A UNIQUE CASE OF FRACTURED EXOSTOSIS

ThomasH. Manley
1889 The Lancet  
636 change which the vessel wall has undergone. Whether injury be the direct cause of the change, or whether (as seems probable in cases where inflammation has supervened without traumatism) there is some obscure physiological connexion between the cells and the blood vessels of a tissue, we are fairly safe in describing that change as "molecular." At all events, it probably means some impairment of vitality, and one can distinguish two ways in which this would favour the escape of leucocytes.
more » ... ape of leucocytes. For impairment of vitality involves loss of elasticity, which must lead successively to increased resistance to flow, dilatation, and stagnation, which last obviously encourages any attack the leucocytes may attempt upon the wall. Again, loss of elasticity must involve relaxation of any stomata which the leucocytes may have discovered or have made by the insinuation of pseudopodia. Such a view of the process of migration is more conceivable and rational than one which refers it "to a special attraction which the bloodvessels exert on the white corpuscles." For this entails certain difficulties. It is, in the first place, not easy to see why injury should suddenly inspire the wall of the vessel with a special attraction for the white cells, selecting them, moreover, in preference to the red. One has next to get over the difficulty that the leucocytes get over when they are half way through, for it might reasonably be expected that a "special attraction" would hold them fixed in this awkward position. Lastly, we cannot but wonder what becomes of the " special attraction" when the leucocytes, having effected their passage, break away from the vessel. I said in the early part of this paper that I interpreted inflammation as an exaggerated manifestation of a normal function, and that when we had determined the function of inflammation we should have found the clue to the, or at all events a, function generally served by leucocytes. We have seen leucocytes serving special functions in the alimentary tract, and in the respiratory tract as carriers and scavengers-functions both allied to what is believed to be the function of inflammation. But in the respiratory and alimentary tracts the functions of leucocytes are special and concern only those two situations. Inflammation, however, may occur anywhere, and what has now to be shown is that, no matter where it occurs, it is an exaggerated manifestation of a process normally going on at that spot-that is to say, it has to be shown that the migration of leucocytes from the vessels into the tissues is a constant physiological event, and that the function served by these leucocytes is the removal of cell debris. It may easily be proved that leucocytes habitually migrate from bloodvessels. Remembering their roaming habits, and remembering their demeanour in the bloodvessels, and remembering the stigmata that exist in capillary walls, and the power, further, that leucocytes possess of insinuating pseudopodia, and then flowing along the narrow isthmus so formed, we seem to have good reason to believe that migration may normally occur by such a mechanism. But we have absolute proof that it does occur. In course of digestion the number of leucocytes in the blood increases considerably. This is understood to be due to the vigorous lymphatic circulation which accompanies absorption at the lacteals, leucocytes being thereby carried into the veins of the neck from the lymphatic system where they chiefly abound. But some hours subsequently the number of leucocytes in the blood is found to be the same as it was before the meal. Rejecting the view that leucocytes are split up in the blood to provide food for the tissues, the conclusion is inevitable that they have escaped from the bloodchannels. The only ways open to them are back into the lymphatics against the current or out through the vesselwalls into the tissues. We need hardly consider the former alternative and are driven on to the latter. (To be concluded.) SOCIETY OF APOTHECARIES OF LONDON.-The results of the examination in Arts qualifying for registration as medical student, held in the Ha11 of the Society on Sept. 6th and 7th, have just been published. There were 155 candidates, and from the pass-list it appears that 3 were placed in the first class, and 18 in the second class, and 114 were certified as having passed in some subjects, but not in all. The next examination will be held on THE case on which this article is written presented many features quite peculiar to itself, seldom heard of, rarely dealt with, and probably seen only occasionally even in the, practice of those of very extensive experience. For, being of an extremely obscure nature with respect to its real character, for the many and unusual coincident pathological conditions, the odd and singular form of this bony excrescence, as well as the surgical measures adopted for its. removal, it would seem to stand nearly alone. Our patient was a young Italian, nineteen years of age. He had been in America two years, and had always enjoyed good health until a little more than a year previously, when he said he commenced to feel slight pains along the inner side of the leg, which, though severe occasionally, at times. would annoy him but very little. During one painful spell he consulted a physician, who treated him for rheumatism. He had finally become so accustomed to the difficulty that it gave him little thought, till one day, while working with other labourers in excavating a drain, in making an effort, to raise a heavy piece of stone he suddenly became weak, and had to desist from work. This weakness was followed by chills and pain all over the left lower extremity. After remaining away from work a week he returned. He now found himself lame and only able to continue at his occupation with considerable discomfort. He soon had to" stop again, when he applied at the hospital for admission. This was sixteen days after the mishap in the trench, and about a year from the date that he first felt anything wrong on the same side. He walked to the hospital--about half a, mile-and readily ascended a couple of sets of stairs without any assistance. Condition on adrnission.-He was extremely weak, very much emaciated, very pale, with the look of one in much distress. How he was able to drag himself to the hospital was. a marvel to all who saw him. His pulse was now nearly 120 beats per minute, with a temperature of 101°. No evidence of organic disease was found. On being stripped of his clothing, the left lower limb was seen to be greatly swollen from Poupart's ligament down to the knee, mostly on the inner aspect ; though the outside was also considerably distended, but to a lesser degree, in the same direction. Now, the question was, What could this great increase in volume be attributed to ? Was it a haematoma, an osteoidsarcoma, a simple serous accumulation due to blocking of the deep femoral vein ; or was it an accumulation of pus ? As there was no history of injury, either recent or remote, we were led to eliminate rupture of a vessel as a cause; and as. there was good circulation in the vessels of the limb lower down, which would not be the case if directly dependent on vascular lesion, we were led to believe that pus was present. This was decided beyond question by the exploring needle. It was clear that there was an enormous formation of purulent matter ; but when we came to consider the question as. to its probable origin and exciting cause, we were obliged to hesitate. There being nothing pointing to traumatism, and no trace or signs of vertebral disease, and the chief symptom being of recent date, it was ratherdifficult to reach a definite conclusion. Had he beem laid up any considerable time in bed, it would have led us to suspect an abscess of the psoas variety, or that there was bone disease involving the hip-joint or upper part of the femoral shaft; but with a man walking into hospital unaided, the existence of any of these lesions. seemed impossible. Regardless, however, of what or where the real seat of this pus was, the indications for treatment, were very plain. The first was to open into the matter and drain it away; the second, two endeavour to find its exciting cause, and if practicable remove it. It was hoped that with a free vent for the abscess and free irrigation of , the parts with some mild non-irritating antiseptic solution, , our patient would soon recover; remembering that for some cause not yet well understood, especially in erysipelas, pus will form in enormous quantities in the deep loose areolar tissues; and also, in what was formerly designated 1 Read before the Amer. Med. Assoc., Newport, R.I., June 25th, 1889.
doi:10.1016/s0140-6736(02)29572-0 fatcat:iik7t7nogbdx7oxkn5izb7txza