A SUGGESTION FOR THE PREVENTION OF
OSTEO-MYELIT1S. Ey
Db. Cheveks.
Cannot we, in amputation, find divided end
covering of Periosteum for the of the lone ?
a
Some thirty years ago, I dissected, at Guy's, a stump which lias, on many subsequent occasions, afforded me a good deal of interesting thought. As a general rule, the soft parts, after amputation in the continuity of a bone, appear to be gifted with the power of healing kindly over the divided cancellated structure. When, in exceptional cases, this does not occur, tlie result is disintegrative suppuration, ending in necrosis, chiefly involving the cancellated structure of the divided bone. This destructive form of inflammation has the still
unex-
plained power of extending upwards to the cancelli of the bone beyond the next joint, as from humerus to scapula. I am not aware that, in any given outbreak of osteo-myelitis, we have any certain power of arresting the infection, still I think that there is a conservative expedient to 'which we might always have recourse, and which deserves trial, on physiological grounds, whenever osteo-myelitis prevails. Further I am strongly disposed to believe that, although it appears to be a retrogressive measure, the following provision could be made, with great advantage, in the majority of amputations. In the case to which I refer, amputation had been made at the The parts were greatly wasted. Anteupper third of the leg. riorly, there was a deficiency of integument, and the posterior flap was integumentary. The operator hid not sawed off the sharp anterior edge of the tibia. Ibis edge of bone was perfectly uncovered, but it was still living. Above, to th extant of about half an inch, and underneath, to nearly the same distance, the soft parts had receded from the tibia, leaving a outjutting right angle of denuded bone; still, although tho soft parts had thus receded, or probably sloughed, from its sharp edge, they had in no way deserted the tibia. Appearing to have considered that the flaps could not heal over a bony edge of such extreme sharpness, the soft parts had actively undertaken the ta^k of removing this troublesome angle. Above, in a semilunar line across the spine of tho tibia, and below, in a similar line crossing the cancelli and the cut edges of the bone, there extended, along the margins of the remains of the anterior and posterior flap, fringes of granulations. This upper and lower row of granulations not. only surrounded the exposed edge of bone, but had buried themselves in the osseous structure, and had grooved it so deeply as to render it evident that, had the patient lived a little longer, the two lines of granulations would have thrown off the angle of bone (closing upon it precisely as the cutting edges of a pair of bone pliers would do) and would then, doubtless, have met one another and thus closed the stump. Place the knuckle of one bent index linger between the index and middle fingers of the other hand, then bring the points of the two latter fingers together, and you will see the manner in which the two lines of granulations isolated the angle of bone. 1
On most careful dissection, I found that the upper line or of bone-excavating granulation was a process into which the retracted edge of [he periosteum had expande 1 it-elf; and that tho lower granulating line was, in a si nilar
lip
precisely flap. periosteum was found
manner, produced by the fascia of the integumental Above its upper granulating line,.tho
quite healthy and firmly attached
to tho front of the tibia
November 1, its
Behind
periosteum,
lino was
1S75.]
A MIRROR OF HOSPITAL PRACTICE.
of granulations tlie fascia, equally closely adherent to
now
the
acting
as
cancellated
struct ure. These two very analogous structures were thus found equally co-operating in a salutary work which, natural as it appears to the periosteum, could scarcely be expected from the fascia. When Aston Key first promulgated the doctrine that, in strumous arthritis, vascular granulation-like productions from the synovial membrane advance upon the articular cartilage, erode it in grooves, and so remove it, I paid close practical Attention to the subject, and convinced myself and (pace MrBryant) have always remained satisfied of the truth of his observations, largely confirmed as they are by what we observe in the processes of caries and necrosis. In this stump, a perfectly analogous process was employed by nature for the removal of the offending bone. My father was a naval surgeon who amputated in the battles of the First of June and Trafalgar, and on many other occasions.
He
was an
insatiable reader, and had
a
most extensive
knowledge of the professional history of his service over a period of forty years. I wrote my paper upon the causes of death after operations in London Hospitals in his presence. I knew all that he knew about amputation. He feared tetanus and that malignant ulcer, which attacked all wounds in the scorbutic [some of his experience of this terrible disease is given at p. 488, Yol. 3 of Trotter's Medicina Nautica]; but I am
confident that he had never
which
term
seen
or
heard of the condition
osteo-myelitis. In his time, allflaps were integumentary. I venture to think that the above facts, proving as they do that fascia can perform the part of periosteum, plead for the re-adoption of integumental flaps, especially during the prevalence of osteo-myelitis and septicajmia. we now
295
OSTEO-MYELIT1S. Ey
Db. Cheveks.
Cannot we, in amputation, find divided end
covering of Periosteum for the of the lone ?
a
Some thirty years ago, I dissected, at Guy's, a stump which lias, on many subsequent occasions, afforded me a good deal of interesting thought. As a general rule, the soft parts, after amputation in the continuity of a bone, appear to be gifted with the power of healing kindly over the divided cancellated structure. When, in exceptional cases, this does not occur, tlie result is disintegrative suppuration, ending in necrosis, chiefly involving the cancellated structure of the divided bone. This destructive form of inflammation has the still
unex-
plained power of extending upwards to the cancelli of the bone beyond the next joint, as from humerus to scapula. I am not aware that, in any given outbreak of osteo-myelitis, we have any certain power of arresting the infection, still I think that there is a conservative expedient to 'which we might always have recourse, and which deserves trial, on physiological grounds, whenever osteo-myelitis prevails. Further I am strongly disposed to believe that, although it appears to be a retrogressive measure, the following provision could be made, with great advantage, in the majority of amputations. In the case to which I refer, amputation had been made at the The parts were greatly wasted. Anteupper third of the leg. riorly, there was a deficiency of integument, and the posterior flap was integumentary. The operator hid not sawed off the sharp anterior edge of the tibia. Ibis edge of bone was perfectly uncovered, but it was still living. Above, to th extant of about half an inch, and underneath, to nearly the same distance, the soft parts had receded from the tibia, leaving a outjutting right angle of denuded bone; still, although tho soft parts had thus receded, or probably sloughed, from its sharp edge, they had in no way deserted the tibia. Appearing to have considered that the flaps could not heal over a bony edge of such extreme sharpness, the soft parts had actively undertaken the ta^k of removing this troublesome angle. Above, in a semilunar line across the spine of tho tibia, and below, in a similar line crossing the cancelli and the cut edges of the bone, there extended, along the margins of the remains of the anterior and posterior flap, fringes of granulations. This upper and lower row of granulations not. only surrounded the exposed edge of bone, but had buried themselves in the osseous structure, and had grooved it so deeply as to render it evident that, had the patient lived a little longer, the two lines of granulations would have thrown off the angle of bone (closing upon it precisely as the cutting edges of a pair of bone pliers would do) and would then, doubtless, have met one another and thus closed the stump. Place the knuckle of one bent index linger between the index and middle fingers of the other hand, then bring the points of the two latter fingers together, and you will see the manner in which the two lines of granulations isolated the angle of bone. 1
On most careful dissection, I found that the upper line or of bone-excavating granulation was a process into which the retracted edge of [he periosteum had expande 1 it-elf; and that tho lower granulating line was, in a si nilar
lip
precisely flap. periosteum was found
manner, produced by the fascia of the integumental Above its upper granulating line,.tho
quite healthy and firmly attached
to tho front of the tibia
November 1, its
Behind
periosteum,
lino was
1S75.]
A MIRROR OF HOSPITAL PRACTICE.
of granulations tlie fascia, equally closely adherent to
now
the
acting
as
cancellated
struct ure. These two very analogous structures were thus found equally co-operating in a salutary work which, natural as it appears to the periosteum, could scarcely be expected from the fascia. When Aston Key first promulgated the doctrine that, in strumous arthritis, vascular granulation-like productions from the synovial membrane advance upon the articular cartilage, erode it in grooves, and so remove it, I paid close practical Attention to the subject, and convinced myself and (pace MrBryant) have always remained satisfied of the truth of his observations, largely confirmed as they are by what we observe in the processes of caries and necrosis. In this stump, a perfectly analogous process was employed by nature for the removal of the offending bone. My father was a naval surgeon who amputated in the battles of the First of June and Trafalgar, and on many other occasions.
He
was an
insatiable reader, and had
a
most extensive
knowledge of the professional history of his service over a period of forty years. I wrote my paper upon the causes of death after operations in London Hospitals in his presence. I knew all that he knew about amputation. He feared tetanus and that malignant ulcer, which attacked all wounds in the scorbutic [some of his experience of this terrible disease is given at p. 488, Yol. 3 of Trotter's Medicina Nautica]; but I am
confident that he had never
which
term
seen
or
heard of the condition
osteo-myelitis. In his time, allflaps were integumentary. I venture to think that the above facts, proving as they do that fascia can perform the part of periosteum, plead for the re-adoption of integumental flaps, especially during the prevalence of osteo-myelitis and septicajmia. we now
295
