and sixteen of a cold solution of carbolic acid ; the latter being of the
same strength as the solution employed for injecting the wound.
Over this Mr. Lister's lac plaster is applied, surrounding the entire
limb and extending several inches above and below the wound. Dr.
A. B. Strachan, of this city, who has been kind enough to furnish me
with these details, taken from his own notes as they were made under
Mr. Lister's instructions, is unable to give me the formula for the lac
plaster. At Bellevue we use a lac composed of gum shellac three
parts, and carbolic acid crystals one part ; the shellac being stirred
in gradually while the crystals are heated nearly to the boiling point.
The subsequent dressings must be made as often as the character
and amount of the discharge may seem to require ; but at each dress-
ing care must be taken not to admit the air to the surface of the
wound; and for this purpose Mr. Lister conducts the changes in the
dressings under a stream of the watery solution of the carbolic acid,
which is continually playing upon the part.
Many years since. Dr. J. Rhea Barton introduced into the Pennsyl-
vania Hospital what has since been called the " bran dressing" for the
treatment of compound fractures of the leg ; the limb being made to
repose in a box filled with this material.^ I have used it very fre-
quently in Bellevue and in other hospitals, and can speak of it as
possessing many qualities of excellence, especially as a summer dress-
ing. The particular mode of using this apparatus I shall describe
more minutely when treating of fractures of the leg.
The treatment of inflammatory symptoms, and of the later accidents,
such as suppuration, oedema, gangrene, tetanus, &c., must be left mainly
to the good judgment of the surgeon. Qentle manipulation, uniform
support, rest, and sometimes cooling lotions constitute the most impor-
tant means by which inflammation is to be controlled. Bleeding is
> Paper on Bran Dressing, by Reynell Coates, of Philadelphia. Amer. Joum.
Med. Sci., April, 1842, p. 515 ; from the Med. Examiner, iNos. 9 and 11, vol. i.,
New Series.
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62 DELAYED AND NON-UNION OF BROKEN BONES.
rarely necessary, and in a large majority of cases it might prove
injurious by lowering too much the vital forces, which need to be
husbanded in view of the requirements of the process of repair and of
the long and exhausting confinement. Catnartics should also "be
administered cautiously for the same reason, and because they are
liable, especially in fractures of the lower extremities, to occasion a
serious disturbance of the limb.
CHAPTER VI.
DELAYED UNION, FIBROUS UNION, AND NON-UNION OF BROKEN-
BONES.*
Most surgical writers concur in the statement that non-union of
broken bones is an uncommon event. Walker, of Oxford, affirms
that of not less than one thousand fractures which have come under
his treatment at some period of the repair, he does not recollect more
than six or eight instances. According to Lonsdale, not more than
five or six cases of false joint, excepting those within a capsule, have
occurred out of nearly four thousand fractures treated at the Middle-
sex Hospital. In a table of 867 cases, collected and arranged by W,
W. Morland, from the books of the Massachusetts General Hospital,
extending through a period of nineteen years, only one example of
false joint is recorded ; but as only seventy-four days had elapsed
when this patient was discharged, it is doubtful whether this might
not have proved to be a case of delayed union simply.^ In 946 cases
of recent fracture treated in the Pennsylvania Hospital, between the
years 1830 and 1840, there was no instance of false union.* Sir Stephen
Hammick, Mr. Liston, and Malgaigne affirm also the infrequency of
these accidents in the cases which have come under their personal
treatment. I have myself seen a large number of examples of non-
union, but in not one of my own patients, whether in hospital or
private practice, except, in cases involving joints, has the bone re-
fused finally to unite ; and my opinion is, that, in proportion to the
number of fractures everywhere, these cases are very rare, perhaps
not in a larger proportion than one in five hundred.
The humerus and femur would appear to be the bones most liable
to non-union, as shown by Norris's statistics; in which forty-eight be-
longed to the humerus, forty-eight to the femur, thirty-three to the leg,
* I shall in this chapter avail myself freely of the labors of Gteorge W. Norris, of
Philadelphia, whose paper, entitled "On the Occurrence of Non-union after Frac-
tures, its Causes and Treatment,^* published in the American Journal of ths Medical
Sciences for Jan. 1842, constitutes the most complete and reliable monograph upon
this subject contained in any language.
2 Address on Fractures, by A. L. JPierson, read before the Massachusetts Med.
Soc, May 27, 1840.
» Norns, loc. cit.
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DELAYED AND NON-UNION OF BROKEN BONES. 63
nineteen to the forearm, and two to the jaw. In my own experience,
I have foand the humerus ununited much more often than the femur.
B^rard has shown that in the growth of the long bones the period
at which the epiphyses are united to the diaphyses depends upon the
direction of the nutritive artery ; for example, ** it is found that in the
humerus^ where the direction of this vessel is from above downwards,
consolidation takes place soonest at its inferior extremity. In the fore-
arm, the course of the nutrient vessels is from below upwards, and
here consolidation of the epiphyses is found to occur at the elbow
sooner than at the wrist. In the inferior members, on the contrary,
the epiphyses composing the knee are the last which become firm,
because in the femur the nutritious artery runs upwards, and in the
bones of the leg it courses from above downwards." A knowledge of
these facts led Gu^retin to inquire into the influence of these arteries
upon the consolidation of fractures; and the cases collected by him
did indeed seem to show a positive relation between the direction of
the artery and the union of the bone ; that is to say, the examples of
non-union were chiefly found where the fracture had taken place on
that side of the nutritious foramen from which the artery entered, as
if to imply that the non-union was in some measure due to the imper-
fect nutrition of this extremity of the bone. In thirty-five cases of
non-union analyzed by Gu^retin, ten belonged to that portion of the
bone which was traversed by the artery, and twenty-five to the other
portion. But an analysis of forty-one cases, made by Norris, does not
seem to confirm this observation of Gudretin, since twenty-seven were
in the direction of the nutritious arteries, and only fourteen in the
opposite portion, or in that which is supposed to be l«ss nourished.
Another observation, made by Curling, that in fractures of the long
bones the portion below the entrance of the nutrient artery, or on that
side of the nutrient foramen towards which the blood flows, being
defrauded of its proper supply, is subjected to a species of atrophy,
presenting a larger medullary canal, with thinner walls, atid a spongy
tissue less dense, also needs confirmation. Malgaigne has not noticed
this fact in any of the specimens contained in the public museums of
Paris ; and we do not know that any other writer has made the ques-
tion a subject of especial inquiry.
According to Norris, there are four principal kinds of false joint : —
In the first, the bones are united ana completely enveloped in a car-
tilaginous mass or callous tumor, but^ in consequence of some retarda-
tion in the process, bony matter is not deposited, and, as a consequence,
it wants solidity, the part continuing easily movable. This may be
regarded as a proper example of delayed union, as distinguished from
complete non-union, or false joint.
In the second, there is entire want of union of any sort between
the fragments, the ends of which seem to be diminished in size and
extremely movable beneath the integuments. The limb in these cases
is found wasted and powerless.
In the third and most common class, the medullary canal is oblite-
rated in both fragments, and the ends are more or less absorbed,
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64 DELAYED AND NON-UNION OF BROKEN BONES.
rounded, and covered, in part or in whole, with a dense tissue resem*
bling the periosteum. A connection also exists between the opposing
fragments in the form of strong liga-
Fig* 1^* mentous or iibro-ligamentous bands,
which, if of any length, are quite
flexible, and allow of considerable
^1 _! , .* ^ u ,. * V J motion at the seat of fracture.
CUTieleanltedbjligameatoas bands. -r ^y t* ^y ti 3 -a
In the fourth, ''a dense capsule
without opening of any kind, containing a fluid similar to synovia, and
resembling closely the complete ligaments, is found." In these cases
the points of the bony fragments corresponding to each other are
rounded, smooth, and polished, in some instances eburnated, and ici
others covered with points or even thin plates of cartilage, and a
membrane closely resembling the synovial of the natural articulation.
It is in this kind of cases, Norris remarks, that the member affected
may still be of use to the patient, the fragments being so firmly held
together as to be displaced only upon the application of considerable
force.
The existence of these newly-formed joints, or true diarthroses,
has been called in question by Boyer, Hewson, Chelius,^ and others ;
but the observations of Sylvestre, Brodie, Beclard, Home, Howship,
Otto, Kuhnholtz, Houston, Cooper, Langenbeok, and Breschet prove
that such examples are occasionally found.* I have myself met with
several examples.
A case is reported as having occurred in Boston, Massachusetts, in
which a*young man, set. 18, broke his humerus near its middle. Before
union had been*completed it Was accidentally refractured, and from
this time the fragments showed no disposition to unite; on the con-
trary, a gradual process of absorption took place, until at length the
whole of the humerus disappeared ; and that, too, " without any open
ulcer." Eighteen years later he was perfectly well, and the arm was
strong and useful, but no portion of the bone had been reproduced.*
Norris is a disciple of Dupuytren, and accepts his doctrine of the
formation of callus, without reservation ; consequently he finds no ne-
cessity for but one form of delayed union, namely, that which we have
described as belonging to the first class. In all of this class he assumes
the existence of a cartilaginous ring or ferrule ; but we think the error
of this exclusive theory has been sufficiently shown by the observa-
tions of Paget and others, and we should be warranted therefore in
affirming the existence of as many varieties of delayed union as there
are varieties in the manner and position of the deposit of callus, even
» Malad. Chirurg., t. iii. p. 108, Paris, 1881 ; North Amer. Med. and Surg.
Joum., No. ix. p. 7, 1828 ; Trait, de Chir., trad, par Pigii6, p. 150, 1886. (Norris,
loc. cit.)
> Nouvelles dela R^jpub. des Lettres de Bayle, p. 718, 1685 ; Lend. Med. Gkiz., xiii.
p. 57, 1833 ; Beclard, Gen. Anat., trans, by Hayward, pp. 149, 248 ; Transac. Med.-
Chir. Boc. of Edinburgh, i. p. 238, 1793 ; Med. -Chir. Trans., viil. p. 517, 1817 ; Otto's
Path. Anat., trans, by South, i. p. 188; Joum. Complement, iii. p. 291 ; Dub.
Med. Joum., viii. p.* 498 ; Cooper on Frac. and Disloc, fourth London ed., p. 508 ;
Recherch. sur les Formation du Cal, 1819, p. 84. (Norris, loc. cit.)
» Boston Med. and Surg. Joum., July 11, 1868, p. 868.
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DELAYED AND NON-UNION OP BROKEN BONES. 65
if their actual existence had not been repeatedly demonstrated by
dissections.
The causes of delayed union and of non-union are either constitu-
tional or local.
The constitutional causes are chiefly those conditions of tho general
system which manifest themselves by ansemia, debility, or some pecu-
liar dyscrasy.
Sanson, Beulac, Oondie,^ and many others have mentioned cases in
which the existence of syphilis in the system has seemed to prevent
the formation of callus ; but, on the other hand, Lagneau and Oppen-
heim' incline to' the opinion that syphilis exerts in this respect but
little influence ; and even B^rard, who admits the pertinence of one
case observed by Nicod, concludes, after numerous researches, that it
has been very rarely shown to affect the formation of callus.'
Pregnancy and lactation have been known to interfere with the union
of bones. Werner, Hildanus, Wilson, Hertodius, Alanson, Bard, of
New York, and Condie, of Philadelphia,^ have all reported examples,
in some of which the process of union was resumed and brought to a
rapid completion so soon as the period of pregnancy was closed, or
when lactation ceased ; but three cases reported by Sir Stephen Love
Hammick would seem to show, what, indeed, other evidences render
probable, that the delay was less due to the fact of the pregnancy and
the lactation than to the debility occasionally consequent upon these
conditions.'
As to the question whether cancer ever causes a delay in the union
of bones, it may be said that where the fracture arises in consequence
of a true cancerous deposit around or in the interior of the bones,
producing absorption of their tissue, no union takes place ; but that
the mere presence of the cancerous cachexy does not usually prevent
the formation of callus.
Scurvy, fevers of a low type, and, on the other hand, fevers of a
highly inflammatory character, profuse uterine and vaginal discharges,
and rachitis, conduce to the same result.
The withdrawal of a habitual stimulus, and especially a change
from a good to a low diet, or copious bleedings, may either of them
delay the deposit of ossifio matter, or prevent it altogether.*
Bonn has furnished two cases in which advanced age seemed to
have retarded the formation of callus, but Horner saw a fracture of the
humerus in a woman ninety years old unite in five weeks.' I have
myself noticed a good many similar examples in advanced life, and
it is now rendered quite probable that surgeons have generally over-
estimated the influence of age upon the formation of callus.
I Diet, de M6d. et Ghir. Prat., iii. p. 492 ; Joum. de M4d. Chir. et Pharm., t xxy.
p. 316. (Nonris, loo. cit.)
' Expose des sjmp. de la mal. Y^n., p. 525 ; Oppenheim on False Joints, 1837.
(Norris, loo. cit.)
» Op. cit, p. 21.
« Cooper's Die, ed. 1838, p. 546; Opera Hild., 1681: Wilson on the Human
Skeleton, p. 214; Bib. Choisie de M4d., xxiy. p. 595; Med. Obs. and Inquiries, 4,
1772; Phllosoph. Trans., xlvi. p397, 1750. (Norris, loc. cit.)
* Practical Remarks on Amputations, Fractures, Ac, p. 121. (Norris, loc. cit.)
« Norris, loc. cit. . ^ Ibid., p. 29.
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66 DELAYED .AND NON-UNION OF BROKEN BONES.
The local causes are, arrest of the arterial circulation by bandages,
paralysis or impairment of the nervous circulation, the ocourreace of
the fracture within a capsule, obliquity of the fracture, overlapping
of the fragments, interposition of a piece of bone, of a tendon, in as*
cle, or of a clot of blood, or separation of the fragments from any
cause whatever, erysipelas, acute phlegmonous inflammation, suppura-
tion, necrosis, too much motion, exclusion of light and air inaucing
local scurvy, wet and especially cold and moist dressings, too early
use of the limb, &c.
In order to hasten the consolidation when it is simply delayed, we
resort to all of those expedients which are calQulated to invigorate
the general system ; and for this purpose the employment of a nutri-
tious diet and the use of mineral or vegetable tonics may not be pro-
perly omitted ; but in our experience nothing has proved so efficient
as encouraging the patient to leave his bed and get out into the open
air ; for which purpose, if the fracture is in the lower extremities,
crutches will be necessary.
As local means, we may enumerate first the removal of those local
causes which seem to have interfered with the consolidation or with
the union. If the fragments have been officiously disturbed, it may
be sufficient to impose upon the limb absolute rest for a certain length
of time ; and the fragments may be more closely pressed against each
other ; in other cases it will be found necessary to remove the band-
ages, expose the limb freely to the light and air at least once or twice
daily, and to rub it gently with the dry hand or with some moderately
stimulating oil, so as to induce a more healthy condition of the soffc
parts, and encourage the natural circulation.
Moving the fragments freely upon each other, sufficient to determine
a degree of excitement in the adjacent tissues, and upon the opposing
surfaces of the bones, and then confining them during one or two
weeks in firm and well-fitting splints, will sometimes succeed when
other means have failed.
Indeed, I may say that by one or another of the simple methods
now enumerated I have never failed sooner or later to effect consolida-
tion, in recent fractures ; and it has only been in fractures of at least
four, six, or eight months' standing that I have been compelled to
resort to more extreme measures.
As a means of combining immobility with compression and health-
ful exercise, the " apparatus immobile," in many of its forms, is pecu-
liarly adapted. White, of Manchester, employed a firm leather sheath
for the thigh. H. H. Smith, of Philadelphia, recommends a more
complex artificial support, upon which the limb may be allowed to
rest while in the act of progression.^ With some surgeons, the
object of allowing the patient to walk in fractures of the thigh or
leg is chiefly to excite in the tissues adjacent to the seat of fracture
some degree of inflammatory action, but which, as the result in one
of White's patients has sufficiently shown, may be carried too far, and
even determiue a suppuration.
> H. H. Smith, Amer. Joum. Med. Sci., Jan. 1855.
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DELAYED AND NON-UNION OF BROKEN BONES. 67
Dr. E. R. Hudson, artificial-limb maker, of New York, has applied
in similar cases, which have come under my observation, an seppara'tus
of his own construction, made of wil-
low, and secured in place by leather ^g- 15.
straps. In case the purpose of the
apparatus is to encourage bony union,
no motion is allowed at the knee-joint.
Blisters, mustard cataplasms, the
tincture of iodine,^ caustics,' &c.,
applied externally over the seat of
fracture, can have no other effect than
to increase moderately the congestion
of the tissues, and in so far they may
aid in the accomplishment of the bony
union; but in this respect they are
inferior to the violent twistings, flex-
ions, and rubbings of the broken ends
of which we have already spoken.
Electricity was first employed by
Mr. Birch, of London, but Dr. Mott
obtained no effect from it in two cases
where he seems to have given it a fair
trial.' Lente, of the New York Hos-
pital, has furnished an account of three
cases treated in that institution by
electricity in connection with acu-
puncturation ; the mode of using
which was to pass a needle down to
the periosteum on each side of the
bone, and to attach the poles of the
battery to these opposite points. t^^'^Z^" "^^'""l I'' ITT^ ^"'"^ ^^
T ,^^^^ xi ^ 1 1 • '^ ^ 1 remiir, Moompanied with thortenlng of the
Lente thinks that electricity employ- umb.
ed in this way is much more efficient
than when the poles are merely applied to the surface. He informs
ns also that other cases than these now reported have been treated
successfully in this hospital by means of electricity.*
Mercury will no doubt prove serviceable occasionally by virtue of
its powers as an anti-syphilitic, but its beneficial influence in other
cases is far from having been established.
The seton is said to have been first suggested by Winslow, in
1787 ; but, what is of much more consequence, the credit of its first
successful application and its general introduction into practice is
due to Dr. Philip Syng Physick, of Philadelphia, by whom it was
employed in 1802.*
« Hartshorne, Eclectic Rep., vol. iii. p. 114, 1818.
« Willoughby, Am. Journ. Med. 8ci., Aug. 1884, p. 444.
» Mott, Med. and Surg. Rep., p. 21, p. 875.
* Lente, New York Joum. Med., Nov. 1850, p. 817.
» Physick, Med. Respository of New York, voL i. 1804.
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68 DELAYED AND NON-UNION OF BROKEN BONES.
Fig. 16. Physick used for his seton, generally, silk rib-
bon, or French tape ; and this he introduced by
means of a long seton needle, between the ends
of the fragments. He recommended that the
seton should remain in place four or five months,
and longer if necessary, and it was his opinion
that the failures were generally due to its bei ng
removed too early. At the present day, however,
surgeons who employ the seton think it serves its
purpose better when it remains in place but a,
few days, not longer, perhaps, than ten or fifteen,
, always taking care that it is removed before ex-
cessive suppuration is induced. It has been found,
especially valuable in fractures of the inferior
maxilla, clavicle, and upper extremity generally ;
but in the case of the femur, it has so frequently
failed, that Dr. Physick himself did not reconri-
mend its use.
In case the seton cannot be passed directly
between the opposing fragments, as recommended
by Physick, we may adopt the practice suggested
by Oppenheim, and carry two setons, one on each
side, close to the bone.
Somm^ of Antwerp, preferred a loop of wire
to the silk seton employed by Physick.^ Seerig
passed a ligature around the ligamentous mass
connecting the two fragments, and then proceeded
to tighten the ligature until it fell oflF.* Dr. Hulse,
^ . . , of the U. S. Navy, employed stimulating injec-
Physick*! flnt case, after ^. .^r •'/ '^ -^ « . ^^ •'
28 yeaw. (Prom AmTjouru. ^lOUS With SUCCCSS lU a CaSC Of nOU-UniOU, aCCOm-
Med. sci.) panied with an external and fistulous opening.'
In 1848, DieflFenbach recommended that ivory
pegs be introduced into holes previously made in the bone,* by means
of a gimlet or drill, and Mr. Stanley has succeeded once by this
method.* Mr. Hill introduced the ivory pegs in a case of ununited
fracture of the femur, pyseraia supervened, and the patient died.*
Malgaigne,in 1837, tried to introduce acupuncture needles between
the ends of an united fracture, but although he thrust the needle
down to the bone thirty-six times, he was unable to make it pass once
between the ends of the fragments.^ Wiesel succeeded better. In a
case of ununited fracture of the ulna, of nine weeks' standing, having
passed two needles between the fragments, at the end of six days, the
needles being removed, consolidation rapidly ensued.* This practice
> Amer. Joum. Med. Sci., vol. vii. p. 497.
« Nome, loo. cit., p. 46.
^ Hulse, Amer. Joum. Med. Sci., vol. xiil. p. 874.
* Malgaigne, trans, by Packard, op. cit., p. 258, note.
5 Stanley, New York Joum. Med., Nov. 1854, p. 441, from Dublin Press.
• New York. Med. Qaz., July 4, 1868, from the London Lancet.
~ Malgaigne, op. cit.
• Wiesel, Amer. Joum. Med. Sci., vol. xxxiv. p. 254, July, 1844.
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DELAYED AND NON-UNION OF BROKEN BONES.
69
DfeffenVaeh's drills for on-
iinlt««d fraetare.
does not differ essentially from the metallic ^ig- 17.
loop of Somm^. It is only a modification of the
seton.
Brainard, of Chicago, has attempted to show
that setons of any kind, whether of wood, ivory,
or metal, placed in contact with the bone, occa-
sion absorption, caries, and necrosis, but that
they never directly give rise to bony callus ; and
that the occasional success of the seton, which
success he believes to have been greatly exag-
gerated, has not resulted from any tendency to
favor the formation of callus, but from the indu-
ration and tenderness of the soft parts produced
by it ; circumstances which, by conducing to rest,
indirectly favor the consolidation.*
In May, 1848, Miller, of Edinburgh, reported
five cases treated successfully by subcutaneous
puncture. The operation consisted in passing
the point of a needle or small tenotomy bis-
toury down upon the ends of the bone, and freely irritating the sur-
faces at several points.* George F. Sandford, of Davenport, Iowa, has
successfully imitated this practice in two cases.'
In 1850, Dr. William Detmold, of New York, performed the opera-