were also in some degree displaced. The tibia appeared to have been broken about the centre, the line of fracture extending from within obliquely outwards and downwards. The lower part of the bone projected above the upper, and a sharp point belonging to the lower portion was perceptible under the skin. There was no shortening of the limb, and the man suffered little or no pain. Such, then, is the condition of the patient, fifteen weeks after the accident. From the quantity of motion between the bones, it is plain that there is no bony union, but I conclude that there is ligamentous union. The question then is-in what manner are we to proceed, so as to make the broken bones unite, and give this man ultimately an useful limb? Now in order to answer this question we must consider, Ist, In what manner do fractures unite under ordinary circumstances? 2d, What are the circumstances under which fractures do not unite? 3d, What are the various means that may be employed for the purpose of procuring the union of a fracture which has not united at the proper period? Lastly, Which of these various means it will be best to adopt in this instance? Union of fractures under ordinary circumstances. It used to be thought, respect ing the union of a fracture and this was Mr. Hunter's doctrine that when a bone was broken, the blood became extravasated; that lymph was thrown out from inflammation; that the two broken ends of the bone were thus united by the coagulum of extravasated blood, and by the effused lymph; that this uniting substance became organized, blood-vessels being formed in it; and that, by and by, bony matter was deposited in the organized blood and lymph. This is a very simple explanation of the phenomena which occur after a bone is broken; but it is too simple-in fact, it does not correspond with what is found in nature. The real process is one of considerable complication. I made several experiments upon animals, many years ago, with a view to the elucidation of this subject; and some of the results of these experiments are on the table. I had thought at that time of publishing a paper on the union of fractures; but before my investigations were completed, I found the whole matter made out by Baron Dupuytren so completely, that any farther publication on it was unnecessary. I broke the bones of animals, and examined the appearances at different periods after the fracture. Immediately after a bone is broken, you find a little blood extravasated; in general, also, you find the bones considerably displaced, riding one over another, owing to the animal not being quiet, and the unrestrained action of the muscles. For the first three or four days you see nothing more than you do immediately after the accident has occurred; but after this period there is a little thickening and consolidation of the parts surrounding the fracture, and this thickening extends to the muscles and neighbouring tendons. In the course of a week all these parts become firmly united, consolidated with one another, and there is a soft yet firm substance, something be. tween ligament and cartilage in consistence, which surrounds the broken extremities of the bone. This newly-formed substance adheres to the bone above and below the fracture; the neighbouring muscles and tendons are closely attached to its surface; and the fractured extremities of the bone lie, as it were, loose in a cavity in the centre, with a small quantity of vascular albumen, resembling a semitransparent jelly. Here, then, is a kind of natural splint which nature contrives, and which is nearly completed within a week after the accident. We call this new formation the callus. This process goes on, the surrounding substance becomes thicker, and of still firmer consistence; and here [presenting it] is a drawing shewing the appearance which the parts exhibit at the end of ten days after the accident. A few days after this you find the thin jelly, which lay in contact with the broken ends of the bone, to have disappeared, and they are united by a gristly substance, or callus, like that which formed the original capsule. Here [presenting a drawing] is the appearance which the parts exhibit at this latter period; and this we may consider as the termination of the first part of the process which takes place after the occurrence of a fracture. The broken ends of the bones are, as you perceive, completely imbedded in a mass of vascular organized substance,or callus, something between gristle and cartilage in consistence; and as yet there is no bone. At this time, if you take off the mass of callus, you find the broken ends of the bone retaining exactly their original figure, and presenting exactly the same appearance as immediately after the fracture took place. At the end of about three weeks, if you make a section of the callus, minute specks of bone are visible, deposited in it here and there; and at the same time some of the callus seems to disappear on the outside, so that the neighbouring muscles and ten. dons adhere to it no longer. The specks of bone become more numerous, and larger, until at last the whole of the callus becomes converted to bone. Here [er hibiting it is a drawing representing the appearance of a fracture thirty days after the injury. It is the broken leg of a guinea-pig, and there is a mass of new bone, into which the callus has been converted. Even at this period the union of the broken bone is not completed; for although the callus is all converted into bone, you may with a penknife pick the new bone off the old, and demonstrate the broken extremities of the latter as having nearly their original shape and appearance. Now, then, the broken ends of the bone lie imbedded in a mass, not of callus, but of new bone; and this completes the second part of the process set up for the repair of the fracture. And now a third series of changes begins to take place. The broken extremities of the bone gradually become attached to each other, by bony matter passing from one to the other; and the mass of newly formed bone which had been deposited externally, in what was originally the callus, being no longer wanted, it be comes absorbed. By degrees the whole of it disappears, and the bone is left, hay ing the dimensions which it had previous to the accident. The preparations on the table, which consist of the limbs of animals examined at various periods after a fracture, shew all the circumstances which I have now mentioned. Thus it appears that the process by which fractures become united, under ordinary circumstances, may be divided into three series of changes, and that these must follow each other in succession, to complete the union of the broken bone. First, there is the thickening of the surrounding parts and the formation of callus; secondly, there is the ossification of this callus; and thirdly, there is a grow ing together of the broken bones, and the absorption of the ossified callus. This process is completed in young persons much sooner than in those advanced in life. In the upper extremities it is completed sooner than in the lower. It is a curious circumstance that, in the lower extremities of man, the process may take, on an average, ten weeks; whereas in the upper extremities of the same individual, it may be completed in eight weeks, or eyen sooner. In growing children it may be completed two or three weeks sooner than in adults; and in animals generally, but especially in those of the smaller species, union takes place more speedily than it does in the human subject. Circumstances under which fractures do not unite.-Now, then, let us consider what are the circumstances under which fractures do not unite. Fractures do not unite sometimes, in consequence of the anatomical structure of the parts in which an accident has occurred. The neck of the thigh bone, when broken, does not unite. This observation was made by some of the older pathologists. You will find it noticed by Morgagni; but it was not generally known till the remark was made again of late years by Sir Astley Cooper. It has been a question much agitated, whether bony union of a fracture of the neck of the femur can take place under any circumstances; but I need not enter into the consideration of this question at present. We may be satisfied that fracture of the end of the femur seldom unites; that it does not unite in the same way with ordinary fractures; and the structure in which this particular kind of fracture occurs, explains the circumstance. Fracture takes place in the neck of the femur, within the cavity of the joint. The neck of the femur has a covering of synovial membrane, but there is none of that mass of cellular membrane and muscles enveloping it, in which union begins when the fracture is in the shaft of the bone; and this is a sufficient explanation of the want of union after this accident. If a fracture were to occur in any other bone, which is covered, as the neck of the femur is, by a reflexion of the synovial membrane, I presume the result would be the same; but in the human subject there is hardly any bone, except the neck of the femur, which can be broken under these circumstances. There are, however, some bones which may be thus broken in animals. When I was making the experiments to which I have referred, the fracture was made, as it were, by chance, sometimes in one place, and sometimes in another; for you cannot, of course, make the fracture in the exact part in which you wish to make it. In one experiment, however, the bones of the leg of a guinea-pig were broken close to the ankle-joint. The tibia in these animals is covered by the synovial membrane a little way above the ankle. The fracture, in this instance, took place under the same circumstances as those under which the neck of the femur is usually broken in the human subject; and when I killed the animal, which was some time after the fracture had been made, I found that the bone was not united. The broken ends of it fitted each other so exactly, that there was scarcely any motion between them; the synovial membrane was scarcely torn; the ligaments were not torn; the cancellous structure had become harder than natural, in consequence of the ossification of the medullary membrane; and there was, nevertheless, no union of the fracture. Fracture of the neck of the femur unites ultimately by a ligamentous substance, at least it does so in many cases. The ligament is sufficient to bind the bones a little together, but it makes a very different bond of union from that which would be formed by actual bone. This union, even by ligamentous substance, is the result of a very slow process; not being completed for some months. It is not merely the neck of the femur in the human subject that does not unite in consequence of its particular structure; at least something like this happens with respect to the bones of the cranium. A fissure of the cranium takes much longer to unite than a fracture of the arm. I first noticed this in examining the body of a person who died six months after an injury of the head. I expected to find the fissure in the skull quite united, but I found on dissection there was no union at all. In the Hunterian Museum, at the College of Surgeons, there is a specimen of extensive fracture of the skull indicating the same fact. The skull has been broken in several places. There is no displacement of the broken edges, yet there is no attempt at union. It is evident that the patient had lived a considerable time after the accident, since the sharp edges are rounded off, in consequence of the absorption of the rough edges of the fracture. You will observe that the bones of the skull have the dura mater lining them on the inside, while on the outside there is the periosteum, and then the tendon of the occipo-frontalis muscle, without any intervening mass of loose cellular membrane. Whether it is to this, or to other circumstances in the anatomical structure of the parts, that the want of union in fracture of the skull is to be attributed, I cannot say; but I have no doubt that this does not unite like other fractures; that is, not at the end of the same period. That which is completed in a few weeks after an accident in other bones, in the skull may require several months. However, union always takes place at last. It has been said that diseased bones, when broken, will not unite, and I believe this may be the case, where there is an abscess in the bone, where there is necrosis, and in some other instances. I know, however, that the rule is not absolute; for, in a great many cases where the bone is diseased, it will unite perfectly. I had a patient who had disease of the bones, whether it arose from syphilis, or mercury, or a cachectic state of the constitution, I cannot say; however, some of the bones had nodes upon them, and were very much enlarged. The principal enlargement was in one of the clavicles. There was a portion of this bone enlarged, and much diseased besides. This man, in using his arm, broke the collar-bone, the fracture going through the diseased part. I bound up his arm, and concluded that there would be no union, (this was many years ago); but to my surprise it united quite as soon as ordinary fractures. Women labouring under cancer of the breast are very liable to a similar disease of different bones in the body. Sometimes this disease, which is indicated by pains like those of rheumatism, will affect nearly the whole of the bones, which then become brittle, and very liable to break. I first observed this fact many ago years, in the case of an old woman who was dying of cancer, and who in turning one day in bed broke the thigh bone. I concluded that the broken bone would not unite; but union took place as well as under ordinary circumstances. I attended a lady two years ago, who had cancer of the breast, and pains of the limbs, indicating cancerous disease of the bones. There was a scirrhous affection of the collar bone; and one day in moving her arm, the collar bone was broken: but it united, just as if it had been a healthy bone. It sometimes happens, when a fracture has been attended with more than usual injury, that a piece of muscle gets between the fractured extremities of the bone, and keeps them asunder. That is quite a different cause of non-union. Cases of this kind are on record, where the fact had been verified by dissection; and I have seen instances where we had reason to believe, on examining the living person, that the same thing had happened." Then it is usually supposed that a great deal depends upon the limb not being kept perfectly quiet; that if there be not a good apparatus employed, such as will fully answer this purpose, union may be prevented taking place. I cannot say that this may not be a sufficient reason in the human subject, but it is not so in animals; for in them I have tried, over and over again, to prevent union by giving motion to the broken bone several times a day; but I never could succeed by this method, and indeed union seemed, for the most part, to go on more rapidly in animals whose limbs were thus exercised than in others. There was, indeed, a single instance, in which, at the end of the usual period, the fracture was united only by ligament; but the animal was killed early; and it is very likely if it had lived three weeks longer, the union might have been completed. However, the human species differs in many respects from the quadru peds on which I made experiments, and I would not assert that too great latitude of motion being allowed to the limb after fracture, may not be sufficient in a man to prevent union taking place. so, In most instances, however, I cannot doubt that the want of union is to be found in the state of the constitution. A gentle man was growing fat, and not liking to do he placed himself on a very spare diet, though accustomed to good living previously. After six months of starvation, he broke his arm, and the bone would not unite. I saw him many months afterwards, and there was scarcely any union, even by soft substance. Another patient about whom I was consulted, a lady, was growing fat, and thought she would also prevent it, by pursuing a similar system of diet. Some months afterwards, she broke her arm, and union did not take place. Cases of ununited fracture are not very common, yet here are two among those which have fallen under my observation, in which the want of union seems clearly to be traced to the bad state of the constitution, produced by an imprudent abstinence from food. A man broke his thigh, his bowels were costive, and his surgeon allowed him to remain without a stool ten days after the accident, and in him the broken bones did not unite. We cannot be certain that it was this long-continued costiveness which prevented the union of the fracture, but it seems probable that it was so. If loose bandaging may prevent a frac ture from uniting, by permitting the bones to have too great latitude of motion, I think it very probable that tight bandaging may in some cases produce just the same effect. If the limb be too tightly bandaged, especially above the fracture, it must have an insufficient supply of blood; and it is reasonable to suppose that if that be the case, the restorative process, which produces union of a frac. ture, may not take place. I have made the following experiment several times :I have broken the thigh of an animal, tied the femoral artery, and killed the animal at the end of four days, and found the parts just as they would have been immediately after the injury. I have broken the bones of other animals, and tied the femoral artery at the same time, and then killed them on the seventh day, and still found no commencement of the process of union. But after this period, though the artery be tied, the formation of callus begins to take place, and then the union goes on as usual. At the end of a week, it is reasonable to suppose that the anastamosing arterial branches will have become dilated, so as to make up for the obliteration of the femoral artery; but till there is time for this change in the state of the vessels to have taken place, it ap. pears that the limb does not receive blood enough for the process of union to be established. Appearances on Dissection of an Ununited Fracture.-The appearances which are observed when you dissect a fracture which has not united at the usual period, are different in different cases. In general, there is union by a ligamentous substance, not by bone. I say ligamentous, for we have no other name to give it; but it is not fibrous: it is merely like a firm, condensed albumen, become organized, without a distinct, fibrous structure. In general, there is this ligamentous union; but there are some cases where even this union does not exist, and these are very remarkable. A new joint is formed-absolutely a false joint. The broken ends of the bone become rounded: there is a capsule as thick as the capsule of the hip-joint or shoulder: this capsule is fibrous, like ligament: it is attached to the bones above and below the fracture, and there is a cavity, like the cavity of a joint, in which the broken ends of the bone lie. But there is more than that: the rounded ends of the bone are covered by a thin, ligamentous substance, and the inner surface of the capsule is lined by a smooth membrane, like the synovial membrane, and capable of secreting synovia, and synovia in abundance. The cap. sule is a new formation; and the synovial membrane is a new formation. It is not to be wondered that a synovial membrane should be formed under these circumstances. It seems very easy for the system to construct a synovial membrane. The bursæ mucosa are made of synovial membrane, just like that of the joints. There is a bursa between the patella and the skin, and this in housemaids sometimes becomes diseased, and converted into a hard lump or tumor. I have frequently removed such a tumor from the knee of a housemaid, and some time afterwards, on examining the limb, I have been satisfied that the bursa was regenerated; that a new one was formed. But this is not a mere supposition; I have positive proof of a bursa being regenerated. There was a woman in the hospital from whose knee the late Mr. Rose removed an enlarged bursa. A year or two afterwards she returned, and came under my care, and not only had the bursa been regenerated, but the new one had become diseased like the old one, and I had to repeat the operation which Mr. Rose had performed formerly. She had gone back to her former occupation, and the pressure on the new bursa had converted the new bursa into the same diseased structure as the old one. These cases of artificial joints are comparatively rare: the union by ligamentous substance is much more common. Means to be employed for the purpose of procuring an union of the Fracture.- Now, then, suppose you are called to a case of ununited fracture, it is a great object indeed to get the fracture to unite; especially when it has occurred in the upper or lower limb. It does not so much matter in a rib. Here is a specimen [presenting it] where a joint has formed in the rib after fracture. This patient, I dare say, suffered little inconvenience from the accident. But it is a very different matter where such a case occurs in either of the extremities. The first question which will occur to you, is, whether there be any thing in the state of the constitution to account for the fracture not having united; and if there be, whatever is wrong must be corrected. One patient may require to be put on a better diet; another may require purgative medicine; another may stand in need of tonics. Mr. Wilson used to relate the case of a woman who was a dram-drinker, and who broke her leg. At first she was not allowed to take her customary drams, and the bones shewed no disposition to unite. At last she was allowed to take a certain quantity of spirit, and union took place immediately. In the way of local treatment, various methods have been recommended by different surgeons, with a view to the cure of these cases. Sometimes it appears that a very little matter will make a fracture unite, which has not united at the usual period. In numerous instances, I have known patients in the hospital kept in bed for ten weeks, and even longer, without union taking place. Here a splint has been bound on each side of the limb; we have put the patient on crutches, made him walk about, put the limb to the ground, and exercise it with the splint on, and the fracture has become united. Then, in other cases, I have applied blisters to fractures slow in uniting. Mr. Sewell, of the Veterinary College, apprised me of some observations which had been made on animals, from which it appeared that the application of blisters was useful where fractures were slow in uniting; and I have employed them often in the human subject, with very great benefit to the patient. But if this method is to be useful, it must be had recourse to in eight or ten weeks after the accident has occurred. An operation was formerly recommended, but a very severe one, in which the surgeon cut down on the broken extremities of the bone, turned them out through the wound, then sawed off a portion of each of them, put them back into their proper place as nearly as could be, afterwards applying splints, and treating the case like one of compound fracture; into which it was, in fact, converted. Of course it was supposed that this method would produce a cure. But I have for merly talked to some surgeons of the old school on the subject, and they have told me that they never had known a cure to have been performed in this way, although they had frequently seen the operation performed: and I believe that it is now acknowledged, that the success of this operation is, at the best, very problematical; that it fails, indeed, much more frequently than it succeeds; and no one can doubt that it must be attended with considerable hazard. It is, in fact, such an operation as ought not to be performed in a case where the patient's life is not in previous danger. Sir Everard Home used to mention, in his lectures, the case of a man with ununited fracture of the humerus, who was under Mr. Hunter's care. There was an artificial joint, and Mr. Hunter made an incision into it, and then having introduced a spatula, irritated the whole surface of the artificial joint. This brought on a considerable inflammation, which ended in anchylosis, and thus the patient was cured. I am not aware that this operation has been performed in any other case. Dr. Physick proposed what appeared to be an improvement upon it. He saw that the only effect of Mr. Hunter's operation was to produce a fresh attack of inflammation, and that this might be equally induced by passing a seton through the artificial joint. This must certainly be a less severe method than Mr. Hunter's, because, when suppu. ration has taken place, the matter will not be locked up, but must be conducted outwards, in one direction or the other, along the seton. The principle of the two operations, however, is the same; and in all probability, Dr. Physick borrowed the idea from what had been done by Mr. Hunter. Dr. Physick was a pupil at this hospital, and afterwards house-surgeon. He was intimate with Mr. Hunter, and probably was here at the time when his operation was performed. The operation with the seton, as recommended by Dr. Physick, has been tried in this country several times, and I have performed it on three different occasions. The first was in the case of an ununited fracture of the femur. I passed a seton between the broken extremities of the bone, and union did take place, but it was not completed until after a long period of time. I tried it next in another case of ununited fracture also of the femur. It was followed by much disturbance of the constitution. I was alarmed, and removed the seton. The symptoms subsided, but I re-introduced it afterwards, and it was now kept in for a considerable time, the constitution not being |