A LECTURE 
$ 
ON 
THE DEVELOPMENT OF THE OSSEOUS CALLUS 
IN FRACTURES OF THE BONES OF 
MAN AND ANIMALS, 
DELIVERED BEFORE THE 
ANATOMICAL AND SURGICAL SOCIETY OF BROOKLYN, 
By HENRY O. MARCY, M. D., 
OF BOSTON, MASS. 
REPRINTED FROM THE ANNALS OF ANATOMY AND SUKGERYi FEBRUARY, l88r. 
BROOKLYN, N.Y. 
2 8 MADISON STREET, 
1881. THE DEVELOPMENT OF THE OSSEOUS CALLUS 
IN FRACTURES OF THE BONES OF 
MAN AND ANIMALS.1 
By HENRY O. MARCY, M. D., 
OF BOSTON, MASS. 
THE results of my investigations upon the repair pro- 
cesses in fractures of the bones of animals and man, 
are quite different from the teachings which I had received, 
or my previous accepted conclusions. My studies in this 
direction were prompted by my clinical observations upon 
the repair of fractures under various modes of treatment, 
and especially from my belief, that after careful adaptation 
and complete rest secured with plastic splints, there occurred, 
under favorable circumstances, a primary union in bone not 
unlike that taking place in the repair of superficial wounds. 
In one or two monographs upon the treatment of fractures, 
published some years since, I inculcated this thought. I 
have availed myself of the great profit derived from tlie 
teachings of Comparative Pathology, and have selected the 
rabbit as the most convenient animal from which to make 
decalcified injected specimens. First of all, I would give 
full share of credit to my friend and co-laborer, Dr. A. F. 
Holt, of Cambridge, whose pains taking and carefully pre- 
pared microscopic sections will be appreciated by all engaged 
in this difficult field of histological research. 
1 A lecture delivered before the Anatomical and Surgical Society, De- 
cember 7th, 1880. 2 
HENR V O. MARCY. 
From the time of Galen, the fathers accepted his teaching 
that “the gelatinous moisture,” as he called it, which sur- 
rounds the fractured extremities of a bone, was the material 
that formed the new osseous growth called callus. 
Dupuytren, enlarging upon the doctrines taught by Galen 
and Haller, asserted that “nature never accomplished the 
immediate union of a fracture save by the formation of two 
successive deposits of callus, one of which is derived from 
the periosteum, adjacent tissues and the medulla, while the 
other, formed perhaps from the broken extremities of the 
bone itself, is found at a later period directly interposed be- 
tween their surfaces.” 
After the publications of Ollier, in 1859 and i860, upon 
the osteo-genetic property of the periosteum, surgeons and 
anatomists were agreed in rejecting the doctrines taught 
concerning the formation of the callus, and maintained that 
the neo-formative process was due wholly to the periosteum. 
These were the teachings received during my pupilage. 
One of Italy’s most distinguished students, Prof. G. B. 
Ercolani, of Bologna, published in 1866 a monograph upon 
the repair of fractures, and gave as his conclusions that the 
extremities of a fractured bone took no part in the process 
resulting from which the osseous callus is formed, and that 
the periosteum near the fracture is a less important factor 
than is usually believed, oftentimes undergoing even a de- 
structive process. 
In 1867, Billroth, in his important investigations upon the 
regeneration of bones in fractures, closed with the following 
conclusions : x“ If we now view the processes as a whole, we 
see that the cell infiltration in the bone itself, as well as in 
all the surrounding parts, aids in the formation of callus, and 
that hence the periosteum plays no exclusive osteoplastic 
role.” This might have been concluded a priori; for if the 
1Surg. Pathology, American edition, p. 181, Development of callus. 
3 
periosteum alone formed the external callus, as was supposed, 
the portions of bone free of periosteum, such as those places 
where tendons are attached to the bone, could form no cal- 
lus, which is directly contradicted by observations. In nor- 
mal growth also the periosteum does not, by any means, 
have the importance ascribed to it in the formation of bone, 
for we may just as correctly regard the layer of young cells 
upon the surface of the bone and extending into the Haver- 
sian canals as belonging to the bone, as to refer it to the 
periosteum. This distinguished surgeon arrived at these 
conclusions after much careful study upon dogs and 
rabbits. 
From the most remote antiquity it has been known to 
surgeons that all about the place where a fracture of a long 
bone has occurred, there is observed in a few days a material 
of a gelatinous appearance mingled with a greater or less 
quantity of blood. This is elastic, becomes more firm, is 
smooth externally, and everywhere embraces the fragments. 
This is the so-called soft callus, and is destined to be changed 
into osseous substance. These neo-formative processes have 
* 
been the subject of careful study by many investigators, from 
Galen to our own day. Differences of opinion have been 
held as to the origin of the neoplasm and the elements 
which share most actively in the new growth. Some have 
believed that it is derived from the blood and its coagulated 
elements. Others regard it as elaborated from the medulla 
of the bones; more recently the periosteum alone has been 
held as the active factor of reproduction. Again, after 
Billroth, these changes have been assigned to the bone it- 
self. “ This new material,” he says, “ is developed from the 
connective tissue of the medullary cavity of the canals of 
Havers, which proceeds from the surface of the fracture, 
meets the like tissue which comes from the other fragments, 
and is blended with it in the same way that the union of the 4 
HENRY O. MARCY. 
soft parts is effected.” This would be analogous to primary 
union in superficial wounds. 
Influenced by his own researches in Comparative Pathol- 
ogy, Prof. Ercolani claimed, in 1867, that the periosteum 
was destroyed in the place where the soft callus was formed, 
and, as a consequence, it could take no active part in the 
formative processes. This was, in a measure, confirmed by 
Billroth, and both are now agreed that it is to a new perios- 
teum, formed upon the soft callus from a thick layer of con- 
nective tissue, to which must be ascribed a very important 
function. 
If there was error in Ollier’s theory which made the form- 
ation of the callus depend upon that portion of the perios- 
teum which is destroyed and absorbed, Billroth’s teaching 
is also incomplete when, to the new-formed periosteum, 
he would attribute the development of the osseous sub- 
stance to the callus, since this is the result of two equally 
indispensable conditions—namely, periosteum or ossifying 
organ upon the one side, and ossiferous organic elements 
upon the other. Wherefore, as the irritated periosteum finds 
in the exudation from its own vessels the ossiferous elements, 
so the new periosteum, which is under discussion, finds in 
the soft neo-plasm ossiferous elements, without which the 
new-formed periosteum, like the old periosteum in sound 
bones, though it repairs the waste of the bone, is yet inade- 
quate to the reproduction of new osseous substance. 
Ercolani says, “ that comparative researches, moreover, 
will show not only that the new doctrine taught by Bill- 
roth on the formative process of the callus is erroneous, but 
also that no single principle is sufficient to explain the form- 
ation of the callus in the different cases of fracture. This 
would naturally differ not only in the long and the flat bones, 
but according as fractures of the long bones are simple or 
compound, and also in simple fractures, whether the frag- DEVELOPMENT OF CALLUS. 
5 
meats are maintained close together or apart from each 
other during the period in which the callus is formed.” 
Before proceeding to study in detail the importance of the 
several elements or tissues existing at the place where a frac- 
ture may occur, it is necessary to refer briefly to the normal 
development of bone, for it would seem a fair deduction to 
suppose that the repair processes in a fracture do not very 
widely depart from those of formation. Examine the grow- 
ing bone of a very young child. The condyles are composed 
of cartilage, and the periosteum is continued from the shaft 
of the bone over the cartilage, the outer layers of which 
have assumed a fibroid character. This is the way in which 
the periosteum is formed, and it may be considered a fibro- 
cartilage developed out of the temporary cartilage, from 
which the shaft of the bone is produced. This newly formed 
fibro-cellular tissue, covering the developing bone, contains 
living cells of precisely the same nature as those from which 
the shaft is constructed, and in this manner the circumfer- 
ence of a long bone is increased, as layer upon layer of the 
cells ossify, arranging themselves into Haversian systems. 
This vitalized matter, the germinal material of Beale, 
under favorable circumstances, surrounds itself with a soft 
hyaline substance which, as it increases in quantity, separates 
the nuclei of the original cells from one another; about the 
nucleus there is secreted, into the hyaline material, lime salts, 
and, so to speak, each cell becomes encased in a shell firmly 
fixed to its neighbor; thus the so-called osteo-blasts become 
bone corpuscles. This is the end of the development series, 
the highest possible form of osseous growth, and the integ- 
rity of its vitalized condition maintained by the nutritive 
supply furnished through the Haversian and canalicular cir- 
culation. 
A priori, it would seem, that from cells thus encased and 
developed to maintain the integrity of firm support required 6 
HENRY O. MARCY. 
in the osseous structure, little or no part could be taken by 
them in the process of repair. Their germinal matter is 
locked up, so to speak, in an earthy encasement, and cannot 
sub-divide for the production of new cell growth ; increase 
of material in the circulatory system of the bone would, 
within a certain limit, only increase the development of 
earthy material to the expense of the cell itself or the inter- 
vening canals, as, for example, the so-called eburnated exos- 
tosis, and exceeding this, as in other tissues, would react to 
the death of the cell itself—the very changes that take place 
in necrosis. 
In the medullary canal of long bones there is found a net- 
work of cytogenic or adenoid tissue continuous with that of 
the endosteum, its meshes being filled with a vast number of 
corpuscles which, histologically and,it is claimed, functionally, 
are not unlike those of the spleen. Several excellent observers 
maintain that this plexus of adenoid tissue is the commence- 
ment of a lymphatic system in bones. We cannot doubt 
these structures play an important part in certain pathologi- 
cal changes of the bones, and it is a fair inference to believe 
they modify and control, to a certain extent, their normal 
nutrition and—when called into especial activity after inju- 
ries—the processes of repair. This is very probably an active 
factor in the production of fatal results which follow septic 
poisoning after compound fractures. 
The material forming the soft callus in the first days after 
a fracture is furnished from the blood of the lacerated ves- 
sels as well as the connective and other tissues injured, in- 
cluding those of the medulla and Haversian canals. Since 
these elements are furnished from these various sources and 
may not be unlike in character, it is impossible, in the mass, 
to distinguish them as to their origin, or to say what part 
they take in the process of restoration. It may be assumed 
that the exuded blood is not a very important factor; DEVELOPMENT OF CALLUS. 
/ 
for we learn clinically that a copious effusion of blood 
always delays, instead of assisting, in the repair. And 
thus we infer that the white globules, as well as the red, 
undergo a process of absorption, and are not especially 
valuable agents of regeneration, and that, even when the 
amount of effused blood in the callus is small, it is an 
entirely secondary and unimportant factor in the formative 
process. It must be conceded that the part which the me- 
dulla takes in the restorative changes may be much more 
significant than that of the effused blood ; for it cannot be 
denied that the exudation from the connective tissue and its 
vessels assumes distinctive importance. This is shown by 
ossific depositions in the medulla after artificial irritation ; 
also in some instances by extensive ossifications of the me- 
dulla in fractured bones, which for a long time impede the 
re-establishment of the old medullary cavity, and by the 
consolidations of fractured flat bones, owing to the ossifica- 
tion of their spongy substance. However, observation 
clearly shows that in the long bones, in some cases, the part 
which the medulla takes, though very considerable, is yet 
not indispensable for the formation of the callus, since it is 
found and very solidly formed in the bones of birds, which 
have no medulla. Neither has it any importance in man or 
animals when the fragments of the broken bone are kept 
apart, since they are then re-united by means of an osseous 
bridge entirely external. The surfaces of the separated 
fragments remain inert and without ossification of the me- 
dulla within their medullary cavities. 
Through the kindness of Prof. Hyatt, of the Boston Nat- 
ural History Society, I have selected two specimens of the 
many at my disposal, which show the formative processes of 
repair in birds. The first is the ulna of the swan. Held as 
it was with very little displacement, resting upon a veritable 
water-bed, the repair has gone on with singular effectiveness 8 
HENRY 0. MARCY. 
and symmetry, leaving so little deformity that it was by no 
means certain that a fracture existed until the bone was 
sawed open. The other specimen—the humerus of a tur- 
key—shows the great deformity which ensued, and the union 
which has taken place is by an osseous development cement- 
ing the fragments separated a considerable distance from 
each other. The femur of a cat, a beautiful specimen from 
the Jeffries Wyman collection, exhibits great displacement 
of the fragments with shortening. We fail to observe not 
only any trace of neo-formative process upon the borders of 
the medullary cavity of the bone, but the fragments sub- 
jected to an actual atrophy of the osseous substance, pre- 
sent smooth and rounded ends instead of sharp and cutting 
angles. Hence, we may conclude that the part taken by the 
medulla in the neo-formative process of the callus in the 
long bones, although usually important, is by no means 
necessary, and, like the white globules of the blood, occupies 
a place of secondary importance. These examples of osseous 
callus in the human species are most frequently met with in 
the clavicle and femur, in which great displacement of the 
fragments is more common. 
In the Peabody Archaeological Museum of Cambridge 
are preserved several long bones from a pre-historic age 
which are interesting, not only as illustrating the formation 
of the osseous callus in bones, the extremities of which are 
widely separated, but teach, so far as these specimens go, 
that the art of surgical appliance to fractures was not well 
understood by the mound-builders of the West. 
Since the publication of Prof. Ercolani, before mentioned, 
my attention has been called especially to fissures in bones, 
or so-called partial fractures, because the significance given 
by him to the changes which supervene was to me new and 
peculiar. They show that it is not possible to accept the 
fundamental part of the doctrine held by Billroth in regard DEVELOPMENT OF CALLUS 
9 
to the formation of the callus. In his monograph, pub- 
lished in 1878, Ercolani figured several old fractures of the 
bones of the horse, which exhibit to a remarkable degree the 
absorptive changes which take place in the line of the fis- 
sures, and stated that he thought the bones of the horse are 
much more liable to undergo these changes than are those 
of man. He described, however, a human skull, in which 
these changes had occurred in a marked degree. 
Believing if processes of absorption supervene in frac- 
tures of human bones they must be very rare, I have 
taken the occasion to examine several of the largest collec- 
tions in the United States, and have failed to find any 
marked illustrations of absorptive changes occurring upon 
the line of fissures in any of the long bones. I have found, 
however, a number of old fractures in the flat bones which 
exhibit very well these processes. 
If it be true, as Billroth taught, that the Haversian system 
is the important factor of repair, we ought to find the most 
favorable condition possible for this in partial fractures or 
fissures of the bone ; for in these we have no displacement 
of fragments, and the injury to the periosteum is reduced to 
the minimum. Yet, it is precisely here a process of absorp- 
tion frequently supervenes and the fracture is never com- 
pletely repaired. 
I would express my great obligation to Dr. F. H. Whit- 
ney, Curator of the Warren Anatomical Museum of Boston, 
for the loan of several specimens, showing these changes 
which hitherto have passed without explanation or even 
special observation. The specimen numbered 983 is cata- 
logued simply as a fracture of the coracoid process of the 
scapula, contributed by Dr. J. C. Warren, 1847. A more 
careful examination of it shows that the edges of the frac- 
ture which had extended into the glenoid cavity have under- 
gone no effort at repair ; yet, upon the superior border of IO 
HENRY 0. MARCY. 
the neck, there is an abundant formation of new bone, 
filling the supra-scapular notch and extending along a fissure 
running nearly the whole length of the supra-spinous fossa. 
Upon the anterior side an extensive periostitis had super- 
vened, yet, instead of a deposit of new bone, there is a 
marked absorption running the whole length of the fissure. 
No. 973, presented in 1859 by Dr. R. M. Hodges, is a cran- 
ium, upon which are seen the effects of an old fracture. 
There is a cleft in the right parietal bone, about five and a 
half inches long, one inch at the widest part, irregular in 
shape and horizontal in its direction ; anteriorly there ex- 
tends from this opening to beyond the median line a fissure 
that has the appearance of a fracture. The internal surface 
is much more irregular and has a peculiar eroded look for 
some distance beyond the depression upon the external 
table. Posteriorly a crevice, with erosion and much rough- 
ness extends from the opening downward into the occiput, 
and is more clearly defined internally than upon the outer 
surface. There is no deposit of new bone, the edges of the 
large opening have a smooth appearance, and the structure 
of the whole bone is quite healthy. This specimen was 
from a dissecting-room subject, about thirty-five years of age. 
There was a deep cicatrix externally corresponding to the 
large opening, and anteriorly there seemed to be a smaller 
one. It was a question whether this might not have been a 
case of burn or disease, but it appeared, on the whole, more 
like a fracture. The specimen, number 974 of the catalogue, 
is also of great interest, as it shows an old fissure of the oc- 
ciput on the median line, entering the occipital foramen, 
which is enlarged considerably posteriorly. Much absorp- 
tion has taken place along the line of the fissure, to which 
is evidently due the irregular enlargement of the foramen. 
Equally important for study is a skull furnished me by the 
courtesy of Pr. J. C. Warren, from the private museum of DEVELOPMENT OF CALLUS. 
11 
his father and grandfather. It is labelled, “ Soldier, Na- 
poleon’s army, wounded at the battle of Pyramids ; died at 
Hotel des Invalides, 1832.” Thus it appears the man sur- 
vived his injuries, probably sabre fractures, thirty-four years. 
It is remarkarble on account of a depressed fracture of the 
frontal bone, a little to the right of the median line, one and 
a half inches long, of U-shaped character, showing failure at 
union along its edges with considerable loss of substance 
from absorption. In the right parietal there is an old fissure, 
extending from the squamous suture upwards and forwards 
three inches, but only through the external table. In the 
left parietal, posteriorly, there is a fissure from near the me- 
dian line through the temporal bone to the base of the 
skull, in part through both tables. The entire skull is very 
thin, the diploe being almost everywhere absent. 
In the Medical and Surgical History of the Rebellion 
there is given a full plate illustrative of a specimen contrib- 
uted to the Army Museum at Washington, by Assistant- 
Surgeon S. E. Ayres, as an example of sabre fractures of the 
vault of the cranium. The patient stated he had been 
wounded several years before by a blow from a sabre, and, 
since his recovery, although still in service, he had been sub- 
ject to occasional convulsions. In one of these he died. 
There are to be seen multiple united sabre fractures of the 
os frontis and united linear fractures of both parietals, and 
disjunction of the coronal suture of the right side. Most 
of the fractures had penetrated the lamina vitrea which was 
much thickened in the vicinity of the injuries. Several de- 
tached fragments of the inner table had reunited, and ex- 
hibited an eburnated appearance. Along the sagittal and 
coronal sutures and in the neighborhood of the incised frac- 
tures, there were osseous deposits of long standing. Along 
the linear fractures marked absorptive changes have taken 
place. Another illustration of Assuring in bone is taken from 12 
HENRY O. MARCY. 
part second of the Medical and Surgical History of the Re- 
bellion. It is a gunshot injury of the left ilium, extending 
to within an inch of the acetabulum, to which it is connect- 
ed by a deep fissure, the edges of which have undergone, in 
a marked degree, absorption. A periostitis had taken place 
all about the injury, except at its superior border where the 
bone is necrosed, yet there is not the slightest evidence of 
repair about the fissure. 
These specimens plainly teach that in the cranial vault, 
where fissures occur without disturbance in bone, osseous 
callus is not deposited, but instead there are found very 
evident osseous clefts. These facts lead to the conclusion 
that the neoplasm which originates from the contents of the 
canals of Havers, cannot, of itself alone, possess a true osteo- 
plastic value. The causes which would seem to have led to 
the absorption in a manner not unlike that seen upon the 
rounded ends of misplaced long bones, may be referred to 
the destruction or devitalisation of the periosteum at the 
place of injury, and will be discussed as we examine, in de- 
■ tail, the part which is taken by the periosteum in the process 
of repair. 
Professor Ercolani stated, in 1866, “that repeated obser- 
vations had demonstrated to him that the periosteum under- 
lying the soft neoplasm surrounding the fractured bone, was 
shortly attacked by a complete process of destruction.” In 
1867, Billroth wrote “that the periosteum disappears in the 
new tissue and in the callus in the course of ossification.” 
After this clear and precise statement, he asserted, “ the peri- 
osteum has not a very important share in the formative 
process of the callus.” When we remember the emphasis 
which he placed upon the osteo-genetic function of the irri- 
tative exudation from the Haversian system, we are led to 
believe he meant the periosteum in general, for he did not 
describe a metamorphosis of periosteum taking place in the DEVELOPMENT OF CALLUS. 
13 
callus, hence we conclude that he must refer to destructive 
changes when he stated that the periosteum disappears. 
This is an important conclusion, and one to be carefully- 
reviewed, even when taught by so illustrious a master. We 
may assume that it is an unquestioned fact that to the integ- 
rity of the periosteum corresponds the integrity of the bone 
which it covers, and that to lesions of the periosteum corre- 
spond alterations in the bone; also that a moderate degree 
of irritation in the periosteum suffices to determine an 
excessive production of osseous substance, while a serious 
and profound lesion of the periosteum produces an opposite 
effect, the devitalisation of the substance of the bone. 
Let us compare these observations, so universally accepted, 
with the specimens before described. In these several exam- 
ples, along the fissures there is found scarcely the slightest 
trace of neo-formation of osseous substance, yet a little way 
therefrom appears a more or less abundant deposit. It 
would seem a fair interpretation that in the place where the 
fissures of the bone occurred, the lesion of the periosteum 
was so serious as to produce a sudden cessation in its osteo- 
genetic function, while in the neighboring parts, where the 
irritating and inflammatory process became necessarily less 
severe, there the process of osseous neo-formation was active. 
If the injury to the periosteum in simple fractures or even 
fissures is followed by results so serious as to put an end to 
its osteo-genetic function, it must, in a yet larger measure, 
be true, in the more severe injuries and in compound frac- 
tures; this is abundantly proved in the long bones, either 
human or animal, which have consolidated with displacement 
of their extremities. We have already shown that the 
osseous substance at the apices in displaced fractures after a 
time undergoes a marked atrophy, and, in the series of micro- 
scopic preparations from the rabbit to be described presently, 
we think it is demonstrated that these changes by absorp- 4 
HENRY 0. MARCY. 
tion of the old bone commence within a few days after the 
injury. 
This is in direct evidence that the exudation from the 
Haversian system, as earlier remarked, has not, in these in- 
stances at least, an osteo-genetic function. From these 
observations and equally important ones derived from the 
study of fractures in flat bones, and especially from the 
demonstrations in the microscopic preparations referred to, 
it seems a conclusion from which there is no escape, that the 
periosteum at the place where the fracture occurs takes no 
part in the neo-formative process, but is actually destroyed. 
One following thus far in the analysis of the different factors 
which enter into the regeneration of bone, and finding that 
each may be excluded or considered non-essential, will be 
led to inquire what then is the physico-pathological process 
by means of which the callus is formed ? This differs in a 
great measure according to the form of the bone, whether 
flat, spongy or long; the kind of fracture, whether simple or 
compound ; and the position which the fragments of the bone 
assume and retain during the period of repair. The results 
of careful study of these processes in the long bones of the 
rabbit we now give as the best possible illustration of what 
we believe occurs in the long bones of all animals when 
placed under similar favorable circumstances. The series com- 
prise fourteen animals from the third to the twenty-fourth 
day inclusive, all having been submitted to the same treat- 
ment. The animals were etherized, the leg fractured and at 
once secured in a plaster splint. They were then chloro- 
formed at the desired period, a canula inserted through the 
left ventrical into the aorta, and blue gelatine solution was 
injected quite warm. After repeated experiments, Dr. Holt 
and myself have determined that the best means of injection 
is by the continuous stream under steady, but not too great, 
atmospheric pressure. DEVELOPMENT OF CALLUS. 
15 
THIRD DAY.1 
The preparations of the third day after the injury, the 
apposition having been nearly perfect, show very few marked 
changes. The edges of the fractured bone, which upon one 
border were considerably splintered, have scarcely altered, 
the neighboring vessels are not enlarged, and only a few red 
and white blood cells are to be seen. There is a small quan- 
tity of plasmatic fluid about the fractured ends, which, mag- 
nified five to six hundred diameters, is shown to be composed 
of fine granules. The Haversian system appears unaltered, 
and the periosteum is infiltrated with red corpuscles. 
The changes from the third to the sixth day are instruct- 
ive. There are seen a few blood vessels already formed in 
the new callus, which is distinct, and the exudate between 
the fragments is blended with the old bone. A nearly amor- 
phous or finely granular material fills the interspace. This 
is under the most favorable conditions, as the fracture was 
not complete. 
SIXTH DAY. 
NINTH DAY. 
The changes which have taken place in the specimen of 
the ninth day are of much greater importance. The blood 
effused into the medullary canal has been largely absorbed, 
and we see in the finely granular matrix loops of new ves- 
sels rapidly forming. Many of them are ectasic in character 
and inosculate with the medullary vessels. The borders of 
the fractured bone are somewhat softened and cemented by 
the same finely granular material, as seen in the specimens 
from the third and sixth days. 
1 The decalcified specimens were cut by Dr. Fisher’s microtome, with the 
exception of a few recently made when Dr. Haile’s freezing microtome was 
used. Both are very valuable instruments for the purpose, Dr. Haile’s giv- 
ing specimens of especial evenness and beauty. The)' are believed to be 
one-thousandth of an inch or less in thickness, and are mounted part in 
balsam and part in glycerine. 16 
HENRY O. MARCY. 
The vessels of the Haversian canals remain unchanged. 
The periosteum presents marked modifications at the side of 
the fracture; upon both borders of the bone there is a 
distinctly defined disintegration of the periosteum with ab- 
sorption, less extensive where the fragments are in close ap- 
position. Extending several lines in either direction there 
is an abundant deposit of the formative callus or grume of 
the earlier writers which infiltrates and incorporates into 
itself certain fibres of tom muscular tissue. This contains 
a few red and white blood cells. Upon one border of one 
of the preparations of this date there is an extensive fissure 
which shows no effort at repair, but, on the contrary, an 
active process of absorption has taken place upon the osseous 
borders and the interspace is filled with amorphous mate- 
rial. There is considerable displacement. 
TENTH DAY. 
The specimens of the tenth day are described because 
they exhibit the development of the so-called internal callus. 
There was no displacement of the fragments, and, hence, a 
less active periosteal development. The new material upon 
the medullary borders is distinctly ossific, and is carried for- 
ward in diverticula separated from each other by loops of 
vessels surrounded by a bed of germinal matter. Upon the 
inner border of the fractured ends there is a very consider- 
able layer of cartilage cells. The capillaries are chiefly pro- 
longations of the medullary vessels, although some are traced 
directly into the Haversian canals, and there doubtless inoscu- 
late with each other. The injected Haversian vessels are no 
larger than in the bone quite remote from the fracture, and 
the active part taken by the Haversian system, as claimed 
by Billroth, is not found. The medullary vessels in the 
vicinity of the fracture are considerably enlarged. There is 
also trace of the necrosis of the old periosteum and the 
overlapping of the new periosteal growth is well shown. DEVELOPMENT OF CALLUS. 
17 
TWELFTH DAY. 
The specimens of the twelfth day show beautifully the 
more perfectly developed series of vessels in the formative 
callus, both of the periosteum and of thd medullary canal; 
many of the loops are ectasic. Cartilage cells are abundant 
and osteoblasts have formed in the new periosteum. The 
point of destruction of the old periosteum is replaced by 
layers of cartilage cells. Here is first seen in the series the 
process described by Billroth—namely, the absorption of the 
bone about the Haversian canals, and a granular amorphous 
deposit on the line of their vessels. These changes are con- 
fined principally to the borders of the shaft beneath the new 
periosteal development; the vessels in the central portion of 
the old bone have undergone no change. 
The separated edges of the fractured bone have a granu- 
lar appearance, and are cemented by a protoplasmic mass, 
which reveals no cellular development, even when magnified 
to eight hundred diameters. 
FOURTEENTH DAY. 
In this radius which was simply fissured, the periosteal 
development is reduced to the minimum, while the finely 
granular material filling the fissure, the edges of which have 
undergone distinct absorptive changes, is more clearly nuclear 
and highly refractive. The Haversian canals are being re- 
joined through the deposited material. The injection failed 
to enter the finer vessels. 
SIXTEENTH DAY. 
The specimen from the sixteenth day shows especially 
well the injection of the vessels in the developed callus, 
which is, in a great measure, ossific. The place of the old 
destroyed periosteum is refilled with cartilage cells, 18 
IIENRY O. A1ARCY. 
The specimen taken at the nineteenth day was mounted 
in glycerine and colored with carmine, and it shows yet 
more interesting Changes than any of the previous ones. 
The displacement of the fragments is very considerable, and 
the callus is in proportion developed. The changes in the 
shaft of the old bone are less marked, and are chiefly con- 
fined to its periosteal surface. The Haversian canals are 
very little altered; the medulla, although the bone is dis- 
placed by half its diameter, has taken equally with the peri- 
osteum an active share in the reparative processes. 
NINETEENTH DAY. 
TWENTIETH DAY. 
The displacement in the specimens of the twentieth day 
was very slight, and the process of repair is much more ad- 
vanced than in the preceding one. 
TWENTY-FOURTH DAY. 
The specimens of the twenty-fourth day show complete 
and truly ossific union. The Haversian canals are re-estab- 
lished throughout the divided portion, and much of the re- 
dundant exudation has been re-absorbed. 
From these microscopic studies we may make several de- 
ductions : 
1. As to the existence of the exudation from the parts 
surrounding the fracture, which as early as the sixth or 
eighth day is well developed and covered with a smooth, 
shining surface—the new periosteum, 
2. The destruction of the old periosteum at the point of 
injury, 
3. It seems to me to be demonstrated that the exuded 
elements have an individuality peculiar to themselves; that 
this protoplasmic or germinal material is placed in such 
relations to the new and very vascular periosteum, that osteo- DEVELOPMENT of callus. 
*9 
blastic cells are rapidly evolved, and arrange themselves in 
relation to each other and the previously formed material in 
accord with a fixed law. Professor Ercolani arrived at a 
somewhat similar deduction when he said “ that this new 
periosteum which is formed impresses its osteo-genetic action 
on the exuded cellular elements, and that it is by this that 
they are transformed into bone.” 
Two conditions are indispensable for the development of 
the external callus and its ossific function. First, there 
should be an exudation of plastic or germinal material; and 
second, that this should be covered by, or in close relation 
with, a newly developed periosteum, and either of these 
conditions failing, the repair processes are not perfected. 
This condition of the transformation of the soft neoplasm 
into osseous substance shows us, as hinted when describing 
fissures of bone, why the consolidation of fissures does not 
take place, and this, in turn, teaches the importance of 
recognizing these two fundamental factors in the formation 
of the callus. 
I call attention to two specimens from the buffalo as illus- 
trating in a marked degree these deductions. The first is 
the spinous process of a vertebra, showing gun-shot injury. 
The bullet was flattened against the bone, and is retained in 
its position by outgrowing spicula of new bone. To the 
very extremity of the process, twelve inches in length, the 
bone is slightly roughened, showing that a periostitis super- 
vened the injury, but accompanied by a very limited exuda- 
tion of neoplastic elements. The second is a compound, 
comminuted gunshot fracture of the scapula near its neck 
from the same animal. The fragments are very firmly 
united by an immense osteo-plastic new growth, increasing 
the weight of the bone perhaps one-third. Irritated peri- 
osteum and neoplastic material were both found in ample 
facturage for the new development. 20 
HENRY O. MARCY. 
The consolidation of fissures does not take place, because 
the exudation is less and the overlying periosteum is injured 
in such a way as to lose its osteo-genetic function, and when 
after a time it returns to its normal state, as shown in the 
examination of the various specimens referred to, either the 
exuded elements have disappeared, usually re-absorbed, or 
have become too old to feel the ossifying action of the peri- 
osteum. As stated, when discussing the development of 
bone, the normal function of the healthy periosteum is to 
supply the nutritive elements necessary to keep the bone in 
a sound condition ; otherwise the bones could not preserve 
their symmetry and their development would have no defin- 
ite limits. 
In fractures with overlapping or marked displacement, we 
have seen that the extremities take no active part in the re- 
storative process, but are united by an ossific mass deposited 
between the sides facing each other, a transverse section 
showing a direct continuity of substance. This osteo-plastic 
development must be assigned to the periosteum, but in a 
manner quite different from that formerly ascribed to it. 
We have noticed already in the ossifying callus, as early 
as the fifteenth day in the specimens from the rabbit, that 
the union between the old shaft and the new bone had be- 
come intimate, and that the new osseous substance was cov- 
ered by new periosteum in direct continuity with that of the 
shaft at a distance from the fracture. When the exudation 
which is given out from the superficies of the two fragments 
meet, they blend, and, covered with the newly-developed 
periosteum, place the callus in a condition for ossification, 
and the union by new bone firmly joined is the result. 
The exudation of soft neoplasm which is necessary for the 
formation of the callus, is of great importance here for de- 
termining more actively the irritation of the periosteum in 
the opposing sides of the fragments ; otherwise there would DEVELOPMENT OP CALLUS. 
21 
be no reason why the external surface should preserve its 
normal condition, and the new osseous substance form only 
at the place where the fragments face each other, and be- 
tween which is necessarily found the exudation in greater 
abundance. 
In compound fractures, these factors which enter into the 
process of repair vary with the condition of the injury and 
the disposition of the fragments. In spongy bones, where 
the displacement is generally inconsiderable, the most im- 
portant share in the restorative process is due to the ele- 
ments that compose the medullary or spongy substance, and 
more rarely do we find an imperfectly formed callus. A 
beautiful specimen illustrative of this is from the Warren 
Museum, and exhibits both modes of union. The patient 
sustained a fall three years before death, due indirectly to 
the injury. The anterior portion of the body of the twelfth 
vertebra is in large measure wanting and separated from the 
eleventh by an interosseous space, but in the posterior part 
the osseous substance of the vertebrae is not only in con- 
tact, but very firmly united by a bridge of dense bone. 
There is a true ossific union externally between the por- 
tions of the fractured vertebra with a sub-periosteal osteo- 
plastic layer of new bone, and upon the right side the fold- 
ing together of the external plates is distinctly marked. 
The internal callus is owing entirely to a transformation 
of the elements composing the medulla. The study of an 
ununited fracture—the humerus, for example—is instructive 
in this connection. Here, owing to motion, the medulla in 
the cancellated structure of the bones ossifies without union, 
and after'a time, by the perverted action of a process intend- 
ed to re-establish the continuity of a part, actually defeats 
it; for the bone-forming elements have gone on to a high 
development of ossific deposit, locking up their germinal 
material and separating the cancellated extremities by a firm 22 
RtENR V O. MARCY. 
bony deposit. This must be surgically removed to bring the 
medullary elements in apposition before it can become an 
active factor of repair. 
Summing up the various factors which we find enter so 
widely into the modes of repair in fractures, we conclude 
that the germinal material which is effused in the vicinity of 
a fracture must be placed under certain defined conditions 
to secure therefrom an ossific development. 
From Ollier’s many and varied experiments upon the peri- 
osteum, he found that to produce true ossification in trans- 
planted periosteum, this must not only be revitalized by its 
connection of vascular character in its new relations, but 
must pour out, or furnish, an exudation of germinal matter 
sui generis. This exudation occurs only when the perios- 
teum is irritated, not destroyed, and then there takes place 
a true, ossific deposit, otherwise it does not produce bone. 
The process of consolidation in fractured bones is not uni- 
form, but varies according to the quality and shape of the 
bones and the kind of fracture, as well as to the relations 
which are established between the fragments. 
These different elements, as we have shown, unite in many 
ways to produce the final result of consolidation. Although 
we have demonstrated that, strictly speaking, there is no 
primary union in bone as in other tissues, we may safely 
draw the conclusion from our studies, which happily has been 
reached from the experimental standpoint of practice, that 
by careful and complete adaptation of the fractured parts 
we place the various factors of repair in such a relation that 
they most readily combine to aid in the restoration of the 
part, and, by retaining them undisturbed a certain period, we 
assist in producing a more certain and satisfactory result.  of and Surgery, 
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