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Course of Lectures on Physiology and Surgery, Delivered at St. George's Hospital, Lecture XI.Suppuration in BoneAuthor(s): John HunterSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 2, No. 25 (Sep. 18, 1841), pp.487-489Published by: BMJStable URL: http://www.jstor.org/stable/25490263 .

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PROVINCIAL

MEDICAL & SURGICAL JOURNAL.

No. 25. VOL. IT.] LONDON, SATURDAY, SEPT. 18, 1841. [ PRED SIXENCE.

COURSE

OF

LECTURES ON PHYSIOLOGY AND SURGERY,

DELIVERED AT ST. GEORGE' S HOSPITAL,

BY JOHN HUNTER, F.R.S.

(From the Manuscript of Dr. Thomas Shute.)

LECTURE XI.

SUPPURATION IN BONE.

ABSCE8SSES form in bone as in soft parts, and are conducted to the skin by ulceration. The ulceration must begin almost at the same time as the matter is formed, for when one particle of

matter is deposited, the surrounding parts must be removed to make room for more. In com pound fractures we have suppuration and granu lations; the latter become cartilaginous, and then bone performs the union: thus we have these salutary processes arising progressively one out of another. Joints, when exposed, suppurate, granu late, and unite by bone, in the same manner as compound fractures. This species of anchylosis forms the fifth kind, four of which have been described before. Suppuration seldom begins in a bone; much more frequently in the external parts, and the bone receives the disposition from them. When a bone has suppurated and ulce rated, it restores the lost part by granulations, these granulations becomg cartilaginou or mem branous according to the nature of the bone, and afterwards ossify. Thus, after trepanning the skull, the granulations become membranous, and then ossify.

The granulations arising from bone sometimes ossify, and cause a disease by forming a bony tumor. Here are several specimens of this: the ossified granulations have a very diffierent appear ance from those parts which have taken on the ossific inflammation. Suppuration in bone may b)e divided into three species: a division is made from the situation of the matter, and not from any difference in the kind of suppuration.

The first species is, where matter forms on a bone or in the periosteum. The second, when it is found in the substance of a bone. The third,

when it is formed in the medulla of a bone. A fourth might be added, when matter is formed in a joint. In the first species, the periosteum is raised from the bone, the surrounding parts take on the ossific disposition, and bone is formed round the abscess in a circle; the soft parts like wise acquire the feel of bone, and the ulceration conducting the matter to the skin goes on faster than the new bone can be formed externally, other

wvise there would not only be a circle of bone No, 51.

formed round the abscess next the bone, but it would be completely encased in bone. The sur rounding soft parts, however, always take on the bony hardness to the touch. When these ab scesses are opened, they give the idea of matter sunk into the bone, havng exactly that appear ance.

Thus, when matter forms on the skull, the new bone forming gradually round it, gives the feel and appearance, when opened, as if the matter sank into the skull, although the bone is perfectly entire. In all these abscesses, the open s made should be free: the granulations are apt to take on the ossific disposition, and the surrounding parts abo.

In the second species, the swelling of the bone is confined to the side which is inflamed: the ul ceration must begin almost immediately, when it suppurates, to make room for more matter. The stimulus for ulceration will be given on that side next the skin, and it will come through the bone by a small opening; the periosteum will inflame, and take on the ossific disposition. The ossific inflammation will be adding bone on the outside

while it is ulcerating within: the ulcerative inflam mation, however, goes on faster than the ossific can add new matter, otherwise no opening could be made for the pus; the opening is usually a small one, sometimes there are two or three: when the matter has passed through the bone, it spreads, forming a second cavity in the soft part, and at last breaks through the skin; thus, then, we have two cavities, one in the soft part, the other in the bone, communicating with each other by a small bony sinus.

When this case is known by the external open ing of the soft part discovering the opening into the bone, it should be dilated by the actual or po tential cautery or trepan; thus, the two large abscesses are thrown into one. If the sore be comes indolent, active stimulating dressings should be applied. Tincture of myrrh is recommended; it seems at least to have a power of correcting mat ter, and rendering it less putrid.

Ulceration will be carried on to the skin, and then the fluctuation may be felt, and the case known to be an abscess.

Before the fluctuation is felt, it is impossible to say what the disease is. If bones could be ex amined in all the different periods of their disease, a great number of curious facts might be ob served.

In the third species, the situation of the matter is much more serious than in the former; the stimu lus being given generally equally on every side, the

matter does not know which way to go, therefore the bone commonly swells all round. If one side of the bone is situated nearer to the skin than the other, then it generally ulcerates on that side, or if one part has a greater tendency to ulcerate than another, then it may make its way out; but if neither of these is the case, it then generally ulcer

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488 HUNTER'S LECTURES ON PHYSIOLOGY AND SURGERY.

ates on every side; the ossific inflammation going before, forms just bone enough to prevent its breaking: thus, a bony shell is formed, contain ing the matter and supporting the bone: this has been considered as a swelling of the bone, but it is entirely a new-formed part, and has none of the original bone in it. In these cases nothing can be done in general but amputation. Sometimes the bony shell becomes so thin as to break.

Granulation of bone.

When an abscess is formed in or upon a bone, it is necessary to open it freely, to cause it to granu late. This is to prevent the granulations from the soft parts growing over the bone, and pressing those down which arise from it. Although the external opening should be made large, the bone should not be exposed, for that would cause death in the part, and then it must exfoliate.

Granulations are by much the weakest part in an animal body; therefore, parts formed by them are very apt to ulcerate. Parts united by the adhesive inflammation are much stronger, therefore com pound fractures are much more apt to become dis united than those which were simple.

Abscesses sometimes form in joints; when the case is known, they must be opened: the matter contained in them is seldom of the true suppura tive kind, but between that and the adhesive.

When these cases do well, they granulate and heal as other wounds. It is to be wished that the gra nulations remain in that state, forming the soft anchylosis, which admits of some degree of motion; but this seldom happens, for they generally ossify. These cases are very apt to terminate ill, frequently causing hectic symptoms, and ending in the death of the patient. Joints are very tedious in all their operatiopis toward a cure. From the matter which is discharged always having a mixture of the coagulable lymph, it shows that there is a con stant irritation kept up, and in the surrounding parts there is always considerable tension. Gra nulations, by becoming ossified, perform the union between bones, when they are exposed; by this means the cavity of the bone at the extremity of a stump is closed. Here is the leg of a bustard

which has been amputated; the small bones answering the purpose of tendons, are united with the great bone by means of granulations becoming ossified.

In -compound fractures, the exposure causes suppuration. The suppurative inflammation is always surrounded more or less with the adhesive or ossific inflammation, therefore in these cases the callus is usually larger than in simple fractures, and larger than the granulations extend; the ossific inflammation extending into the soft parts increase it. Compound fractures in general do

better than large exposed joints. In these, as in joint cases, the adhesive inflammation does little

mischief to the constitution; it is the su purative which destroys the patients, when they do not go on well. The cause of the suppuration doing so much mischief in these cases, is the great extent of exposed surfaces, which, if all were apparent, would frequently be larger than the largest stump.

In amputations, the mischief done to the con stitution arises more from the size of the ampu tated part, than the extent of the wound; there

fore we have not so much injury done to the constitution in amputations of the breast, or a large wound on the buttock, as in amputation of the thigh, when the surface of the wound is equally large in both. The removing a large por tion of the body gives a great shock to the con stitution.

Rickets.

This disease is a defect in the formation of bones. The fault may be in the constitution, or from a wrong principle of action in the bones. Perhaps particular constitutions are subject to this disease, for it appears to arise from a particular kind of weakness. T'his seems probable, for we frequently see patients weakened to a great degree, and it does not produce this disease.

There seems to be a want of power to form cal careous earth, for these bones are always soft. The extremities of the bones are very much enlarged, and all those which are of a spongy texture natu rally. From the bones growing so large, it appears as if the calcareous earth in bone checked its growth. A perfect bone should have a certain proportion of calcareous earth and animal matter. In these cases there is not the proper proportion of calcareous earth. Adults may have the same disposition to this disease as young subjects, and their bones may become soft, which sometimes happens; but they will not grow larger, for when the growth of a part is completed it will not grow again, although changes may happen to it.

The disease may arise from the same disposition in both the young and adult subject: which is, perhaps, a want of dispositionto deposit calcareous earth. It may be accounted for by the ossific

matter not being deposited in proper quantities, while the absorbents are removing it as usual, by which means the bones are deprived of their cal careous earth.

From this account the rickets may be defined, a softness of the bones caused by a deficiency of calcareous earth, with an increase of their animal part.

The pressure on the bones, from the weight of the body, wil produce great distortion, which is frequently seen in the spine. The action of mus cles will likewise cause distortion, as seen in the legs; therefore we never see the tibia bent back

wards; the weight of the body will likewise assist in bending the bone. The os humeri is often bent forward by the action of the triceps extensor cubiti.

Knocked-knees are caused by the femurs bear ing on the tibia in an oblique direction, which

makes them give way when the bones are weak, the pressure being continually inward. Bow legged people are generally stronger than others,

which is owing to their joints being straighter, the femurs in them bearing more perpendicularly on the tibiae, than in those whose tibie are upright.

The cure for the rickets consists in strengthening the constitution, which will be best effected by giving the bark, sea-bathing, cold-bath, exercise, and perhaps steel.

Exostosis.

This disease may be divided into two species, the local and the constitutional.

The bony tumor does not arise from the ossific

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HUNTER'S LECTURES ON PH4YSIOLOGY AND SURGERY. 4i9

inflammation, extending into the soft parts and ossifying them, nor from granulations becoming ossified, but it is a luxuriant disposition in one part of the bone to increase, growing out as the hoofs or horns of animals. The tumor arises sometimes suddenly, and is of various shapes. It is generally from the soft ends of the bones that it grows: from their size and situation, they some times obstruct the action of muscles and motion of joints. Sometimes there is only one, appearing to be a local disposition in the bone to form the tumor. In some people they are so numerous, that it appears to be from disease of the constitu tion. Probably they are of rickety habits. Some times they may be removed with success, not afterwards returning. They are generally so soft that they may be pinched off. I performed the operation on a young gentleman, who had this kind of tumor under the deltoid muscle, near the head of the bone; it was pinched off with a large pair of pincers, which is in general a more con venient instrument than a saw, because the latter cannot be well carried between the muscles down to the bone.

Fractured patella.

The fracture of this bone differs in several cir cumstances from every other bone. It is some times united by callus, and at other times by tendinous and ligamentous substance.

This fracture partakes both of the simple and compound; perhaps more of the last than the first, but this will greatly depend on the manner of treatment. If the bones are brought in contact, they may unite as a simple fracture; but if they are separate from each other, then the extravasated fluids will run into the joint, and leave the bones in the state of a compound fracture, except their not being exposed. WXhen the fractured pieces of bone are kept at a distance from each other, they unite by a ligamentous substance instead of callus. It is well the union is such, for if it was by bone, its length would be very inconvenient in motion, and from its projection would be very subject to fracture.

In what manner callus is formed between the broken pieces of a fractured patella is difficult to conceive; it cannot be as in a simple fracture, for the extravasated fluids are lost. In these cases, the joint may usually be felt distended with extra vasated fluids. The union is not probably per formed by granulations; for it is not knowvn that parts will granulate without exposure.

I conceive that the union may be performed by the coagulable lymph becoming extravasated from the fractuired pieces, and coagulating the moment it is extravasated. This lymph then becoming vascular, may perform the union as with blood. The union, however, (where the bones are at a distance,) must, I think, be formed in a manner somewhat like granulations, but I never have been able to see these parts at the time they were forming.

It was the l)ractice, thiirty years ago, not to bring tlle pieces of a fractured l)atella in contact, from an idea that the callus would form a ridge on the

inside, and impede the action of the joint. Such

a bony ridge may be formned, if the bones are kept long inactive; but if the joint is soon and fre quently moved, it will be prevented, a slight de gree of pressure being sufficient. In fractures of the ribs, the luxuriance of callus never projects into the chest; the )ressure of the lungs from their action prevents it. The motion of the limb should be passive, that is, performed by the hand, and not the action of the muscles; it should be slight, and performed with great caution. When the union is performed by a ligamentous substance, the ossific disposition never extends far into it; if it did, the patella would be too long, and unfit to admit of free motion in the joint.

'The union by ligamentous substance is very tedious, and it is usually very long before there is a l)erfect motion of the joint. The time required for the union of the bones by ligament, will be in proportion to their distance of separation.

The following case shows the connexion between

the mind and the living principle. The will in

fluences the nerves, and the muscles, though in

capable of acting by that stimulus at first, gradually

acquire the power of action. The living principle

being stimulated, gradually produces the new

power in the muscles, whereas if it was not stimu

lated, it never would produce such a power. In this case the bones had been left to them

selves after the accident, and had retired to a con

siderable distance, about four inches from their

natural situation; the divided pieces united, but

the patient had not the least power of extending

her leg five or six yearE after the accident; the

muscles had not acquired any new action. She

was directed to sit on a high chair with her legs bent, and to endeavour to move her leg forward;

at first she could not produce the least motion, nor

after many attempts; however, after a number of

attempts, a slight degree of motion was produced, and by degrees she was able to perform the com

plete extension of her legs. It was a month before

any motion at all was produced. The action being

acquired, then it was necessary to increase the

strength of the muscles, which was accomplished

by attempting to raise herself from a chair, by the

action of the extensor muscles alone. It was

three years before the action and strength of the

muscles were perfectly acquired, at the end of

which she walked very well.

Bandages are frequently applied to give strength

to a part, but strength will be sooner acquired without them. Mlechanical action can never give

strengtlh to a part, wvlere it is to be acquired by

action produced by itself. Mechanical action, by retarding the living action, wvill prevent instead of

assist the strengtlh of the )art. Bandages in such

cases are tlherefore hurtfuil; they give the idea of

strength from the part feeling firlme;r with

stengthening plaster it is the samne.

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