spongy and hypertrophied bone below, which, however, seemed otherwise sound. At one point the gouge opened the medul- lary artery, which bled very freely, and which was only arrest- ed by pressing a plug of wax against the bleeding orifice. The wound was left open and dressed lightly. November 29^A. Xo improvement followed the operation. The wound did not assume a healing action, but produced anew the peculiar wart- like granulations, bleeding freely from the slightest injury. Several large pieces of bone came away, and the ulcerative ac- tions were progressive in the centre of the sore. His general condition was rapidly deteriorating, and, at his own request, the leg was amputated just below the knee. On examination, the lower two-thirds of both bones were found very greatly hypertrophied. At the point of ulcer there was a loss of substance of the bone equal to more than one- third of its diameter. This excavation was covered and partly EPITHELIAL CANCER OF BONE. 367 filled up with cauliflower-like granulations containing no bone. The bone-substance seemed to be irregularly excavated, and worm-eaten, but without any reparative formation of new bone. The posterior surface of the tibia showed that the diseased action was penetrating throughout its whole structure. It was prominent, with irregular nodules of bony deposit on its surface, and the substance of the bone gave the idea of being infiltrated throughout with the same material as that composing the granu- lations. The same substance seemed to form the basis of the skin-granulation, and was, in several places, infiltrated into the muscles. My friend Dr. John T. Metcalfe made the micro- scopic examination of the tumor for me, and found the mass composed mainly of cells. In the fluid pressed from the bone- granulations these cells were of various characters. There were many small, round cells, with well-marked, sometimes double, nuclei ; others larger, with branching processes ; others spindle- shaped, but among them a considerable proportion of large, flat, single nucleated cells which were manifestly epithelial. The patient made a good recovery, and when the stump was healed he left the hospital ; but already some enlarged lym- phatics in the groin looked suspicious. On the llth of March 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 tumors, which had broken out into foul and fungous ulceration, which were rapidly destroying their surface, while their base was being as rapidly increased. The pain, and discharge of matter and blood, were rapidly bringing on true cancerous cachexia. I heard from him occasionally till his death, which took place a few weeks after I saw him. I heard that the autopsy showed large cancerous masses developed in the pelvis, and in some of the internal organs, but I got no authentic report of the ap- pearances. Mr. Stanley considers the disease as a local malady, and I am not prepared to deny that it is so in some cases. He does not give, however, the after-history of any of his patients, but I think there is good ground for believing that the malignant history of my case was repeated in at least some of his. Dr. Delafield gives me the following account of a knee-joint, which was the seat of a large tumor which had been growing 368 MALIGNANT DISEASES OF BONE. for some years, the knee having been in a condition of disease for about sixteen years. The limb was removed by Dr. James E.. "Wood. "The articulating extremities of the femur and. tibia, the patella, and the soft tissues around the joint, are softened, ulcerated, and partly replaced by new tissue. There are several fistulous openings into the joint. The new tissue consists of cells of various size and shape, mostly of an epithe- lial character. Hound and polygonal nucleated cells, and large, flat, pavement epithelial cells predominate." StachelzeUen " are also found in considerable numbers. The characteristic mark of the tissue is the nests of epithelial cells packed together. The cancroid structure is most complete in the tissue replacing the bone, least so in the tendons. In the latter are found portions consisting of round granulation-cells." CHAPTEK IV. MELAKOID CA3TCEK Df BOXE. PATHOLOGISTS are hardly yet agreed as to whether this form of cancer can lay claim to any other anatomical peculiarity than the existence of the black pigment through the structures of which it is composed. Mr. Paget is very emphatic on this point. He says : "I have not seen or read of any example of melano- sis, or melanotic tumor in the human subject, which might not be regarded as a medullary cancer with black pigment. In the horse and dog, I believe, black tumors occur which have no cancerous character; but none such are recorded in human pathology." In the main, this view prevails with the best writers on the subject, who generally agree that melanotic tumors are, in the human subject, medullary cancers into which the melanotic material has been introduced, without in any other way altering the anatomical features of the structures in which it is found. It exists mainly in the shape of black or brown granules which are sometimes found in the cells, some- times in the nucleus, and, often enough, entirely independent of cells or fibres, merely disseminated through the intercellular MELAXOID CANCER IN BONE. 359 substance of the tissue. In this distribution it is extremely irregular, sometimes affecting single cells, and not their neigh- bors, generally more abundant in some cells than in others, often found plentifully infiltrated through one lobule, while those around it may be of a natural color, sometimes all in the cells, and sometimes mainly outside of them, and not unfre- quently affecting one or more tumors in a very marked degree, while several others may be entirely free from it. What the source of the black material may be, whether it be essential black pigment, like that of the choroid or lungs, or whether it be altered hematoidin, is not by any means positively ascertained, but this much is certain, that in the eye and in the integuments it is more common than in regions which naturally contain no pigment, or but small quantities of it. The disease itself is one of the rarer forms of cancer. Mr. Paget gives a table in which he found, out of 365 cases of cancer of all kinds, 25 were of the melanoid variety; of these 14 were in the skin, 9 in the eye and orbit, 1 in the testicle, and 1 in the vagina. He alludes 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 which may be said to be, at least in its extent, peculiar. I mean the very remark- able disposition it has to generalization ; so marked that in some instances no tissue almost no organ, and scarcely a single bone in the whole body can be found which does not show some trace of the black deposit. And here a question suggests itself, whether, with all this constitutional propensity to the formation and deposit of the melanotic substance, it may not sometimes be found accumulated in the healthy tissues independent of any cancerous formation whatever. This question I cannot answer, but, from analogy in the inferior animals, from the extremely general and abundant manner in which it is often distributed over all parts 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 spots, as seen particularly in the can- cellous structure of bone, I am disposed to expect that the microscope will show us that these secondary black-pigment in- filtrations are sometimes projected into tissues otherwise per- fectly normal, and entirely independent of any cancerous forma- 24 370 MALIGNANT DISEASES OF BONE. tion. These views were suggested to me, and, I think, con- firmed to a great extent, by the observation of the following case, which, perhaps, will aiford us a study of the most impor- tant clinical features of melanoid disease : Peter Ries, aged thirty-three years, applied at the German Dispensary of this city, April 27, 1869, on account of several black tumors on different parts of the surface of his body. The patient stated that he had had, from his earliest childhood, a pigmentary nsevus of the size of a small bean, situated over the angle of the left scapula, which, without any known cause, be- gan to grow larger about two months before, and had then attained the size of an egg. The first melanotic tumors devel- oped in the immediate vicinity of this mole. From the first day 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 surface of the body or inside of the cavities of the mouth, larynx, or ear. From close observation of hundreds of these melanotic tumors of the skin, Dr. Simrock, under whose care the patient was during almost the entire course of the disease, states that they all took their origin from the subcutaneous tissue, and en- croached upon the cutis only after they had attained a certain size, until finally they reached the surface of the skin, by thin- ning its elements by pressure from below. As soon as the growths reached the surface, they began to undergo marked retrogressive metamorphosis, and, shrivelling up and decaying, they gradually disappeared, and left only a black mark as indi- cating their former presence. In some cases even this last dark pigmentary discoloration was observed to fade away, leaving the skin only of a somewhat darker hue than in the surround- ing parts. In some instances the surface of the tumors became ulcer- ated, and a scab formed over them which finally desquamated, leaving only a discolored surface beneath. A few tumors were observed, which showed no pigmentation. About two months after he first came under observation, he began to complain of his eyesight, and especially of soreness of the left eye, when the existence of a melanotic tumor of the size of a large pin's- head was detected in the inner and upper half of the iris. In MELANOID CANCER IN BONE. 371 a very short time about fourteen days the iritic tumor devel- oped to its utmost size, about the diameter of a large pea, and then, in about the same length of time, it ran through its retro- gressive course, until finally only some extremely slight discol- oration of the aifected spot could be observed. Vision was at first slightly interfered with, but, upon the subsidence of the tumor, it became normal. A similar growth appeared in the right eye, with much more severe impairment of vision. The patient's general condition underwent no marked change for the worse, until some large tumors developed in the tongue, the painful condition of which materially interfered with mastication and deglutition, and this began to tell upon his nutrition. Up to the latter half of October the man continued to work at his trade, and had not lost a single day. About that time he had a slight attack of varioloid, from which he recov- ered without any untoward symptom, but he steadily failed in strength afterward. One of the melanotic tumors, on the right side of the tongue near its root, was very deeply ulcerated, and so painful that it was difficult for him to swallow. The surface of the body was covered with innumerable black tumors, vary- ing in size from that of a small shot to that of a hickory-nut. He continued to fail in strength, and died, exhausted, January 13, 18TO. Dr. Simrock says : " The diagnosis of the character of all these metastatic tumors was based upon the microscopical ex- amination of the primary one, and of several others which were taken out for the purpose. The primary tumor from the back proved to be true sarcoma, in the formation of which the fusi- form and round cells equally participated. Pigmentary parti- cles I was not able to see in any of the sarcomatous cells. The pigmentary part of the tumor was entirely intercellular, and appeared in the form of irregularly-shaped particles and cakes of different tinges, from blood red to deep black, in the forma- tion of which the extravasated and stagnated blood may have had its part. One small tumor, the size of a bean, was extir- pated from the inner side of the left humerus, and showed the same sarcomatous elements as the primary one, with pigmen- tary interspersion as the chief characteristic part of its constitu- ents. Five particles were removed from tumors which after- 372 MALIGNANT DISEASES OF BONE. ward disappeared almost entirely, leaving only a discoloration of the skin, and in both the same characteristic elements of sarcoma were undoubtedly preva- lent. If late microscopical exami- nations corroborate my diagnosis of true sarcoma, then its sponta- neous disappearance will prove a precious experience to the pathol- ogist. Yirchow remarks, in his book on tumors, that ' up to this time he knows of no well-proved case of sarcoma having spontane- ously disappeared. ' " On post-mortem examination, black tumors were found here and there on the membranes, and in the substance of the brain. The pleurae, both parietal and visceral, and also the pericardium, were studded with small black masses. External surface of heart covered with pigment-spots, some project- ing, others not. In the substance of the heart, the pigment seemed to follow the course of the mus- cular fibres. The columnse car- ne93, as well as all the internal surface of the organ, were mottled with similar masses. Both lungs were infiltrated with pigment-mat- ter throughout. Mucous surface of larger bronchial tubes contain- ing spots of pigment. Bronchial glands enlarged and black. The diaphragm contained melnnotic tumors on both surfaces and in its substance, as did also the peri- tonaeum, both visceral and parie- tal, the omentum, the stomach, the intestines, large and small, FIG. 103. (Museum, College of Physi- cians and Surgeons.) COLLOID CANCER OF BONE. 373 the pancreas, the mesenteric glands, the liver, the spleen, the kidneys, the urethral mucous surface, the bladder, the prostate, the corpora cavernosa, the testicles, and the cord. The muscles everywhere were infiltrated with the same black pigment, which followed in a marked manner the course of the muscular fibres." Dr. Delafield made a careful examination of many of the locali- ties mentioned, and his observations are of much interest. In all the situations where distinct tumors existed, the pigmentary matter was contained either in round or oval cells, or in their intercellular substance, in granules fine and coarse, or infiltrated into the neighboring tissues, thus forming, as it were, the out- skirts or borders of the sarcomatous nodule. In several situa- tions, however, it was distinctly made out that the deposit had taken place in the substance of, and in the interstices between, the elements of perfectly normal and unchanged original tis- sue. This was particularly the case in the bronchial mucous membrane, in the kidneys, in some parts of the skin, and in a portion of the fibrous structure of the dura mater. These ob- servations were made with much care ; and in reference to this very point, as to whether, in the human subject, pigmentary accumulations ever take place independent of cancerous disease, in any of the situations where pigment is not normally found. They seem to me quite conclusive. Several of the bones were marked by black spots, and when sawed through the cancellous tissue presented numerous black dots, and irregularly-shaped spots, due to the infiltration of the melanoid matter into tissue otherwise perfectly healthy. Fig. 103 represents a section of the lower portion of the femur, which exhibits quite a number of the peculiar black spots. CHAPTER Y. COLLOID CANCER OF BONE. THAT form of cancerous disease which is characterized by numerous alveoli, containing a glue-like material, is occasionally seen in the bones. Mr. Stanley gives a very well-marked ex- ample, occurring in the phalangeal bone of a finger. The case 374 MALIGNANT DISEASES OF BONE. was under the care of Mr. Lawrence, in St. Bartholomew's Hospital. " A man, sixty-five years old, had been healthy from birth, and both his parents had been healthy and long-lived. Rather more than a year ago, he noticed a swelling in the first phalanx of the right fore-finger ; it was moderately firm, gave him little pain, but gradually increased. Six months ago a lancet was thrust into it, and some blood, with a watery fluid, was discharged, and ulceration of the opening ensued. A seton was afterward passed through the swelling, and immediately afterward it rapidly increased. The hand was amputated at the wrist-joint, and, in the examination of the diseased parts, the following particulars were observed : The tumor was of a globular form, soft and elastic, and about two inches and a half in diameter. It enveloped the first, with part of the second phalanx of the fore-finger ; its interior consisted of a semifluid, jelly-like substance, contained within cells formed by dense, white, fibrous bands. The tumor closely surrounded the bone, which was rough in one situation, while, in another, part of its wall had disappeared. Within the bone, gelatinous substance was deposited, like that of which the tumor consisted. Mr. Paget submitted this substance to microscopic examination, and found that it possessed none of the characters of cartilage, but apparently consisted of a structureless, viscid jelly." He also remarks that there is in the museum of St. Bartholomew's Hos- pital an example of this same form of tumor growing from a rib. In the museum of the New York Hospital there is a cast (No. 47) of the head of a patient with a huge tumor, involving one side of the face, which is stated to have sprung apparently from the antrum, and to have extended from that point in all directions, so as to fill the mouth and pharynx, pressing upward into the orbit, and causing absorption of the septum narium, extending up through the sphenoid bone to the base of the brain, and forming externally a large tumor upon the lateral and lower parts of the left side of the face (Fig. 104). The tumor was surrounded by an imperfect capsule, and consisted 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 involved. COLLOID CANCER OF BONE. 375 The patient was a man thirty-five years old, who had long suf- fered from symptoms resembling those of ozsena, but the tu- mor was not discovered in the fauces until within a year of his death, which took place chiefly from exhaustion, from continued ptyalism, and inability to swallow food. FIG. 104. (N. T. Hospital Museum.) Dr. Louis Bauer laid before the New York Pathological Society, at its meeting in January, 1857, a tumor of the size of a man's fist, which he had removed from the surface of the left femur just behind the great trochanter, which presented all the appearances^of colloid disease. The tumor had been growing about two years. At one time, an abscess had formed, dis- charging a viscid substance with the pus. He had suffered much pain, and was greatly reduced by the disease. About six months previous to the time of presenting the specimen, Dr. Bauer had removed the tumor. After the portion presented had been taken away, the femur was found to be extensively carious. All diseased bone, as far as could be reached, was gouged oif, but the whole of the tumor could not be got away. The wound healed, however, and, at the time of reporting, the man remained well. Lebert gives the history of a case which was under the care 376 MALIGNANT DISEASES OF BONE. of Roux in 1846. A man, aged thirty-eight, had two moderate- sized tumors of the upper end of the tibia, one on either side of the knee-joint. They had been growing about three months without pain, and followed a strain. There was no heat nor red- ness about them, and no other feeling but a growing weakness of the limb. There was a slight pulsation felt on laying the hand gently over the surface of . either swelling. Supposing them to be of a vascular nature, Roux tied the femoral artery. Secondary haemorrhage occurred ; a second ligature was applied higher up ; but the man died from pyaemia. No change had been produced in the tumors by the operation. The upper part of the tibia was found occupied by an encephaloid mass, pro- jecting on either side into the two tumors noticed during life. This mass contained, in all parts, numerous gelatinous points. The bone-substance was displaced by the tumor, and had at that point entirely disappeared. In the inside of the mass the mor- bid deposit was of a yellowish, pale-rose color. " By micro- scopic examination, as well as by the naked eye, the colloid nature of the cancer can be seen, which is besides very vascular. There is everywhere a very abundant transparent substance, in which are a few fine, rare, divergent fibres. This substance everywhere contains fusiform cancerous elements, having a length of -$ of a millimetre. Some of these were pointed, and some rounded at their ends. The nuclei are round or elliptical, and from -fa to ^ of a millimetre in diameter. Some are free. The nucleoli are about T f ir of a millimetre in diameter. There are almost no fatty elements in the cancer." Cruveilhier figures a very beautiful case of alveolar cancer which grew in the bones of the face of a woman who died of it at the age of fifty-two. It occupied the ethmoid, nasal, and frontal bones, made a huge projection on the anterior and upper part of the face, and encroached back into the fauces, filling up the nasal cavities, and pressing backward upon the brain. It had grown slowly for about ten years, with great pain, though the patient, who was a painter of some merit, had continued at her work almost to the end. On section, the whole mass pre- sented the peculiar alveolar arrangement which characterizes colloid. The alveoli were large, and, though of different size, were nearly uniform in every part of the tumor. The peculi- OSTOID CANCER. arity of the case was, that these alveoli, instead of being filled with a transparent, jelly-like material, contained a whitish-yellow substance, which Cruveilhier, in one place, likens to concrete pus, and in another speaks of as consisting of caseum. No can- cerous disease was found in any other part of the body. These cases all are instances of the primary form of the col- loid disease, and of this they present a tolerable picture. From what we know of the tendency to generalization of this disease in the softer parts of the body, we can well suppose that it may sometimes appear as a secondary deposit in the bones ; I think, however, it must in this form be rather rare. I have never seen an instance, nor have I encountered any statement of one, in any of the authors whose works I have had an opportunity of consulting. CHAPTER YI. OSTOID CANCER. SEVERAL writers have insisted upon giving this name to a form of cancer containing a very large proportionate amount of bone ; and yet in other parts and in other respects present- ing all the characteristics of true cancer. These ostoid cancers are found most often in the lower end of the femur, and most commonly affect equally the inside and the outside of the bone. The softer parts of the growth do not exactly correspond either with the scirrhous or encephaloid material. Mr. Paget describes the substance as " usually exceedingly dense, firm, and tough, and may be incompressibly hard ; its cut surface uprises like that of an intervertebral cartilage, or that of one of the toughest fibrous tumors of the uterus. It is pale 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 appearing banded with fibres set vertically on the bone." The bony portion of the mass is still more peculiar. He says : " In the central parts it is, in the best-marked specimens, extremely compact, scarcely showing even any pores, white and dry. To cut it is nearly as hard as ivory, yet, like hard chalk, 378 MALIGNANT DISEASES OF BOXE. it may be rubbed or scraped into fine dry powder. At the periphery it is arranged in a knobbed and tuberous form, the knobs being often formed of close, thin, gray, or white lamellae, whose presenting edges give them a fibrous look, exactly like that of pumice-stone. In this part, also, the bone is very brittle, flaky, and pul- verulent. In some specimens, the whole of the bone has this delicate lamellar and brittle texture ; but, more generally, as I have said, the central part is very hard, and this, occupying the walls and cancellous tissue of the shaft, equally with the surrounding part of the tumor, makes of the whole such a compact, white, chalky mass as the sketch here represents." Fig. 105 is the picture Mr. Paget gives of the disease thus described. "Whatever may be thought of the expediency of erecting this form of disease into a separate class of can- cers, its well-marked features evi- dently entitle it to a position as an important variety. It has already been remarked that, with most of the cancers of bone, the osseous tissue is displaced by the cancerous growth, and that very little and often no new growth of bone accompanies the destruction of the old bone-substance, at the expense of which the morbid growth is constantly increasing. Even in those cases where something like a bony skeleton is formed in the cancerous mass, this skeleton is usually composed of exceed- ingly slender spicula, and thin and delicate laminae, which hold a very small proportion to the whole mass, and which are usu- ally so imperfect in their construction, and so fragile in their consistence, that, when macerated and dried, it is exceedingly difficult to preserve them from falling to pieces almost by their own weight. To all this a very strong contrast is presented by the tumors now under consideration, whose most striking FIG. 105. (From Paget.) OSTOID CANCER. 379 feature is a very great deposit of new bone as a basis of the growth a deposit which seems to be a constant accompaniment of that growth, and to increase paripassu with its increase, so that, in some of the largest tumors of this kind which have been described, the proportion of bone in the growth was quite as great as in the smallest. Another feature, equally striking and equally important as clearly marking the true cancerous character of the disease, is found in the tendency to generalization which these tumors so markedly display, in which the most distant and most unex- pected organs are sometimes implicated. The secondary de- posits preserve the character of the original growth, and hence we have the lymphatic glands, the uterus, the blood-vessels, and even the thoracic duct, filled up or infiltrated with bony sub- stance so completely as in some instances to become unrecog- nizable. Mr. Stanley gives three cases of this disease which he terms malignant osseous tumor of bone : " A man, aged thirty, was admitted into St. Bartholomew's Hospital under the care of Mr. Lawrence, with a swollen and painful state of the right knee-joint, consequent on a fall, for the removal of which anti- phlogistic treatment was successfully employed ; but, shortly afterward, a painful swelling arose immediately above the knee, and gradually extended around the lower third of the thigh. A softening of the swelling at one point being discovered, an incision was made into it, from which arterial blood flowed freely. Pulsation was now discovered in the swelling, and at the same time it was observed that the leg had become redema- tous, and that the toes were colder than in the opposite limb. The femoral artery was then tied. Pulsation in the tumor ceased, and its size gradually diminished ; but after some time it again enlarged, sloughing of the skin and central substance of the tumor ensued, but unaccompanied by haemorrhage. The man gradually sank from exhaustion. " On examining the limb, I found the tumor to consist of a compound, soft, fibrous, and dense osseous substance, the latter extending completely round the femur. The whole series of femoral, inguinal, and lumbar absorbent glands, were converted into osseous tumors. The femoral and popliteal vessels were 380 MALIGNANT DISEASES OF BONE. sound. In this case the tumor of the femur, and the tumors of the absorbent glands, were identical in structure, both being composed almost wholly of a solid, dull-white, chalk-like, osse- ous substance, which, in the femur, was continuous with a sim- ilar deposit in the medullary and cancellous tissue of all that part of the bone which was surrounded by the tumor." As a general rule, this form of cancer is rapid in its prog- ress, and Mr. Paget reckons them about equal to the medullary in the length of life they allow to the patient. Some cases are spoken of in which life was prolonged for many years. Thus, Mr. Stanley mentions one where the disease was in progress for eighteen years. Mr. Paget 'alludes to two cases where death did not occur until in one instance twenty-four, and in another twenty-five years, had elapsed from the time of the first appear- ance of the affection. On the other hand, some cases are re- corded in which the disease has run a course as rapidly destruc- tive as the most rapid medullary cancers. Mr. Paget gives one case of this rapid progress of ostoid cancer in a girl of fifteen, who was admitted into St. Bartholomew's Hospital " with gen- eral feebleness and pains in her limbs, which had existed for two or three weeks. They had been ascribed to delayed men- struation, till the pain, becoming more severe, seemed to be concentrated about the lower part of the back and the left hip. A hard, deep-seated tumor was now felt, connected with the ala of the left ilium. This gradually increased, with constant and more wearing pain ; 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; and she died, cachetic and exhausted, only three and a half months from her first notice of the swelling. " A hard, lobulated mass was found, completely filling the cavity of the pelvis, and extending across the lower part of the abdominal cavity. It was firmly connected with the sacrum, both ischia, and the left ilium ; it held, as in one mass, 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 recog- nized. The general surface of this growth was unequal and nodular. It was composed of a pearly -white and exceedingly hard structure, in which points of yellow bony substance were TREATMENT OF MALIGNANT DISEASE OF BONE. 331 embedded, and which had the characters of ostoid cancer per- fectly marked. The ilium, where the tumor was connected with it, had the same half-fibrous, half-bony structure as the tumor itself. The common iliac veins, their main divisions, and others leading into them, passed through the tumor, and were all distended with hard substance like the mass around them. From the common iliac veins, a continuous growth of the same substance extended into the inferior cava, which, for nearly five inches, was distended and completely obstructed by a cylindrical mass of similar fibrous and osseous substance one and a quarter inch in diameter. At the upper part this mass, tapering, came 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 traversed by hard, coral-like bands, which proved to be branches of the pulmonary artery plugged with firm white substance, intermingled with softer cancerous matter, and re- sembling the great mass of disease in the pelvis. The rest of the lung was healthy, with the exception of some scattered grayish tubercles ; and so was the left lung, except in that there were a few small abscesses near its surface, with hard, bone-like masses in their centres, like those in the branches of the right pulmonary artery. The skull, brain, pericardium, heart, and all the abdominal organs, were healthy." In the other aspects of its general pathology, the ostoid can- cer differs in no material respect from other forms, except per- haps in the fact that it shows no particular tendency, under ordinary circumstances, toward ulceration, or any other form of rapid destruction. It is acknowledged, however, by those who have best studied the disease, that materials for the full story of its life and terminations have as yet hardly been accu- mulated. CHAPTEK YH. TREATMENT OF MALIGNANT DISEASE OF BONE. THE cancerous tumors, of bone present, as a matter of course, nothing more encouraging, as far as their treatment is con- cerned, than cancerous tumors in other parts. A large share 382 MALIGNANT DISEASES OF BONE. of the success which some of the older surgeons claimed as the result of their several methods of treatment we can now ex- plain, with great plausibility, by their want of accurate diagno- sis ; while the few instances in which the cure is unequivocal, we are disposed to refer to the coincidence of a spontaneous or natural retrogression, rather than to the result of the reme- dies employed. It is somewhat disheartening to find that, as our knowledge of these growths advances, our conviction of their utterly intractable nature grows deeper ; and that surgeons of the present day, with all their increased light, and with their greatly-improved means of diagnosis, are less sanguine and less confident, as to the therapeutics of cancer, than were the men of half a century ago. The hopes which have been excited by the various remedies lauded as curative of cancer have one by one been sadly disappointed, the expectations roused by the vaunted powers of compression, electricity, caustic fleches, gal- vano-cautery, acetic acid, etc., have sobered down to the simple question, not whether these remedies are curative, but whether they are in any degree beneficial to the sufferer. Indeed, I think it would not be too much to say that, in the minds of the best men who are now occupying themselves with this study, the question of cure has very much given place to 'the question of palliation ; and that the labors and hopes of such men centre more upon alleviating suffering, and prolonging comfortable life, than Ihey do upon Utopian projects for the fundamental cure of the disease. Much may be done short of a cure, for the great benefit of our cancerous patients, and it seems very clear to me that it is in this direction that our therapeutical labors are likely to be most fruitful, and our efforts on behalf of our patients most beneficial. I am far from wishing to undervalue or to deny the useful- ness of certain internal remedies, from some of which I think I have myself derived benefit. Indeed, I consider the subject is worthy of our most serious attention. The most recent statements I have seen on this subject are those of Mr. T. Weeden Cooke, whose long experience as sur- geon of the Cancer Hospital in London gives great weight to his opinion. In his work on " Cancer, and its Allies and Coun- terfeits," he devotes much space to the subject of treatment, TREATMENT OF MALIGNANT DISEASE OF BONE. 383 and passes in review the various internal remedies which have been most used in the hope of curing cancer. His verdict upon all of them is unsparing and decisive. He has found no benefit from their use which is worth naming, and he dismisses them all as unworthy of confidence, as having any specific influence on the course or termination of the disease. Nevertheless, he is one of the most hopeful and encouraging of modern writers on the treatment of cancer. Viewing the disease as 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 imparted by appropriate treatment, he asserts most confi- dently that, by the judicious use of certain nutritive tonics, with proper local applications, much may be done in arresting the progress, relieving the suffering, and actually curing the disease. The internal remedies which he relies upon with most confidence are cod-liver oil, iron, hydrochloric acid, and cin- chona-bark. The first two are the principal remedies he em- ploys, the latter auxiliaries, to which he sometimes adds other tonics according to the condition of the digestive and nervous systems. Of the oil he says : " There is only one other medi- cine which has any large claim upon our attention, either as an assistant and rectifier of the digestive process, or as a direct alterative and tonic to the blood. In my hands cod-liver oil, administered in the occult stage of a scirrhus of the breast, has more nearly approached the character of a specific than any other agent. It seems to supply that aliment to the cells of new formations, for the want of which they droop from their rotund form, and lose the power of creating normal tissues." The results of his treatment are encouraging and surprising, for he gives an outline of fifteen cases in which manifest benefit was derived from the course adopted, of which cases, all under his personal observation, he says : " These are a few instances of arrest of scirrhus of the mamma by constitutional means, for ten, twelve, even sixteen years, and the patients are still living evidences of the conservative powers of Nature, when properly supported by art, to stem the 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 few of the local remedies, which have gained most 384 MALIGNANT DISEASES OF BONE. favor with the profession, as favorably modifying the progress and result of cancer developed in the bones. Of these, five are of chief interest : 1 . Repeated local depletion by leeches ; 2. Systematic compression ; 3. Galvano-electricity ; 4. Ligature of artery leading to tumor ; 5. Ablation. 1. Repeated Local Depletion ty Leeches. This method of treating cancer is one of the oldest known. In former times, when almost every swelling was regarded as a modified form of inflammation, the idea very naturally suggested itself to treat the cancerous form of inflammation by local abstraction of blood. Something was found to be gained by this practice, and it has maintained its popularity perhaps more steadily down to the present day than any other remedy on the list. The explanation of its good effects, according to our present view, must be based upon its influence in abating local conges- tions, and accidental inflammations in the tumor, to which local actions modern pathology ascribes a certain considerable share in the destructive agencies which are at work in any cancerous growth. That any thing can be gained in modifying what may be called the normal nutritive processes of such a tumor, by a remedy which, like leeching, can only have an occasional appli- cation, does not seem to be likely ; but that, by relieving fulness, and averting or curing inflammation, it may do good in diseases where the worst influences in operation are acknowledged to be those of the inflammatory character, is, it seems to me, a reasonable expectation. On this point "VYalshe, after alluding to the long - continued popularity of the treatment, says: " Modern experience has established the degree of utility of local abstraction of blood. In the earliest stages of diseased induration the application of leeches is strongly advisable ; even as a guide to the diagnosis of tumors of a doubtful character, it is useful. The progress of growth of undoubtedly carcinoma- tous nature may be thus retarded, and incidental inflammatory symptoms in the adjoining tissues successfully combated ; but beyond this capillary depletion has no power. The number of leeches applied must be regulated by the size of the tumor ; it should vary between twelve and six ; a smaller number causes an aiflux of fluids to the part without emptying the vessels sufliciently. AVhen the tumor is adherent to the skin, there is TREATMENT OF MALTCIXANT DISEASE OF BONE. 335 danger in continuing the practice, as the bites have frequently been known to pass into persistent ulcerations." Whatever may be the decision of a more rigorous statistical inquiry into the retarding influence of occasional leechings, there can be no doubt that in certain instances they do accom- plish some good by the relief of pain. Much of the suffering inflicted by these dreadful diseases is caused by or aggravated by accidental inflammations, which are under the control of well-regulated local depletion ; and, it is a wonderful fact, recognized by all who have much employed the remedy, that in some instances the immunity from pain procured by a sin- gle application of leeches will last much longer than can be ex- plained by the relief of a simple attack of inflammation. It would seem as if the sedative effect of loss of blood sometimes remained after the immediate depressing effect had been appar- ently recovered from, and the vital actions of the affected parts seem to be modified for a certain indefinite period by a cause which we ordinarily consider to be of temporary and generally of brief influence. This relief of pain, and its accompanying soreness and tenderness, is an immense benefit to the sufferers with cancer ; and we can hardly help associating with the means of procuring alleviation, the idea of at least a tendency toward a cure. The testimony of many writers is favorable to the use of this remedy, although it must be acknowledged that those who have spoken most eulogistically of its effects have been those who upheld most earnestly the inflammatory nature of all cancerous disease. Much caution should be exercised in the use of this means, which is powerful for evil if used too freely. By too frequent or too liberal an employment of local depletion, it is very evi- dent we may so reduce the vital power of the part affected as to favor rather than to check morbid action, and thus, by weak- ening the power of resistance, we may increase the evil tenden- cies of the disease by the very means we employ to relieve it. Again, as Mr. Stanley remarks, care should be used in applying leeches over a tumor which is already adherent to the skin, the leech-bites becoming sometimes the starting-point of ulceration, which might perhaps have been long postponed had th,e skin remained un wounded. 25 386 MALIGNANT DISEASES OF BONE. 2. Systematic Compression. This is not a new remedy for cancer. It was first brought to notice by Dr. Young in the earlier years of this century, and was tried very fully at the Middlesex Hospital in 1816, with so unsatisfactory results that but little more was heard of it till M. Recamier revived its use, and announced some wonderful successes. Unfortunately, the enthusiastic experimenter claimed a great deal too much for his pet plan, and accordingly the profession generally has dis- credited his results. He says : " Of one hundred patients, six- teen appeared to be incurable, and underwent only a palliative treatment ; thirty were completely cured by compression alone, and twenty-one derived considerable benefit from it ; fifteen were cured by extirpation alone, or chiefly by extirpation and pressure combined, and six by compression and cauterization ; in the twelve remaining cases, the disease resisted all the means employed." Even the high character of M. Recamier can hardly give currency to such magnificent statements, and yet something must have been realized by the treatment to have formed a basis for such exaggerated praise. What this some- thing was, we can glean from the reports of other, perhaps more candid, experimenters with the same method. In the year 1859, my late venerable and esteemed friend Dr. J. P. Batchelder published, in the New York Journal of Medi- cine, an account of his experience in the treatment of various affections by pressure applied by compressed sponge. Among other things, he had tried the effect of the remedy in a number of cases of cancerous and other morbid growths, and the results he obtained are well worthy of attention. No one who knew him could doubt the truthfulness of his statements, certainly not the honesty of his convictions. His explanation of the modus operandi of his plan he thus states : " The pressure occasioned by the expansion of the compressed sponge disturbs the cancer- cells, and forces them out of place ; affects their consistency, and causes them to be dissolved ; and the tumor, thus freed of its malignant ingredients, may be more readily removed by absorp- tion, if the process be continued, or, if not absolutely removed, it may be so divested of its malignity as to remain harmless for years, as happened in a case which will be related. Does this pressure, as the doctrine teaches, deprive the cancer-cells of their TREATMENT OF MALIGNANT DISEASE OF BONE. 337 power to contaminate other parts, or the system in general ? The cancer-cell, like the pus-globule, is dissolved, and, being thus changed in its nature, is more readily absorbed, and of course, enters the circulation, not as a malignant, but as an in- nocuous substance ; and, instead of contaminating the system, is eliminated therefrom, as are other disintegrations of tissues and structures, without harming any part. Cancerous affec- tions, locally considered, seem to derive their nutriment from surrounding parts by a sort of imbibition or endosmosis, and not from any direct vascular medium. The sponge, by its pecul- iar mode of pressure on the diseased part, either destroys its texture, or prevents its being nourished, and continues to do so until its agency is fully resisted by the circumjacent parts which are in a healthy condition." In support of his views, he then goes on to relate a number of cases in which great benefit was gained by the use of the sponge ; in one of them the tumor en- tirely disappearing in less than two months from the commence- ment of the treatment. Some of the cases were treated in pri- vate practice, and some in Bellevue Hospital, and all of them were watched more or less carefully by some of our best sur- geons. I give the full history of one which is most to our pur- pose, inasmuch as the disease was seated in a bone : "A lad, about eight or ten years old, from New Jersey, was brought by his mother to Dr. Mott's clinique, in 184/T or 1848, with a fungous tumor protruding from the lower jaw, situated in the space formerly occupied by the first and second molar teeth, on the left side. This morbid growth had made its ap- pearance some months before, loosening the teeth, protruding 011 each side of them, and pushing away or involving the gums, previous to his coming to the clinique. The teeth had been extracted, and the tumor, with, I believe, a portion of the alveo- lar process, removed by a surgeon in the boy's immediate vicin- ity, which operation was now repeated by Dr. Mott. In a few weeks, the little fellow was brought again to the clinique, the disease having returned. Unable to lay my hand on the notes of the case, I have indeed forgotten, as well as Dr. Mott him- self, whether another operation was performed. "Whether it was, or was not, is quite immaterial to our purpose. The dis- ease had returned ; and at my suggestion the compressed sponge 388 MALIGNANT DISEASES OF BOXE. was to be tried ; and lie was assigned by Dr. Mott to my care and management. I took him, with his mother, to my office, and cut two or three pieces of thoroughly compressed sponge sufficiently large to cover the whole tumor, and indeed extend beyond it on the outer and inner sides of the alveolar process, and rising higher than the upper surfaces of the adjacent teeth before and behind it ; and then bound the lower maxilla firmly to the upper by means of a roller, leaving the pieces of sponge to expand by the imbibition of saliva. The mother was sup- plied with several pieces of compressed sponge, and directed to apply them in the same manner once or twice a day. She was told by Dr. Mott that the disease was of a malignant character, and would be very likely to destroy her son certainly, if not properly and faithfully attended to. The doctor's faith in a favorable result was obviously not very strong ; nor was any- body's else, except my own. Notwithstanding, in the course of five or six weeks the mother and lad again appeared at Dr. Mott' s clinique, not to ask advice, but to show the result, that the boy was perfectly cured. The remedy had been entirely successful. The location of the disease had been favorable to the application and action of the sponge. The result in this case was analogous to what I had witnessed in others." The doctor then alludes to one other case in which a similar tumor, situated on the lower jaw of a lady between fifty and sixty years of age, was treated by the compressed sponge with an equally perfect result. The theoretical views expressed by the advocates of this mode of practice are ingenious, and not improbable. That cell life and growth may be modified and destroyed by pressure, seems entirely likely, as the mere result of the action of me- chanical force ; that it is actually accomplished is demonstrated by the cases published. Thus much is practically certain, that tumors, even malignant tumors, can be entirely removed, un- der favorable circumstances, by the mere action of carefully- regulated pressure ; and this clinical fact adds just so much to our means of contending with cancerous disease. That the method has any power of modifying the local cancerous action on the surrounding parts, or on the general system, is not only not proved, but not rendered probable by any of the facts which have as yet been made public. TREATMENT OF MALIGNANT DISEASE OF BONE. 389 3. Galvano- Electricity. This agent has been employed in the treatment of cancerous diseases in two modes quite dis- tinct from one another. One of these methods is that in which the circuit through which the electricity passes is so arranged that, at a certain point, the conducting material becomes in- tensely heated, and this heated portion, being in contact with the point of disease on which it is desired to act, produces the cauterizing effect of intense heat, and destroys the part ex- posed to its influence. This s is an exceedingly convenient method of employing electricity to produce the effect of the actual cautery, but it must be evident that the action is simply that of a caustic, not, so far as appears, specially modified by the fact of electricity having been used to produce the heat. There is no breach of contact, and therefore no passage of the electric fluid through any part of the tissues ; and, therefore, any specific effect of electricity, as such, in modifying the mor- bid actions in the parts through which the conductor passes, may, I think, be properly left out of consideration, and this form of electrical application may be considered, as it is com- monly named, a mere galvano-cautery. The other method is one in which the electrical current is caused to pass through the part to be acted upon the mode of its passage, and the extent of its action upon the tissues, varying very much according to the manner of its employ- ment. Either the Faradaic or the direct current may be used, and either may be applied externally on the unbroken skin, or either may be caused to act upon the deeper tissues through needles thrust into their substance. The use of electricity by external application is much the oldest method, but much the least effective ; indeed, the testimony we have of its usefulness, in the discussion of tumors of any kind, is confined to so few well-authenticated instances, that not many surgeons now em- ploy it. The method which has of late attracted most attention is that in which the power of the current is so great that, when introduced into the tissues by properly-prepared needles, a de- composition of some of the textural elements takes place, by which such alteration in the mass is set up that absorption or alteration of the tumor is the immediate or ultimate conse- quence. What is the precise extent of this decomposition, and 390 MALIGNANT DISEASES OF BONE. how precisely it affects the elements of tlie tissues, are points which are not yet fully explained. The method itself, from the decomposition which accompanies it, is called electrolysis. Electrolysis has now been used in quite a large number of tumors of all kinds, and with a degree of success which leads us to hope that it is to be a positive addition to our means of dealing with these intractable and unpromising deformities. I do not know that any thing has yet been achieved in the direc- tion of controlling the malignant features of these diseases, but, merely speaking of them as tumors, much has certainly been accomplished. I cannot better present the main features of this method of treating tumors than by giving an outline of a case recorded by Dr. R. P. Lincoln, in the Medical Record of this city, for December 15, 1870 : A gentleman, aged thirty-three, was the subject of a soft tumor in the supra-clavicular space of the left side. It had appeared, without known cause, about eighteen months before, and with slight interruptions had pretty steadily increased up to the time of his coming under Dr. Lincoln's care. The tu- mor was now the size of a large goose's-egg, moved to a certain degree with the trachea, was rounded in shape, two inches in diameter, and rising about five-eighths of an inch from the natural surface of the neck. The tumor was soft and compres- sible, but elastic, and when pressure was removed resumed its usual shape. There was no pulsation, but it grew turgid when the breath was held, or any straining effort made. Under ex- citement, as from public speaking, this turgid condition of the tumor would become constant, and was sometimes attended with very alarming symptoms of suffocation. The diagnosis was venous erectile tumor, and electrolysis was applied, Sep- tember 30, 1870. " The patient having been chloroformizecl, I introduced four gilded steel needles, insulated to one-half or three-fourths of an inch from their points, into the four quarters of the tumor, the two upper being one and one-fourth inch apart, and one inch above the lower, which were one inch apart. The two inner needles were connected with the subdivided anode, and the outer two with the subdivided cathode, and ten elements of the battery, which was working with a weak current, connected TREATMENT OF MALIGNANT DISEASE OF BONE. 391 witliin a few moments, and gradually the power of the battery was increased to its maximum, and the number of elements in- creased to fifteen. At the expiration of fifteen minutes, the two lower needles were disengaged from the current, thus con- centrating the whole force upon the two upper ; at the expira- tion of fifteen minutes more, the needles were removed. Dur- ing the operation all the prominences of the tumor disappeared, and a delicate examination detected a hard mass 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 normal position. " October Wth. Patient presented himself for examination. There was no tendency to a reappearance of the tumor ; on the contrary, the induration in the neck was steadily diminishing in size. " October 22d. The following is an extract from a letter from the p'atient, who had already made several public address- es :' I am feeling very well, and there is nothing to indicate any thing like a recurrence of my malady.' ' : It is true that this case is probably one of an erectile tumor, and as such would be likely to be more easily affected by such local action as that of intense decomposing electricity than almost any other form of growth. It is nevertheless a fact of great interest as it stands on the record, and perhaps will be more encouraging when we reflect how large a portion of tu- mors, and particularly of malignant tumors, are made up of a very abundant reticulation of vessels. But electrolysis has been tried on malignant tumors. Alt- haus, Von Bruns, and Gherini, have used it each in a number of cases. Althaus reports that he has gained some advantages in the treatment both of scirrhus and encephaloid, and particu- larly speaks of the relief which he has obtained from the severe lancinating pains which are so distressing a feature of many cases of cancer. Yon Bruns is not so sanguine, and says that electrolysis rarely, if ever, disperses or even materially dimin- ishes a malignant tumor. The most surprising case on record, however, is one pub- lished by Dr. William B. Neftel, of this city, in the Medical Record of September 1, 1869. It is substantially as follows : 392 MALIGNANT DISEASES OF BOXE. A gentleman, fifty-eight years old, had a tumor of the left mamma, which by several good surgeons was pronounced can- cerous. It was successfully removed by the knife, and the wound healed favorably. The axillary glands of that side began to enlarge soon after the healing of the wound, and formed a large tumor which also was successfully removed. This wound healed slowly, and upon its cicatrix a new tumor grew, which soon attained the size of an orange. The general system had by this time become seriously impaired. To this third tumor electrolysis was applied by Dr. Neftel, at three sittings, on the 27th of April, and on the 4th and 7th of May, 1869. He used the "large apparatus of Kriiger and Hirsch- mann, with elements of Siemens, subdividing, at the second and third operation, the cathode into three or four branches, connected with the needles by serres-fines. The latest improve- ments of the apparatus afforded the possibility of gradually increasing the quantity of the current without interrupting the circuit, and of diminishing it in the same way, so that the cir- cuit was broken only by the extraction of the last needle. Not a drop of blood escaped. The first operation lasted two min- utes, using ten elements ; the second five minutes, with twenty elements; and the third ten minutes, with thirty elements. After the operation the tumor increased considerably in size, but became softer and more elastic. ~No febrile or other local or constitutional symptoms followed. On the contrary, the patient, who before was weak, anaemic, and cachectic, began to gain flesh and strength, the tumor at the same time diminishing slowly but constantly. A month after the first sitting the tumor was found a great deal softer and smaller ; at the end of the second month it had almost disappeared, and a fortnight later no trace of it remained. The 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: 'I am not able to discover any new deposits anywhere, nor would the tumor in the right breast be detected by any ordinary observer.' " A year and a half after this date Dr. Neftel reports this gentleman as doing well. It is of course unsatisfactory, certainly unwise, to attempt to generalize from a single case like the above. We must wait TREATMENT OF MALIGNANT DISEASE OF BONE. 393 for more light. When we remember the natural tendency to retrogression of some cancers a tendency which, under im- proved general and local management, has been certainly very much more prominently recognized during the last few years ; when we recollect that under all reasonable modes of treatment some cases have appeared to be benefited; and when, still further, we make allowance for the natural disposition for all men to believe what they wish to be true we shall, I think, be disposed to receive these confident and sanguine statements with some grains of hesitation, and, instead of accepting them as decisive of any therapeutical result, we shall be disposed to lay them away for future comparison with other facts which are yet to be accumulated ; satisfied with the encouraging hope that they are pointing us in the right direction. 4. Ligature of Arteries. In a previous chapter some allu- sion has been made to the cutting off the vascular supply as a means of modifying the growth of certain very vascular or erectile benign tumors. The same idea has been applied to malignant growths, and particularly those in which great vascu- larity of the tumor is a prominent feature. The idea of starving malignant tumors by cutting off their circulation has been a popular one with surgeons, and confideut hopes have been en- tertained that it would prove to be a valuable resource. Theo- retically it has some considerable plausibility. Though all pathologists recognize a certain independent life, and indepen- dent function in all forms of cell, yet it is equally recognized that the continuance of this life, and the perfection of the func- tion, depend directly upon the supply of appropriate material from the blood. The absolute stoppage of this supply involves death, the diminution of it certainly modifies activity: why may not this diminution, carried to a point extreme, but not fatal to the tissue involved, act so as to change the morbid actions, either by stopping them altogether, or reducing them within the limits of health ? For the answer to this question we must of course turn to experience ; and I think I may say that experience is ready with an answer probably not a final and decisive answer, but one which I think will enable us, in some good degree, to appreciate the true value of the remedy proposed. 394 MALIGNANT DISEASES OF BONE. The advocates of the operation claim for it three distinct points of benefit to the patients : 1. A relief of pain ; 2. An arrest of progress ; 3. A perfect cure. Of the first point, that of relief from pain, the claim seems to be pretty well sustained; a very large majority of all the cases operated on expressing themselves very greatly benefited, as far as relief from suffer- ing is concerned. With regard to the second point, that of arrest of progress, it must be borne in mind that we have here a problem much more uncertain in its elements than the mere existence or non-existence of pain. What the rate of progress was before operation, and what it would have been if no opera- tion had been performed, are questions which we cannot answer with precision ; and hence it comes that we are very liable to be deceived in our estimate of what has been accomplished by the ligature in diminishing a rate of progress, which rate we have not the means of very accurately determining. Still,' good observers have, in so many instances, felt warranted in record- ing such arrest of growth as one of the common results of the application of a ligature, that we are constrained to accept it as a fact. Of the third point a perfect cure the record is of course by no means promising. I must here, however, explain what is meant by perfect cure, as used in this connection. Cer- tainly it does not mean that a perfect removal of local cancerous growth has been followed by an evident eradication of cancer- ous diathesis, and a restoration of the patient to perfect sound- ness, both local and constitutional. Indeed, so far as I under- stand the views of the reporters, it is not intended to imply that under this treatment there is necessarily any better chance of escaping secondary tumors, generalization, cachexia, and death, than in cases where other means of removal are em- ployed. Some enthusiastic admirers of the ligature, encour- aged by their theoretical views of its action, do evidently try to persuade themselves that these bright hopes are to be real- ized in the cases they give ; but no high authorities that I have had access to claim any thing more than a local cure, leaving the question of final result unsettled, either by their opinions, or by the facts which they present. With this understanding, then, of the meaning of the words we use, we may say that, in a very small proportion of the reported cases, a perfect cure TREATMENT OF MALIGNANT DISEASE OF BONE. 395 has resulted. I 'have not myself been so fortunate as to see one of these perfect cures, nor, indeed, have I met with any published case with full details. I give two cases, one of which I saw often with the gentleman who reports it, and the other occurred in the practice of one of my friends, though I am not sure that I ever saw the patient. These cases are not cures, but will perhaps represent the average benefit which results from the operation, and therefore are truer clinical examples than if they were more perfect in their results. Madelaine Nichols, aged fifty-four, a married woman, was admitted to the New York Hospital, March 30, 1855, under the care of Dr. Halsted, with a large tumor of the antrum on the right side, the history of which she gave as follows : " Two years ago was first attacked with pain in the upper jaw of right side ; the pain constant and lancinating in character. During the next two months a swelling of the jaw showed itself, gradually increasing, projecting not only upon the exter- nal surface, but also upon the roof of the mouth, and in its growth pushing out the last two molar teeth. About two months before admission, the tumor having in the mean time greatly increased in size, it began to ulcerate, and, since it has presented an open sore, frequent haemorrhages have taken place. Mastication of food is difficult, and deglutition much embarrassed. Since ulceration commenced, the increase of the tumor has been much more rapid. The general condition of the patient is pretty good. " March 3()tk. An attack of haemorrhage came on, in which she lost about four ounces of blood. During the following night she lost about the same amount. "April 2d. On consultation it was determined, with a view of arresting temporarily the growth of the tumor, and prevent- ing the frequent and exhausting haemorrhage, to ligature the common carotid artery. This was accordingly done by Dr. Halsted, just below the point where the artery is crossed by the omo-hyoid muscle. The first effect of the operation was to pro- duce some giddiness, with dimness of vision in right eye. This made us feel some anxiety for the brain ; but in a few days this passed away, and, with the exception of an attack of erysipelas, every thing went on favorably. 396 MALIGNANT DISEASES OF BONE. " April 9th. The wound lias not healed by first intention and is commencing to suppurate. She has had no haemorrhage since the operation, and there has been a visible decrease in the size of the tumor. Deglutition is more easy. " May 3d. The ligature came away to-day. The tumor is now about one-quarter of its original size." From this point the improvement continued. She left the hospital on the 8th of May, the tumor continuing to diminish in size, until it is stated in the notes to have almost disappeared. The patient regained her general health and appearance, and remained well for seven months, when the tumor again began to grow. She died February, 1856, unwilling to submit herself to any further surgical treatment. The other case occurred in Bellevue Hospital, under care of my friend Dr. Stephen Smith. Alice Griffiths, aged fifty-three, a widow, of good habits, was admitted to the wards of Bellevue on the 13th October, 1856. She had a tumor of the left upper jaw, which had come on about seven months previously. She had had some slough- ing of this tumor, leaving an open sore, which gave great dis- tress on attempting to eat, and from which flowed a large and offensive discharge. She was then much broken down from suffering, and inability to masticate her food. She did not re- main long in the hospital at that time, but was readmitted January 23, 1857. " The cheek was now much enlarged from the growth of the tumor. The fissure from the slough had nearly filled from new growth. The tumor now extended back along the mesian line as far as the soft palate (part of which had sloughed away), and both within and without the jaw, from the second incisor of the left side to the last molar. She had great difficulty in swallowing, owing to the size of the tumor, which was now as large as a hen's-egg, and also from the tenderness. There was a constant oozing of matter into the mouth, rendering her stomach very irritable, and also oozing of blood from time to time, on her attempting to masticate any food of unusual hardness. Her health had rapidly failed during the time she was out. The left naris was so perfectly occluded that she was unable to force air through it in blowing. "April <2Mh. The tumor, instead of diminishing by the TREATMENT OF MALIGNANT DISEASE OF BONE. 397 treatment which had been adopted, has increased. The dis- charge into the mouth and from the left naris is extremely offensive; her hearing is so much impaired on the left side, that it is with great difficulty that any conversation can be had, or the patient made to understand any thing. There is ex- treme tenderness in the roof of the mouth, and bleeding almost every time the patient attempts to take any food of greater con- sistency than fluids. Her general health is rapidly failing ; the tumor now extends across the mesian line, back to the soft palate, and is of the size of a medium-sized lemon. The pains are of a lancinating character, and almost constant ; the integu- ments over the tumor are tense, shining, and painful to the touch. The patient is willing to submit to any operation that will aiford her even temporary relief from the pain. The haemorrhage averages from one ounce to two ounces per day from the roof of the mouth, which is so sensitive that the patient is unwilling to take her wine, from the pain it pro- duces ; the erysipelatous attacks have become more frequent ; the breathing is so much interfered with that the patient is obliged to keep the mouth open in respiration ; she is rapidly failing from repeated losses of blood." In this condition the carotid was tied by Dr. Smith, April 24, 1857, in the usual situation. She bore the operation well. ~No evil consequences followed. The ligature came away on the 20th day, being the 14th of May. " May 2Sth. The wound is almost entirely healed ; a small point remains where the ligature was removed, which is pro- gressing favorably. The tumor remains about the same size ; the integuments are much paler ; the pain has almost disap- peared ; the integuments can be corrugated without complaint on the part of the patient ; the hardness still remains ; there has been no haemorrhage from the mouth since the operation, except that mentioned as occurring on the second day, and that followed the attempt at vomiting. The breathing is still inter- fered with ; patient unable to force air through the right naris ; slight discharge from the nares and mouth continues ; she has improved in health and strength ; the pain has been alleviated ; the comfcrt she has enjoyed since the operation, from the arrest of the disease, and improvement of the general health, are daily remarked by the patient." 398 MALIGNANT DISEASES OF BONE. The history taken from the records of the hospital goes no further, but Dr. Smith has recently informed me that this im- provement lasted only a few months, when the disease again began to make progress, and soon destroyed her life. In both these cases the arrest of the disease was manifest, and in both so great an improvement took place in the local and general conditions, from the time of the application of the ligature, that we are justified in regarding the remedy as having shown great power in modifying and retarding the pro- gressive development of the cancerous affection. This same re- sult, sometimes more and sometimes less pronounced, is stated to have occurred in quite a large proportion of the cases which are recorded. In the July number of the New York Journal of JSfedicins, for 1857, Dr. James E. "Wood has collected all the cases he could find of ligature of the common carotid artery by Ameri- can surgeons. Of these cases, seventeen were performed for the relief of cancerous tumors, mostly of the jawbones. Of the seventeen, four are stated to have resulted in the apparent cure of the disease ; ten were decidedly benefited, the growth of the tumor being for the time arrested ; two died ; one not noted. Looking at the operation merely as a palliative procedure, and it is only in this light that we have any warrant for regarding it, this certainly is an exceedingly satisfactory exhibit. To these statements I might add the recollections of Dr. Mott, con- tained in a letter to Dr. Wood, and published as part of the paper above referred to. Dr. Mott says : " The conclusions I have come to are the following : that in malignant disease of the nares, antrum, sides of the head, posterior fauces, and orbit, the ligature of the common carotid of the side affected is, not only a safe, but proper operation. If the disease is not arrested by the tying of one carotid, the other ought also to be tied, as soon as the in- crease of the disease is in the slightest degree manifested. In several of each of these classes of cases, I have operated myself, and have seen it done by others, and never without manifest advantages to the patient, provided a recovery from the opera- tion has followed. It is well known that some have only lived three to five days after tying the first carotid. TREATMENT OF MALIGNANT DISEASE OF BONE. 399 " I have seen a case lately, a malignant tumor in the poste- rior fauces, originating probably from the periosteum and bodies of two or more of the cervical vertebrae, closing one side of the posterior nares, obliterating the Eustachian tubes, and impeding deglutition, which was greatly benefited by tying the carotid of that side. The tumor obviously diminished in size, and all the unpleasant symptoms were assuaged. When he left for home, he promised to return and have the artery on the other side tied, as soon as there was a return of his suffering. In the first case of this frightful affection, in which the artery was tied, the tumor actually sloughed. In four instances of this disease which we had previously met with, and in which the artery was not tied, they all lingered out a most painful and distressing existence. " I have seen and known more than one year elapse before it was deemed necessary to tie the second artery. During all this time the disease was not arrested, but atrophy was going on constantly ; and, upon tying this second artery, the tumor, though malignant, has entirely disappeared. Two instances of this kind I can now refer to, in which the individuals have en- joyed good health for years without a vestige of the disease remaining." It may fairly be deduced from the above statements, that ligature of the artery leading to the region affected by a cancer- ous growth does, in a certain quite large proportion of cases, favorably modify that growth in all the three ways claimed by its advocates. But the other side of the question is still to be considered : In how many cases does the operation involve the death of the patient ? The answer to this question depends upon many inquiries, and the most important, perhaps, 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 jaws and head, and in these the carotid artery has been tied. The femoral and brachial have also been several times operated on for growths of the lower portion of each ex- tremity. The larger trunks have very rarely been subjected to ligature for cancerous disease. The question, therefore, might be narrowed down to these three arteries, and even to the carotid alone, for I think few surgeons would be willing to risk 400 MALIGNANT DISEASES OF BONE. the dangers of applying a ligature to the great trunks, where the expectation can only be one of palliation and temporary benefit. It is not easy to get at the dangers of these operations, as separated from the diseases and injuries for which they were performed. Dr. C. Pilz, assistant to the Physiological Institute of Bres- lau, has published, in Langenbeck's " Archives of Clinical Sur- gery " for 1868, a most elaborate and valuable table of all the cases in which the carotid artery was tied for all causes, in all countries, and by all surgeons. This wonderful specimen of German in- dustry and thoroughness contains 586 cases, and gives some details of the operation, the disease, and the result. Of course, in such a vast table, the details must be very slight, and it is, therefore, only general results which can be obtained from its study. He gives 142 cases in which the artery was tied for tumors of all kinds, and of these he reports 87 cures, 49 deaths, and 12 not stated. The cases embrace all forms of tumors, erectile, malignant, etc., and it is evident that the term cure refers only to recovery from the operation, and not at all to recovery from disease. How much the condition of disease had to do with death cannot be educed from this table ; but this very striking fact appears : that, while in the cases where the ligature was applied for haemorrhage, for aneurism, for tumors, the mortality ' was from forty to fifty per cent., when we come to operations performed for epilepsy and for neuralgia, we have the surprising statement that, out of 34 operations, in 33 the patient recovered, and in only one was death the result. Still further, Dr. Pilz refers to some tables published on this very point by Yelpeau, of Paris, and Xorris, of Philadelphia, in which a better result still is given, viz., eight cases by Xorris, in which the carotid was tied for the cure of some affection of the nerve centres, all of which recovered; and Yelpeau, three cases and three recoveries. This statement is all the more remarkable when we reflect that out of every hundred cases in which the carotid is ligatured for haemorrhage, for aneurism, and for the cure of tumors, twenty-two patients die of cerebral symptoms, supervening after the operation, and manifestly depending on it as a cause. That this should be the testimony of statistics on so large a scale, and collected by TREATMENT OF MALIGNANT DISEASE OF BONE. 4Q1 three independent and reliable observers, seems enough to con- vince us that the ligature of the carotid artery in itself is almost free from danger, and yet the statement is so -surprising, and so contrary to all our preconceived notions, that I am sure sur- geons will be slow to accept it without qualification. The fact stands on the record, however, and we are bound not to over- look it ; but, at the same time, the careful surgeon will not be willing to act, in any given case, as if he knew that the ligature he was about to apply to the carotid artery could never be pro- ductive of injury. The same statistics that show that the liga- ture of the carotid, in one class of cases, is never followed by death, show as clearly that, in another class, including the one in which we are now specially interested, the mortality after ligature is somewhere in the neighborhood of thirty-three per cent. It is but just to make one class of cases rectify the results of the other ; and to deduce our practical rules, not from the con- sideration of one, but from a fair comparison of both, and an honest recognition of the value of each. My own feeling in the matter is that, in all suitable cases where the cancerous disease is making rapid progress, or is attended by excessively painful, or dangerous, or exhausting complications, the patient has a right to expect from us the mitigation of suffering, the rescue from immediate danger, and the hope of prolonged life, which we may with intelligent confidence promise him as the proba- ble result of the ligature of the artery from which the morbid growth derives its sustenance. The patient should be fairly informed that death may be the effect of the operation to which he submits ; but it is our privilege to say to him that he has a chance of a perfect cure, and a much better chance of an im- provement in his condition, such as will fully warrant the risk he runs. 5. Ablation. It can hardly be appropriate for me to discuss in this place the general subject of the propriety of operation in cancer. The views of surgeons on this point are gradually assuming so much of positiveness in the light of recent studies, both in diagnosis and in the statistics of treatment; we know so nearly just what to expect, and just what we may promise ; the result of our procedure is so nearly uniform in each class of cases that it would seem as if the canon law of surgery 26 402 MALIGNANT DISEASES OF BONE. might almost now be recorded on this subject, with the hope that future revelations would not materially affect its provisions. Certain things seem to be definitely ascertained with regard to the effect of removing cancerous tumors: 1. Jso degree of thoroughness or promptitude in operation will, in any given class of cancers, secure an immunity from recurrence. This statement is one which most surgeons find it hard to accept. The idea that cancer is, in its earliest stages, merely a local disease which begins to affect the system only after it has gamed a certain development, and the feeling that, if operated on at this period, it will be eradicated from the system, and that, therefore, the early extirpation should be insisted on with the hope of permanent cure, are so plausible, so much in analogy with many other pathological actions in our system, that even such men as Mr. Erichsen and Sir William Fergusson, fully informed as they are of all that has been done of late years in giving us precise information on this subject, cannot avoid clinging to it as one of the grounds upon which they base their advice for early operation. That nothing is to be gained by early as compared with late operations, I would not be under- stood to say. On the contrary, it seems quite certain that the local disease is, at all times, a centre of contamination, both to the neighboring parts 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 no period in the history of cancer where it is so unequivocally a local disease that its ablation will protect the system against its reappearance. I believe this to be, if not positively proved by the statistics of Mr. Sibley and Mr. Paget, so fairly fledudble- from their researches, that it may safely be accepted as a patho- logical fact, and that upon it we may wisely base our concep- tions of the value of treatment. 2. Want of completeness in an operation for cancer, whereby any portion of the diseased mass is left behind, is injurious in its effect upon the progress of the disease, usually exciting it to a more rapid growth, and hurrying the disease more quickly through its worst and most distressing phases to an earlier death than would have occurred had it been left entirely un- touched. TREATMENT OF MALIGNANT DISEASE OF BONE. 403 This proposition is so clearly demonstrated, both by reason- ing and experience, that I think it will hardly be denied. Even in those recurrent tumors which have no other quality of ma- lignancy than their tendency to return in loco, we have ample evidence of the evil effect of partial or imperfect operations, in provoking a more rapid development of the disease ; and, in the most benign form of tumor, a portion of the growth, left behind, is almost sure to reproduce, in aggravated form, the original difficulty. The exceptions I have seen to this patho- logical law have been mainly in those softish fibrous polypi of the uterus where, after ligature, the stump left behind shrinks away and disappears ; and in one instance of fatty growth, where no line of demarcation could be traced between the original and the morbid tissues, the operation whereby a large portion, but evidently not the whole of the mass, was removed, was followed by a perfect cure. These are so manifestly excep- tional instances, that they do not invalidate the general law, applicable to all morbid growths of the tumor character, and especially and emphatically true of those belonging to the es- sentially malignant class. 3. The operation itself is an element of danger to the life of the patient so important, that it must not be overlooked. It is extremely difficult to separate this element entirely from the others which go to make up the problem of the value of life in these cases, taken as a class, and still more difficult to es- timate its value in studying any single case ; but it is not diffi- cult to perceive that death, as a consequence of the operation, is sufficiently common to modify very seriously any statistical re- sults we may wish to arrive at, and to be an important matter of consideration in estimating the propriety of operation in any individual case. Taking, however, the statistics of Mr. Sibley, we find that, of sixty-three operations for cancer of the breast, sixty recovered from the operation, and three died ; giving a mortality of about five per cent, due to the operation itself. Mr. Paget states that out of two hundred and thirty-five opera- tions which he collated, without selection, twenty-three died a mortality of ten per cent., which he is willing to accept as probably not too high, at least for hospital cases. Of the op- erations likely to be required in cancer of the bones, we have 404 MALIGNANT DISEASES OF BOXE. extirpation of the jaws and amputation of the limbs. The mortality, after removal of the upper jaw, taking Hutchinson's and Esmond's collections together, is, out of thirty-three cases, six deaths. The average mortality of the larger amputations, when performed for disease, is sixteen and one-half per cent. These statements, though not claiming to present the danger of the operation itself, separated from the effects of the disease for which it is performed, show very clearly that the risk to the life of the patient, from the operation itself, must enter as a large and a very important factor in the sum of the considera- tions against the operation, when deciding as to its performance in any given case. These three considerations : 1. That operation does not cure, but merely palliates ; 2. That incomplete operation hastens the fatal termination ; 3. That the operation itself adds largely to the dangers of the condition, seem to me to embrace the strong- est points that can be made against an attempt at removal of a cancerous tumor. Let us look now at what should be said on the other side : 1. A certain number very small, it is true of those oper- ated on do recover, and retain their health for such a number of years so perfectly, so far as cancerous symptoms are con- cerned, as almost to entitle them to be considered perfect cures. Most of the practical writers on this disease have noted exam- ples of this unexpected success. Yelpeau speaks of cases where fifteen and twenty years of health have followed an operation for cancer. Sir Benjamin Brodie speaks of two cases, one of thirteen years' and one of fourteen years' immunity from the disease after extirpation. Mr. TTeeden Cooke gives a very in- teresting case of scirrhous breast removed sixteen years previous to his report, by Mr. Lawrence. It remained well for ten years. The disease reappeared, and was treated on two occasions by caustic, and three times afterward by extirpation, one of the operations embracing two enlarged axillary glands. At the time of the report, the patient was in good health ; and, though the arm had become within a few months cedematous, there was no certain evidence of the reappearance of the original disorder. Mr. Cooke says that he has met with four instances in which, after operation, the patients have remained free from the disease TREATMENT OF MALIGNANT DISEASE OF BONE. 4Q5 for a period of ten years. Mr. Paget alludes to a case where a patient died of cancer of the pelvis, twelve years after the re- moval of a cancerous testicle; and finally, Mr. Baker, in his' statistical paper, gives a case in which a chimney-sweep had a soot-cancer removed from his scrotum, and remained well for thirty-five years, when the disease reappeared as an epithelial growth on the finger and hand. All authorities agree in con- sidering these as only exceptions to a general law, but the prac- tical surgeon, in estimating the chances of life in any given case, is fairly entitled to all the encouragement which can be derived from the knowledge that his patient may be one of the fortu- nate ones where, by the operation, life is prolonged almost in- definitely. 2. All the statistics which have been published on this sub- ject go to show that some prolongation of life is gained by a complete extirpation of a cancerous tumor. The principal Eng- lish writers, who have given their attention to the comparing of large numbers of cases of cancer, are Mr. S. W. Sibley, of the Middlesex Hospital, London, and 'Mr. William M. Baker, of St. Bartholomew's. These gentlemen, working each in a separate field, have collated more than one thousand cases of all forms of cancer Mr. Sibley five hundred and twenty cases, all treated in the Middlesex, and about half of them observed by himself, and Mr. Baker five hundred cases, all of which were seen and diagnosticated by Mr. Paget, about two-fifths of them having occurred in St. Bartholomew's Hospital, and three-fifths in private practice. These numbers are sufficiently large to give value to the deductions made from them, and they bear internal evidence of having been carefully and conscientiously studied, besides having received the approval and indorsement of the highest surgical authorities. Mr. Baker's cases are the most valuable to us, as they were all external cancers, or such as come under the care of the surgeon, while Mr. Sibley's ta- bles embrace both external and internal ; the latter, however, in a very small proportion. Both writers give special attention to the question we are now considering, viz., the length of life of the cancer-patient from the commencement to the termination of the disease, and the effect of extirpation of the cancer upon the duration of the 406 MALIGXAXT DISEASES OF BOXE. disease. Mr, Sibley gives for tlie average duration of life for scirrlious and medullary cancer 32J months, and of epithe- lial cancer 53 months. These he considers the average times of duration when no operation has been performed, the dis- ease being allowed to run its course without any surgical treatment other than palliative. Of the whole number there were 63 operations, and no operation is admitted into this table, or into Mr. Baker's, which was not supposed to be a complete one. Of the 63 operations, three died and 60 recov- ered from the effects of the operation 33 of these cases were kept in view, and the rest lost sight of. Of the 33, 27 had re- currence of the disease, in periods varying from a few days up to 108 months, which was the longest period to which the local return was in any case delayed ; six cases remained under ob- servation, being as yet free from the disease, the time since the operation extending in four of them to 7, 29, 36, and 6i months respectively. The average period of recurrence, in those where it was known to have reappeared, was about 15 months. Mr. Baker's results are founded on 111 cases in which opera- tion was performed. He gives the average tune of recurrence in scirrhous about Itt months, in medullary 7-J- months, in epithe- lial five months, some of them returning in a few days, others being delayed to 42, 9, and one to 110 months. The very small number of medullary 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 as stated by the two writers not differing more than one or two months. ISTow, comparing the length of life from the beginning to the end of the disease, in those not operated on, and in those on whom one or more operations had been performed, Mr. Sibley says: "Taking the period at which death took place after the operation, it is found to vary from five to 72 months, the average duration of life, after operation, being 30 months. It is thus seen that the patients operated on lived 53 months, while those upon whom no operation was performed lived only 32 months, showing that the cases operated on lived 21 months longer than those left alone." In this estimate the three that died from the immediate effects of the operation are included. TREATMENT OF MALIGNANT DISEASE OF BONE. 4Q7 If they had been left out, the average length of life in those operated on would have stood at 56 months. Mr. Baker's results are not very different from Mr. Sibley's. He gives the average duration from the beginning to the end of the disease, for those not operated on, as, in scirrhus, 43 months, in medullary cancer 20 months, and in epithelial can- cer 27 months ; while, in those who have undergone extirpa- tion, the length of life is stated to have been in scirrhus 55|- months, in medullary cancer 33 months, and in the epithelial form 57 months. He makes the average length of life in all cases not operated on as 30 months, in those operated on 48 months. Mr. Baker still further shows that the period at which the operation is performed makes a difference in the result which is quite far from what was commonly supposed, and that late operations usually give late recurrences, and a longer aver- age life than where the cancer is extirpated early. This, how- ever, he explains by the fact that late operations are usually upon chronic cancers, which maintain after operation the same slow progress which characterized them before, and he does not seem to consider that his statistical result militates in any way against the propriety of an early operation. In applying the results obtained from these tables to cancer of the bones, we can only do so upon general principles. The number of cases of bone-cancer is so small that no reliable results can be obtained from their comparison. It seems pretty certain, however, that life is much more rapidly destroyed by primary cancer in the bones than by any other external or sur- gical form. Thus Mr. Sibley gives the duration of life in cancer of breast as 32J months, of the stomach 8-J- months, of the bone 10 months ; and M. Lebert gives very nearly the same view of their comparatively rapid fatality, though he places the duration of life in cancer of breast 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 why the gen- eral results, obtained from the study of this large number of cases occurring in the soft parts, may not safely be applied to the bones. The sources of fallacy in such tables become more evident the more they are studied, and yet, making all abate- ments from their authority which the most fastidious may 408 MALIGNANT DISEASES OF BONE. require, there remains enough to indicate very clearly, if not to prove the fact, that, as a general law, operations on cancerous tumors, if performed in suitable cases, and thoroughly and faith- fully done, promise, even including the risk to life of the opera- tion itself, a prolongation of life, which, it is much to be hoped, improved methods of constitutional and local management, and a better knowledge of the appropriate hygiene of the cancer- patient, will very materially increase. 3. When, after removal, the disease returns, it does so, either entirely or mainly, in the internal organs, and the patients gen- erally die from the gradual exhaustion of the cachexia accom- panying secondary cancer, rather than from the direct and dreadful effect of local disease. That this is a positive advan- tage on the side of operation, few will doubt who have carried a case of external cancer through all its fearful stages of ulcera- tion, sloughing, haemorrhage, pain, and sickening fetor, to the weary and distressing end, and have compared this dreadful progress with the more quiet, more supportable, and infinitely less offensive features which characterize the equally unrelent- ing advances of cancer of the lungs, or of the liver. In making the statement that the return of the disease is apt to be in the internal organs, rather than in the original spot, I wish to be understood as confining the remark to medul- lary cancer, which is the class to which almost all the cancers of the bone belong. How it may be in other forms I do not know, nor am I prepared to support the point by statistics, for I know of none which bear on it that are sufficiently extensive to be reliable. I give it merely from the recollections of my own cases, many of them not recorded, a few typical examples of each kind having left a strong impression on my memory. Among the internal organs I include the lymphatic glands, particularly those within the pelvis, where recurrent cancer of the bones of the lower limbs is apt to expend its greatest force. 4. If the patient recover from the operation, he has an in- terval of perfect freedom from the disease, varying, according to the character of the case, from a few weeks to many months. In estimating the blessing which this complete respite confers upon one who has been long a sufferer under the steady ad- TREATMENT OF MALIGNANT DISEASE OF BONE. 4Q9 vance of cancerous disease, we ought to take into our account the effect on the mind as well as on the body. This effect is one of elation, of hope, of confidence a state of mind which, apart from the happiness which it confers, must necessarily be more favorable as to the progress of the constitutional disorder than the same number of months passed in the gloom and anx- iety of steadily progressive local disease. Few patients, who find themselves perfectly well after the removal of a cancer, can resist the feeling that they are permanently well. Their judg- ment may not tell them so, and probably the most intelligent of them would not be willing to acknowledge it to themselves, but there is a certain feeling, which I think I have often recog- nized, which gives as much comfort, in certain dispositions, as if their own judgment and that of their surgeon combined to assure them that their cure was as certain and as permanent as it would be after the removal of a cystic or a fatty tumor. Of these patients Mr. Paget very justly remarks : " When they are no longer sensible of their disease, there are few cancerous patients who will not entertain and enjoy the hope of long immunity, though it be most unreasonable, and not encour- aged." In connection with this point, and in strong contrast, as far as the mental condition is concerned, let us remember that a refusal to operate is often a deadly blow not only to the hopes, but to the courage and endurance of the unfortunate patient. Many of them have only gradually brought their minds to con- sider the possibility of an operation, and have finally nerved themselves up to the point of consent. Many perhaps have come in this frame of mind from a distance, with much personal discomfort and pecuniary sacrifice, to consult a surgeon, ready to submit to any thing which he may deem necessary for their relief. After careful examination and mature deliberation, the refusal of an operation is to them the verdict of the jury, and the sentence of the judge, in the same breath, condemning them to death. It must sometimes be our painful duty to pro- nounce this fearful doom; the circumstances of the case, the condition of the disease, may require us not only to discourage, but absolutely to forbid any attempt at removal ; but we should never forget that in so doing we are taking away the last human 410 MALIGNANT DISEASES OF BONE. hope, and leaving our patient to the darkness and hopelessness of despair. I have thus laid down, as fairly and as candidly as I am able, the considerations upon which we must base our advice, as to the propriety of an operation, in any given case. But no gen- eral application of these considerations can be made in dealing with individuals ; each case must be studied by itself; and I know no more difficult problems, in all the practice of surgery, than some of these cases present ; and no more delicate ques- tion than to decide how earnestly we may persuade our patient to, or dissuade him from the operation, which he either regards with terror, or looks to as his only human hope. Nevertheless, as our knowledge has assumed more precision, so may our ad- vice become more unhesitating and more positive. Let us hope it is becoming more valuable as it becomes more emphatic. Acting upon the principles we have now considered, I would refuse to operate : 1. In any case in which there was not a reasonable certainty that the whole of the diseased tissue could be removed. 2. In any case where there was clear evidence that secondary cancer had taken place. This requires some modification. The mere fact of internal cancer having begun to show itself might not, in all cases, forbid an operation. If the local disease pre- sented unusually distressing or threatening appearances, we might sometimes be warranted in relieving the patient, by oper- ation, of his immediate sufferings and dangers, though we might be sure that no prolongation of life could be gained by the oper- ation. As a general rule, however, no operation should be per- formed where secondary disease has already developed itself. 3. In any case in which cancerous cachexia was already well marked. It is to be presumed, in this case, that the general sys- tem is already poisoned by the disease, and that the powers of reparation are materially reduced. If the removal of the local cause could be relied on as a removal of the whole disorder, then we might hope, as in other cases in surgeiy, that the con- stitutional disturbance would abate on the removal of the source of irritation ; but this is not to be expected in cancer. The constitutional impairment is not the mere reflection of a central irritation with which all parts suffer, but it is the effect, and at TREATMENT OF MALIGNANT DISEASE OF BONE. 41 1 the same time the sign, of a change in the actions of the whole economy, which is as much a part of the disease as the ulcerated tumor itself, and which will not be arrested in its progress by the most successful extirpation of the primary disease. 4. In any case where the operation required was so formi- dable in its extent or character as to add materially to the dangers of the patient's condition. "We would not hesitate to amputate a forearm, where we might refuse to exarticulate at the hip-joint, and generally a trifling and safe operation would be more readily resorted to by the surgeon than one of great magnitude and danger. Our hopes of benefit do not warrant the running of greatly increased risk of life. 5. Where the patient was very old, and the cancer chronic in its course. The slow progress of the disease is likely to con- tinue if it is left alone ; the operation would be very likely to hasten a fatal termination in advanced age. 6. 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 think, too, that unconquerable fear of an operation, or unrea- sonable dread of its consequences, should be a contraindication not to be overlooked. On the other hand, I would advise 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 bone, I could be sure of removing, not only the disease, but the whole organ affected by it. This, I think, is a very im- portant practical point ; and I believe that the cases in which any other operation than amputation should be performed on one of the long bones affected with cancer must be very rare indeed. 2. Where there was no suspicion of any secondary disease in any internal organ, and no extensive affection of the lym- phatic glands. The mere enlargement of a few of these glands by local infection is no contraindication of an operation, statis- tics not showing that this condition adds materially to the unfavorable prognosis, particularly if they admit of complete removal. 3. Where the true cancerous cachexia was not as yet devel- 412 MALIGNANT DISEASES OF BONE. oped in any marked degree. It is not always possible to dis- criminate between the constitutional effects of cancer, as such, and those depending on the ordinary causes of failing health and strength, such as pain, haemorrhage, excessive discharge, and the like. In many cases, however, it can be arrived at, and, where there seems to be no failing of the powers of life but what can be accounted for by the effects of the local actions, we have a right to recommend an operation, in the hope that, for this form of constitutional impairment, the removal of the local cause will prove a remedy. 4. If the operation required for the thorough removal of the disease be not one seriously imperilling life. In cancer of the bones this question is brought down to the comparison of a very few operations ; mainly, amputations and excision of the upper or lower jaws. All these are serious operations, and should not be lightly determined upon ; but, for most of them, the precise grade of danger is almost mathematically proved by reliable statistics ; and, inasmuch as in these operations we are cutting through perfectly sound parts, we may almost say that we can announce the precise amount of risk we are recom- mending our patient to assume, in undergoing any given am- putation. Of course this risk will be modified by the condi- tion of the patient in other respects than the cancer for which the operation is to be performed, but this condition presents nothing which we are not accustomed to deal with in the ordi- nary problems of surgery, and is to be appreciated in accord- ance with its well-known laws. 5. If the cancer be of slow growth, and the patient not old, we have very good reason for believing that the recurrence will be long delayed, and the period of exemption from the disease will be a long, perhaps a very long one. It is from this class of cases that most of the so-called cures are derived, and, though I cannot assert that statistics prove the fact, yet I think their results render it highly probable, that the slower a cancerous growth is in passing through its earlier stages, the longer is it delayed after operation, and the slower its progress when it does return. Yery acute cancers are generally unfavorable cases for operation. 6. The good general health of the patient is a strong point TREATMENT OF MALIGNANT DISEASE OF BONE. 413 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, ?md strong conviction that it will be successful, on the part of the patient, may be accepted by the surgeon, not only as a good omen, but, so 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 our patient a brief respite from death, our mistake may secure for him an uncontaminated and a healthy life. INDEX. ABLATION of malignant disease, 401. Abscess, 27 ; treatment of, 31 ; chronic sinuous, 33 ; tuberculous, 90. Atrophy, 16. Brodie, Sir B., treatment of abscess of bone, 31. Cancer, colloid, 373 ; epithelial, 360 ; scirrhus, 336 ; medullary, 340 ; ostoid, 377 ; melanoid, 368. Caries, 94 ; lacunal changes in, 100 ; prognosis of, 106 ; treatment of, 107 ; passive motion after, 112. Cartilaginous tumors, 217; malignancy, 221 ; change into bone, 224 ; seat of, 233. Chronic sinuous abscess, 33 ; diagnosis of, 41 ; treatment of, 43. Cloacae, 135. Colloid cancer, 373. Compression In malignant disease of bone, 386. Craniotabes, 59. Diffuse suppuration, 45. Dentition in rickets, 69. Enlargement of bone, 24. Epithelial cancer, 360 ; secondary, 361 ; microscopical characters, 361 ; ulcera- tion in, 364.' Epulis, 311. Exfoliation, 151. Exhaustion from necrosis, 150. Exostosis, 240 ; intracranial, 245 ; mul- tiple, 246 ; of fangs of teeth, 246 ; can- cellous, 239 ; ivory, 247. Exsection of bones, 116. Fibro-plastic tumors, 276. Fracture of cervix femoris during Reid's manipulation, 18. Fragilitas ossium, 82. Galvano-electricity in malignant disease of bone, 389. Generalization of malignant disease, 369. Great-toe, exostosis of, 228. Haemorrhage in necrosis, 150. Hypertrophy, 16. Inflammation of bone, 19 ; lacunal changes in, 21. Involucrum, formation of, 132. Ivory exostosis, 16. Lacunal changes in caries, 100 ; hi in- flamed bone, 21. Ligature of arteries in malignant disease of bone, 393 ; in pulsating tumors of bone, 297. Malacosteon, 74 ; shape of pelvis after, 78. Malignant diseases of bone, 335 ; treat- ment of, 381. Medullary cancer of bone, 340 ; micro- scopic characters of, 345 ; stroma of, 346 ; fluctuation in, 350 ; secondary, 351. Melanoid cancer of bone, 368 ; generali- zation of, 369. Mercury in osteitis, 110. Mollities ossium, 74. Myeloid tumors, 276. Necrosis, 119; causes of, 121; seat of, 126 ; pathological conditions of, 128 ; sources of new bone in, 133 ; extrusion of sequestrum in, 137 ; symptoms of, 138 ; haemorrhage in, 143 ; source of haemorrhage in, 145 ; treatment of haemorrhage in, 145 ; superficial, 152 ; in heads of bones, 153 ; of short bones, 155 ; of cranial bones, 157 ; traumatic of cranial bones, 166 ; treatment of cranial, 166 ; of jawbones from erup- 416 INDEX. tive fevers, 169 ; phosphorus necrosis, 170 ; reparation after phosphorus, 176 ; prognosis of phosphorus, 179 ; treat- ment of phosphorus, 179 ; operations in phosphorus, 182 ; recurrence of phos- phorus, 183 ; phosphorus in upper jaw, 183 ; after fractures, 184 ; in simple fracture, 186 ; treatment of, after frac- tures, 187 ; fractureof involucrum, 188; after amputation, 193 ; explanation of, 197 ; without suppuration, 200 ; with- out exfoliation, 201 ; treatment of, 204 ; removal of sequestrum in, 206 ; evi- dences of loosening of sequestrum in, 207 ; operations for removal of seques- trum in, 208 ; instruments used in op- erations for, 210 ; condition of bone after, 214. Ollier's views on reproduction of bone, 133. Osseous tumors, 238. Osteo-myelitis, 45 ; causes of, 50 ; treat- ment of, 51. Ostoid cancer, 377. Pelvis deformed by rickets, 63 ; by mala- costeon, 78. Phosphorus necrosis, 170. Pulsating tumor of bone, 288 ; ligature of arteries in, 297. Question of operation hi malignant dis- ease, 402. Rickets, 54 ; symptoms of, 55 ; analysis of bone in, 58 ; shape of pelvis in, 63 ; shape of head in, 66 ; shape of thorax in, 62 ; causes of, 72 ; treatment of, 73. Scirrhus of bone, 336 ; primary, 336 ; sec- ondary, 337. Sedillot's operation for caries, 118. Sequestrum, 128; separation of, 129. Sub-periosteal resections, 117. Superficial necrosis, 152. Suppuration in bone, 27 ; diffuse, 45. Treatment of inflammation of bone, 26 ; of abscess, 31 ; of osteo-myelitis, 51 ; of rickets, 73 ; of caries, luf ; of haem- orrhage iu necrosis, 145 ; of phosphorus necrosis, 179 ; of necrosis, 204 ; of pulsating tumors of bone, 297 ; of ma- lignant diseases of bone, 381. Tumors of bone, 215. cartilaginous, 217; causes of, 220; anatomy of, 218 ; relations to malignancy, 221 ; size of, 222 ; changes hi, 223; softening of, 223. osseous, 238 ; cancellous, 239 ; seat of, 241 ; ivory, 247 ; seat of, 249 ; operations on, 253. fibrous, 256 ; seat of, 258. spindle-celled fibroid, 259 ; malig- nancy, 264 ; recurrence of, 274 ; duration of, 275. myeloid, 276 ; anatomical elements of, 277, 282 ; malignancy of, 279 ; spontaneous disappearance of, 280 ; color of, 282 ; seat of, 281 ; cysts in, 286. pulsating, 288 ; causes of pulsation in, 289 ; erectile structure of, 291 ; C. D. Smith's case of, 292 ; W. Parker's case of, 294 ; treatment of, 297 ; ligature of arteries hi, 297 ; actual cautery in, 299 ; ex- tirpation of, 299. of the jaws, 300 ; inflammatory dis- tention of antrum in, 301 ; cysts and cystic growths in, 305 ; treat- ment of cysts in, 309 ; connected with gums, 311 ; solid, 313 ; fibrous, 316 ; myeloid, 317; ade- noma, 320; treatment of, 322; removal of upper jaw for, 325 ; removal of lower jaw for, 328 ; removal of both upper jaws for, 227. Upper jaw, phosphorus necrosis hi, 183; removal of both, 327. THE END. Date Due CAT. NO. 23 233 PRINTED IN U.S.A. A ""HI Hill 000 499 523 WE200 1872 Markoe, Thomas M A treatise on diseases of the bones CALIFORNIA COLLEGE OF MEDICINE LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 at >- i