BONE, PATHOLOGICAL CONDITIONS OF. 



449 



that it is difficult to say which structure is the 

 source of the purulent secretion ; the disease, 

 indeed, is generally described under the name 

 of periostitis. We are disposed, however, to 

 regard it as inflammation of the bone in the 

 first instance, although the membrane comes 

 very soon to be engaged ; because in many 

 cases the pain in the commencement is not ag- 

 gravated by external pressure, which it uni- 

 formly is when the periosteum is engaged, 

 and also because in very severe cases, such as 

 paronychia periostei, a portion of the bone 

 becomes carious, and is lost even from the 

 earliest period. It is most frequently ob- 

 served in connexion with some constitutional 

 taint, such as scrofula or syphilis,* but it may 

 and very often does appear purely as an idio- 

 pathic disease. " Inflammation of the pe- 

 riosteum, unconnected with any known con- 

 stitutional disease, is an affection with which 

 practical surgeons are well acquainted. It is 

 remarkable, however, that a disease so impor- 

 tant in its consequences and of such frequent 

 occurrence, should not have been noticed in any 

 systematic work, nor have been made the sub- 

 ject of any separate inquiry ."f 



Whether we consider this affection to belong 

 primarily and principally to the bone or pe- 

 riosteum, it is certain that the former structure 

 always is engaged, and shews the most evident 

 marks of activity in the disease, although this, 

 perhaps, may in part be explained by the 

 fibrous texture of the membrane and its defi- 

 cient organization. The bone is always in- 

 flamed. Even in the most chronic case that 

 leads only to a thickened condition of the pe- 

 riosteum, the bone is preternaturally vascular, 

 and so soft that it is often difficult in such 

 cases to distinguish the limits between the sof- 

 tened bone and the condensed periosteum. J 

 In the severer forms, the bone, unable to sus- 

 tain itself under the excitement, is always dead, 

 and must be gotten rid of by ulceration or 

 exfoliation : in these cases the periosteum is 

 detached, and a fluid, very generally thin, 

 ichorous, and fetid, is interposed between them. 

 Between these extremes there is every possible 

 variety, and, therefore, there will be vast dif- 

 ferences in the results of the inflammation, 



* Of all the causes that produce these affections 

 of the bones, an irregular or protracted use of mer- 

 cuty seems to be the most efficacious. Many sur- 

 geons of the present day doubt whether a suppu- 

 rating node is a true or genuine venereal symptom. 

 We have learned from an experienced army surgeon, 

 who spent many years on the western coast of Africa, 

 where the venereal disease is not known, but where 

 mercury is profusely employed in the treatment of 

 liver complaints and other diseases incident to the 

 climate, that affections of the bones, resembling 

 those considered to be venereal, are of exceeding 

 frequency. It is a remark worthy of attention to 

 the curious in such matters, that nodes, &c. formed 

 no part of the symptoms of syphilis as first observed 

 and described, and that the first practitioner who 

 noticed them (John de Vigo, 1519,) is mentioned 

 by Astruc, (page 158,) as an eminent promoter of 

 the mercurial method of cure, and as having by that 

 means acquired great reputation and riches. 



t See a paper by Mr. Crampton, in the Dub. 

 Hosp. Reports, vol. i. 



t Ibid. 

 VOL. I. 



sometimes in the mere thickening of the pe- 

 riosteum, sometimes in the deposition of more 

 bony matter, or the apparent ossification of the 

 membrane (exostosis) ; occasionally in the ab- 

 sorption of the bone, and most frequently, 

 particularly in specific diseases, in that which 

 is our more immediate object, the deposition of 

 purulent matter. 



A node is a swelling situated over a bone, 

 hard, firm, and exquisitely tender to the touch, 

 not round or circumscribed at its base, but 

 gradually subsiding to the level of the adjacent 

 parts, and not discoloured on the surface. It is 

 at all times painful (except in some scrofulous 

 cases), and when arising from a venereal cause, 

 is subject to nocturnal exacerbations of great 

 severity. The morbid anatomy of the disease 

 is not always the same even when examined 

 at the same period of duration, being modified 

 by a number of circumstances, such as the 

 age of the subject and consequent vascularity 

 of the bones; the structure of the bone en- 

 gaged being solid and firm or soft and spongy ; 

 but more particularly by the fact of the disease 

 being idiopathic, or produced by some consti- 

 tutional affection. The scrofulous diseases of 

 bones seldom or never exhibit the symptom of 

 nodes, although attended by suppuration, be- 

 cause they affect their substance rather than 

 their surfaces : idiopathic nodes, or those pro- 

 duced by injury, do not suppurate unless the 

 violence used is great ; on the contrary, these 

 are cases which so frequently terminate in 

 thickening of the periosteum, &c., and often, 

 when cut into, scarcely afford any perceptible 

 discharge. The venereal or mercurial node 

 offers the best example of suppuration. At an 

 early period, if an opportunity occurs for exa- 

 mination, the periosteum round the margin of 

 the effusion shews a more than ordinaiy degree 

 of vascularity ; immediately covering the tu- 

 mour it is somewhat paler, more opaque and 

 thickened. The bone underneath is denuded 

 and soon runs into caries ; between it and the 

 membrane the matter is deposited, thin in con- 

 sistence, dark-coloured, and sanious. 



There are other forms of suppuration on the 

 surface of a bone of too much interest and im- 

 portance to be omitted, such as those large de- 

 pots which occasionally occur after severe in- 

 juries or operations, as the accompaniments of 

 inflammation of the veins, or as the sequelae 

 of acute fevers. In general, the matter is in 

 great quantity and of a good and healthy cha- 

 racter, though sometimes it is otherwise, and 

 particularly in that form which attacks a stump 

 after amputation. We have seen the entire 

 remnant of the bone up to the next articulation 

 denuded of its periosteum, while quantities of 

 green and fetid pus could be pressed from the 

 very depths of the wound. In these cases the 

 veins are generally inflamed, the divided ends 

 of the muscles pale, flaccid, and sloughy, and 

 the patient seldom or never recovers. Where 

 the deposition has taken place after fever, if 

 the patient is young and the constitution has 

 enabled him to combat the original disease, a 

 recovery very frequently takes place by the 

 process of necrosis. 



