Chromicized Catgut as a Means of Direct 
Fixation in the Treatment of Fractures 
and Osteotomies, with a Report 
of a Case. 
BY F. W. JAY, M.D. 
COLUMBUS MEMORIAL BUILDING, CHICAGO. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
MA 1' la, 18%. 
CHICAGO: 
PRINTED AT THE OKKICK OK THE JOURNAL OK THE ASSOCIATION. 
1894. Chromicized Catgut as a Means of Direct 
Fixation in the Treatment of Fractures 
and Osteotomies, with a Report 
of a Case. 
BY F. W. JAX* M D- 
COLUMBUS MEMORIAL BUILDING, CHICAGO. 
REPRINTED FROM 1 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
MA Y 19, 189!,. 
CHICAGO: 
PRINTED AT THE OFFICE OF THE JOURNAL OF THF. ASSOCIATION 
1894. CHROMICIZED CATGUT AS A MEANS OF DI- 
RECT FIXATION IN THE TREATMENT OF 
FRACTURES AND OSTEOTOMIES, 
WITH A REPORT OF A CASE. 
Without attempting to depreciate the mechanical 
value of unabsorbable material as a means of direct 
fixation of the bone fragments in operations per- 
formed for the cure of fracture, the writer believes 
that bone repair is accomplished more rapidly and 
satisfactorily in the absence of foreign bodies from 
the bone. He is further convinced that in many 
cases in which some form of direct fixation of the 
fractured ends is required, a comparatively readily 
absorbable material will suffice. Consequently this 
case, an ununited fracture of the femur of one year’s 
standing, in which some immediate mechanical sup- 
port was required to retain the bone ends in apposi- 
tion, and in which sutures of chromicized catgut met 
the requirements perfectly, is reported. 
From the conditions found at the operation, and 
the methods adopted to secure fixation and union, 
some points of practical value may be gathered. 
Histological research has demonstrated facts in 
regard to bone growth and bone repair, that should 
indicate to surgeons operating for the cure of frac- 
tures the value of details in the operative procedures 
which will greatly aid the vis medicatrix naturae, and 
in the use of material of but temporary mechanical 
value we must carefully carry out all procedures that 
will aid nature’s resources, in the accomplishment of 
bone repair. The case also demonstrates the opera- 
tive procedures necessary to faithfully carry out in 
operating with absorbable material, which will enable 4 
the temporary fixation to serve its purpose, and with- 
out which it is valueless. 
Each detail of an operation performed for the cure 
of an ununited fracture, may prove of decisive value 
in obtaining union; and it was by the minor steps 
in the operation, as they are by some regarded, that 
union was effected in this case. As Senn says: 
“Brilliant operators are not always the best surgeons. 
The best results in surgery follow the one who is the 
most painstaking in following out the minutest de- 
tails.” 
Considering the periosteum, or its inner layer, the 
cambium, and the endosteum as the two principal 
regions of bone, in which are found myeloid tissue 
with its bone-producing cells, or osteoblasts, the pro- 
liferation of which is to accomplish definitive union 
of fractured bones, (Virchow, C. 0. Weber, Gurlt, 
Billroth, Volkman, Senn), we have in this case 
some points of interest and value demonstrated. 
While definitive union between fractured bone 
ends is accomplished by proliferation of the osteo- 
blasts of the compacta, as well as of the periosteum 
and marrow, the latter are regions in which are 
found bone-producing cells that are in a condition to 
respond more quickly to the requirements of repair 
by the early production of callus. These regions are 
the seat of osteoblasts in a constant and physiologic 
state of proliferation at the time the fracture occurs, 
and lose no time in initiating the process of repair. 
Kraft asserts that karyokinetic figures can be seen 
in the nuclei of the bone-producing cells of the peri- 
osteum twenty to thirty hours after the occurrence 
of fracture. Hence it is in these regions that we 
look for that early callus production that will allow 
of the use of such temporary fixation material as 
catgut. That such a process can take place promptly 
only under aseptic conditions is positive, as the 
method of repair of bone wounds is subject to the 
same division as the healing of any other tissue, 
e.g., healing by primary and secondary intention, 5 
considering healing by secondary intention where 
the proliferating cells are compelled to combat in- 
fected and suppurating surroundings. 
As this was the second operation performed for the 
cure of this fracture and a buried wire suture had 
been used in the first operation, which had been per- 
formed six months previous to the one reported, the 
condition of the bone in which this wire suture was 
found may demonstrate the tendency of aseptic, un- 
absorbable foreign substances in bone to expedite or 
retard the process of repair. 
The word aseptic is italicised because, in regarding 
the action of unabsorbable material in bone, we shall 
consider the material used as being absolutely asep- 
tic in aseptic tissue and not influenced in any way by 
the action of bacteria. 
I consider the most thorough antiseptic precau- 
tions necessary when catgut is to be used for the di- 
rect fixation of bone fragments, although should sup- 
puration occur at the seat of fracture it is a question 
if an unabsorbable foreign body when infected has 
not disadvantages that may overtop its mechanical 
virtues. In this paper we shall consider materials 
from their influence when aseptic. I believe in the 
ability of a conscientious and painstaking surgeon to 
prevent infection, and consider catgut in these cases 
a blessing to humanity made possible by antiseptic 
surgery. The possibilities of even aseptic foreign 
bodies in bone to determine subsequently the locali- 
zation of bacteria floating in the circulation is wor- 
thy of serious consideration from the influence which 
such bodies possess to vitiate the surrounding parts,, 
and thus establish a locus minorus resistentise. 
The fact that chromicized catgut was used for the 
direct fixation of the bone ends, and the more perma- 
nent fixation accomplished by the external dressing, 
and not by more decided means of direct fixation; 
such as bone or ivory pegs or wire sutures, etc., and 
less substantial external support, as extension, is, I 
think, suggestive. 6 
What served to retain the fractured ends in this 
case until union was accomplished will not establish 
any surgical rules, yet the fact that such means did 
serve, and serve perfectly, must be of some value 
and indicates a rather ideal method to adopt in suit- 
able cases. 
A maiden lady, 28 years of age, of good previous 
health, sustained Oct. 14,1892, a fracture of the right 
femur, at the juncture of the upper and middle thirds. 
She was taken to her home and treated by Buck’s 
extension and long-side splints for eight weeks. As 
there was no union at this time, her physician advised 
the forcible rubbing of the bone ends together, as a 
means of expediting union. She, however, desired to 
obtain hospital care, and was admitted to one of the 
large hospitals of the city Dec. 6, 1892. Here exten- 
sion was applied and retained until April 24, 1*893, 
during a portion of which time she was subjected to 
a thorough administration of iodid of potassium. 
As union had not been accomplished at this time, 
more radical treatment by means of an open opera- 
tion was advised and consented to. The operation 
was performed April 24, 1893. The ends of the frag- 
ments were denuded and freshened, and one wire 
suture was introduced through the fragments, the 
ends of the wire buried, and wound of soft parts 
sutured. Buck’s extension was applied. Primary 
healing of wound of soft parts. Patient stated that 
she felt motion at the seat of fracture on the third 
day following the operation. The use of extension 
and long-side splint was continued until her discharge 
from the hospital July 31,1893. She returned to her 
home with very great and free mobility at the seat of 
fracture, completely bedridden. No further treat- 
ment was employed until October, 1893, at which 
time Dr. Milton Jay, by whose kindness I report the 
case, being called to see the patient, advised another 
radical attempt to secure union by open operation. 
The operation was performed at her home, Oct. 2, 
HISTORY OF CASE. 7 
1893. After a thorough preparation of the surround- 
ings of the patient, and the site of the operation, an 
incision eight inches in length was made in the line 
of cicatrix, present as a result of the first operation, 
and the seat of fracture exposed. There had evi- 
dently been no attempt at callus formation, as the 
ends of the bones were conical in shape. They were 
considerably separated, freely movable, and covered 
by cicatricial tissue. The upper fragment was ab- 
ducted and firmly ankylosed at the hip joint. No 
attempt was made to produce motion at the hip joint, 
as the immobility of the upper fragment would prove 
a strong factor in aiding fixation ; and if the upper 
fragment was brought to its proper axis, a recurrence 
of the abduction would in all probability occur. It 
was better treatment to bring the entire limb into a 
line with the upper fragment and restore the motion 
at the hip joint after union of the fracture. A wire 
suture was found in the exposed end of the upper 
fragment in a perfectly aseptic condition, it having 
pulled through the lower fragment. It was easily 
removed, as the bone surrounding it was extremely 
osteoporotic. In denuding the ends of the fragments, 
the tissue in immediate contact with the bone was 
stripped back from the ends of the bone but not 
removed. It was found that the cicatricial tissue 
covering the lower end of the upper fragment was 
but loosely attached to the exterior of the bone, and 
its separation caused no hemorrhage from the bone; 
in fact, the bone appeared avascular, and a fear was 
expressed as to the viability of the upper fragment, 
or, at least, its lower two inches. This fear was in- 
tensified when the medullary cavity was exposed. 
The marrow was found pale, granular and avascular, 
as no hemorrhage was excited by removing fragments 
of it. The tissue surrounding the lower two inches 
of the upper fragment presented no appearance of 
active healthy periosteum, but resembled this mem- 
brane converted into cicatricial tissue, and its capac- 
ity to produce callus by proliferation of the osteo- 8 
blasts of its inner layer was doubtful. On sawing 
through the upper fragment, the vessels of the bone 
were found pervious, as hemorrhage was excited and 
the bone was therefore viable; but with the little 
prospect of active cell proliferation from either peri- 
osteum or endosteum of the upper fragment, the 
accomplishment of bone repair and union of the 
fracture appeared hardly possible. It was believed 
that the proliferating capacity of the structures in 
the interior of the upper fragment, in the condition 
in which they.were found, would not be sufficient to 
produce new bone; but that by curetting the medul- 
lary tissue from the cavity, until more active tissue was 
exposed, a growth of granulation tissue would occur, 
and that this new tissue would contain active prolifer- 
ating osteoblasts. By the growth of this granulation 
tissue into the medullary cavity of the lower fragment 
and its union with the apparently healthy medullary 
tissue in this part of the bone, with the subsequent lay- 
ing down of new bone, union would be greatly facili- 
tated. The medullary cavity of the upper fragment 
was therefore curetted for a distance of three inches 
from the exposed end until healthy and vascular 
tissue was exposed. Wifh the loss of bone from two 
operations permitting of the greatest mobility and 
the small surface of bone in apposition, inactivity- 
atrophy having greatly diminished the diameter of 
the bone, it would have been impossible to have 
retained the fragments in apposition without some 
means of direct fixation. 
The bone sutures in this case, were of chromicized 
catgut, carefully prepared and reliable, of moderate 
size and used double. 
The bone was drilled and sutures passed through 
a drill-hole into the medullary canal, out at a corre- 
sponding drill-hole in the other fragment and tied. 
There were four of these circumferential sutures 
applied. The end of the lower fragment was made 
slightly convex from above downward to fit into a 
corresponding concavity made in the lower end of 9 
the upper fragment, and when the sutures were tied, 
the bone ends were found to come periectly into ap- 
position with the limb abducted, into a line with the 
upper fragment. 
The bone ends were in the apposition produced by 
a Fenwick’s curvilinear osteotomy, which has been 
found efficient in preventing displacement, as well as 
having the advantage of sacrificing but a slight 
amount of tissue. 
The atrophic and cicatricial periosteum of the 
upper fragment was stitched to the periosteum of 
the lower fragment, covering as completely as possi- 
ble the break in the continuity of the bone. A most 
important detail in the operation is to provide a 
covering of periosteum for the line of fracture by 
suturing this structure carefully around the bone, 
thus incasing the space between the bone ends with 
an osteogenetic structure capable of filling the gap 
with new bone, as well as preventing the interposi- 
tion of surrounding soft parts. 
The slipping of the bone ends into a ferrule of de- 
calcified bone, as advised by Dr. N. Senn, (Annals of 
Surgerg, August, 1893) would prove a valuable aid to 
the reparative process, especially where it is found 
impossible to suture the periosteum over the line of 
fracture. 
The wound of the soft parts was sutured from the 
bottom with several layers of buried catgut. This 
was done as carefully and thoroughly as could be, 
in order to obtain as early definite healing of the 
wounds of the soft parts as possible, especially in the 
immediate vicinity of the bone; the skin was sutured 
with catgut and a capillary drain of catgut applied 
in each end of the wound. 
It will be evident that the incision in the soft parts 
was not only made ample, but that the bone ends 
were brought clearly into the wound and subjected 
to radical and thorough treatment. In operating for 
the relief of ununited fractures, the procedure must 
be most thorough and radical, being conservative 10 
only to a rational degree. The treatment of the bone 
ends, in such a case as the one here reported should 
consist in an absolute subperiosteal resection and 
the bringing together of bone capable of initiating 
and completing the reparative process. If the bone 
is subjected to such treatment as this, the aseptic 
cases of ununited fracture in which union will not 
be accomplished are rare. 
Jacobson—Ununited fractures of the femur: “The 
large number of failures after operations for this con- 
dition are well known. The difficulties which may 
be present during and after these operations are very 
considerable; among them, sufficient exposure of the 
fragments and keeping the wound aseptic are most 
prominent.” He recommends the use of wire sutures, 
either temporary or permanent, and to treat the 
wound open to allow of perfect drainage. 
Treves—As regards wiring the fragments, says: 
“ So far as the long bones of the extremities are con- 
cerned, I think that this measure may very well be 
dispensed with. It is said that this wire excites the 
growth of new bone, but if it does it appears to effect 
its end at a great cost.” 
“As a practical measure, the wire is a delusion and 
a snare, so far, certainly, as the long bones are con- 
cerned.” 
Treves does not make use of any direct fixation of 
the fragments, but makes a subperiosteal resection of 
the bone ends, and the careful application of an 
efficient external dressing. This, I am sure, in many 
cases, providing the treatment of the bone ends is 
radical, and Treves certainly accomplishes this, will 
make the use of unabsorbable material unnecessary; 
but I believe that by the use of bone sutures of chro- 
micized catgut, or some other resisting absorbable 
material, with the additional procedure of suturing 
the periosteum over the line of fracture, we have 
greatly aided the process of repair. 
If the presence of permanent buried aseptic, unab- 
sorbable foreign material, used for the direct fixation 11 
of fractured bone ends, has a tendency, aside from 
the mechanical fixation, to expedite the reparative 
process in the bone, and the definitive union of the 
fracture, it must be due to the fact that the presence 
of such material in bone excites and retains a repar- 
ative process, and not a destructive one. 
The presence of aseptic foreign bodies in bone 
must excite an osteosclerosis, and not an osteoporosis 
of the bone in order to complete the process of bone 
repair. All wounds of bone must heal by the forma- 
tion of a bone cicatrix, of greater or less extent, and 
a bone cicatrix is formed of sclerosed bone. “ But 
as soon as the fragments are fixed this union occurs, 
and ossification, running onto sclerosis follows.”— 
Green. 
Osteoporosis is an early step in the reparative pro- 
cess. “A rarefying osteitis begins probably imme- 
diately after the injury and results in a round-cell 
growth, which slowly eats away the walls of, and en- 
larges the Haversian canals.”—Green. The value of 
this rarefying process in the early steps of bone re- 
pair is well demonstrated in the production of callus 
as a result of Brainard’s drill operation. 
The use of teviporary ivory nails to expedite union 
of fractures, as recommended by Dieffenbach, is a 
valuable procedure, from the fact that their presence 
in the bone excites an osteoporosis at the seat of 
fracture, increasing the vascularity of the part and 
initiating the reparative process. After they have 
served this purpose they are a hindrance to repair. 
The continuation of this rarefying process is, if not 
actually destructive, at least inhibitory to repair, and 
will prevent the laying down of new bone in the im- 
mediate vicinity of the foreign body. To obtain 
union, requires the perfect completion of the repara- 
tive process; not the simple production of osteo- 
porosis, but the subsequent proliferation of osteo- 
blasts, with the final deposit of lime salts around the 
new cells. “ Prompt bone union does not imply 
that the osteoblasts at the seat of fracture should 12 
undergo karyokinetic changes and multiply, but that 
the new tissue must be placed under the influences 
of favorable chemical conditions, which will enable 
it to be transformed into bone.”—Senn. 
In the case here reported, the wire suture has been 
present in the bone six months,*in a perfectly aseptic 
condition, and the surrounding bone for a consider- 
able distance was in an extremely osteoporotic condi- 
tion, while the upper end of the lower fragment in 
which there was no wire suture was of almost normal 
density; the slight osteoporosis present in this frag- 
ment was simply that due to inactivity. 
This suture should have been imbedded in bone 
scar, or osteosclerotic tissue, after six months influ- 
ence, if such influence has a tendency to produce this 
condition in bone. 
As far as the conditions found in this case are con- 
cerned they demonstrate what is true, that the pres- 
ence of aseptic unabsorbable material placed in the 
bone to serve as direct fixation, when allowed to 
remain beyond a certain limit of time tends to pre- 
vent union by retaining in its immediate vicinity a 
condition of osteoporosis. 
“ The ends of the fragments are variously affected 
in accordance with the extent of the rarefying and 
productive processes which follow the injury; ac- 
cording as one or the other predominates the ends are 
diminished in size,sometimes to slender conical points 
or enlarged by the formation of irregular masses of 
bone on them. 
“ In a very few cases the rarefying process has 
gone so far that a large portion or even the whole of 
the shaft has gradually disappeared. 
• This tendency to excessive rarefication, when pres- 
ent is a serious obstacle to the success of the opera- 
tion undertaken to secure union, and it has seemed 
to some writers to be increased by the presence of 
metallic sutures binding the fragments together.”— 
American Text-book of Surgery. 
The osteoclasts, excited into activity by the pres- 13 
ence of any foreign body in bone, produce the osteo- 
porosis, although in any case where the material and 
its site remains aseptic the osteoclasts are sure to be 
conquered finally, and the material become encysted 
by the action of the osteoblasts, the battle has delayed 
union to a greater or less extent, depending upon the 
relation of the amount of the foreign body to the size 
of the bone. I believe this rather theoretical asser- 
tion to be of real practical value, although I realize 
that many surgeons at the present time use telegraph 
wire to retain the fragments of a fractirred ulna in 
apposition. 
While the ability of bone to encyst aseptic foreign 
bodies has been proven by clinical and experimental 
demonstration, I believe that these foreign bodies 
retain a condition of osteoporosis at their site for a 
longer time than is compatible with early, prompt 
definitive union, and although this is probably never 
sufficient in itself to cause non-union, it is at least 
an indication to use as fine a wire as possible, and as 
small an amount of it as will meet the mechanical 
requirements. 
“The use of metallic suture and similar devices to 
maintain the fragments in contact with each other is 
rarely desirable, since sufficient support can usually 
be given by the external apparatus; the presence of 
the foreign body appears somewhat to retard bony 
union.”—American Text-book of Surgery. 
Now, if by any method we can make a readily ab- 
sorbable material serve the mechanical requirements 
in any of these cases, such a method should be 
adopted. Although among the cases requiring direct 
fixation, we may find at the present time but few in 
which the surgeon believes such temporary means 
will suffice, I predict that the number will con- 
stantly increase. In describing the repair of recent 
fractures, Green says: “ The ends of the fragments 
are actively granulating at the end of three days; 
on the tenth day the periosteum has united and 
covers the spiral-shaped enlargement of the external 14 
callus-.” And while in ununited fractures the history 
of the case has already proven that there are factors 
present that have prevented this rapid and satisfac- 
tory callous formation, it is believed by the writer 
that these factors are local in practically every case, 
and that if the operation is made thorough, as regards 
the resection of the bone ends, and the careful sutur- 
ing of the periosteum, such a process as Green de- 
scribed will follow in the great majority of cases of 
ununited fracture. 
In regard to the etiology of delayed union and 
ununited fractures, I will insert here the classifica- 
tion as found in the syllabus of Surgery by N. Senn, 
after the “American Text-Book of Surgery:” 
' Suppuration. 
Scanty covering of soft parts. 
In joints. 
Defective local and general 
nutrition. 
Lateral displacements. 
Longitudinal displacements. 
Defective produc- 
tion of callus. 
Rachitis. 
Syphilis. 
Pregnancy. 
Lactation. 
Marasmus. 
Acute disease. 
General causes. 
Displacements. 
Interposition of soft parts or 
foreign body. 
Delayed union and 
pseudarthrosis. 
Defect in innervation. 
Defective blood supply. 
Inflammat’n of surface of limb. 
Loss of substance. 
Local causes. 
Application of cold. 
Imperfect reduction. 
Imperfect immobilization. 
Circular compression. 
Early passive motion. 
Early use of limb. 
Faulty treatment. 15 
According to Lewis A. Stimson, “the causes of un- 
united fracture maybe general or local. Among the 
former, are included general conditions and diseases 
which give rise to notable deterioration of the health, 
such as severe acute diseases, anemia, pregnancy and 
syphilis. Cases have been reported in which these 
affections have appeared to be the efficient causes, 
but they are so few that it must be admitted that the 
influence upon the healing of a fracture in general is 
very slight. Local causes are classified as follows: 
1, unfavorable relations or conditions of the frac- 
tured part; 2, interposition of a foreign body; 3, de- 
fective innervation; 4, defective blood supply; 5, 
disease of the bone; 6, inflammation of the surface; 
7, defective treatment.” 
Without commenting upon the causes of ununited 
fracture, I will make the assertion that the cases in 
which the essential factor is a constitutional one are 
very rare. 
White and Wood report an interesting group of 
cases of ununited fractures in the American Journal 
of the Medical Sciences for January, 1893, and illus- 
trate the use of an ingenious mechanical device for 
the direct temporary fixation of the bone ends, which 
should serve a most valuable purpose, especially in 
cases in which an open treatment of the wound was 
necessary on account of suppuration. They state 
that Hennequin, in a report of a series of unsuccess- 
ful cases of osteotomy and wiring for ununited frac- 
tures which he had published, attributed his failures 
to some constitutional condition interfering with 
repair. White and Wood state that Hennequin’s 
report certainly illustrates the need of some more 
reliable and satisfactory method of fixation than the 
wire suture. This, they believe, will be found in the 
use of their apparatus. 
I would say that in many cases absorbable mate- 
rial can not rationally take the place of unabsorba- 
ble and more decided mechanical fixation, and that 
the apparatus figured by White and Wood is ingeni- 16 
ous and valuable from its mechanical virtues and 
the fact that it is of a temporary character, but I 
should attribute a certain number of Hennequin’s 
failures, or any other series of failures, not to a con- 
stitutional factor interfering with repair, or to imper- 
fect mechanical fixation of the bone ends, but to 
local conditions retarding or preventing union, con- 
ditions which he had not been able to overcome with 
even decided direct mechanical fixation, the use of 
which had perhaps led him to make use of insuffi- 
cient external support. I believe that in selected 
cases the use of absorbable material for the direct 
fixation after a subperiosteal resection of the bone 
ends, with careful attention to the suturing of the 
periosteum, less reliance being placed upon decided 
means of direct fixation of the fragment, but extra- 
ordinary care in the external dressing, will be pro- 
ductive of better results. 
Extension is out of the question when using 
absorbable material in a fracture of the femur, and 
in this case as the fracture was transverse, at the time 
of operation, and there was considerable loss of bone 
with very little inclination of the fragments to over- 
lap there were no indications for its use. A plaster- 
of-paris cast was applied, encasing the entire limb, 
and the body to the armpits, and while hardening, 
the limb was abducted into a line with the upper 
fragment. 
The catgut sutures in the bone would hold the 
bone ends in apposition until the cast hardened; 
they would be of effect until the periosteum and 
entire wound of the soft parts had united, and the 
drilling of the holes for the suture and the presence 
of the suture material itself would tend to excite a 
reparative process in the bone ends and would allow of 
such a process accomplishing early union of the frac- 
ture. The recovery in the case was uneventful. A 
fenestrum was made in the cast opposite the seat of 
fracture at the end of the third week, and the prog- 
ress noted. There was not at any time much exter- 17 
nal callus. Rotation of the foot was communicated 
to the pelvis at the end of ten weeks. The cast was 
removed at the termination of eleven weeks, at which 
time there was very little external callus perceptible. 
Another cast was applied, and allowed to remain five 
weeks, at the end of which time passive motion was 
begun at the hip and knee joints. 
The fact that absorbable material answered so 
perfectly in this case may suggest the possibilities 
of such material as a means of direct fixation of the 
bone ends in operations of recent and ununited frac- 
ture, and the writer believes that the near future will 
find catgut more frequently used for the direct fixa- 
tion of fractured bone ends, while the use of unab- 
sorbable material will be less frequently adopted. 
As regards direct fixation in osteotomies, we can 
best introduce what we have to say by quoting from 
an article by Dr. Wilson which appeared in the 
American Journal of the Medical Sciences for March, 
1893, on “Fixation After Excision of the Knee Joint :’r 
“There is abundant evidence to prove that in many 
cases, notably those in which there was tubercular 
osteitis, primary bony union is rarely obtained until 
after months or years have elapsed, and often when 
it has apparently been accomplished it yields, result- 
ing in subsequent deformity. 
“This would indicate that temporary methods of 
fixation are inadequate and tend to the abandon- 
ment of catgut, which can exert retaining force for a 
comparatively short time only. 
“Steel nails are of doubtful efficiency, because of 
the short time in which they are employed. They 
are usually removed at or about the fourth week, 
and are generally found to be loose, and therefore easily 
removed. (Italics my own.) 
“These facts show that they could not have exerted 
any force. The same statements would apply to 
screws, gimlets, drills, dowels, or other methods 
which are removed during the course of the first 
treatment. 18 
“In four cases in which I have used steel nails 
four inches long, I have found that there was abso- 
lutely no resistance to their easy removal, and that they 
were simply loosely imbedded principally in the cancel- 
lous matter. (Italics my own.) 
“In experiments on the cadaver, screws or dowels 
did not prevent motion, but upon lifting the leg by 
the thigh the weight of the leg produced great sepa- 
ration. 
“Rotation of the leg broke loose the attempted fix- 
ation, and they appeared to be perfectly useless with- 
out efficient external support, and the employment 
of the latter appeared to be just as efficacious. 
In the same cadaver, I employed stout wire at four 
points, through holes drilled in the compact tissue, 
and found that the objectionable movements were 
entirely absent although great force was exerted. 
“If the wire suture is efficiently used, it would 
appear to be the method promising the best ultimate 
results, but its success depends upon its long-con- 
tinued use. 
“I can not agree with Treves, that primary union 
is apt to be hindered by the use of the metallic 
suture, and that their presence excites carious action. 
“I have seen cases where the wire sutures were in 
two years after an incision, and Bryant says that he 
has not removed the wires in any case, unless trouble 
was caused by them and this rarely occurred. 
“The accurate approximation of the tibia and 
femur, secured by metallic sutures, naturally permits 
of less dependence being placed upon the external fixa- 
tion apparatus, but should not tend to its disuse.” 
(Italics my own.) 
I quote from Dr. Wilson’s paper at some length 
because I take exceptions to his conclusions. 
I do agree with Treves that the primary union is 
apt to be hindered by the use of metallic sutures. 
I would never allow decided means of direct fixa- 
tion of the fragments to take the place of decided 
external support, but always place my reliance on the 19 
nature of the external dressing, and make use of such 
means of direct fixation of the fractured ends as would 
be productive of the earliest possible bony union. 
The only guarantee against later deformity is the 
absolute and perfect repair and complete ossification 
of the bone ends, which is accomplished best in the 
absence of foreign bodies, and if this is not accom- 
plished, wire sutures will never prevent such deform- 
ity taking place. 
Dr. Wilson reports in his paper a case of excision 
of the knee, in which he used internal fixation of 
chromicized catgut, and applied an efficient external 
dressing of plaster-of-paris including leg, thigh and 
pelvis, which was allowed to remain five weeks. 
At this time, as apparently bony union had 
occurred, the patient was allowed to walk about, using 
a light posterior apparatus of plaster. Six months 
from the time of resection there was found a back- 
ward displacement of the tibia. 
Dr. Wilson doubts the value of catgut as a means 
of internal fixation in these cases, and he suggests 
the use of wire sutures. 1 attribute the occurrence 
of post-operative deformity in the case he reports, to 
the fact that the apparent bony union present at the 
time the primary cast was removed was not yet com- 
plete. I must defend the manner in which this ope- 
ration was performed, and attribute the latter deform- 
ity to some other cause than the use of catgut. I 
believe with Dr. Wilson that an important point in 
preventing such an occurrence is the prolonged use 
of an external support; but I do not believe as Dr. 
Wilson does, that wire sutures will prevent such late 
displacement taking place. I attribute the late 
deformities in these cases to the too early removal 
of substantial external support. In the case reported 
by Dr. Wilson, five weeks was too early a date to dis- 
continue the plaster cast. Some of the late displace- 
ments take place as a result of an epiphyseolysis, or 
continuation of the osteoporosis from incomplete 
removal of the tubercular foci. 20 
“The use of direct means of fixation of the resected 
ends in resection of the knee joint is being gradually 
abandoned. If the hip is well supported by a circu- 
lar plaster-of-paris splint, or a posterior suspension 
splint, accurate apposition of the sawn surfaces and 
perfect immobilization of the limb are maintained 
almost to perfection, rendering the use of fixation 
nails or sutures unnecessary. The use of proper 
mechanical support should not be dispensed with 
until the resected ends have been united by an osse- 
ous callus, which will require, according to the age 
and general condition of the patient, from six weeks 
to three months.”—Senn’s Tuberculosis of Bones and 
Joints. 
In arthrectomies and joint resections for tubercu- 
lar affections in which Tilings’ most valuable sug- 
gestions can be carried out, e.g., temporary resections 
of those portions of the bone extremities to which 
important muscles and joint structures are attached ; 
which can after the completion of the removal of the 
diseased tissue be replaced and fastened to the bone, 
catgut will serve a most excellent purpose. In the 
knee joints the patella is cut across transversely and 
later united with catgut sutures; at the elbow joint 
the olecranon is sawed with the insertion of the 
triceps and at the ankle joint temporary resection of 
the malleoli; at the hip joint the trochanter is tem- 
porarily resected and after the completion of the 
resection of the head of the femur the trochanter is 
united to the end of the bone, thus saving the attach- 
ment of important muscles, as well as securing a 
center of bone growth for the upper extremity of the 
femur; an important factor in the prevention of the 
shortening that follows removal of the epiphysis 
during the period of bone growth. In all these ope- 
rations chromicized catgut will meet the fixation 
requirements.