ununited ends. The fracture was of the upper arm, had happened ten months previously, and been kept in splints six weeks, after which it seemed to have united, but in a few days' time was again broken, whilst the woman followed her usual occupation. The splints were reapplied, but without benefit, and afterwards two setons, at some interval of time apart, were passed by the side of the ununited bone, but not between its ends, and worn for some time, but no union resulted. It was then determined to cut down and saw off the ends of the fracture, and when the incision was made for this purpose, the upper end of the bone was found covered with cartilage, and the lower surrounded with a sort of capsule, containing several loose pieces of bone. These were removed and the ends of the fracture sawn off; suppuration continued for some time, and she left the house at the end of two months, the wound not having scarred, and no fixing of the fracture having occurred. Some time after an abscess formed nearer the elbow, and several small pieces of bone have voided by it, and continue so to do. At present, eight months after the operation, there is not any union.-J. F. S.]

714. According to the variety of the cause of unnatural joints, the mode of treatment must vary, to prevent their occurrence. If, however, they already be formed, their cure is only possible by the broken ends, which are covered with cartilage, being put in the condition of a recent division, that is, by producing in them a suitable degree of inflammation, which is sought to be effected by rubbing the fractured ends against each other, by an apparatus of pressure, by the application of caustic, by sawing off the ends, and by the introduction of a seton.

[JOHN HUNTER proposes a different method from either of these. He says:-" In this case it is necessary to lay open the new cavity and irritate the ends of the bones, and then, by keeping them in position, bony union will often take place. It has been recommended to saw off the ends of the bones; but all that seems necessary is, to irritate them sufficiently to excite a fresh inflammation." (p. 505.) He does not, however, mention any examples in which either of these modes of practice was successful.]

715. Rubbing the fractured ends together, (Exasperatio, Lat.; Reibung der Bruchflächen gegen einander, Germ.; Frottement des extrémités d'une fracture, Fr.,) and subsequently fixing them with a suitable apparatus, can only be advantageous during the establishment of the unnatural joint, because afterwards it can seldom produce a sufficient degree of inflammation (1). With the same object it has also been attempted to fix the broken ends by tightly-fitting bandages, for the purpose of exciting inflammation by the patient's standing and walking (2).

[(1) Rubbing the ends of the bone together is at least as old as CELSUS (a), as quoted by OPPENHEIM. "Si quando vero ossa non conferbuerunt, quia sæpe soluta, sæpe mota sunt, in aperto deinde curatio est; possunt enim coire. Si vetustas occupavit, membrum extendendum est, ut aliquid lædatur; ossa inter se manu dividenda, ut concurrendo exasperentur, et si quid pingue est, eradatur, totumque id quasi recens fiat, magna tamen cura habita, ne nervi musculive lædantur." Lib. viii. c. x. sect. vii.

BOYER considers that this coarse and uncertain practice often destroys a callus when first forming, which by longer continued rest and contentive bandaging might have effected a firm union. CITTADINI's case (b) of a false joint in the thigh-bone cured by violently rubbing together the fractured ends and by the subsequent application of a contentive bandage, can scarcely be considered to support this practice, as the fracture was only two months old; and, as is well known, many cases unite after as long or longer period of seeming want of union, as completely as under the most favourable circumstances."-J. F.S.]

(2) In cases of this kind I have covered the limb with compresses, and over these applied wet pasteboard splints, so as to enclose it completely; and then employed the usual swathing, with SCULTETUS'S bandage, and the common splints with chaff pads, and having made the apparatus sufficiently tight, have left it for a long while.

716. The use of Pressure for the cure of artificial joints rests partly on the close coaptation of the broken ends, and the preservation of complete quiet, and partly on the excitement of a due degree of inflammation, (b) In OMODEI Annali Universali de Milana, vol. xxxvii. p. 415, 1826.

(a) De Medecinâ.

The pressure may be employed either with the usual apparatus of splints, as in recent fracture, and at the same time with padded straps and tourniquets upon the fractured ends (a), or by simple strong pressure, with swathing of the whole limb, and graduated compresses with tightly drawn rollers (b). These modes of treatment, although many cases prove their good effect, do not, however, frequently effect a cure, because the necessary degree of inflammation cannot be produced, and applies rather to cases of not long standing and to those in which no firm intersubstance is formed.

The repeated application of blisters on the surface, opposite the seat of fracture, has been recommended, at six or eight weeks after the occurrence of the accident (c). Cauterization of the skin with caustic potash (d), and painting with tincture of iodine (c). [I believe that pressure and perfect rest are the most efficient remedy for fractures in which there is tardiness or indisposition to deposit earthy matter in callus; and I have very great doubt whether firm union is ever effected except when its absence has arisen from this deficiency alone. In simple fracture it can only be surmised what the actual cause of the want of union is, and in operating on such cases it appears quite as often that the diagnosis which has been formed is wrong, as that it is right. It must also be remembered that the deposit of earthy matter in the callus is frequently a very slow process, double and treble the time beyond that ordinarily requisite for the parpose, sometimes elapsing before a fracture is perfectly united. CHELIUS has just mentioned that an unnatural joint may be considered as formed if more than six months have elapsed after the fracture, and the ends of the fracture be still movable. But AMESBURY mentions cases which have united by pressure after six, eight, ten, and even sixteen months have gone by. And therefore I cannot but think that these must only have depended on deficient earthy deposit; for cases have occurred again and again in which pressure of all kinds has been employed without advantage, and when operated upon no callus connexion has been found.

That the pressure to be employed in these cases should be sufficiently great and so directed as to bring the fractured ends closely together cannot be doubted, and in fraetures which unite slowly is absolutely necessary. But I am not quite sure it is necessary that the pressure should be so great as to produce pain in the course of a few days after the application of the apparatus, as stated by AMESBURY, although “in the different cases it differed very much in degree. In some of them it amounted only to a slight aching pain, accompanied with now and then a lancinating sensation in the fracture; but the inconvenience felt in all the cases varied more or less in the course of the day: and I am not aware that in any one of them it was at any period sufficiently severe to affect the pulse-certainly not so as to produce any noticeable fever.” (p. 806.)

External irritation in these cases, so far as I have seen, is of little value.-J. F.S.] 717. For the purpose of destroying the cartilaginous surfaces on the ends of the bone, and to produce a suitable degree of plastic inflammation, various kinds of caustic have been employed, strong nitric acid (OLLENROTH)(f), caustic potash (the younger CLINE) (1), (HEWSON) (g), butyr of antimony (WEILINGER) (h), and nitrate of silver (KIRKHIDE) (i). Here also belong (MAYOR) (k) experiments of repeatedly introducing between the ends of the bone a metallic canula, and in it a steel probe dipped in boiling water, and the injection of some irritating fluid into the wound (HULSE) (1).

(a) AMESBURY, Jos., above cited.

(b) WRIGHT's three Cases of Cure of False Joints, by a pressure apparatus; in American Journal of Medical Sciences, vol ii. p. 270.

FLEURY, Des effets de la Compression dans le traitement de plusieurs maladies externes et surtout dans les Fractures et Fausses Articulations, avec quelques réflexions sur cette dernière maladie; in the Memorial des Hôpitaux du Midi, par DELPECH, Sept., 1830, p. 539.

(e) BRODIE; in London Medical and Surgical Journal, October, 1823.

(d) HARTSHORE, Philadelphia Medical Recorder, 1826, April.

(e) BUCHANAN, cited at the head of this article.

-TRUSEN, in Preuss Vereinszeitung, Juni, 1834, p. 114.-WILLOUGHBY; in Transactions of the Medical Society of the State of New York, Albany, vol. i. pt. ii. p. 76.

(f) BERNSTEIN, über Verrenkungen und Beinbrüche, Second Edit., Jena, 1819, p. 280.

(9) North American Medical and Surgical Jour nal. Philadelphia, 1838, Jan.

(h) RUST's Magazin, vol. xxxiv. p. 330.

(i) American Journal of the Medical Sciences, Feb., 1835.

(k) Nouveau Système de Déligation Chirurgicale, &c. 8vo. Geneva, 1832.

(1) American Journal of Medical Sciences, Feb. 1834.

Cases of happy cure of ununited fractures of WHITE, CLINE, LEHMANN, and BARTON, are collected by OPPENHEIM and others in RUST's Magazin.

[(1) CHELIUS has quoted HEWSON as having first proposed the use of caustic potash in ununited fractures. The fact is, however, that it was practised by the younger CLINE more than twenty years before in St. Thomas's Hospital, in proof of which, I copy from my notes the following

Case.-P. M., a sailor aged thirty years was admitted into St. Thomas's Hospital, April 13th, 1815; having on the 7th of September, of the preceding year, fallen down a ship's hold, by which compound fractures of both legs were produced. For these accidents he was received into Chatham Hospital, and there continued till the 1st of March last. During this time the wounds of both legs healed, and the left shin-bone united properly by bone, but the right only by fibro-cartilage. Strengthening plasters and blistering were employed to promote bony union, but without effect.

When first admitted into St. Thomas's, he was directed to walk about for the purpose of exciting the ossific inflammation, but although this was attended with much pain, there was no improvement. Towards the latter end of May, the part was blistered, but without advantage. It was therefore determined to have recourse to an operation, which was performed.

June 12th. The skin was cut through on the inner and fore part of the shin-bone, and the connecting substance, which was solid, being completely laid bare, portions of it were cut away with a small crowned trephine, till the ends of the bone were reached. Into the hole thus formed, caustic potash was introduced, and allowed to remain for a few minutes, after which a poultice was applied. The patient suffered great pain when the intermediate substance was cut into, and indeed was much excited during the whole operation. He had no pain till the evening of the 14th, when the leg became very painful, continued so for ten hours, and then became easy. On the 16th the pain recurred, and continued for the same length of time, after which it ceased. In a day or two after a free discharge was established, and there was not any return of the pain. On the 21st the poultice was left off, adhesive plaster applied, and an outside splint put on to support the leg. On 9th of July he got up and walked about on crutches. On the 20th he felt that his leg was stronger. On the 27th he left the house with the connexion of the broken ends decidedly firmer; but the wound was not healed, and he returned again, Aug. 17, with the sore still opened. He continued in the house till Oct. 10, and then left, at which time the union was complete.-J. F. S.

HEWSON'S case was successful, and union was complete in twelve weeks after the operation.]

718. To saw off the cartilage-covered ends of the fracture, they must be laid bare by a longitudinal cut on that side of the limb where the bone is most superficial, and the large nerves and vessels can be avoided; they are then to be separated from the surrounding and connecting parts, thrust up through the wound, the soft parts protected by a spatula introduced beneath, and first the lower, then the upper portion of the fracture cut off with a suitable saw. The bleeding vessels are to be tied during the operation; the broken ends are to be brought into contact, and the case is to be treated as a compound fracture. In the after treatment, subsequent to the removal of the ends of the bone, it must be especially remembered not to expect too early the consolidation of the ends of the bone, because, from my experience, this occurs only after a very considerable time. I am convinced that, in many cases, amputation of the ends of a fracture have had an unsatisfactory result from want of attention to this circumstance (1).

If the ends of the bone lie very deep and cannot be easily protruded through the soft parts, it is best to use HEINE'S osteotome. It is frequently very difficult and even impossible to reach that end of the bone which is overlapped by the other end, and surrounded with much soft parts. In such cases it is advantageous according to DUPUYTREN's experience to saw off that end which can be reached, and bring it in contact with the other which has not been cut off (PIGNÉ). BRODIE (a), in a case of false joint of

(a) London Medical Gazette, July, 1834.

the leg, in which seton and pressure had been used in vain, cut upon the shin-bone, removed the half ligamentous and cartilaginous mass with which the ends of the bone were united, scraped both broken surfaces, and filled the wound up with lint. This was left for three or four days in order to fill the wound with granulations, and then pressure was employed to keep the fractured ends in firm and close contact.

(1) In a case of section of an artificial joint in the upper arm in a young scrofulous man I found the ends of the fracture still quite movable, but complete consolidation ensued two months after under the continued use of the apparatus.

[According to GUIDO DE CAULIACO (a), the Arabian physicians recommended cutting down on the fractured part and getting rid of the callus either by rubbing or scraping. "Verum si multum infestitur et aliter fieri non potest, consulet AVICENNA incidatur caro et atrosboth (callus) fricando separetur. Si fuerit attritio et timetur membri corruptio, scarpelletur." (p. 45.) This appears, however, from AVICENNA's account to have been a very severe and not unfrequently fatal operation.

The operation of sawing off the broken ends of the bone seems to have been first pro posed and successfully practised by CHARLES WHITE (b), in 1760, on the upper arm of s boy, nine years old, which had been fractured six months. In his second case, which was a fractured shin-bone, he could only saw off the upper end, behind which the lower had so fallen that it could merely be scraped, and it was found necessary to introduce butyr of antimony, to destroy some muscular fibres between the fractured ends. Both cases did well. This operation has been repeatedly performed, but with very variable success. I think it is only applicable to the upper arm and leg where the bones are not very thickly covered with muscles; but not in the thigh or fore-arm. LAWRENCE's observations (e) on the subject are well worthy of attention. “If the operation be in the fleshy part of the thigh, it must be a very difficult thing to accomplish: you have to inflict a very severe wound, a wound very likely to be followed by considerable inflammation, and that with a still more serious effect. In many instances in which this has been done the patient has at least been left in a worse situation than he was in before." (p. 265.) My friend GREEN's operation on an ununited fracture of the thigh-bone, detailed by AMESBURY (d), fully proves the difficulty to which LAWRENCE refers. "A semicircular incision was commenced about the middle of the rectus and then carried round through the belly of the vastus externus. The flap was dissected back and the fractured end of the upper portion of the bone brought into view. Upon clearing away the muscles it was seen that the two broken extremities of the bone were connected together by a thick dense capsule, resembling the capsule of the hip-joint, the inner surfaces of which were perfectly smooth and shining. The integrity of this capsule was destroyed, by re moving a portion of it from the upper fragment; but in consequence of the difficulty which was experienced in getting at the fractured end of the lower portion, which, as has been said, lay on the inner side of the upper, it was left covered with the ligament ous matter. In removing about half an inch of the fractured end of the upper fragment, which was done by one of HEY's saws, in order to give room, it was found that the bone had become soft and spongy at this part, apparently from interstitial absorp tion. From the manner in which the ends of the bone lay, it was evident that the lower portion could not be cleared of the ligamentous deposit which covered it, without enlarging the wound in the soft parts, a proceeding which appeared objectionable." (pp. 821, 22.) The greater part of the wound soon healed without any constitutional excitement, but there was suppuration, and the matter burrowing, an abscess was formed at the upper inner part of the thigh, which was punctured. He was imme diately placed on a fracture-bed with inclined planes and no splint applied till the tenth day, when one well padded was put upon the outside of the thigh, and worn for seven weeks, but no union was effected. An inner splint was then also applied and the fractured ends pressed tightly together by the web of a tourniquet twisted closely on them and continued for a fortnight. But no advantage was gained; the limb was an putated above the seat of fracture, and the patient did well. On examination, it was found that the unnatural joint" was now again complete. The greater part of it was nearly the thickness of the capsule of the hip-joint, but at one part it was thin like the capsule of the shoulder-joint; the capsule was accidentally torn at this part with the finger, and the inner side was seen smooth, and had very much the appearance of synovial membrane, being moist and shiny. The ends of the bone were rounded, and where they came in contact, were flattened and covered with a dense fibrous structure,

(a) Chirurgia Magna. Venetiis, 1498.

(b) Phil. Trans., vol. li. 1760. Also in his cases, above cited.

(c) Lectures in Lancet, 1829-30, vol. ii. (d) Above cited.

very similar in appearance to the intervertebral substance when divided transversely, but especially that part of it which is found half-way between the centre and circumference." (p. 826.) It appears to me, in regard to this case, that if WHITE's treatment had been followed out and the ligamentous covering of the lower end of the bone had been destroyed with caustic the result might probably have been more favourable. As it was, the object of the operation, to wit, that of getting rid of the ligamentous or cartilaginous coverings of the fractured ends was only partially effected.-J. F. S.]

719. The introduction of a seton is to be effected in the following manner: -It should be attempted by extension and counter-extension to bring the broken ends into proper position, and even to separate them somewhat from each other. With due caution the place is to be chosen, where the setonneedle armed with silk can be so thrust into and through the whole limb, that no large vessel nor nerves should be wounded, and so that the setonthread be placed between the two ends of the fracture. It might be better, perhaps, in most cases, to cut down on both sides to the bone, for the purpose of more certainly and accurately carrving the seton through between the fractured ends. The limb should then be duly extended, and kept in proper position by a suitable apparatus. The seton-threads are to be drawn daily backwards and forwards between the fractured ends, and to be entirely removed as soon as the ends are found to be knit together. If, after three or four months, no firm union have ensued, all hope of cure must be given up; there remains then, if the patient will be relieved of the inconvenience of the unnatural joint, no other remedy than amputation.

WEINHOLD (a) himself employed with advantage his needle-trephine with which he introduced a wedge-shaped seton smeared with some irritating matter.

OPPENHEIM (b) recommends, in order to make the operation of the seton more powerful, enduring and effectual, where the circumstances previous to the introduction of a seton had not promised, à priori, any result, the introduction of two setons, not indeed as already proposed, through the newly-formed cartilaginous intermediate mass, but in such way that each seton should be in contact with one of the fractured ends: the setons not to be left too long, but only till such time as suppuration was properly established, and then at once withdrawn, instead of by repeated and gradual thinning the size of the seton. In two cases OPPENHEIM pursued this practice with success under the most unfavourable circumstances.

According to JOBERT's opinion (c), the seton should be left in only eight days.

be

720. The use of the seton may be accompanied with difficulty and danger, when in an oblique fracture the surfaces of the fracture correspond, so that in passing the needle through, important vessels and nerves may injured. If the fractured ends be so close together that their surfaces touch only at one little point, the proper position of the bone must be first attained by permanent extension, after which by the introduction of the suture some advantage may be gained.

721. The introduction of the seton is more simple and less dangerous than sawing off the ends of the fracture; healing also takes place without shortening of the limb; but in many cases, on account of its less activity, it is not beneficial, as when the ends of the bone are united by a wide mass of cartilage, or by an actual false joint. The seton should be left for a long time, for four or five months, even to the consolidation of the bone (PHYSICK.) Smearing the seton-thread with irritating ointment, for the purpose of strengthening its operation, may easily excite erysipelatous inflammation, abscesses, and constitutional irritation. The symptoms after sawing off

(a) Von der Heilung des falschen Gelenkes, (c) Archives Générales de Médecine, 1840, Octou. s. w.; in HUFELAND'S Journal, May, 1826. (b) Hamburg Zeitzschrift.

VOL. I.

bre, p. 224.

2 Q