Elements of Surgery. Robert Liston

wound are thickened by the granulations; the discharge from the wound still considerable; feels quite well in health.

      “12. The wound continues much the same; the rollers have been discontinued.

      “14. Feels himself gaining strength daily; can walk without pain; wound is contracting and hard; granulations seem to lessen the depth of the opening in the bone; there appears to be no sequestrum.”

      When caries is fairly established, and the integuments have given way, the best and most successful proceeding is that pointed out by nature—destruction of the diseased portion; and the means must vary according to the particular circumstances. In many cases, nature seems to wait but for the separation of the sickly parts, either by accident, or by the interference of art. The means are to remove, partially or wholly, the diseased part, or to effect such a change of action as will throw it off. The first indication will be accomplished by trephines, scoops, saws, and forceps; the second by active escharotics; frequently both are required.

      If there be extensive disease in the medullary canal of a bone, several perforations may require to be made, and these may be connected by the use of a small saw, or the cutting forceps. The diseased cancelli, thus exposed, can be readily removed by the scoop or graver, as recommended by Mr. Hey, primus, in his excellent work. If, with the probe, it is ascertained that a portion of the cancellated texture has become dead and loose, it is to be removed after dilatation of the external opening. It may frequently be difficult to distinguish in the effused blood, between what is diseased and what is not; it will often be necessary afterwards to cauterise freely the exposed surface, and for this purpose the oxidum hydrargyri rubrum ought generally to be preferred. The slough will soon be thrown off, and healthy granulations fill up the breach. The application of the actual cautery may be by some considered necessary: at one time I employed this remedy very extensively in caries, and occasionally with very good success; I have since, however, been led to change my opinion, and am now inclined to prefer the potential cautery already mentioned. By the application of the red-hot iron, the diseased portion is destroyed effectually, but at the same time the vitality of the surrounding parts is often very much weakened and their power of reparation diminished, so that they are incapable of assuming a sufficient degree of action for throwing off the dead part; their action being increased whilst their power is diminished, they may become affected with caries, and thus, instead of being arrested, the original disease will either be increased, or extensive necrosis may take place. The red oxide of mercury is not calculated to produce such bad effects; it does not spread or insinuate itself into the bony tissue, as liquid caustics are apt to do; and it is sufficiently powerful for complete destruction of the diseased parts. It will be necessary to keep the wound open, by proper dressings, till all the dead portions of bone be discharged, and every part of the parietes of the cavity produce healthy granulations: if the discharge be offensive, its fetor may be corrected by the use of spirituous applications, such as the tinctures of myrrh, opium, or aloes, separately or combined. After healthy granulations have appeared, and the cavity has begun to contract, light dressing is all that is necessary.

      In operating on the carpal and tarsal bones for removal of caries, the surgeon must be well acquainted with the connexions and relations of the parts. If one bone is diseased, its removal will be sufficient; if several, the operation becomes more painful and difficult. When one only of the tarsal or carpal bones is almost completely destroyed, and the surfaces of those articulated with it are also more or less affected, it is not sufficient or safe merely to remove the loosely attached portions of the one primarily attacked; the diseased parts of those surrounding it must also be taken away, and it will often be necessary to apply the caustic afterwards. In caries of the distal range of bones, the bases of those supported by them are in general involved, and must also be removed. If one only is diseased, with the base of the metacarpal or metatarsal bone attached to it, the removal of these will be enough, and can be accomplished without difficulty. Some have recommended the total extirpation of a metacarpal or metatarsal bone, leaving the finger or toe appended; but the member, when thus left unsupported, can never become of any service to the patient, and may be productive of much inconvenience; whilst removal of them, along with the diseased bone, renders the operation much more easy of execution. If the whole disease can be extirpated, leaving the surfaces of the surrounding bones covered with healthy cartilage, the use of the caustic is not required, and would be productive of harm; but wherever it is impossible to avoid encroaching on the cancellated texture, such as of the os calcis, which it would be unsafe or imprudent to take away entirely, its use is then indispensable. After the removal of carious bones, the symptoms soon disappear, and the patient obtains a rapid, and often permanent cure. The instruments for these operations, and the method of performing them, will be afterwards mentioned. In conclusion, it may be remarked that the temporary cicatrix of a sore leading to a diseased bone has a very different appearance from the sound scar which is formed after its removal. The former is bluish, soft, on a level with the surrounding parts, and moveable; the latter is depressed, white, and firmly adherent to the bone.

      NECROSIS

      Death of bone, or Necrosis, is an effect of violent inflammation, particularly of the medullary web, or external injury; a termination of inflammatory action in bone corresponding to sphacelation in the softer tissues. It has been observed, that the bones are not extensively supplied with bloodvessels, and that their natural powers are inferior to those of the softer parts; and from this circumstance the frequency of necrosis can be readily accounted for. The short bones and the heads of the long bones, are more vascular than the flattened bones and the shafts of the long ones. Hence necrosis most frequently occurs in the latter. Necrosis, fortunately, seldom occurs in the heads of the long bones, or penetrates the separation betwixt the cancelli of the shaft and the epiphysis. Bits of dead bone in the articular ends, however, very often lead to disease in the joint. There are in my private collection a few specimens of necrosis, in which matter found its way into the neighbouring joint, leading to disease of the tissues composing it, and rendering amputation necessary for the preservation of the patient’s existence. External injury may produce this disease by causing a violent increase of action, or it may be so severe as at once to deprive part of the bone of its vitality. Destruction of the periosteum, and of the vessels which enter the surface of the bone, frequently gives rise to superficial necrosis or exfoliation. Such a result, however, does not always follow; for we not unfrequently find, when the periosteum has been forcibly torn off, to a considerable extent, by external injury, that the part still retains its vitality. When, however, the bone has been at the same time contused, it is extremely probable that external necrosis may occur. Again, when the periosteum has been removed in the most careful manner possible, exfoliation occasionally takes place. If the exposed bone remain of a brownish hue, it will generally retain its vigour; if, on the other hand, the colour is white, it will most probably be cast off. Necrosis may come on at various periods of life, but is most commonly met with in young subjects, in whom the inflammatory action is allowed to make progress before it is noticed or attended to. It may affect the external or the internal part of a bone, or nearly its whole thickness. The whole of a bone seldom or ever dies in consequence of increased action, and it is not often that the entire thickness of any part of it is found to be necrosed. If the entire thickness dies to a great extent, there is no reproduction; the epiphyses approximate, and the limb, if there is only a single bone, must be lost. A large portion of a bone, or numerous small irregular portions, may die; but still a part of the original shaft remains, and by its vessels reproduction is accomplished. The articulating extremity is very rarely destroyed by this disease. Many writers have talked of death of a bone throughout its whole extent, and, in fact, the term necrosis was originally adopted on this supposition.

      The progress of necrosis is, as has been said, similar to that of sphacelation. The affected bone gradually changes its colour, and loses its sensibility; a line of demarcation is formed, and ultimately the dead portion is completely detached from the living. Previous to its separation, the surrounding parts, the portions of bone which are not doomed to perish, have commenced forming new osseous matter, which is secreted in nodules, and from continued deposition soon becomes consolidated. The commencement of the process is well seen in the following sketches from specimens