UNUNITED FRACTURE 
SUCCESSFULLY TREATED, 
WITH REMARKS ON THE OPERATION. 
By HENRY J. BIGELOW, M.D. 
Professor of Surgery in the Medical College of Harvard University. 
WITH 
ABSTRACTS FROM DR. BIGELOW'S CLINICAL LECTURES 
ON THE SUBJECT, AND CASES. 
[Reported by Richard H. Debby.] 
BOSTON: 
DAVID CLAPP & SON-334 WASHINGTON STREET. 
1 867. UNUNITED FRACTURE SUCCESSFULLY TREATED. 
The following paper gives the details of eleven consecutive cases of 
ununited fracture, successfully treated, with the exception of one, 
in which the bone was diseased. Such continued success justifies the 
belief that this operation will effect the desired object with more 
uniform certainty than any other method now in use. 
Two cases are appended in illustration of the extent of the osteo- 
plastic power of the periosteum. In one of these the condyles of 
the humerus were reproduced after excision. In the other the peri- 
osteum failed to form a new bridge for the nose, after a rhino- 
plastic operation. 
Having1 failed, in a number of cases, to effect by rest, com- 
pression, blisters, seton, drilling, excision of bone, dovetailing, &c., a 
union of ununited fracture of the humerus, and having in mind the 
experiments of Ollier* for the production of bone from periosteum, 
I determined, wrhen the opportunity presented, to avail myself of 
the osteoplastic function of this membrane. In trying the experi- 
ment for the first time (Feb. 14th, 1860), I was not aware that any 
previous attempt had been made to produce bony union of ununited 
fractures by preserving the periosteum for that purpose; but in the 
ensuing spring, at the time of the successful issue of the case allu- 
ded to, I happened to meet with a paper recently published upon this 
subject, a superficial perusal of which seemed to show that its author 
had covered the ground, at least of novelty, in the method. The 
pamphlet was mislaid, and I thought no more of the matter, but had 
not infrequent occasion to repeat the operation, with successful result, 
and annually referred to the subject in my lectures before the class 
of Harvard University. A report of this method was also publishedf 
incidentally in connection with the testimony of the writer in a suit 
for malpractice, and afterwards alluded to in the London Medical 
Times and Gazette,\ in which I stated that my own operation had 
* Gazette Medicale, 1859, Nos. xiv. and xv. 
t Boston Medical and Surgical Journal, vol. Ixix. p. 218. 
t February 6, 1864. 4 
heen anticipated abroad. Within a few weeks, however, my atten- 
tion was directed, by my able house-surgeon, Mr. R. H. Derby, to 
the following paragraph in Holmes's System of Surgery :*•- 
" Jordan ascribes the failure of resection to the removal of the 
periosteum. He, therefore, by means of some blunt instrument, as 
die handle of a scalpel, dissects this membrane from the portions of 
bone which he is about to remove, and leaves the two empty pouches 
passed one within the other, and, in some cases, connected by suture, 
to form new bone. The suggestion is undoubtedly theoretically 
sound. Its practical value, however, remains to be proved. In two 
of the three cases which Jordan records, it failed of success; and 
he admits its failure in the hands of M. Scdillot." 
Upon again examining more carefully the original paper of Mr. Jor- 
dan,! I find that his method differs so essentially from my own as to ex- 
plain both the failure of two out of three cases cited by him, and 
the almost uniform success of the cases reported in this paper. 
Briefly, in the method of Mr. Jordan, no means arc taken to secure 
the perfect and permanent coaptation of the bones-a measure 
which underlies the success of the whole proceeding-if we except 
a suture of the periosteum, which is wholly inadequate to that 
object, and which must also give way in a short time. This omission 
alone is fatal to any considerable success in the operation. 
2. The muscle is detached from the periosteum,! and the perios- 
teum then pounded to detach it from the bone; measures both tend- 
ing materially to devitalize the tissue upon which success most 
depends. 
3. Mr. Jordan believes that suppuration hinders bony union, and 
therefore ingeniously modifies the whole operation for the purpose of 
preventing a suppuration which is in reality inevitable, and which 
must therefore be met and provided for, controlled and directed, 
and which docs not prevent the desired result. 
Finally, it may be added that an oblique section of the already 
tapered bone, as recommended by him, and especially the rabbet,§ is 
not to be advised, as it tends to denude and devitalize the protruding 
extremities; while an apparatus of plaster is hardly sufficient to en- 
sure subsequent immobility, and one of gutta percha, by confining 
transpiration, is irritating to the skin. 
Abstract from Dr. Bigelow's Surgical Lectures at the 
Massachusetts Medical College. 
The chief cause of ununited fracture is undoubtedly the severity 
of the local injury, although perhaps the constitution of the patient 
or an obliteration of the osseous artery may, in a few cases, have to do 
* Vol. i. p. 804. 
+ Traitement des Pseudartliroses par 1'Autoplastie Periostique. Par Joseph Jordan, 
F.R.C.S., Chirurgien en chef de 1'hopital de Manchester. Paris, 1860. 
t See Plate III. 
$ An interlocking, called also in carpentry rebate. 5 
with it. It occurs in an arm which has been run over, or after acci- 
dents from machinery, which bruise and devitalize the part. The 
obstinacy and persistence of this lesion under treatment are well 
known, and have arrested the attention of surgeons, who have de- 
vised many expedients, though often unsuccessfully, for its relief. The 
present operation must be deemed a successful one. * 
Operation.-The extremities of the false joint are to be attacked 
where they approach nearest to the surface, unless vascular oi* ner- 
vous trunks are in the way; in the arm, in all the cases I have seen, 
upon the outside; a free incision being contrived in each case with 
especial reference to the free exit of pus. In the arm, the musculo- 
spiral nerve, which is often displaced and tied by the lymph, is to 
be carefully looked for and avoided, and were it not for the care 
here requisite the bone might be exposed by a single incision. The 
principal bony extremities being found, the interval, which is some- 
times quite irregular and interlocked, is gradually divided, and the 
ends turned out, the dissection being materially aided by an assistant 
who powerfully flexes the false joint. As it yields, care is taken to 
prevent the muscles from being stripped from the periosteum, which 
they adhere to and aid in nourishing. When one extremity is fairly 
exposed, a crucial or other regular incision is to be made in the rag- 
ged callus which overlies the periosteum at its tip, which should be 
then seized by strong-toothed forceps and efforts made to tear it 
out of the rugous inequalities of the formerly inflamed bone. 
After a little delay and dissection, the flaps begin to yield; with 
some coaxing, the terminal adhesions are detached, and the sound 
bony shaft is reached, where the periosteum is only too easily 
stripped from the bone, requiring great care lest the shaft should 
be denuded higher than the intended section. The soft tissues 
being now protected by spatulas, or flexible strips of copper, 
the end of the shaft is removed by a common saw, the length of 
this fragment being determined by the amount of periosteum it 
has been necessary to detach. A half an inch of good cylindrical 
periosteum, with half an inch more of ragged tissue hanging 
at its extremity, has usually covered from three quarters to an inch 
and a half of bone. Perhaps half an inch of sound shaft, with an 
irregular or conical extremity varying in extent, is a good rule for the 
excised piece in most cases. The other extremity is now to bo turned 
out and treated in the same same way, and this terminates the dis- 
section, leaving only the wire to be inserted. For this purpose holes 
'are bored in each extremity with a good bone drill, larger than the 
wire, at a little more than half an inch from the end, and through 
one wall only. A pure silver or plated copper wire is inserted from 
without inward in one end, and inversely entered in the medulla from 
within outward in the other; the size of the wire ordinarily used is 
No. 10 of Stubbs's iron wire gauge. The ends are brought together 
accurately, and the wire twisted long enough to protrude at the ex- 6 
ternal wound. The incision is then brought together by sutures, 
leaving an abundant exit for pus, and the apparatus is applied. 
Apparatus.-The best apparatus for the humerus I have found, on 
the whole, to consist of a firm concave splint of iron and leather, 
made to fit the top and outside of the shoulder as low as the axilla, 
and thence horizontally to the neck, and secured by a strap around 
the opposite axilla; a similar gutter to receive the elbow and fore- 
arm flexed at a right angle; and the two united by a narrow iron 
strap on the back, and another on the front of the humerus, adjusta- 
ble as to its length. The splint can be thus shortened when in place, 
so as to keep the extremities of the bone in contact, and nearly im- 
movable, in spite of the great leverage of the arm upon the wire, 
while the dressings can be readily applied in the open interval, with- 
out disturbing the apparatus. 
For the thigh, a pasteboard splint may be moulded to the anterior 
aspect of the thigh and leg, and then stiffened with dextrine, an in- 
terval for the wound being left. The whole limb is then secured to 
this by bandage; and surmounting the whole, a Smith's anterior splint 
is applied, by which the leg is suspended from a railway on a frame- 
work over the bed. 
I have usually employed water-dressings at first, and poultices or 
oakum to absorb the discharge afterwards. The patient has remain- 
ed in bed for several weeks, and in fact till some stiffening has taken 
place, after which fresh air has been enjoined as an invigorating and 
osteoplastic agent. The diet has been as generous as the appetite 
would bear, and the phosphates have been generally administered* 
upon the principle of giving egg shells to hens. 
The wire has remained in place until the bone was firmly united, 
generally during several months, and there has been in no case evi- 
dence of any ill effects from its presence, either in producing ne- 
crosis or undue inflammation. In fact, it has, in some cases, remained 
quietly in place after the arm was in use, and before the patient 
returned for its removal. In Case II. the wire remained for two 
years. 
To remove the wire, the loop is best divided with cutting pliers, 
and forcibly drawn out; hence an advantage in flexible wire. This 
loop is sometimes quite superficial, but in other cases is so deep as 
to require an incision to reach it. 
It may be remarked that a partial stiffening, dependent on the in- 
flammation of the soft parts, may take place in a few weeks, but the 
bone afterwards becomes gradually loose if the periosteum fails to 
do its duty. 
The one great point to be observed in treatment is the preven- 
tion of abscess, or, in other words, the early and free evacuation of 
imprisoned pus, by large and dependent incisions, which here as else- 
where are incomparably less injurious to the tissues than the burrow- 
ing of pus. Again, the formation of an abscess is always attended 7 
with fever, which destroys appetite and weakens the patient. Hence 
especial care is needed to detect any inflammatory induration super- 
vening after suppuration has begun, and the first decided pointing should 
be the sign for an opening, to be explored by the finger, and enlarged 
inside or outside accordingly. I need not say that it is, in general, 
cruel to use the knife without an anaesthetic, but here the careful ex- 
ploration and the tearing of the adjoining sinuses with the finger, if 
adequately done, absolutely demands it, for the comfort of both sur- 
geon and patient. After a long experience, I have never seen a pa- 
tient, unless already moribund, really worse for ether, and I have 
often seen a weak person prostrated by the excitement and suffering 
of an operation, when it was withheld by the timidity or haste of 
the surgeon. As for freezing, it is sometimes more convenient for 
short and superficial incisions, and in private practice, but when its 
novelty is gone it will yield in other cases to general anaesthesia. 
In operating upon the humerus, the musculo-spiral nerve demands 
especial consideration. Winding around the outside of the arm 
near the usual place of incision, it is sometimes difficult to avoid it, 
especially when displaced by the deformity, and tied into an indu- 
rated mass of lymph. I have twice accidentally divided it, in spite of 
more than ordinary care; once completely, and once leaving only a 
single fibre at one side. In one case, an operation had been un- 
dertaken one month only after a previous one, while the arm was 
still inflamed. It was on thak account absolutely impossible to keep 
the wound dry, and after a protracted dissection the knife was at last 
used beneath the blood; the nerve was imprisoned and concealed in a 
deep groove in the new bone, and was divided in separating the bones. 
On this ground, I should not advise a second operation until the traces 
of active inflammation from a previous one had disappeared. In this 
instance the neurilemma was re-united by a small suture. In both 
cases, the power of the paralyzed extensors ultimately returned, 
completely and unequivocally. In another case, now under treatment, 
partial paralysis ensued after the operation, but the nerve had been no 
where seen, and could hardly have been divided. On the other hand, 
the fragments were so short that a powerful and continued effort had 
been required to make their ends protrude, jamming the muscles in 
their interval, and very likely thus injuring the nerve. The fingers 
are now regaining their motion. In the same case, which was one 
of gun-shot wound, the operation twice failed, there being still some 
necrosis about the bone, of which the lower fragment was enlarged 
to at least double its diameter. In a future case, I should consider 
that necrosis contraindicated the operation, if there were any good 
chance of getting rid of it by time or interference. 
The case most favorable for operation is undoubtedly that of a 
healthy subject, where the bony extremities are of natural size. In 
a case of long standing, atrophy tapers the bones, which need in 8 
consequence longer excision. Other things being equal, it is better 
not to wait unnecessarily. 
The only case I have encountered of ultimate failure, was one of 
extreme softening of the bone by interstitial absorption, a condition 
which was not ameliorated by invigorating measures, including the 
free and protracted use of the phosphates. 
Case I.-Humerus. 
Patient, E. J., aged 22, entered the Hospital, October 15th, 1857. 
Eleven months before, his right arm was caught in a " splitting ma- 
chine," and drawn in between the cylinders. A compound, commi- 
nuted fracture of the radius and ulna was produced at about their 
middle; and a compound fracture of the humerus rather below the 
middle. The fracture of the humerus did not unite, that of the fore- 
arm did. 
October 14th.-A seton was passed between the fractured ends. 
February 24th, 1858.-No union. Seton removed. Subsequently, 
emplastrum cantharidis was applied over the fracture; the ends of 
the bone were rubbed together. 
May 12th.-No union. An incision was made over the fracture; 
the two ends were exposed, and an inch removed from each. 
November 21st.-He was discharged, not relieved. 
November 15th, 1859.-He returned to the Hospital; the arm 
was perfectly useless, and occasionally caused pain. He was pre- 
pared for anything that should offer a reasonable prospect of suc- 
cess, or even amputation as a last resort. 
December 17th.-He was etherized, and, with the view of produc- 
ing irritation, each fractured extremity split with a pair of strong 
forceps, made for the purpose with chisel blades (which punctured 
the skin at opposite points, and slowly penetrated the bone, the ends 
of the forceps being placed in a vise), and a splint applied, consist- 
ing of a shoulder-cap, with a band around the opposite side, and a 
cap for the elbow and forearm. These two caps were made to ad- 
vance towards each other by a screw, so as to crowd the ends of the 
bones together. 
18th.-Comfortable. 
January 15th, 1860.-In consequence of pain about the shoulder, 
the apparatus was removed, and the arm bandaged. Little or no 
union. 
February 14th.-Operation by Dr. Bigelow. He was etherized, 
and a crucial incision made over the external surface of the arm over 
the fracture. The band of ligamentous tissue connecting the bones 
was divided, and each extremity of the humerus turned out. The 
periosteum was carefully detached, for an inch or more, from each 
end. The denuded ends were then sawed off. A hole was drilled 
through each end, and a stout silver wire passed through. The ends 9 
of the wire wore then twisted, and the ends of the bone brought 
into exact apposition. The external wound was united with sutures; 
the ends of the wire were left protruding, and the former splint re- 
applied. After the operation, opiates were needed and freely given. 
21st.-Wound smelling badly. A solution of chlorinated soda 
injected under the apparatus. 
25th.-The apparatus was removed, washed and reapplied. 
March 5th.-Wound closing by granulation. General condition 
good. 
23d.-Arm apparently stiff. 
29 th.-To-day, the arm and shoulder becoming somewhat painful 
from pressure of splint and necessary want of cleanliness, everything 
was with-great care removed; on slight examination of the arm, no 
motion was detected. The arm and shoulder wore then carefully 
washed, lateral splints applied, and the hand and elbow supported 
in a sling. 
April 4th.-The dressings were again removed. Slight mobility 
was detected at the point of fracture. As, however, only six weeks 
had elapsed since the operation, it appears to have progressed as 
rapidly as any compound fracture of an equally severe character 
could bo expected to do. External wound nearly healed. 
23d.-Apparatus frequently removed. Union firmer. 
June 13th.-Union appearing to bo very firm, and the wire caus- 
ing some pain, there appeared to bo no further indication for its re- 
maining longer. He was etherized; the wire was untwisted and 
removed. 
July 1st.-Arm was stiff and strong, with considerable motion in 
the elbow. 
July 12th.-At request, patient was this day discharged, being 
able to return to his work, which is that of a leather splitter. The 
arm appeared to be nearly as useful as the other one. 
Case II.-Radius. 
Patient, A. D., farmer, aged 56, entered the Hospital February 
6th, 1861. Four years before, he received a fracture of both bones 
of the right forearm, with other injuries, by being caught in machi- 
nery. Splints were applied and kept on for nine weeks, the patient 
being confined to bed during this time on account of necrosis of both 
tibiae, resulting from the injuries sustained. At the expiration of 
this time there was no union. A starch bandage was applied and 
allowed to remain for four months, but no union was secured at the 
point of fracture. During this time his health continued good. Nino 
months after the receipt of the injury, an incision was made over the 
lower border of the forearm, the ends of the fractured ulna were 
turned out and sawed off, and the extremities then wired together. 
Various other means ■were subsequently resorted to, but with no 
success. 10 
On entrance, the fractured ends of the ulna could be felt distinctly; 
there appeared to be some ligamentous union in the radius. He had 
a very considerable use of the hand. 
February 9th.- Operation by Dr. Bigelow. He was etherized; a 
tourniquet was applied over the brachial artery to keep the wound 
dry. An incision was then made along the upper border of the ra- 
dius, about two inches in length. The ends of the bone were turned 
out, the periosteum was dissected up, and about half an inch of each 
fragment sawed off. A hole was now drilled through the upper wall 
into the medullary cavity of each end, and the ends of the bone 
firmly wired together by means of a stout silver wire passing through 
the holes and twisted. Two small arteries required ligature. The 
edges of the wound were drawn together by sutures and a compress 
applied. The arm was placed in an external angular splint, and 
bandaged firmly, to prevent motion. 
12th.-The pain in the arm is quite severe and constant. Con- 
siderable swelling about the wound. The bandage is daily removed. 
March 1st.-Wound nearly healed about the wire. Appetite and 
strength excellent. 
23d.-Patient allowed to go home, to return for the removal of 
the wire. 
February 13th, 1863.-Patient has been able to saw wood with 
his right arm. He came to have the wire removed, which has re- 
mained since the operation. 
14th.-He was etherized. An incision half an inch in length was 
made over the point of fracture; the wire was divided, and easily 
removed, two years from the time of its insertion. 
Case III.-Humerus. 
Patient, J. C., laborer, aged 24, entered the Hospital November 
4th, 1861. Eight months before, while turning the crank of a hand- 
car, he became entangled in some way, and his left arm was drawn 
under the crank and fractured above the elbow. A physician ap- 
plied splints to the arm, and for two weeks took them off and reap- 
plied them every day. At the end of eight weeks the splints were 
removed, but no union found at the point of fracture. Four months 
ago, the fractured ends of the bone were rubbed together, but with 
no success. 
Now, the left arm is about one inch shorter than the right, from the 
ends overlapping each other. The fracture extends from a point 
about four inches from the lower end of the humerus, on the outer 
side of the shaft of the bone, obliquely inwards and downwards, 
terminating at a point about two indies above the internal condyle. 
Crepitus and motion in the fracture are very distinct. There has 
apparently been no callus thrown out around the fracture. Motion 
in the elbow-joint is perfect. 
November 9th.- Operation by Dr. Bigelow. Patient was ctheriz- 11 
ed. An incision, three and a half inches in length, was made through 
the skin over the seat of fracture. The subjacent fibres of the tri- 
ceps were then divided, as was also, accidentally, the musculo-spiral 
nerve, with the exception of a single fasciculus, by which the extremi- 
ties hung together, and which was afterwards carefully respected. 
The ends of the fractured bone were then turned out; the perios- 
teum was carefully detached from both; a piece one and a half 
inches long was sawed from the lower fragment, and a piece one 
inch long from the upper. A hole was then drilled through each end 
of the fractured bone, and the two surfaces kept in apposition by a 
silver wire, passed through the holes and the ends twisted. An in- 
side and outside angular splint, well padded, were then applied. A 
single suture was introduced to keep the edges of the wound 
slightly in apposition. The extensors of the hand are paralyzed. 
13th.-Splints were removed and reapplied. Position excellent. 
Slight suppuration in wound. 
16th.-Splints removed, and arm dressed. 
21st.-He has slight paralysis of sensation on the posterior radial 
aspect of forearm, and no sensation over the back of thumb and 
radial side of forefinger. 
29th.-Appetite poor. Pulse accelerated. 
December 17th.-Slight stiffening at point of fracture. 
27th.-Considerable stiffness in humerus. Wound nearly closed. 
January 10th, 1862.-Union moderately firm. 
March 1st.-On careful examination, a slight yielding was detect 
ed at the point of fracture. 
11th.-A small piece of necrosed bone came away from wound. 
May 10th.-Patient was etherized. An incision was made down 
upon the wire, which was then extracted. 
22d.-Discharged, well. 
This patient wrote, April 28th, 1867, that he was a " section hand 
on the Northern Railroad," had not lost a day since he left the hos- 
pital, and was " well, doing the hardest kind of work." Sensation 
and motion in hand perfect. 
Case IV.-Humerus. 
Patient, E. D., laborer, aged 31, entered the Hospital December 
4th, 1862. A year before, his left arm was caught by a revolving 
shaft, and the humerus fractured. The skin was much contused, but 
not penetrated. A physician was called, who, after examination, 
pronounced the humerus comminuted through nearly its whole extent. 
He applied splints, bandages, &c., and on the third week reapplied 
them, at the same time making considerable extension to bring the 
fragments into position. At the end of the fourth week he announc- 
ed that the union was getting firm, and a week later he removed the 
splints and applied strips of pasteboard. A few days after this, by 
a sudden movement, the fragments were displaced, although very 12 
slightly. After two weeks, they had become firmly united again, by 
the report of the physician. In the middle of May, he reported that 
all was well united, but not strong, and applied bandages, &c., with 
the intimation that it would be a year before the union would be 
strong enough to bear hard usage. Three weeks after this, the pa- 
tient had the bandages removed to wash the arm, and his wife at once 
declared that the bones were loose. Various measures were then 
taken to procure union. For the past four months he has not inter- 
fered with the false joint, but has given his attention to recovering 
the motion of the. elbow, stiffened by long disuse. Now, he has a 
false joint a little below the middle of the humerus. 
December 6th.- Operation by Dr. Bigelow. Patient was ether- 
ized. An incision, four inches long, was made over the outer aspect 
of the false joint, and the ends of the fragments were exposed. Both 
ends were irregular in shape, especially that of the upper fragment. 
They were bound together by a tough, pearl-colored, gristly material, 
quite firm to the knife. The periosteum was dissected up and turned 
back from about an inch of the end of each fragment; the ends were 
then sawed off square, and a hole bored through each fragment at a 
point a quarter of an inch from their ends. The two fragments 
were then brought into apposition and held in place by a silver wire 
passed through these holes and twisted. The free ends of the wire 
were long enough to project from the wound. Sutures were then in- 
serted, and angular splints, external and internal, were applied. 
10th.-Suppuration well established. Splints removed, and wound 
dressed. 
20th.-He has lost appetite during the last twenty-four hours. On 
removing splints, an erysipelatous blush was seen over the whole 
upper arm. R. Quinite gr. ij., ter die. Beef-steak and 
wine, if he will take them. 
24th.-Splints changed. Doing better. 
January 2d, 1863.-Patient is quite strong and cheerful. On 
removing the splints to change dressings, considerable stiffness is 
found in arm. Suppuration is moderate; the wound is closed, ex- 
cept immediately about the ends of the wire. 
4th.-Considerable pain at the point of fracture, and in elbow. 
14th.-He walks about. 
16th.-The pus has burrowed towards the elbow. Much weaker. 
Beef-steak, wine and eggs. 
23d.-There is tenderness and redness over the internal condyle, 
apparently from the commencement of a large abscess. 
27th.-He has been very wretched since the last record, from 
great pain in the abscess. The 'splints were unbearable and were 
removed yesterday. The arm is laid on a large poultice, with an 
external straight splint. The abscess was freely incised under ether, 
and the various sinuses were torn into one. 
31st.-Patient was etherized, and the wire cut and withdrawn. 13 
February 4th.-Patient is improving wonderfully. He sits up all 
day, and walks about freely. 
18th.-Wound entirely closed. 
26th.-The arm is quite stiff at the point of fracture. 
March 9th.-Discharged, well. 
Case V.-Femur. 
Patient, B. II., teamster, aged 27, entered the Hospital March 10th, 
1863. Five hours before admission he was run over by a heavy 
team, the wheel passing over the middle of the left thigh. The whole 
of the left thigh is greatly swollen and ecchymosed, shortened about 
two and a half inches. The fracture is perhaps comminuted, and at 
the middle of the femur. Desault's apparatus was applied. 
April 18th.-Comfortable since the last report. Desault's appa- 
ratus was removed to-day. Limb in excellent position. There is 
apparently considerable callus, but the thigh appears flexible at the 
point of fracture. 
21st.-A starch bandage, stiffened with pasteboard, applied to 
the limb from the middle of the leg to the upper third of thigh. 
30th.-He sits up daily. 
May 4th.-Upon examination to-day, it was found that there was 
no union. 
6th.-Desault's apparatus re-applied. 
7th.-Apply over fracture emplastrum cantharidis (6 by 4). 
23d.-No union. Apply extension by weight. 
August 1st.-Starch bandage was applied over leg and thigh. R. 
Calcis phosphat., gr. x., 3 t. d. 
15th.-The starch bandage was removed, and extension by weight 
applied. 
September 2d.-After a careful examination, it was decided that 
there was no union at the point of fracture. 
8th.-A starch bandage was applied, and he was allowed to sit up. 
December 5th.-Patient now came under Dr. Bigelow's care. No 
union. He was etherized, and a seton passed between the fractured 
ends of bone and out through the other side of the thigh. 
16th.-Profuse discharge from lower wound. 
27th.-Seton removed. 
February 2d, 1864.-Discharge from wound diminished. Appa- 
rently but little stiffness. 
June 4th.-Patient has continued in the same condition since the 
last record. There is no union. He was etherized, and the ends of 
the fracture were drilled in several different places. 
18th.-There has not been the slightest inflammation in the thigh, 
produced by the drilling. 
July 20th.-There has been no change in the thigh since the last 
report. The ununited ends of bone are surrounded by a large 
amount of indurated tissue, which makes it very difficult to get at 14 
them. He was etherized, and the ends of the bone were again and 
more thoroughly drilled. At most parts the bone was quite hard and 
normal, but at one point it was soft, and on withdrawal the drill was 
followed by quite a stream of oil from the degenerated marrow. 
The limb was placed in a straight splint. 
November 4th.-There is no stiffness at the point of fracture. 
12th.- Operation by Dr. Bigelow. The patient was etherized. 
A long, semi-circular incision was made on the outside and back 
of the thigh, its convexity downwards, over the ends of the 
bone, to favor the discharge of pus. The muscles of the thigh 
were found to be indurated, so that the ends of the bone were 
turned out with great difficulty. The ends of the bone were 
smooth, rounded and conical. The periosteum was then turned back 
for about one inch on each end, and the bones, thus denuded, cut off 
with a chain saw. The medullary substance was slightly degenerat- 
ed and fatty. A hole was then drilled through each extremity of 
the bone, and a wire passed through these holes and twisted, not tight, 
but leaving a small space between the ends, to allow of sufficient 
motion to prevent breaking the wire or the bone. The periosteum was 
then brought together and the wound closed by sutures. The limb 
was placed in a McIntyre's double-inclined, iron splint, bent at an 
angle of 135°. The operation occupied about two hours, during 
which time the patient was kept thoroughly etherized. Cold-water 
dressing. 
13th.-He has considerable irritative fever to-day. Pulse 132. 
Tongue thickly coated. The pain is relieved by acetate of morphia, 
one sixth of a grain, subcutaneously. 
15th.-Much brighter to-day. Pulse 100. 
IGth.-Suppuration has commenced. 
23d.-The leg and thigh have remained until to-day on the McIn- 
tyre splint, but the suppuration has increased so much that it re- 
quires removal for daily dressing. A pasteboard splint has been 
moulded to the anterior and inner part of the thigh and stiffened 
with dextrine; to this the thigh and leg are firmly bound, leaving 
the wound open. Above this a Smith's anterior splint was applied, 
by which the whole leg is swung from a framework over the bed. 
27th.-The splint works admirably. Less pain. The wound 
looks well, and is suppurating freely. Appetite good. 
December 24th.-The bandages and splints were removed and re- 
applied. There seems to be considerable stiffening, and the bones 
are in good position. 
January 13th, 1865.-No motion is observed at the point of 
fracture. 
February 12th.-The limb is so firm that it was laid on a pillow, 
with only pasteboard splints applied. 
April 26th.-Under ether, the wire was cut down upon and re- 
moved. 15 
May 17th.-He is up and dressed. Appetite and general health 
excellent. He wears a dextrine bandage for the support it affords 
him. 
June 1st.-He walks about on crutches. The knee is quite stiff. 
July 1st.-Wounds entirely healed. The motion in the knee is 
returning. 
12th.-The femur is perfectly firm and free from pain. He was 
furnished with a thick-soled shoe. Discharged, well. 
November 10th.-He came to the Hospital to-day. He is able to 
walk without the aid of a cane. Not the least motion can be detect- 
ed in the femur. The knee is flexible. 
Case VI.-Humerus. 
Patient, T. C., soldier, aged 41, entered the Hospital April 15th, 
1864. He was wounded by a Minie ball in the right humerus at the 
first assault on Port Hudson, summer of 1863. The bone was broken 
at about the junction of the middle and upper thirds, and was con- 
siderably splintered. According to patient's account, the surgeon 
sawed off about an inch from each end, and then approximated the 
ends of the bones by means of splints, but did not wire them. He 
was then put in an ambulance, carried fifteen miles over a rough 
country, then in a steamer for some distance, so that it was two days 
before he arrived at a hospital. The wound soon healed, but the 
bones did not unite, and have not since. 
April 16th.- Operation by Dr. Bigelow. He was etherized. An 
incision was made over the point of fracture. The ununited ends 
were forcibly everted. The periosteum was carefully dissected up 
and reflected, and the denuded ends sawed off. A hole was then 
drilled through each end of the fragments. A wire was then passed 
through these holes and twisted. The periosteum was brought to- 
gether, and the wound closed by sutures. The arm was placed in 
an outside angular splint. 
20th.-The arm has moved from the splint, and is quite out of po- 
sition, so that the ends of the bones are at a slight angle with each 
other. The angular splint was removed and the arm placed on a 
broad straight splint, with two shorter side splints to keep the frag- 
ments in place. 
23d.-The wound is suppurating freely, and the arm is'in good 
position. 
May 2d.-The wound has nearly healed, except at the point where 
the wires emerge. 
June 10th.-Patient walks about the yard, with the arm firmly 
supported. There is considerable firmness at the point of fracture. 
24th.-The arm is stronger. Discharged. 
September 17th.-He returned to the Hospital to-day with the 
arm so strong that he can use it for all ordinary purposes. The 
wire was removed, and the humerus was found to be perfectly firm. 16 
December 16th, 1865.-The arm is perfectly firm, and for some 
time he has done a great deal of heavy lifting, such as wheeling 
coal, without favoring the injured arm in the least. 
Case VII.-Humerus. 
Patient, E. S., female, aged 45, entered the Hospital Nov. 10th, 
1864. She had an ununited fracture of the right humerus, the result 
of a compound fracture received a year and a half previously. Seven 
months after the accident there was no union at the point of frac- 
ture. A seton was passed between the ununited ends, and allowed 
to remain for a month. Notwithstanding this and other forms of 
treatment, no union followed. On entrance, there was a fracture of 
the humerus in its lower third; the ends of the bone were drawn 
widely apart by the weight of the forearm, unless held in place by 
an apparatus which she had worn for the previous seven months. 
She was a large, corpulent woman, with flabby tissues. 
November 19th.- Operation by Dr. Bigelow. She was etherized. 
An incision, three inches long, was made, on the outer and posterior 
aspect of the arm, just above the external condyle. The ends of the 
fragments were then turned out, the periosteum was dissected back 
for about an inch and a half on the lower fragment, and two inches 
on the upper. The denuded bone was then sawed off; on the upper 
fragment by a single stroke of the saw. The bone was much 
atrophied, softened and degenerated, the holes for the wire being 
easily made with an awl, and the bony tissue easily cut with a 
knife. A wire was then passed through the outer sides of the shaft 
of the bone, and twisted so as to bring the ends nearly but not quite 
in apposition, lest the tight wire should break the bone. The edges 
of the wound were brought together with sutures, and the arm 
placed in an inside angular splint. 
P. M.-The arm is so unwieldy that it cannot be sufficiently con- 
fined in the inside splint. It was therefore laid on a flat right- 
angled splint. « 
27th.-Pulse and appetite good. Wound clean, and suppurating 
healthily. 
December 30th.-R. Calcis phosphat., gr. x., 3 t. d. 
January 7th, 1865.-The wire has apparently torn out of the 
bone. No stiffening at point of fracture. 
March 20th.-No union. 
April 1st.-Patient was etherized. An incision was made down 
upon the bone, and the wire was removed. The ends of the frag- 
ments were turned out and found so degenerated that they could be 
easily broken with the fingers. Forearm oedematous and tender. 
26th.-The arm was to-day amputated, at the patient's desire. 
The end of the upper fragment was removed. 
May 21st.-Stump has nearly closed. 
June 17th.-Discharged, well. 17 
Case VIII.-Humerus. 
Patient, W. W., carpenter, aged 28, entered the Hospital January 
2d, 1865. He had his left humerus fractured, twelve weeks before 
entrance, by the falling of an elevator in the Pacific Mills. The 
fracture was simple, and treated in the usual way with splints, but 
there never had been any attempt at bony union. On admission, 
there was an ununited fracture of the left humerus at a point a little 
below its middle. The ends of the fragments were in apposition. 
R. Syr. hypophosphit., 3 ij., 3 t. d. 
January 7th.-He was etherized. A narrow-bladed knife was 
pricked through the integument and muscles to the bone, at the point 
of fracture. A small drill was then introduced through the wound, 
and each end of the bone was drilled in three places. The arm 
was placed in an inside and outside angular splint. 
26th.-On removing the splints, no union was detected. 
February 25th.- Operation by Dr. Bigelow. Patient was etherized. 
A straight incision was made through the integument, on the outside 
of the arm, to the bone. The musculo-spiral nerve was so drawn out 
of place and embraced by the bone that it was accidentally divided 
in the blood which welled up from the tissues, still inflamed from the 
operation of six weeks before. The ends of the bone were dissect- 
ed from the periosteum, everted and sawed off. A piece, half an 
inch long, was taken from the upper fragment, and three quarters of 
an inch from the lower. A hole was then drilled through each end, 
and a silver-plated, copper wire passed through and twisted. A 
suture was passed through the neurilemma of each end of the divided 
nerve and the extremities brought together. Several arteries were 
tied; the wound was closed by sutures, and the arm placed in an 
inside angular splint, to which it was first firmly bandaged, and then 
placed upon a flat angular splint, reaching from shoulder to hand. 
26th.-He complains of great numbness over the dorsal surface of 
thumb and index finger, and has general paralysis of the extensors 
of the wrist and fingers. 
March 3d.-Wound suppurating healthily. 
8th.-Hand considerably swollen, and elbow looking angry and 
red. The wound is everywhere open. The suture applied to neuri- 
lemma came away to-day. R. Pil. ferri iodidi., gr. v., 3 t. d. 
16th.-Wound closing. 
31st.-Considerable stiffness at point of fracture. 
May 6th.-Humerus quite stiff. 
25th.-But little discharge from sinus about wires. Appetite and 
general health excellent. 
June 24th.-Under ether, the wire was untwisted and withdrawn. 
The humerus is perfectly stiff. Sensibility has returned to the thumb 
and index finger, but motion in all the extensors of the hand and 
wrist is absent. 18 
March 17th, 1866.-He reported at the Hospital to-day. He has 
worked at his trade since last August, without inconvenience. Mo- 
tion in the extensors of hand and wrist has returned perfectly. 
The humerus is perfectly firm and free from pain. 
Remarks.-The union of the musculo-spiral nerve, which was com- 
pletely divided and brought together by suture of the neurilemma, 
with restored function, is a point of great interest. 
Case IX.-Humerus. 
Patient, T. G., laborer,aged 26, entered the Hospital June 12th, 1865. 
A year before entrance he was thrown from a hand-car, one wheel of 
which passed over the middle of the right humerus, inflicting a com- 
pound fracture. The arm was placed in an inside angular splint, 
and kept in position for six weeks. The external wounds healed 
readily. At the end of this time, the arm was again broken at the 
original point of fracture and never again united. 
June 21st.- Operation by Dr. Bigelow. An incision, three inches 
long, was made on the outer aspect of the arm, over the seat of frac- 
ture. The musculo-spiral nerve was then sought, carefully dissected 
in its sheath from the bone, and turned aside. The periosteum was 
stripped back from the end of each fragment. A piece, half an inch 
long, from the lower, and three quarters of an inch from the upper 
bone, was sawed off. The ends were then drilled on the outer side, 
and a silver wire passed through; the ends of the bone were placed 
in apposition, and the wire twisted by four half turns. The arm was 
placed in the same apparatus as that used in the previous case. The 
edges of the wound were brought together by sutures. 
23d.-Apparatus re-applied. The bones are in good position. 
Some oedema of the arm. 
27th.-Suppuration is established. R. Calcis phosphat., gr. x., 
three times a day. t 
July 3d.-The arm is much swollen about the wound, and covered 
with an erysipelatous blush. He complains of some headache and 
nausea. R. Quiniae sulphat., gr. ij., three times a day. 
10th.-The swelling and redness have disappeared. No union at 
point of fracture. 
28th.-An outside angular splint was applied, the arm supported 
by a leather sling, and he was allowed to sit up. 
August 7th.-Apparatus removed and re-applied. There is slight 
stiffening at point of fracture. 
22.-Only slight motion can be detected in the humerus. 
September 11th.-The arm is stiff, but he complains of pain at the 
seat of fracture when it is examined. 
November 4th.-All discharge and soreness having disappeared, 
and the humerus being perfectly stiff, a pair of curved scissors were 
thrust down, the wire cut close to the bone, and easily withdrawn. 
December 15th.-The humerus is firm. Discharged, well. 19 
Case X.-Humerus. 
Patient, W. M. W., carpenter, aged 33, entered the Hospital Janu- 
ary 26th, 1866. He was wounded with a rninie ball at the battle 
of Gettysburg, and suffered a compound comminuted fracture of the 
right humerus. July 5th, the bone was resected and about three 
inches removed. The wound healed in five months after exfoli- 
ation of the sawn extremities of the humerus. No attempt was made 
to keep the bones in apposition, and no union was obtained. He 
resumed duty and served out his full time with his regiment. The 
wound has never re-opened or caused him any trouble. Now seve- 
ral inches of the middle of the right humerus are gone, and the two 
extremities can be felt, pointed and considerably absorbed. The 
whole arm is quite small from disuse. The motion in the shoulder 
and elbow is perfect, but the arm hangs useless from the loss of 
substance in the shaft of the humerus. 
January 27th.-Operation. Being temporarily disabled, Dr. 
Bigelow requested Dr. Hodges to perform the operation. Patient 
was etherized. A longitudinal incision was made over the ends of 
the fragments. The end of the lower fragment was then everted; 
the periosteum was carefully detached for a sufficient distance and 
turned back, and half an inch was sawn off from the end of the bone, 
which was firm and healthy. The upper fragment was treated in 
the same way, but the end, three quarters of an inch of which was 
removed, was degenerated and quite soft. These ends were then 
drilled: silver wire was inserted and the ends approximated, leav- 
ing a small interval to allow slight movement. The periosteum was 
returned to its place, a few vessels were tied and the external wound 
partly closed by sutures. The arm was placed in an internal angu- 
lar splint. Water dressing. 
30th.-The arm is in excellent position. Suppuration is beginning. 
Feb. 21-st.-A large abscess above wound evacuated itself to-day. 
March 11th.-He walks about every day. Apparently some 
stiffening at the point of fracture. 
17th.-An abscess is forming on the inner aspect of arm. 
20th.-The abscess was opened and discharged freely. 
31st.-The humerus is quite firm. He was discharged to-day, to 
return once a week. 
April 27th.-Scarcely any motion can be detected at the point of 
fracture. 
May 23d.-An incision was made down upon the wire, which was 
cut and withdrawn. The union of the fractured ends is firm. The 
apparatus was removed. Patient returned to work. 
Case XI.-Humerus. 
Patient, P. M., laborer, aged 23, entered the Hospital, January 
12th, 1867. He was wounded at the battle of Cedar Mountain, 20 
18G2, by a musket ball. The left humerus was shattered at a 
point a little above its middle. The small pieces of bone were re- 
moved ; the ends sawed off and the fragments approximated. Six 
months later there was no union; the ends were again sawed off 
and the bones wired together. At the end of two weeks the wire 
was removed. In October, 1864, a number of pieces of necrosed 
bone were removed from the seat of fracture; there was no union. 
In November, 1865, he entered the Hospital. The left humerus 
had a false joint at its middle. There was necrosed bone at 
the bottom of a couple of sinuses in the lower fragment. An 
incision was made over the fracture; the periosteum reflected and 
the ends of the bones sawed off. In March, 1866, there was no 
union. March 31st, Dr. Bigelow again operated. The periosteum 
was detached from both fragments for a sufficient distance; about 
one and a half inches was sawed off from the lower and one inch 
from the end of the upper fragment. The ends were drilled, 
silver wire inserted, and the fragments placed in apposition. The 
periosteum was then replaced and its edges united by sutures. 
April 28th, the arm had stiffened at the point of fracture. June 
10th, he fell upon the arm and broke it. July 15th, he was dis- 
charged with an ununited fracture, to return when the arm looks and 
feels better. 
January 12th, 1867.- Operation by Dr. Bigeloiv. Patient was 
etherized. An incision, three inches long, was made over the outer 
aspect of arm and carried carefully down to the point of fracture. 
The two ends were found to be much roughened. Great difficulty 
was experienced in everting the ends of the now short fragments 
and in detaching the periosteum. The bone was finally separated 
from the periosteum for a sufficient distance, and a piece, one inch 
long, sawed from the upper, and one, three quarters of an inch long, 
from the lower fragment. The lower fragment was two inches in 
diameter; the upper one was of normal size but with fatty degene- 
ration of the marrow. A hole was drilled through the sides of both 
fragments; a silver wire was inserted; the ends were placed in 
apposition and the wire twisted. The periosteum was replaced 
and its edges united by sutures. The external wound was partly 
closed by sutures. A folded towel was placed in the axilla to lift 
out the short upper fragment, and the arm secured to the side, the 
forearm across the chest. 
13th.-There is almost complete paralysis of the extensors of the 
fingers of the left hand. No nervous trunk was known to have been 
divided in the operation, and the paralysis is perhaps due to a 
compression of the nerve in very forcibly everting the shortened 
fragments. 
21st.-The arm was placed in an apparatus, which consists of a 
firm cap about the shoulder, secured by a strap around the chest; 
this is made firm by two steel bridges to a splint that invests the 
forearm like a coat sleeve. 21 
27th.-The arm remains in excellent position. The power of 
extension is returning to the fingers. 
February 3d.-The wound is contracting by healthy granulation. 
6th.-Slight stiffening at point of fracture. 
16th.- R. Calcis phosphat., gr. x., 3 t. d. 
March 4th.-Allowed to walk about. 
April 16th.-The humerus is quite firm at the point of fracture. 
He flexes the forearm and raises the humerus from the side freely. 
22d.-Discharged, probably well, although sufficient time has not 
elapsed to determine the fact. 
Remarks.-As will be readily inferred, this humerus was materi- 
ally shortened by these consecutive operations, two before entering 
the Hospital, and three subsequently by Dr. Bigelow. In fact, by 
measurement it wTas seven inches shorter than its fellow, yet the biceps 
and triceps were fulfilling their functions, and the patient was re- 
gaining excellent motion. There can be no comparison in the value 
of an arm of this sort, however short, and an ununited humerus. 
In the first operation and during the existence of undefined necrosis, 
the bony tissue of the substance of the lower fragment was of a red- 
dish hue, and of a dense, brittle and amorphous texture, sometimes 
to be observed in the denuded walls of the cavities of sequestra, 
when chiselled. At the end of about a year, at the next operation, 
when the probe no longer detected dead bone, the operator was 
agreeably surprised to find that this tissue had given place to a 
comparatively healthy one, with cancellated interior. 
Conclusions. 
1. This operation is a successful one. 
2. Though not a trifling operation, it is not dangerous. 
3. In the operative procedure the points deserving attention are, 
the zncmows, which should be arranged for the free escape of pus. 
The periosteum, which is not to be detached from the muscles, and 
which, after incision, is best torn out from the rugous inequalities 
of the bony extremity, and subsequently attached by suture or not. 
The excision of at least a quarter of an inch of sound cylindrical 
bone, besides the irregular and tapering end. The wire, which should 
not be twisted too tightly, lest it break out of the bone. 
4. The wire may be left in place indefinitely without danger of 
necrosis; and usually until union has unequivocally taken place; a 
period of from two to six months. 
5. Burrowing pus is to be evacuated, when it approaches the sur- 
face, so that the wround will ensure it free and permanent exit. 
6. The patient is to be invigorated by such food as he bears, fresh 
air, and other stimulus if required. 
7. The operation may be repeated if it fails, but only*after seve- 
ral months' interval. 22 
Case. 
Bone. 
Causes of Injury. 
Duration. 
Wire 
remained. 
Result. 
Remarks. 
*Seton; blisters; rub- 
1 
Humerus. 
Arm caught in a 
splitting machine. 
3 years. 
4 mos. 
Well. 
bing ends of bone to- 
gether ; excision of 
ends of fragments. 
2 
Radius. 
Arm caught in 
machinery. 
4 years. 
2 years. 
Well. 
3 
Humerus. 
Arm caught in a 
hand-car crank. 
8 months. 
6 mos. 
Well. 
*Rubbing ends of 
bone together. 
4 
Humerus. 
Arm caught by a 
revolving shaft. 
1 year. 
2 mos. 
Well. 
♦Blisters; seton; drill- 
5 
Femur. 
Crushed by a hea- 
vy team. 
20 mos. 
mos. 
Well. 
ing ends of fragments 
twice. 
6 
Humerus. 
Gun-shot wound. 
11 mos. 
5 mos. 
Well. 
7 
Humerus. 
Compound frac- 
ture. 
18 mos. 
4A mos. 
Ampu- 
tation. 
Softening of the bone. 
8 
Humerus. 
Arm struck by a 
falling elevator. 
5 mos. 
4 mos. 
Well. 
♦Drilling ends of frag- 
ments. 
9 
Humerus. 
Crushed by wheel 
of hand-car. 
1 year. 
4<£ mos. 
Well. 
♦Excision of ends of 
fragments; excision 
10 
Humerus. 
Gun-shot wounds. 
5 years. 
Well. 
of ends and wiring 
fragments; two ope- 
rations byDr.Bigclow. 
11 
Humerus. 
cC <c u 
2% years. 
4 mos. 
Well. 
♦Excision of ends of 
fragments. 
* Previous operations, which had failed. 
Recapitulation. 
The following cases, condensed from the hospital record, are in- 
troduced in this connection as evidence upon the question how far 
the periosteum may be relied on to reproduce bone. In the first of 
these cases the condyles of the humerus were regenerated so as to 
afford an excellent attachment for the muscles. In the second, a 
rhinoplastic operation, no new bone was formed. 
Case XII.-Periosteal Reproduction of the Condyles of the 
Humerus after Excision of the Elbow Joint. 
Sept. 14th, 1857. 0. P. F., aged 29, married, clerk. Is a light- 
haired, unhealthy-looking man. His family are liable to scrofulous 
affections. Five years ago, while at work hoisting goods, he struck 
his right elbow a violent blow, causing great pain. The elbow 
swelled, and he was laid up a fortnight. Since that time, whenever 
he struck this joint, it would swell up in a similar manner. Last 
July, a fistulous opening appeared a little outside of the olecranon, 
and a week or two later a second one broke about two inches below 
the first. 'These discharge a thin, purulent fluid. A probe passes 
under the skin from one opening to the other. No diseased bone is 
felt. 23 
From this date until March 27th, 1858, the record states that vari- 
ous sinuses formed and were laid open. 
March 27th.-Etherized. Dr. Bigelow made an incision over the 
olecranon, and found in the bone a cavity with carious walls, the size 
of an almond. The diseased parts were removed by the gouge. 
28th.-Very little pain. Doing well. 
April 21st.-Abscesses continue to form. 
June 19th.- Operation by Dr. Bigelow. Patient etherized. Joint 
opened by a semicircular incision, and the ulnar nerve sought and 
turned aside. The ends of all the bones were found to be much 
diseased, and about an inch of the ulna and an inch of the humerus 
were removed. The head of the radius was also excised. But lit- 
tle blood was lost. No arteries tied. The periosteum being firmly 
attached to the coral-like surface of the bone, was torn out from the 
inequalities with strong forceps. Wound brought together by sutures. 
Flaps riddled by old fistulous openings. Arm placed on an angular 
splint, with water dressing. Evening.-Very little pain. Skin 
warm. Pulse 100. No haemorrhage. 
22d.-Edge of wound looks sloughy. Stitches removed. Patient 
comfortable. 
26th.-Pulse good. General condition as good as before opera- 
tion. Edges of wound have opened and sloughed. Sinuses clean. No 
pain. Porter. 
August 17th.-Wounds closing slowly.- Discharge much dimi- 
nished. Appetite good. Walks out every day. 
22d.-Wounds flabby. No dead bone felt. Adhesive straps. 
Sept. 5th.-General health is very good. Ulcers have contracted 
somewhat. Patient advised to go into the country, and is discharged. 
Nov. 11th, 1858.-Since leaving the Hospital has been in the 
country. Has had more or less cough. Looks as well as when last 
seen. About a month after his discharge, an abscess opened, two 
inches below head of radius. Now, integument around elbow is red 
and inflamed. There are five fistulous openings which connect with 
one another and centre in a cavity formed by the removal of the 
bones. Nd dead bone can be felt. The discharge is very slight. 
No pain. Still keeps on the angular splint. Has made up his 
mind to have the arm off, and enters for the purpose of operation. 
House diet. Ale. Poultice. 
16th.-Has more or less cough. Cod-liver oil, 3 ij., thrice daily. 
20th.-Operation. Patient was etherized, and the arm amputated 
just above the elbow. 
Feb. 28th, 1859.-Discharged, well. 
It has lately been ascertained that this patient, who manifested 
indications of tubercular disease of left lung before his arm was 
removed, died of phthisis about Dec. 1st, 1859, the disease not hav- 
ing been arrested by the amputation. 
The interesting points in this case of excision of the elbow-joint 
are:- 24 
1. The reproduction of the condyles of the humerus by the peri- 
osteum, which was torn from the interstices of the surface of both the 
original condyles. The horns which were reproduced for the inser- 
tion of the extensors and supinators and of the flexors are conical 
processes, each somewhat more than half an inch in length, and regu- 
larly curved forwards and inwards, as seen in the accompanying 
wood-cut from a photograph of the bone. The rugous surface of 
the excised condyles is also shown.* 
2. The unfavorable issue of this case corroborates what seems to 
be the fact, viz., that while the elbow is a most favorable joint for 
resection in cases of recent injury and in healthy subjects, yet when 
this articulation which is so near the centre of the circulation, and 
which should therefore be well nourished, and prompt to take on 
the reparative process, becomes carious from disease, it implies a 
general feebleness of constitution, which calls rather for amputa- 
tion than excision. 
Case XIII.-Periosteum of the Forehead Transplanted in a 
Rhinoplastic Operation. No New Bone Formed. Necrosis of 
the Exposed Skull. 
Dec. 1st, 1866. A. B., aged 22. This young woman, at the age 
of ten years, was attacked with scrofulous lupus, which resulted in the 
destruction of the principal part of the nose, including the bones and 
as far down as the ala?. A hole of the size of a silver dime, sur- 
rounded with cicatricial tissue, exposes the nasal cavity. The 
* For a somewhat similar specimen, from the practice of Prof. Syme, of Edinburgh, the 
reader is referred to the Lancet, March 3, 1855. 25 
margin of the alas remains half an inch wide and retracted into the 
cavity of the nose, especially upon the right side. 
15th.- Operation by Dr. Bigelow. The al® were dissected from 
their adhesions within the nasal cavity, and being cut square, left a 
margin a quarter of an inch in width. A flap was taken from the fore- 
head, in the usual way, and brought into place so as to form a nose 
and unite at its lower margin, with that of the alae and septum. In 
dissecting up the flap, the periosteum to which it was attached was 
carefully removed from the skull, in the hope that it would form a 
new bridge. 
16th.-Wound looking well. 
19th.-Every other suture removed. 
20th.-Remaining sutures removed. 
25th.-It is now evident that the exposed bone is becoming 
necrosed. 
March 2d, 1867.-The margins of the wound upon the forehead 
have shown little tendency to approximate over the exposed surface 
of bone, the whole of which is dead, and is becoming gradually elas- 
tic and detached from the subjacent tissue. To-day (eleven weeks 
after the operation), forceps were introduced at the edge of the 
wound and the entire bony surface lifted off in two fragments, being 
itself a scale of almost papery thinness, covering a healthy granula- 
ting surface. 
31st.-Patient was etherized, the pedicle divided, and the eyebrow 
transplanted to its normal position. 
April 30th.-Wound of the forehead completely healed. 
May 15th.-No bone can be detected in the new nose. 
Remarks.-Having, in four previous instances, had occasion to 
make an entire new nose from the forehead, and having been on the 
whole dissatisfied, owing to the tendency of the new nose to flatten, 
with the want of resemblance in the result of my own efforts to the 
classical nose usually portrayed in standard works on surgery as the 
result of the rhinoplastic operation, I determined in this instance to 
invoke the aid of the periosteum in the formation of a new bridge. 
This had already been done abroad; with what result, I have not 
learned. I had, however, been previously deterred from the experi- 
ment, in apprehension of the injury to the bone, which has been men- 
tioned as having occurred in the present case. The necrosis of the 
whole surface of the exposed bone, in connection with the entire ab- 
sence of osseous formation in the new nose five months after the 
operation, is not favorable, so far as the evidence of a single case 
may be relied on, to a repetition of this experiment. It may be 
added that the cicatrix of the forehead is more than usually pro- 
nounced.