A CASE OF FRACTURE OF THE HUMERUS; DEATH ON THE 
EIGHTEENTH DAY FROM FATTY DEGENERATION OF THE 
HEART; WITH REMARKS ON OSTEOGENESIS. 
T • 
BY EDWARD S. DUNSTER, M. D., A. M., 
Professor of Obstetrics and Diseases of Women and Children in the University of Mich- 
igan and in Dartmouth College. 
Reprinted from the April number ofTiiE Physician and Surgeon, Ann Arbor, Michigan. 
A gentleman, aged fifty-six years on the day of his death, 
was knocked down by a horse and sleigh driven at a rapid rate. 
The end of the shaft or thill struck him on the right arm just 
below the shoulder, and he was thrown somewhat forcibly to the 
ground, his right arm, which was extended to prevent the force 
of the fall, being underneath him. No part of the sleigh passed 
over him, nor was he trodden upon by the horse. lie was not 
stunned by the force of either the blow or the fall, and on being 
assisted to rise, he was supposed to be not materially injured, and 
was conveyed to his residence in a carriage. 
1 saw him about an hour subsequent to the reception of the 
injury. lie was pale ; skin, especially of the extremities, was cold ; 
pulse rapid (120) and small ; there was a marked degree of pros- 
tration with some anxiety of countenance, heightened perhaps by 
the consciousness of an extensive though superficial bruise, and 
ecchymosis of the right side of the face and forehead. The right 
humerus was found to be fractured obliquely at about the junc- 
tion of its upper and middle thirds. The muscles enveloping the 
fracture were in a state of clonic convulsion which was the cause 
of much annoyance and some pain. There was apparently no 
comminution of the bone, nor was any laceration of the soft tis- 
anes discoverable. On the outside of the arm, somewhat above 
the point of fracture, was a circular bruise about an inch in 
diameter, already ecchymotic and evidently caused by the blow 
irom the end of the shaft as described above. A careful exam- 
ination showed no other injuries, beyond a few slight superficial 
bruises of which no note was taken. The patient was put to 
bed, warmth and restoratives applied, and a temporary splint was 
adjusted to the arm after bandaging the same from the fingers 
up. Four hours later he was found in a comparatively comfort- 
able condition, having recovered pleasantly from the shock, and 
complaining of but little pain. That night he was ordered a pill 
of opium, one-half grain, and extract of valerian two and one-half 
grains, to be repeated every two hours if necessary. By the aid 
of this, lie secured a fair night’s rest, and on the following morn* 2 
iug felt as he expressed himself “all right.” The rebellious 
muscles around the seat of the fracture were subdued by the 
jucssure of the bandage, and were resting quietly in a compara- 
tively flaccid condition. There was but little heat and swelling, 
ni the point of injury ; the pulse was still rapid, but altogether 
the case, so far as the injury was concerned, was as favorable as 
could be desired. 
The details of the treatment of the fracture arc not given, as 
they present nothing of interest or out of the-usual experience met 
with in such cases. It should be noted, however, as bearing upon 
the condition of the fracture as found after death, that after the per- 
manent splints were applied, the fragments retained a remarkable 
accurate apposition to each other, and that the movements at the 
point of fracture were reduced to an absolute minimum by the 
extreme carefulness of the patient and his disposition to quietude 
of body, which had been his habit for years. 
His general condition was as follows: He suffered severely 
at times from acute lancinating pains variable in duration and 
shifting in position, but usually located in the neighborhood of 
the joints or over fibrous structures. By way of a euphemism, 
these pains were styled neuralgic, but in truth, they were depen- 
dent upon a syphilitic diathesis, for (as the family physician 
informed me), the patient had suffered severely from syphilis 
some twenty years back, and had received before he came 
under his—the physician’s—observation, some pretty sharp treat- 
ment. Sleep at night was not very regular or refreshing, but 
this was in a measure compensated for by sleep during [the 
day. The bowels were constipated, and on two occasions, 
unknown to me, the patient took a dose of Brandeth’s pills, for 
which he had for some years manifested a decided partiality. 
These produced copious catharsis, and along with it a consider- 
ble degree of prostration. The upshot of this was a positive 
interdiction of all medication, except with my knowledge and 
consent. The appetite was variable, but by no means keen, and 
resort was had to tonics, with an allowance for each twenty-four 
hours of a bottle of ale with his dinner, and four ounces of whisky 
or gin in two portions. The pulse remained all through the 
treatment unusually weak and rapid, never falling below one 
hundred per minute. This condition of the pulse unattended as it 
was by any febrile condition, was the occasion of considerable 
anxiety, and was believed to indicate some grave disturbance of 
the circulatory system, possibly aneurism which was suspected, 
though nothing positive could be elicited by physical exploration 
several times repeated. By his family physician who for twenty- 
five years had been his medical adviser, it was attributed to the 
nervous excitement and prostration resulting from the injury 
superinduced on the syphilitic diathesis before mentioned. 3 
Thus matters stood with a gradual, though perceptible decline 
of strength until seventeen days after the receipt of the injury, 
when I was called in haste at 7 p- m., to visit the patient, 
and found that he had apparently fainted, but had not entirely 
lost consciousness. He was lying on a lounge, his face preter- 
naturally pale, but otherwise manifesting no anxiety ; no diffi- 
culty of respiration; mind clear; and no complaint of pain, but 
with a pulse of one hundred and forty very feeble and small. 
The first sound of the heart was not perceptible on ausculta- 
tion, and the impulse was very slight. No medication was 
ordered, but a stimulant of brandy toddy moderately strong was 
allowed, and absolute rest in the recumbent position was enjoined 
until I should visit him again at his hour of retiring, as I feared 
that the rising into an upright position might produce sudden 
syncope. Such, however, was not the result; for some three 
hours later he rose and walked unassisted to his bed in an adjoin- 
ing room. The pulse at this time had fallen to one hundred and 
thirty, but was raised again by the movements just described. 
The following morning the pulse was one hundred and thirty- 
two, the patient then sitting up and in good spirits; complaining 
of a severe pain in the back of the head and neck ; and occupied 
in the reading and dictating business letters to an amanuensis. 
About two hours after my "visit, another “fainting turn” came on 
similar to that of the evening previous. He was again laid on 
the lounge, and in a short time was dead, breathing up to the 
moment of death being entirely unembarrassed. 
Permission was obtained to make an incomplete examination 
of the body, and this was done forty-eight hours after death, the 
temperature of the apartment meanwhile ranging from eight 
degrees to twenty-two degrees above zero. In the peridicardial 
cavity there were about two ounces of clear serum. The heart 
itself was of normal size, and was partially covered by a very 
thin layer of fat; the walls were extremely pale and flabby, and 
softened to such an extent that the finger could be easily pushed 
through them. The wall of the left ventricle was very thin, and 
could be torn almost by the weight of the organ itself; the right 
cavities were stained a deep brownish red color, but the lining 
membrane showed nowhere any roughening, or evidences of 
inflammatory action ; the valves were healthy, and there were no 
atheromatous or ossific deposits. The lungs were healthy ; the 
right one showing old pleuritic adhesions. No other organs 
were examined. 
Under the microscope with a magnifying power of three 
hundred and fifty diameters, the muscular structure of the heart 
showed the most extreme fatty degeneration I have ever witnessed. 
Not a trace of the markings could be found after a careful and 
prolonged examination, but the whole structure of the fibre con- 4 
sisted of granular and fatty matters. There were also extensive 
deposits of oil globules between the fibres. 
The prevailing impression left by this examination was one of 
wonder that the patient with a heart in so extreme a degree of 
degeneration had not long ago died, as he most assuredly would 
have, had not his habits been of the kind above described. 
Rupture might readily have taken place on any unusual excite- 
ment, < r sudden and violent movement or strain, and had he died 
at the moment of receiving the blow which caused the fracture, it 
would have elicited no surprise, when once this condition of the 
heart was known. Of course the beari ng of tl ic syphilitic diathe- 
sis on this kind of degeneration is evident, and well understood. 
About four inches of the humerus including the seat of the 
fracture were removed. The principal interest attaching to the 
specimen, is in the opportunity it aiiords for observation of the 
process of repair in bones which have been broken. Examina- 
tion shows numerous points of ossification in the periosteum, on 
the fractured surface, also in the medulla and the connective tis- 
sue outside the periosteum, and even in the adjacent muscular 
tissue. Many of these points of ossification have been examined 
microscopically, and found to be true bone tissue and not simply 
points of calcification ; thus showing conclusively that bone may 
develop under certain conditions of irritation (perhaps not very 
well understood) wherever connective tissue is present. The 
bearing of this property on the reproduction of bone after sur- 
gical operations that involve the removal of bone and of perios- 
teum is apparent. Surgical experience has long since demon- 
strated that Duhamel’s theory of the production of bone from 
periosteum, enunciated in the last century (1739-1757)1 and par- 
tially accepted by Dupuytren, although pronounced untrue by 
such men as Haller, Bichat and Scarpa, is unquestionably cor- 
rect. Outside of surgical experience, however, Flourens* and 
subsequently Ollier,f in that remarkable series of experiments 
which gained for him the grand prize of the French Academy of 
Medicine, demonstrated that Duliamel’s views were essentially 
correct and forced them into general acceptation. They would 
to-day scarcely need re-affirmation, but for the fact that Sedillot, 
the Strasbourg surgeon, who shared with Ollier the grand prize, 
has thrown all the weight of his eminent name against them. 
♦Theorie Experimentale de la Formation des Os. Par P. Flourens. 
Paris, 1847. See Review and Summary of this work in the Medico- 
Chirurgical Review, Volume L.T, October, 1S47, PaSe 42(J- 
fTrait<§ experimentale et clinique de la Regcnetation des Os, et de 
la Production artificielle du Tissu osseux. Par. L. Ollier. Paris, 1S67. 
Reviewed in Edinburgh Medical Journal for May, 1S67, page 1039-1122, 
and in the American Journal Medical Sciences, for January. 1S68, page 140. 
See also an excellent article on this subject by Dr. \V. R. Whitehead, New 
York Medical Journal, Volume XI, June, 1870, page 376. 5 
ITc asserts that when the periosteum is detached and isolated 
from the subjacent bone no growth of bone occurs. lie makes a 
distinction between the periosteum proper and a hypothetical 
plastic tissue underneath it, but declares that for all surgical pur- 
poses they aie practically one, and new bone will not be formed 
unless some portions of the old are left attached to the inner sur- 
face of the periosteum. Ou this he bases the advocacy of his 
well-known operation — V dvidemeut des os—the hollowing or 
scooping out of diseased bone. That this operation is valuable 
under some circumstances is doubtless true, but as to its congener 
—subperiosteal resection—it is quite unnecessary to quote the 
authorities, for the surgical records of to-day are full of instances 
of the absolute destruction and sequestration of bones in their 
continuity in which the structure has been renewed solely by the 
ageuev of the periosteal envelopes. It seems then to be a logical 
conclusion that subperiosteal resection is a good and safe surgical 
procedure, and I presume there are but few practical surgeons 
who would dispute this point. 
The osteogenetic property of other tissues, medullary, con- 
nective and muscular, which is so beautifully illustrated in the 
specimen taken from this patient, is now generally conceded and 
mav even be manifested in parts distant from bone though it is 
well known that the near presence of periosteal tissue sets up an 
increased tendency to the formation of bone. Of course this 
propertv is not of such great practical value in surgery as the 
allied power in periosteum, but its bearing on the repair of frac- 
tures especially in the long bones (as shown in the specimen 
before us) and more particularly its relation to certain well-known 
but rare pathological conditions is obvious enough. Such are the 
progressive ossification of the muscles; the costal osteophytes 
sometimes found in chronic pleurisy ; bony deposits in the iris, 
etc. Deposits of calcareous salts which are not true ossification 
may also be found in tissues far away from the bones; such 
deposits as well as the true bony deposits being the result of 
chronic inflammation. The osteogenetic power of medullary 
tissue like that of the periosteum is not lost even when trans- 
planted to distant parts, though of course we cannot avail 
ourselves practically of this power. Goujon* in his experiments 
demonstrated this and showed at the same time that such newly 
formed tissue was very apt to disappear soon by absorption. 
This accounts for Ollier’s failure to obtain bone from trans- 
planted marrow because he waited too long after the trans- 
plantation before examining the animals experimented upon. 
This property of medullary tissue is now conceded to be next in 
activity and power to that of the periosteum, and hence it is of 
the greatest importance in the repair of fractures in the hollow 
* Journal de l'Anatomic et de la Physiologic, 1S69, Number 4. 6 
bones by the formation of what may, with propriety, perhaps, be 
called an intra-osseous splint. 
Professor Feltz, of the medical faculty of Nancy, in some 
recent experiments upon the regeneration of bone has arrived at 
conclusions quite different from the generally accepted ones as 
given in the above brief and very general remarks. He holds 
that preliminary to the formation of bone, there is laid down by 
a process of direct genesis a soft grayish-white tissue* which may 
be called embryonic. This tissue histologically is analogous to 
that found in the stumps of limbs in the foetus in which the 
various anatomical tissues, whether temporary or permanent, 
develop themselves. This embryo-plastic tissue is not formed 
from the periosteum, for in the cases of scooping out, evidement, 
it is developed inside the bone itself, where it (the tissue alluded 
to) is separated from the periosteum by the osseous lavers which 
are left undisturbed and which continue to live. Furthermore, 
in the cases of entire resection of the diaphvses of bones, if this 
tissue were of periosteal origin we must admit the preliminary 
formation of a periosteum and then an ossification passing from 
without inward. Can we attribute the embryonic tissue to pro- 
liferation of the bone marrow in the large and small Haversian 
canals? If this were so we ought to be able to show the absolute 
identity between young—newly formed—marrow and the tissue 
of which we are speaking, but neither the histological characters 
nor the chemical reactions permit any such assertion. Further- 
more, if ossification were dependent upon the soft medulla 
reformed under the influence of the traumatic irritation, we can 
not readily comprehend why the new bone does not encroach 
both on the central medullary canal and on the Haversian canals 
which are opened in the sections and in which marrow reforms 
at the very outset of the work of reparation. Thus, excluding 
these sources as the origin of this embryo-plastic tissue, Dr Feltz, 
if we have rightly comprehended his views, suggests that it is the 
result of a direct genesis resulting from the -traumatic irritation. 
Even this, however, it seems to us, fails to show the constant 
relation which must obtain between the embryo-plastic tissue, if 
any such exists, and the development in it of bone cells, so that it 
is necessary to introduce some additional factor which after ;dl 
guides the development. May not this be, in accordance with 
the older views, the near presence of the periosteum or ti e 
medullary '.issue? Dr. Feltz’s views are so interesting that I 
have thought it advisable to add this brief summary of them evtn 
though they may not command ready assent. His paper '.s 
published in the Journal de l'Anatomic ct de la Physiologic. 
1876, page 375. 
* Haller long ago taught that in the formation of bone there is first a 
jelly-like tissue which gradually changes into bone passing through the 
stage of cartilage. Is not this identical with Feltz’ embryonic or embryo- 
plastic deposit?