c.v,cc('G^( C^CCC CCCC CC.Cc c CCCC ccc cc occc C C c c - CC° Lond. Med. Gazette, vi. p. 355, 1830. OCCURRENCE OF NON-UNION AFTER FRACTURES. 89 which, after some weeks or months of confinement, with a good deal of pain and danger, the union has been effected in this way ; but in other cases the introduction of the seton has failed." Speaking of the seton in his lectures, in 1833, Brodie mentions his having used it in three cases. The first was in an ununited fracture of the femur, and union took place though it was not completed until after a long period of time. The second case, also of the femur, was followed by so much dis- turbance of the constitution, that he became alarmed, and the seton was removed. The symptoms after this subsided, and it was re-introduced and kept in for a length of time, but no cure was effected, and the patient left the hospital with the bones as loose as when he was first admitted. In the third case the injury was in the clavicle, and was of many years' standing, and here a perfect cure was accomplished after the use of the seton for several weeks. He then adds, " The result of the practice in England appears to be, that sometimes it has succeeded in the upper extremities, but that where it has been performed on the lower extremities, as far as I know, it has only succeeded in a single instance, viz., that of the patient under my care." 1 Mr. Palmer, 2 writing in 1835, speaks of its having succeeded " in a few cases." Syme thinks the irritation determined by the presence of a seton cannot be useful but when there is a commencement of union. a M. Sanson summarily condemns the treatment with the seton, and advises its rejection. 4 Larrey says he would never recommend the seton or resection, in these cases ; 5 and M. Velpeau 6 de- scribes it as a very uncertain method of treatment, and gives a preference to the operation of resection, if frictions, or the immovable apparatus, are not sufficient for the cure. The opinions expressed by the above quoted gentlemen show the estimation in which the method is held by many in Europe. Most erroneous notions of the estimation in which the seton continued to be held after an experience of many years, by 1 Lond. Med. Gazette, xiii. 2 Edit, of Hunter, i. p. 505, 1835, note. 3 Edin. Med. and Surg. Journ., July, 1835. * Diet, de Med. and Chir. Prat., iii. p. 504. 5 Clin. Chirurg., iii. p. 460. 6 Op. citat., ii. p. 587. 7 90 CONTRIBUTIONS TO PRACTICAL SURGERY. its discoverer, as well as of the opinions entertained of it by the great mass of surgeons in this country, are at this time circulated abroad. In some editorial remarks of one of the French journals, 1 it is gravely asserted that in the United States so little benefit has been derived from the employment of the seton in false joints, that it is now no longer employed there — Dr. Physick himself having renounced the treatment during the latter years of his life. "We have authority for stating that up to the period of his death, Dr. Physick always advocated the treatment of these cases by the seton, and may safely assert, that results in America have proved it one of the safest, least painful, and most effectual, of the numerous ope- rations that are performed for the cure of pseudarthrosis. The following instance, taken from the Case Book of the Pennsylvania Hospital, 2 is interesting, as showing that Dr. Physick was not prevented from resorting to the seton even after an accident had occurred on a first attempt at placing it. On the 20th November, 1807, Bryan Malone, aged thirty, received a fracture of the right leg, a little below its middle, and also a fracture of the thigh of the opposite side. The thigh united in the usual time, while in the leg the fibula united but the tibia remained loose. At the end of a year a seton was introduced between the ununited fragments and a large bloodvessel wounded. Hemorrhage was with difficulty restrained by firm compression, elevation, cold, etc. The seton was withdrawn during the treatment for the bleeding, and no union had taken place after the ulcers resulting from the wound had healed. In March, 1809, the patient entered the hospital, and on the 24th of that month, Dr. Physick passed a seton; some fever and pain followed it. On the 18th of June the fracture was firmly united and the seton was removed, and he left the hospital on the 29th. Another in- stance in which a second seton was used successfully, after a previous attempt by this mode of treatment had failed, is given by Koux. 3 1 Gazette des Hopitaux, No. xlix. p. 196, 1839. 2 Vol. i. p. 88. 3 Gaz. Med., No. 26, p. 407, 1842. OCCURRENCE OF NON-UNION AFTER FRACTURES. 91 Much difference of opinion prevails, not only as to the mode of applying the seton, but also as to the length of time which it is necessary to allow it to remain in place. Dr. Physick recommends it to be passed through the integuments and between the ends of the bone, by means of a long seton needle armed with a silk ribbon, or French tape, without previously cutting down to the bone, and advised that it should be left in place for four or five months, or longer. 1 Other practi- tioners, however, have preferred that the soft parts should be first divided, so as to expose the seat of the fracture, and that it should be removed at the end of a week or two. The first method of operating, as being less painful, and attended with less danger, should, we think, be preferred. The length of time the seton should be allowed to remain, it is impossible to fix upon, but, as the object of it is to excite action in the bone and parts around, and not to promote suppuration, which we know in compound fractures often prevents the union, it would seem that it should be removed without regard to time, as soon as a considerable degree of action is excited, and before excessive suppuration is established. After its withdrawal the limb should be splinted with great attention, and every possible care taken, to keep it in a state of perfect quietude. The seton is especially suited to those cases of preternatural joints which occur in the upper extremities, inferior maxilla, and clavicle, where the fragments can be placed in apposition. In the femur it has often failed ; Dr. Physick has tried it in three cases of artificial joint in this bone, without satisfactory results. The experience of Sir B. Brodie, as we have seen, is to the same effect. The cause of failure in these cases is pro- bably owing to its inadequacy in the larger bones to excite a degree of inflammation sufficient to give rise to ossific action. One of the cases in which the seton failed in the hands of Dr. Physick, was that of an adult male who was admitted into the Pennsylvania Hospital, Feb. 17th, 1810, with an artificial joint of the femur following an oblique fracture of the bone just below the trochanter major. His accident had happened eight 1 Hays, in Am. Journ. Med. Sci., Nov. 1830, p. 271. 92 CONTRIBUTIONS TO PRACTICAL SURGERY. months previously. On the 28th an incision down to the bone was made over the seat of the fracture, and a seton introduced. On the 4th day, fever and retention of urine followed, but soon disappeared. On the 20th of April an extensive abscess formed in the thigh, and his health had become in some de- gree impaired. On the fourth of July, on account of the fever, diarrhoea, and debility of the patient, the seton was removed, having been allowed to remain four months and four days, without producing any bony union. 1 I have myself witnessed in our hospital two cases in the femur where the seton was tried without benefit. The first of these was in a woman, aged 83, who was admitted in February, 1848. The accident had happened eight months before admission by being thrown from a swing, and the upper end of the bone had pro- truded slightly, but the wound healed kindly. The injury was near the middle of the bone and no trace of union could be detected. Pressure and rest had been used before her reception, and were again tried for three months after her ad- mission, without benefit. A seton was then introduced on the 24th of June with no beneficial result, and in October it was removed, and soon afterwards I amputated the thigh at her urgent request. In the second case, that of a laborer, aged 23, the injury was of nine months' standing, and three weeks after its insertion by Dr. Peace the patient died of pyaemia. The situation of the fragments — their being widely sepa- rated, or placed in such a direction that they cannot be readily kept in contact ; or the abundant deposit of callus about their extremities, may be obstacles, sometimes insurmountable, to its use. The existence of great malposition in the fragments will generally preclude its employment. Close proximity of the fracture to the main artery and nerve, or to an important joint, may also at times prevent a trial with the seton. Where the bone has been for years disunited, and the fracture is very loose, or presents irregular surfaces, the seton is entirely un- suited. In all other cases, it should be preferred to all other operative procedures, as in case of a failure with it some of 1 Perm. Hosp. Case Book, i. p. 108. OCCURRENCE OF NON-UNION AFTER FRACTURES. 93 the more serious operations may always be resorted to. Wein- hold 1 imagines that the principal cause of failure with the seton (as used in Europe in connection with an external in- cision) is, its permitting the access of the external air to the extremities of the bone, which, for that reason, are extremely disposed to become carious ; and to obviate this he proposes making the wound funnel-shaped, and using a conical or wedge- like seton. In addition to the cases treated by the seton which have been already alluded to, or are included in our tables, this method of treatment has been successfully used in the forearm by Delpech, 2 in the leg by Rigal de Gaillac, in the clavicle by Eandolph, and by Saurer in the leg in a case of eight months' duration. 3 Of three ununited fractures of the humerus in which the seton was used by Mr. Crompton, 4 two were successful after extensive suppuration, and in the third, the needle could not be passed between the ends of the bone, and, as there was a good deal of strength in the member, the patient was advised to allow it to remain as it was. In three cases situated in the tibia, treated by the same surgeon, all were much benefited by the seton, combined with pressure and rest, and he believes they all got well finally. A fourth instance which he saw in the tibia, where the fractured ex- tremity became loose during a severe attack of pleurisy, was also caused by the same means. In the case of a non-united fracture of the humerus, cited by Lombard, 5 it was employed without benefit, and on the same bone with only partial suc- cess, by Beclard of Strasburg. In another case on the humerus treated at the Kichmond Hospital with the seton by Mr. Car- michael, its introduction was followed by a severe attack of erysipelas and very nearly caused the death of the patient. 6 An ununited fracture of the acromion process of the scapula, occurring in a female, which was treated by the seton some years back at the almshouse infirmary of this city, termi- nated in death. Professor Mott's experience in the use of the 1 Med. Recorder, xiii. 2 Clin. Chir., i. p. 255. 3 Oppenheirn, op. citat., p. 15. 4 Lond. Med. Gaz., vol. ii., N. S., 1850. 5 Velpeau, op. citat., ii. p. 586. 6 Cyclopaedia of Pract. Surg., p. 91, 1842. 94 CONTRIBUTIONS TO PRACTICAL SURGERY. seton has been large ; eleven cases have been treated by this method by him, of which three were of the femur, three of the tibia, and five of the humerus. In all it succeeded per- fectly except in three of the last-mentioned bone, which were afterwards cured by resection of the ends. 1 Keference to the tables appended to this paper exhibits the following results in 46 cases in which the seton and its modi- fications were employed. Of these, — 13 were in the femur, of which 9 were cured. 10 " leg, " 10 " 16 " humerus, " 10 " 6 " forearm, " 6 " 1 " jaw, " 1 " Of these 46 cases, 21 are stated to have had an incision made down to the bone previous to the introduction of the seton, and 24 had it passed without a previous incision. Of the 21 where previous incision was made, 17 were cured, 2 improved, 1 failed, and 1 died. Of the 24 in which there was no previous division of the soft parts, 18 were cured, 1 amended, 4 failed, and one died. In one case the seton was passed through a fistulous open- ing which previously existed. The longest period that the fracture had existed in these cases was 10 years (femur, set. 26). The shortest period was six weeks (tibia, set. 48). The average period was 12 months and 12 days. The longest period that the seton was allowed to remain was 13 months (humerus, aet. 48, failed). The shortest period was 7 days (forearm, cure). The average period was 7 weeks and 3 days. The longest period required for the cure was 8 months (femur, ast. 41). The shortest period was 3 weeks (humerus, aet. 23). The average period was 2 months and 24 days. In 17 of the cases in which the seton was employed, other methods of operating are stated to have been tried and to have failed. 1 Vache, in Am. Journ. of the Med Sci., ix. p. 262. OCCURRENCE OF NON-UNION AFTER FRACTURES. 95 In the 46 cases treated by the seton, accidents dependent upon the method emploj'ed, and not terminating in death, are noted as having occurred 12 times (arterial hemorrhage twice; severe fever, erysipelas, or profuse suppuration, ten times). 4. The application of caustic to the seat of fracture. — The application of caustic to the ends of the fractured bone after free exposure of them is a more powerful means of effecting the requisite irritation in the periosteum and bone than the seton, and seems worthy of more extensive employment than it has heretofore received. From the ease with which the operation can be done, the little pain attendant on it, and the almost certainty of producing by it a degree of action in the parts sufficient to excite a deposit of callus, without at the same time keeping up that action so long as to cause excessive suppuration, which often leads to failure, I am induced to prefer it to excision of the ends of the bone, and would re- commend it in those cases which are rebellious to the simpler modes of treatment, viz., compression, frictions, and the seton. In performing the operation, the seat of fracture is to be fairly exposed, the substance connecting the ends of the bone divided, and the wound carefullv dried ; after which the 7 «• 7 caustic is to be rubbed over them. The wound should then be filled with lint, and the limb placed in a state of the most absolute rest. The operation with the caustic is as applicable to the lower as the upper extremity, and is the only procedure, except resection, that is well suited to cases which have been for years disunited, or are very movable, and surrounded by a preternatural capsule. Different caustics have been made use of in these cases. White and Lehman employed the butter of antimony. Ollen- roth has proposed the nitric acid. In the cases reported b}^ Cline, Earle, Barton, and myself, the caustic potash was used, and is, I think, preferable. 5. Resection of the ends of the hone. — This method of treat- ment, though it has been frequently adopted with success, is nevertheless attended with great danger. All writers who . ., ;! ! !;M 96 CONTRIBUTIONS TO PRACTICAL SURGERY. have practised it acknowledge its severity, and few recom- mend its employment except in extreme cases. Mr. Lawrence thus notices resection : " This is a serious proceeding ; indeed, in the middle of a fleshy limb, as the thigh for example, it must be a very difficult thing to accomplish." 1 Boyer de- scribes it as one of the most serious operations in surgery, and speaks of it as "painful, bloody, and of uncertain suc- cess." 2 Barton views it as difficult for the surgeon, besides being painful, and of doubtful result both to the limb and life of the patient. 3 Liston regards it as a "difficult and severe process;" 4 and states that he has never attempted the opera- tion but once, and then failed in procuring union. Somme mentions an instance of ununited fracture of the arm, in which he witnessed the operation of amputation of the frac- tured extremities without any benefit resulting, and pro- nounces the method "barbarous," and thinks "it ought to be rejected from surgical practice." 5 Gouraud looks upon it as a retrograde step in surgery. 6 Mr. Eynd, 7 speaking of sawing off the ends of the bone in these cases, says: "I suppose no surgeon of the present day would seriously entertain it." A recent continental writer 8 well remarks, that "in pseudar- throsis of the thigh the question may seriously be asked if we should not prefer amputation at the point of the false joint to any other dangerous or doubtful operation. This question only the peculiarity of the individual case can decide. In some cases the safe aid of a suitable splint apparatus is preferable to any operation," and M. Yelpeau, though an advocate for this mode of treatment, candidly exposes its great dangers. We should never, says he., " decide upon this opera- tion without having well considered it. Requiring a deep and large incision into the soft parts, it places the bone in the state of a recent fracture accompained with severe wound, 1 Lond. Med. Gaz., vi. 1838. 2 Maladies Chirurgicales, iii. 3 Med. Kec., ix. p. 276, 1826. 4 Lancet, ii. 1835-6, p. 169. 5 Med. Chir. Trans., xvi. p. 39. 6 Med. Op. Velpeau, ii. p. 589, Paris, 1839. i Dublin Quart. Med. Journ., vol. iv. 1847. s Billroth, trans, by Hackley, 1871, p. 210. OCCURRENCE OF NON-UNION AFTER FRACTURES. 97 from whence results the danger of excessive suppuration, erysipelas, caries, necrosis, as well as of purulent absorptions, and phlebitis." 1 Jourdan thinks that resection is only prac- ticable on the humerus, or at furthest on the femur, and that the accidents which terminate almost always in death should make us prefer amputation. 2 Mr. Rowlands, after reporting a case in the femur successfully operated on by resection of the ends, states, that the operation far surpassed in sev.erity "anything I had ever undertaken or witnessed, and I am doubtful as to the propriety of recommending it to others." 3 On the femur this operation is particularly severe, and the great length of time required for its performance on that bone is alone, in debilitated patients, a sufficiently strong objection to it. In a case of resection of the thigh-bone noticed by M. Vallet, 4 the operation is stated to have been of extreme sever- ity, and to have lasted more than an hour : the patient, who was young and vigorous, had convulsions, and died the same evening. In the case of "Walb, reported by Dr. Kirkbride, 5 the operation lasted near two hours, the patient afterwards dying of pyaemia on the sixteenth day. And in a patient that I saw operated upon at the Pennsylvania Hospital in 1833, the operation was tedious and painful, though, after a long confinement and exposure to great dangers, he was finally cured. In one of the cases reported by Dr. Bigelow on the femur, the operation of resection and drilling "occu- pied about two hours," and "the ends of the bone were turned out with great difficulty." Speaking of the treatment of un- united fracture by excising the ends of the bone, Mr. Crosse observes, that he has known excision cure; "but it so often fails as to render the practice very discouraging," 6 and M. San- son thinks that "all prudent practitioners will agree that it is better to leave the patient with his infirmity, which in no way endangers life, than seek to remove it by an operation which greatly perils it." 7 1 Idem., ii. p. 592. 2 Diet, des Sc. Med., art. Fausse Articulation. 3 Med. Chir. Trans., ii. p. 49. * Med. Op. Velpeau, ii. p. 589. 5 Am. Journ. Med. Sci., xvii. p. 46. 6 Retrospective Address, p. 80. 7 Diet, de Med. and Chirurg. Prat., iii. p. 505. 98 CONTRIBUTIONS TO PRACTICAL SURGERY. The mode of treatment by resection is more particularly applicable to such fractures as are accompanied with great deformity, or have been for a very long period disunited, and have the ends of the bone very widely separated and loose, or such as are surrounded by a preternatural capsular liga- ment, with the fractured ends enlarged, than to those cases in which the ends of the bone are connected together by a liga- mentous band only. It is better adapted to parts in which but a single bone exists, as the humerus and femur, than to the forearm or leg. As with the seton and other methods of treatment, it must necessarily fail where the want of con- solidation arises from any constitutional cause. Where the preternatural joint is near to an important articulation, it is altogether inapplicable. By some writers it has been thought to be peculiarly suited to such pseudarthroses as are pro- duced by a necrosed state of the extremities of the fragments; but in these cases, as a general rule, any very serious ope- ration is unjustifiable, experience teaching us that it is better to leave the removal of the bone to nature, and in no way interfere until the diseased parts are separated by the absorb- ents, when they should be removed, and the limb after- wards supported as carefully as in cases of recent fracture. A cure by resection, it is to be remembered, is always ac- compained by more or less shortening of the limb — a slight inconvenience for the arm, but a matter which should enter into our calculation when the lower limb is the seat of the infirmity. In performing the operation of resection of the ends of the bone, a longitudinal incision is to be made opposite to the point of fracture, and, in that part of the limb in which the bone is most superficial, care being taken at the same time to avoid the neigborhood of large arteries or nerves. The surrounding soft parts are then dissected from the extremities of the fragments, which are to be successively pushed out and removed with a saw, no more of the bone being taken away than is absolutely required. The ends of the bone are after- wards to be brought in contact, and the limb so placed as to favor the discharge of pus from it, care at the time being taken OCCURRENCE OF NON-UNION AFTER FRACTURES. 99 to retain it at perfect rest, and to treat it in every respect as a severe compound fracture. My own experience, together with a close examination of most of the recorded cases of excision of the ends of the bones, leads me to regard it, particularly in the femur, as an opera- tion of so formidable a nature, both as to the risk incurred by the patient and the great amount of suffering that it gives rise to, that it should never be resorted to until all other modes of treatment have failed, or are from some peculiar circumstances inapplicable. In addition to the instances which I have noticed elsewhere, resection has proved successful in the hands of Josse, 1 Hysern, 2 Andrews, 3 Dupont, 4 and Langenbeck, 5 on the humerus: with Fricke 6 and Holscher 7 on the forearm ; with Dubois, 8 Josse, 9 Dupuytren, 10 and Diisterburg, 11 in the leg; and with Yiguerie 12 and Moreau, Jr., 13 upon the femur. Mr. Amesbury has seen the operation of removal of the ends of the bone twice unsuccessfully performed in the humerus. The first was a man of strong constitution, who, after many months' confinement, was allowed to get up. He saw him eighteen months after the operation, when the wound had healed, but the arm was much worse than when it was performed. In the second instance, after many months' suffering from exfoliation and abscesses, the man left his bed with the limb much worse than before. 14 Dupuytren lost a patient after this operation on the humerus, and derived no benefit from it in another case on the same bone. 15 Mr. James has employed it in the arm unsuccessfully. 16 Yiricel lost a 1 Med. de Ckirurg. Prat., p. 321. « Med. Operat. of Velpeau, 1. 3 Lond. Med. Journal, 1781, i. 4 Archives Generates, ii. p. 628, 1823. 5 Cooper's Surg. Diet. 6 Med. Operat. of Velpeau, ii. p. 590. ' Oppenheim, p. 11. 8 Velpeau, ii. p. 590. a Mel. de Ckir. Prat., p. 311. 10 These of Berard, p, 52. 'i Oppenheim, p. 11. 12 Larrey, Military Surgery, trans, by Hall. 13 Med. Operat. of Velpeau, ii. p. 590. 14 Op. citat., p. 216. 15 Q az> Med. 1831. 16 Retrospective Address— Provin. Med. and Surg. Trans., viii. 1840. 100 CONTRIBUTIONS TO PRACTICAL SURGERY. patient a few days after rasping the fractured extremities. 1 Mr. Allan knew the operation to fail in the hands of John Bell, whom he assisted in a case on the humerus of twelve months' standing; 2 and Physick mentions an instance in which it was performed unsuccessfully upon the humerus, and states that the patient afterwards entered the hospital in this city, where the limb was amputated, and related to him the great suffering which he had experienced in the operation of excision. 3 Eesection has also altogether failed in the hands of Ansiaux, 4 Moreau, 5 Beck, 6 and Eoux, 7 on the humerus, with Warmuth 8 and myself, 9 on the ulna; and Dr. Guntz, of Leipsic, 10 mentions two instances of failure after resection, of false joints, without specifying the bones ope- rated on. Of the 38 cases in the table in which resection was per- formed, 24 were cured, 1 amended, 7 failed, and 6 died. Of these- 12 were in the femur, of which 7 were cured. 6 " leg, "5 " 12 " humerus, "6 " 7 " forearm, " 5 " and 1 amended. 1 was " jaw, " 1 was " The longest period that the fracture had existed in these cases was 5 years (adult — femur). The shortest period was 10 weeks (humerus, set. 50). The average period was 13 months and 19 days. The longest period required for the cure was 13 months (femur, set. 26). The shortest period was 1 month (forearm). The average period was 4 months. In 17 of the cases in which resection was employed, other methods of operating are stated to have been tried, and to have failed; of which the seton was used 6 times. In the 38 cases in which resection was resorted to, acci- 1 Velpeau, op. citat., ii. p. 587. 2 System of Surgery. 3 MS. Notes of Lectures. * Velpeau, op. citat., ii. p. 590. 5 Idem, idem. 6 Jaeger's Thesis on Resections. 7 These of Berard, p. 53. s Oppenheim, p. 11. 9 Amer. Journ. Med. Sci., vol. v. N. S. 1843. 10 Idem, p. 12. M OCCURRENCE OF NON-UNION AFTER FRACTURES. 101 dents dependent upon the treatment followed, and not termi- nating in death, occurred 9 times (erysipelas 6; profuse suppuration and abscesses 2 ; phlegmasia dolens 1). Despite the constitutional and operative measures for the relief of ununited fractures which have been passed in review, the following case, under the care of a late eminent hospital surgeon of London, Mr. Key, well shows that instances occasionally are met with in which all measures will prove ineffectual, however ably they may be carried out. " Henry Udred, set. twenty-five, a stout muscular man, by trade a butcher, who had never had syphilis nor taken mer- cury, and, in fact, never remembered a day's illness, broke his left humerus about its lower third on the 4th of November 1839. The limb was at once put up in splints and bandages, which were removed and readjusted every other day for the first fortnight ; and after this once a week for six weeks, during which time he could occasionally distinctly feel the ends of the bone rub against each other. At the expiration of this time the bones were still ununited, and all treatment was abandoned for four weeks more. "He then consulted another surgeon, who secured the limb in splints, and kept him in bed for a month, but without avail. 11 He next went to Eamsgate and bathed for six weeks, but, this being equally inefficacious, he became a patient in Guy's Hospital, under Mr. Key, on the 8th of July, 1840. "Every means that held out any prospect of producing union were made use of, but were all equally unattended with benefit. After the ordinary methods of perfect apposi- tion, rest, pressure, etc., had met with failure, Mr. Key cut down to the separated portions of bone, and attempted, by placing wire around their extremities, to excite periosteal inflammation and so to lead to the desired union. This not succeeding, he again divided down to the line of fracture, and, having exposed the surfaces of the disjoined portions of bone, removed a thin layer from each by means of a fine saw. On this occasion, a portion of substance, having a car- tilaginous appearance, apparently muscular tissue, which had become altered by pressure, was found separating the two extremities of the bone, and was removed. 102 CONTRIBUTIONS TO PRACTICAL SURGERY. " This operation having proved unsuccessful, notwithstand- ing a considerable degree of inflammation was excited, as a dernier resort, a seton was passed between the separated surfaces. This, however, failed equally with the other attempts in producing union, and the man left the hospital unrelieved. At one period in the course of the treatment above mentioned, he was subjected to the influence of mercury until salivation was produced, but apparently without pro- ducing any effect on the fractured ends of the bone." 1 A remarkable instance of a similar kind in the humerus, aged 47, occurred to M. Yelpeau, in which, after the immova- ble apparatus, frictions, and seton had been tried and failed, resection was done by him in the month of October, 1844, without benefit. In May, 1845, resection was a second time resorted to, after which the ends of the bones were drawn together and so retained by silver wire, but without any benefit. 2 Another case, demonstrating the occasional futility of our most approved methods of treatment in ununited fractures, even in the most skilful hands, occurred to Sir Wm. Fergus- son. A fracture in the middle of the thigh, which had become firmly united with deformity, was rebroken and union failed to take place. Resort was had to scraping the ends of the fragments by means of a tenotomy knife, resection of the ends of the bones, and the ivory pegs, and all uselessly. The limb was ultimately amputated. 3 From all that has been observed in the preceding pages upon the treatment of ununited fractures, it will be seen that we recommend : — 1st. To apply the method of cure by rest and compression. If the fracture has been regularly treated, and is not consoli- dated at the usual period, replace the limb in the apparatus, and insure to it a state of complete immovability : if the treatment of the injury has been altogether neglected, or been inefficient, apply proper splints and moderate compression 1 A. Cooper on Dislocations and Fractures. New edit., 8vo. Lond. 1842, p. 575. 2 Gaz. des Hopiteaux, No. 5, 13th January, 1846. 8 Med. Times, vol. xix. p. 33, 1859. OCCURRENCE OF NON-UNION AFTER FRACTURES. 103 with a roller, and renew these as soon as they become in any degree lax. 2d. If, from want of action in the seat of injury, rest and compression are in themselves insufficient to produce a cure, continue the state of immobility in which you have placecl the limb, and apply blisters, moxas, iodine, or some other stimulant to the seat of fracture. 3d. If both of these modes fail in producing a deposition of callus, employ frictions. 4th. If the methods mentioned fail to produce a change, or the patient has already been suffering from his injury for eight or ten months, and there is no contra-indication to it, resort to the seton. 5th. If the case be one to which, from its long standing, or state of the injured parts, the seton is inapplicable, expose the fracture, and apply caustic potash to the fractured ends. 6th. If all the above means have been carefully resorted to unsuccessfully, and not till then, resect the ends of the bone. 7th. Never resort to amputation of the member until fair trials have been made with all of these methods, and then only at the request of the sufferer, after he has found that the limb can be of no possible service to him. In employing any of the above means, the obstacle to the occurrence of union which may exist, arising from the state of the constitution, should be carefully sought for and com- bated by an appropriate treatment. APPENDIX. The accompanying table, arranged in such a manner as to exhibit the chief points in each individual case, together with the sources from whence they are derived, is added in proof of the remarks made in the foregoing pages. No reference is given which I have not myself examined, and the collec- tion, so far as the American, English, and French journals, and surgical works are concerned, will be found tolerably complete. A number of cases might, I doubt not, be added from the German, and it is a source of much regret, that but few works in that language were within my reach. 104 CONTRIBUTIONS TO PRACTICAL SURGERY. -1 u "3 © p. tu -d S3 lM 73 A fa", Ti J-l oo .3 W 3 a* fe k h 05 O .2 *=. t. -« oo *H (J) 03 *3 '£ -73 : I'D fl n V a w < © c3 a;' to f(3 03 03 ol oo •£> .2-3 oo &0 ^ £ © a 00 I- •Si oo ^ u 3 3 a o s a o CO o tn 05 „j

(h Sh © ^* U © © © a o o « « u © © © © © w '3 5 © a ° ©^2 t © « © o © o >- '-3 © 5 1=1 qj as © 3 fl J B s .05 .03 d t2 <2<2 «2 '-2 V-4 «2 -3 f£ © © © © © t4-H ^-i **— t U-* (m ft a :~J .t: s- c u eg o3 05 a © ■~ u ■~ &H 05 05 83 CL 05 © © 03 © © « © © © © © pu,<3 EupHD-ibb m o » oS i>> -t^ 00 03 CO >> M . 00 X 00 00 a a OOJH a a * '. * : © o aa * H c > ® co a a d ■3 2 d a © a r— i d lO l-H MNC r-l CO CM (M Ph t> i-H rH Tt< «5 C CT H«O00iO(M -d « i Tt . co o r-l Lengt of tim seton r © d a . od • rH 00 00 a © oi aa* eo » ;-a ; j l— 1 8| a^ "O CM ■» .d o o fl a a o -a . . a © 03 © a bo 03 XI — - fe T3 .2 £ 3 o © d OB eS OS'S . d d © erab] initio elas 1 00 03 00 03 © ® .3 •d © © 05 00 -d 03 p | 5*^ : d . 05 "© o3 a onsid flam rysip "oo heme 8th d rysip < < "w r> o w ta w a, O -« .a 5? 03 p.p,.H o © P ? a » « a © 03 P5ot o © © a rs 'j3 .j-i © a a a as r/i nj j - - ©03©°5cB^®o3?© ©fl"'-i© a a 00 03 © © «Ph ,,- .pH © ««J3 00 00 © o JS Q5 03 00 © © ^ © © K « O Ph0hB3cocc ^ ^ t3 o oi a> © aaa >%3 a .as?. r-l CM CD CM aa a a 2 03 00 00 00 oaoog >>a t* aa^a -H CM -# t~ Oi r- (M d a aa 03 © PhPh 00 00 00 00 -» _ a d d d .* g 9h ** ~ ~ U *- •_ t- ^©.©©-©Sse 00 00 00 add i- - >- © © asa| r-( M p W a 03 a 2 Pm 53 E-i K M fe K i_3 Ph Pk 5h5353Ph pq P^ "2 afe -3 © *m T-i ^"l *■' ~ r3 s sb^ ® a- OO^rS © 2 w^ in a o ts ti' a 00 —I rH ^ © 3 -r,» r* 03 00 rd 00 U X a a 03 © -<53rVlr^ 63 53 53 o © 00 00 oo oo oo 05 © "^ •g 'E'Sbb* U t- UJS rd r. a o c oj oj o 55 fe S5 Pm Ph A- fs a a 3 " :S ► HH oo © © aa . a ° -: ►-» •-. . :s :S :S :s > . . "a > > > M X « £,£■»« r< rl ^"^ :s :3 .2 > > X M M o © u © o " co co coco aa coco 00 00 a a C3 03 «H U 03 03 03 !h -. t. In (- U t- fci rd^j OO rrjrjj © © aa -a.a.d OOO -©•-o'd' © 05 © aaa 00 ,d Si _JH ap.pHg'S h © ® © g gasa£ . oj ci ai u «j3rdJ4 a a ph pnfc tt r-) 03 © aa a a a aaaa a a t< fc. r- «H b, fc. aaaa a a © © © © © O hrjrjrj ,-}>-} © © © © aaaa 05 © a a « X K H '© '3 •£« "3 «2 CO jg rg 'd "d rrj .rj aaaa ® **-• «»-i fH 1- •„ U -r> CD 03 © © -d aa aa 2 "OH I CO * "O © t» 83 O) O r- ^N CO-fiOCO t>O0 OCCURRENCE OF NON-UNION AFTER FRACTURES. 105 3 ■- "O O o3 <£ • •d ►, ill £ a .•d s * • O CO S| S.2 8 4> O) 43 a) a; « e U (- t- u i- 3 3 a 3 a s 3 a o o o o u u O o ^.3 ffi ^J ^J *J ^> ^> ^_, .,_, o u u o O o o il o 43 d o> 0) '- s- [~ t- u !-. l- i-. d IS X 4) m Ofch P* £< OhPui^PhO-i '©oooooooo © o © © 1 13 13 T3T3 "d 13 "d 'd 13 "3 "d 13 13 P-cpM «2oo©'d0 H rt _, ^ o g g 00 ^ fe-d d " o J3 3 ®l d S43 00 oo oo »5 a a d d d d o © o a © © o .w ^ B o dB 3 a o o o . ro O .-( ■■"« Ti "rt s.s^S|S.S22 OJ 43 43 © 03 — i— CO «- 2 ® a 43 TO OJ _, 00 00 00 a a d d d *?fc! <-. Ul U »H — fc. «- Od fl fl j eS 434)343 j-JffifojJj p&. [=, e- &, ,j B K Ea ffi >1 .2 3 d '"« t a S -. 00 CO O r-l x a> "b s d o3 . .J „J .J ^5 O w B B B B ^ (» « X ^'«ao _j vT tT C* tTco S ^3'3'3'3'd rH KQ t- u ^ »< •> . . O O O O 4> 00 03 O U O U ° 43 ~ 43 d U p? ® d, 1 a. u '««) JO' ^.® 43 03 ^a «K« p- ,.. 4 1 | ^_, cd rt od m O « a T3 T3 T3 t- 43 41 4) hs^^s 8 106 CONTRIBUTIONS TO PRACTICAL SURGERY. 9 co t* co OT3(g 33.2 o CO^.r-, g£ > to ce T3 r a a 9 Its ? w SO • *• O * 2 g 3 a- 1 P ft d r| v< O g; A qj 33 > 2 ° CO CO > niii •g P- P -g .© & pit a. 2 © o o ©-* o o •d ■© '^ T) "d Pn o o o *T3 ^ r^J O O O/d 'O'O'o * O O O O O o o o © co ;-, « B d co co d 2 fr- ee PL, ® 4 CO to ^j o *a CO CO MM * P , CO CO CD .MMM :& p p ' CD CN CM 5'^ f H H (1) d -w o "-> © <** -^ ce ~ ° $ a rd . fe'd p- ce « £ d © to .--* CO • cj o . CD CO CO . © £«« d • » 8 co ^ CO CO CN CM eo to io ■ ~ S- li «d d © « »-i 5-1 goo O co co .* .2 a *d 'd -d CD^^ d a 1-3 u d n © >-. i-s d o 60 >^ d sot» d <*J en J3 T3 CO 13 CO g >©' a, §1 w^; CO CO (0 o K a ce >D hhO CO > 00 A -co ^J U H• B 2 © CO ^5 O ©.^ ce S tl u •33 X 1-1 ► ► -J C ^T C A CD CO © g nj'd'd 2 »)>< g b © CO © . Ph eg g g g jg CN CO ■«* 'O CO t-; CO CO CO CO CO CO OCCURRENCE OF NON-UNION AFTER FRACTURES. 107 u p. © ©•f • © co to t-j p, c3 © -^ i. * * t, © © 5 2 ? °" * I'S'SS © P a 9 5 — • o>J .^ a J § * • ce © «; <* .2 ™ «• o o © b © "u '— '-« * h Ph &H X CO . 00 OB O ©^ © S rH 3 r- d cm '— os . aj j. a zn k 3* a. 2 ego 3 3 "^ ?4 .rH fn — — J ® Sj «) O 3 © ti Sh 0> © o3 .--h PhCUQ © -h sh gS =1 ? o w rP _^ — ©.©rrH .©. .2 o*5 c3 p fl o a; a -r; © © CO o „ © © © 2 ." 00 CO fc, "g u © © CO CO © © 9 2d w x a 00 os p, 22S 5 p. a © co '-3 a _g 2 e " "u 2 © °ci- a ?s c3 © o. 2 | a © <° © ** © »* S o^ a d -r" © •rH fe CO eS "* © 13 a © a ©.5 £-3 a -s- <1M K 03 CM Ph « PJ tfg» Ph 'Una -a Ph- K © fl C fc. o p H a P a " CO M Tj( *" •*lHt«HO) a a a? ■"^ to ,y o -!* -g I a q 2 fl © © © 2 2 © .rH .rH tj CO . © 3 to' 2 "3 -3 Ph cp '-s c_, t^ <« ^ © © "rH — 1 d d ■Safe Oo • « o'-->-5 2 "^ bo . . OS c3 o3 f>l ' >l rH tH — - • CO CT> O rH CM 03 03 0)0 «* ©" 2 © a d^ d "5 'S .© '3 •3 -S^ *3 © © © © ^o © a d* d a «H tH »H f^ a s d a o o © © r-jK-jr-J K, >-! >J |SH fr-j fer?ir< r5 . CO r3 =- . Phx a r3^ ® •3' 2^ © r 2 a ^ coO dd-rn rt -HXI d d © © O r< br) d i © Sco "» •3- s ©* « •3 a a © 03 O •on 108 CONTRIBUTIONS TO PRACTICAL SURGERY. © 3 hi "3 co © . K CO © g a 3 O © >> d © CO © CO Ct © co hi © © . S 3 -3 D o3 d O CD © eo O © IS o ■a © CO ao a © ** U hi '£& d © d • a ^s-ggs J2 co co -^ "5 to ce 50 g ■g cs p. £ <2 fa fa CO © cc © . ,2© ©■c Pm © £ © P 3 CO © 05 00 hi 3 3 2 co •". co 73 ©.2 hi hi PhCsi CD © hi hi Q, © *• d P5 X V © B3 a O to 3 a 3 yj © c8 5j •a U *J fa © © © © © © © © © © © © © © 3-3 Jm h h h ^ (4 !- *i U J- ^H hi a • 3 c 3 3 3 3 3 3 3 3 3 3 3 3 3 w © © u u © © u © © u © © © w © •2 d « -« © MM u (0 © hi 3 S 2 c u u u u © © © u u © h. U © U hi © <£ <2 c2 «2 «S 3 ,8 <2 -d © .© © CZ '—i <«i h h ^ h © s- >- 1- hi a hi hi hi .a © fc 'd Eh © a: © © © o5 © © © © © © 03 © © © 03 03 © fa fa fafafa fe Pk Ph s P^Ph^I PhP>^ CLiCUPh fa ft fa ■a fa o«i -3 -a a "** c3 © © © o "3 hi "3*5 S a? c • © h, . CO **£ I— 1 CO i— 1 CO o CO O 01 O to c 09 ^ . . . *^^o ^ is ts £3 OS CO t^ -3 . ; © CO co *» O ■Bis ©CM CO h, to cj3 © • • • J_3 h, 0! CO X Tg h o ©I 1" te 3 p S a s a a CO e QC c a © fi IS £ o iO©CO^ CO < a o I2J oE $5 co A a>

> 00 I O © t*-i ■*-» ci £Z * ^ : a & • n3 -a i-3 °$6 CO CO CO C^ (M O ■* ■ • • a< lO .4 , u ( u 3 © 3 2 • P< ^S Pi U^ CO : p : 3 . 3 ^ . . 3 j2 £ o j2 C3 "© : « . 5 © . . to ' ; © a G, . v> 3 . co O te O "© © "to ! 3 ts © •n 2^ ^«2 ! ! S3 2^ p. P4 CK t/3 pi t»P CO GO 3 < a CO - n 00 » a > » . . CO to CO . • . ■3 t3 © © o »5-S c > ^ © a c c ) O K CC ^ o _M CO CO CO "tJ *i CO CO a fa A to .■s'S E CC 3 & a c E ! E 1 F- i goo *a CM O fe^J^! o ™ K O O o^-g^s a © i- H M i-i t> < ■- ■1 r-l CO CO r-( CO >0 •* «2< «?« CO to © to 00 00 Cl 3 CO CO CO CO CD CC o 3 1 fa 3 3 3 E 3 3 3 3 3 3 3 h hi © ^2^3^ 3 HiatJtrl hi hi CD © a a 3 3 a a hi hi © © a a 3 3 aa •9gy < i »o >o 'O I NCMCN CM CO CM r-l ja :n *>< to «q o -«i «i --' c o <5 CM ■X9S * > © © . 1 -3T3pc s S IS SE :g§ fa'S g'g'ss a" g' IS fa' f i .§.§ 3 t i ■ d o © 60 t-i © ( 3 ( c e 1 J I , '© '© a d a 3 S © © 3 "^ fl fl © >t o © ■£ d 3 .^ H -d tj Is i7d 03 60 60 6C3 2 60 O co 3 a t, Ch » P< d 2 08 > 3 ©^^3 3 Q W^H 'S 'C 'C 2 hi R >>>•> CO ft 3 : 3 P 3 O s,Q, 3 aOO 3 o > < 5 £ © CD oca e8 O 1-3 hH e« e3 sa t^r-." : co' . CO ! e j tS CO '^ OC CO I— 1 !-H I X «^ OS . . . CO d . -*^ -*J 1 1 s «* i •-'be 1 ao . . . r* b. O-Ph * C *h £ a :z te eo © 1 - [ J" « „ © © 0> 02 GO. t- • • •s-o-o i ™ -© ^D 2 g^S 3 3 «" © H i— 1 a> 00 3 P. © ® » 3 2 a c o d 3 CO CO !-H 05* fe ©~ s S** « « '3 H?^" W3 'Sb "S b^7v2 • CO ■a rH -3 .a T3 n . 08 PO © a © 2 a3 3 ." 'o te» « • 3 © £ 1 r 3 : 3 j 3 * "3 © •3 ^© O W3^ © 3 3 © 02 . ^ o o o g d a b° hi «- hi • d 3 3"d fa° ° 3 © © M CO BG K «;*« i 3 _K> m -^ © © 1 * d g^^ "^ ^ 3 5 oo" W ® « © So.. ©S 'd . a" S <=> S O o o o © »- ' h" **fa CD CD © ^J aaag © rd 3 © .? a 3 q3 a rO © © 'O hi S © §a 3 P 3 H,wpq O IT 5 ? 3 t-s OP3Z; UtJ -Sl C 5 aH CM CO Tt< ic 5 « 5 r CO cs o a CM CO ■*)> iO to t^ 00 OS o •OH 1 c 5 r ■< r -4 f -■ i- 4 H f H r ' — -d " • r«J a CD 5 a & _2 ^^ fa | .r< CO — CO ed Methods of which had viously fai If. CD 1-1 o ? O d . co 3 2 - a, © « © J S ^ •- * Socll -d CD a '3 "d **H rp — cW fa © . CO 33 « d 2 x rH © D3 Ci ^^•s £ o c o o £ £ £ ■