456 



BONE, PATHOLOGICAL CONDITIONS OF. 



surface and not able to accomplish it quickly, 

 occasion much suffering, and if there is ever 

 danger to life or limb from the disease, such 

 cases are most likely to produce it. 



The sequestrum or dead bone is disposed of 

 either by presenting externally and permitting 

 of its removal by the process of ulceration or 

 by manual operation, or else it is never seen, 

 and is entirely carried off by the absorbent 

 vessels. Mr. Russell accounted for the disap- 

 pearance of the sequestrum in a very unsatis- 

 factory manner. He considered the dissolution 

 of the dead bone to be " greatly accelerated by 

 the solvent power of the purulent matter," a 

 property, the existence of which in pus both 

 observation and experiment render question- 

 able : and when thus macerated, he conceived 

 it to be prepared to be removed by absorption 

 or washed out by the discharge of the matter. 

 But, if the surfaces of a sequestrum are exa- 

 mined, that which is next to the granulations 

 of the new bone will be found to be irregularly 

 marked and indented, as if by the action of the 

 mouths of the absorbents, whilst the other is 

 comparatively smooth ; and as every part ex- 

 posed to the action of the fluid should suffer 

 equally if the removal of the osseous particles 

 was effected by maceration, there are strong 

 reasons for believing that the disappearance of 

 the sequestrum depends not on any power 

 chemical or mechanical, but on some vital pro- 

 cess, and therefore probably on the action of 

 the absorbents. 



When the sequestrum presents externally, 

 either one end of the bone (almost always the 

 superior one) protrudes through the soft parts 

 and remains there dry, hard, and dead for a 

 longer or shorter time, until it becomes de- 

 tached by the slow process of nature, or is 

 separated by a surgical operation ; or else the 

 middle of it presents, and can be seen or felt 

 through an aperture in the surrounding new 

 bone whilst its extremities are confined. In 

 either case the process of removal is extremely 

 tedious. When the end presents, it is gene- 

 rally moveable, and seems as if very little 

 force would be sufficient to detach it altogether ; 

 yet if an attempt is made to pull it away, it is 

 by no means easily accomplished, and a con- 

 siderable time elapses between the first pro- 

 trusion and its final and complete separation. 

 When the middle presents, the process is still 

 more protracted. All bones do not seem equally 

 liable to necrosis. Perhaps the tibia is as fre- 

 quently attacked as all the other bones of the 

 skeleton taken together ; next in frequency is 

 the humerus, the bones of the fore-arm, the 

 thigh, the clavicle, and lastly the lower jaw. 



Thus far, it will be seen that we have con- 

 sidered necrosis as a disease, distinct and dif- 

 ferent from every other affection of the bones 

 whatever, and that its chief and most marked 

 characteristic is the process of regeneration. 

 Regarded in this point of view, it is as much 

 and even more an action of health than of dis- 

 ease, and it can easily be understood why the 

 constitution suffers so little, why the hectic 

 fever is of so mild and mitigated a form, and 

 why in a simple and uncomplicated case re- 



covery is nearly certain. It is also evident that 

 this disease will not be likely to occur in a 

 constitution contaminated with syphilis, scro- 

 fula, scurvy or any of those other vices which 

 the continental surgeons not only think it may 

 be united with, but which they adduce as its 

 occasional exciting causes. Doubtless, if the 

 death of a bone from any cause or under any 

 circumstances if caries, exfoliation, and other 

 such destructive maladies are to be included as 

 species under the generic name of necrosis, 

 such affections may not be inconsistent with 

 the existence of any poison or any taint ; but 

 if the idea of a process of reproduction co- 

 existent with that of disease must be admitted 

 as appertaining to this affection, it will be im- 

 possible to recognise scrofula or syphilis as 

 connected with it in the remotest possible de- 

 gree. Perhaps we shall incur censure for thus 

 attempting to limit the signification of the 

 term, but it has been observed that the nomen- 

 clature of surgical pathology is too loose and 

 undefined, and in no instance is the remark 

 more applicable than with reference to the dis- 

 eases of the osseous system ; and again, patho- 

 logy to be useful must be practical, and we can 

 by no means assimilate caries which is so des- 

 tructive of the limb or fatal to life or exfo- 

 liation, which is always attended with loss of 

 substance with necrosis, the essential cha- 

 racter of which is a process of reproduction, 

 and its natural termination recovery. 



In attempting to describe, or even to arrange 

 the remaining diseases of the osseous system, 

 the pathologist has to encounter difficulties al- 

 most insurmountable. Some of these are na- 

 tural to and inseparable from the subject, as 

 1st, the depth at which a bone maybe situated 

 will render it difficult to discover a change of 

 shape or size, much more to ascertain an altera- 

 tion of structure. 2d. The bones do not al- 

 ways exhibit a very active sensibility ; when 

 attacked by chronic forms of disease, they do 

 not cause very great pain, and consequently 

 the evil may be well established and irreme- 

 diable before the patient is fully sensible of his 

 condition. 3d. These affections are not fatal 

 at an early period ; they run a long and tedious 

 course before they destroy life or render the 

 removal of the limb indispensible. And hence 

 in any individual case it may be difficult to 

 learn even the early history or commencing 

 symptoms, much more the nature of that pecu- 

 liarity of constitution that disposes to these 

 diseases, or the first changes that take place 

 from a healthy to a morbid structure. Little, 

 indeed, can be ascertained with certainty as 

 to the nature of osseous tumours until the part 

 has been removed, and then the information 

 comes too late for any useful purpose. Another 

 source of embarrassment exists in a want of ac- 

 cordance as to the nomenclature of these affec- 

 tions. One surgeon calls that exostosis which 

 another has named osteo-sarcoma, and a third 

 has designated as cellular exostosis an affection 

 which he himself in another place has named 

 spina ventosa. In order, in the present in- 

 stance, to avoid similar confusion, we must 

 endeavour to construct an arrangement which 



