Surgical cases : with observations / by James Spence.

  • Spence, James, 1812-1882.
Date:
1854
Catalogue details

Licence: Public Domain Mark

Credit: Surgical cases : with observations / by James Spence. Source: Wellcome Collection.

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    iii it less amenable to treatment by removal of the sequestrum, than similar disease occurring in the shafts of bones. At first sight, this appears contrary to what we might expect, for whilst the looser texture of the cancellated structure would seem less likely to suffer from the pressure of abnormal congestion or exudation than the denser structure of the shaft, its larger amount of vascular supply would also lead us to expect not only a greater degree of vitality and power of resistance to disease, but likewise of reparative power after the sequestrum was removed. I think the unsatisfactory re¬ sult of operations for the removal of sequestra, and the recurrence of disease so frequently met with in such cases, are mainly attribut¬ able to a peculiar condition of the bone in patients of a scrofulous diathesis, predisposing it to disease, and rendering it less capable of reparative action. The condition I allude to is well seen in cases where amputation has been performed for disease of several of the tarsal bones. In such cases we generally find not only that parts of the diseased bones, but that other bones, not affected by positive disease, exhibit this tendency to degeneration. On making a sec¬ tion of such bones, we find the cancellated texture more opened out than usual, and filled with a peculiar lardaceous deposit or altered medulla; at other times by a deposit of cheesy or tubercular con¬ sistence, varying in colour from a white to a dark reddish brown. At other points, we often find the cancellated texture obliterated, and its place occupied by a dense hard structure, similar to what has been noticed in dental caries. Most generally, however, the bone is opened out and softened in texture ; whilst in most cases the outer fibrous lamella is attenuated to a mere shell, and often per¬ fectly diaphanous. When actual disease does occur in a texture so altered in struc¬ ture and impaired in vitality, its character must necessarily be of a low type, and with little tendency to repair. Hence if, under such circumstances, a portion of the cancellated structure be deprived of its vitality, and form a sequestrum, on its removal by operation, it does not leave behind it a healthy granulating surface, but a surface of bone affected by a weak form of ulceration. In fact, there seems little doubt that necrosis occurring in the spongy texture of bone, is, in the great majority of cases, the result of a form of interstitial caries, in which the ulcerative process has so isolated a portion of the cancellated texture, that it perishes—the original diseased con¬ dition still existing, to a greater or less degree, in the immediately surrounding parts. The section of the os calcis in L-’s case shows this condition in the bone surrounding the sequestrum at the heel, whilst more anteriorly and distinct from it, we have another carious cavity, showing the predisposition to disease. From this state of matters, we can readily understand how, after the removal of one seques¬ trum, other portions of the cancellated texture, after a time, perish from the continuance of the morbid action, necessitating further