With the Compliments of the Author. 
ADDRESS 
ON 
CERTAIN POINTS IN THE PATHOLOGY OP 
BONES, ESPECIALLY TUBERCLE. 
BY 
HENRY Ht SMITH, M.D., 
' 
PHILADELPHIA, PA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 105 JAYNE STREET. . 
1878. ADDRESS 
ON 
CERTAIN POINTS IN THE PATHOLOGY OF 
BONES, ESPECIALLY TUBERCLE. 
BY 
HENRY H. SMITH, M.D., 
PHILADELPHIA, PA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, Y05 JAYNE STREET. 
1818. ADDRESS ON SURGERY AND ANATOMY. 
THE PATHOLOGY OP THE BONES. 
Mr. President and Members of the 
American Medical Association:— 
In selecting a subject worthy of the consideration of this 
learned assembly, representing as it does, the erudition and ex- 
perience of the Medical profession in the United States, [ feel 
the responsibility of my position, and my inability to justly offer 
you any points for study, on which, many are not perhaps better 
informed than myself. 
Had I yielded to personal wishes, I should not have intruded 
myself on your time and attention; but as your Nominating Com- 
mittee and a vote of the Association have placed this duty upon 
me, I have sought to execute it to the best of my ability. 
As Chairman of the Section of Anatomy and Surgery, the By- 
laws require me to prepare and read, in the general session of 
the Association, a paper on the advances and discoveries in an- 
atomy and surgery, during the past year. 
At the close of their Report in 1877, the Nominating Commit- 
tee recommended a change in this By-law, suggesting “the 
preparation of an essay on some subject selected by the writer, 
in place of the former reports by chairmen ; the reading of such 
paper not to occupy more than forty minutes.” 
Without presuming to anticipate the action of the Association 
on this proposed change, and with sincere distrust in my power 
to do justice to an extended question, in so brief a period as that 
assigned it, I venture to ask your attention to a pathological sub- 
ject, which, whilst appropriate to the Section I represent, also 
presents points of interest to the entire profession. 4 
ADDRESS ON SURGERY AND ANATOMY. 
Billroth has justly said,1 that it is a happy advance in science, 
that there is no longer the same separation of surgery from 
medicine that formerly existed, and that there is in fact only an 
apparent distinction between them; the separation being arti- 
ficial, though founded on history and the large and ever increas- 
ing literature of general medicine. 
I trust, then, that in tendering you a few remarks on certain 
points in the Pathology of the Bones, especially Tubercles, 
I may be enabled to exhibit such physiological and pathological 
discoveries, as are pregnant with thought and may elicit useful, 
practical discussion. 
In our elementary studies some years since, we, as students, 
were taught to regard the skeleton as “the bony framework of 
the body, and that its function was to afford points for the at- 
tachment of muscles, to form the joints, and protect the viscera.” 
The Surgeon then considered the knowledge of this tissue as 
pertaining especially to his department, and to be limited to the 
study of the process of repair in injuries. Now, the bones have 
a more extended function assigned them, and are investigated 
microscopically, not only by the physiologist and anatomist, 
but, also, by the pathologist, as one of the sources from ivhich are 
furnished the white and red corpuscles of the blood, and through 
which is introduced into the system, a inateries morbi, that is 
closely connected with some of the most rapid and fatal disorders 
requiring the skill of the physician. 
At present, leukasmia, or leucocythemia, pyaemia, septicaemia, 
and similar dyscrasias, have, in the opinion of many, a direct 
origin in the perverted action of the myeloid cells and lining 
tissue of bones, and the investigation of the truth of this doctrine 
is one of the problems of the present time. 
In attempting to solve it, the examination of the elements 
found in the spongy tissue of bones, has become an essential 
point in a thorough autopsy; quite as much so as the examina- 
tion of the condition of the spleen, liver, or lungs has always 
been. Now, until the cancellated tissue of some of the bones 
has been chipped, or cut out by bone nippers, and made by com- 
pression to yield the liquid matter that fills its cells, to microscopic 
examination, or, it has been decalcified, colored, and then placed 
under the field of the microscope in a thin section, we shall not 
1 Billroth, American edition by Hackley. PATHOLOGY OF BONES. 
5 
be possessed of all the knowledge a thorough investigation ought 
to furnish in some cases of diseased action. 
It is especially to the German, Italian, and French physiolo- 
gists that we are indebted for our knowledge of this new function 
of bone, though our own countrymen have not neglected their 
suggestions, but in several instances have strengthened and con- 
firmed the views of their European co-laborers. 
It has been well said that physiology is the basis of all sound 
pathology, and as the disorders of the bones present only modifica- 
tions of, or departures from, the normal processes of growth and 
repair, their diseased condition must be constantly compared with 
the changes noted in the embryonic cells and functions.1 From 
special anatomy we learn that the cancellse of the spongy bones 
and the medullary canals of the long bones, communicate freely 
with the compact layer of bone, through the nutritious vessels 
and intei vening Haversian canals. Every bone, even those com- 
posing the vault of the cranium and the mastoid portion of the 
temporal bone, presents, therefore, a large system of anastomos- 
ing tubes and bloodvessels (Plate I, Figs. 1 and 3), the existence 
of which, as well as of lymphatics, has been proved by fine injec- 
tions by Bichat; by the numerous bleeding points seen when 
healthy bone is scraped, and by the passage of mercury through 
the lymphatic vessels accompanying the intercostal arteries from 
the ribs to the vertebras, as shown by Cruikshank,2 and admitted 
by Soemmering, Breschet, and others. It has also been demon- 
strated that the canaliculi and reticulated tissue of bone, the canals 
of Deutsch, and corpuscles of Purkinje are formed of threads or 
fillets, around which the bloodvessels, both arteries and veins, 
anatsomose in countless capillaries, it being estimated that every 
point of a bone is brought within T4<*th of an inch of a bloodves- 
sel.3 This minute distribution of bloodvessels in the cancellae of 
the bone bears thus a close resemblance in vascularity, to the 
arrangement of the air-cells and pulmonary vessels of the lungs, 
though of course not so readily traced owing to the presence of 
the salts of lime and the consequent induration of the tissue. 
In this medullary structure, which is so extremely delicate 
that it is compared by anatomists to an amorphous film, yet lines 
1 Cornil et Ranvier, Histologie Pathologiqne, Part 2, page 340. 
2 Anatomy of Absorbing Vessels, page 198. London, 1790. 
3 Horner: Special Anat., vol. i. p. 81, 1851. 6 
ADDRESS ON SURGERY AND ANATOMY. 
the diploe and cancellated tissue of every bone, modern physi- 
ologists have placed a focus for the origin and development of the white 
and red blood corpuscles, from which, as well as from those of the 
spleen and lymphatic glands, the elements of’the general circula- 
tion are being constantly renewed in health, or disturbed and 
vitiated in disease. 
In order to make this more apparent, reference is necessary to 
some of the recent views of the anatomical relations of the struc- 
ture involved in this new and important function. 
According to Strieker,1 the medulla of the fully developed 
long bones is composed of a delicate connective tissue, traversed 
by vessels, and containing numerous fat cells (yellow medulla), 
and has no osteogenic activity; but in the medullary spaces of the 
spongy or cancellated substance, there is found a reddish mass, 
traversed by numerous bloodvessels (red marrow), and present- 
ng few fat cells but a large number of granular cells, similar to 
those seen in embryonic medulla. Amoeboid movements also 
occur in these medullary cells, analogous to those seen in the 
colorless blood-cells. Large nucleated masses of protoplasm are 
also described by Robin as “ myeloplaxes,” and are most abun- 
dant in the external layer of the medulla that occupies the above 
cavities. These giant cells or myeloplaxes, proceed, as Bredi- 
chini thinks, “from the bone cells coincident with the absorption 
of the matrix, and are continuous with the formation of medul- 
lary canals during the growth of the bone. As the different sized 
medullary spaces of the bone are continuous with one another, 
so do the yellow and red medullae gradually pass into one an- 
other.” 
That the internal structure of bones, and especially the medul- 
lary cells of the red marrow exercise an influence upon the blood 
corpuscles through the myelitic cells, and are even believed to 
be the seat of the changes of leucocytes into red-corpuscles, has 
been much discussed. Among the most prominent of those en- 
gaged in such investigations have been Neuman and Bizzozero.2 
Neuman of Kdnigsberg, in 1869, in a paper with the title of “ The 
significance of the marrow of bones in the formation of blood,” 
having presented the two following propositions: IsL “That 
there takes place in the vessels of the bone-marrow, favored by 
a considerable retardation of the blood current, a transformation 
1 Manual of Histology, by Powers, Sydenham Society, 1870, p. 145. 
! Gazzetta Medica Italiana Lombardia, p. 381, et su/jra. 7 
PATHOLOGY OF BONES. 
of abundantly accumulated white corpuscles into red blood cor- 
puscles.” 2d. “That a continuous passage of the medullary cells 
into the vessels, contributes to tbe accumulation of white cells in 
the bloodvessels of the marrow.” 
He also found, besides colored nucleated cells, a remarkable 
number of lymph cells (leucocytes) in the marrow, and that there 
were intermediate forms between the white and the red cor- 
puscles, as well as other transitional forms that showed the trans- 
formation of the white blood corpuscles into the red nucleated 
cells, and indicated the change from these to the red non-nucle- 
ated cells.1 
Eales, of Leipsic, in 1870, obtained similar results in the in- 
vestigation of the marrow of young rabbits and the vascular red 
marrow of children, as well as in the spongy bones of adults.2 
Neuman, confirmed by Eales, describes the blood forming 
structure as a remarkably developed capillary network, and a 
special tissue contained in the meshes of this network he calls 
the “ medullary tissue,” the capillaries of which have this peculi- 
arity—that their calibre is, on an average, four times as great as 
that of the small arterial branches that immediately supply them; 
this sudden enlargement of the blood-channel causing consider- 
able delay, or diminution in the velocity of the blood. Within 
the vessels, especially at their wider part, he saw a great accu- 
mulation of the white cells as well as transitional forms in vari- 
able proportions, and these, he thinks, mark out this locality as 
the seat of the blood metamorphosis. The red form, or as Neu- 
man calls it, “ the lymphoid medullary tissue” around the vessels, 
are said “to bear a marked resemblance to the cytogenous con- 
nective tissue of Kolliker, or the adenoid tissue of Wilhelm His 
of Basle.” 
According to Neuman, the lymphoidal cells of the blood are 
also formed in the medullary tissue, and find their way into the 
vessels by a process of immigration similar to but the reverse 
of that of emigration, described by Cohnheim. Eales’s researches 
whilst confirming this change, also proved that similar modifica- 
tions of the corpuscles took place in the apophyses of the long 
bones, in the sternum, and in the diploe of the skull; thus estab- 
lishing the medulla of the bones as one of the sources of the 
elements of the blood. 
1 Newman, as quoted in tlie Philada. Med. Times, March 1, 1871, p. 250. 
* Ibid. 8 
ADDRESS ON SURGERY AND ANATOMY. 
The fact of the influence exercised by the medullary tissue of 
bones upon the blood, as ad vanced by Neuman, has been strength- 
ened by the observations of our own countrymen as well as by 
recent observations in Europe. In the United States, Dr. II. C. 
Hand, of St. Paul, Minnesota, has recognized1 the usual normal 
existence of leucocytes (or granular cells of °f an inch in 
diameter) in the red marrow of bones. As the myeloid cells of 
Virchow, and in the blood as its white corpuscles, or as the lym- 
phoid cells of Neuman, or as the pus corpuscle in oedematous 
connective tissue, these leucocytes he thinks occupy diverse 
positions and fill diverse functions in the economy both of health 
and disease. How the red blood corpuscles, that arise in the mar- 
row, find their way into the vessels, has been variously explained 
theoretically ; but Dr. Hand regards it as readily explainable by 
the description offered by Mr. Gray, viz., that in the blood-making 
marrow, the vascular walls lose themselves in the formation of 
lacunas, like the lacunae of the spleen, and hence the entrance 
from these lacunae into the vessel of the red corpuscles, is as easy 
as that of the white corpuscle. 
In a valuable paper, by Dr. Horatio C. Wood, of Philadelphia, 
on Leucocythemia and Pseudoleukaemia, he alludes2 to Neuman’s 
views, and the question is asked, “Is there any change in the 
marrow of bone at all peculiar to leucocythemia?” and after 
quoting Neuman’s case, in which the vascular network, as before 
described, and generally so richly developed in the medulla, was 
absent, he gives the result of an autopsy of a case of leucocy- 
themia in which the lumbar vertebrae, on section, were a bright 
carmine red ; contained various corpuscles, often not nucleated 
and granular, and the right and left femora presented in their 
medulla very little oil, very few red corpuscles, and an immense 
number of cells of y2ouT<j to 4oo<r an inch, the left tibia pre- 
senting a somewhat similar condition. Dr. Wood regards this as 
sufficient evidence that hyperplasia of the medullary cells is not 
improbable in scrofulosis, as well as in pyaemia. In another case 
the principal lesion was apparently the changes in the bone mar- 
row. To the dyscrasia accompanying this no name has yet been 
given, though “Haemic cachexia,” as suggested by Dr. Wood, may 
be appropriate. 
1 Philada. Med. Times, Feb. 1, 1872, p. 164. 
2 Am. Journal of Med. Scieuces, Oct. 1871, p. 378. PATHOLOGY OF BONES. 
9 
Dr. William Pepper, of Philadelphia, in a paper on “Progres- 
sive Pernicious Anaemia or Anaematosis,” also says: “It is proba- 
ble that the bone-marrow, is connected with the process of 
transformation which the blood globules undergo either in for- 
mation or destruction ; that there exists three forms of anaemia 
or leukaemia and pseudoleukaemia, viz., splenic, lymphatic, and 
medullary,” thus showing the important influence of this recently 
discovered function of the medulla of bones on the general con- 
dition of the blood, and the relative number of the red and white 
corpuscles. 
In an autopsy of a marked case he found “the marrow from 
the radius made up almost entirely of granular cells, round, or 
nearly so, varying in size from a diameter of gg'ijii to 2of an 
inch. A few of the cells were granular to a marked degree, and 
a smaller number contained a single drop of fat.” 
Orth,1 in describing the post-mortem examination of the bones 
of the thorax, also describes “the marrow of the sternum as of a 
red color, even in adult life, and as often presenting leukaemic, 
tubercular, and other changes identical with those found in the 
bones of the extremities.” But we are not limited to autopsies 
in proving the medullary changes in bones, as Paul Voigt ex- 
plored a diseased sternum in a case of medullary leukaemia, and 
found the bone very soft, yielding to the canula a blood-tinged 
mass which contained a quantity of large white corpuscles, simi- 
lar to those found in the blood; whilst red blood-corpuscles and 
oil drops were sparingly present.2 
In the Dublin Journal, December, 1877, a case of pernicious 
anaemia, ending in medullary leukaemia, is reported from the 
German journal, the Gentralblalt of the same year, in which “the 
medulla of the tibia was a drab-gray color, with solitary, large, 
liquid, purulent deposits, and smaller viscous and gelatinous 
spots, the latter being interspersed through the otherwise normal 
looking marrow ; large round cells, with purple-shaped nucleus, 
solitary lymph-corpuscles, and red blood corpuscles also being 
present. Charcot’s crystals were abundant, both in it and in the 
spleen. Hyperplasia of the medulla, the starting point of the per- 
nicious anaemia, here became the starting point of the leukaemia.” 
1 Pathological Anatomy, Am. edition (p. 105), 1878. 
2 London Med. Record, Aug. 15,1877, from Berlin Klenisch, Dec. 1876. Medul- 
lary Leukaemia, by Mosler. 10 
ADDRESS ON SURGERY AND ANATOMY. 
Dr. J. M. Purser, of Dublin, in a recent paper1 on “Progressive 
Pernicious Anaemia,” describes the post-mortem appearances, 
especially in connection with the medulla of the sternum, ribs, 
and lumbar vertebrae, in all of which it was of a soft consistence 
and reddish-brown color. The cancelli seemed larger and more 
numerous, and the bone trabeculi slighter and fewer than nor- 
mal; whilst the medulla in the left femur resembled that in the 
spongy bones. There were no traces of yellow marrow. The 
medulla seemed to consist of colored and colorless cells, with 
transitional forms of all sizes. Myeloplaxes were not met 
with. His description of the tissue, he says, coincided with that 
of Cbhnheim, viz., red color, and absence of fat. Similar ceils to 
those noted in the medulla were found in the liver and spleen; 
hence he concludes “that in pernicious anaemia there is probably 
an imperfect formation, and certainly an increased destruction of 
the red corpuscles, and that the products of this destruction pass 
off by the urine. This disordered action may be recognized be- 
fore death by examining microscopically a drop of blood from 
the linger, and by ophthalmoscopic examination of the fundus of 
the eye, where ecchymosis will sometimes be found.” In Mr. Pur- 
ser’s case, the bones of the cranium were dense and heavy, and 
the dura mater very closely adherent; but no account is specially 
given of the condition of the diploe. 
As the Spleen has been long known to exercise considerable 
influence on the number of the white corpuscles of the blood, 
we might readily suppose, that if the medullary tissue of the 
bones also possessed such action, there would be a reciprocal re- 
lation between the bones and the spleen, and that extirpation 
of the latter, would be followed by a change in the action of 
the medulla of bones and of the lymphatic glands as the other 
sources of leucocytes. This has been established by Mosler and 
Shindler, who, in April, 1871, found, that after extirpation of 
the spleen, or artificially produced atrophy of that organ, the 
medulla of bones for a long time subsequently underwent a 
marked change resembling leukaemia, the function of the lym- 
phatic glands also showing increased activity.2 
The Spleen being admitted to influence the constituent ele- 
ments of the blood in certain fevers, a similar action of the me- 
dullary tissue of bone, upon certain blood disorders, as erysipelas, 
1 Dublin Journal Medical Sciences, No. 71, 1S77, p. 405. 
* Centralblatt fur die Med. Wissenchaften, May 13, 1871, No. 9. PATHOLOGY OF BONES. 
11 
scarlet fever, etc., is not only indicated by the complaints of pa- 
tients in such expressions as “coldness; pain or aching in their 
bones:” or by popular names, as “break-bone fever;” but is 
also positively demonstrated by the most competent medical 
authorities. 
Recent observations even go further and show that the disor- 
dered action in both the spleen and bone-medulla, may be the 
cause and not the effect of perverted action of the elements of the 
blood; Friederiehs,1 of Heidelberg, not only recognizing the in- 
fluence of an enlarged spleen in diphtheria and facial erysipelas, 
but having also found a reciprocal action between the spleen and 
the general circulation ; the tumefaction of this organ preceding, 
by five days, the development of a typhoid fever ; whilst it dis- 
appeared as soon as health was restored. Of this, he cites the 
case of Dr. Yon who had not been previously in any way 
exposed to a cause likely to induce an enlarged spleen. 
Bearing in mind the close connection in function and the re- 
ciprocal action claimed by Mossier and Shindler, as existing 
between the spleen and the medulla of bones, we must also recog- 
nize the influence of the latter upon certain blood diseases, and 
admit as correct, the facts presented in the autopsies of leukaemia 
and pernicious anaemia before quoted. The well-known experi- 
ments of Hunter and Duhamel in coloring the bones of a young 
pig by feeding it on madder, the color being permanent for many 
months, also clearly prove the freedom of the circulation and the 
intimate reciprocal action of the bone-tissue and the general cir- 
culation. The rapidity with which food will thus color the 
bones was shown by Mr. Tomes,2 who found one day sufficient 
to tinge the entire skeleton; consequently, less than one day 
would suffice for disordered action in the myeloid cells, to seri- 
ously affect the constituents of the blood and develop disease. 
With these anatomical proofs of the intimate connection of the 
bone-cells and the blood, strengthened by several autopsies that 
establish the connection between the medullary tissue and the 
blood corpuscles, we can readily assent to the explanation now 
offered, why erysipelas, septicaemia, etc., so often ensue on opera- 
tions that involve the bones; as, in these cases, the blood-form- 
1 Acute Splenic Tumor, aud its Relatious to Infectious Diseases, Sydenham So- 
ciety, vol. 61, 1877. 
2 Todd and Bowman, p. 123. 12 
ADDRESS ON SURGERY AND ANATOMY. 
ing function of the myeloid cells is impaired by the injury and 
the cell action which furnishes the general circulation with 
healthy elements, is so modified as to induce diseased and albu- 
menoid blood ; the first evidence of which appears near or around 
the seat of injury. 
The knowledge of the influence of the myeloid tissue upon 
the general constituents of the blood, also presents an explana- 
tion of the curious result often noted after contusions and blows 
upon the head, of an apparently trifling character, but which are 
subsequently followed by abscess of the liver, or by serious nervous 
disturbance and pyaemia. Thus the diploe of the skull presents 
us in many cases with a remarkably well developed cancellated 
structure, traversed by the canals of Fleury1 and lined by deli- 
cate veins that anastomose freely with the scalp and empty into 
the large sinuses near the base of the cranium as well as into the 
emissaries of Santorini; communicating freely through the porosi- 
ties of the skull, with the superficial veins of the meninges of 
the brain (Plate I., Fig. 1). It is therefore easily understood, that, 
when a blow is sufficiently severe to induce congestion and ecchy- 
mosis in the diploe from a slight rupture of a vein, a clot forms: 
osteo-myelitis and phlebitis follow, and pus is soon thrown into 
the general circulation. Or, an increased number of leucocytes 
are produced and subsequently arrested in the lungs and liver as 
foci, that by retrograde metamorphosis develop the so-called me- 
tastatic abscesses. 
Morgagni alludes to the influence exercised by the vessels of 
the diploe, when injured by the concussion from a heavy blow 
on the head when he says,2 “ Ut vascula. quae inter tabulas me- 
dulla subserviunt rumpantur et sanguinem fundant.” 
Velpeau sustained the opinion that the bones were often the 
points from which purulent infection originated. 
Fayrer, of Calcutta, regards osteo-myelitis as one of the causes 
of pyaemia, and Holmes thinks pyaemia is often developed simul- 
taneously with osteo-myelitis; but, with our knowledge aug- 
mented by Neuman’s discoveries of the blood-producing function 
of the myeloid cells, we must regard the medullary tissue as the 
fans et origo of the diseased action excited by the blow. 
If this is admitted we may readily doubt whether the practice 
1 Horner’s Anatomy, vol. i, p. 170. 
2 De Sedibus et Causis, vol. i. PATHOLOGY OF BONES. 
13 
of modern surgeons, in neglecting the condition of the diploe, is as 
correct as those of a past century; many of whom are not spoken 
of reverently by the present age, because they recommended 
trephining and perforation of the diploe, in bone contusions. 
The present age is in truth too apt to be disrespectful to those 
of the centuries which preceded it; forgetting that the man of 
to-day is the same physically as the men of the time of the Pyra- 
mids, or earlier; and that similar injuries produce very much 
the same results now as then, requiring the same principles and 
treatment for their relief; the main difference between the cen- 
turies being noted rather in the means of treatment, than in 
the principles that directed their application. History, as exhib- 
ited in numerous treatises on anatomy and surgery, distinctly 
proves that the ancient surgeons fully recognized the influence 
of the diploe; thus Celsus speaks of “granulations arising 
from the diploe;” and Heister, when speaking of corruption 
of the cranium says, “The surgeon ought to bore several holes 
through the bone, as far as the diploe, with an awl or other in- 
strument;” evidently fearing congestion in this structure from 
falls or blows, where no fracture was created. In the “ Medici- 
nal Dictionary of all branches relating to Medicine,” bv Dr. R. 
James, published in three quarto volumes, in London, in 1745, 
under the article “OS,” and referring to Pyaemia as at present 
known, he says, “The pus in internal inflammation of a bone, 
being retained in a warm, close place (medullary canal) will be- 
come attenuated, acrid, and putrid, and as there is no means for 
its evacuation, troublesome symptoms will supervene, and as an 
incision can be safely made into the bone, it should be perforated 
to its cavity, that thus the corrupted sanies may be evacuated.” 
Recently, a similar practice has been advocated by Boeckel of 
Ghent, who insists on the advantages to be derived from trephin- 
ing any bone, and particularly those suffering from osteo-myelitis, 
after amputations. Too often, says he, “ when a patient who 
has suffered an amputation, is taken with a chill, we regard him as 
lost, and folding our arms give him some internal remedy, and 
when the autopsy proves the existence of osteo-myelitis, declare 
it is secondary and produced by pyaemia, whilst in reality it is 
the suppuration of the medulla which abandoned to itself, and 
not treated energetically (that is freely evacuated by numerous 
applications of the trephine), ends by infecting the blood.” 
When on post-mortem examination we are desirous of recog- 14 
ADDRESS ON SURGERY AND ANATOMY. 
nizing this now well-known disease in the diploe, we have an 
excellent characteristic appearance, suggestive of osteo-myelitis» 
as described by Orth,1 viz., “a greenish-yellow or slaty discolora- 
tion of the sawed edge of the diploe, which is so marked as to 
prevent its being lost sight of in the small amount of cancellated 
structure sometimes present in the bones of the skull.” On the 
other hand, the diploe may be fully developed or even hypertro- 
phied to a marked degree (Plate I., Fig. 2), this condition being 
necessarily accompanied with greater vascularity and larger sin- 
uses which, with the augmented cancellated tissue, must greatly 
modify the results of blows upon the skull, and the liability to 
blood-clot in the diploe. 
In resections, amputations, compound fractures, and similar 
injuries involving the bones of the extremities, the function of 
the myeloid tissue is also impaired, and the vital force of the 
cells being thus weakened, the leucocytes soon degenerate into 
the well-known pus-corpuscle or ichor, and septicaemia super- 
venes. 
As Virchow has shown2 that it is only a short step from mar- 
row to perfectly fluid tissue, and that the boundaries separating 
the medullary cells from pus cells cannot with certainty be de- 
fined, it is easy to comprehend the rapidity of the development 
of septicaemia after these operations, and the facility with which 
leucocytes and pus corpuscles may undergo retrograde metamor- 
phosis, and pass into the general circulation after the develop- 
ment of perverted cell action in the myeloid cells from any of 
the causes just stated. When the septicaemia chill has appeared, 
the necessity of perforating the medullary cavity, and evacuating 
the pus should be promptly considered. 
Another important result from suppuration in osteo-myelitis 
is seen when the modified nutrition of the epiphyseal cartilages 
of the young destroys the continuity of the diaphysis of the bone 
with its epiphysis; as when the epiphyseal head of the femur 
(Plate V., Fig. 4), separates from the neck of the bone in hip- 
disease, luxation of the femur or motion similar to that noted in 
false-joint, being subsequently induced by muscular action. But 
the extent of this portion of the subject precludes further refe- 
rence to it on this occasion, and I can only hope to stimulate 
some who have the opportunity to its further elucidation. 
1 Diagnosis in Pathological Auat., Am. ed., p. 51. N. Y. 1878. 
2 Cellular Pathology. PATHOLOGY OF BONES. 
15 
Allusion has been previously made to the effects of fever on 
the sensibility of the medullary tissue of bones and the relief 
offered to “ pain in the bones” (as noted in the cold stage of 
intermittent fever and some of the exanthemata), by surface fric- 
tion, the application of a tourniquet1 and other means of equal- 
izing the superficial and deeper seated circulation. Similar results, 
indicative of the close connection and reciprocal action of the 
skin and medullary tissue of bones, have been recently most posi- 
tively established in England, thus—Mr. Savory reports a case 
in which the exposure of a limb to sudden extremes of heat and 
cold, by plunging it into ice-cold or very warm water, caused 
acute osteo-myelitis, and Macnamara, of Westminster Hospital, 
cites2 the case of a boy in perfect health, who fell through the 
ice Dec. 20th, and on Feb. 15th suffered amputation at the knee- 
joint, in order to prevent further absorption by extension of evi- 
dent septicaemia. Dissection of the limb showed that the can- 
cellated tissue and medullary canal of the tibia were entirely 
destroyed, and that the outer shell (compact tissue) of the bone 
was more healthy than any other part; the myelitis being evi- 
dently not due to extension of inflammation from the periosteum 
to the medulla through the Haversian canals, as might naturally 
be supposed. 
The close relation of the circulation in the skin and that in 
the bones, is also exhibited in the valuable tables of Gibney of 
New York, hereafter referred to, where he cites3 rubeola, scar- 
latina, varicella, vaccinia, and variola, with their respective 
sequences, as causes of bone and joint disease : thus—of 209 cases 
of Spinal Caries investigated with reference to this point, he found 
rubeola the exciting cause in 18 cases, scarlatina in 4 cases, vac- 
cine in 3 cases, and in 106 cases of Hip Disease, the exanthemata 
were the exciting cause in 15. As Dr. Gibney does not refer to 
Neuman’s observations on the blood-making function of the 
myeloid cells, he makes no reference to the view, just expressed, 
that the diseased action in the medullary tissue of the vertebra 
might be a cause and precede the development of the exanthemata 
in these cases, and not the result; just as the enlarged spleen, 
quoted by Fredericks, preceded the development of typhoid 
1 Wood’s Practice of Medicine, vol. i. p. 240. 
2 London Lancet, May, 1877. 
3 N. Y. Med. Journal, vol. xxvi. No. 1, July, 1877, pp. 15, 18, 20. 16 
ADDRESS ON SURGERY AND ANATOMY. 
fever. In other words, the diseased condition of the blood as 
expressed by the skin eruption, might have originated in these 
cases in the disordered action of the bone cells, these being prima- 
rily disturbed and the general circulation subsequently affected. 
In analyzing the evidence thus presented by capable and care- 
ful observers in anatomy and physiology, we must admit that 
our present knowledge justifies our belief, 1st, in the probability 
of the cells of the medulla of bones, creating or influencing the 
creation of both the white and red blood corpuscles; 2d, that the 
medulla of the long bones and the cancellated tissue of the spongy 
bones present a loose connective tissue that readily develops pus; 
3d, that through its proliferation of cells and vascularity, the 
medullary membrane readily becomes congested, and develops 
the inflammatory process; 4th, that under congestion, there is 
increased sensibility or pain in the bones, as complained of in 
intermittent fever, erysipelas, scarlet fever, etc.; 5th, that the 
product of this inflammation, especially pus, which so readily 
forms in the medullary tissue, may rapidly enter the circulation 
and create a dyscrasia and so-called metastatic abscesses; lienee 
should be promptly evacuated; 6th, that the deficient action of 
the myeloid cells is closely connected with the development of 
leukaemia and pernicious anaemia; 7th, that “ Haemic cachexia,”1 in 
many points, closely corresponds with the condition known as 
scrofulosis, and that this condition or similar disordered nutrition 
of the myeloid tissue leads to and aids the development of tubercu- 
losis, and the retrograde action of tubercle in the bones. 
Let us next study the speeial development and course of Tuber- 
cles in the bones, a disorder which, though long recognized and 
described by European pathologists, especially Nichet and Ne- 
laton, has not been as systematically investigated in the United 
States; bearing in mind the fact that the general laws of tubercle 
are the same, no matter in what organ or tissue they appear, and 
that, consequently, a review of the doctrines at present held in 
reference to the production, characteristics, and progress of tuber- 
cles anywhere, will be the soundest basis for the consideration 
of their development and progress in the bones. 
The minute study of tubercle is one of such extent, that I do 
not propose to tax your patience with a full account of its micro- 
1 Wood’s Practice, vol. i. 251. PATHOLOGY OF BONES. 
17 
scopical characteristics; or the varied opinions held of its nature 
and origin. 
The question “What is tubercle, and whence does it come?” 
has been often propounded, and offers, in a condensed form, the 
whole subject, and though the opinions hereafter quoted, show 
great diversity of sentiment on these points, numerous recent 
investigations and the evidence they offer, have greatly contrib- 
uted to settle the question, viz., What is tubercle? Virchow 
describes1 tubercle as “the growth of single cells of connective 
tissue by the degenerative proliferation of single groups of con- 
nective tissue corpuscles.” In the formation of the higher forms 
of tubercle the new growth, he thinks, springs from the connec- 
tive tissues; but in graver cases the cell-growth is associated 
with the lining of the alveoli and of the lymphatics, which accom- 
pany the terminal bloodvessels. 
Wynne Foot, of Dublin, says,2 “tubercles are small-celled over- 
growths of lymphatic tissue (as in acute miliary tubercle), that 
have preserved such uniformity of size, color, and shape, as to 
have long since suggested the probability of their lymphatic 
origin.” 
D. J. Hamilton, of Edinburgh, says,3 “ to the naked eye tubercle, 
whether primary or secondary, forms a nodule the size of a pin’s 
head, elevated above the surface, sharply isolated from surround- 
ing tissue, and invariably of a rounded shape. Each nodule is 
composed of two or three or more ‘giant cell’ systems, and con- 
sists of masses of extremely granular protoplasm of a rounded 
or oval shape; frequently containing from ten to one hundred 
nuclei, and several nueleoles, in whose meshes lie cells of differ- 
ent kinds, each space of the reticulum generally containing a cell 
of one or the other variety, which are either epithelioid-leuco- 
cytes, or small giant cells; the whole system resembling very 
much the wonderful transformations seen in the amoeba,” the 
protoplasm being in his opinion endowed during life with similar 
powers of expansion and retraction. 
Rindfleisch4 says “we call tubercle (par excellence), singly and 
alone, a certain originally gray, translucent, very compact nodule, 
which is seldom larger than a millet-seed, but is found in many, 
1 Cellular Pathology, pp. 520 and 521. 
3 Dublin Journal, August, 1877. 
2 Edinburgh Med. Journal, p. 289, et supra, Oct. 1877. 
4 Path. Histology, translated by Kloman, etc. Philadelphia, 1872. 18 
ADDRESS ON SURGERY AND ANATOMY. 
nay! innumerable numbers together. Cheesy degeneration and 
miliary tuberculosis very commonly occur side by side, the in- 
troduction of the cheesy detritus into the juices of the individual, 
resulting in the occurrence of miliary tuberculosis, and it is, there- 
fore, a matter of indifference whether the cheesy material is trans- 
ferred by inoculation, or arises in the organism itself. The 
smallest portion of the cheesy detritus is a poison, which by 
direct irritation, causes the tuberculous new formation of certain 
constituents of the tissues. This much, he says, is certain, the 
formation of a tubercle is the expression of a commenced dys- 
crasia ; a corruption of the juices, which, in many cases, diffuses 
itself through the organism; in others is probably already con- 
genital.”1 
Hamilton, of Edinburgh, says,2 “the difference between the 
caseous or cheesy products of inflammation and true tubercle is 
the result of a retrograde process from the first in the caseous 
product; whilst tubercle becomes more highly organized instead 
of degenerating.” The cause of the formation of tubercles he 
regards as the “absorption of the cheesy debris, which passes 
along a lymphatic vessel, irritates its endothelium, and excites 
it to proliferation.” 
Hr. Rodenstein,3 of Yonkers, N. Y., maintains “the identity of 
the white blood-corpuscle with tubercle cells and regards tubercle 
as being caused by an extravasation of the leucocytes, an opinion 
originally stated by Addison in 1843, and more recently by 
W aldenburg.” 
As tubercles are usually developed along the course of blood- 
vessels, this, he thinks, is additional testimony to their origin 
from the blood. “As pus cells, leucocytes, and tubercle cells are 
identical, it is a special pathological cause which leads to the 
development of one or the other in any case.” Wilson Fox4 de- 
scribes tubercles as “an overgrowth, or hyperplasia of lymphatic 
tissue, resulting from irritation of the lymphatic elements.” 
From all these opinions we may justly conclude, that tubercles 
are formed from the blood through the action of the lymphatic 
vessels; or by emigration of white corpuscles from the blood- 
vessels, to the latter of which they are often found attached, and 
1 Op. cit. at page 124. 
2 Edinburgh Journal, October, 1877. 
8 New York Medical Journal, December, 1871. 
4 Fox, Transactions Path. Society, London, vol. xxiv. p. 382. PATHOLOGY OF BONES. 
19 
as lymphatics are a form of connective tissue, we can harmonize 
Virchow’s views with the others just quoted. Our previous in- 
vestigations having shown the existence of lymphatics and blood- 
vessels in the bones, as well as the functions of the myeloid cells 
and cancellated structure, I think it must be admitted that there 
is in the cells of the spongy bones and the medulla of the long 
bones, the proper tissue to serve as a nidus for the creation and 
rapid development of tubercles, and that their development and 
progress in the bones, rest upon the same general principles as 
their development and degeneration in the lung, viz., formation 
along lymphatics and bloodvessels; development as cells, and 
disintegration by fatty degeneration, liquefaction and softening; 
their development being at first induced by an inherited weak- 
ness of cell action, or a pre-existing inflammatory caseous deposit. 
The recent observations of Budge1 have also proved by minute 
injections of Berlin blue into the periosteum of the bones of the 
metatarsus of the cow and calf, “that injected peri-vascular lym- 
phatics surround the bloodvessels of the Haversian canals and 
that the bone lacunae or corpuscles, are directly connected with 
them by their canaliculi, the injection showing that the radicals 
of the lymphatics of bone, are identical with the bone-corpuscles ; 
lead by their canaliculi into the peri-vascular lymphatics of the 
Haversian canals and these empty themselves into the lymphatics 
of the periosteum,” thus developing in a minute manner the ex- 
istence and free anastomosis of bone lymphatics, around all the 
bloodvessels of bone, a fact originally noted nearly a century 
before by Cruikshank. 
What special causes tend to the development of tubercles in 
the bones ? 
We have noticed the influence of congestion of the medullary 
tissue of bone on its cell proliferation and the increase of its 
sensibility, as well as on the number of its leucocytes ; or, as 
Cornil and Banvier2 have said, “the formation of embryonic 
tissue in the medullary cavities.” We can, therefore, readily 
trace the analogy between these and the similar results of con- 
gestion in the parenchymatous structure of the lung; especially, 
the formation of tubercles from a pre-existing unhealthy in- 
flammation. 
1 Quarterly Journal of Microscopial Science, by Lancaster, London, Jan. 1878, 
p. 102, from the Archives. 
t Anat. Pathologiqne, p. 205. 20 
ADDRESS ON SURGERY AND ANATOMY. 
We have also seen that the defective elaboration of blood, or 
deficient ansematosis, as described by Pepper,1 was a result of 
perverted myeloid cell action, combined with disordered action 
in the lymphatic glands and spleen; and we may now ask, what 
is the difference between this defective angematosis and the con- 
dition long designated as Scrofula and what is the relation of 
scrofulosis to tuberculosis as in both instances the bones suffer. 
Pepper defines angematosis as “an affection of the blood-making 
tissues (spleen, lymphatic glands and marrow of bones) that causes 
defective elaboration of the blood; the changes in the blood 
consisting of a great reduction of its mass, with diminution in 
the relative proportion of the red globules, without increase in 
the white corpuscles; with probable changes in the vital pro- 
perties of both the red and white corpuscles.” 
Scrofula is very much the same condition ; but scrofula is 
unfortunately so imperfectly defined by writers, that it is dif- 
ficult to recognize it as a specific pathological condition. 
Dunglison2 gives the origin of the name as from scrofa — a 
sow—because swine were presumed to suffer from a similar com- 
plaint; that is, in modern terms, the patients exhibited hyper- 
plasia of the subcutaneous and other connective tissue cells, that 
caused swelling or thickening of the neck, like that of a hog. 
Raige Delorme,3 also ascribes the name to the resemblance of 
the knotted and swollen neck of those afflicted with scrofula, to 
the enlarged neck of the animal, and traces a similar explanation 
of the term to Hippocrates and Galen, all of which and innume- 
rable other explanations give no expression of a true and dis- 
tinct pathology. 
In the nomenclature of diseases issued by the London College 
of Physicians, scrofula is defined as “a constitutional disease, 
resulting either in the deposit of tubercle or in specific forms of 
inflammation or ulceration.”4 
Percival Pott nearly a century since, regarding only symptoms, 
defined scrofula5 “as an indisposition that occasioned a thick 
upper lip; a tedious ophthalmia; indurated glands in the neck 
and under the chin ; a hard dry cough ; obstructed mesentery ; 
1 Am. Journal, No. cxl., p. 342, October, 1875. 
2 Dictionary of Medical Science. 
8 Dictionnaire de Medecine, xxx tomes. 
4 Howard, Chronic Boue and Joint Disease, St. George’s Hospital Reports, vol. 
iv. 1869, p. 143. 
6 Cliirurgioal Works, vol. iii. London, 1783. PATHOLOGY OF BONES. 
21 
glairy swellings of the wrists and ankles; thickened ligaments 
of the joints and enlargement and caries of the bones, especially 
the vertebrae;” a description which is readily recognized even at 
present, as perfectly correct and in accordance with the extent of 
the pathological knowledge of his day and still admitted in ours. 
Owing probably to this want of a definite pathological description, 
as to what constitutes scrofula, a confusion of ideas has arisen ; 
some contending for a specific disorder which is the result of a 
cachexia termed scrofulosis ; others regarding scrofula as identical 
with tubercle, and scrofulosis, the same as tuberculosis, or the 
morbid state of the liquids—often congenital—which results in the 
formation of the growth called tubercle ; or as Virchow has said, 
“of a pitiful production or new formation, that is miserable from 
its outset.” It would be useless at present to attempt an extended 
account of this much vexed question, and I can only cite a few of 
the prominent pathological opinions published on this point. 
Wagner,1 in discussing the disordered conditions termed scrof- 
ulosis and tuberculosis, says “they are, by many, held to be 
identical ; by others, to be different; but more recent investiga- 
tions have shown, that there is no histological distinction between 
tuberculosis and scrofulosis; that scrofulous children become 
tuberculous, and that scrofulous new formations resemble the 
tuberculous not only of themselves, but, also, in their most fre- 
quent metamorphoses—cheesy transformation or simple atrophy.” 
Foot2 says, “the two characteristics of tubercle and scrofula are, 
a tendency to chronic thick suppurations and irritability of the 
system of the lymphatic glands ” 
Rindfleisch remarks3 “that the characteristic sickliness of scro- 
fulous persons is especially shown by the easily induced inflam- 
mations of the mucous membrane that habitually disturb the 
lymphatic glands; either because the products of these inflamma- 
tions contain something abnormal, or, because the glands in such 
constitutions are unusually irritable; the real relationship be- 
tween scrofula and tuberculosis being the elaboration of a poison 
from the cheesy infiltration and from the suppuration, which, 
when absorbed, produces tubercle; the tubercle poison in most 
cases being manufactured by the patient himself.” 
1 Wagner, General Pathology, 1876, pp. 458-9. 
2 Dublin Journal, August, 1877. 
3 Ziemssen’s Cyclopaedia, vol. v. pp. 637 to 639. 22 
ADDRESS ON SURGERY AND ANATOMY. 
Hayward1 defines scrofula, for practical purposes, “ as a disease 
which manifests itself by a peculiar vulnerability and proneness 
of the subject to chronic inflammations of the mucous membranes 
and skin, lymphatic systems and bones: which inflammations are 
characterized by great pertinacity, and the products of which 
have a retrograde tendency.” He thinks “it is quite distinct 
from tuberculosis, as scrofulous inflammation (chronic) often 
exists for years without any tubercles being found in the subject, 
whilst innumerable cases of tubercle are met with without a sign 
of any such chronic inflammation.”2 
Without attempting the settlement of the varied opinions of 
such authorities, I would simply express my individual faith in 
the idea, that the disordered nutrition designated as scrofulosis, 
is due to the blood changes created by perverted cell action in 
the true blood forming structures before named ; that this is the 
result of an inherited or acquired weakness in the vital force of 
the tissue cells, and results in a condition similar to that described 
by Cohnheim, Wunderlich, and Wagner as “lymphatic pseudo- 
leukaemia,” or the “leukaemia mvelogenica” of Neuman, with or 
without splenic disorder, but frequently evincing perverted action 
in the cells of the myeloid tissue of bone. This is indicated by 
enlarged joints, diseased vertebrae, and arthritis coxae vel genu, 
and enlarged lymphatic glands; the latter being partially the 
origin of the defective anaematosis, subsequently noted. 
If the ancient term Scrofula is to be continued, as seems pro- 
bable, it should, I think, be simply regarded as expressing the 
external evidence of the pre-existing blood and cell disorder that 
results in imperfect nutrition and development of tissue ; this 
pre-existing condition being designated as Scrofulosis. 
Tuberculosis may or may not be connected with scrofulosis, 
and, according to Wagner,3 “ is a constitutional disorder, character- 
ized by tubercle, as previously described; in which the deposit 
or formation (tubercle) after long duration, passes into cheesy 
atrophy and early softening, rarelj'- appearing as a local affection. 
Its causes are partly hereditary and partly acquired, having been 
developed by insufficient food, bad dwellings, infection from a 
cheesy focus, the result of tuberculous inflammation, inoculation 
1 St. George’s Hospital Reports, 1869, vol. iv. p. 146. 
2 Ibid, p. 147. 
3 Manual of Pathology, translated by Van Duyn and Seguin, p. 444. PATHOLOGY OF BONES. 
23 
and the ingestion of tuberculous masses as food,” an example of 
which is found in the meat and milk of tuberculous animals, an 
interesting account of which was presented last year to this Asso- 
ciation, by our fellow-member, Dr. A. N. Bell of New York. 
Tubercle, when once formed in the bones, encroaches upon 
and occupies the place of the normal tissue in which it is devel- 
oped, the capillaries becoming gradually obliterated in the process 
of its growth, and no new vessels, such as are developed in 
healthy inflammation (or that which is reparative in its tendency) 
being formed. Wagner also asserts1 “ that the obliteration of the 
capillaries near the seat of tubercle is due to the enormous new 
formation of nuclei around them, as well as from the increase of 
nuclei in the walls of the vessels.” 
Tubercles in bone, as elsewhere, may terminate, according to 
Rokitanski’s well-known opinion, by withering, cretification or 
carnification, and caseous degeneration, softening or liquefaction; 
as well as by ulceration around its periphery; by which process 
an outlet is formed and the softened tubercle gotten rid of: or, 
“if the tuberculous mass remains inclosed or encysted, it under- 
goes desiccation and calcareous transformation ; the fatty matter 
is decomposed into oily acids, as crystallized stearic acid and 
cholesterine, in the form of rhomboidal plates, the calcareous granu- 
lations forming hard concretions that can remain indefinitely.”2 
In the bones, tubercle may thus be evacuated by perforation 
of the compact layer, through periostitis, ostitis, and ulceration 
of bone; or it may escape into a joint (Plate III. Figures 1, 2, 3, 
4) and develop intense acute arthritis and the subsequent evacua- 
tion of the joint tissues, by articular abscess. 
According to Nelaton, tubercles in the bones, as in other tis- 
sues, are seen as encysted (Plate IV. Fig. 3) and infiltrated (Plate 
II. Fig. 1), each of these undergoing the usual change from crude 
to softened tubercle; in the course of which it is accompanied by 
inflammatory thickening, or even destruction of the part involved 
in the deposit. 
In the long and thick bones, crude encysted tubercle is found 
in the cancellated tissue, where through inflammation of bone it 
creates a closed cavity (Plate IV. Fig. 3), the walls of which are 
lined by a membrane or cyst. 
1 Manual General Pathology, 1876, p. 450. 
2 Cornil aud Ranvier, p. 210. 24 
ADDRESS ON SURGERY AND ANATOMY. 
This cyst is soft and white on its internal face, but often pink 
on its outer surface from the presence of a vascular network, 
which increases in structure as the tubercle softens; in other 
words, there is vascular congestion of the cancellated tissue 
around the tuberculous mass. The osseous cavity thus created 
by tubercle, at first fits closely to the deposit, but enlarges with 
the progress and softening of the tubercle; becomes sinuous, 
sends out its sinuses in various directions, and terminates by vari- 
ous small openings (Plate III. Fig. 2) either on the periosteal sur- 
face of the bone, or into the articulation (Plate IV. Fig. 2). When 
evacuated, this tuberculous cavity heals very slowly, because the 
tubercles having pressed on the capillary vessels and displaced the 
medullary cells and cancellae, none of the embryonic cells remain 
to create new bone, and the adjacent tissues are slow in recover- 
ing the healthy circulation that is essential to their vital action in 
the process of repair. The cancellated tissue around a tubercular 
cavity is often indurated or solidified (Plate II. Fig. 2 and Plate 
IV. Fig. 1), and shows a reddish circle of one or two lines in thick- 
ness, due to congestion and increased local circulation, like that 
seen in an inflammatory focus of the soft tissues. As encysted tu- 
bercle increases, it tends towards the surface of the bone; the peri- 
osteum increases in vascularity, and soon a new ossification may 
develop; creating osteo-phyles, and sometimes alteration of shape, 
so that the head of the femur may be greatly changed, especially 
at the points where motion causes the greatest friction ot the ar- 
ticular surface (Plate III. Fig. 4). Sometimes the upper portion 
of the head of the femur appears perfectly flat (Plate III. Fig. 2), 
and the new shape is the result of fatty degeneration, softening of 
the bone corpuscles and the gradual attrition of the old bone;1 
aided by the creation of lactic acid, as a product of the arthritis, 
this acid favoring the solution and absorption of the carbonate 
and phosphate of lime in the bone-corpuscles. At other times, 
owing to interstitial deposit and erosion of the cartilages, the head 
of the femur or a portion of the acetabulum takes on a polish, 
like ivory (Plate IV. Fig 2), from the friction of the adjacent 
points and becomes eburnated; ora new ossification is established 
so as to serve as a barrier to the exit of the pus in its course to 
the surface of the limb (Plate III. Fig. 1). 
When encysted tubercle is seated in the bone, near to an ar- 
ticular surface, the articular cartilage being but slightly organ- 
1 Orth, op. citat., p. 40. PATHOLOGY OF BONES. 
25 
ized (Plate I. Fig. 4) soon loses its vitality from diminished blood 
supply; is eroded and destroyed by chondro-necrosis, and the tuber- 
culous pus may then pass directly into the cavity of the joint and 
develop acute tubercular arthritis (Plate III. Figs. 2, 3, and 4). 
This is one of the modes of the creation of arthritis coxae tubercu- 
losa, or so called hip-disease ; or arthritis genu, or white swelling, 
as usually named. One of the frequent results of this arthritis, 
is seen in the adhesions contracted by the head of the femur with 
the bottom of the acetabulum, so as to fill it up (Plate V. Fig. 1); 
or on the dorsum ilii, where after separation from the neck of the 
femur at the epiphyseal junction, it forms a false joint, the old 
acetabulum being gradually obliterated by hypertrophy of the 
cancellae around its margin (Plate Y. Fig. 4). 
In the Vertebrae, the inter-vertebral fibro-cartilages act like the 
articular cartilages of the joints; thus they lose their vitality 
from arrest of circulation ; are destroyed by erosion (chondritis) 
and ulcerate by the removal of a central piece, “ as if cut out by 
a punch.”1 The tuberculous pus then continues to extend its 
course through the cartilage, until by the destruction of the can- 
cellated structure of one or more adjacent vertebrae, a consider- 
able cavity is created at the expense of the bodies of the diseased 
bones, which, being then unable to sustain the vertical pressure, 
are crushed in the pus; which, with particles of tubercle and 
scales of molecularly necrosed bone, forms a pre-vertebral ab- 
scess by burrowing beneath the anterior vertebral ligament; 
escaping by the psoas or quadratus muscles by following the 
course of their respective sheaths. 
Once evacuated, the osseous cavity created in a vertebra by 
softened tubercle, unlike that seen in the lungs, may be healed 
and obliterated by the approximation of the surfaces of the adja- 
cent vertebrae, and the formation of bony spines (Plate YI. Figs. 2 
and 4), though always with more or less deformity of the spinal 
column from the projection of the spinous processes; whilst the 
cavity in the bone is obliterated by the gradual thickening, granu- 
lations, etc., of the cyst membrane; thus creating a partial repair 
of the surfaces from which the loss has occurred. This spon- 
taneous cure, by the cicatrization of tuberculous cavities in the 
bones, has been incontestably established by Nelaton. 
In the miliary or infiltrated tubercle of bones, the tubercles at 
first resemble small, gray granulations, being pinkish and par- 
1 N61aton, op. citat. 26 
ADDRESS ON SURGERY AND ANATOMY. 
tially transparent; constituting a deposit in the cells of the can- 
cellated tissue (Plate II. Fig. 1) analogous to that in which en- 
cephaloid deposits fill up the cells of connective tissue. After a 
varying period, these tubercles soften and are succeeded by a pu- 
rulent infiltration and an interstitial thickening of the bone struc- 
ture, like the thickening of the soft tissues around an abscess 
(Plate II. Fig. 2). 
This thickening around the bone cells, by obliterating the in- 
terstitial nutrient bloodvessels, induces necrosis of the infiltrated 
bone, which, owing to its minute plates or scales, is often desig- 
nated as caries, or more correctly as molecular necrosis (Plate VI. 
Figs. 2 and 3); though such a result may also be due to osteitis 
from other causes than tubercles. 
Whilst, however, admitting that true caries and tubercular 
molecular necrosis may exist simultaneously, yet Nelaton1 points 
out the distinction to be noted between the destruction of the 
cancellated tissue of bone caused by tubercle and that due to in- 
flammatory caries, in the following comparison: “The cellular 
tissue of bone when infiltrated by tubercle presents us with inter- 
stitial hypertrophy; increased density and absence of vascu- 
larity; whilst in caries there is expansion of the bone-cells (rare- 
faction); softening and increased vascularity. Caries always 
proceeds from the surface, to the interior of bone; whilst tubercle 
passes from the centre to the periphery ” (Plate VI. Fig. 2), a dis- 
tinction easily made on post mortem examination and the condi- 
tion commonly found in “Pott’s disease.” 
The mode in which the deposited tubercle creates destruction 
of the bodies of the vertebras and the adjacent inter-vertebral 
cartilage will be apparent from reference to the structure. 
In the child, the bodies of the vertebrae are imperfectly ossified 
and separated by cartilage from the processes; the latter being 
only fused to the bodies about the fourth year. 
The upper and lower faces of the bodies are also in the state of 
cartilage (Plate VI. Fig. 1), only being ossified about the fifteenth 
year; so that in early life, when the vertebral column is mace- 
rated, it is found that the bodies of the vertebrae appear as small 
rounded masses (Plate VI. Fig. 1), and that nearly one-half of the 
whole length of the spinal column is made up of cartilaginous epi- 
physes and inter-vertebral cartilages.2 In youth, the ridge or mar- 
1 Op. citat., p. 31. 
2 Horner’s Special Anatomy. PATHOLOGY OF BONES. 
27 
gin of the circumference of the superior and inferior faces of the 
bodies of the vertebrae is also an epiphysis (Plate YI. Pig. 1), 
and is not always fully ossified until adult age. The cancellated 
structure is fully developed in the bodies of the vertebrae, is 
very vascular, and presents veins which correspond with the 
diploic sinuses of the cranium, and are known as the sinuses of 
Breschet, who described them in 1819 (Plate I. Fig. 8). The 
inter-vertebral substance or cartilage, is formed mainly of con- 
centric lamellae, which are more abundant anteriorly than pos- 
teriorly, the fibres crossing in every direction and leaving inter- 
vals filled with a soft, pulpy substance, which in the centre is 
very soft (Plate VI. Fig. 1). This soft, pulpy mass is in a state 
of considerable compression and will rise up as a flat cone when a 
vertical section is made. This pulp is most abundant in early 
youth ; diminishes concussion of the brain in falls on the feet, and 
concussion of the bodies of the vertebrae through the ribs, from 
blows on the chest, the head of the rib being specially sustained 
by it. It is well known, that this condition of the cancellae of the 
bones of the young, exposes them especially to these disorders; 
thus Gibney, of New York, says,1 Age is a predisposing cause, 
and furnishes a table of 5461 cases of joint disease during thirteen 
years (1864 to 1877), in which 84J per cent., including the vertebrae, 
occurred prior to the fourteenth year. 
Orth also describes2 cheesy osteo-myelitis as occurring almost 
exclusively in children, the cancellated tissue being found filled 
with cheesy material, in the vicinity of which small tubercles 
may be plainly recognized. 
Tubercles being then once developed in the cancellated tissue 
of the body of a vertebra, create a cavity, with consequent loss 
of bone substance. This cavity increasing as the tubercular mass 
softens, the pus perforates the centre of the inter-vertebral carti- 
lage, and the body of a second vertebra becomes diseased. When 
the period arrives that the bodies of one or more vertebrae are 
reduced to a mere shell and unable longer to sustain the weight 
of the parts which they should support, they suddenly yield for- 
wards, the spinous processes project backwards at an angle, and 
we have the deformity of antero-posterior curvature; this result- 
ing from the mechanical force consequent on the vertical pressure 
on the bodies of the vertebrae and the inter-vertebral cartilage, by 
1 N. Y. Med. Journal, July, 1871, p. 9. 
2 Op. citat., p. 384. 28 
ADDRESS ON SURGERY AND ANATOMY. 
the weight of the head and upper extremities, as well as from the 
lesion induced by the flexion of the body, due to the weight of 
the thoracic and abdominal viscera, which we know are sustained 
by a healthy spine. The parietes of a tuberculous cavity in the 
body of a vertebra being approximated by flexion of the trunk, 
the tuberculous pus is forced out, the cyst becomes hypertro- 
phied and undergoes fibrous changes, the anterior vertebral liga- 
ment and the periosteum by periostitis ossificans throws out 
bony spines or osseous splints, and these tend to support the 
spine and make up for the lost bone through anchylosis of adja- 
cent vertebrae. (Plate VI. Fig. 4.) 
The creation of these bony spines and processes from the an- 
terior vertebral ligament and the periosteum, as well as the ver- 
tebral circular epiphyses, is also often seen in healthy men and 
animals that have been compelled in labor to sustain heavy 
burdens through the spinal column. 
There has been much discussion of the question whether the 
affection and loss of substance in the inter-vertebral cartilage was 
primary or secondary; but, from careful study, I have long main- 
tained the correctness of the opinion advanced by Nelaton, that 
the alteration of the inter-vertebral cartilage was consecutive to 
the destructive action in the bone. Anatomy also shows that the 
vitality of these cartilages is almost entirely due to the blood- 
vessels which reach their two faces after permeating the bone 
structure, and these vessels being previously compressed or 
obstructed by the tuberculous mass, the supply of blood to the 
cartilage is interrupted, it ulcerates in its centre, and subse- 
quently dies and is macerated in the pus; whence the odor which 
attends the evacuation of pus from diseased vertebra. The can- 
cellated structure of the body of a vertebra being also exceed- 
ingly vascular in childhood, and its cells filled with a carmine 
red substance which is extremely vascular, giving but little evi- 
dence of the grease or marrow seen in the short thick bones 
elsewhere, it appears to be specially prepared for tubercular 
formation. 
True miliary tubercles, according to Billroth,1 at first gray 
but susequently caseous, sometimes are developed in the vertebrae 
as the result of “ osteitis caseossef this being consequent on the 
caseous degeneration that follows inflammatory neoplasia; por- 
1 Billroth, Pathol., Am. edition, p. 420. 29 
PATHOLOGY OF BONES. 
tions of the necrosed bone, mixed with the cheesy pulp, filling 
the cavity so as only to be diagnosed when the caseous pulp is 
evacuated through an external opening. 
In the long bones we find tubercles most frequently developed 
in the epiphyses, as the head and condyles of the femur, or in 
the head of the tibia ; these bones in children—-like the vertebra— 
presenting a large amount of red cellular tissue or red marrow. 
The extremities of these bones are the usual seat of tubercle, 
though it is occasionally, though very rarely, also found as en- 
cysted tubercle, in the shaft. When tubercle is developed in the 
extremity of a long bone, it is generally situated in the centre of the 
spongy or cancellated tissue of the extremity, where the bone is 
expanded to form the joints. Usually, tubercles when here de- 
veloped, spread in every direction (Plates III. and IV.) tending 
towards the cavity of the joint as well as to the periphery of the 
bone just outside the articulating ligaments. 
If, in its progress, it reaches the surface of the bone outside 
the joint, it breaks into the adjoining connective tissue, an ab- 
scess forms, discharges, and leaves a fistulous canal with a tit-like 
orifice in the skin; the tuberculous cyst is obliterated by granu- 
lations, and a spontaneous cure, after a time supervenes. If on 
the contrary the tuberculous softening and suppuration enter 
the joint, either in consequence of the proximity of the joint or 
the growth of osseous lamellae consequent on the osteitis or peri- 
ostitis, preventing its escape outwardly, sudden and severe arthritis 
supervenes accompanied by grave general symptoms, and fol- 
lowed by disorganization of the articulation. (Plate V. Figs. 1, 2, 
i$.) Such results are of sufficiently frequent occurrence when 
tubercles run their course either in the head or condyles of the 
femur, inducing acute hip-disease or white swelling of the knee. 
Nffiaton relates such a case in which a child aged twelve, 
after complaining of the knee-joint, though able to execute many 
motions of the limb, suddenly complained of intense pain, which 
was followed by marked external redness, a swelling of the 
knee, and the formation and evacuation of an abscess, this dis- 
charging a liquid tuberculous pus, that eventually caused death. 
At the autopsy, Ndlaton found “the joint full of pus, with a cir- 
cular perforation in the cancellated tissue of the condyle of the 
femur at a corresponding point, and a globular cavity lined by a 
very vascular membrane, half a line in thickness. Around this 30 
ADDRESS ON SURGERY AND ANATOMY. 
perforation, the articular cartilage had not been materially 
changed, but it had lost its usual polish; whilst the synovial 
membrane presented all the evidences of arthritis.” In another 
patient he saw “tubercular perforation consequent on lobular 
pneumonia that followed measles, the sudden appearance of 
arthritis being taken for rheumatism.” 
In another case a coxo-femoral arthritis was announced by a 
sudden and violent pain in the hip, numerous abscesses super- 
vened, giving exit to a serous pus containing floceuli of tubercles, 
which, after a long period, was cured. 
In these varieties of the progress of tubercles in and near the 
joints, we can readily trace, says Nelaton, the resemblance in 
their course, to the perforations caused by tubercles in the lungs. 
In one case, “acute pleurisy is suddenly developed by tubercles 
softening and opening beneath the pleura; just as acute arthritis 
supervenes on tubercles opening into a joint; whilst in the peri- 
articular abscess created by tubercle we see a repetition of the 
process, by which, owing to adhesions forming between the 
pleura pulmonalis and costalis, the softened tubercle remains in 
the lung substance, and is evacuated through a bronchus.”1 
In the peri-articular tuberculous abscess, comparatively little 
injury is done to the articular surfaces and fair motion may 
remain. In the other instance, necrosis supervenes and adhesion 
of the articular faces, or anchylosis, is established. 
In reviewing now this portion of our subject, I think it will be 
admitted, 1st. That tubercles, either miliary or encysted, are closely 
connected with the lymphatics, or result from the “lymphangitis 
nodosa” of Rindfleisch, and may be formed by or developed 
through the lymphatic and capillary vessels found in the cancel- 
lated structure of the bodies of the vertebrae, in the epiphyses or ex- 
tremities of the long bones of both extremities, as well, as in the 
spongy bones of the wrist and ankle joints. 2d. That the de- 
development and progress of these tubercular deposits, whether 
preceding or consequent on “caseous osteitis interna,” is the same 
as in other tissues. 3d. That in all cases, tubercles arise in the 
vessels of the cancellated tissue of bone and not in the ligaments 
or articular cartilages; the ligaments or white desmoid tissue being 
sparingly supplied with bloodvessels and these chiefly capillaries. 
(Plate I. Fig. 4.) 4th. That the destruction of cartilages and liga- 
1 NSlaton, op. citat. PATHOLOGY OF BONES. 
31 
merits, especially the round ligament of the hip-joint, is the effect 
and not the cause of impaired nutrition, their supply of blood being 
chiefly derived from the adjacent bloodvessels in the bony struc- 
tures near them. 5th. That softened tubercles tend rather to 
intra-articular than periosteal or peri-articular evacuation. 6th. 
That in softening of tubercles, there is always congestion and 
inflammation of the bone-cells immediately around the seat of the 
deposit and that this results in more or less extensive molecular 
necrosis of the structure involved. 7th. That the perverted 
medullary cell-action, consequent on the formation of tubercle, 
reacts on the formative power of the myeloid cells and modifies 
the blood-corpuscles; thus proving that, when general tubercu- 
losis appears, or the constitution is invaded, it follows rather than 
precedes the bone disease. Lastly, that scrofula means the evi- 
dence of defective ansematosis or haemic cachexia, dependent in a 
great degree on disordered action in the myeloid cells. 
Now the practical lesson deducible from all this is, that we 
should “ hold fast to the landmarks of our forefathers” and ponder 
on the expressions of those who, like Franciscus Delaboe Silvius 
in 1695, held to the lymphoid origin of tubercle; or Portal, who, 
in 1809, expressed the opinion that tubercles were formed by 
engorgement of the lymphatic glands as well as by lymphatic 
swellings of the cellular tissues of the lungs; or Broussais, who 
regarded tubercles as the result of chronic inflammation of the 
pulmonary lymphatics;1 or of Percival Pott, who, nearly a cen- 
tury since, after a thorough investigation of the subject of 
scrofula in the bones, announced opinions the soundness of which 
has not yet been disproved, though greatly ignored by some 
surgeons of the present day. Speaking of antero-posterior curva- 
ture of the spine, Pott says,2 “ The true cause of this disease 
is a morbid state of the spine and some of the parts connected 
with it; which distempered condition will, upon careful inquiry, 
be always found to have preceded the deformity some length of 
time. In infants [children] this is the sole cause, and external 
violence has nothing to do with it. In the adult, I will not 
assert that external mischief is always and totally out of the 
question; but I will venture to affirm, what is equal, as far as 
1 Dublin Journal, 3d Series, No. lxvii. July 2, 1877, being lectures delivered 
by Arthur Wynne Foot, before the King and Queen’s College of Physiciaus in 
Ireland, February 19th and 26th, 1877. 
£ Chirurgical Works, London, 1783. 32 
ADDRESS ON SURGERY AND ANATOMY. 
regards the true nature of the case, which is. that although acci- 
dent and violence may in some few instances be allowed to have 
contributed to its more immediate appearance, yet the part in 
which it shows itself, must have been previously in a morbid 
state and thereby predisposed for the production of it, as no 
degree of violence whatever is capable of producing such an 
appearance (antero-posterior-curvature) unless the bodies of the 
vertebra were by a previous distemper disposed to give way.” 
When we thus note the opinions of one whose study of the 
disorder has been so universally recognized as to have attached 
his name to the complaint,1 and who wrote thus positively, in 
opposition to the Traumatists of his day, and when we recall the 
similar discussions of the subject within the last few years, we 
may exclaim with Ecclesiastes, “ surely there is nothing new 
under the sun that hath not already been in the old time.” If 
the experience of our fore-fathers in surgery is not to be entirely 
ignored; if pathological demonstrations have any prac.ical value; 
if the anatomical description of the growth and development of 
the spine is not a fiction—I think it is incontestably established 
that antero-posterior curvature of the spine is consequent on 
the destruction of the cancellated tissue of the bodies of one or 
more vertebras from a pre-existing caseous deposit that develops 
osteitis and ulceration of bone in the natural tendency to evacu- 
ation of softened tubercle. The opinions of Percival Pott have 
also been recently sustained by statistics, Gibney of New York, 
in an extended and valuable paper,2 showing that out of 860 
cases of joint disease including caries of the vertebrae, no cause 
such as a blow, fall, or other injury, could be ascertained in 483 
who were closely questioned, and in 107 cases of knee-joint 
disease not a single case was found with a clear record3 from 
scrofula. He therefore expresses the opinion4 that every case, 
supposed to be traumatic, was vulnerable by a predisposition and 
was simply induced by traumatism as the exciting cause. 
Billroth expresses a similar opinion when speaking of chronic 
inflammation of bone, which he says® “ is chiefly due to consti- 
tutional dyscrasial disease, and although injuries, blows, falls, etc. 
may be the exciting cause, the ultimate cause must lie in the 
injured part or the system at large, otherwise it would take the 
1 Malum Pottii. 
5 Ibid , August 1877, p. 130. 
2 New York Journal, July 1877, p. 6. 
4 Ibid., August 1877, p. 151. 
6 Surgical Pathology, by Haekley, 1871, p. 414. PATHOLOGY OF BONES. 
33 
course usual to traumatic inflammations and soon terminate”— 
thus repeating the surgical opinions of the preceding century, 
and strengthening the position of such modern surgeons as re- 
cognize a pre-existing cachexia in all cases supposed to be caused 
by injury; “ the injury being only the spark that lights up in 
the bone or joint, an inflammation of a destructive or unhealthy 
character, instead of one that was healthy or reparative in its ten- 
dencies.” 
It is an instructive instance of the tendency of “ history to re- 
peat itself,” to find the discussions of to-day—whether Pott’s 
disease originated in a local or constitutional cause—only a 
renewal of the ideas of a past century; whilst the treatment of 
antero-posterior curvature of the spine by Suspension, is but a 
repetition of a former practice. Nearly fifty years since, J. K. 
Mitchell, of Philadelphia, employed it, and the points to which 
swings were attached by him can yet be found in that city. 
Suspension,1 the principal and main portion of the apparatus for 
which is regarded as a modern discovery, was also recommended 
and published, with an illustration of the apparatus, by Francis 
Glisson, M.D., in London, in 1660, so that it is now more than 
two hundred years old. 
After describing the swathing bands, Glisson says:2 “it is a 
pleasure to see the child hanging pendulous in the air and moved 
to and fro by the spectators.” Though thus lauded at first, sub- 
sequent experience so slightly sustained its claims to confidence 
as a remedy, that it was forgotten, until recently revived as an 
improved mode of treatment. There is, however, another point 
of a practical character which was highly esteemed by the older 
surgeons in these complaints, that modern practice has too much 
ignored. I allude to the value of counter-irritants in deep-seated 
osteitis, especially of the caseous variety. In spine disease, Pott 
insisted3 on the advantages derivable from “a large discharge of 
matter by suppuration from underneath the membrana adiposa, 
on each side of the curvature, by an issue, and advised the main- 
taining of such a discharge until the patient was well.” Glisson 
in 1668, also says:4 “Issues in this disease are much approved, 
and we have known some children cured only by the help of this 
1 London Lancet, Feb. 2, 1878, as quoted by N. Y. Med. Record, March, 1878. 
2 A Treatise on Rickets, by Francis Glisson, Geo. Bate, and Ahasuerus Rege- 
moster, Doctors of Physick, London, 1668, p. 363. 
3 Op. citat., p. 415. 
4 Op. citat., London, 1668, p. 313. 34 
ADDRESS ON SURGERY AND ANATOMY. 
means.” Although modern surgery almost entirely rejects the 
remedy, yet I think there are few physicians who will not admit 
the value of flying blisters, sinapisms, tincture of iodine, and 
stimulating linarnents applied near the clavicles in tubercular 
disease of the apices of the lung. 
When we also recall the cases of Messrs. Savory and Macna- 
mara, as before stated, in which osteo-myelitis was induced by 
variation of temperature applied through the skin, it is very 
evident that decided counter-irritants applied to the surface of 
the' limb or a diseased bone or joint, must exercise a marked 
influence on the local congestion and diseased cell action existing 
in the cancellated tissue of the bone. Similar principles may be 
justly urged as applicable to the treatment of arthritis coxse or 
hip-disease, which has been shown to be due to ostitis interna 
from caseous and tubercular deposit in the cancellated structure 
of the bones forming the articulation. 
In such cases, our distinguished countryman, Dr. Physick of 
Philadelphia, at the early part of this century, secured perfect 
rest of the articulation by a carved splint; but he also laid much 
stress on the importance of general treatment in diminishing the 
internal congestion, insisting on the regular and long-continued 
use of purgatives; administering the compound powder of jalap 
of the Pharmacopoeia twice a week for eighteen months continu- 
ously, if requisite. Nor was such treatment otherwise than use- 
ful, especially when combined with ferruginous tonics and good 
food, and I have over and over again, thus treated feeble, scrof- 
ulous children, with arthritis coxae, and had them improve in flesh 
and color, instead of becoming exhausted by purging. I cannot 
but admire the improved splint for hip-disease of the present 
day, by which the articulating faces are kept at rest, and separated 
from the adjacent points of friction, whilst the patient benefits by 
fresh air and moderate exercise; but years of experience have 
only confirmed me in the correctness of the opinion, that no 
matter what splint is employed, regular purging and a general 
alterative and tonic treatment greatly contribute to the cure. 
Tubercles in bones—whether in the hip-joint, vertebrae, knee, or 
ankle, certainly require a general treatment (such as is applicable 
to tubercular phthisis), in addition to the purely mechanical ap- 
pliances that prevent motion in the joint, and the general verdict 
of the profession is in its favor. Special means of doing this, 
have from time to time been highly lauded. Thus Hufeland in PATHOLOGY OF BONES. 
35 
1829,1 recommended muriate of baryta, as well as the muriate of 
lime, in doses of ten to fifty drops of a solution of f‘5ss to fi?j of dis- 
tilled water and syrup, and professional attention has been recently 
directed by Robert Bell, of London, to the chloride of calcium, as 
directly influencing assimilation and nutrition, the most conve- 
nient form of administration being, he says,2 a solution of the 
salt of which the dose for an adult is twenty to fifty minims in 
milk or syrup, both of which are worthy of trial as alteratives. 
Some of the mechanical appliances for keeping the diseased bones 
at rest, like the plaster jacket recommended by our distinguished 
member from New York, are excellent for splints and have 
gained for his practical skill the plaudits of two continents; but 
it is certainly not fully adapted to the treatment of these cases, 
without the constitutional remedies which all appreciate as modi- 
fying congestion and inflammation at the seat of the disease. On 
this point, that is, the importance of other treatment than mechan- 
ical appliances, surgery and medicine occupy common ground 
and highly appreciate the value of general and local medication 
in modifying the vitiated cell action and blood disorder, and it 
cannot be too forcibly asserted, that the separation of internal 
from external remedies, is apt to prove injurious; the internal 
treatment tending to delay or prevent the development of the 
tubercles in the bones, whilst the mechanical appliances only 
limit the deformity or the destructive action, consequent on their 
retrograde metamorphosis in the affected part. 
Whilst however we admit the similarity of the principles in- 
volved in the treatment of tubercles anywhere, we cannot fail to 
recognize the advantages sometimes possessed by the surgeon, in 
the mechanical treatment of tubercular deposits in the bones; as 
his resection of a necrosed joint, in its last stages, may eradicate 
the local disorder, check hectic fever, and prolong life; whilst 
unfortunately the physician, in treating the advanced stage of 
phthisis pulmonum, is unable to keep the affected organs at rest, 
or remove the diseased structure. 
Attempts have, it is true, been recently3 made (1878) to apply 
remedies directly to the interior of pulmonary cavities, by pass- 
ing a long trocar through the intercostal tissues and injecting 
1 On the Scrofulous Disease, translated by C. D. Meigs, 1829, p. 126. 
2 American Medical Record, Dec. 1877, from London Lancet, Aug. 1877. 
3 Dr. Wm. Pepper in M. T., May, 1878. 36 
ADDRESS on surgery and anatomy. 
ffbxxv of a diluted Lugol’s solution of iodine ’R.xij to f5j; Dr. 
Pepper of Philadelphia having at present thus treated1 fourteen 
cases, in which twenty-five, or even a larger number of distinct 
injections were made without hemorrhage or any accident ensu- 
ing in a single case. These results are so favorable as to make 
an era in the treatment of phthisis pulmonum, and justify further 
trial. 
Dr. Pepper has also likewise injected circumscribed spots in 
two cases of consolidation of the lung with apparent benefit, and 
will soon publish his experience. 
Whether it would be wise or safe to aspirate a diseased ver- 
tebra, in order to hasten the escape of the lardaceous or caseous 
pus; or, as proposed by Bransby Cooper, “to inject phosphoric 
acid diluted with an equal weight of water, to expedite the re- 
moval of the moleculary necrosed bone;” or lactic acid that would 
make a soluble lacto-phosphate of lime; or to evacuate the pro- 
ducts of the arthritis in hip-disease, in addition to the other 
means of treatment, is one of those problems that yet remain to 
be solved, but which I think may yet be accomplished without 
difficulty by any good anatomist. 
The evacuation of softened tubercle from the head and neck of 
the femur by perforation of the cancellated tissue through the 
trochanter major, is one step in this direction, and worthy of 
further investigation, it having been shown2 in 1868 to the Brit- 
ish Medical Association by Dr. Fitzpatrick, of Dublin, that it 
could be advantageously performed. The case was “a young 
man whose wasted buttock—obliterated fold of the nates, etc.—pro- 
claimed hip-disease,” in whose trochanter Dr. Fitzpatrick made 
a deep issue by caustic potassa cum calce, on March 22, the flex- 
ion of the limb being of three months’ duration. On the ensuing 
May 11th, seven weeks subsequently, the contour of the limb 
was restored, the patient could walk, and his general health was 
greatly improved. 
In conclusion, I thank the Association for the patient conside- 
ration accorded to my subject, which, whilst not claiming origi- 
nality, may yet, it is hoped be found to offer “ such a review of 
the facts collected by pathological writers of the present time, as 
1 Am. Journ. Med. Sciences, Oct. 1874. Treatment of Pulmonary Cavities by 
Injection, by Wm. Pepper, M.D. 
2 Biennial Retrospect, New Sydenham Society, 1867-68, p. 261, et supra. PATHOLOGY OF BONES. 
37 
will enable you to deduce therefrom legitimate conclusions of 
practical importance.”1 
Perhaps it may also induce a more extended investigation of 
such general principles as alone can safely regulate the practical 
efforts of every surgeon, as well as physician, especially in this 
class of disorders, the physician, in our extended country, being 
often expected to unite all professional knowledge and accom- 
plishments in one—often over-taxed—mind and body. 
1 Ordinances of the American Medical Association. 
BIBLIOGRAPHY. 
The following works, for the inspection of many of which I 
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ADDRESS ON SURGERY AND ANATOMY. 
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Knight, Orthopajdia, p. 258. 
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Strumous Diathesis). 
Braidwood on Pyaemia, London, 1868. 
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Laverne, Tuberculous Disease of Joints, Le Progrfes M6dicales, Oct. 25, 1877. 
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Cruikshank, Anatomy of Absorbent Vessels, London, 1790. 
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Friederichs, Splenic Tumors, Sydenham Society, 1877. 
Orth, Diagnosis in Pathological Anatomy, New York, 1878. 39 
Watson, Pymmia and Septicaemia, New York, 1877. 
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PATHOLOGY OF BONES. EXPLANATION OF PLATES. 
The following illustrations, the artistic accuracy of which is appa- 
rent, have been drawn from nature and on stone by Dr. Hubert 
Praeger, of Philadelphia. 
The preparations have been taken from the collections known as 
“the Wistar and Horner Museum” of the University of Pennsylvania 
at Philadelphia, and the “Mutter Cabinet” of the College of Physi- 
cians, an ancient medical society in the same city. The drawings 
from the first-named collection are designated by the letters U. P., 
University of Pennsylvania; those from the second collection b}' the 
first letter of the bone—as F. for femur, and the letter M. indicating 
the Mutter Cabinet. 
Excellent as are the drawings, the specimens from which they are 
taken are necessarily much more instructive, and can be seen on 
application to the Curators of either collection on specifying the 
number and marks attached to each preparation. PLATE I. 
Illustrations of the Blood Supply in the Cancellated Tissue of the Cranium, Vertebrae, 
and Femur. 
Fig. 1. The Sinuses of Fleury, in the Diploe.—These Sinuses show the free blood 
supply of this structure and the communication of the diploic veins, through various 
foramina, with the sinuses of the dura mater. The outer or compact layer of the 
cranium has been carefully removed, and the sinuses of Fleury colored by Prussian 
blue. Oue or more “ torculares,” or cavities in the bone made by the junction of the 
sinuses, are seen, and illustrate the facility with which thrombi, pus, etc., could accu- 
mulate at these points after severe contusion of the bone, and pass into the general 
circulation, unless arrested in the lungs or liver, as so-called metastatic abscesses. 
From Preparation No. 211, U. P. 
Fig. 2. Hypertrophy of the Diploe.—The Diploe of this cranium was 1J of an inch 
thick, and the outer table presented numerous foramina resembling ulcerated points 
which communicated with the diploe. The subject was a negro lad, about fourteen 
years of age, and with no evidence of syphilis. Like many of his race he was 
probably tuberculous, and was remarkable for “butting” his head against hard 
objects. Whether this caused the diseased bone, or not, is unknown; but with such 
a development of diploe the sinuses must also have been much enlarged and the bone 
circulation greatly augmented. 
From Preparation No. 704, U. P. 
Fig. 3. Sections of Dorsal Vertebrae.—These sections exhibit the large sinuses found 
in the cancellated tissue of the bones, and their communication through the foramen 
on the posterior face of the spinal canal, with the veins of the meninges of the spinal 
cord. Tubercles in this structure would necessarily modify the circulation in the 
medullary tissue of the bone, as well as induce congestion of the meninges of the 
cord, thus creating a tendency to paralysis of the legs. 
From Preparation No. 406, U. P. 
Fig. 4. A view of the Articular Cartilage and Round Ligament of the Femur, 
showing their connection with and nutrition from the bloodvessels in the cancellated 
tissue of the head of the bone. The capsular ligament has been cut off close to its 
insertion, and the articular cartilage separated and turned back from the round head 
of the femur, thus exhibiting the source of the blood-supply to the cartilage, and 
showing how readily the cancellated structure of the head of the femur would unite 
with that of the acetabulum and create anchylosis, when ulceration had destroyed 
the articular cartilage of each surface of the joint. A transverse section of the 
inferior portion of the head of the bone exhibits the origin of the round ligament and 
its connection with the cancellse from which it is nourished. Tubercles in the can- 
cellse, by compressing the vessels of supply to the round ligament, would soon induce 
its necrosis. 
From a Wet Preparation, U. P. PLATE I 
Fig. 1 
Fi§ 2. 
Fig. 3. 
Fig. 4. 
B.Pracger M.D pinx ! : PLATE II. 
Infiltrated and Encysted Tubercles of the Head of the Femur. 
Fia. 1. Numerous crude, disseminated tubercles are shown in the cancellae of the 
head and neck of the femur. A vertical section of the bone with the section turned 
to one side exhibits the relation of the parts. Thickening of the septae of the can- 
cellae—or the trabeculae of the bone—similar to induration or hepatization of the lung 
tissue—is quite apparent, inducing solidification, increased weight, and, at the sur- 
face points exposed to friction, creating eburnalion or ivory-like formation of the 
bone. The tubercles are seen in the centre of the cancellated tissue of the head 
and neck of the femur, and when softened can only be evacuated by the pus travel- 
ling to the surface of the bone and finding its exit either within or without the 
attachment of the capsular ligament, thus creating inter- or peri-articular abscess. 
From Femurs No.-102, M. Cabinet. 
Fig. 2. A similar section of another tuberculous femur exhibiting tubercular cavi- 
ties of different dimensions in the cancellated structure of the head and neck of the 
bone. These abscesses have discharged through numerous small perforations on the 
surface of the head of the bone after inducing loss of vitality—softening and so- 
called ulceration of the articular cartilage. The change in the spherical head of the 
femur consequent on the fatty degeneration, etc., attendant on the progress of tuber- 
cle, is apparent. The induration of the trabeculae of the adjacent cancellae is also 
seen. 
From Femurs No. 98, M. Cabinet. PLATE II. 
Fi£..l. 
Fig: 2. 
H.PrHcjf&rM.b.jnnx f Illustrations of the Effects of Tubercles of the Cancellated Tissue on the outer face of the 
Head and Neck of the Femur. 
Fig. 1. The head of this bone shows osteophytes around the origin of the round 
ligament, on the inferior anterior portion of the head and around the epiphyseal 
junction of the head with the neck, this portion of the bone being rough and more 
solid than is usual in health. The round ligament has been necrosed at its origin in 
consequence of the cutting off of its blood-supply by the tubercles. The acetabulum 
has similar deposits at corresponding points, influenced probably by friction, after 
the loss of the articular cartilage of each bone. 
From Femur No. 102, M. Cabinet. 
Fig. 2. Another example of the changes produced in the head of the femur and 
its articular cartilage. Under the modified nutrition of the cancellated tissue created 
by tubercles, the head of the femur has lost its spherical shape, and the compact 
layer is crushed out into a bony ridge in the line of its epiphyseal junction with the 
neck. Numerous perforations of the surface of the head of the bone exhibit the 
points through which the softened tubercles have escaped into the articulation. The 
largest ulceration on the surface of the head of the bone communicates with a tuber- 
culous cavity in the cancellae beneath it. 
From Femur No. 98, M. Cabinet. 
Fig. 3 Tubercles in the neck of the femur having induced a modification of the 
normal action of the medullary tissue, fatty degeneration, softening, and the forma- 
tion of lactic acid have created disintegration and absorption of the neck. The head, 
by muscular pressure against the acetabulum, has been forced to the trochauteric 
extremity of the neck, thus creating marked shortening of the neck and bringing 
the trochanters near to the margin of the acetabulum from muscular action. Tuber- 
culous ulcerations of the head, show where the exit of the softened tubercles has 
occurred into the articulation. These ulcerated points are most numerous on the 
superior face of the femur, where it presses against the acetabulum in sustaining 
the weight of the body. 
From Femur No. 91. M. Cabinet. 
Fig. 4. A marked example of the changes created in the shape of the head and 
neck of the femur by tubercles. The spherical form of the head is greatly changed— 
the epiphyseal line is hypertrophied and ulcerated into several deep notches, whilst 
large ulcers of the surface of the head indicate the tuberculous cavities existing in 
the cancellm of the neck and the escape of the softened tubercles. Numerous similar 
ulcerated points are seen on the trochanteric portion of the neck, resulting from the 
destructive action induced by disseminated tubercles, without evidencing by “peri- 
ostitis ossificans” any eflort at repair. The trochanters and upper portion of the shaft 
of the bone, as is generally the case, do not appear to have been involved in the 
diseased action. 
From Femur No. 90, M. Cabinet. 
PLATE III. PLATE III. 
Fig. 1. 
Fig.2. 
Fig. 3. 
Kid 4. 
JL Praeger MD. pin x ? PLATE IV. 
Tuberculur Cavities in the Head of the Femur. 
Fig. 1. A. vertical section of the femur, represented in Plate III, fig. 3, shows the 
ohanges in the cancellated tissue and the cavities corresponding with the ulcerated 
points seen on the surface of that bone. The septas around the cancellae are hyper- 
trophied ; the entire structure is thickened and unnaturally indurated or solidified. 
Some of the cavities show the thickened edge, similar to the false membrane lining 
a pulmonary abscess, the vascularity of the adjacent tissue being also increased. The 
softened and cheese-like cancellae give evidence of fatty degeneration in the greasy 
appearance and touch, when recent. 
From Femur No. 91, M. Cabinet. 
Fig. 2. A beautiful example of the changes in the head of the femur caused by 
Arthritis Coxse Tuberculosa. The spherical shape of the head is changed, several 
deep ulcers indicate the cavities and other changes in the cancellae; whilst the indu- 
ration caused in the reparative effort near the margin of the largest cavity, has devel- 
oped an ivory-like structure, that by friction against the corresponding surface of the 
acetabulum has become “ eburnated.” The neck is somewhat atrophied and shortened, 
and a new ossification near the insertion of the capsular ligament indicates the 
reparative efforts of nature. 
From Femur No. 28, M. Cabinet. 
Fig. 3. A vertical section of Fig. 2, exhibiting the changes in the interior of the 
bone. At a point corresponding with the largest exterior ulceration, shown in Fig. 
2, we note a large tubercular cavity caused by the molecular necrosis of the cancellae 
of this part, having a well-defined margin like an indurated lining to a pulmonary 
cavity. The flattening of the head of the femur; the extended margin of the epi- 
physeal line; the shortening of the neck; the induration (hepatization) of the sur- 
rounding structure, and the marked trabeculi, are also seen. 
From Femur No. 28, M. Cabinet. PLATE IV. 
Fig. 1. 
Fig. 2. 
Fig. 3. 
ILPr«*$«r MJf.jiinx * '■ Changes in the Acetabulum and Head and Neck of the Femur, induced by Tubercles. 
Fig. 1. An exterior view of the left Innominatum, showing the changes induced in 
the acetabulum by “ hip-disease.” Under tuberculous influence the margin of the 
acetabulum has become ulcerated, and a few osteophytes have been created, rendering 
it rough and spinous. The articular cartilage of the acetabulum having been eroded 
(“chondro-necrosis”) and the head of the femur having likewise been exposed, the 
superficial layer of the head of the femur has adhered to or become anchylosed with 
the bottom of the acetabulum. Muscular action having ruptured the union of the 
exterior face of the head of the femur, the latter remains in the acetabulum and par- 
tially fills it up, a portion of the femur subsequently moving in it, as in pseudarthrosis. 
From I. Femur No. 21, M. Cabinet. 
Fig. 2 Exhibits the Femur of the same preparation as Fig. 1, above. The neck of 
the femur, having undergone tuberculous degeneration, has been largely absorbed at 
its base, and the head of the bone has been depressed and rests upon the trochanter 
minor, the shaft of the femur being drawn towards the crest of the ilium, whilst a 
portion of the head remains in the acetabulum. The ulcerated points on the surface 
of the head, where the outer lamina has been removed by adhesion to the acetabulum 
and the ossification connected with the effort at repair, are also seen. 
From I. Femur No. 21, M. Cabinet. 
Fig. 3. View of the Acetabulum of the right innominatum, to which the femur 
shown in Fig, 2, Plate IV, belongs. Although the head of this femur was so much 
diseased, the acetabulum as yet is but slightly affected. The osteophytes on the 
anterior superior rim of the acetabulum are well developed, and ulcerations of the 
other portions are apparent. At the superior anterior edge of the acetabulum, 
directly under the projecting osteophytes, the acetabulum is partially eburnated, 
though this is not seen in the drawing The eburnation of the acetabulum corre- 
sponds in position with that seen on the head of the femur. The depth of the ace- 
tabulum in this preparation is augmented by the osteophytes on its rim. 
From I. Femur No. 28, M. Cabinet. 
Fig. 4. The Femur in “arthritis coxae tuberculosae,” being luxated on the dorsum ilii, 
has become anchylosed there. The outer lamina of the head of the femur has then 
separated from the remaining portion and a false-joint has been established. The 
acetabulum has been greatly diminished in size by ossific deposits. The pelvis and 
spinal column deviate to the side of the hip-disease. 
From I. Femur No. 15, M. Cabinet. 
PLATE V. PLATE V 
Fig. 1. 
Fig. 2 
Fig. 3. 
Fig. 4. 
EPraej'erUD pinx? PLATE VI. 
Fig. 1. A view of the normal structure of a Vertebra and inter-vertebral cartilage, 
showing the epiphyseal margin of the face of the body of the vertebra. The lower 
portion of the drawing exhibits the superior and inferior inter-vertebral cartilages, 
showing the soft central portion. The thick edges of the cartilages have a close 
attachment to the epiphyseal margin of the vertebra just alluded to, and derive their 
blood supply mainly from it. The central portion of the drawing shows the condition 
of a vertebra in the early months of infancy, the body of the vertebra being the 
small round central portion of the drawing; the spinous process is opposite to it, 
and the bony arches of the spinal canal intermediate to both; all these processes 
often not being fused together till the fifteenth year. 
From Preparation No. 403, U. P. 
Fig. 2. An illustration of the results of tubercles in the dorsal portion of the ver- 
tebral column. Bony spines (osteophytes) extend from one epiphyseal margin of a 
vertebra to another. The ulcerated openings through which the tuberculous pus and 
molecularly necrosed bone have been discharged, are seen, and a white spot in the 
second of the bones is the end of a loose sequestrum. Attention is called to the 
smooth and defined edges of the openings in the bodies of the vertebrae, which differ 
greatly from the superficial and apparently worm-eaten edges attendant on Caries. 
The diseased action in this example of tubercles, as in others, has evidently travelled 
from within the cancellated tissue, outwards, and not from the surface, inwards, as in 
Caries. Anchylosis has enabled the diseased vertebrae to sustain the weight resting 
on the spinal column at this point. 
From Preparation No. — of Vertebrae, M. Cabinet. 
Fig. 3. A view of the extensive destruction sometimes caused by Tubercles of the 
dorsal vertebrae. The numerous well-defined orifices of tubercular cavities in the 
cancellated tissue; the entire destruction of one and nearly all of the body of another 
vertebra—the part being sustained in the preparation by a rod; the approximation 
of the ribs from the change of the vertebral column and the soundness of the half 
arches and processes of the vertebrae whose bodies have been destroyed, are also 
shown. 
From Preparation No. 65, M. Cabinet. 
Fig. 4. Another example of Osteophytes of the vertebral column, each of which 
arises from the epiphyseal margin of one vertebra and extends to that of another, 
thus strengthening the bodies in the process of repair. Several points of tubercu- 
lous ulceration, are seen on the front of the vertebrae. 
From Preparation No. 77, U. P. 
Illustrations of Tubercular Disease of the Vertebrae. PLATE VI 
FijS.l. 
Fig. 2 
Fig.'3. 
Fi§ • 4 
fl. Pracjfer 1I.D. pinx?: