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known causes, of a man and woman who had confined themselves to one kind of diet for the purpose of lessening embonpoint, in whom a fracture was followed by non-union, are highly instructive and affirmative of the proposition under consideration.

Several cachectic conditions of the system are considered by authors as predisposing to the non-consolidation of fracture. Many of these are at least doubtful; scurvy, however, and violent febrile conditions of the system are of undoubted potency in preventing the reparative process. Cancerous diathesis, also, at times exerts a like deleterious influence. Constitutional syphilis has been known to delay union in repeated instances; the delay be. ing protracted in certain cases for more than a year, and resulting finally in the establishment of the reparative process only after appropriate anti-syphilitic treatment.

Under the second head, which we have styled "Peculiarities at the seat of the fracture," we propose to include not only actual peculiaritities of the fracture, but also such local conditions as shall tend to render non-union in a given bone a liable result. Prominent among such peculiarities and conditions we notice diseases of the fractured bone. We do not stop to enumerate them; a simple generalization is all that is necessary; any disease of the bone which impairs the energy of the nutritive process in that boue, will necessarily predispose to a non-union result.

The interposition of an intervening substance between the ends of the fragments will most effectually prevent union. This substance may be most emphatically a foreign body introduced from without, as might occur in case of a compound fracture; or it may be a splinter of bone in a case of comminuted fracture; or still again, it may be inter posed muscular or fibrous tissue, or even an extensive coagulum of blood. No argument is necessary to prove the potency of any of these conditions.

The wide separation of the fragments, either from mus

cular action or loss of substance constitutes another pecu. liarity, the efficacy of which to produce non-union is at once apparent.

Marked obliquity of fracture is another well recognized cause of non-union. The peculiar mode by which it operates has been the subject of not a little discussion. Dupuytren considered that the mobility of the fragments disturbed the consolidation of the reparative material; while it is urged by others that the almost necessary shortening separated the surfaces to so great an extent as to require the effusion of more organizable material than would readily consolidate. Both of these reasons undoubtedly obtain in every case of oblique fracture; the proportionate influence of which, however, it is unnecessary to determine, as the practical means to rectify the one would tend also to correct the other.

Defective nutrition of one of the fragments, as in case of intra-capsular fracture, or in some cases of multiple frac ture will prove a cause of non-union, which will be almost certain in its effects.

Profuse suppuration in compound fractures is another cause, the operation of which is occasionally witnessed. Abscess in the vicinity or immediate locality of the fracture greatly enhances the danger of non union.

Paralysis of a limb, or the loss of its principal artery, in consequence of ligation, are also circumstances worthy of consideration in contemplating the causes of the subject which we are discussing.

Our last head includes mal-practice of both surgeon and patient. The mal-practice of the surgeon may consist in, 1st. Imperfect adjustment of the fractures; 2d. Insecurity of dressings; and 3d. The abuse of cold water dressings. The first and second items in this enumeration need no comment. With regard to the third, we would remark that the locally sedative and depressing influences of the topical application of cold water are too powerful to admit

of indiscriminate application. In only a limited number of cases is it productive of good; in all cases where it is resorted to, the indication for its use should be unmistakable; and in cases where a low grade of activity characterizes the nutritive process, it should be religiously interdicted. The mal-practice of the patient will consist in interference with the dressings and disobedience to the directions of his surgeon. Neither of these should be tolerated for a day. The result of treatment is too important to allow anything short of absolute control on the part of him who bears the responsibility.

The consequence of non-union is the formation of an abnormal and additional joint. In a vast majority of instances the location of such a joint will be such as greatly to impair or wholly destroy the usefulness of the limb. The surgical treatment which is to destroy such a joint and restore the limb to usefulness is therefore a subject which commands our serious attention. In bestowing this attention, it is well to consider the nature of the joint requiring treatment. Norris describes four varieties

1. When the fragments are united by a cartilaginous callus, in which ossification has not taken place. Absence of lateral motion, bending of the bone at the seat of the callous, and pain referred to the same point in a quick movement, will serve to diagnosticate this form of false joint.

2. When the fragments are wide apart, atrophird, and very moveable.

3. When a fibrous tissue, varying in amount and firmness, unites the fragments, permitting more or less motion. The ends of the fragments are rounded off, and the canal obliterated at this point.

4. When a genuine diarthrosis may have been formed, united by a ligament of the capsular variety, and lined by a synovial membrane.

Fortunately, the 2d and last of these varieties are very

rare. The widely separated condition of the fragments in the one, and the development of a synovial membrane in the other, are circumstances which would greatly diminish the probability of success in any form of treatment which might be adopted.

In the first variety quietude, frictions over the part, and an invigorating constitutional treatment, will usually suf fice to effect a cure.

The 3d variety is the form which will usually demand treatment. Attention to the general state of health and to any constitutional diathesis which may exist is in all instances to be instituted. Appropriate treatment of these is of paramount importance. The success of the strictly surgical management of a case will depend in a great measure upon the efficacy of the constitutional treatment. A generous and stimulating diet, reference being had to the supply of such elements as are required in the reparation bone, a full supply of pure air, and strict cleanliness. should all be enjoyed by the patient of debilitated condi tion. Where any of the dyscrasia exist, special treatment for that form of it which obtains, should be instituted.

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Of the surgical treatment proper, a variety of plans have been recommended. The most antiquated plan on record dates back at least to Celsus, and is termed rubbing together the ends of the fragments. In detail, the plan requires the limb to be put upon the stretch until the adhesions are completely destroyed; the ends of the frag ments are then forcibly rubbed upon one another to roughen the ends and lacerate tissue; thus converting, as near as possible, the parts to the condition of a recent fracture. This method, though the oldest on record, has been very seldom resorted to; it is, notwithstanding, when thoroughly instituted, successful in a majority of instances.

Next, in chronological order, stands the operation of resection. It was originated in 1760 by White, and consists

of cutting down upon the bone and resecting the false joint by either saw or bone forceps. A collection of 60 cases of this operation, from Malgaigne, shows as follows: 27 fractures of humerus, 11 cures, 14 failures, 2 deaths; 17 fractures of femur, 10 cures, 3 failures, 4 deaths; 9 fractures of forearm, 7 cures, 2 failures; 8 fractures of the leg, 8 cures; 1 fracture of the jaw, 1 cure.

From this table, as well as from general experience, it will be seen that, with not a large per centage of cures, we have such a proportion of deaths as to render the operation an unpopular one. The operation is a difficult one to perform, and from the experience which we have had in two cases, we confess to a decided disinclination to repeat the operation. Rowland states that it was the most difficult operation he ever performed. Vallet occupied an hour in the operation, and his patient died in convulsions on the same day. In an operation by Hewson, two hours were consumed. A modification of this operation was per formed by Dr. J. K. Rodgers in 1825; it consisted of drilling a hole through each fragment, passing a wire, and bringing the extremities through a canula which he left in the wound. On the sixteenth day, the canula and wire came away, and on the sixtieth day the cure was perfect. This operation, with slight modifications, has been several times successfully repeated, but it has not gained general favor.

The introduction of a seton between the ends of the fragments was originated in 1787. The operation is simple, and, except in the humerus and femur, is eminently successful. But this exception of the two most important bones-bones, too, which are liable to false joint-renders the operation somewhat unreliable. A collection of 72 cases is as follows: 30 fractures of humerus, 13 cures, 16 failures, 1 death; 18 fractures of femur, 9 cures, 8 failures, 1 death; 14 fractures of leg, 13 cures, 1 failure; 6 fractures

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