A CONTRIBUTION 
TO THE 
STUDY OF BONE REPAIR A CONTRIBUTION 
TO THE 
STUDY OF BONE REPAIR. 
BY 
JOHN S. MILLER, M.D, 
OF PHILADELPHIA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
JUNE 27, 1888. 
PHILADELPHIA: 
WM. J. DORM, PRINTER. 
1888. A CONTRIBUTION TO THE STUDY OF BONE REPAIR. 
By JOHN S. MILLER, M.D. 
[Kead June 27, 1888.] 
The recent observations of Macewen1 have done much to stimulate 
the study of bone repair, and have thrown not a little light upon the 
function of the medullary cells in osteogenesis. 
The resort to mechanical irritation of the medullary tissues as a 
means of accelerating bone repair, is an old procedure. Nancrede2 
claims a priority in this for America. As far back as 1793, Eve3 relates 
that the lay surgeons of the frontier were wont to make multiple perfora- 
tions of the external table of the skull where necrosis had followed the 
Indian mutilation of scalping. And twenty years ago Agnew2 resorted 
to the same procedure in a case of injury to the head. A fatal termi- 
nation of the case, however, by encephalic complication, rendered the 
experiment incomplete. Reports of success by this procedure have 
been recently multiplied to an extent which will excuse us from repeat- 
ing them in detail. 
That furthermore, medullary proliferation is not only an element in 
osteogenesis, but is of itself sufficient to that end without periosteal 
cooperation, is evidenced by the case of Macewen,4 in which a con- 
siderable restoration of the humerus was secured " by bone-transplanta- 
tion," after a suppurative inflammation had destroyed both the shaft 
and its periosteum. The date of this observation is 1878. 
The patient was a boy, two years of age. A suppurative periostitis of the 
right humerus of nine weeks duration had resulted in total necrosis of the 
entire diaphysis, and this latter had been removed, leaving a tube of granula- 
tion material lining the periosteum. This tube had been kept patent by 
suitable dressing, until the whole space had become filled with granulation 
tissue, and had finally become a mass of cicatricial tissue. No bone had 
1 Annals of Surgery, vol. vi. pp 289 et seq., 389 et seq. 
2 Internat. Encycl. of Surg., by Ashhurst, vol. v. p. 8. 
3 Remarkable Cases of Surgery, p. 35. Philadelphia, 1857. 
4 Loc. cit., p. 301. 4 
MILLER, 
grown from this periosteum, except in a small part next the proximal epi- 
physes, where at the outset the periosteum had been found covered with 
plaques of adherent osseous tissue. In the remainder there had been no 
osseous deposit, the result being a flail-like arm, which the patient found so 
useless that the parents desired its removal. 
Macewen determined, however, upon another procedure. An incision was 
made into the upper third of the arm, exposing the head of the bone, to which 
was found attached a spike-like process of cartilage. This was removed, 
leaving as remains of the diaphysis a portion of bone one and three-fourths 
inches in length. From this point a sulcus about two inches in length was 
made in a downward direction between the muscles. The former presence of 
bone was nowhere indicated, and there was no vestige of periosteum, and the 
sole guide as to the correct position into which the transplant was placed was 
an anatomical one. Two wedges of bone were then removed from the tibia 
of a patient aged six years, with anterior curves. The face of the osseous 
wedges consisted of the anterior portion of the tibia, along with its peri- 
osteum, the wedges gradually tapering toward the posterior portion of the 
tibiae. 
After removal they were cut into minute fragments with the chisel, quite 
irrespective of the periosteum. The bulk of the fragments had no periosteum 
adhering to them, they having been taken from the interior of the bone. 
They were then deposited into the muscular sulcus of the boy's arm, and 
the tissues drawn over them, and carefully adjusted. The wound healed 
without pus production. Two months after, a portion of bone an inch in 
length and three-quarters of an inch in thickness was found firmly attached 
to the upper fragment of the humerus. 
Two other wedges of bone, larger in size, were similarly dealt with, and 
inserted two months subsequently to the first graft, and a third couple were 
placed in position five months after the first. These filled up the gap in the 
arm to the extent of four and one-quarter inches. The arm then measured 
six inches in length. 
Soon the utility of the arm was greatly restored. Seven years afterward he 
was seen and examined. The shaft of the humerus was found to have increased 
in length by one and three-quarters inches, being now seven and three-quarters; 
and it had increased in circumference to a marked extent, and assumed a 
somewhat irregular shape. The length of the sound arm had, however, con- 
siderably outstripped the length of the transplanted humerus. He could use 
the arm for many purposes, taking his food, adjusting his clothes, and many 
games. 
Whether the introduction of proliferating medullary cells into ordi- 
nary connective tissue granulations may convert the whole into osseous 
tissue, or that a few osteoblasts will, so to speak, leaven the whole mass, 
is a question involving grave doubt, but the affirmative would seem to 
receive some support from the case which Nancrede1 relates in 1883. 
An extensve laceration had caused denudation and necrosis of the ulna 
1 Transactions of the Philadelphia Academy of Surgery, 1888. STUDY OF BONE REPAIR. 
5 
in two-thirds of its extent. The process of repair had been delayed; 
he drilled numerous holes through the sequestrum into the medullary 
canal, and, to quote his own words, "in a few days granulations sprang 
up from the ulna and fused with the granulations of the soft parts, and, 
in course of time, the fragment was separated." 
That the procedure in this case had the effect of stimulating osteo- 
genesis from within, we can readily believe; but concerning the fusion 
with granulation tissue without, a more accurate observation than is 
recorded by Nancrede is desired. Although 'by analogy we might 
conceive it possible, inasmuch as repair within the bone is by ossifica- 
tion of an embryonic tissue derived from the connective tissue around 
the bloodvessels of the medullary spaces. A similar case is reported 
by Macewen,1 in which granulations appeared upon a surface of bone 
completely denuded of its periosteum, and gradually spread until they 
became united with the granulation tissue at the periphery of the 
wound. Macewen, however, infers from this observation that 
" The periosteum covering a bone may be completely destroyed or perma- 
nently removed, yet the denuded bone may not only retain its vitality, but 
may throw out cells which will cover it and form a new periosteum." 
These cases would seem to confirm Macewen's dictum that the peri- 
osteum has no part whatever in the regeneration of bone. But the 
first case I shall present to your notice this evening demands a different 
hypothesis for its explanation. 
The patient, D. M., aged fourteen years, suffered from an osteomyelitis of 
the right tibia, resulting in total necrosis of its diaphysis. A complete 
involucrum had formed around the sequestrum and afforded an unsteady sup- 
port to the body weight. It was covered with the thickened periosteum, A 
number of fragments had been removed from time to time, and the parents 
had refused to entertain for him the proposal of amputation. The case, how- 
ever, when it came into my hands, had become from septic infection so 
desperate that I was compelled to do something radical at once. 
Exposing the shaft, or rather the involucrum, through its whole length, I 
made with trephine and saw a fenestrum large enough to permit the removal 
of the remaining sequestra, and cleared out the whole canal. Both epiphyses 
were found carious upon their exposed surfaces, and were scraped to the limit 
of safety. In a few days a superficial necrosis took place upon the inner sur- 
face of the tube. 
Demarcation was, however, promptly effected by the free use of aluminum 
acetate5-that sheet-anchor in all sloughing wounds-and a fine layer of fine 
granulations became the field for any osteogenesis which we might hope to 
witness. During the long process of repair with the carious epiphysis as a 
1 Loe. cit., p. 293. 
3 ty.-Pot. et alum, sulph.,1 part; plumb, subacet., 5 parts ; aquae bull., 100 parts. M. Filtra. 6 
MILLER, 
never-failing source of bacterial supply, it was no trifling task to keep this 
extensive opening dry and sterilized. Furthermore, neither the patient, the 
household, nor the neighborhood could endure frequent dressings without 
great nervous prostration. 
The requirements of the case were successfully met by a mixture of iodo- 
form and starch, in proportions which varied with the changing conditions. 
The cavity of the wound was filled with this dry powder, and to the whole 
was applied a closed dressing of gutta-percha tissue. The purpose of the 
starch was to absorb the excess of moisture incident to a closed dressing as 
well as to dilute the iodoform. As soon as the powder became saturated, it 
was removed by a stream of sterilized water, and the wound was filled and 
closed as before. The periods of dressing were gradually increased from three 
to ten days. I mention these details, because without them, or similar ones, 
we can wait in vain for the desired repair. In process of time the hollow of 
the involucrum became completely filled with granulation tissue, which con- 
tinued to extend until it fused with the granulations from the soft parts, and 
finally, the whole became covered with a new epithelium, which had gradually 
spread from the edges of the wound. The tissues became now denser, and 
offered more and more support to the body weight until, as you see, he has 
acquired a very useful limb, and can walk without discomfort. 
We must, therefore, infer that a metamorphosis into bone has taken 
place, and as the original diaphysis was gone with its medullary struc- 
ture, we can find no osteogenic agent in the result other than the 
periosteum. 
We must draw a similar conclusion from the recent case reported by 
Ceci: 
The patient, a young man, developed an acute osteomyelitis of the left 
scapula five days after circumscision for inflamed phimosis. One month later, 
Ceci1 extirpated the bone, making the usual L-flap. The periosteum was left 
intact as far as possible, and the arm was preserved. The patient recovered 
rapidly, and there was a subsequent regeneration of the bone. 
The only possible explanation of this result is by the hypothesis of 
periosteal agency or cooperation. 
The second case which I present is in confirmation of Macewen's 
proposition that 
"A portion of bone which has its continuity severed on all sides, and has 
had all its periosteum removed, is capable of living and growing." 
This is in contradiction to our inference in the case of the tibia, and 
can be reconciled only by the assumption that the discovered laws of 
osteogenesis are of a lower order, subject to some general law of which 
we are as yet ignorant. But to the case. 
1 Centralbl. f. Chirurgie, Dec. 17, 1887. STUDY OF BONE REPAIR. 
7 
Mrs. L., aged forty-seven years, had suffered with a neuralgia of the maxil- 
laris inferior, for the relief of which all medical means had been exhausted 
in vain, and which, therefore, left to my option only the dernier ressort of neu- 
rectomy. The mode of operating was the usual one. The ramus was tre- 
phined near the angle of the jaw, the canal was exposed, and about two inches 
of the nerve trunk were drawn out and exsected. The button was, however, 
returned after having been sterilized in a 1 to 1000 solution of corrosive sub- 
limate, but it was not returned to its old position. With a view of imposing 
a barrier to the reproduction of the nerve, it was so rotated around its vertical 
axis that the groove upon its lower surface stood at right angles to the axis of 
the canal. Not only did the wound close by first intention, but the button 
grew solidly in its position. Now, the curious thing in the case is that, before 
trephining, I had carefully removed the periosteum, so that the latter can 
claim no part in the subsequent bone repair. After seven months there has 
been no return of the disease.