some cases, however, the ulcers closed up for a few days, and then burst out again. If in this state of the disease, a probe is passed carefully into the little orifice of the ulcer, it usually enters readily, into the cavity of the Tibia, where the loose piece or pieces of exfoliated bone are frequently to be felt. Under these circumstances, I have never known a perfect cure to take place, unless where the appropriate treatment had been resorted to,

"In this disease, the surface of the Tibia, immediately around the orifice, becomes often, though not always, knotty and irregular, and the periosteum is sometimes thickened, so as to give an appearance, resembling that of a venereal node. This disease, however, differs totally from those affections of the Tibia produced by syphilis, as it does like wise from those usually denominated necrosis, or from any of those which are produced by scrophula. In short, as far as I have been able to observe, it is a disease sui generis, the relic of fever usually affecting "the Tibia,t

"From the violence of the pain, and sudden erosion of the bone, an inflammation appears to attack its internal part. Suppuration takes place, and matter is first formed there, and then makes its way through the substance of the bone, to the outer integuments.-As, however, the ulcerative process in the bone sometimes takes place in different parts, thereby producing several apertures in the Tibia, matter is, in these cases probably, formed in distinct places, previous to the ulcerations in the bone. One of the most remarkable circumstances attending these cases is, that one or more pieces of loose bone are usually found within the cavity of the Tibia, opposite to each aperture.

"Some of these exfoliations are so small and thin, as to require a nice examination with the probe, in order to discover them. They are, however, generally found of a larger size, sometimes even exceeding an inch in length. I have always found these exfoliations of an oblong and spiral shape, and evidently separated from the internal laminæ of the Tibia within the cavity of the bone. The separation of such a portion of bone is probably the effect of the previous inflammation and ulceration; by which it is deprived of circulation, and of course loses its connection with the living bone, of which it was once a part."

the

Having enquired into the probable cause of this disease, and passed through the various appearances it assumes, author proceeds to describe the curative process.

"During the painful and inflammatory state of the disease, and be fore the erosion of the bone has taken place, it would be proper to apply emollient fomentations and poultices to the limb: to keep the patient in bed; and to endeavour to ease the pain, by occasional doses of opium. I must confess, however, that I have seldom seen the disease in this stage. I have commonly been applied to, after the erosion of

* In one or two cases, I have perceived this orifice so small, as not to admit the round end of a probe, of the usual size. In a few other cases, it has been so oblique, as to be entered with much difficulty by that instrument.

I have some recollection of having, many years ago, seen this disease in the Fibula; but in that case, the Tibia was likewise affected.

the

the bone has taken place, and when the patient has been, in some measure, able to follow his usual employment. In this stage of the disease the cure of the ulcer, by the common external remedies, is impossible, the loose piece or pieces of bone, pent up within the cavity of the bone, must set that mode of procedure at defiance. The imprisoned exfoliations, therefore, must be extracted, and this is desirable to be done, by the mildest methods possible; avoiding all unnecessary pain and operations to the patient.

"The loose bone within the cancelli, is commonly longer than the ulcerated aperture in the bone. It is in many cases, indeed, considerably longer, and though confined to its situation, it may sometimes be taken hold of by a pair of forceps, and moved upwards and downwards, in its bony case. The examination by the probe should, therefore, be made with great care and gentleness; otherwise, much unnecessary pain will be excited. It may happen also, that the exfoliated bone may be removed from the favourable situation it is in, when it is directly under the ulcerated aperture, and be pushed under the arch of the Tibia, as I have more than once experienced; by which the difficulty of extracting it must be greatly increased.

"As the orifice in the Tibia, as well as the exfoliations, are of different sizes in different cases, and as these are generally covered by the integuments and granulations, it requires a nice examination with the probe, to ascertain the true state of the parts. In some cases, as before observed, the aperture in the Tibia is so small, as not to admit the round end of the probe, to pass into the cavity of the bone, and the contrary end, or an eyed probe, will pass into it with so much difficulty, that no accurate examination of the parts beneath can be made. In most cases, however, it freely admits the round point of a probe; and our attention should first be directed, to find out the size of the aperture in the bone. Having ascertained this, we should next examine, whether there be a loose piece of bone within the cancelli. The size of the aperture may be known, by passing the probe, in a gentle manner, from side to side in all directions. But it is not so easy, either to find out the exfoliated piece, or to ascertain its exact dimensions, when discovered.

"Where the aperture in the Tibia is large, and the exfoliated piece very small, the latter may be moved about, with the end of the probe, so readily, as to leave no doubt of its easy extraction, by the introduction of a pair of fine forceps. Under such circumstances, the operation should be instantly performed; and if the whole be removed, the wound will generally heal up in the course of a few weeks: the application of any common dressing, aided by bandage, will be sufficient for the purpose. The utility, therefore, of first examining with great nicety, by the probe, in order to avoid, if possible, the use of more violent remedies, must be evident.

"In more difficult cases, the exfoliated piece may, likewise, be readily moved in the cavity of the bone, by the end of the probe; yet the hand of the operator will be sensible that it is confined, by the sides of the surrounding Tibia. In some cases of this kind, the opening in the Tibia may be large enough to admit of our taking hold of the exfoliation, by a pair of common forceps; but in others, it is so small, that,

a

a pair of the finest forceps that can be made, cannot be made to enter, so as to embrace the bone. When possible, we should endeavour to extract the exfoliated bone by the forceps; and in these attempts I have readily succeeded, when the exfoliation was not longer than the apertare in the Tibia. But where it proved to be of greater length, which might be known, by its being moved upwards and downwards in its bony case, by the forceps, but whence it was not possible to extract it; I have been sometimes able to accomplish the extraction, by moving it upwards or downwards, as far as it would go, and then raising one end of it. Where I could not succeed by this procedure, I have been sometimes obliged to resort to a more violent method, that of endeavouring to break the exfoliation into two parts, by means of the forceps. This I have been able to do, where it has not been very strong, and having thereby extracted it, the cure has been speedily completed.

"There are other cases, however, in which methods, very different from those, must be taken. We may have the strongest reasons for concluding, that there is a loose exfoliation, within the cancelli, and yet may not be able to feel it by the probe. In this case, as well as when the opening in the Tibia is too small, to admit an exfoliation to pass, by any of the methods above described, we must apply the kali purum to the integuments around the ulcerated opening in such a manner, and in such quantity, as to destroy them, to the extent of about half an inch from the centre of the opening. This is done with a view to expose as much of the surface of the Tibia, as is requisite for the cure.* proceeding, here recommended, is attended of course with some pain; and it requires particular attention, in order to prevent the kali from destroying more of the integuments than is necessary; and from penetrat ing through the orifice into the cancelli.

The

This caustic may be applied in several different ways. That which I prefer is, to take about as much of it (bruised into parts of the size of a pin's head) as will lie upon a seven shilling piece, and apply it, both to the ulcerated opening in the skin, and to the surrounding integuments, to the extent already mentioned. Pieces of dry lint, or adhesive plaister, should be applied around the caustic, to prevent it from extending on the adjoining skin. In a few minutes, the kali liquifies, and begins to operate.

tic

"The leg should be placed in a horizontal position; and if the causappear to act equally, the limb must remain in that position for about ten minutes, or a quarter of an hour; after which, a pledget of dry lint should be applied over the kali, large enough to cover the adjoining sound skin. The leg should then be slightly bandaged with a flannel roller.

"It is to be observed here, however, that during the action of the caustic, some additional attentions are not unfrequently required, in order to ascertain the depth to which it has penetrated. If in one part, the integument is thicker than in another, or if the caustic is acting more

*The orifice in the bone is situate so near to an angle of the Tibia, in some eases, that it does not admit of its being exposed, to the extent of half an inch, on all sides of it.

powerfully

powerfully on one part than on another, a little of it may be removed with the probe, to or from such part; or a little more fresh caustic may be applied to any particular part, if it appear to require it. During the action of the caustic, particular attention must be paid to its effect on the little ulcer on the skin, and on the orifice in the Tibia, as it is desirable to prevent its penetrating the cancelli, much harm and disturbance being likely to arise from its action on this part.

"If the integuments adjoining to the wound be thick, the kali may be applied to this part, nearly in the same quantity as to the other parts; as, in general, it ceases to act, before it can penetrate into the cancelli. But if the integument, on this part, be very thin; or if there be no integument or granulation over the ulcerated orifice, a small piece of lint should be passed down it to the cancelli, previous to the application of the kali, to prevent it penetrating too far: a piece about the size of a pea will generally be sufficient. This should be rolled with the finger and thumb, and firmly pressed down the orifice by a probe, till it passes into the cancelli; where it should remain. If this should not perfectly plug it up, a second, or even a third pledget should be applied. This is often attended with some pain, from the made on the granulated flesh, at the bottom of the wound, which generally springs from within the cancelli, and is exquisitely sensible. The kali should remain on the part to which it is applied, for about six hours. After this, the wound should be dressed twice a day, with some dry lint, and an emollient poultice. In about a week, or ten days, from the application of the caustic, the slough will come away.

pressure

"If the caustic have performed its office, the surface of the Tibia will be perfectly bare; and now the unequal, knotty state of the bone, and thickening of the periosteum, will often be seen; and if the granu lations on the surface of the orifice have been destroyed by it, the loose exfoliation within the Tibia will often be visible to the naked eye. But where the granulations are not destroyed, the internal exfoliation cannot be discovered without introducing the probe into the wound, as before directed.

"Sometimes the surface of the Tibia around the ulcerated aperture, will be found, on the separation of the slough, not to be sufficiently exposed.---In this case, a little of the kali must be applied a second time, to such parts as require it. This should be done in the course of a few days, otherwise the wound will begin to fill up with granulations. Though a repetition of the caustic is seldom attended with as much pain as accompanies the first application, it being seldom necessary to destroy a fresh portion of the skin; it should nevertheless be applied with all the precautions, recommended in the first instance; the like dangers being to be guarded against, on the subsequent application as on the first. It must be remembered, however, that a proper quantity should be applied, otherwise the surface of the bone will not be sufficiently exposed, when the new slough separats. When the second application has been properly conducted, we seldom have occasion for a third.

"The surface of the Tibia, with the aperture into its cavity, being thus exposed to view, we proceed to search for the loose exfoliation, if it be not already visible. The orifice in the Tibia must again be care

fully

fully examined by a probe, and as this examination can now be assisted with the eye, the size and situation of the exfoliated piece will for the most part be readily discovered. If indeed the granulations within the cavity of the bone shall not have been destroyed by the caustic, some impediment to the examination may arise from them, as they are in ge neral extremely sensible, and are apt to bleed, on the slightest touch of the probe. But as the exfoliated piece generally lies buried in these granulations, and is perfectly detached from the contiguous bone, it may frequently be discovered, by its yielding to the pressure of the probe.

"Its situation being discovered, and its size, compared with that of the aperture in the Tibia, pretty fairly ascertained, we must endeavour to extract it by the forceps; and sometimes we shall succeed, where the endeavours made, previous to the application of the caustic, have failed. The exfoliated bone, however, will often be found to be larger than the opening in the Tibia, in which case it will, in general, be impossible to extract it, till the orifice has been widened.

"If the trephine be used for this purpose, it may be sometimes difficult, though probably never impracticable, to remove the piece encir cled by the instrument after it has been worked to a proper depth. I remember to have succeeded many years ago by this method, in extracting a large piece of bone, pent up within the cancelli. The case to which I allude occurred to me when I was a very young practitioner, and has been already published. From the date of this operation, there has not occurred a single case in my practice, in which I have found it necessary to use the trephine. I have, for some years, practiced with great success a method of enlarging the opening in the Tibia, which is much more simple, as well as less painful. It is by means of the kali purum; and the way in which I use it is as follows: I apply this caustic to the bare surface of the Tibia, around the hole, and to the sides of the hole itself, after the separation of the slough; taking care to guard against its touching the adjoining parts, or penetrating into the cavity of the Tibia: each of which dangers may be prevented, by the application of the lint, as before directed. In about ten minutes after the application of the kali, the bone should be covered with a pledget of lint; and on the following day the kali should be again applied to all the parts, as before. After this the limb should be dressed twice every day with a fresh poultice; it should be light'y covered with a flannel roller, and the patient may be generally permitted to take moderate exercise. In a month or less from this period, an exfoliation of all that part of the bone, to which the caustic has been applied, will take place.* effect may be known by occasionally pressing a probe upon the surface of the bone. For when the intended extoliation is accomplished, the ex

This

* I have not known this exfoliation take place in less than three weeks from the application of the caustic, and it happens, not unfrequently, that it is not separated in less time than a month. The granulated flesh around it, therefore, generally covers this dead part of the bone before it is taken out. This, of course, obscures it from the view, but when loose, it is as readily extracted, with the loss only of a few drops of blood, as if it was perfectly exposed.

foliated