Читать книгу Elements of Surgery - Robert Liston - Страница 23

Caries most frequently occurs in the heads of long and in the cancellated structure of the short bones, as unhealthy suppuration most frequently takes place in the loose, fatty, and cellular tissues of the soft parts. The formation of abscess in the cancelli is generally preceded by deposit of tubercular matter, isolated or collected in masses, and by the softening of this cheesy substance. When pus has formed in the substance of a bone, the outer lamella, in the end, becomes absorbed, and the effusion undermines the periosteum, which, from the distension, also ulcerates: the matter then spreads into the neighbouring cellular tissue, or makes its way to the surface, and is evacuated, or, what is still worse, it escapes into an articulation. The discharge is often continued, as already stated, in consequence of a dead portion of the cancellated structure being imbedded either in the carious cavity, or in the soft parts, where they sometimes are lodged for a long period.

It was formerly remarked that bones become highly sensible from incited action; hence, during the progress of this disease, which is attended with more or less inflammation, the patient generally suffers most excruciating agony—so great, in general, as to prevent him, perhaps for weeks, from enjoying the least repose. The affected part is considerably swollen, but the enlargement is seldom so general, or so great as in the diseased state of the ligaments and other apparatus of a joint. White swelling, however, may be the precursor of caries; or, in other words, a disease commencing in the bursæ, ligaments, synovial membrane, or cartilage, may extend to the bone; and breach of continuity, attended with weak action, be the consequence. In caries the affected portion appears neither to possess vitality enough to enable it to repair the breach, nor to be sufficiently deprived of vitality to be thrown off by the surrounding parts. Considerable portions of dead bone are occasionally found in carious cavities, in the heads of bones, and even in the vertebral column. Small portions are also detached piecemeal in the progress of ulceration, and discharged; but it is seldom that the whole surface is thrown off, so as to give place to a healthy and reparative action. When the parietes of the cavity have remained a considerable time in this inactive state, the surrounding vessels become more active, and the surface of the bone in the vicinity is studded with nodules of new osseous matter. The disease here delineated affected only a small portion of the cancellated texture of the condyle. An ashy looking substance fills the cavity, and this again was concealed in the recent state by lardaceous matter. The elbow joint is unaffected, excepting only that, from the deposit of new bone in spiculæ and nodules, and the condensation of the soft parts, almost complete anchylosis had taken place. This deposit is not always limited to the affected bone, if one only be the seat of the disease, but frequently extends to those articulated with it. The soft parts are commonly more or less thickened, and rendered exceedingly dense by effusion of lymph into the cellular texture; and so great is this thickening sometimes, that the knife is resisted as if by cartilage. The discharge which proceeds from the carious part is generally highly fetid, very profuse, is often poured through several openings, and the surrounding skin is excoriated and generally of a livid colour. The ichorous discharge occasionally dries up for a short period and again breaks out more violently. The surface of the ulcer is, in some cases, occupied by soft unhealthy granulations; in others the earthy part of the bone is most prominent. When the parts have been macerated and dried, the disease is often found to have proceeded more in width than in depth, and the absorption has not reduced all points of the diseased surface to the same level, thin portions remaining somewhat elevated, and giving the part a cancellated appearance; and there often project numerous minute osseous fibrillæ of considerable length, which intermix with one another, and form a most delicate network. In other instances, the ulceration has extended more deeply and uniformly, and a considerable cavity is formed, with irregular margins and surface; not unfrequently it contains dead portions of the cancellated structure, in some of a dark, in others of a light colour; or it is occupied, in the recent state, by a substance resembling lard. The surrounding bone is much softened, and, after maceration, becomes exceedingly light. The disease is generally confined to one or two bones, but occasionally involves a whole chain. It may be limited to a part of one bone in a joint, or may embrace the whole of it. Its extent will depend on the severity of the primary action, or on the degree and duration of the pressure of fluid which has been allowed to exist, whether from the nature of the superincumbent texture or the carelessness of the surgeon.

Interstitial absorption of those bones which are in the neighbourhood of the carious ulceration often occurs in the tarsus and carpus. The superincumbent integuments are livid and cold, and pain is felt in the situation of the bones; yet they are not affected with continuous ulceration, but portions of their substance are gradually removed by absorption, so that they are much loosened in texture, and may be altogether destroyed, or come to consist merely of a thin and reticulated osseous shell, whilst at the same time their cartilaginous surfaces often remain in their healthy condition.

The constitutional disorder attendant on caries is at first very great; the sympathetic fever is followed by hectic, under which, and the discharge, many patients sink. The general affection in some degree keeps pace with the local in violence and duration. The irritation is in some cases so great as to destroy the patient in a very few months or weeks; but not unfrequently a constitution, by no means strong, will be enabled to bear up for a long period under very extensive disease of a bone. The paroxysms of pain and inflammation occasion fresh attacks of constitutional derangement: this occurs till the patient’s health and strength are exhausted, and he sinks under the disease, or is relieved by the spontaneous or artificial removal of the cause.

A natural cure of caries may occur in consequence of the diseased parts so far recovering their natural degree of vascular action as to form granulations and repair the breach; but most frequently it is necessary, for the accomplishment of this purpose, that incited action occur to a very considerable degree; and the diseased parts, already extremely weak, have not sufficient power to withstand the action, but perish; whilst the action of the surrounding parts, not being increased to such a degree as to overcome their powers, throws off the dead, secretes a more bland discharge, and deposits healthy granulations, which gradually fill up the cavity.

Treatment.—In inflammation of bone, resolution must be brought about, if possible; the other terminations are to be prevented by all possible means, since they frequently endanger the limb, and even the life, of the patient, and, at best, never admit of a speedy cure. To promote resolution, blood must be drawn copiously from the part; and general bleeding may also be required, though in some constitutions it cannot be safely carried to any great extent. After local bleeding, fomentations assiduously applied will tend much to relieve the sufferings of the patient. Purgatives, nauseating doses of antimony, and all safe measures likely to subdue the vascular action, must at the same time be adopted. Free incisions through the periosteum sometimes relieve the pain, and cut short the disease, the distended vessels being thereby emptied; but such practice is only a last resource, when the action has resisted all other means, and threatens an unfavourable termination. If, notwithstanding the resolutive means employed, the inflammation proceeds unabated, and suppuration occurs, the effused pus ought never to be allowed to remain on the surface of the bone, but must be evacuated by early incision. Otherwise the pressure of the extraneous fluid will cause absorption of the bone, or detachment of periosteum and superficial necrosis; the absorbed surface will, in its turn, secrete pus, and thus an ulcer will be produced; and, from the vascular action becoming debilitated in consequence of the previous incitation, that ulcer will in all probability degenerate into caries. Much mischief is produced by squeezing and bandaging tightly the inflamed parts, as can readily be understood; yet such practice is frequently adopted after suppuration. By it the inflammatory action is excited anew, the formation of matter is very much increased, and however useful such manipulation may be in stiffness of a joint, or mere swelling of bursæ, and sheaths of tendons, still, in inflammation and abscess of bones or joints it is extremely prejudicial, and from its indiscriminate employment by those ignorant of the profession, many limbs have been destroyed. General chronic periostitis, which is produced by exposure to cold, or occurs after or during mercurial courses, and is often supposed to be a symptom of syphilis, is relieved by the internal exhibition of the bichloride of mercury, or other mercurial preparations, combined with sarsaparilla and diaphoretics. In many instances such an affection will yield to no other treatment; and thus the practitioner is occasionally obliged to have recourse to a somewhat paradoxical practice, that of giving mercury for a disease which seems to have been produced by that mineral.

In inflammation of the short bones or heads of the long bones, if the action does not yield to topical bleeding and becomes chronic, counter-irritants must be employed. Blisters repeated are often useful in subduing the remaining action, and in obstinate cases small caustic issues are sometimes of service. During the adhesion of the eschar, the best application is a common poultice or water dressing, which, on the separation of the dead part, may be exchanged for any simple ointment, it not being at all desirable in general to check the discharge and heal up the breach of surface. Moxa is sometimes employed to make an issue in these and other cases, but it is not superior in any respect to the potential cautery, whilst its employment is generally very alarming to the patient. The sores following the use of the moxa are in some instances tedious in healing; and this may be ascribed to the vitality of the surrounding parts having been diminished by the application.