rally attacks the surface of a bone, and extends deeper and deeper, but occasionally it begins in the centre; when the bones of the carpus, tarsus, or vertebræ are attacked, it very frequently spreads from one to another; the cartilaginous surfaces of these bones resist the disease longer than the osseous shells. When this disease attacks the sternum, or any other superficially seated bone, the malady is more easily cured, than when a deep seated one, such as the acetabulum of the os inno Caries attacks the young constitution much oftener than the adult, and spreads with greater rapidity, but heals more quickly, and occurs chiefly in the scrofulous and syphilitic constitutions. From the preceding facts and observations, it appears that caries may be divided into as many species or varieties as ulcers; therefore there are, the simple, the inflamed, the indolent, the phagedenic, the gangrenous, the scrofulous, the syphilitic, and the scorbutic caries; and consequently on this account the carious ulcer, described by authors, evidently involves two or three species of caries or carious ulcers. Some authors make other divisions of this disease, which are equally objectionable. The simple caries is clearly seen in the end of a bone which protrudes after amputation, in compound fracture when the bone is freely exposed, and in caries which commonly attacks the sternum. In these there is no difference from that which occurs in the simple ulcer of the soft parts, and none in the treatment. If the carious portion is not freely exposed, the integuments and all sinuses of the bone should be freely laid open, there being as much or more necessity for bringing it into view than even the ulceration of the soft parts. The irritable or inflamed caries presents the same granulations and discharge as the inflamed ulcer does; it is this species only which tinges the silver probe yellow or black, and when it attacks one of the bones of the carpus, or tarsus, spreads and involves so many, that not unfrequently amputation of the hand or foot is necessary. The antiphlogistic treatment requires to be vigorous in such cases, and all abscesses or sinuses must be freely laid open. If the caries becomes phagedenic, the portion must be removed with the trephine or knife, or destroyed with the actual cautery, nitrates of silver or copper, and if these fail, amputation ought to be performed. The cautery requires to be applied with great caution. But if the caries assumes a simple or healthy aspect, it is to be treated accordingly; or if it becomes indolent, to be stimulated with solutions of the nitrates of silver and copper, sulphate of copper, muriate of mercury, and oxide of arsenic. Moxas applied in the neighbourhood of caries are powerful auxiliaries; thus when the astragalus, tibia and fibula have been carious, moxas around the ankle joint have cured them. The phagedenic caries is best exemplified in severe cases of noli me tangere. The fungous caries is best illustrated in caries of the sternum, where the granulations are occasionally very large and flabby. The scrofulous caries, or caries occurring in the scrofulous constitution, affects either the vertebræ or the joints, the latter of which have already been considered; and when the former are the seat of this disease, either distortion with or without paralysis of the lower extremities, or lumbar abscess, is the result. From the great weight which the spinal column has to support, and the delicate spongy nature of its structure, it is very readily distorted even from continued awkward or awry attitude in the young and delicate scrofulous female. Whenever the muscles on the one side of the spine gain the least ascendency over their antagonists, they instantly lay the foundation for distortion, and in many cases, sooner or later, caries is the consequence. If early attended to, the common steel stays, as represented in Fig. 22, Plate DXVI. should be worn when the patient is erect, but the greater portion of the twenty-four hours should be passed in the recumbent or horizontal position. Open-air, sea-bathing, flesh-brush, attention to the diet and bowels are powerful auxiliaries. If the affection has been neglected, repeated cupping, and moxas, with acupuncturing, should be applied in succession from the occiput to the coccyx, together with the means just mentioned. The patient should remain in bed on a firm hair mattress, until all pain has been subdued, and even all tendency to a relapse has disappeared. In severe spinal affections, as they are termed, the spinal marrow is found sometimes quite disorganized, a complete mollescence, with more or less purulent matter exterior. There is a peculiar affection of the cervical vertebræ confined at first to the articulations of the occiput and atlas, and atlas and dentata, which consists in ulceration of the cartilages, ligaments, and bones, ultimately involving the periosteum, the theca vertebralis, the dura mater, the medulla oblongata and brain, and also the pharynx. There is a peculiar expression of pain in the countenance, with dread at moving the head, which inclines generally to one side, and that most frequently the left, and when moved a most acute pain darts to the larynx and scapula of the affected side. The patient experiences most insufferable pain when swallowing a large mouthful, or taking a deep inspiration. These symptoms increase, and excite others fully as distressing, under which the patient lingers for months, when death puts a period to his sufferings. The treatment consists in repeated cuppings and moxas to the nape of the neck, confinement to bed, with the head and neck fixed with the chin-stay, see Fig. 22, Plate DXVI; low diet, and attention to the bowels. When the long cylindrical bones are attacked with inflammation, their vessels having no latitude to expand and form ulcerative papillæ, become gangrenous, so that the bones are deprived of vitality, and either exfoliate or undergo necrosis. Exfoliation or necrosis seems to take place, according to the exposure or non-exposure of the bones; thus the bones of the cranium exfoliate, while the os femoris becomes necrosed: the tibia, however, either exfoliates or necroses. If the tibia be inflamed, and an abscess occurs superficially to it, the bone generally exfoliates; the inflammation being too violent for necrosis, according to the interpretation of the moved; but whenever the health begins to sink, the bone must be removed, otherwise amputation will be the only alternative, which otherwise need not be considered, until hectic fever threatens to destroy the life of the patient. During the cure, the patient must be guarded against using the limb before the bone has become properly consolidated, as it is very liable to be fractured. Various absurd remedies are recommended for this disease, as madder, assafoetida, hemlock, &c. Its causes are very obscure; the exanthematous fevers, syphilis, mercury, scrofula, and scurvy, also cold and blows, are considered predisposing; while inflammation is the proximate cause in early life, and obliteration of the blood-vessels in advanced age. term by surgical writers, who consider it the death of the old bone, with the formation of a new one exterior to it, whereas, etymologically, it means merely the destruction of the old bone, being derived from vexgo, to destroy. In such a case, the abscess is to be freely laid open, and the condition of the bone examined; and if it appear divested of vitality, either the nitrate of silver or copper applied to accelerate the exfoliation of the sequestrum, or removed with cutting instruments, the latter of which is preferable. The tibia is sometimes deprived of vitality in extensive ulcers of the leg, in consequence of the periosteum being removed by the ulcerative absorption; in which case granulations are occasionally formed beneath the outer layer of bone, which thus becomes a sequestrum, so that both caries and necrosis exist at the same time. Caries and necrosis also sometimes exist together in ulceration of the spongy bones. When the cranial bones are exfoliating, they are to be gently shaken from time to time, and not rudely removed. When the shaft of one of the long bones dies, a separation takes place between it and the epiphyses; the periosteum inflames, with an accumulation of blood vessels, and thickening of this membrane; and if the inflammation be moderate, these vessels, together with those of the epiphyses, begin to secrete callus, in order to replace the decayed portion; and after the secretion of the new bone has extended from the one epiphysis to the other, the periosteum loses its injected appearance, and returns to its natural colour and density. The new shell now separates from the old bone, and the latter is either forced through the former, or is absorbed. A profusion of callus is at first poured into this new shell, rendering it solid for a time, but afterwards the absorbents make it nearly as hollow as the original. The new bone is at first merely a reddish fluid, next gelatinous, then cartilaginous, fourthly ossific or the or the phosphate of lime is deposited. Portions of the cranial bones occasionally die, apparently in consequence of too great a deposition of phosphate of lime obliterating their blood-vessels, the dead part becomes a neutral object, excites irritation, and causes a separation between it and the living portion. When the piece exfoliated is small, it is regenerated by the vessels of the pericranium, dura mater, and diploe; but when very large, is never regenerated. If we are permitted to continue the analogy, with which we set out, between the bones and the soft parts, they should be subject to the same varieties of tumours, of the truth of which we have not the least shadow of doubt, particularly when affected symptomatically. At present they are confined to Exostosis (from, out, and Ter, a bone), which is divided into various species by different authors, as true, false, periosteal, medullary, cartilaginous, and fungous exostoses, and sometimes acquire considerable magnitude. Exostosis chiefly attacks the dense bones, which are thinly covered, such as those of the cranium, inferior maxilla, sternum, clavicle, ulna, and tibia; although all the bones are occasionally affected. The periosteal exostosis is simply a diseased thickening of the periosteum, forming a tumour chiefly attacking the bones of the cranium and tibia, and occurring generally in the syphilitic constitution; but if not attended to, it commonly involves the bone. Sir A. Cooper considers this affection an osseous deposition between the bone and the periosteum, which adheres firmly to both. In its early stage, it may be removed by the application of the moxa, and the internal administration of the muriate of mercury. Medullary exostosis is when the medulla is primarily affected, and the cancellated structure secondarily; this may be treated in the same manner, but generally requires the knife. The cartilaginous exostosis is when cartilage forms the nidus for ossific deposition, which sometimes grows to an enormous size, and frequently attacks the inferior maxillary bone, requiring the removal of more or less of the sound bone on each side. It also takes place on the sternum and ribs, from whence it may be removed. The fungous exostosis is still softer, containing spicule of bone, and being of a malignant nature, acquires occasionally a prodigious magnitude. This is evidently the cellular or laminated osteo-sarcoma of some authors, or osteo-sarcosis, or osteo-malakia, or spina ventosa. Necrosis occurs chiefly in early life, except when the inferior maxillary bone is affected, which is generally after thirty years of age: it attacks the tibia, os femoris, clavicle, os brachii, fibula, radius, and ulna; and there is a case detailed by M'Donald, wherein nearly all the bones of the body were affected. This peculiar disease of the bones is characterized by inflammation, either acute or chronic, tumefaction of the limb, diffused pain along the bone, ulcerous openings or abscesses, discharging purulent matter, which ultimately become fistulous. There is more or less fever throughout, which at first is inflammatory, and afterwards hectic. As long as the fever is inflammatory, and the limb acutely inflamed, the treatment should be antiphlogistic, with fomentations and poultices; and when these conditions have been subdued, if no ulcers have formed, moxas should be repeatedly applied; but if there are ulcerous or fistulous openings, simple dressings and gentle bandaging; the constitutional remedies being mild nutritious diet, exposure to the open air, and sea-bathing if practicable. The dead bone ought to be left alone as long as the health will permit, unless it has begun to force its way outwards, when it should be re It attacks the diploe of the cranial bones, the inferior maxillary bone, and the long cylindrical bones. This exostosis can be only cured by the knife, or amputation. Besides these, there is the exostosis eburnea of some authors, a small hard tumour generally situated on the os frontis, the exostosis petrosa, and the stalactitical exostosis. Hydatids are occasionally found in exostosis. From the magnitude which some of these species of exostosis acquire, they impede the functions of the contiguous soft organs; thus when situated in the antrum, the eye; on the cranium, the brain; on the cervical vertebræ, the spinal cord, and in some cases the subclavian artery; on the inferior maxillary bone, the pharynx and larynx; and on the symphysis pubis, the urethra. Various ridiculous remedies have been recommended for these tumours, and different instruments invented; for example, Jeffray's flexible saw, Machell's chain saw, Graefe's orbicular saw, and Thal's rotation saw. Mollities ossium, named also malacosteon, is that disease wherein the bones become so soft that they may be twisted or bent in any direction, and in which, being deprived of their earthy property, as if they had been macerated in diluted muriatic acid, their animal constituent only remains. When analysed, the quantity of phosphate of lime amounts only to about an eighth. This disease occurs more frequently in women than in men, and generally about the middle period of life. It is preceded by fever and acute pains in the bones, and the urine contains a quantity of phosphate of lime; it is of long duration, Madame Supiot having lived five years. Its treatment is by attention to the early febrile affection, and afterwards to diet and regimen, exposure to the open air in the horizontal attitude, cold-bathing, flesh-brush and stays. Rachitis or rickets, which depends also on a deficiency of the earthy property of bones, is closely allied to mollities ossium, but generally attacks the child, even the fœtus in utero. In rickets, the spine and ribs are commonly first affected, and afterwards the long cylindrical bones; the abdomen is tumefied in consequence of the liver, spleen, and mesenteric glands being enlarged; the intestines are filled with flatus, the digestion impaired, the breath fetid and sour, and the stools fetid, acid, and liquid. The respiration is also more or less affected; the head is peculiarly large, with a precocity of intelligence. The singular peculiarity in this disease is, that those children who recover from it in early life and continue strong until adult age, become again af fected with it. The bones, after death, are found lighter, flatter, of a red or brown colour, porous, spongy, soft, compressible, and vascular; the cranial are thicker, the long bones thinner, and the medulla is like reddish serum. For the treatment, and a fuller account of this disease, the reader is referred to the Article MEDICINE, Vol. XIII. p. 29. Fragilitas ossium may be considered the opposite of mollities, although, according to Boyer, the two diseases are combined. In this, there is a superabundance of the phosphate of lime in the bones, and hence it occurs in advanced life, and in either the syphilitic, scorbutic, arthritic, cancerous, scroVOL. XVII. PART II. fulous, or rachitic constitutions, and therefore symptomatic of some other disease. It is only in the scorbutic and syphilitic cases that any hopes of cure, always very doubtful, can be held out. Saviard details a very remarkable case of this disease, where all the bones after death crumbled under the fingers. Anchylosis, the last remaining disease of the bones, has been already described under affections of the joints, a result much to be desired on many occasions; but it has occurred without any marked increased action, as in the extraordinary case of Clark, detailed in the forty-first volume of the Phil. Trans. where all the bones, from the crown of the head to the sole of the foot, were completely soldered together, and whose skeleton is still preserved in the Museum of the College of Surgeons of Dublin. This species or variety of wounds has ever been considered an important branch of surgery, either in military, naval, or private practice. These wounds are considered by systematic writers to be essentially different from all other kinds of wounds, and to require a different kind of treatment, as mentioned by J. Bell and Mr. Guthrie; but we contend, that they in no degree differ from contused wounds, and demand precisely the same kind of treatment. If a round stone or bullet is thrown from a sling, as in the days of Celsus, with the same velocity with which a musket bullet is fired, it will inflict precisely the same kind of wound; besides, we know there is no difference between the wound inflicted with an air gun, and that exploded with powder. It would appear that the whimsical notions of the writers on surgery before Paré, who conceived that musket bullets were poisonous, still haunt us. If the above be correct, it is easy to apply the same reasoning with respect to all the variety of gunshot wounds, and it consequently follows, that these wounds differ in no degree from contused wounds caused by stones and other foreign bodies, but in the contusion which the rapidity of the projectile produces. When a person is wounded with a musket bullet within half or quarter musket shot, the missile will most probably pass through the body, and there are then two wounds with a long sinuous tube between them; the aperture made by the entrance of the bullet is of a livid ecchymosed colour, is depressed inwards or indented, and smaller and rounder than that made by its exit, which is rugged and lacerated, having everted edges. These, however, sometimes vary, the exit appearing a mere slit, and in cases where the musket has been close to the wounded person, the entrance is as rugged and everted as the exit; much, therefore, depends on the velocity of the projectile, and the medium of the resisting body. Bullets run most circuitous routes in the body, if their course is diverted by a bone, and the position of the patient when wounded may throw light on this point. Bullets flying with great velocity and striking a part of the body which is clothed, seldom carry the clothes before them; the reverse, however, occurs if they are nearly spent in their career. therefore, this projectile has passed through the calf of the leg, or any other fleshy part, there will be little or no pain in consequence of the parts 4 A If, beneath or centrad of the fascia of the arm or leg, it not unfrequently produces erysipelas phlegmonodes, which, besides the treatment already recommended for such, often requires the orifices of the wound to be enlarged. Wounds of the joints generally demand immediate amputation, for such a degree of inflammation and fever with suppuration follow, that the individual sinks under it, and there is no opportunity for secondary amputation. being chemosed, and little or no bleeding, because When a musket-bullet is arrested in the body, and not situated in the contiguity of a vital or important organ, it ought to be abstracted wherever that is practicable, even if lodged in a bone, and as it generally prevents the wound healing, and produces inflammation, suppuration, and sinuses, and may prove an annoyance to the patient in after life, sometimes causing lameness if situated in the leg. All the bullet forceps and probes invented are of little or no avail, the finger in many cases being only admissible: the limb of the patient should be laid in the attitude in which it was wounded, and the left hand placed opposite the wound, into which the fore-finger of the right hand is to be inserted. If this fails, the patient should be requested to move gently the limb in various ways, and the seat of the bullet may by this means be ascertained, and removed, due attention being paid to important objects, for when situated near a large blood-vessel, it ought to be allowed to remain. If the bullet which continues in the body is lodged in cellular or muscular substance, and produces no immediate irritation, a membranous cyst is gradually formed around it, which adheres so close as to be with difficulty detached in a few months afterwards; and when situated close to a bone, the periosteum forms an osseous pouch. Sometimes they gravitate down a limb before becoming thus imbedded, and occasionally excite the formation of abscesses at a later period; at other times they excite so severe a pain that they compel the patient to have them extracted. From the earliest records of surgery there have existed much diversity of opinion and discussion, upon the propriety and manner of extracting bullets and other foreign bodies on the receipt of a wound. With respect to dilatation, it is now an axiom in British military surgery, never to dilate, unless necessity requires it. According to the velocity and ruggedness of the missile, will an artery bleed immediately, or at some more remote period; but in the majority of instances, the hemorrhage is primary, and if it be the principal artery of a limb, so much is instantaneously lost as to produce syncope; if the surgeon is on the spot at the time, a tourniquet should be loosely applied, the artery cut down upon, and secured above and below the wound, but at a little distance from it, to avoid its being involved in the inflammatory action of the wound, which must follow. But if the surgeon is not at hand, and inflammation has begun, a tourniquet must be loosely applied, and an assistant appointed to watch until sloughing and suppuration have taken place; and if then secondary hemorrhage ensues, the artery must be secured; but secondary hemorrhage is so rare, that not above four in the 1000 are attacked with it. In musket-bullet wounds of the hand or foot, the bones of these are generally fractured, and in the treatment, we must always keep in view, that gunshot wounds are more contused than others. The other bones of the extremities when struck with musket-bullets, are also very often fractured, and commonly splintered, and require the same treatment as described under fractures, bearing in mind that immediate amputation is more necessary in compound fractures from gunshot, than from any other causes. When a musket-bullet runs close Wounds inflicted by large shot, named large round, double-headed or bar-shot, grape, cannister, langrel, langrage, and shells, only differ from those caused by musket-shot, in the greater destruction of the part, and the more violent constitutional derangement; for in musket-bullet wounds, unless the head, knee-joint or some important organ be injured, there is trifling constitutional derangement on receipt of the wound. In severe wounds from cannon-shot, there is a dreadful concussion of the nervous and circulating systems, the patient has a pallid anxious countenance, a cold clammy skin, a feeble pulse, and most acute pain. In such a condition of the constitution, and supposing the knee-joint the seat of the injury, amputation cannot be performed any more here than in compound fractures of the bones forming this joint; and if the patient has lost much blood, there will be probably convulsive motions of the limb, and even of the whole body, together with irritability of the stomach, hiccup, wavering of the intellect, and extremely feeble voice, and a pulse scarcely perceptible. These constitutional symptoms, however, are said by Dr. Quarrier not to be always present. When the patient rallies, which will be after a longer or shorter time, according to the extent and nature of the injury, and the idiosyncracy of his constitution, for no precise period can be mentioned as described by authors on this subject, amputation should be performed. The rallying of the patient is characterized by pain, and a sensation of heat in the wound, a warmth of the skin, a quickness of the pulse, and thirst. There is another reason against immediate amputation, when the patient has been exposed to external cold after the receipt of the wound, for he then becomes in a measure frost-bitten, and requires to be thawed. On the On the propriety of immediate amputation, according to the hitherto received idea of this expression, there has existed much diversity of opinion from the early part of the sixteenth century. Dr. Quarrier and the other medical staff who were at the battle of Algiers, consider the expression "immediate" to apply to amputation performed as soon after the receipt of a wound as possible; while it had been formerly applied to the operation, whenever the system had rallied from the shock received by the wound, and contradistinguished from amputation performed when suppuration had taken place. The advocates for primary amputation, or when the constitution has rallied from the shock of the wound, are Du Chesne, Wiseman, Dionis, Le Dran, Ranby, Faure, De la Martiniere, Morand, Van Gescher, Pott, Schmucker, Boy, J. Bell, Dupuytren, Sanson, Begin, Larrey, Graefe, Guthrie, Thomson and Hennen. The advocates for secondary amputation, or when suppuration has taken place, are, Le Conte, Boucher, Bagieu, Bilguer, Percy, Sabatier, Mehee, and J. Hunter. Drs. Dewar and Quarrier, and Mr. C. Hutchison, recommend amputation instantaneously after the receipt of the wound, and contend that constitutional symptoms do not take place immediately; indeed the latter surgeon treats with contempt nervous commotion occurring to British seamen or soldiers: so that the only way of reconciling the opposite sentiments of Drs. Dewar, Quarrier, and C. Hutchison, with those of Drs. Hennen and Guthrie, is, that in the navy a man is brought instantaneously after being wounded to the surgeon, before constitutional symptoms have had time to appear, which, says Dr. Hennen, is a much earlier opportunity than any army surgeon can possibly enjoy; whereas a few minutes at least must elapse before the army surgeon can arrive at the wounded soldier, however fleet or active his ambulance may be. It is to be feared this instantaneous amputation was performed indiscriminately in the reign of Louis the XIV., which from its fatality alarmed him and all France. There appears two conditions of the constitution after gunshot wounds, the one wherein no commotion follows, as in the seamen at the battle of Algiers; and the other wherein nervous agitation exists, as occurred to the duke of Montebello, narrated by Larrey: that in the former, amputation may be instantaneously performed; while in the latter, some time must be allowed to elapse; and even both Mr. Guthrie and Mr. C. Hutchison recommend these methods of practice. In amputation of the upper or proximal third of the thigh, the operation is allowed by all writers on this subject to be seldom or ever successful; and many cases are on record of those wounded in this region dying in a few minutes, before amputation could be performed. In gunshot wounds, the brain, the lungs, and the liver are often injured when the wound is quite remote. See Larrey's Account of General Caffarelli, Duke of Montebello, &c. The wind of a ball, as it is termed, is now completely established to depend on the projectile striking the body, but not producing any apparent injury of the skin; many interesting cases of which are related by Schmucker, Hennen, and Guthrie. Tetanus, which has been already described in the article MEDICINE, Vol. XIII. p. 16, supervenes more frequently to wounds made by pieces of shell, langrage, and splinters of wood, than any other kind of missiles, and is then termed traumatic. See Larrey's Military Memoirs, and Sir J. M'Gregor's Observations on the Peninsular War. Barons Percy and Larrey invented flying ambulance, that of the latter great surgeon being evidently the better; it consisted in an admirable arrangement of surgeons, assistants, soldiers, officers, instruments, and medicines, all at a moment's command, to afford immediate assistance to the wounded, even while under the fire of the enemy. They followed the advanced guard, and the instant a soldier was wounded, he was dressed, or had his limb amputated on the spot, and then put into a light covered wagon, which conducted him to the hospitals in advance. The number of people attached to each division of ambulance amounted to 113, and consisted of one staff surgeon, two staff assistants, twelve assistants, two of the latter of whom did the duty of apothecaries; a lieutenant to command the economy of the division, but under the orders of the staff surgeon; a sub-lieutenant, who was inspector of the police of this division; a serjeant-major; two serjeants; a trumpeter, who also carried the instruments; twelve horse soldiers, among whom was a farrier, a shoemaker, and a coachmaker; an inferior or deputy commissary; two provision searchers; three corporals; a drummer, who also took charge of the surgery; twentyfive soldiers; twelve light cars or covered wagons capable of being driven on all kinds of ground, with the exception of a very steep hill; four heavier carriages. The light cars were mounted, some on two, and others on four wheels. In the explosion of gunpowder, an individual is commonly scalded as if with boiling water, but occasionally so severely injured as to be instantly deprived of life. Burns differ in the extent of the surface injured, in the depths of the parts destroyed, and in the vitality of those parts; these three being equally destructive. In cases where |