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Another random document with
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 In the so-called subperiosteal method the operator endeavors, so
far as possible, to preserve the periosteum of the parts exposed to
attack, and, if possible, the capsular ligament as well. Thus at the
elbow the capsule, if not diseased or obliterated, should be
preserved, the osseous tissue being shelled out from within, so far
as possible. The less, then, the connections between the capsule
and the periosteum are disturbed the better. The French apply to this
method the term “subcapsular periosteal.” When the bone covering
can be preserved new bone is easily formed to replace that which
has been lost, especially during adolescence, while the preservation
of the capsule, with its ligamentous connections, affords a better joint
cavity than will the substitute which results from natural processes.
Furthermore the surrounding tendons are less disturbed and the
condition remains more like the original. Nevertheless one does not
exsect healthy joints, and the method is not always easy nor even
possible of performance. It will suffice to say that it should be
adhered to only as far as circumstances may justify or permit.
Surgeons, however, have not been satisfied with the older
methods, and have endeavored to still further enhance motility in
operated joints. (See above—Arthroplasty.) To this end the
interposition of muscle, fascia, or of foreign membrane has been
suggested. Thus, after removal of the head of the femur a strip of
fascia lata may be interposed between the raw-bone surface and the
cavity of the acetabulum, being fastened there by catgut sutures. In
the shoulder a similar procedure has been carried out, utilizing a
strip of deltoid muscle. At the elbow a piece of the pronator radii
teres may be detached and fixed by sutures to the brachialis anticus.
In every case the method should be adapted to the demands made,
the intent being to cover divided bone ends with tissue which will
prevent osseous union, as it is known to do in many cases of
fracture where such interposition produces non-union. In so far as
one attempts here to imitate conditions which are considered
undesirable in certain other traumatisms, Murphy has done more
than any other American surgeon, both in the experimental and
clinical study of this subject. (See above.)
For the joints below the hip and shoulder the bloodless method will
facilitate operative work. In case of a septic joint, however, it would
not be advisable to apply the elastic bandage below and then over
and around the joint, as by the pressure thus made some septic
material may be forced into the absorbents. In clean cases the
rubber bandage is a great advantage to the operator. It has this
objection, however, in that hemorrhage which does not occur during
the operation has to be checked after its conclusion, and I have often
thought it advisable to avoid the use of the bandage and to secure
vessels as they are divided, in order that when bleeding has once
ceased there be no fear of its recurrence later.
The question of drainage is one of importance. In a general way
one may feel that in an absolutely clean case drainage is not
required, save possibly a small opening for escape of blood. If
practised at all it should be thoroughly done. Drainage tubes are
often too small and do not permit the escape of either clotted blood
or debris of injured tissue.
The after-treatment of excisions demands, first of all, physiological
rest of the part involved, especially if, as at the knee, sutures or other
expedients for maintaining apposition have been inserted. When
motion is sought there will soon come a time when passive motion
can be begun. This will vary with the size of the joint and the
magnitude of the procedure. Actual rest should be maintained until
firm wound healing has been secured. Passive motion is then begun,
to be practised daily, the sensation of the patient being the guide as
to the range of the movement and extent of manipulation. Thus, after
exsection of an elbow with prompt union of the wound passive
motion should be begun in about two weeks, but it should not be
begun for a month if the joint has been thoroughly disorganized and
the cavity is still discharging. Motion should be begun as early as is
considered feasible in order to guard against a false joint.
The remote consequences of joint excisions are usually very
satisfactory. The best results are obtained in the young, i. e., those
whose tissues are still undergoing natural changes and whose bones
are growing. In the course of time, by condensation of surrounding
tissues, a new joint capsule is formed, its interior smoothed off,
apparently covered with endothelium and filled with a sufficient
amount of fluid, similar to that of normal joints, to serve the purpose;
in this way a new joint becomes gradually substituted for the old,
which serves the original purpose, in a surprising and gratifying way.
Even in those of advanced years a satisfactory result is often
obtained. It is often necessary to afford some support, by which too
great a range of motion may be avoided; thus at the elbow the result
at first is what may be called a “flail-joint,” which permits much
undesirable lateral movement. This can be avoided by having light
leather corsets fitted to the forearm and arm, connected by two
lateral hinged braces. This being constantly worn, and no motion
permitted which is not an imitation of the normal, the parts in time
adapt themselves to the purpose, so that all apparatus can after a
while be removed.
Excisions, like amputations, may be practised and the general
methods learned on the cadaver, but their actual performance in the
presence of extensive disease will be found to be a different
procedure from that learned upon the dead body. For reasonably
representative cases typical operations can be devised, with explicit
directions. It is not advisable to try to do such work through too short
incisions. A long incision heals as kindly as one shorter and affords
more room for operative work. The incision should be so planned
and executed as to afford the maximum of exposure with the
minimum of damage to important structures. The region of the great
vessels is avoided in all the classical operations, while nerve trunks,
if exposed, are retracted and kept out of harm’s way. After the knife
has once laid open the joint it is used but little except for the division
of resisting structures, e. g., ligaments. The greater part of the work
is then done with elevators, or periostomes with reasonably sharp
edges and sufficiently broad surface, so that the periosteum can be
divided with the latter and separated with the former to the
necessary extent. Obviously epiphyseal junctions should be spared
whenever possible, especially in the young. To remove an entire
epiphysis is to materially impair the later growth of the limb. In some
of the most serious cases it will be found already loosened and lying
as a sequestrum in the joint cavity. In this case it may be easily lifted
out of place. Tendons should never be divided unless absolutely
necessary. Incisions in their neighborhood should be so planned as
to be parallel with their direction and permit their displacement
without division. The sharp spoon should be employed for curetting
the interior of a joint capsule or cleaning out a bone focus (erasion).
A capsule involved in tuberculous disease should be completely
extirpated. Diseased bone ends should be sufficiently exposed to
permit of the use of an ordinary saw or a chain or wire saw.[34]
Considerable force will often be necessary in making bone ends
accessible for this purpose. The chisel is rarely used except in cases
of bony ankylosis, where it is not possible to force bone ends
through the opening in order to attack them with the saw. As
remarked above, clean cases may be closed without drainage.
Visible vessels should be secured, and, while a certain amount of
oozing may be expected, if the part be enclosed in suitable
compressive dressings and elevated, it need not cause alarm. The
gentle application of an elastic bandage for three or four hours may
afford additional security. It should not, however, be allowed long to
remain. The terminal portion of the limb will always afford an
indication as to the condition of the circulation. Should it become
cyanotic or cold the dressing should be renewed and the wound
examined promptly.
[34] Wyeth’s “exsector” is an admirable substitute, especially at the
shoulder and hip.

Special Incisions. The Shoulder.—A longitudinal incision suffices

for most cases (Fig. 214). This may be made
posteriorly between the fibers of the deltoid or anteriorly and
externally over the bicipital groove. It is better to separate the deltoid
fibers than to divide them, although they may be divided. Should the
straight incision afford insufficient room another incision at right
angles will afford ample access. The capsule, having been exposed,
is opened, the wound widely separated with retractors, the arm
rotated through a wide arc, while with a stout knife the capsular
ligament and the various muscular attachments around the neck of
the bone are divided. The greater and lesser tuberosities, with their
muscles undivided, should be retained, when circumstances permit.
The head of the bone, being freed, is dislocated and forced out
through the wound, where it may be seized with large forceps and
removed with a saw. The higher the bone is divided the better. Every
other consideration, however, should be sacrificed to removal of all
foci of disease. The capsule may then be extirpated and the glenoid
cavity thoroughly cleaned out with a sharp spoon. Should the case
be one of serious infection it is advisable to make a posterior
opening, even through the deltoid, for purposes of thorough
drainage. The greater part of the first incision is to be closed with
sutures, the arm dressed in a comfortable position, with the elbow at
a right angle, and the patient allowed to be up and around as soon
as he feels in the mood for it.
 Fig. 214

Excision of the shoulder: A, regular incision; B, supplementary. (Ollier.)

The Elbow.—Here a variety of methods have been advised, and the

extent of the operation must depend, to some degree at least, on the
nature and extent of the condition which necessitates it. Partial
excisions have been recommended, though in the writer’s
experience incomplete operations often give less satisfaction than
those which are complete. However, when it is a question of
removing callus or displaced bone fragments, which, after fracture
into the joint, impair its function, then partial resections may be
serviceable.

Fig. 215 Fig. 216 Fig. 217

Excision of the elbow-joint: Excision of the elbow-joint: Osteoplastic method: A,

A, von Langenbeck; B, A, Nélaton; B, C, Hueter. by external incision; B, von
Ollier. Mosetig-Moorhof.

The essential incision is a long posterior one, which may be

somewhat modified (Figs. 215, 216 and 217). It is essential here to
avoid the ulnar nerve, which passes between the internal epicondyle
and the olecranon, and the vessels and nerves in front of the joint. If
it be made an inviolable rule to always keep close to the bone both
of these dangers may be avoided. Ligamentous and muscular
structures, among the latter the anconeus, should be spared as
much as possible. After separating the joint surfaces thoroughly, by
forced flexion, it is usually easier to force out the lower end of the
humerus and first remove it, after which the upper ends of the radius
and ulna are exposed and removed. When there is bony ankylosis it
is preferable to divide the bones of the forearm first. The tendon of
the triceps is not only detached from the olecranon, but divided by
the first long incision. After concluding the incision, the capsule, if it
remains, is to be closed with chromic catgut sutures and the end of
the triceps tendon or some of its periosteal attachment united to the
periosteum of the upper end of the ulna.
The arm is now fixed in the right-angle position and held
comfortably to the body by a suitable sling.
The Wrist.—It is rare that in disease of the wrist-joint this is found to
be limited to a single bone of the carpus. Should an x-ray
examination indicate such limitation then the focus can be exposed
and cleaned by an incision upon the dorsum of the wrist, where it
may seem best adapted for the purpose. Suppurative and
tuberculous affections of the wrist usually necessitate removal of the
carpal bones, including, possibly, the lower extremities of the ulna
and radius. When the wrist-joint is involved it may be sufficient to
remove the latter with the first row of the carpus.
Fig. 218 illustrates the incisions to be recommended for wrist
resection, of which the Langenbeck line is to be preferred.
Occasionally two lateral incisions, with through drainage, will better
serve the purpose. It may be necessary to divide the short radial
extensor, but this may be united again with suture. In most instances
it is possible to retract the tendons to either side and thus clear the
carpal region. By hyperextension the extensor tendons are relaxed
and more room is thus made. The incision marked “A” combined with
that marked “B” in Fig. 218, affords the best exposure when disease
is extensive. The incision along the inner border of the wrist is made
5 Cm. above the styloid process of the ulna, and between the latter
and the ulnar flexor down to the middle of the last metacarpal bone.
Here the tendon of the latter muscle should be divided at its insertion
and lifted out of its groove in the ulna. The collection of extensor
tendons is then separated from the back of the wrist and lifted up, it
being usually necessary to divide the unciform process of the
unciform bone with forceps. The knife should be kept from the
palmar surfaces of the metacarpal bones in order to avoid injury to
the deep arch. After dividing the anterior radiocarpal ligament the
carpus is extirpated through the ulnar incision. The ends of the ulna
and radius are now easily accessible for removal with forceps or a
metacarpal saw. The same is also true of the proximal ends of the
metacarpals. After spreading the hand and forearm upon a flat splint
drainage can be made to the desired extent and the wound closed.
 Fig. 218 Fig. 219

Excision of the wrist: A, Lister’s radial Excision of the hip: A, Sayre; B, Ollier.
incision; B, Lister’s ulnar incision; C,
Ollier; D, von Langenbeck.

So far as the hand and fingers are concerned little resecting need
be done, the surgeon usually confining himself to the removal of
sequestra or curetting of carious bone. In cases of compound
comminuted fracture bone fragments may be removed; only in cases
of lost or destroyed phalanges will amputation be necessary.
The Hip.—In its structure the hip-joint is one of the simplest in the
body. Although it lies deeply it is easily made accessible. Fig. 219
illustrates the incisions by which the joint is attacked for the purpose
of exsection. If necessary either extremity of the incision can be
extended or enlarged by a cross-cut. When the joint is disintegrated
by disease, especially when partially dislocated, the parts will lend
themselves to an easy and simple operation. When, however, the
operation is done for ankylosis or for disease, by which great
thickening and fixation have been produced, the measure may
become difficult. For ordinary purposes the simplest method is to
drive a sharp-pointed, strong-bladed knife directly down upon the
neck of the bone from a point midway between the great trochanter
and the crest of the ilium; then keeping the knife-blade in contact
with the bone the incision is carried downward over the trochanter
and along the shaft to a length making it sufficient for easy exposure
of the bone and of the joint. Nothing is gained in these cases by
trying to work through a short incision. A long one heals as readily
and makes the operation more simple. It is as easy to make the
entire incision in one cut as to divide the muscles layer by layer. The
capsule of the neck of the femur being exposed by a wide retraction
of wound margins, it is necessary next to divide muscular
attachments to the great trochanter by raising the periosteum to
which they are attached and saving both. To expose these insertions
the femur should be rotated inward and outward, while the capsule is
at the same time divided. The ligamentum teres, which offers a
theoretical obstacle, usually disappears in the presence of any active
disease and is scarcely ever encountered; it can be divided with
curved scissors. Now by more or less powerful effort, including
flexion and adduction to the extreme limit, with more or less rotation,
the head of the bone is forced out from its socket and through the
wound. Whether the bone should be decapitated with chain saw,
metacarpal saw, or by the exsector of Wyeth will depend partly upon
the freedom with which it can be exposed and on the equipment of
the operator. It may be advisable to divide the neck with a chisel.
The trochanter major should be preserved whenever its removal is
not made imperative by the progress of the disease. The head and
neck of the bone having been removed, the acetabulum is now more
or less easily exposed, especially with retractors, and it should be
cleaned with a sharp spoon. The capsule also should be removed, at
least when the operation is done for tuberculous or other infectious
condition. It is advisable to irrigate, then to wipe dry all the original
joint surfaces and raw bone, and finally to cauterize either with pure
carbolic or with zinc chloride, which should be washed away with the
irrigating stream, the intent being to close the mouths of all the
absorbents and prevent absorption from fresh exposure. Sinuses if
present should be thoroughly excised, scraped, and treated in the
same way. A drainage tube is usually preferable to the use of gauze.
The above is the method usually relied upon for hip exsection.
Other methods have been devised, especially by anterior incision; of
these the best probably is that of Barker. The cut is made along the
outer border of the anterior surface of the sartorius and rectus, and
through it the femoral neck is reached. By wide retraction the
anterior surface of the joint can be completely exposed and opened,
and through this opening the neck of the femur can be divided with a
chain saw or chisel, before removal of the head from the
acetabulum. The disadvantage of anterior incision is that pertaining
to drainage. Nevertheless this can be obviated with capillary drains.
Its advantages are that splinting and protection can be more
perfectly effected, with less necessity for frequent interference. In
other words it makes the subsequent care of the patient easier.
Many English surgeons are in favor of it. Ollier devised a so-called
osteoplastic excision, made through a curved incision with a
downward convexity, the top of the great trochanter being exposed
and divided with a chisel sufficiently to permit of its being turned up
with the flap, and then being reunited to the main part of the bone
after the removal of the neck and head. This method has its
advantages in a limited number of cases, but it has not become
popular in this country. It would seem to be an advantage to
preserve the trochanter, although some surgeons remove it. So long,
however, as disease is confined to the head and neck of the bone it
is unnecessary to remove this projection.
The after-care of a hip excision is not an easy matter. Most
surgeons prefer to maintain the limb in position by the aid of traction,
with sufficient weight to overcome all muscle spasm. If the case be
such that dressings need only be made at long intervals, then it
matters little, but in a septic case in which there is considerable
discharge the problem is sometimes a serious one. Various beds or
suspension splints have been devised, consisting essentially of
frames with cross-strips of stout material, upon which the patient lies.
After raising the frame one or two of these strips are released and
the parts exposed. This arrangement also permits of the easy
management of a bed-pan. In young children a wire splint with a
fenestrum, or a plaster-of-Paris spica or breeches with large opening
cut opposite the wound, will often be serviceable. The tendency is
rather toward adduction, and this should be overcome. Something
will depend upon whether the surgeon is working for ankylosis or for
a movable joint. In the former case a rigid dressing should be
employed as soon as the condition of the wound permits. In the latter
passive movement should be begun as soon as the wound is
healed.
While the operation is usually performed quickly, and is not
regarded as serious, it nevertheless has a considerable mortality,
especially in the young and the aged, because of the conditions
which necessitate it. After a complete exsection, even by the most
ideal method and in the most ideal case, the limb remains somewhat
shortened. This may be compensated by raising the heel of the shoe
worn on the affected side. In severe cases it may be necessary to
supply even two or three inches of artificial support for this purpose.
Unless this is done compensatory spinal curvature will ensue.
—The knee is generally more accessible for operation than the
elbow, as the important structures which should not be disturbed lie
grouped upon its posterior aspect. Protection for one of these is
protection for all, and the freedom with which the joint may be
opened makes it especially easy to do either complete or partial
operation. Here the surgeon should endeavor to preserve the
epiphyses, especially in children, as they have much to do with the
growth and length of the limb. So long as incision is confined to the
anterior aspect of the joint it can be made in almost any manner. The
usual method is that represented by line A in Fig. 220, by which a
horseshoe flap is raised and the joint interior exposed. Occasionally
the direction of the flap is reversed, and it is turned downward rather
than upward. In the former case the ligamentum patellæ is divided;
in the latter, the tendo patellæ. Whichever way the flap is turned it is
made to include the patella, although this bone can be removed at
any time. The lateral ligaments being divided, as well as the crucial,
and the limb completely flexed, exposure of the joint surfaces is
 The Knee.made. It is Fig. 220
now possible to do an
arthrectomy, a partial
exsection or a
complete one,
according as the
disease is more or
less extensive. In the
complete operation
the articular surfaces
of the femur and of
the tibia are usually
removed with an
amputating saw. If
this be introduced
from the front and
made to work its way
backward the
popliteal vessels
should be amply
protected against
possible injury. Here it
should be borne in
mind that the leg is
not constructed in a
straight line, but that
there is a lateral
angle at the knee, as
the femurs diverge as
they pass upward,
and this angle should
be imitated in
directing the saw and
removing the bone
end. Again, a slight
bend anteriorly will
make the limb more
useful than one which Excision of the knee-joint: A, semilunar incision; B,
is absolutely straight. Ollier’s incision.
The intent thus
should be to give the knee at a slight angle anteriorly and interiorly,
and the saw should be manipulated with great care. In a complete
operation the patella is also removed. In tuberculous and other
septic disease the capsule should be completely extirpated. This
offers no difficulty, save at the posterior surface, where it may
approach closely to the region of the great vessels.
Various modifications have been practised in these operations.
Some open the joint by straight cross-incision with division of the
patella, the latter being reunited with tendon or wire sutures. Others
have practised a more complicated H-shaped incision, the
transverse portion being carried either through the patella or just
below it. The line marked B in Fig. 220 was suggested by Ollier. It is
questionable whether any of these methods offer any advantages
over the one first described.
After exsection it is desirable to maintain the bone ends in an
accurate position if speedy reunion be desired, and for this purpose
various methods are in vogue. The bones may be drilled and
fastened together with tendon or wire sutures, or ivory nails may be
driven in, one on each side, directing them obliquely, so that
displacement cannot easily occur, or metal nails may be used for the
same purpose. Another plan is to insert two long metal drills, one on
either side, which perforate the skin two or three inches above the
wound, and are passed downward and toward the other side so as
to fix the surfaces, as it were, by a cross-forked arrangement. After
two or three weeks these drills may be withdrawn. Fixation of this
kind is advantageous, for when complete excision has been
practised the surrounding tissues are lax and the parts are not easily
held in position by external dressings alone. In a clean case, with
careful hemostasis, very little drainage will be required. What is
needed can be provided by an absorbable drain passed through the
lower portion of the wound on either side. In a septic case it would
be well to provide for ample drainage on each side.
The limb may be dressed upon a fenestrated wire or gauze splint,
which is easier when frequent change of dressing can be foreseen,
or it may be immobilized in a plaster-of-Paris splint.
The Ankle.—The ankle is usually reached by an incision on either
side, three or four inches in length, extending from above each
malleolus downward and forward on to the tarsus. The knife-blade
should be forced to the bone, so as to divide the periosteum, which
is subsequently separated and lifted by an elevator, in order that the
operation may be made subperiosteally. The fibula is usually first
divided, with a chain saw or a chisel, an inch above its tip. The
divided fragment is wrenched from its place with forceps, and
severed from the ligaments by knife or scissors, being careful not to
injure the external lateral ligament. The inner incision is made in
practically the same way, the periosteum separated, the internal
lateral ligament divided, and the end of the tibia forced through the
incision by everting the foot. Its joint end may be removed with a
saw, dividing on the same level and plane with the lower end of the
fibula. Through the gap thus made the astragalus may be either
removed or its upper surface divided with a metacarpal saw. The
fresh bone surfaces left in this way will unite and ankylosis will result,
unless fibrous or muscular tissue be interposed to favor the
formation of a false joint.
As in other operations methods may be varied to meet the
exigencies of certain cases. Longitudinal incisions may be placed
farther forward than indicated above, as is shown in Fig. 221, which
illustrated König’s method. Here the bone surfaces are divided with
broad chisels. A transverse incision of the front and upper part of the
ankle may be made, through which the tendons are exposed, lifted in
a group out of harm’s way, and curetting and bone sawing
performed. Kocher makes a semilunar incision from the outer border
of the tendo Achillis to the outer border of the extensor tendons, its
line passing beneath the external malleolus. By this method the joint
is opened and the peroneal tendons divided, their ends being
reunited after the completion of the balance of the work. This method
is usually applicable in children.
Ample drainage is required in these cases, for the operation is
seldom performed in the absence of septic complications. The foot
should be kept in proper and right-angled position by metallic splints,
or by plaster of Paris, the latter preferable, fenestra being cut in
order to make access to the wound.
Excisions of the Tarsus and Osteoplastic Excision of the
Heel.
—Removal of the tarsal bones is confined usually to cases of
tuberculous disease, and may be performed by a variety of methods.
Thus the tissues of the sole of the foot may be divided transversely
by an incision carried from the tubercle of the scaphoid beneath the
sole and across to a point one inch behind the base of the
metatarsal. Through this, access can be made to the inferior surface
of the tarsus. Conversely the upper portion may be exposed by a
similar transverse incision across the dorsum of the foot, by lateral
incisions, or by a combination of both. It is seldom necessary to
divide the tendons, it being nearly always possible to gather them
into a group and lift them out, while the bones are attacked with a
sharp spoon or a chisel.
Occasionally the calcis becomes involved in cancerous or
tuberculous disease and it would appear that removal of the heel
proper would be all that is required. To meet these indications
Wladimirov, in 1871, and Mikulicz, in 1880, independently devised a
method by which the ankle-joint may be opened and as much of the
heel and adjoining tarsus as necessary removed, the foot being later
fixed in the extreme equinus position. This is referred to as
osteoplastic excision or amputation of the heel. Fig. 222 illustrates
the line of incision, which extends from the tubercle of the scaphoid
beneath the heel to a point on the opposite side, then obliquely
upward and backward to the base of each malleolus, and then
transversely and posteriorly, thus including within its line the region
of the heel. These incisions extend to the bone, the ankle-joint is
opened posteriorly, the lateral ligaments divided, the lower
extremities of the tibia and fibula removed with a saw, the astragalus
and calcis separated from their attachments, and the posterior
articular surfaces of the scaphoid and cuboid also removed. The
lines of division of bone are indicated by dotted lines in Fig. 222.
Thus the lower ends of the leg bones are brought into contact with
the upper end of the divided tarsus by straightening the foot in the
extreme equinus position and maintaining this position with wire
sutures or bone or metal pins.

Fig. 221

König’s incision for excision of the ankle.

 Fig. 222

Osteoplastic excision of the foot. (Mikulicz.)

The cases in which this method is of use are rare, but when
indicated it has usually given satisfactory results. It is a substitute for
amputation of the leg, and it is often an open question as to which
will give the most satisfactory result. It has probably not been
practised a hundred times.
 CHAPTER XXXII.
SURGICAL DISEASES OF THE OSSEOUS
SYSTEM.
At the outset of a study of surgical diseases of the osseous system
it is necessary to emphasize a fact which students and young
practitioners are liable to forget, namely, that bone, even the
densest, is a tissue, and that as such it is liable to infection,
suppuration, gangrene, etc., just as is any other tissue; that all
infectious processes are identical in general character, their gross
manifestations varying only by virtue of the peculiar characteristics of
the tissue in which the infection occurs. Bone is vascular, and even
that exceedingly hard variety, which is met with in the petrous portion
of the temporal, or the ivory exostosis, has sufficient connection with
the vascular system to permit of its proper nutrition. The firmest and
hardest bone will bleed when divided or injured, and any tissue
which will thus bleed can react injuriously to various irritants.
All bone-marrow begins as red marrow, with 1 or 2 per cent. of fat,
and ends by becoming yellow, with 60 or 70 per cent. of fat, and
whether this change shall take place suddenly or rapidly depends
upon diverse conditions. Many years ago it was claimed by Bourgery
that bone is simply a large cavernous arrangement where stagnation
of the blood current favors the deposition of fat. Fatty alteration
progresses from periphery to centre, and the bones of the hands and
feet undergo fatty alterations before those of the trunk and pelvis. In
other words, the truncal skeleton remains as “red bone” longer than
the balance of the osseous system, and he whose sternum has
become a “yellow bone” should have reached a ripe old age. In long
bones distal extremities first become fatty. Individual peculiarities
seem to govern these changes. Thus the neck of the femur will
sometimes be fatty and friable at the fortieth year, or reasonably firm
and still red at the eightieth. This fatty condition is not to be
confounded with true osteoporosis or rarefaction in bone, though it is
often associated with it. When the two conditions are combined we