Loose cartilaginous bodies are found in the joints, particularly the knee, and if they cannot be confined with a laced knee cap, so as not to impede the mo tions of the joint, they should be extirpated. The patient ought to be previously confined to bed for a day or two, and have a cathartic administered; the cartilaginous substance should then be pressed to wards one side of the patella, and there held firmly by an assistant, while the operator drawing the skin downwards, or upwards, or to one side, makes a lon gitudinal incision over the substance, and extracts it either with the fingers, forceps, or a hook. The skin is instantly to be allowed to retract, the lips of the wound approximated with adhesive plaster, and the eighteen-tailed bandage applied, the limb gently ex tended, and perfect rest, with low diet, enjoined. Inflammation is to be apprehended after this opera tion, and treated accordingly.
The bones are subject to the same diseases as the soft parts of the body, the phenomena merely differ ing in consequence of the hardness of their struc ture; thus they are attacked with inflammation, sup puration, abscess, ulceration, mortification and car cinoma. Inflammation is termed ostitis, and is cha racterized by the same symptoms and appearances, as described under inflammation, the pain being more or less severe, according to the hardness or compactness of the bone, which, in consequence of its unyielding nature; prevents the expansion of the nerves and blood-vessels; the redness, tumefaction, and increased heat being more or less developed, according to the exposed nature of the bone. The same mode of treatment is also to be followed, with this difference, that as the bones are deeply seated, incisions, the moxa, and other counter irritants are more necessary. The soft spongy bones of the carpus and tarsus, the epiphyses of the long ones, and vertebrx when inflamed, are, in consequence of the blood-vessels having sufficient latitude, capa ble of forming suppurative papilla, and thus ab scesses are formed, which are treated in the same way as formerly directed. Abscesses in the bones frequently accompany necrosis.
These bones, upon the same principle when in flamed become carious, or, in other words, the ab scess bursts, or the supurative papillae are exposed, and the bone is found ulcerated for caries, (from yip. to abrade,) is considered by modern surgeons, ulcer ation of the hones, and, consequently, is subject to the same varieties as ulcers of the soft parts; and caries not unfrequently follows ulceration of the contiguous soft parts. When caries attacks one of the carpal bones, a deposition of callus is occasion ally generated, which forms a barrier to the pro gress of the disease; at other times a carious bone becomes soft and diseased throughout, having a fleshy or fatty appearance; on other occasions it be comes dry and friable, crumbling down under the probe; in some instances a separation takes place between the carious and healthy portions, the for mer being thrown off like a slough. Caries gene rally attacks the surface of a hone, and extends deeper and deeper,but occasionally it begins in the centre; when the bones of the carpus, tarsus, or vertebrae are attacked, it very frequently spreads from one to another; the cartilaginous surfaces of these bones resist the disease longer than the osse ous shells. When this disease attacks the ster num, 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 minatum. Caries attacks the young constitution much oftener than the adult, and spreads with greater rapidity, but heals more quickly, and oc curs chiefly in the scrofulous and syphilitic con stitutions. From the preceding facts and observa tions, it appears that caries may he 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 conse quently on this account the carious ulcer, descri bed 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 clear ly seen in the end of a hone which protrudes after amputation, in compound fracture when the bone is freely exposed, and in caries which commonly at tacks 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 cari ous 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 unfrequent ly amputation of the hand or foot is necessary. The antiphlogistic treatment requires to he vi gorous 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. 'Ile cau tery requires to be applied with great caution. But if the taries assumes a simple or healthy as pect, it is to be treated accordingly; or if it be comes indolent, to be stimulated with solutions of the nitrates of silver and copper, sulphate of cop per, 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 con stitution, affects either the vertebrae 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 acupuncturir.g, 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 some times quite disorganized, a complete mollescence, with more or less purulent matter exterior.