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CONTRIBUTIONS
BONE AND NERVE SURGERY.
       /by
      i /
  J. C. JgOTT, M.D.,
PROFESSOR OF SURGERY IN MOBILE MEDICAL COLLEGE.
    PHILADELPHIA:
J. B. LIPPINCOTT  & CO.
       18 66. 
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    Entered, according to Act of Congress, in the year 1865, by
          J. B. LIPPINCOTT & CO.,
In the Clerk's Office of the District Court of the United States for the Eastern
            District of Pennsylvania. 
PREFACE.
   This little volume is intended simply as a contribution
 to a department of surgery which has been  strangely neg-
 lected, and in which there is a remarkable want of medical
 literature, viz.,  the sequelae of gunshot and other injuries
 of bones.
   We  have works in profusion on field surgery,  primary
 and secondary  operations,  organization of  hospitals, camp
 diseases,  etc., but little on the  class  of cases to  which  I
 ask attention.
   Although the war has been over for some months, there
 are  still  thousands of soldiers  scattered  throughout  the
 United States who are suffering from  injuries  of bones,
 and for years to come many of them will be seeking sur-
 gical assistance.  I have been  called on to treat a great
 many such  cases  and not a few of  them dating  their in-
juries  back two, three, and even four  years,  to  the first
 battle of Manassas.
   The  principles I  have  endeavored  to   inculcate  are
                                             (iii) 
IV                      PREFACE.
equally applicable in civil  as  in  military surgery, and if I
can aid in directing other minds to this important field,
my object will be fully attained.
   The cases of injuries of nerves appended are probably
unique, and  cannot fail  to interest  the  Physiologist and
Pathologist.
                               J. C. NOTT, M.D.,
                        PROFESSOR OF SURGERY IN MOBILE MEDICAL COLLEGE.
1st November, 1865. 
             CONTRIBUTIONS
                      TO

BONE  AND  NERVE  SURGERY.
  The civil war just terminated,  after four  years of
bloody strife, has left the land filled with wounded sol-
diers, in all its length and breadth, dating their injuries
back to the various battle-fields,  from the beginning to
its close; and from the nature of many of the injuries,
it is evident that there will be much work for  surgeons
during the next year  or two to come.
  These chronic cases are accompanied almost invari-
ably by fistulous openings, which have been kept dis-
charging by the presence of dead bone,  balls, fragments
of shell, pieces of clothing, or  other foreign  bodies—
the first cause being by far the most frequent.
  The pathology  and surgery  of  gunshot  injuries of
bones have therefore become subjects, for the first time
in  our country, of the highest  importance, while our
army  surgeons, as a  class, possess but  meager attain-
ments to meet the demands made upon them.
  Not only has little  attention  been paid  to gunshot
wounds in the  schools of America, but if  we turn to
the medical literature of Europe, a great deficiency will
be found in  connection with those  chronic  injuries of
which I am about to  speak.  Guthrie, McLeod, Ballin-
gall, Hennen, Baudens, Dupuytren and other writers on
military surgery, have well covered the  ground of what
                        1*              (5) 
6
BONE  AND NERVE  SURGERY.
might be  called 'primary and  secondary surgery;  but
here they stop, and we are left to grope our way in the
dark in tertiary surgery.   None  of them follow up the
shattered and  diseased bones for months and years, and
give us well-defined rules  by which we  are enabled to
treat this large class of tedious, painful, and  dangerous
gunshot sequelae.
  It is  true that many of our standard works  in civil
life, as those  of Stanley, Miller, Vidal  de Cassis  and
others, give us much information  and many useful gen-
eral principles of practice; but the principles and prac-
tice laid  down in  these works are mostly drawn from
observations made  on  diseases of bones connected with
some vice of the system, as scrofula, syphilis, rheuma-
tism, etc., and the surgeon  who  turns his  attention to
the subject at this time will  soon discover  that bone
pathology and bone surgery are  but in their  infancy.
Gunshot wounds have introduced a new class of cases
among us, which makes it absolutely necessary that the
whole subject should be thoroughly worked over.
  My object at present is not a regular monograph, but
simply to blaze out a  few prominent land-marks in the
wilderness  to assist the explorer in finding his way.  As
I am writing more particularly for the instruction of the
younger members of the profession, I deem it proper, at
the risk of being charged with prolixity, to  give a re-
sume* of those facts and general principles of bone pathol-
ogy and practice bearing on the points to be elucidated,
that may  be  found scattered  through our systematic
works.  This  will  be followed  by the practical applica-
tion of those principles and the results of my own obser-
vations.  It will therefore be convenient to divide the
essay into  Parts I. and II. 
PART   I.
  The osseous system is subject  to an  infinite variety
of injuries and affections, which authors have found it
difficult to classify in  a  satisfactory manner.  Besides
fractures and dislocations, there are many forms of dis-
ease, which, although interesting and important, do not
come within the  scope of our present inquiry, as they
belong more to the province of civil than military sur-
gery, and would, moreover, extend this essay far beyond
its proposed limits. For example, hypertrophy, atrophy,
softening, fragility, scrofula, gout, rheumatism, cancer,
syphilis,  hydatids, scurvy,  aneurisms, etc.  All  these
may come  under  the  eye of the army surgeon, and not
unfrequently complicate  gunshot injuries, and therefore
demand his attention.
  My especial object is  to  draw attention  to  the rise,
progress, and  results  or  events  of  simple inflammation
in the osseous tissue as witnessed  by the army surgeon
after gunshot injuries.  In this  connection I shall com-
mence  with simple Periostitis,  Endostitis,  and Ostitis,
or, in other words, inflammation of the  periosteum, the
endosteum, and of the substance of the bone itself, all
of which are so closely connected in structure and func-
tion as to partake readily of each other's diseases.  They
should be studied  separately and in connection, and no
student  can hope  to make a surgeon until  he has mas-
tered this department of pathology.
                                           CO 
8            bone  and nerve  surgery.
                     Periostitis.

   The periosteum is a white, fibrous, membranous cover-
ing, which surrounds the bones  everywhere except the
articular  surfaces covered  by cartilage.   Its external
surface is united, in a more or less intimate manner, to
the  surrounding structures  by connective tissue.  Its
inner surface  covers the bone, whose  depressions it ac-
curately follows.  It is united to the bone by delicate
fibrous prolongations, and especially by numerous vessels,
which penetrate  its  substance.   The periosteum unites
the bones to  the neighboring parts;  it assists greatly
in the growth of bones, and  is mainly instrumental in
their reproduction in cases  of fracture and  other in-
juries.                                            I
   With such  structure  and  functions it will be readily
understood that the periosteum is liable to inflammation
of all kinds and grades, whether simple or  specific, and
that the part it plays in the practice of the  military sur-
geon is a very important one.  The bone and periosteum
being so  intimately connected, it is rare  that one in-
flames without involving  the  other.  Periostitis soon
implicates the bone, producing ostitis, and in like man-
ner  ostitis soon involves the  periosteum.   Cold, gout,
rheumatism, syphilis, etc. often produce periostitis ;  but
for these  forms  we refer the  reader to surgical works,
as we  are now treating periostitis  and  ostitis  arising
from gunshot wounds, as seen most commonly in army
practice.
   In acute periostitis, the fibrous membrane presents all
the  characteristics of  acute inflammation; it  becomes
highly injected;  the blood-vessels  are engorged; it is 
PERIOSTITIS.
9
red,  thickened, and softened from interstitial deposits.
Its attachment to the bone is diminished;  it is readily
peeled off,  and the connective tissue surrounding it is
infiltrated with sero-albuminous matter.
   Periostitis not unfrequently  runs into  suppuration,
particularly in the bones of the  lower extremity, as  the
tibia and femur, and in phalanges of fingers.  Mortifi-
cation is not an unfrequent termination of this affection,
and  is characterized  by the dirty, ash-colored appear-
ance of the affected membrane, its texture being broken
down and  emitting  a very offensive gangrenous odor.
The  death of the periosteum coming on in  this way,
generally results  in the death, to a greater or lesser ex-
tent,  of the corresponding part of  the  bone; but  the
depth to which the  necrosis  extends differs  greatly in
different cases, and we have no  data by which we  can
determine a priori the extent or depth of the injury to
the bone; the mere surface of the bone  may be thrown
off by insensible  exfoliation, or the  death may involve
any  extent, from the  surface to the entire thickness.
   The son of  a friend, Dr. F. M. Ross, received a slight
flesh wound from a minie'-ball on the back of the fore-
arm,  which was followed by severe  hospital gangrene;
the slough extending from an inch of the wrist to within
an inch of the elbow-joint, and destroying  all the mus-
cles on the back and  sides of  the limb, leaving only the
muscles lying  on the anterior  aspect of radius and ulna.
The  radius was laid  bare and its periosteum  destroyed
for about three inches; the ulna was also laid bare some
two weeks  later, but only to the extent of one inch. The
surface of  the radius  turned  black, and a  thin leaf of
bone, not thicker than  paper, was  thrown off, leaving
healthy granulations  below.   From  the exposed surface 
10
BONE  AND NERVE  SURGERY.
of the ulna, which was of an ivory white, no exfoliation
ever took place;  the  granulations from the circumfer-
ence of the ulcerated surface around the bone gradually
closed over and coalesced; the parts healed up solidly,
contrary to my expectation, without any  sensible ex-
foliation.
  I am  now visiting a stout mulatto man, in  consulta-
tion with  Surgeon Richards, U. S. A., who had a large
portion  of the triceps muscle of the arm torn  off by
a piece  of  shell, exposing  the humerus  for  an inch;
some sloughing, and very copious suppuration occurred,
and the  periosteum was removed over the exposed part
of the bone; the injury  was so severe, and the  condi-
tion of the wound so bad, that  the arm was condemned
to amputation at one  time,  but was  spared.  It is  now
nearly healed; healthy  granulations sprung from the
bone without any apparent exfoliation.
  I have  also under treatment a third case, in the per-
son of one  of my friends, Mr. Alexander  Campbell, of
Mobile.   In this case acute periostitis occurred to the
extent of three inches on the  front of the  tibia without
injury or assignable cause, supposed to be from cold.
The case went on to  suppuration beneath the perios-
teum, and he experienced, for  several weeks, all  the in-
tense suffering that usually attends such cases.   My
first visit was  in  consultation with another  physician,
and the fluctuation being distinct, at my suggestion the
abscess was  laid open;  the pus being beneath the perios-
teum, and the  surface of the  bone  being  rough to the
probe, I concluded that exfoliation would take place,
and accordingly stuffed the wound with lint to facilitate
both the discharge of pus and  the exfoliation.
   In the  first two of the above three cases, the perios- 
PERIOSTITIS.
11
 teum was destroyed by disease extending to it from the
 surrounding ulcerating and sloughing tissues; and there
 was every reason to expect that the bone would exfo-
 liate, as this  is  the  course usually pursued  by nature
 where the  periosteum is  removed  by ulceration.  No
 sensible, and I think  no insensible exfoliation  took place
 in these two cases where the granulations sprouted up,
 and I believe  that the internal circulation of the bone
 made its way to the surface and threw out healthy gran-
 ulations, which soon adhered to those of the soft parts
 closing over them.
   In the third case, the bone did ulcerate, and I passed
 a probe through the  covering granulations and into the
 medullary cavity directly  through its anterior wall.
   It is clear from these cases that  death of the perios-
 teum may  or  may not  involve the corresponding sur-
 face of bone  in  necrosis, and  that  we have  no  certain
 criteria by which we  can predict the involvement of the
 bone.   In the great majority of cases when the perios-
 teum dies, the bone  beneath  exfoliates to a  greater or
 lesser extent, and the same law holds with greater force
 in disease of the endosteum.
  Periostitis,  as seen in  civil  practice, is usually very
 different from that which the army  surgeon has  to deal
 with; it is there most commonly the offspring of syphi-
 lis, gout, rheumatism, scrofula, with a strong tendency
 to the destruction of tissues and requiring specific treat-
 ment.  In army practice, on the contrary, the periostitis
 to which I refer is the result of gunshot injuries which
 rudi ly contuse the  periosteum, or when more severe
lacei ate it, and at the same time fracture and splinter
the bones.   In these cases high inflammation ensues in
the periosteum, in the bone and surrounding tissues, ac- 
12
BONE  AND NERVE  SURGERY.
companied by suppuration, acute abscesses, etc.  Slough-
ing to some extent both of soft parts and bone necessarily
follows in the great majority of cases.
  When struck by a  ball, the  periosteum inflames at
the injured point,  and in consequence of the unfavor-
able  circumstances under which the wound is generally
treated  (bad  air, bad diet, cold, heat, neglect, etc.), un-
healthy inflammation not unfrequently is set up in the
periosteum, which  travels along the shaft of the bone,
involving a part or its  entire length.  I have before
me a beautiful  specimen, presented to me by Dr. H. A.
Schmidt, of diseased bones of the arm and forearm, suc-
cessfully amputated by him just below the insertion of the
pectoralis major.  The patient, a soldier, received a blow
from the butt of a gun on the olecranon process, which
fractured it.  Violent inflammation seized on the elbow-
joint ; next the periosteum of the humerus took on the
same action,  extending to  the head;  the bone formed
one solid sequestrum  in  its whole length, and was sur-
rounded by a covering of new bone,  one-fourth of an
inch thick, thrown out by the periosteum, and  having
nine openings, through  which  pus  exuded,  connected
with fistulous channels opening on  the  surface.   The
ulna was diseased in like manner for half its length.
   This  case beautifully illustrates the intimate  connec-
tion  existing  between periosteum and  bone;  the exten-
sion  of disease from one to the other, and the disposition
in some cases of the inflammation to  extend by conti-
nuity along a bone.   This kind of traumatic periostitis
is usually rapid in its  course at first, causing the death
of a portion  of the bone, and not unfrequently becom-
ing chronic, and working on for months or years. 
PERIOSTITIS.
13
   The following is the excellent description by Vidal de
Cassis:

   " In the first degree of inflammation, the  periosteum is
only injected, without sensible thickening; the surrounding
cellular tissue partakes of this injection as well as the bone
itself; the periosteum adheres lightly to the bone and is
detached with facility, as may be seen in the  stump of one
dead  after recent amputation.   Later,  the  periosteum is
redder and thickened;  it is infiltrated with fluids and is
more  easily peeled off  from the  bone it covers.   If the in-
flammation  becomes chronic, this  membrane is  less red;
becomes thickened;  more dense, and adheres firmly to the
bone.
   "If the periostitis continues, it becomes further  thickened
and is the seat of  osseous deposit.   By suppuration, the
periosteum is  thickened and covered with fungous granula-
tions.   Pus, moreover, may be poured out,  by either the
external or internal surface.   If there  be a neighboring
abscess, the membrane is at first thickened, and opposes for
a time a barrier to the  product of the suppuration ; but by
degrees it inflames, makes a part of  the abscess, suppurates,
and at length is destroyed, and the pus reaches the bone. It
is in  this way that an  abscess frequently terminates by at-
tacking a  bone.  Something very similar takes place in
chronic ulcers, situated over superficial bones, as  the tibia;
but more often there  is  hypertrophy,  ossification  of the
periosteum, and a kind of flattened exostosis of  the tibia.
In other cases, the  pus commences  to  form between the
periosteum and bone;  the bone is  then involved, and the
suppuration forces its way through  the periosteum, involv-
ing the superimposed tissues, and makes its way toward the
surface."—Pathologie Interne.

   The above facts make  evident the danger of abscesses,
even in the vicinity of bones, and  the necessity  of evacu-
ating pus  early to prevent its extension and complica-
tions.   When  pus  forms beneath  the periosteum, it has
a tendency to  accumulate and separate the  periosteum
                           2 
14           BONE AND NERVE SURGERY.
to an indefinite  extent from  the  bone, and thus cause
necrosis; while abscesses  external to the bone  have a
constant tendency to involve the periosteum, and through
it the bone itself.   After  gunshot wounds particularly,
we  see  the  periosteum  and  bone becoming more  and
more  involved from the  burrowing of matter  and de-
structive ulceration, all of which  may generally be pre-
vented by early and free openings, with the use of tents.


            Endostitis, or Osteomyelitis.

  The medullary  membrane, periosteum internum, or
endosteuin, are names which have  been given to a vascu-
lar  areolar web of extreme tenuity, which envelops the
marrow and lines the inner  surface of  the medullary
cavity of the long bones, and  which has been considered
as the internal periosteum of those bones. It has  numer-
ous vessels  which bury themselves in the  thickness of
the marrow, and  others  which nourish  the innermost
plates of the bones.   The function of this membrane is
similar  to that of the external covering of the bones;
it is also liable to inflammation, which often results in
the death  of  the portion of osseous tissue nourished
by it.
  The cause of endostitis is usually traumatic, being
the result  of  fractures,  gunshot wounds, lodgment of
foreign bodies in the bones, violent contusions, laceration
of endosteum  by the saw  in  amputations, etc.   A com-
mon predisposing cause is a  disordered or vitiated con-
dition of the system, and it is often the result of abscess
from injuries communicating with the medullary cavity.
We occasionally  have an opportunity of studying the 
OSTITIS.
15
 morbid anatomy of endostitis, in the long bones, super-
 vening on amputations.  Some days after the operation,
 the membrane is seen to be injected and  thickened, the
 marrow softened, with a sero-sanguineous discharge from
 the medullary cavity.  The inflammation progresses; the
 vascularity  increases, and  the  discharge  becomes puru-
 lent; the membrane after a time sloughs away; the  dis-
 charge is fetid, and the external periosteum detached,
 and the bone dies in its entire thickness.
   The symptoms of  endostitis are obscure and unre-
 liable, resembling closely those of inflammation of the
 bone or periosteum.  When it occurs after amputations,
 where the disease is open to view, we may then connect
 the lesion and  symptoms together; but where  the  dis-
 ease is concealed,  we are often left to conjecture.  The
 constitutional symptoms are usually severe, accompanied
 by rigors, hectic,  sweats, prostration, terminating often
 in fatal pyemia.

                       Ostitis.

   As before remarked, inflammation of the  external or
 internal periosteum  necessarily involves more or  less
 the bone, and  inflammation of  bone in like manner is
 readily transmitted  to these membranes, which supply
 its  nutrient  vessels.   Ostitis may affect only the outer
 plate of a bone, as in cases of  slight contusion from a
 ball or other blow; at other times  it implicates the in-
 ternal surface alone;  while in a third class the entire
 thickness of  the bone is involved.
  The causes are the same as those enumerated for  the
production of periostitis.   Ostitis may result in ulcer-
ation  simple or carious; in necrosis;  or the action may 
16           BONE  AND  NERVE SURGERY.
be  of a lower  grade, leading  merely  to  a change  of
structure.*
   I shall never forget a blunder I made thirty-five years
ago, the first year of my practice, at a time when little
was known or taught of bone pathology in this country.
   A negro man was brought to  me from the country,
with a painful  enlargement of the tibia, of several years'
standing,  and  without any  assignable cause.   On  ex-
amination  I found the bone  enlarged to double  size; it
was warmer than natural; was often  the  seat, partic-
ularly at night, of severe pain, and incapacitated him
for any prolonged labor, although he  was  a  good  por-
tion of  his time moving  about.   He  had received no
injury that he  recollected; had  no scrofulous or syphi-
litic taint; there  had  been no ulceration, abscess, or
purulent discharge of any kind,  and no evidence of any
disease but simple inflammatory  hypertrophy.
   In the fullness of my pathological ignorance,  expect-
ing to find necrosed bone, I cut dowTn upon  the enlarged
shaft of the tibia at its most prominent point, about the
middle, and chiseled off a portion of what I supposed to
be  a cortical formation,  within which I expected to find
  * The periosteum, we have seen, is freely supplied with blood-ves-
sels from the surrounding tissues. The endosteum is also freely sup-
plied in the long bones mainly through the nutritious arteries which
perforate the  shaft, get to the medullary cavity, and ramify freely
up and down  through its whole extent.  The substance of the bone
itself, receiving vessels from both these sources, is exceedingly vas-
cular, as may  be seen by injecting it through either of the above sets
of vessels.   The extremities  of the bones particularly which are
spongy in structure are very liberally supplied with  blood.   The
anastomoses of  the vessels of the periosteum, the endosteum, and
bone are very free, and it is therefore easy to comprehend how in-
flammation passes readily from one to the other. 
OSTITIS.
17
a sequestrum. But my surprise and mortification may be
imagined  when I failed to  find dead bone or internal
suppuration.  The bone being rarified,  its blood-vessels
greatly enlarged  and multiplied  in  number, the blood
oozed from every pore of the chisel-cut,  as it would from
any other inflamed tissue, and I for the  first time dis-
covered that I had to deal with structural change, from
chronic inflammation, falling short of caries or necrosis.
   I learned an important lesson from this case when I
came to study it out, and I relate it for  the  benefit of
the young surgeon, as  I have witnessed many similar
blunders in  others since.  The lesson was this: where-
ever caries or necrosis exist, there must be suppuration ;
and this  suppuration must be revealed, after a certain
time, by the presence of one or more  sinuses,  leading
to the dead or dying  structure.  I learned, moreover,
never to cut down upon a bone before there is evidence
of the existence of pus.
   Change of Structure.—-This, we have already hinted,
is one of the results of inflammation,  and may attend
the latter either in its simple or specific forms.  In this
grade  of  morbid action, the bone is at  first softened,
apparently by absorption of a portion of its earthy mat-
ter.   The texture at the same time  becomes more open
and spongy; its surface presenting a porous appearance,
as if the enlarged  vessels  had  pushed aside  the solid
structure. The bone itself becomes expanded,  enlarged,
vascular and less dense. As the action becomes chronic,
lymph is deposited, becomes organized, transformed, and
there is condensation and induration of structure.   The
bone becomes larger, heavier and more dense, resembling
ivory.   The bone is now less  vascular, is impaired in
vital power,  and therefore less likely to resist a reacces-
                         2* 
18           BONE  AND  NERVE  SURGERY.

sion of inflammatory process.  Liability to suppuration,
ulceration, and  necrosis is  increased.   If the morbid
action ceases, and  care  be  observed,  in the  course  of
time nature does much toward restoring the bone to its
normal condition, although it never regains its original
dimensions.
  The symptoms are very like  those of periostitis;  deep-
seated pain,  with nocturnal  exacerbations;  puffiness;
tenderness; redness;  fever, etc.   The  treatment, like
that of periostitis, is antiphlogistic, with iodide of potas-
sium and mercury.
  Suppuration  of Bone.—When acute periostitis  oc-
curs, the subjacent  bone is soon involved in the inflam-
matory action;  effusion  takes  place  between;  if the
vascular  action  runs high,  abscess is there inevitable,
and such cases are common from gunshot injuries. Pain
is excruciating;  distinct rigors  usually accompany the
formation of  matter;  swelling  follows, and ultimately
fluctuation, with redness and all the signs of superficial
abscess.
  In those cases of periostitis  accompanied by  severe
pain and  effusion of serum and lymph, with tendency
to suppuration, it is proper  to make a small opening at
the lower part of the swelling,  introduce a probe-pointed
knife flatwise, pass  it along  between the skin and peri-
osteum to the upper border of the swelling, then turn-
ing the cutting  edge toward the periosteum, and while
withdrawing  the knife,  divide  the  periosteum  subcu-
taneously down  to  the bone through the whole  extent
of the swelling.  By this procedure, tension of the peri-
osteum is taken  away, pain  is greatly relieved, and an
exit given for pent-up fluids, which are causing pain and
tearing up the periosteum from  the bone.   If this had 
OSTITIS.
19
been  done sufficiently early in the case of Mr. Camp-
bell,  above  related, most  of the suffering and  loss of
time  would  have  been saved.  A subcutaneous cut of
this kind can  never do harm, and is often productive
of great good.  If pus has already formed, it is only a
stronger reason for  making  an  opening; but where we
are sure that suppuration has taken  place, it is better
to make a free incision with a bistoury through the skin
and other tissues down to the bone, stuff it with lint,
give the pus free exit, and allow the wound to granulate
from  the bottom.   The bone may exfoliate, but if  it
should, this is still the best practice.
   When in such  cases the matter is easily discharged
by a  free opening,  the ulceration of  the  bone  ceases;
the surface becomes healthy; granulations spring up,
and cicatrization  follows.   If the incision be omitted,
the matter burrows; the disease extends in every direc-
tion;  the patient suffers intensely, and the constitution
deeply sympathizes.  The periosteum  is gradually sepa-
rated from the bone by lateral extension of the abscess;
the bone dies from the  want of its accustomed supply of
blood through its investing membrane,  and the pernicious
effects of putrid pus in contact with it.  The periosteum
becomes more  or less  destroyed  by  ulceration, and  a
probe introduced through the  external  opening  will
readily detect the denuded and roughened bone.
   Instead of forming on the surface as above described,
small circumscribed abscesses occasionally form in the
substance of bone, and particularly in the cancellated
structure of the extremities  of long  bones,  and more
particularly in the tibia.  The intense local pain, ten-
derness  on firm  pressure,  constitutional  disturbance,
sleepless nights, etc. declare  the seat and nature of the 
20
BONE  AND NERVE  SURGERY.
 affection, and a trephine should be  applied, which by
 the discharge of a  small quantity of pus affords immense
 relief.
   Instead of a circumscribed abscess, the inflammation
 being  of an asthenic or unhealthy character, suppura-
 tion pervades the internal, particularly the cancellated
 structure, resulting in the destruction of bone, and often
 death, through hectic fever and pyemia.   On the other
 hand, cases occur  in which  the most violent acute in-
 flammation  seizes  upon the  bone, pervading  the whole
 thickness and leading rapidly to necrosis.  The pus not
 only burrows beneath the periosteum, but diffuses itself
 through  every pore of the portion of bone attacked, and
 implicating  the neighboring soft parts, works its way to
 the external surface.  If a bone be sawn through in this
 condition, pus is seen  everywhere  oozing out from the
 cut surface.
   Ulceration of Bone.—This may be simple and manage-
 able like a simple ulcer in the soft parts, or peculiar and
 difficult to cure as  in caries.
   Simple ulcer of  bone is the product of simple inflam-
mation, however induced, and although  it occurs  with-
out contact of air, it is likely to be  aggravated by its
presence.  I am  satisfied  that an  exposed,  ulcerating
bone,  when  well protected from the  air constantly by
wet lint or cotton, generally extends less and granulates
sooner, than when  not thus protected.   As soft tissues
may inflame, suppurate, and  ulcerate, so may bone, the
inflammatory process originating in and being nearly
limited to the ulcerated part.  Not unfrequently, how-
ever, the  site  of the ulcer is not that which  was pri-
marily,  but  that which  is  secondarily  involved.   An
abscess, occurring  either by  ostitis  or by inflammation 
OSTITIS.
21
of neighboring  soft textures,  compresses a portion of
bone not originally inflamed, and thus induces its molec-
ular destruction.   Such pressure may come from with-
out or within; the  abscess may form in the soft tissues
and cause ulceration on the surface of the bone, or sup-
purative ostitis having occurred in the cancellated struc-
ture, and the pus making its way outward by ulcerative
action, in obedience to a general law, an  opening in the
bone  is formed.   A minie'-bail, for  example, may  pass
through the fleshy part  of the thigh or  leg, without
touching the bone, and an abscess will form, extending
down to the periosteum, then  to the  bone itself, pro-
ducing in some cases  simple superficial ulceration of the
surface of the femur or tibia.   Or if the action be more
intense, and the  constitution  deranged, necrosis  may
ensue in a large portion of the shaft of the bone.  If
the suppuration be near either  extremity of the bone,
implicating  the  cancellated structure, destructive ulcer-
ation is apt to  involve not only the head  of the bone,
but the neighboring articulation, requiring amputation.
   So long as pressure from the swelling or accumula-
tion of  pus  continues, ulceration advances with more or
less rapidity, but ceases on its  removal, and the process
of repair commences;  healthy granulations sprout up
from the ulcerated surface of the bone, as from the sur-
face of  an ulcer in soft parts, and are  slowly converted
into bone;  thus supplying  to a  considerable extent the
part destroyed by ulceration.   All  this is the result of
simple inflammation,  identical  with that of soft parts,
and requiring the same general principles of treatment. 
22           BONE AND NERVE SURGERY.
                       Caries.

  By this term  we designate a morbid  action of very
different character.   It may follow simple inflammation,
but more frequently it is primary.  Although not ma-
lignant, it is  something  more than what is called weak
ulcer  of  bone, and is a  term which has been far too
loosely and indiscriminately employed.
  Caries is a breaking down  of the structure  of bone, a
peculiar action,  which, left to itself,  is almost incapable
of cure.   In dense bones it is preceded by  interstitial
absorption, which gradually softens  the  structure; but
it is in the cancellated  structure, as  the extremities of
long bones, and  the carpus and tarsus, that this morbid
action is most commonly seen.
  The margins  of  the   cavity in  caries have not the
abrupt and firm  character of simple  ulcer, but are soft,
spongy, and worm eaten in appearance, without  defined
limits. It has no adequate power of  reparation; it may
be open and uncovered, giving a crumbling sensation to
the probe when  introduced into it, like a loaf of bread
or  piece of decayed wood;  or it may be covered by
tall, flabby  granulations, incapable  of  transformation
into bone.   The ulcerative process  is usually chronic,
and the  destruction of bone slow, though  sometimes it
is  acute  and rapid.   The whole of  a  small  bone, even
the whole of a  chain of  small  bones, or all  the articu-
lating extremity of a long bone, may be attacked, or a
thin external portion alone  may suffer.   A  thin, fetid,
purulent discharge, often bloody, always acrid,  usually
more or less mixed with ulcerative de'bris, and often con-
taining small detached sequestra, exudes in considerable 
CARIES.
23
quantity.   The surrounding soft parts are swollen, in-
filtrated, and broken up by suppuration.   One or more
openings take  place in the integuments,  presenting the
characters of a weak, scrofulous, or irritable  ulcer.   A
probe  passed  in through  these  apertures reaches  and
penetrates the softened bone.   Caries may be  simple,
scrofulous  (tubercular), or syphilitic.   The first is the
variety I wish  to call  attention particularly to, as most
frequently seen  by the  army  surgeon in the  spongy
bones of carpus, tarsus, and extremities  of long bones,
from  gunshot  wounds.  Persons of strumous  or syphi-
litic constitutions are, of course, more liable to caries;
but yet it is often seen as a  consequence of  wounds in
others,  particularly in hospital  practice,  where the  air,
diet, etc. are bad.  Under all circumstances, the consti-
tution is liable to suffer severely.
   The treatment requires  much  tact and care when  de-
veloped, and the surgeon should use all his skill to pre-
vent it.   When inflammation occurs in  the  soft parts
covering bone, or in the periosteum or bone itself, active
antiphlogistic  treatment  should  be adopted,  together
with  perfect  quiet  of the  part.   When suppuration
occurs, the matter should be evacuated  early, and  the
treatment  for  acute  abscess  and ulceration  be rigidly
pursued.   The condition  of the  system should be care-
fully attended  to.  If action runs too high, deplete; if
too low, give tonics, generous diet, etc.   If it be scrofu-
lous or syphilitic, appropriate specific remedies must be
employed.  In army practice the supporting treatment
is  almost invariably called for.
   After caries  has fairly set in, there is no alternative
left but removal of the diseased  bone by surgical inter-
ference. All the disorganized parts should be removed, 
24
BONE AND  NERVE SURGERY.
and the  surgeon must  not stop until  he reaches per-
fectly sound bone, from which granulations may sprout.
When  this is done, the  part may be treated as a simple
ulcer.
  A very important rule in these operations is too often
overlooked, and instead of  good much  harm is done  by
the ill-timed interference, viz.:
  " No operation of any  kind should be  performed  on the
bone, unless the adjacent and superimposed  soft parts are
in a quiet state.  They may be undergoing the acute inflam-
matory process ; they may be the seat of acute suppuration,
of acute ulceration, or of both; and the removal of a portion
of bone imbedded in such parts is almost certain not only
to prove futile as a means of cure,  but actually to aggravate
and extend the disease.  The carious portion of bone may
be taken away, but ulceration, instead of  reparation, is cer-
tain to ensue, and, by rapid degeneration, the carious con-
dition is renewed.   Or a more intense  and general  ostitis
is kindled,  and the partial  caries  is  merged  in general
necrosis."
  Too much weight cannot be given to the above general
rule laid down  by Professor Miller, of Edinburgh, in  his
Principles of Surgery.   I have again and again seen it
violated  to the great injury of  the patients, during the
recent war, both in caries and necrosis.
  After  proper treatment  has  been  pursued, sufficient
time has been allowed for inflammation and suppuration
to subside, and the acute sensibility of the soft parts has
disappeared,  a  free incision should be made, so as effect-
ually  to expose  the diseased  bone, and by the saw,
trephine, bone  pliers, or gouge,  it should be thoroughly
removed.  The articulating surfaces of long bones  are
managed best  by the  saw; in the  flat bones, as  the
cranium or scapula, the trephine is  often most  conve-
nient; while in the shaft of long bones, in the bones of 
NECROSIS, OR DEATH OF  BONE.          25
the tarsus, etc., the gouge is  most efficient.   In some
cases where the disease cannot be well circumscribed by
cutting instruments, escharotics,  as chloride of zinc, red
precipitate, or caustic potash, may be substituted.
   For  information respecting caries  in those parts of
the  skeleton  not  accessible  to  the  knife, as chronic
affections of some of the large joints, vertebrae, pelvis,
we refer the reader to surgical works.   The  army sur-
geon is rarely  called on to treat ihem.
   Where the carpus or tarsus is deeply involved, com-
plete excision is the only reliable remedy;  and for the
application of this remedy to the wrist,  the reader is re-
ferred to an admirable article in  the July number (1865)
of the London Lancet, by Mr. Joseph Lister.   To make
the operaiion  effective,  he recommends that  not  only
the  whole  carpus,  but  the  articulating  ends  of the
radius,  ulna, and the bases of  all five metacarpal bones
be removed.

             Necrosis,  or Death of Bone.

   The  vitality  of  a bone may be destroyed in a  few
seconds by fire, or strong acids,  etc.; usually, however,
it is the indirect result of injury, the  bone perishing by
violent  inflammation.*   When unaccompanied by  any
  * The  causes of necrosis are all those already enumerated for
ostitis and periostitis.  The following instance from Mr. Stanley's
work is curious and interesting.
  In enumerating the causes of necrosis, Mr. Stanley makes  the
following interesting  statement:  "During the progress of  fever,
necrosis of the shaft of a long bone has occurred without any evi-
dence of  previous inflammation, either in the periosteum or medul-
lary tissue.   And here it might be suggested, that the inflammation
and death of the bone are analogous phenomena to the local con-
                           3 
26
BONE AND NERVE  SURGERY.
other form of disease, it is said to be simple. Compound,
on the other hand, if combined with caries, or attendant
on fractures, as often  seen in gunshot injuries.   When
consequent on wounds, or  other  external injury, it is
called traumatic; and idiopathic when arising without
assignable cause.  Often, in the young, a bone is acutely
inflamed without  any apparent  reason,  and rapidly  be-
comes the seat of suppuration and dies to a greater or
lesser extent.
  Necrosis may also be either acute or  chronic, accord-
ing as the inflammation which leads  to it assumes one
or the other type.  In one  sense,  necrosis  is  always
chronic,  for the separation of the dead from living bone,
and  the  formation of  a substitute always  requires  time,
while the inflammation may be of low grade.
  Necrosis differs greatly in its extent—a mere leaf or
scale may be thrown off  from the  surface, and this is
called exfoliation.  A larger portion  of  the compact
structure may die, or this may retain its vitality  while
the cancellated interior perishes.    The  dead portions
or sequestra  are called  external or internal accord-
ingly, and  like  terms  are  applied to  the  necrosis.
Again,  the  whole thickness  of the  bone dies  in one
continuous mass, and the  disease  is then said  to  be

gestions and inflammations occurring, under similar circumstances,
in other organs.  In a young female, necrosis of the entire shaft of
the tibia occurred during,an attack of fever, from which she died in
about a month from its commencement.  I found the tibia through-
out its osseous substauce of a deep-red color, while the medullary
tissue was unaltered.  But that the bone had perished was evident,
by the entire separation of  the periosteum from it, and by the lines
of separation commencing between the  shaft and articular ends.
Here,  therefore, it appeared that inflammation in the tissue of the
bone had preceded its necrosis." 
            NECROSIS, OR DEATH  OF BONE.         27

general.   This general necrosis differs much in extent,
involving a part or even the whole of the femur or other
long bone.
   It  is seldom, however, that the  entire bone suffers;
usually the articulating extremities  remain, the line of
separation occurring about the position of the epiphyses.
This fact is well known to surgeons, and it is fortunate
that it is so;  the process of reproduction is  thereby
facilitated and the joints are saved from all the horrors
of disorganizing articular inflammation.
   The cancellous portions of long bones, and the smaller
bones of spongy  structure, as those of  the  carpus  and
tarsus, are most liable to caries, while the compact por-
tions  are the  common seats of necrosis, and  this ac-
counts for the fact that the  latter kind of action stops
at the articulating extremities of the long bones.  The
extremities,  however,  are not  exempt  either from in-
volvement in general necrosis of the shaft, nor from the
disease  occurring in a more  limited form within them-
selves.   It may be the result of some vice of constitu-
tion or of injury.   Wounds or injuries of the cancellated
structure of long bones near a joint are always danger-
ous, as the joint soon or late is generally involved.
   Necrosis,  like  other diseases,  has its stages, and to
comprehend fully the process,  they must be  watched
from beginning to end.  In the first stage, a portion of
bone inflames.   This may be the result of external in-
jury,  as  wound, contusion,  or fracture;  or it may be
apparently of  spontaneous origin;  it may terminate in
local death,  either in consequence of its own intensity,
 or on account of this  being  associated  with diminished
 power in the  part affected.  The associated  cause  is
 more  frequent than the single,  in cases of traumatic 
28
BONE AND  NERVE SURGERY.
origin, the injury not  only kindling  ostitis, but, at the
same time, diminishing the vital power by which it is  to
be opposed.  This remark applies with peculiar force  to
gunshot injuries of bone.
  It often happens in  wounds, that a portion of the
periosteum is removed from a bone, or it is so contused
as to  destroy  its vitality.  Such injuries impair the
power  of the bone, and, if  ostitis supervene, necrosis is
apt to follow,  but  not  necessarily.  The periosteum
is sometimes  rudely torn off and  still the  bone granu-
lates,  a new periosteum is formed, and the  injured bone
lives;  it may even survive acute ostitis.  I  have already
given  cases in  which  the periosteum was  removed by
ulceration and gangrene from the external surface, and
yet the bone  has survived  without  exfoliation.   Such
cases,  however,  are exceptions to the general rule, that
when  the periosteum  is removed  by  disease, the corre-
sponding surface of bone dies.
  But if the periosteum  and endosteum both be stripped
off, or  removed by disease, the death of the bone to the
extent implicated is certain to follow, from  want  of a
sufficient supply of blood.

  "A  marked sympathy of function has been observed be-
tween  the periosteum and endosteum.   When the former
has been destroyed, the corresponding portion of the latter
becomes peculiarly active, often causing an obliteration of
the medullary canal, at  that point, by deposit  of  bone.
After  injury to the endosteum, similar  sympathy is evinced
by the periosteum.  In  fact, destruction of either membrane
involves  an increased duty and  activity of  production  in
that remaining.
   " When exposed bone retains its vitality, it is of a brown
hue ; sounds dull on being struck; emits blood when rudely
handled, and  is  covered by  a self-secreted fluid.  On the
contrary, if it be dead or dying, its color is white; it  is 
            NECROSIS, OR DEATH OF BONE.         29

resonant when struck ;  it is dry, unless when moistened by
purulent secretion from the surrounding parts, and does not
bleed when touched, however rudely.  Such signs are use-
ful as not only auxiliary to diagnosis, but bearing strongly
on the  mode of  dressing.  It must, however, be also well
understood, that a bone stripped of its periosteum may, at
first, show all the usual indications of retained vitality, and
yet whiten  and die.   And, also, that an exposed portion of
bone may become white, sonorous,  and apparently non-vas-
cular shortly after the infliction of the injury, and yet re-
cover with  the thinnest possible exfoliation.  In the  latter
class of cases, the process of renewed and increased vas-
cularization, in a part previously exsanguine, may be seen
beautifully  exemplified."—Prof. Miller, Principles of Sur-
gery.
   In the second stage the  bone dies, and the process
which leads to it may  be  completed in  a few hours;  but
in others,  it  requires  days.  While the  inflammation
was in progress, the periosteum  was adherent,  but now
it  is detached and  pus  infiltrated  between  it  and  the
bone.   If  the death of the bone be rapid, it has had no
time  to change its structure under the  inflammatory
action resident  in  itself, and  it consequently, as a se-
questrum,  retains the character of normal  bone.  Its
external surface is  compact—looks like healthy  bone,
which has  been macerated and  stripped of periosteum.
But  if  ostitis have  existed  in the  part for  some  time
previous to its death, then its  appearance will vary
when dead, according to the duration and intensity of
that  action—rough, porous,  swollen,  ulcerated,  dense,
etc.   The  first condition  is most frequent.
   The third stage  in the process  is the separation of
the dead from the living bone.   The  second stage, or
death of the  bone,  is often rapidly completed, and is
never long protracted; but this third stage is invariably
slow.    The detachment  is  effected by  the  same vital
                          3* 
30           BONE AND NERVE SURGERY.
action, that sloughs in soft parts are  separated, but the
time  consumed  differs greatly in the  two.   A  slough
may separate in a few days, while weeks or months may
elapse,  and  the  detachment of  a  sequestrum be still
incomplete.
   The extent of the necrosed portion is indicated by
its denuded, white, sonorous, insensible, and non-vas-
cular characters, and these it retains  through the whole
process,  resembling  a macerated  bone.   No change
occurs in this except that of color from exposure to air
or unhealthy pus, it  becoming, sometimes, black.  But
great changes are progressing in the parts contiguous to
the dead bone.   There is great activity—the color of
the living  bone is red, or dark-brown,  from increased
vascularity;  it  is painful  to the  touch  and  bleeds
readily;  lymph  is exuding and  the  part becomes soft-
ened  from loss  of earthy matter;  it  is also swollen.
While the  dead  bone remains a  foreign body, the parts
all around are soft,  swollen, and increased  in  vascu-
larity, carrying  on  the  inflammatory  process.   This
soon  terminates in suppuration  and  ulceration, and  at
the line of demarcation, the absorbents commence their
work, and, step  by step,  the  sulcus  between the dead
and  living  portions  is deepened, until the  former is
completely detached,  reducing it to  the condition of a
sequestrum.  This process requires an indefinite, and
often long  time.
   Rokitansky, in his Pathological Anatomy, denies the
action of the absorbents in the separation of dead from
living bone, but this  is rather a dispute about  words.
The following is  his view of the matter :
  "All  around  the necrosed portion,  that is to say, its
margins and at the part where its surface is opposed to that 
NECROSIS, OR DEATH OF  BONE.          31
of the healthy bone, the latter undergoes a gradual expan-
sion  or  rarifaction of its tissue by the enlargement of its
Haversian canals, assumes a rosy color and  becomes succu-
lent. It acquires gradually an areolar structure, and is thus
more rarified : at length it disappears altogether, and a red,
soft, spongy substance, a layer of granulations, occupies its
place.   This change is produced by an inflammatory pro-
cess, which gives rise to suppuration  and granulation: the
bony tissue, beginning  with the Haversian canals, is dis-
solved by the matter secreted within them, while the granu-
lations  which shoot forth at the same time, fill up the
enlarged canals.  The immediate result of this process  is
the formation of a  furrow of demarkation  which encircles
the margin of the dead bone and is filled with granulations;
and so far as the process is completed on that  surface, also
of the living bone which faces the  dead, so far is the seques-
trum separated.   In this process, that is, in the solution  of
the layer of healthy bone adjoining the dead  by means of
the purulent  matter,  and  in  the  attendant  formation  of
granulations, I find  enough to account for the  demarkation
and  separation  of  the sequestrum;  and  the absorption
which has been assumed to go on at the borders of a por-
tion of necrosed bone, I hold to be incompatible with in-
flammatory  process, while  the  analogy of  the process by
which mortified soft parts  are cast off renders such a view
admissible."

   I  am not prepared to receive, without  a doubt, the
above  views of Rokitansky.  I think there  are good
reasons to believe that not only living and dying bone,
but dead bone may be  acted on by absorbents.  We
know that  pressure upon a  living bone,  as  by aneu-
risms,  tumors,  etc.,  will cause  its  absorption.  It  is
equally true that granulations do possess great absorb-
ing power, as is proven by the absorption of morphine,
arsenic, strychnine, and  other soluble salts, when sprin-
kled on them; and one of the  worst cases of salivation I
ever saw, was caused by inserting calomel  (an  insoluble
powder) into an  abscess.   On the  other hand, I know 
32
BONE  AND  NERVE SURGERY.
of no facts to prove that pus has any power  of  dis-
solving dead or living bone.
  It is true that a loose piece of bone will float about in
a pus cavity for months or years without losing weight,
but this does not  prove that a sequestrum, when  closely
applied  to granulations, may not  be acted on by theii
absorbents, and I do not see  how else we  can explain
the worm-eaten appearance of dead bone and its inti-
mate relations with the underlying granulations.
  Mr. Savery's experiments (see  vol. xxix. Med.-Chir.
Transactions,  1864,  London) prove  that   pegs  made
out of the compact substance of the shaft of a  human
femur, when driven tightly into the bone of an  animal
and left there  for some weeks,  are found to have dimin-
ished in their  weight.   Mr. S. attributes  this absorp-
tion  to  the effect of pressure; and the same  law maj
apply to the sequestrum  pressing on granulations.  It h
probable  that the close  apposition  has as much to dc
with the absorption as pressure, for Ave  can easily con-
ceive  how granulations might act,  through their absorb-
ents, on a bone or other substance in close contact, whei
they could not if the same substance was floating loose
in the superimposed pus.
  Mr. Stanley, in his  " Treatise on  the  Diseases Oj
Bones," gives some strong corroborative facts, of whicl
I can only quote  a paragraph or two.

  "In a case where a portion of the front of the tibia  per-
ished  and had become of a black color, granulations from
the surrounding soft parts were observed to extend gradually
over the dead bone.  While  this was in progress, I  raised
upon the edge of a spatula, the free border of these  granu
lations, and exposed little  hollows in the surface of the deat
boue,  to  which  the  granulations were exactly fitted.   L
these  several instances, the dead bone certainly disappeared 
NECROSISf OR DEATH  OF BONE.          33
but not by any sensible exfoliation ; the question will be
respecting the mode of its disappearance.
   "Miescher has attempted to explain the  facts by the
agency of what he calls insensible exfoliation, but to my
mind both facts and reason are in favor of absorption of bone."

   I have seen many cases similar to that related above by
Mr. Stanley, and have already related two.  The argu-
ment of insensible exfoliation in these cases has been drawn
in part from the fact that much earthy matter is found in
the pus; but it should be borne in mind that it is a func-
tion of bone granulations to supply bone material.
   When a slough separates from soft parts, the process
of repair has  already  commenced and follows  closely
upon  the separation—granulations sprout at once from
the sound surface, as  fast as the absorbents divide the
parts, and the  work of repair steadily progresses.  Pre-
cisely  the same course is followed  by nature  in the
necrosis or sloughing of bone.  As soon as the sulcus is
formed, granulations  begin to spread, and here, in ac-
cordance with  the law of   diseased  tissue, they are
osseous granules, soon to be  transformed into bone.
   The process of separation  is always slow, and  it is
well that this is so, as that by which bone  is formed  is
always  so.  The work of  destruction  and  repair, by a
wise provision  of nature, advance together  without in-
terference.  The  old bone is not thrown off until the
new formation has  sufficient strength to  supply  its
place.
   There is necessarily during the process of separation
a  copious  formation  of  pus, which  either  discharges
through natural openings, already  existing, or it bur-
rows around, often doing much harm to parts not before
involved.  The surgeon should watch closely, and make 
34
BONE  AND  NERVE  SURGERY.
sufficient openings in dependent parts  and keep  them
open by the insertion of lint.   The discharge is usually
thick, yellow, and  charged more or  less with ulcerated
debris, and of peculiar and very offensive odor, readily
recognized as characteristic of  necrosed bone; it con-
tains earthy matter.
  In the fourth stage, the separation of the dead bone
is completed, the ulcerative process having encompassed
it on all sides.   It is now loose, except where  hemmed
in  by the  formation  of new  osseous  matter, as  is  often
the case.  The sequestrum is now a foreign body, having
lost all vitality, and  as such keeps up inflammation and
suppuration, and cannot be too soon  got rid of.
  Sometimes the  death and separation is  not in one
mass; but a gradual disintegration  and destruction of
the bone occurs, in particles so small as to escape ob-
servation—a process which has been very   properly
called  insensible  exfoliation  by  Miescher, who has,
however, I think, given it  too wide an application.
  In the fifth stage, the dead bone is extruded,  like any
other  foreign body,  by the process of suppuration and
granulation; it is  gradually floated to the  surface and
exposed.   Nature is  sometimes powerful enough to
throw it out completely,  but  usually the  assistance of
the surgeon  is required,  and can always  hasten the pro-
cess and save much time.   The granulations gradually
advancing, will sometimes push the  dead bone entirely
through the opening in the soft  parts, but  on the other
hand, they not unfrequently surround and embrace it so
as to  retain it in its position.   The granulations not
only incase it, but they  will  shoot into its irregularities
and openings,  so  as to  nail  it down  firmly.  These
irregularities and  perforations  of the  dead bone are 
             NECROSIS, OR DEATH OF BONE.         35

 generally believed to  be the result of the ulcerative pro-
 cess before the bone had lost its vitality, and although
 this is doubtless true  to a great extent, we have given
 reasons for  the contrary opinion, that granulations in
 close contact with dead bone do, through their absorb-
 ents, act upon and eat into it.
   In the sixth stage reparation is completed after being
 commenced  in  the  old bone, at the  time of separation
 on the  living margin.  It  advances  in  two parts, deep
 seated  and superficial:  the former,  following close in
 the track of ulceration, consists of bony production
 from the living  bone, beneath the loosening sequestrum;
 the other is carried on by the periosteum, and invests
 the dead bone  on the exterior, gradually enveloping it
 like the  bark of a  tree, and hence called  cortical part
 of the substitute.
   It has been  proven that periosteum is the principal
 agent in the reparation of  bone.  The  ulceration will
 form openings here and there in the  periosteum for the
 discharge of pus, and, at these points,  there is  a de-
 ficiency of the cortical or new bone, and a probe passed
 in at these points will strike the dead  sequestrum be-
 neath.  These openings usually remain  until the seques-
 trum  is  removed.   The openings through  the  cortical
 formation are called cloacae, and afford proper drains for
 the accumulating  matter.  There is sometimes one, and
 at others, several;  as many as eight  or ten of these
 openings terminating on the external surface, in a little
 elevated orifice  called the papilla.   The probe readily
finds its way through these openings down to the seques-
trum, and the condition of the bone from  time to time may
be examined, and when it has become loose, one of the
openings should  be enlarged and the dead bone removed. 
36
BONE  AND NERVE  SURGERY.
When it has been removed, the cavity is gradually filled
by osseous matter, and the substitute or  new bone is
completed.  There being  no longer any dead body  to
keep up suppuration, it ceases, the  cavity fills up and
contracts, and all becomes firmly consolidated.
  Surrounding the diseased parts, before the dead bone
is removed, there  is much swelling and  hardness from
the copious deposition of lymph,  but  absorption  now
takes place, and  the  thickened  soft parts are in due
time brought  down to their  normal dimensions.   En-
larged  bone  rarely if ever  regains  its  former size,
though all its functions are restored.
  What we have  heretofore  said has  been mainly  in
reference to disease of the exterior periosteal surface of
bone.  When  the necrosis is internal, a  part only  of
the cancellous  texture having died, reparation follows
rapidly  on extrusion of the  sequestrum.-  The  seques-
trum makes its escape through an aperture, formed by
ulceration, in the laminated portion, which  opening, like
that described in the cortical formation, is called cloaca.
When the  sequestrum by art or nature has been re-
moved,  reproduction  is accomplished  entirely  by  the
surrounding living bone,  which constitutes the parietes
of the  cavity in which the sequestrum is incarcerated.
In the  diseased  action which precedes  this internal
necrosis of the walls of the medullary cavity,  the in-
ternal periosteum or endosteum is destroyed  by ulcera-
tion, and the bone itself is therefore the only source of
reproduction.
  Where the inflammatory action has been limited, the
internal sequestrum is small, and also the suppuration.
The ulceration  by which the  bone is perforated  for  the
discharge  of the  sequestrum  and pus  may be very 
NECROSIS, OR  DEATH OF BONE.          37
tedious.   The  presence, however, of the foreign body
keeps  up a low degree of ostitis; the bone  often  be-
comes  much enlarged, condensed in structure,  and often
roughly nodulated  on the exterior.  The whole shaft of
the bone may be involved, with only a small opening or
two through which the pus escapes.
   Instead of the disease  being confined to the external
or internal surface, it may attack the whole thickness of
the bone, and the process of separation advances in the
usual  way,  as also the commencement  of reparation,
viz., osseous  production from  the living margin of the
sulcus.  The  bone itself does a part of the work,  but
most  of it  is  accomplished by the periosteum, which
forms  a complete casing of the  dead portion; the seques-
trum,  by means of ulceration,  suppuration, and granula-
tions  from  the living surface,  may be gradually  ex-
truded from  its nidus, by  the efforts of nature alone.
The new cortical formation then contracts, and with the
aid of what is contributed by  the old bone, a  solid,
efficient substitute is  finally formed.

   " Complete reproduction, however, is not to be expected
in all cases.   If a small portion  only of the entire thickness
perish, say half an inch or an inch, doubtless it will be ulti-
mately, though slowly, reproduced; the parts are equal to the
task required of them.  The bone more especially is quite
able to undertake its part of the duty; the osseous forma-
tion from either end uniting to  form a dense and compact
reunion of the central  portions  of the shaft.  In all cases,
the periosteum, when left  entire, is capable of executing its
share,  namely, formation of the  cortical portion.   But this
is not enough;  the cortical portion, if left to itself, after ex-
trusion of the sequestrum, unsupported by internal produc-
tion from the bone, shrivels and bends—is altogether insuf-
ficient  as a column of support, and ultimately becomes, in a
great measure, removed by absorption.  Now, reproduction
from the mutilated osseous surface  can only extend a cer-
                           4 
38
BONE AND NERVE SURGERY.
tain length.   In the higher classes of animals, reproduction
of tissue is not indefinite, but has its limits.  The two por-
tions of bone will shoot out new matter  readily, so as to
effect union by restoration to the extent of an inch or two;
but, in  seeking to traverse a greater space, the reparative
process is apt to flag and fail;  the  osseous granules do not
coalesce, but taper  finely  off, ending in  a  point coherent
with the condensed, soft tissues  around.  Therefore, prac-
tically, it must be  remembered, that when a sequestrum has
come away, including almost the entire shaft of a long bone,
reproduction can scarcely be expected to  prove complete;
and probably the  limb will ever  after be more or less inef-
ficient as an organ of support and motion.
  " It  is astonishing, however, how successful the restora-
tive effort sometimes proves, even in circumstances of little
hope ;  in not a few instances long bones  have been almost
wholly reproduced ;  and therefore in necrosis of the entire
thickness of the  shaft,  even of great extent, a chance  of
cure, in the ordinary way, ought to be invariably afforded.
The short bones, however, if wholly necrosed, are never re-
produced, and reproduction is  also  rare  in the flat  bones,
especially the cranium."—Miller's Principles of Surgery.

  Professor  Miller's  reasoning   and   conclusions  are
doubtless drawn  principally from  the  class  of cases of
necrosis seen in  civil  hospital   practice,  which  are
usually very different from gunshot injuries in soldiers.
In  the latter class  of patients, the power of reproduc-
tion is much greater than the  professor admits.   After
resections it is common to see large portions  of bone re-
produced.   After resections of the humerus, I have cer-
tainly  seen as much as three inches of bone reproduced,
and the length of the  arm fully maintained.   One of
these cases was Gen. Daniel Adams,  of Louisiana, who
had about three  inches  of the  humerus taken out by a
surgeon  (Dr.  Moses, I  believe), after one of the battles
in Tennessee.  Exfoliation of the ends  of  the  bones
followed in consequence of the high inflammation and 
•   NECROSIS, OR DEATH OF BONE.         39
profuse suppuration, and  about  ten months after  the
injury,  I  removed, by  incision,  four small  fragments,
completely incased,  except the cloaca, in a thick cor-
tical formation, bridged across, between the ends of the
bones;  the cavity soon closed, the bone became firm,
and the use of the arm is now perfect.*
  For the reproduction of bone, under any circumstances,
it is essential that true  inflammatory action should sub-
side;  otherwise,  healthy  fibrin  will not be deposited,
but destructive ulceration  and suppuration  result.  As
long as there are much inflammation  and suppuration,
there is danger of extension of the disease, and the in-
volvement of new portions of bone.
  Symptoms.—Necrosis being the  result of inflamma-
tion, the symptoms are in the early stage those of acute
ostitis, and, when suppuration occurs, they  are aggra-
vated by tension  and pressure. As soon as the pus finds
vent  naturally or artificially, there is  marked  relief.
An opening should  be made  as soon as fluctuation is
discovered, not only for the relief of pain, but to arrest
extension of the disease.   The soft parts around are in-
filtrated with serum  and plastic matter, and are the  seat
of redness, swelling, heat, and pain.
  One or more openings are established  through which
the  pus  escapes, and  a  probe  introduced will pass
through the cloaca  and come  in contact with the dead
bone; this channel  becomes fistulous, and will remain
open for an indefinite time.  If the opening  be large
enough, the finger is the best  probe.   The  sequestrum

  * The remarkable case of M. Maisonneuve is one strongly in
point.  He  removed twelve  inches of the  tibia,  leaving only the
periosteum, and the bone was reproduced, and made a good and effi-
cient limb. 
40
BONE  AND NERVE  SURGERY.
may be within the medullary cavity of a long bone, or
on the external surface covered by bony product of the
periosteum.
  Instead of the constitutional symptoms which accom-
pany acute ostitis in the first stage, as the suppuration
advances the powers  give way and hectic  follows with
all its train.
  So long, however, as  the  sequestrum remains, nature
makes  increasing efforts to  throw  it  off, and local  in-
flammation is kept up.  While the absorbents are at
work cutting loose  the  condemned  portion, the perios-
teum and living bone are  doing their work of repair,
are reconstructing the substitute. The soft parts at the
same time are much thickened and increased in vascu-
larity; so that when incised, they cut more like gristle
than ordinary soft textures.  Hemorrhage, under these
circumstances, is always  profuse for two reasons: first,
there is  an  increased  number of  blood-vessels; and,
second, from  the  inability of the vessels  to contract, in
consequence of being held  open by the dense, unyield-
ing tissues in which they are imbedded.
  After the inflammatory action has subsided to a great
degree,  and the disease seems  to  be approaching  its
termination, the morbid action is again lighted  up from
trivial  provocation,  and  often without apparent cause.
If the  pus do not  find ready exit, rapid  extension of
the disease may take  place  and new parts be involved
in the necrosis.  Thus  it  may happen  that necrosis,
originally limited to but a small part of laminated text-
ure, may ultimately involve not only the whole  thick-
ness, but almost the whole extent of a bone.
  Although  the  sequestrum  becomes  completely de-
tached from  the living bone, it is not necessarily loose 
            NECROSIS,  0,R DEATH OF BONE.         41

and movable.   It may be held  firmly in its  position by
the tight embrace of the  cortical formation thrown
around it by the periosteum, or even by fibrous, carti-
laginous  texture, or by  granulations which have shot
into  the  interstices of the cribriform  parts, thus  as it
were  nailing it  down  firmly.   Most frequently,  how-
ever,  so soon as the sequestrum is detached, it is  more
or less movable when pressed upon by probe or finger.
If then not removed by art, as it should be, it makes
its appearance, or attempts to do so, at the surface, ami
projects,  becoming black from exposure to the air.  If
the sequestrum be not  removed at the proper time, in-
flammation  is again lighted  up,  and the substitute  or
new bone, being of feeble vitality, may perish, and thus
all that has been gained will be lost.
  One of the greatest difficulties the surgeon has to con-
tend with is that of anticipating the time to be consumed
in the various  stages  from the commencement to the
termination of  the  complicated process which  leads to
necrosis  from  the incipient inflammation.   It is ex-
tremely variable.   In  acute external  necrosis, of very
limited extent, but a few days may be required;  when
more  extensive, weeks may  elapse; and, if the whole
thickness of the bone has perished  to  a considerable
extent,  many  months  are  usually consumed  ere the
bone  is released, and quite as much time may then pass
before the limb resumes its form and  function.  Where
relapses  occur, the course of the disease may be pro-
longed indefinitely for years.   In spongy bones,  on
account of their greater vascularity, the process is ordi-
narily more rapid than in the dense.  The bones of the
upper extremity usually require less time than those of
the lower.
                          4* 
42
BONE AND NERVE  SURGERY.
  Vidal de Cassis gives from one to six months as the
limits for  the death  and detachment of bone, and this
answers well as a genera^rule.  The same general laws,
however, govern the inflammatory process in bones as
in the soft parts.  Pn soft parts, the  leg  particularly,
we see ulcers become indolent and chronic, and run on
for years;  the  same thing occurs in ulceration and in
necrosis of bone ; the diseased action becomes fatigued,
exhausted, and, like an old ulcer, remains stationary for
an indefinite time.

  " The exfoliation of bone is  an uncertain  process in re-
spect to the rapidity of its progress;  nor can this  always
be explained by the circumstances of the age or health of
the individual:  for, in some instances, the process advances
more actively in old  than in young persons; in those of
feeble health than in others  of robust constitution.   There
are also instances of  necrosis in  which  separation of the
dead bone never commences; and other instances in which
the  process,  having  commenced,   is, without appreciable
cause, arrested in its progress.  The following  is an instance
of the latter kind.  Amputation of the thigh was performed
thirty-five years after  the fracture of the  femur, which had
been followed by an abscess in the soft parts, and the forma-
tion of  a fistulous passage in the walls of the bone, which
was still open at the time of the  removal of  the limb.  A
section  of the femur discovered  a small portion of its inner
wall of  a dark-brown color, and in part  exfoliated.   Here,
therefore, it appeared  that a portion of the inner wall of the
femur having perished, its exfoliation was but in part effect-
ed :  it had retained its connection with the living bone, and
through the long period of thirty-five years  had been the
source of suffering, which at length induced the patient to
solicit the removal of  the limb.   That dead bone may thus
retain its  connection  with  living bone  for  an indefinite
period, is an  important fact, as it bears upon the question
hereafter to be considered,—under what circumstances opera-
tions for the removal of dead bone may,  with propriety, be
undertaken.     *        *        *         *        *
  "Instances of necrosis in early life have occurred, wherein 
NECROSIS, OR  DEATH OF BONE.         43
a small portion of dead bone, not separated from the living
bone, has remained unchanged for many years, and the
fistulous  passages in the soft  parts  leading  to it have
become closed.  Under these circumstances, the patient has
presumed upon the sound condition of the parts; but after
the lapse of some time, it may be a year or more, a fresh at-
tack of inflammation, followed by abscess and the reopening
of the fistulous passages, has shown the original source of
irritation  still existed.  But  the complete  cicatrization
of the soft parts over dead bone, however small its extent,
is a rare occurrence, and it probably occurs only in instances
where the separation  of the dead bone from the living has
failed to take place.  When the dead bone is detached from
the living bone, it becomes a foreign body, an irritant to the
adjacent parts; purulent fluid is consequently formed around
it, the outlet for which is the fistulous passages  in the sur-
rounding  soft parts.   So  long, therefore, as this suppura-
tion continues, the fistulous passages are sure to remain
open.  But, on the other hand, a small piece of  dead bone,
retaining its connection with the living bone, may excite so
little irritation in the surrounding parts, that no suppuration
from  them ensues, and, under such circumstances, it  is not
unlikely that the fistulous passages leading to the dead bone
may become closed."

   I can vouch for the accuracy of Mr. Stanley as  to the
facts and principles laid down in the foregoing extracts,
and could fully  corroborate them by cases of my own,
were  it not for transcending my prescribed limits.
   It  is remarkable  how  long foreign bodies  will often
remain buried in the  tissues without producing any ap-
parent irritation.  I  recently removed from an eyeball
a piece of copper percussion cap, which had been buried
in  it for four  years.
   A short time  ago  I removed a small splinter of pine
wood  from the  cheek,  where  it  had been  encysted
twenty-seven  years;  and a few years ago I opened  an
abscess of recent formation, on the buttock  of a Grer- 
44
BONE AND NERVE  SURGERY.
man, and out dropped a ball, which had been there since
the battle of Austerlitz, about forty years.
   Treatment.—As remarked, when speaking of caries,
prevention is better than cure.  The preliminary ostitis
should be promptly met  and  treated, to guard  against
the destruction to which  it leads.   After suppuration
has taken place, and necrosis is actually progressing, we
must watch patiently, combat  symptoms, and assist the
process of  repair.  A prominent indication is to evacu-
ate the pus  as soon as formed.
  "Time, texture, and  torture may all  be  saved, by an
early, free, and direct incision,  which should be practiced
as soon as the indications of suppuration are  sufficiently
manifest.
  " Detachment of the sequestrum we commit  entirely to
nature; contenting ourselves with overlooking her opera-
tions, and taking especial care that she shall  not be  inter-
fered with.  With this latter object  in view, the part is kept
quiet, used as little as possible,  and not put in  the way of
external violence.   By some exercise of the affected part is
enjoined, with a view to  expedite the separation of the dead
portion, when that seems to be  unreasonably slow  ; but,  to
my  mind, the practice seems fraught with danger, as regards
aggravation and extension of the disease, by inducing excess
of vascular action.   Should inflammatory reaccession at any
time threaten, leeches, fomentations,  absolute repose, and
general antiphlogistics, if need  be, are at once employed,
with a view of its speedy  arrest.   On  this  account  also,
during the chronic stage, when  perhaps purulent  secretion
is great, and hectic is  either threatened or fully developed,
and when, consequently, we are anxious  to support the
system in its difficulties—that support must be prudently
conducted, and  made to vary from  time to time, as circum-
stances may demand, in order to avoid its  being the  cause
of local overaction."

  So far, operative  surgery has  little excuse for  inter-
ference; but  when  the sequestrum  is  completely de-
tached, nature's  part is  over, and  we are then called 
NECROSIS, OR  DEATH OF  BONE.         45
upon  to  do ours.  The power of nature,  though ad-
mirable up to this point, is of  little avail  in  the  extru-
sion of dead bone, and the system is exhausted by long
and painful efforts.
   The neglect to aid  nature at the  proper time is one
of  the great  errors of practice, but one perhaps  still
greater, is the attempt to remove the sequestrum before
it is loose.
  " To lay hold of it then and use violence,  after exposure
by  incision, is  certainly to  induce a combination of evils.
The evulsive effort  fails, and, consequently, the patient has
been put to a grave amount  of pain unnecessarily and fruit-
lessly.  By the  violence,  inflammatory  reaccession  is cer-
tainly induced in and around the part originally implicated.
In  other words, a fresh ostitis, probably both acute  and ex-
tensive, is induced, and aggravation of  the necrosis is most
likely to follow.   Also the loss of blood, that  attends such
attempts, whether successful or  not, is invariably consider-
able ;  coming from a wound of soft  parts,  which  are not
only unusually vascular, but besides unfavorable to natural
hemostatics, as  formerly explained.   Moreover, the  con-
dition of the patient in the  advanced  stage of necrosis is
such  as to be altogether intolerant of  a repetition of  such
hemorrhages."

  Therefore,  until the process of  separation is com-
pleted, it is the part of the surgeon  to watch patiently;
to  guard against  too  much inflammation;  to regulate
the action of nature as far as possible, both general and
local; and  to  forbid any motion which might bend  or
fracture the weakened  bone.
  By probing  from time to time, we ascertain the  con-
dition of the bone, and sometimes we are much facilitated
by  using two  probes simultaneously; thus pressing the
sequestrum at two points,  we  are more  apt  to  detect
motion.
  If the shaft of  a long bone be separating in its entire 
46
BONE  AND NERVE  SURGERY.
thickness, and  to a considerable  extent,  it is all-im-
portant to keep  it well supported and  immovable, to
guard  against bending, fracture, shortening, injury of
blood-vessels from spiculse of bone, etc.
  But  when the  sequestrum  of bone has become loose,
and not  before, it is the duty of the surgeon to remove
it promptly, if in an accessible part.   An  incision  suf-
ficiently  free to  get well  at the  part to  be removed
should be made  down upon one of the cloacae,  and the
condition of the sequestrum  examined.   If the natural
opening  in the cortical portion  is not sufficient for its
removal,  it  should be  enlarged by trephine, gouge, or
bone nippers, and a strong pair of forceps should be in-
troduced, the dead bone seized,  and, by  steady motion,
pulling, twisting, etc., be extracted.
  While, on the other hand,  it is indispensable  that the
opening should be sufficient for the extraction, it should
be remembered  that as little as  possible of  the  new
bone should be  sacrificed, for, once removed, it will not
be reproduced,  and  the limb, in consequence,  may be
permanently weakened and deformed.  Strong, narrow,
long forceps are constructed, and are  convenient for
such operations;  but I  have  often used, with excellent
effect, common tooth forceps,  a little curved—their firm-
ness of grip and  power are well illustrated in  the  ex-
traction  of a molar tooth.   Where the sequestrum is
long,  the  operation  is much  facilitated  by  cutting
through its center with bone  pliers.
  It has  been supposed that dead bone may, by contact
with pus, by the action of absorbents, or both combined,
be disintegrated, taken up and removed from the system
through  efforts of nature alone.  But this is now known
to be a mistaken idea.  Ulceration and disintegration may 
NECROSIS, OR DEATH OF BONE.         47
 take  place  in  living bone, or absorbents  may act on
 living bone; but when a part is fairly thrown off from
 its attachments,  it becomes a foreign body, and is no
 more under the control of  pathological or physiological
 action, than a piece of  wood or  porcelain.   Such is the
 pathological doctrine now universally taught, and yet I
 have  seen cases  during the war in which I could ex-
 plain the disappearance of dead bone on no other prin-
 ciple  than that of absorption.
   After the sequestrum has been removed, the wound
 should be stuffed with lint, covered by a compress  and
 bandage, to arrest  hemorrhage, and the antiphlogistic
 treatment enforced.  The  lint dressing  should be  con-
 tinued, in order to keep the wound open, and to force it
 to fill up from  the  bottom.  It  should be remembered
 that when the sequestrum  is removed, the substitute is
 hollow, imperfect, weak, and prone to give  way,  even
 from its  own weight.   The part should be kept in  per-
 fect rest until the wound is entirely healed, and then it
 should be well supported by binders' boards and starch
 bandage before the patient is allowed to get up.  It may
 even  then require  months before a leg or an arm can
 be  safely used, to  perform  its  accustomed functions.
 During the  whole treatment, both before and after the
 separation and removal of the  sequestrum,  it is  im-
 portant to look to  the  condition of neighboring joints,
 which, from  long  inaction, become anchylosed; to guard
 against this, passive motion should be used from time to
 time.
   In  the cranium, superficial exfoliation, involving a
 layer or the whole  thickness of the external  table, is
common,  both from injury and  disease; and the  dead
leaf may seem firmly fixed,  even  after  all connection 
48           BONE  AND  NERVE  SURGERY.
with the living parts is cut off.   This cannot be by cor-
tical formation, for in the cranium this is seldom if ever
produced.  It may be  the result either of redundant
granulations or of atmospheric pressure.   Granulations
not unfrequently spring profusely from  the margins of
living parts, and overlap the plate of bone, so as to hold
it  in  place like the crystal of a watch; or the plate
of bone lying flat on a bed of granulations may fit  so
closely as to be held in  place by the atmospheric press-
ure of fourteen pounds  to the square inch.  In either
case, one edge should be freed of its coverings, and an
elevator inserted  beneath,  when it is easily  raised from
its bed.  Although  amputation is sometimes demanded
for the relief of necrosis,  this is  the exception to a
general rule.
   In  young subjects particularly, the symptoms, local
and general, are so violent that it becomes evident that
the patient cannot  abide  the time  necessary  for  the
tedious process of nature, and  we must amputate to save
life.   There are also  chronic cases, where suppuration,
hectic, etc. are going on  for  months, without  prospect
of the sequestrum being thrown off in time,  in which we
must  take the choice of  evils and  remove the  limb,
while the patient has still strength to stand the opera-
tion.  Nature, in some of these cases, is utterly incom-
petent to the  amount of work required,  together with
the long wear  and tear of the system;  and the first con-
sideration is life, which can be saved  only by timely and
decisive action. 
PART  II.
   As  before stated, what I have  said in Part  I. re-
specting injuries of bones, has been mainly a resume of
those general pathological principles and rules of prac-
tice which may be considered as the  matured opinions
of the present day; reserving any peculiar views I may
have, resulting from my own experience, to Part II. of
the essay.
   It will be remembered that I have intentionally passed
by those specific forms of disease, scrofula, syphilis, etc.,
which belong more to civil than military practice, and
which are well  treated in  systematic works on surgery.
Recruits laboring under these diatheses, or forms of dis-
ease,  do not come  much under the eye of the army sur-
geon,  as most  of  them are rejected, or if received in
service, break  down early, and are discharged before
getting into battle.  It is therefore, I repeat, simple in-
flammation and its consequences that I propose to con-
sider.  Having, during and since the war, been called on
to treat a large number of both acute and chronic in-
juries of bone, many of them of several years' duration,
and having, from the want of medical literature in this
department,  been  obliged to  a great extent to make
out my own  rules  of practice, I hope I may be able to
supply some useful hints to younger surgeons.
  After being  connected  with the  army, and seeing  a
                          5              (49) 
50
BONE  AND NERVE  SURGERY.
good deal of field surgery from the first battle of Manas-
sas to the close of General Bragg's Kentucky campaign,
I resigned my position on the general's staff and retired
to private practice in Mobile.  Few  surgeons  of the
South, during the  last two years, have seen as many of
the class of cases, of which I am treating, as myself.  I
have not only taken  an active part voluntarily in the
surgical work of some half a dozen hospitals in Mobile,
but have been consulted  by many from the  interior of
Alabama, Mississippi, Florida, and other parts, in my
private practice, who have  been victims of the  various
battle-fields  of the war.
   These cases all come with suppurating wounds, the
discharge being kept up by retained balls, fragments of
shells, pieces of clothing, and other  foreign bodies, but
by far the greater number have received some injury of
the bones,  and necrosed  or detached fragments cause
the trouble.   In some, nature has long since completed
her work, and thrown off the  condemned  portion of
bone;  while  in others, from neglect,  imprudence, and
other causes, the diseased action is still going  on and
necrosis extending.
   Most of these patients have been seen and treated by
surgeons of  no experience  in this class of  cases, and
little  or nothing has been done for them, although relief
might have  been  afforded long before they were  pre-
sented to me.  A man comes wTho has had a minie'-ball
passed  through  the arm or leg, striking  a bone, and
either simply contusing its surface, and perhaps knock-
ing off  the periosteum, or fracturing and  splintering it.
In a few instances, perhaps, the surgeon has, in the con-
fusion of the battle field, cut  down upon  the shattered
bone  and removed  the  detached  fragments,  but more 
BONE  AND NERVE  SURGERY.
51
frequently the patient has been in the hurry sent off to
some  distant hospital without anything  having been
done and  the time  passed for primary operations.   In
either  case, the patient  eventually comes to me at the
end of  two  or  three months, or  more,  and not unfre-
quently after the expiration of one, two, three, or even
four years  (I  have  very  recently operated on  one,
wounded at the first battle of Manassas, and am now
writing in July, 1865); and he comes with one or more
fistulous openings, discharging pus.
  Now, wThen such a case presents, what is the first con-
clusion  arrived  at by the surgeon on simple inspection?
It is simply this, that the suppuration must be kept up
by dead bone or other foreign body.
  Can  any  general rule of practice be laid down  for
such cases?   The great  difficulty  is not so much to de-
termine what should be done, as when to do it.  The rule
I adopt, and I  think it a very important one, is, to cut
down and search for the offending body as soon as cir-
cumstances  will permit,  as recovery cannot take place
until  it is removed.  But  what are the circumstances
that should guide our course ?
  The following are the most important considerations :
First, if there  is much inflammation and swelling, with
a baggy feeling, and particularly if the inflammation
presents an unhealthy or  erysipelatous character,  the
knife  should be withheld, as its premature use will be
followed by increase of inflammation, suppuration, ulcer-
ation, and probably sloughing, with corresponding con-
stitutional disturbance.  Second,  the process of exfo-
liation or  separation of the dead  from the living bone
may not have been  completed, and we have already laid
down the  rule, that no operation  should be  attempted 
52          BONE AND NERVE SURGERY.
before  the detachment  is  complete.  Now comes  the
important point;  how are  we to determine the actual
condition of the bone?   Has or has not the sequestrum
been detached?   Frequently the  probe skillfully used
will determine the question, but in spite of all that books
say on  the subject, there  are many cases which the probe
alone will not decide.  A probe passed through a small,
and often long and circuitous channel, may fail to reach
dead bone at all, or if it does, we may not be able to
determine whether  it is detached or  not.   The dead
bone is not unfrequently so  bound down  by surround-
ing granulations as to be immovable.   It will  not  then
be safe in all cases to wait until we can feel loose bone.
  The  study of bone pathology of gunshot  fractures,
where  the inflammation is  simple, and the constitution
uncontammated by specific diseases, or not complicated
by typhoid disease, will show that exfoliation goes on
rapidly, and  that in the majority of cases in the  long
bones  of  the  upper and lower  extremity, two to four
months are  sufficient for nature to do her work, and to
hand the case over to the operative  surgeon.  In the
small bones of the fingers,  those of the metatarsus, and
the radius and ulna, a  month  or six  weeks is often
sufficient.
  My  general rule, therefore, has been this; if a patient
comes  to me two, three, four, or more  months after a
gunshot  injury, with a fistulous opening (unless such a
procedure be distinctly  contraindicated by an inflam-
matory, unhealthy condition of the part, or unfavorable
condition of the  system), I cut  down  boldly in  the
direction of the sinus, laying it open to the  bone,  and
then introduce my finger and explore it fully so as to
ascertain certainly what is the  condition of the bone, 
BONE AND NERVE SURGERY.
58
and whether I  am justified in removing the dead  por-
tion.  A clean, incised cut, under these circumstances,
does no  harm, and it enables us to obtain at once  the
information wanted.   If the bone is not detached, close
the  wound and let it heal, as it often will, by first in-
tention,  without giving the patient any inconvenience.
   In the majority of cases I find balls, clothing, frag-
ments of bone, or other foreign body,  and the patient is
relieved  at once  by its removal.   In  others, the  ex-
ploration is  unsatisfactory, particularly in fleshy parts,
as the thigh  and shoulder, where the bone is  thickly
imbedded in the  muscular and other tissues, and  also
in complicated anatomical structures.
   The  foreign  body  is  sometimes  in a very different
position  from that expected by the surgeon; a ball, for
instance, having been diverted from its course, or having
burrowed off from its original site.
   I would ask  the reader's  attention to  the following
extract  from the work  of  Baron Dupuytren,  entitled
"TraitS des blessures par amies a feu."  It is well  ex-
pressed and full of instruction.
   "The  local  symptoms,  in wounds from balls fracturing
bones,  result principally from  the presence of splinters,
which act the part of foreign  bodies;  they are of differ-
ent kinds, and require special notice.  I divide these cases
as follows:  1. Primitive  Splinters, that  is to say, those
which have been completely separated from the  bone and
soft  parts by the projectile  at  the  moment of the  injury;
they are entirely detached.   2. Secondary Splinters, which
are not completely detached  from  the bone and soft parts,
and  which cling to the latter  by  tendinous, muscular, or
ligamentous bands.  These splinters are  eliminated by sup-
puration,  at the end of very variable periods; eight,  ten,
fifteen, twenty,  thirty,  or even more days.    3. Tertiary
Splinters, that is to say, those that result from the contu-
sion  of bone by projectiles, in the  parts which surround  the
                          5* 
54           BONE AND NERVE  SURGERY.
point of fracture, and which nature produces by virtue of a
peculiar morbid process; a process ordinarily very tedious,
and which sometimes will continue for ten, fifteen, or twenty
years.   Thus, for  example, we saw at the Hotel Dieu, in
1830, an old  soldier affected with tertiary splinters, caused
by  a gunshot wound received in 1813.
  "When a bone has been fractured by a ball, it sometimes
happens that the contused bony extremity becomes necrosed
and detached at the end of some weeks or months, and then
the fracture may consolidate.   At other times the necrosed
extremities" (instead of being pushed aside) "remain in situ,
and the two ends cannot unite; a provisional callus forms
around  them, and gives  them  a  certain solidity; but the
definitive callus  never  forms—the provisional  callus  alone
envelops them, becoming hard, and incloses in the center
of its substance the dead  parts, which  thus represent a true
sequestrum.  The  sojourn of these tertiary splinters in the
midst of callus is  one  of the most common causes  of de-
formity, and endless fistulas.   In some cases, not even pro-
visional callus is formed, and it is not  till after  the detach-
ment of the  necrosed  parts, that the consolidation  takes
place.   This  division of splinters into primary, secondary,
and tertiary,  is of the  greatest importance—each one de-
manding particular treatment.   Thus the first should be
removed immediately—the second in the majority of cases
should not  be removed  until their extraction would be free
from the danger of hemorrhage, severe pain, and only after
they have been more or  less completely detached by suppura-
tion.  As to  the third,  they should not be removed  before
nature has completed  her work of elimination; and,  as we
have seen, this period cannot be fixed with precision."

  The three classes of cases  have been presented to me
in considerable numbers, and  both the arrangement and
the precepts  of  the Baron strike me as being eminently
judicious and practical.
  Now there is an important practical point  involved
in many of these cases, which has  not been fully met
by  the  Baron, and which is too important to be passed
over.    By way of illustration,  suppose  a  minid-ball 
BONE  AND NERVE  SURGERY.
55
strikes the shaft of one  of the long  bones,  passing
through and  fracturing it—what is the usual condition
of the bone in such cases—what does observation teach
us to expect?   The bone  is not only  fractured com-
pletely across, but it is splintered up and down more or
less, and sometimes for several inches, and the question
arises, to what  extent  should  we  attempt  to  remove
these fragments?—should  all the  fragments detached
from  the shaft be immediately removed?  Now, I con-
fess that I  have  adopted, in the  latter part of the war,
very different practice from that followed at the begin-
ning.  Surgeons have generally become more conserva-
tive.  In the first place, we  now amputate much less than
formerly, and not only save more limbs, but more lives,
by avoiding amputation and trying to save the limb.  In
the next  place, I am  much less scrupulous now than
formerly in leaving fragments in situ,  and have been
astonished  at the manner in which nature would  solder
them together.  Those fragments  which are knocked
entirely loose from all attachments should be removed
as soon after the injury as possible.   The finger should
be passed into the wound and made to explore the parts
fully, and all the small fragments that are out of place,
and  movable, should be  taken out.  The  finger will,
however, detect  longitudinal fractures, or pieces of some
size  split  off, but  remaining  in  apposition  with the
mother bone, covered with periosteum, and attached to
the neighboring soft parts and receiving nourishment
from  them; now such  pieces  should not  be  removed,
they have  all the  elements of vitality and will become
firmly consolidated  if  left, and  carefully managed by
absolute  quiet,  antiphlogistics,  etc.   Their  removal
would be attended  by a degree of  violence  to  the soft 
56
BONE  AND NERVE SURGERY.
parts, which, added to  the  injury already done by  the
projectile, would result  in painful and dangerous inflam-
mation and  suppuration.  If nature should fail to con-
solidate the fragments, they will be cast aside  by sup-
puration, and may be  removed with less danger by a
secondary than primary operation,  some weeks later.
  How  many  limbs  have  been saved during our war,
by this conservative course?
  It is  always  an important,  and often  exceedingly
difficult point,  in  the  second  and third  divisions  of
Baron Dupuytren, to  determine  when  to operate; if
too soon,  we aggravate the  disease and increase  the
difficulties and  danger; if we  defer too  long, the  con-
stitution becomes worn, the disease extends beyond its
wonted  limits, and callus, in excess, is  thrown around
the dead bone,  rendering its removal difficult and  often
impossible.
  How  are these difficulties to  be overcome? what rules
of action have we ?   It must be confessed that the cases
are so varied and complicated  as to defy general rules,
and experience  alone must guide.   Most of the difficul-
ties may be  satisfactorily met by the experienced prac-
tical surgeon, while others are involved  in  so  much
obscurity  that  a Dupuytren or a  Guthrie would be at
a loss for a clear rule of action.
  Where  we have to  deal with external inflammation
and its  events, nature  is working  before our  eyes, we
are enabled to direct her  operations, and give efficient
aid at the proper time; a fragment of  bone is  here
thrown  off from its  attachments, in full view, and we
have nothing to do but  take it away with a pair of  for-
ceps from the  surface.   But where  the  process  of
exfoliation is  going on in an injured  bone, deeply 
BONE  AND  NERVE SURGERY.
57
buried beneath soft parts and encircled  by complicated
anatomical structures, much must be left  to conjecture
as to the actual condition; and the ablest  surgeon may
interfere too soon or too late.   Our embarrassment is
greatly increased  by the fact that the  work of nature
does not always progress at the same  pace.   Necrosis
in one case will  involve  but a  superficial leaf, or small
portion of the entire thickness  of  the  bone, while in
another it progresses from point to point, involving a
larger part, or even the entire shaft; and it often hap-
pens  that we cannot determine whether  necrosis  has
terminated,  or is still progressing; and whether the de-
struction of bone  be great or small, the time consumed
in accomplishing a similar result varies greatly in  dif-
ferent cases.   This  variation  depends  on an infinite
number of circumstances, which often  we can neither
comprehend nor control; such as original  peculiarity of
constitution, specific taints, as  scrofula, syphilis, etc.,
bad air, bad diet, badly placed spicule of bone, depress-
ing moral influence, etc., etc.
   The pathology of bones  is in itself a difficult study,
but no inconsiderable light is thrown on the subject by
watching  through all its  stages, necrosis, in those super-
ficial bones which are often exposed to view by injuries.
We witness every step of the  morbid process, and are
enabled to  infer, from what we  see  in  the superficial,
what takes place in the deep-seated parts.
   Owing to the predominance of earthy matter in bones,
and their  lesser vascularity and sensibility, inflammation
is considerably modified in this tissue, but  still the gen-
eral laws governing the  hard and soft tissues are essen-
tially  the  same.  Bones are subject to  inflammation,
simple, specific, acute, and chronic.  They  suppurate, 
58
BONE  AND  NERVE  SURGERY.
 but  with more difficulty than  soft parts; while on the
 other hand,  they soften and lose vitality, often,  from
 apparently slight causes, and under low morbid  action.
 Inflammation in soft parts  leads readily to suppuration,
 and  not  unfrequently  results in large  abscesses; while
 in pure  ostitis, on  the contrary, pus is rarely seen in
 any  form, much less in that of abscess.   Bones inflame
 with difficulty, but  when inflammation  fairly  sets in, it
 almost invariably leads to structural disorder, resulting
 sooner or later in necrosis.
   Bones too when wounded,  or  divided, heal by the
 same process as  soft parts.   In a simple fracture, if the
 parts can be placed in perfect apposition at once, and
 there retained,  they  heal  by  immediate  union  very
 much as soft parts do.  When close apposition is not
 attainable, lymph is thrown out between the fragments,
 and  this  becomes gradually organized, and transformed
 into  kindred  bony tissue, uniting much  in the  same way
 as tendon, muscle, or other soft  structure.   In com-
 pound  fractures, where suppuration and ulceration are
 brought into  play, the  fragments unite  by granulations,
which in  turn become consolidated into  bone.
   I  shall now  bring  before  the  student the rough
 sketches  of a few cases, which may serve to give a more
 satisfactory  idea of the morbid process I wish to illus-
 trate.
   I had,  some months ago, a young soldier, just recover-
ing from  frost-bite of the feet, received in the Tennessee
army;  and another, at the same time, in whom the toes
had  been much  contused by the  wheel  of  a caisson.
The  progress of disease in  the two,  and the results,
were almost identical.   The vitality of the soft parts in
both, to about midway of the several toes, was destroyed, 
             BONE  AND NERVE  SURGERY.          59

and periostem and bone, in both cases, more or less im-
plicated. In both, the soft parts mortified and sloughed
off to the extent of the injury,  leaving the naked pha-
langes projecting and exposed to the air.   Owing to the
greater  vascularity of the soft  parts, but a  few days
were required for the formation and separation of its
sloughs.
  The bones having suffered from  the original causes,
contusion and frost, then  being  stripped of their cover-
ings (including periosteum) by mortification, and being
moreover exposed  to the  action  of  atmospheric air,
their death, like  that of the  soft parts, was inevitable,
and  was only  a question of time.   While .in  the soft
parts a few days were sufficient, in the less  vascular
tissue almost as many weeks were necessary to com-
plete the morbid process.  After the soft coverings of
the bones were removed by sloughing, from loss of cir-
culation, they first  turned white and then almost  black
from the action of  air.
  In the soft  parts the  extent of  the injury was soon
determined, and at the end of four or five days a line
of demarkation was  established between the  dead and
living parts;  and while  the circulation  was disappear-
ing from the dying part,  the living was becoming more
vascular, for  the reason that it was called  upon not
only to maintain its  own existence, but to repair, to a
certain extent, the injury done.   The absorbents now
came to the rescue, having an important part  to  play;
they went  to work, at the line of demarkation, to sepa-
rate  the dead from  the  living portion, and to cast off
what was  useless and  an incumbrance;  in a  few days
this was accomplished  through their  agency.  As the
absorbents cut  deeper  and deeper from  the surface 
60
BONE  AND NERVE  SURGERY.
toward the bone, leaving a dead  wall on  one side and
a living  one on the other, the latter  became covered
with healthy granulations, ready for the work of repair;
and soon a  new skin was  seen gradually forming from
the margin of the old, and extending  over the granu-
lation*.
  All  this  being completed, we next watched,  with
interest, what transpired in the bones, and  observed the
process here to  be identical with that which had taken
place in the  enveloping soft parts, only requiring weeks
instead of days for its completion.   In the  bone, in-
flammation,  suppuration, ulceration, and sloughing were
but repetitions of what  had occurred in the soft parts.
The  dying portions of  the bones gradually lost their
vascularity,  while the  living increased in vascularity,
and the absorbents, pari passu, separated the two. When
the absorbents had completed their work,  and the dead
bone become detached, I took a pair of forceps and
lifted it off,  leaving the living bone  from which it had
been removed, raw, bleeding, and covered  with healthy
granulations; the end  of  the bone having lost all ap-
pearance of  the original tissue.
  The next  step in the  process was the extension, over
these granulations, of the skin which had already covered
the soft parts up to the margin of the bone.  The work
of reparation was now finished, and nature was seen in
these examples, as she always  is  under  like circum-
stances, to have performed a  complete amputation.
  The amputation in the different  toes required from
three to six  weeks, according  to the degree  of contusion,
the rapidity  of  the mortification,  and the size  and com-
pactness  of  the bone involved.
  Had I seen early the patient in whom the injury was 
BONE  AND NERVE SURGERY.
61
the result of contusion by a caisson,  before severe in-
flammation commenced,  much  time might  have been
saved by amputating the  toes; the nature of the injury
was such, that it was evident the parts involved could
not be saved, and by amputating high enough to reach
sound tissues, good stumps were attainable, and the cure
certain and speedy.   After, however, severe inflamma-
tion and swelling set in, it is better not  to interfere till
nature has exhausted her resources. In  cutting tlirough
inflamed tissues  there is always danger of giving exten-
sion to the gangrene.
  In  the  frosted foot, on the contrary, the case was
best left to nature, who  alone could determine  the ex-
tent of the injury, and where the line  of demarkation
would be established.
  In  a third case, now under treatment in one of the
military hospitals  in Mobile, the patient  accidentally
shot himself  in  the  hand with a pistol.  The palm of
the hand was resting on  the muzzle, when  it exploded;
the ball passed  obliquely through, coming  out  at the
back of the hand, fracturing and shattering the meta-
carpal bones of  the  middle and ring fingers.  In con-
sequence of the shattering  and violence of the explo-
sion,  the   back  of  the   hand was much  torn,  high
inflammation followed, with sloughing to the extent of
a dollar, leaving the  ragged ends of the bones exposed
to view.   At the end of three weeks, healthy granula-
tions began to appear, the slough having separated, and
the jagged ends of the bones began to be thrown off in
small fragments;  while  the  compact shafts, seen deep
in the wound,  were white, non-vascular,  and firmly
adhering to the  rest of the bones which were  covered
by soft parts.  Here it is evident that a portion of the
                          6 
62
BONE  AND  NERVE  SURGERY.
bone is dying, but in a wound still suppurating freely, it
is impossible to say how far necrosis will extend.   Gen-
erally where the extremity of a bone undergoing necrosis
is exposed  to view,  we can, at the end of three or four
weeks, determine pretty satisfactorily where the line of
demarkation  will be  established,  by running  a probe
gently along its  surface from the extremity  up under
the superimposed soft tissues; the  probe  glides along
the naked, smooth  bone, till it is stopped by granula-
tions  sprouting  from its  surface  and adhering to  the
surrounding tissues.  Here we have proof positive that
the bone is living at  that  point,  and here is  the  point
where the  dead  bone will separate from  the living.
The bone usually does not die in all its thickness  up to
this point,  but throws off, in most cases, a cap or  thim-
ble-shaped  exfoliation.
  With regard to the case above alluded to, all I  know
positively  is,  that  the ends  of  the bones are dying
and passing  through the  process of  necrosis  already
described, and thus, in a week or two more, nature "will
complete the work of separation, and that she should
not be interfered with till the sequestrum is fairly de-
tached.  When  the dead  bone is removed by forceps,
granulations  will sprout iip, and a firm cicatrix  soon
close  the chasm.
  It  is not uncommon to  see the end of  the bone ex-
posed, after  amputations,  either  from insufficiency of
flap or from unavoidable sloughing of the stump.   Here
we  have an excellent opportunity of studying the pro.
cess of exfoliation;  a portion of bone dies and is gradu-
ally cut loose by the absorbents and thrown off.  Some-
times it is a little scale, not larger and thicker than the
thumb nail, and is liberated  in  fifteen  to  thirty days, 
             BONE  AND NERVE  SURGERY.          63

leaving healthy granulations. I have seen three stumps,
two below the knee, and one in the middle of the thigh,
within the last few weeks, in which  this has occurred;
the largest fragment, that of the femur, was half an inch
wide, quite thin, and covered half the circumference of
the bone at the sawn extremity;  those of the two tibiae
were smaller, and took about the same time to separate.
   In  amputations  where  there  is abundance of  flap,
with imperfect adhesion, followed by copious suppura-
tion of the stump, from amputating through unsound tis-
sues  (as in  secondary amputations),  or  from constitu-
tional disturbance,—I say in such cases, where the bone
becomes diseased, and  necrosis  follows,  the process is
usually slow, and of very uncertain duration; frequently
several months pass before the sequestrum  is severed
from the living bone.  The surgeon, in such  cases,  must
be patient, pass a strong probe or director from time to
time to  ascertain whether  nature has completed  her
work,  and,  when  she  has,  he  should lose  no  time in
cutting down  and removing the  loose bone.  Forty to
sixty days will generally  complete  the  process,  but I
have  sometimes  been  obliged  to wait  many  months.
Here,  as in  suppurating  gunshot  wounds  involving
bones, the course the diseased action takes, as to time
and  involvement of adjoining parts  by  continuity, de-
pends upon  the character of the inflammation. Healthy
pus  will burrow  around the periosteum  of a  bone or
ligaments of a joint without implicating either, while a
very different result follows the contact of unhealthy pus.
Where the  discharge is fetid and ichorous, it is very
irritating, and its  contact  with healthy  bone will first
implicate the periosteum, then the bone, and may thence
extend along an entire shaft.  Whenever I see a pallid, 
64
BONE  AND NERVE  SURGERY.
ashy hue of the  lips of a stump, with a baggy, swollen
condition of the flaps,  thin ichorous discharge instead of
thick  laudable pus, together with quick pulse, feverish
thirst,  occasional sweats, etc.,  I  always feel  alarmed,
expecting the spread  of disease along  the shaft of the
bone,  and  even  danger to  life from hectic fever, and
perhaps pyemia.
  In  those cases  where  the  bone projects from  the
stump, the inexperienced  surgeon is often  tempted to
interfere,  not only unnecessarily, but  injuriously with
the operations of nature.  I .have been often consulted
to know whether it is  not best  to saw off the projecting
bone; but though a contrary opinion has recently been
advanced  by an  army surgeon,  I unhesitatingly say no.
Where  a  bone  projects  from  an open,  suppurating
stump, under any circumstances, it will require at least
a month,  and probably six  or  eight weeks, before the
stump  can be healed, whether the bone  is  on  or off.
Experience teaches that nature will amputate  the bone,
and generally at  a very good point, by  the  time  the
rest of the wound closes up  to its margin,  and thus
do away with the necessity  of  amputation by the sur-
geon:  the  absorbents  set to work, at  the  line between
the dead  and living  bone, and in  from four to eight
weeks, the work  is complete, and the  skin  soon  closes
over it.
  If while a stump is swollen, inflamed, and suppurating
freely, the surgeon cuts  down to remove  a projecting
end of bone, he  adds  to the inflammation, causes more
or less hemorrhage, shocks the system, makes the con-
dition of the stump altogether worse, and gains no time
in the final result, even if the case does well.   One of
the greatest objections to the operation is  the danger of 
             BONE  AND NERVE  SURGERY.           65

extending the necrosis, by exposing a fresh surface of
bone to unhealthy pus of the stump.  This must neces-
sarily be the most common result; the projecting  bone
to be removed dies because it is  exposed to air and pus,
and  the surface  exposed by the second  operation is
likely to be followed by similar result, from the  same
causes.   We have already laid  down the general  rule,
that no  attempt  should be made to remove a  seques-
trum before it is completely detached,  and the  same
rule applies to these stump cases.
   There is, however, sometimes a  sequel  to some of
these cases, that requires surgical interference.   It hap-
pens, where nature has performed the amputation of the
projecting  bone,  and the soft  parts have completely
covered it  over, that a conical  stump results, and the
end of the bone being covered merely by a thin cicatrix
of new skin, it is  tender, easily chafed, or hurt by slight
injuries, inflames,   sometimes  ulcerates,   is  trouble-
some in various ways, and  particularly  if an artificial
limb be worn.  In  such cases, the  conical form of the
stump is increased by the retraction  of the muscles, and
it  thus becomes  quite pointed. Under  such circum-
stances, it is often good surgery to  cut  down  upon the
projecting bone, detach freely its coverings, and saw it
off an  inch or two within  the soft parts, when a  rapid
cure usually follows.  Here we are operating on  tissues,
all of  which are sound,  and union by first  intention
ensues.
   With the view of farther  illustrating principles of
practice, I will give  a few abstracts  of gunshot  wounds
treated during the war.
   Case A. was  that of the  gallant General  Gracie,
since killed at the siege of Petersburg.  He was  wound-
                         6* 
66          BONE AND NERVE SURGERY.
ed in a skirmish at Bean's Station, in  Tennessee.   He
was struck by a musket-ball on the forearm, about  two
inches below the elbow-joint, the ball entering from be-
hind, grazing the  ulna,  passing  transversely,  deeply
below the flexor  muscles, and coming out in front of the
radius.   He came to Mobile, and called on  me to ex-
amine the wound,  stating that his surgeon had  pro-
nounced  it a simple flesh wound, which would be  well at
the end of his thirty days' furlough. The parts  around
the track of the ball were much inflamed, swollen,  and
evidently in the process of suppuration.  This was about
twenty days after  the receipt of the injury.   I gave at
once, as  my opinion, that the periosteum and bone  had
been contused, that exfoliation would  follow, with trou-
blesome abscess; and that at least three months would
be required for the recovery of the use of the arm.  The
little and ring fingers were also paralyzed.  The  inflam-
mation progressed and  two  abscesses  formed, one near
the entrance of  the ball and the other on the back of
the arm  between the radius and ulna.  At the end of six
weeks, the one near the entrance of the ball was  opened
and several small pieces of exfoliated bone removed.   A
week later the other abscess was laid open freely through
the fascia  and discharged a gill of pus.  The two  ab-
scesses now closed from  the bottom and the case went
rapidly on to cure.  There was great enlargement of the
forearm from deposition of lymph, which, together with
the paralysis of  fingers, was rapidly disappearing when
he returned to his command  two months after  the in-
jury.   He wrote me afterward that  his recovery  was
complete.
  Now the point in this case  I wish to impress  on  the
mind of  the student is the effect of contusion on bone. 
BONE  AND NERVE  SURGERY.           67
My  experience  leads me to believe that contusion  is
often quite as bad  or even worse  than a gunshot  frac-
ture.   When  a ball  grazes a bone in this  way and
passes out, the track of the ball often heals and closes
before the mischief in the bone is fully developed; the
disease of osseous tissue works slowly, and after the soft
parts have closed, the  inflammation  of the bone results
in abscess and necrosis, and  having no exit, much mis-
chief is done by burrowing of matter.   Where the bone
is broken by the ball, a compound fracture is  made, the
wound remains open,  there  is  free exit for  pus as it
forms, and the disease is less likely to extend.
   The surgeon who first treated the  case of General
Gracie passed his finger into the wound, and finding no
fracture  or splintering,  concluded  that it  was only  a
flesh wound and would soon close, and this opinion in
many cases would have been justified.
   When the spongy extremity of  a  long bone is struck
and contused by  a projectile, even where there is  no
break of  periosteum, I have seen  considerable extrava-
sation of blood into the cancellous structure ; and in the
case of General Deas, who was struck on the  knee by a
spent musket-ball,  at Shiloh, though there was no break
of the skin, he had serious inflammation of the joint, from
which he recovered with  difficulty.  I  have seen many
similar joint cases.
   Generally  speaking, the contusion  of a bone by a
projectile causes inflammation of  periosteum  and bone,
and the latter  dying gradually, finally exfoliates.  On
the  other hand, where the blow is  sharp and violent, the
contusion is sufficient to kill a part of the bone outright;
the  living parts around  increase in  vascularity, and the
dead part by  a vital process is gradually thrown off. 
68
BONE  AND NERVE  SURGERY.
  In these cases of contusion, it not unfrequently hap-
pens that  the concussion is communicated to the medulla
in the long bones;  it is torn, its blood-vessels ruptured,
blood is extravasated, and destructive inflammation may
be set up, followed by internal necrosis.  Where a long
bone is fractured  by a minie-ball, this  injury of the
medulla by concussion is not  unfrequent;  the shaft of
the bone even is often split for four or five inches.
  B. was  a soldier of the army of Virginia, whose radius
had been  fractured, about the junction of the lower and
middle third, twenty months before I was consulted.  I
found, on examination, a  considerable  enlargement of
the bone,  extending up and down between four and five
inches, with a fistulous opening on the anterior aspect.
On introducing a  probe, which  reached  the  interior of
the enlargement, dead bone was detected.   I cut  down
upon it, and discovered  that the shaft of the  bone had
been shattered, and no operation ever having  been per-
formed  before, all the fragments,  except several small
ones which had been floated out by the pus,  were still
in situ and inclosed  in a  cortical  formation, leaving a
single cloaca.  I removed  as many fragments as could
be heaped in the bowl of a tablespoon. Some of the frag-
ments were splinters knocked off by the ball at the time
of injury, while others were exfoliations from the ends
of the bone,  caused probably by the irritating presence
of the splinters and the  consequent suppuration.
   The work of reparation then went on rapidly, and the
cavity was soon filled up and permanently closed.
   This was a very common and simple type of a class
combining the first and second divisions of Dupuytren.
Many of  the fragments had been pent up from the time
of the original  injury and were gradually  incarcerated 
BONE  AND NERVE SURGERY.          69
by osseous deposit  from the periosteum.   The indica-
tions were clear, and still no attempt had been made to
meet them.  Had these fragments not been removed, the
suppuration might have continued for years. If the loose
fragments had been removed at the time of injury, the
case would have been reduced to a mere compound frac-
ture, which would have healed in six or eight weeks.
  C. was a soldier  in the army of Vicksburg, and  had
his  thigh fractured, eighteen months  before consulting
me, by  a  musket-ball, which struck the  femur  just
below the trochanter, on the outside, and  came out at
the opposite point on the inner side.  A number of frag-
ments were  removed by a field surgeon soon after the
injury, and  the  fracture was  then  treated by Liston's
splint.   The limb was shortened about three inches, but
the bone was firmly united.  There remained, however, a
fistulous opening, which continued to discharge until he
fell into  my hands.
  On examination,  I found the scars left by the entrance
and  exit of  the ball, and  of several other  openings
natural or artificial, but all had closed except one small
one about an inch and a half above the trochanter, to-
ward the crest of the ilium, which was discharging very
freely.   I concluded that the suppuration was  kept up
by dead bone or other foreign body,  but  could not, by
the most careful exploration with a probe, detect  any-
thing.   This small  opening was through the very dense
fascia that covers the gluteus muscle, which I laid open
freely for the purpose of proper exploration.  My finger
was passed into a  large  cavity  extending around  the
trochanter, hip-joint, and up toward the crest of the ilium,
the matter being forced to burrow by the fascia above
alluded to.  I could feel the capsular  ligament and pass 
70
BONE  AND NERVE  SURGERY.
my finger all around it.  No necrosed or diseased bone
could be detected, except one small fragment, not larger
than  a grain of Indian-corn, at  the  bottom of  the
abscess, beneath the trochanter, as he lay on his  back.
This  was removed  and the wound  stuffed  with lint, to
insure healing from the bottom, and give free exit to the
discharges.   Very rapid improvement followed, and the
abscess soon healed.
   I should have  mentioned, as  an important point in
this case, that the patient was much emaciated, greatly
prostrated by hectic, night sweats, etc., and his friends
thought  in a dying condition; he could certainly have
lived  only a few weeks without relief.
   After the  abscess closed, fever  came on,  with  the
formation of another  abscess on the upper and  inner
part  of  the  thigh.  As soon as this was  sufficiently
mature, it was opened and explored  as  the other had
been,  but no foreign body detected.  It was treated as
the other, and soon healed.  This  second  abscess was
doubtless caused by the burrowing of the matter from the
first abscess beneath the neck of the bone  to the inner
side.  The recovery of the patient was then so rapid and
complete that he gained twenty pounds in a  month.
   Now this case possesses two instructive points: first,
it shows how small a cause will produce a large and
even  fatal abscess; and,  second, it  shows how little
periosteum and  ligamentous covering  of  joints  are
affected by the contact of healthy pus.  Unhealthy sup-
puration would have diseased the shaft of the bone, and
opened the hip-joint, in all  probability.
   About the same time I was treating the above case I
had on hand another  equally remarkable;  the subject
was Mr. Luzenberg, of New Orleans, a young lawyer of 
BONE  AND NERVE SURGERY.
71
promise, who had been wounded in one of the battles in
Tennessee.  A single buckshot entered one  hip, and
after  following a very circuitous route,  lodged in  the
upper and  inner part of  the thigh of the opposite side;
a large  abscess resulted, which  continued to discharge
for several months, and  when  he came  to  me he was
gradually sinking from the discharge, hectic, etc., and
colliquative sweats.  The probe yielded no information be-
yond the existence of an enormous cavity. I  made a free
opening on the upper  and inner part of the  thigh; had
the good fortune to find the shot lying  at the bottom of
the cavity, and extracted it without difficulty.   He was
greatly emaciated, the muscles were contracted so as to
flex the thigh on the  pelvis and the leg on the thigh,
and yet  his recovery was rapid and complete.  Small
balls usually produce little irritation,  and  it is hardly
conceivable how a buckshot should have produced and
kept up such an enormous abscess.
   D.  had  his  thigh-bone  fractured,  at the  battle of
Chickamauga,  by a  minnie'-ball passing through  the
limb, at the junction of the upper and middle third,  five
months after which he came to consult  me.   No opera-
tion had  been  performed  for the removal of bone.  The
ball entered on the outside and came out at the inside
of the thigh,  and pus was still discharging from both
openings.  On probing, dead  bone was  detected on both
sides, but I could not determine whether  the work of
nature was finished or whether  necrosis was  still pro-
gressing.   The parts around were in good  condition
(a.i my  friend General Danl. Adams  remarked on  his
o^u case, of which I shall have something to say) for
"a reconnoissance in force," and in accordance with the
rule already laid down, I cut  down to  the bone on both 
72           BONE AND NERVE SURGERY.
sides to ascertain its condition.   On either side loose
fragments of bone  were found, the result both of the
original splintering, and of exfoliation of the  rough
angular ends.  The  ends of the bones had been smoothly
rounded off, were overlapping, and  firmly united,  and
the shaft seemed perfectly sound throughout.  The only
indication therefore was  the removal of the loose frag-
ments.  About a dozen small  pieces from one to three-
fourths of an inch in length were removed.  The wounds
were stuffed with lint, filled rapidly from  the  bottom
with granulations, and the man was soon perfectly well,
with the inconvenience of shortening of the limb to about
three inches, which occurred before I saw him.
   The foregoing  cases involve important rules of prac-
tice, and I think are worthy of being remembered by the
student.   A. is  a good example of the morbid  action
which often  follows the simple contusion of a bone with-
out fracture and the rule of practice which should guide
us.  In  such cases inflammation should be combated
from the  beginning, the wound should be kept open as
long as there is any suppuration within, and if an abscess
form, the earlier it is opened the better.
   B. C. and D.  are also representative  types of a class
of cases, in which loose fragments have  been allowed to
remain about the ends of the shattered bones, easily got
rid of by incision, and not incased by cortical formation.
When  such cases  are presented, two, three,  or  four
months after  the injury, or at a much  later period (as
very many are), I repeat, the rule is, if there be little local
inflammation or constitutional  disturbance,  "to  make a
reconnoissance in force," cut down, explore, and remove
all loose fragments  of bone, or other foreign  body; keep
the wound open until it heals from the bottom. 
BONE AND NERVE SURGERY.
73
   The following case is interesting in several points of
 view,  but more particularly as illustrating  one I have
 called attention to, viz., the tendency which bones have
 to necrosis, when exposed  to a suppurating  cavity.  In
 this case  the loose fragments  and rough ends  of  the
 bones were sawn  off and  the arm  well dressed with
 splints,  yet inflammation and profuse suppuration  fol-
 lowed, involving the  distal  end of the bone in necrosis
 which had to be removed.
   I saw the case in consultation with  Dr. C. H. Mastin,
 who has obligingly furnished me with the following state-
 ment:

   "J. H. Taylor, aged twenty-eight years,  private  in  Co.
 G, 8th Alabama Vols., Wilcox Brigade, had his right humerus
 fractured b . gunshot, in front of the lines at Petersburg, Va.,
 on the afternoon  of the 23d  June,  1864.  The  ball entered
 the arm  just above the condyloid expansion of  the bone,
 fracturing the same. On the morning of the twenty-fourth,
 the regimental surgeon removed, with the saw, the fractured
 ends of the bone and dressed the arm with a carved  splint.
 Owing to the great pain, swelling, and continued discharge,
 he was placed on the retired  list and returned home.   He
 reached Mobile in September, 1864, and  since  that date to
 the 12th May, 1865, he has suffered with violent pain and a
 very profuse discharge.
   " On the 12th of May, he was induced to submit to an
 operation for the removal of the necrosed bone.  A seques-
 trum  two and a half inches in length by one inch in width,
 with a thickness of half an inch, was removed from the  ex-
 ternal  condyloid  ridge.  A  thick  cortical shaft  had been
 thrown around the entire circumference, together with much
 thickening of the capsule  and ligaments of the joint, pro-
 ducing partial anchylosis of the elbow-joint.
  "After the  removal of the  sequestrum  the  discharge
 rapidly decreased, and the external wound, together with
 the sinus leading to the bone, healed in fifteen days.   He
has now very good use of the arm, which is daily increasing
in strength.
  " It  required considerable  force to effect  the removal of 
74
BONE  AND  NERVE SURGERY.
the sequestrum which was bound in by the new bone.  From
appearances I am induced to believe that the sequestrum
had not been fully detached, and that the operation for its
removal was done at as early a date as was justifiable.
  "In this  case, from 23d of June, 1864,  to  12th  May,
1865, three hundred and thirty-three days had elapsed, and
since the removal of the ends of the bone to the date of re-
moval of the sequestrum, three hundred and thirty-two days.
From his statement I am inclined to believe that periostitis,
which resulted in the death of the bone, set in immediately
after the ' resection' was performed by the regular surgeon.
He tells me he had  very great pain, followed by profuse dis-
charge, within a very few days after the operation."
  July 15th, 1865.

  This case is interesting as illustrating the liability of
such cases to  necrosis, the difference in time required
for the completion of the process, the necessity  of  re-
moval  of the  sequestrum, and  the promptness of the
relief from the operation.
  I will now give the type of a class of cases that often pre-
sent great difficulties and embarrassment to the surgeon.
  E. was wounded with a minie'-ball about twelve months
before consulting me.   The ball entered on the outside
of the thigh just  below the middle, and passing along
the posterior surface  of the femur, came out on the in-
side, knocking off  some  splinters.  High  inflammation,
with profuse suppuration, ensued, involving the tissues
around to some distance.   When presented to me there
was great enlargement and induration, covering nearly
the whole of the middle and lower thirds of the shaft of
the femur.  The outer wound had  closed, but the inner
one  continued to  discharge freely.  On introducing  a
probe, dead bone was discovered, but  what was its  ex-
tent, or whether detached or not, were points I  could
not determine; and in spite of all the books say, I re- 
BONE  AND NERVE  SURGERY.          75
peat that nothing but "a reconnoissance" can determine
the true condition of the parts  and the practice to be
pursued in such cases.  This man had been and still was
a great sufferer; the discharge was profuse, hectic fever
and sweats were wearing him away, and he called loudly
for relief at any risk. My belief was that nothing short
of amputation could be of any avail, but this would have
to be done near the trochanter,  and he was not in con-
dition to  stand such an operation, and I was  not  dis-
posed to undertake it.   It  was  therefore determined to
make a "reconnoissance in force,"  as had  been done in
other cases, and "feel the way."
   The anatomy of the thigh on the inside, where the
opening existed, and the dead bone was felt, is so com-
plicated as to render free incisions  at that  part hazard-
ous.  I therefore made an incision  down upon the outer
side of the bone, toward the back part, but failed there
in finding any disease  or obtaining any useful  informa-
tion.   I next  made carefully an incision  on the inner
side, following the fistulous track down to the bone.  On
inserting my finger, its point passed into a small cloaca,
in the cortical formation, thrown out by the periosteum,
around the necrosed shaft.   There were  no loose  ex-
ternal fragments, and it was evident that the shaft was
necrosed up to about the junction of the middle and upper
thirds,  about five inches above the cloaca  I  had dis-
covered.  I could feel the dead bone through the cloaca,
but it was firm in  position, and  I had  no evidence  that
it was detached.
   The question arose,  what should be done  next ?   To
afford relief, one of two procedures must be adopted, viz.,
either with trephine and gouge to cut away a large por-
tion of the cortical formation, in order to get at and re- 
76
BONE  AND NERVE SURGERY.
move  the necrosed bone, which might or might not be
detached; or secondly, to amputate  the limb  near the
trochanter as first suggested.  In the prostrated hectic
condition of the patient, neither of these  alternatives
could  be entertained;  he would have sunk from the
shock and hemorrhage.   If  the  cloaca had been on the
outer  side of the limb, where the bone is thinly covered
by soft parts, and where there  is little vascularity, it
might have  been  justifiable  to go on feeling the way, a
part of the new bone might have been removed and the
sequestrum  explored; but even  that would have been
doubtful practice.  Not only was there danger from the
immediate effects of such an operation, but great danger
in removing too much of the cortical formation, of pro-
ducing  a  fracture which would  have made a hopeless
complication in his condition.
  I concluded on  the whole that it was best to abandon
the operation,  to keep the wound open, and wait further
developments.   In the  course of a few weeks his con-
dition improved greatly, fever left him, appetite returned,
and he was up  and going about on crutches.  This opera-
tion was performed about eighteen  months ago,  and  I
see the patient from time to  time.   The discharge occa-
sionally does not  get out freely,  and he suffers pain and
has fever for  a week or two; he then gets better and
goes about again.  He  is constantly talking about am-
putation, and  although in good  condition  for it, cannot
make up his mind to have it done.   I  do not feel in-
clined to urge him on the subject,as he leads a  pretty
comfortable existence as he is,  and amputation  in the
upper third of the thigh is  always attended by fearful
risk.  He is dependent on his labor for support, and may
therefore be obliged to  submit to amputation, or  nature 
BONE  AND NERVE SURGERY.
77
may in time extricate a sequestrum that can be removed
without amputation and without danger to life.
  Now this is another good example of contusion of bone.
A musket-ball knocked off a fragment of bone, which
was  removed  by the  regimental surgeon, and it  might
reasonably have been expected that the case would do
well, but the  bone was contused, extensive  ostitis and
periostitis followed, resulting in necrosis of a considera-
ble portion  of the shaft  of  the femur,  which became
completely surrounded  by a thick cortical  formation.
When I cut down I found no loose fragments, and it is
reasonable to  conclude that  contusion of the bone was
the principal cause of all  the subsequent trouble.   If  a
similar extent of bone had  been chipped out with a chisel,
and  consequently  without contusion, no  suppuration or
other troublesome  symptoms  would have occurred.
  In relating  the  symptoms of this  case, I  stated that
there was enlargement and induration  involving nearly
the whole of the middle and lower thirds of  thigh; and
when the thigh was grasped it felt as if there was an enor-
mous bone within, one four or five times the normal size.
  The young  surgeon is  almost  sure to mistake this
enlargement for bony deposit, and in some very rare
instances it is  so;  the enlargement and hardness is from
deposition of lymph  in the  cellular and other tissues,
and when cut into  it is almost as firm  as cartilage.
  It will  be seen  that no harm was done, even in this
case, by cutting down and exploring the  parts fully.  I
failed in doing good, beyond gaining  positive informa-
tion  to guide my action, but  the  patient soon regained
his previous status.   There was no other way of  ascer-
taining the true condition of parts, and I felt it a duty
to give the man the benefit of the doubt. 
78           BONE AND NERVE SURGERY.

  The above case is presented as the type of a very im-
portant class of which I have seen many during the war;
they are almost endless in variety, and the practice to
be pursued  depends  greatly upon  the  particular bone
involved, the character of the surrounding soft parts,
the degree  and kind of inflammatory action, condition
of constitution, etc.  Had the bone involved in this case
been  one of  the leg, arm, or forearm, my course would
have been very different. I should have removed, boldly,
enough of  the  new cortical formation by trephine and
chisel, to get fairly at the sequestrum, and to remove it
with  forceps.  The  superficial covering of soft parts,
their  lesser vascularity, the little danger of hemorrhage,
and the facility of  supporting the  part  properly  by
splints  after the operation,  would have fully justified
such  a procedure; but  in  the case  of  the thigh-bone,
with  the immense thickening and  other circumstances
detailed, the dangers were too great.
   These cases of the thigh are those most  calculated to
embarrass  and baffle the surgeon, and more often render
amputation necessary than  others, although its  dangers
in the upper third are fearful.
   I will next  call attention to another class of cases
which are  embarrassing and in which it is impossible
to  lay  down very explicit  rules of action.   They can
only  be treated well by those who have had much expe-
rience, and used it wisely.   I allude to those  cases in
which the long bones  have been fractured and badly
shattered by balls, the fragments removed, the ends of
the bones sawn off, and there has been a loss of substance
to the extent of one, two, or three inches. Here we have a
compound fracture of the worst kind, necessarily accom-
panied by  profuse suppuration, and if union takes place 
BONE  AND  NERVE  SURGERY.           79
it is effected by the process of granulation after the lapse
of months.  Although all the fragments may have been
removed by the surgeon immediately after the injury,
and the parts placed in the most favorable position pos-
sible for union, still the high inflammation and suppura-
tion which necessarily follow, not only retard the work
of repair, but  often  complicate it greatly by  causing
necrosis of one or both extremities of the sound  bone.
It has already been  stated that  an abscess in contact
with the shaft of a sound bone covered by its periosteum
is fraught with danger; the periosteum first becomes
implicated, next the  bone  nourished  by it,  and exfolia-
tion to a greater  or  lesser extent follows.  Nay more,
the medullary  cavity being exposed  to the contact of
pus and air, endostitis, with internal suppuration, ensue,
and  death of the  inner surface, or entire thickness of
the bone,  results;  the bones having little circulation ex-
cept what is supplied through the external and  internal
periostea. This diseased action sometimes travels rapidly
and involves the whole shaft of the bone.
  Endostitis would seem to be more common after gun-
shot wounds than others, and this has  been attributed to
the violent concussion of the blow, which extends its in-
fluence far beyond the actual point of fracture,  but still
I feel assured that it has been much less frequent in our
American war than it is said to be in Europe.
  M. Jules Roux, Dr. Valette, Baron  Larrey, and others
have recently written much on the subject, and  particu-
larly in connection  with  the Crimean  war; and  from
their account osteo-myelitis or  endostitis has there been
very frequent and fearful in its results.  Now  this has
not been  my  experience  in the United States; these
cases occur  occasionally, but by no means  bear a large
proportion to external periostitis and  exfoliation. 
80
BONE  AND  NERVE  SURGERY.
   I will here remark that the climate of our Southern
 States of America seems peculiarly favorable to wounds.
 Our surgeons have been writing much on gunshot frac-
 tures and  the facility with which good recoveries  are
 made.  I  feel assured that no experience of the Old
 World  can compare, in success, with that of the sur-
 geons of the Southern States, not from  any peculiar
 skill  on their part,  but from the superiority  of  the
 climate.  When  endostitis does occur, and consequent
 exfoliation, the case should be left to nature until  the
 sequestrum is  detached.   Amputation of  the stump is
 rarely justifiable in these  cases, nor should disarticula-
 tion,  as recommended by distinguished French surgeons,
 be  thought of.   Where endostitis exists in  a shaft, if
 amputation be performed above, the same diseased action
 is almost certain  to attack the new stump.  There is
 good  reason to believe  too that endostitis is a common
 cause of death after secondary amputations.  Where an
 amputation of the  thigh, for  example, is  performed a
 few hours after a gunshot injury, not more than  half a
 dozen arteries ordinarily  require ligature, but if it be
 deferred two or three or more days, double the number
 will have to be secured; thus proving the increased vas-
 cularity of  the soft parts.  The  bone is influenced  in
 the same way,  and its increased vascularity predisposes
 to  endostitis  and periostitis.   The flaps in secondary
 amputation hardly ever do any healing  by first inten-
 tion,  and are liable to suppuration and gangrene.
  But let us return from this  digression  to that class of
 cases where  there has  been loss of one, two,  or three
 inches of bone, and nature is  called on to repair  the in-
jury,  after  the surgeon  has, as far as possible, removed
 all  impediments, in the shape of detached  fragments, 
BONE  AND NERVE  SURGERY.
81
jagged ends, etc.  While the suppuration is going on in
the interspace between  the ends of the bones, these be-
come inflamed and throw out granulations; the whole of
the ends  may  throw out granulations, or  the whole of
the ends  may  become necrosed and  exfoliate; what  is
more common,  the  prominent  angles and  edges  are
thrown off, while the rest granulates, and after the little
exfoliations take place, the whole of both extremities
become entirely covered with granulations, and ready to
adhere to any healthy tissue they may come in  contact
with.  This is what  occurs in favorable  cases.  In the
unfavorable cases, the soft parts become  extensively im-
plicated  in  unhealthy   inflammation  and  suppuration
which the bone, both externally and internally, may
propagate to the articular extremities, and even involve
one or more joints.
   In the favorable cases, while the healthy action above
described is going on in  the ends of the bones, the peri-
osteum is throwing out bony matter;  and there is every
reason to believe that the surrounding tissues play a de-
cided and important part in  this osseous deposit, for I
have  seen, in the humerus, particularly where the weight
of the forearm drags down the lower fragment in fractures
after considerable  loss of bone, or rather perhaps holds
the lower fragment about the position  it  held before the
injury, the  muscles  not contracting with force enough
to draw it up,—I say I have seen in such cases a gap of
full two inches hedged over and around by cortical forma-
tion,  inclosing  an  internal cavity filled with fragments.
The proof of this bony formation filling up  the inter-
space was given in  the facts,  that  bone, periosteum,
and all were removed for at least two  inches, and yet
perfect bony union  took place  without  any shortening 
82
BONE  AND NERVE  SURGERY.
 of the limb.   The  case of General Adams was  one in
 point.
   Where, in such  cases,  the granulating ends  of  the
 bones can  be brought in contact, adhesion and  subse-
 quent firm bony union readily follow.  Where, on  the
 contrary, a gap is allowed to remain between the  bones,
 while suppuration is progressing, more or less exfoliation
 often occurs—a cortical  structure forms  around  them,
 leaving a cloaca  to  which a fistulous channel  leads.
 Under such circumstances, the incasing bone forms very
 slowly, being greatly interfered with by the inflamma-
 tion and suppuration kept up by loose fragments of bone.
 Three, four, six,  twelve months may pass before there
 is consolidation enough to prevent motion  at the point
 of fracture.
  These, I repeat,  are embarrassing cases; if the sur-
 geon  waits  too  long, such an amount of callus may be
 thrown around the necrosed bone, and  the  soft parts
 become so thickened and indurated, as to obscure  every-
 thing and make operative interference exceedingly diffi-
 cult.   On the other hand, if  he interferes too soon, the
 inflammation is aggravated, suppuration increased ; there
 is risk of hemorrhage calculated  to injure a debilitated
 subject, and the bone not being in condition for removal
 of all the dead parts,  the case is set back materially, or
 much aggravated.
  In  the cases of exposed necrosing bone, in stumps,
 where the progress of the exfoliation can be  watched
 from day to day, we never can be at a loss for the point
 of time at which the surgeon should interpose, but the
 condition of parts under  consideration is very different.
 Here  the work of nature is all  hidden from view, and
the  difficulty  is to know when nature has finished  her 
BONE  AND  NERVE  SURGERY.
83
work and the time for the surgeon has come.   There
are no  abstract principles on which we can  rely; the
detachment of the necrosed bone may require two, three,
six, or more months, and if morbid action is progressing
from point to point, years even may be consumed before
it is accomplished; but such examples are  rare.   Most
of the cases that  have consulted me have  been treated
for  several months in military hospitals, or by surgeons
in the country, before coming to me.
  Whether the time after  the  injury had been  three
months or three years, I have not hesitated to  introduce
a director  into  the fistulous opening, cut  down  to the
bone, and make a full reconnoissance of its condition.
If the necrosed bone is detached, remove it; if not, close
the wound, except a small opening for a tent, and wait
till  nature has completed her work.
  I am deterred from  this course only by high local  in-
flammation, or  great  constitutional  disturbance, with
prostration, etc.
  Both reason and  experience justify such procedure;
no one can calculate the mischief which may arise from
the retention of one or more fragments of dead bone;
while on the other hand, a simple incision adds little to
the  local and nothing to the constitutional irritation.
Give  the patient  chloroform, make a sufficiently free
incision with a keen  knife to allow the finger  to be  in-
troduced; if there is loose bone, remove it; if there  is
not, close the wound, retaining a tent or bit of lint, and
await patiently the process of nature.  There are now
thousands of poor fellows, mutilated by this  war, who
might have been saved months or even years of suffer-
ing, to  say nothing of the loss of life, by  timely oper-
ative interference. 
 
ADDENDUM  No.  1.
  I heretofore laid it down as a rule, that when a stump
bone  is  exposed and projecting from deficiency of  flap
(from whatever cause) and  is necrosing, it should, without
interference, be  intrusted  to the process of nature for its
amputation, and  not  be subjected to a secondary operation
by which the inflamed soft parts would have to be cut loose
with a knife, and the saw then applied an inch or two above
the end, say one, two, or three weeks after the  primary am-
putation.   I have said  that it was best to wait until the
bone had sloughed off and  entirely healed over, and if it
formed a conical inconvenient projection, a secondary opera-
tion might then be resorted  to, to rectify the difficulty.
  I believe still that the above is the best general rule, but
I have witnessed some cases which satisfy me that there are
exceptions, in which much time  may be saved by selecting
proper cases and proper time for interference.
  About six months  ago, I was asked by Dr. F. A. Ross,
of Mobile,  to see in consultation with him Mr. Brenan, who
a week before had had his foot severely wounded by a rail-
road accident.  The four small toes were  badly bruised, the
sole of the anterior part of  the foot lacerated, and the skin
on the dorsum of the foot  and back of the toes, for  two
inches, scraped off, and the big toe alone was left intact.
  The four small toes  I  found completely mortified,  and
clipped  them all  off with scissors at their articulation with
the metatarsal bones.
                           8                  (85) 
86
BONE AND NERVE  SURGERY.
  The parts  suffered severely from  inflammation  and bur-
rowing suppuration between the metatarsal bones and plan-
tar fascia;  but improvement went on gradually, the sinuses
closed, the  ends of the four bones were covered with healthy
granulations,  and the new skin advanced from the foot  all
around to the base of the projections formed by the meta-
tarsal bones.  The accompanying rough sketch from memory
will give an idea of the appearance presented at the  time of
operation.
The dotted lines mark out the metatarsal bones.
  The big toe is sound, but much drawn out of position  by
its flexors.   The ends of the four metatarsal bones are seen
rough with  granulations,  and projecting.   A black line
crosses each of the four small bones at right angles, show-
ing the points at which they were removed by bone nippers.
An oblique black line is also seen on the metatarsal bone of
the great toe, indicating the point at which it was sawn off.
  It would have been bad surgery, under any circumstances,
to have left the great toe standing alone, as it would  have
been a great impediment in walking, and I therefore deter-
mined to make a complete stump at once.  I amputated the
great toe  in  the manner usually recommended, and at the
same time with bone  nippers removed the ends of the four 
ADDENDA.
87
small bones on the same level.   As expected, these bones
had become so vascular and soft that they cut without resist-
ance, like cork.  The cut ends immediately threw out healthy
granulations, and the whole stump soon healed over.
   In another case, McKoy, a soldier,  aged thirty-seven, in
whom  I amputated a thigh at the middle,  for the relief
of a terrible neuralgia, the result  of a previous amputa-
tion.  I removed, in like manner, the granulating extrem-
ity of the bone.  The limb was removed by the rectangular
flap operation of Mr.  Teale; there  was abundance of flap,
and the stump seemed in every way satisfactory.  But the
patient  having  been suffering for nearly three years with
neuralgia, his nervous system being much deranged, and the
neuralgia not at all relieved  by the operation,  it was impos-
sible to keep the stump quiet;  it was constantly subjected
to both  voluntary and involuntary motion, and every time it
was raised, the psoas and iliacus muscles drawing it inward
as well  as  upward, the end  of the
femur protruded  at the inner angle   (Y^,/^^~~\
of the wound. As soon as the stump   3^>\     '  \
was replaced on its pillow, the bone   L  \  \      \
receded to its proper position be-   \  ■ \  \     ■ \
neath the flap.                       |   \   \    '■'■%.
   The  accompanying sketch, from
memory, will give a sufficiently ac-
curate idea of the manner in which
the granulating  extremity  of the
bone protruded  when  the  end of
the stump was elevated.
   The  first consequence  of the constant  motion, friction,
and exposure of the  bone  to  air, was partial  necrosis;  a
thin scale half an inch wide, a line in thickness, and cover-
ing the anterior half of the sawn extremity, exfoliated, and
was thrown off at  the end  of  twenty-seven days  after the
amputation.  The whole stump had healed  except the open-
6 
88            BONE  AND  NERVE SURGERY.

ing through which the bone played at the inner angle;  and
the bone, which projected an inch or a little more when pro-
truded, as well as the cavity in which it lay when retracted,
had become covered by an adventitious membrane similar to
that of old sinuses.   The end of the bone, when protruded,
was not unaptly compared by a by-stander to the glans penis
of a large dog, being  perfectly red and smooth like the object
of comparison.
  After trying in vain by means of caustics, retentive band-
ages, and  adhesive straps,  to keep the bone in place and
heal the parts over it, I determined to excise it, being satis-
fied that it was sufficiently soft from its increased vascularity
to be easily removed  with bone nippers, which was done.
  Although the femur would  have defied any instrument of
this kind in its normal state, it was in this condition nipped
off with perfect ease.   I then had no difficulty in closing  the
soft parts over the orifice left, by adhesive straps and band-
age, and the wound soon closed  without  any unpleasant
symptom.   The bone in this condition of increased vitality,
which  is equal to that of  a  muscle, granulates and heals
readily.
  Nature in this case had done  all  the amputating she was
capable of, the  necrosed portion had been thrown off, and
the remaining bone forced into an abnormal degree of vitality.
After the exfoliation, the end of the bone was left covered by
granulations, which soon became coated with an adventitious
membrane, that could not  unite to the surrounding parts,
particularly when disturbed by constant motion.
  Now the practical points in this case and the one of Brenan,
as well as the pathological conditions, are the same.  Nature
had in each case  thrown off by exfoliation the condemned
portions of bone—had left  the ends vascular and softened—
the remaining part of her  work would not only have been
accomplished with difficulty, but would have  ended in very
unsatisfactory results; cicatrices would  have formed  over 
ADDENDA.                    89
these projecting bones after the consumption of much time,
but the cicatrices would have been projecting, conical, sensi-
tive, subject to abrasion, and altogether sources of discom-
fort  and annoyance.  In the case of the foot, it was  clear
that the patient could  never walk, with or without a shoe,
until a new stump was made by an operation.
   When the end of a  bone  is necrosing, the sound  bone
above the line of demarkation always becomes more vascu-
lar and softened (as in the two examples just given), and
after a  certain time may be easily divided by nippers, or
even strong scissors.   A question has therefore arisen in
my mind, whether the practical bearings of this fact have not
been too much overlooked.
   Where  the process of exfoliation is slow, or where  after
the exfoliation is accomplished, it is clear that there will be
an undue projection of the bony point of the stump, may we
not only gajn time but a better stump, by removing the pro-
jecting  bone  at an early period by  properly shaped  bone
nippers, which may be glided up the bone beneath the over-
hanging granulations and made to divide it transversely ? It
is  impossible  in such cases to remove the bone with a saw
without disturbing the soft parts around more than would
be prudent, and moreover, cutting would do  much  less vio-
lence to the softened bone than the rude action of a saw.
   The important practical point in such cases would be the
question of time.  At what period after amputation would it
be prudent to remove  the extremity of the  bone as above
proposed ?  This would necessarily vary much according to
the circumstances of the case.  Sometimes a stump will do
well for a week or two  after amputation, and then be seized
with gangrene and the bone become exposed; at other times,
from immediate gangrene, or from  deficiency of flap, the end
of the bone is exposed at the offstart, and the work of necro-
sis commences forthwith. In  other cases, as that of Brenan,
                           8* 
90
BONE AND NERVE SURGERY.
the bones are exposed by the direct action of some mechan-
ical injury.
  The following general rules will apply to almost all cases:
When the end of a bone is exposed, wait until the process
of exfoliation is fairly under way, the surrounding inflam-
mation subsides, and healthy reparation is going on in the
whole wound, then with  an awl,  exploring trocar, or the
point of a narrow bistoury, puncture the bone and determine
whether it is soft enough to be  easily  divided  by bone nip-
pers or strong curved scissors.   In the small  bones twelve
to fifteen days, and in the  larger from  fifteen to twenty-five,
would be sufficient to justify the operation.
  If the wound  be gangrenous or pale, ulcerative and dis-
charging unhealthy matter, any such  procedure would be
likely to result in more harm  than good,  and  should not
be undertaken.
  I confess that my experience in such cases has not been
sufficiently long and varied to justify me in laying down any
positive  rules, but I am satisfied there is here a field that
has not been sufficiently explored, and  all I hope  is to at-
tract the attention of others to it. 
ADDENDUM  No.  2.
  I have, during the war, witnessed a number of cases of
neuralgia following gunshot wounds and amputations, which
I may work up at some future day, and can make room at
present  for but two cases, which are of unusual interest,
both from their novelty and practical bearings.
  Case  1.—This case is the same one of Marshall McKoy,
a soldier, aged thirty-seven, already alluded to in Adden-
dum No.  1, in connection with the treatment of a stump
after amputation of  the thigh, and will for the present com-
plete the history of this extraordinary example of  human
suffering and complicated surgery.
  The subject  had his leg crushed above the ankle by a rail-
road accident,  1st  August,  1862, and was amputated on the
twelfth, about the junction of the lower with the middle third,
by a regimental surgeon.  According to his statement, the
operation was not well done, the bone being left exposed from
insufficiency of flap.   The amputation was performed at the
Greenville hospital,  Alabama.  Two months  after the am-
putation he obtained a furlough, though the stump was not
healed, and went to his home in Mississippi.  The weather
at the time of  his journey was very cold, and he thinks he
"took cold in  the stump," as  neuralgia, the source of his
subsequent troubles, commenced soon after.
  Some time during the early part of the summer of 1863,
he came to Mobile to  consult me, and I then saw him for
                                          (91) 
92
BONE AND NERVE  SURGERY.
the first  time.  He was, and had been  ever since the time
above alluded to, suffering intensely with neuralgia in the
stump.   I  advised a second amputation,  to which  he ob-
jected, and returned home.   After  continuing to suffer at
home, he was again amputated by Dr. J. M. Baylis, on the
11th September of the same year, 1863.
  He continued to suffer without  intermission,  and came
back to consult  me about  1st May, 1864, and finding  no
relief from any remedy I could  recommend, .and thinking
that some twig of nerve might have  been inclosed  in a liga-
ture at the last operation, I advised a third amputation, to
which he submitted on the 19th of May, 1864.
  I made a double skin flap, took off only about one inch
of the stump, and sawed off the bone just below the tuber-
osity of the tibia.   The stump healed by first intention; the
ligatures all came away  in ten days, and in a few  more the
parts were entirely healed  over.  On examining the part
removed, the portions  of two large nerves  removed  were
found enlarged and engorged.
  No relief whatever followed this operation; the pain was
not referred to any particular spot or spots, but was diffused
over the whole surface of the stump, and so intense as to
make existence intolerable.    Opiates, which he bore badly,
stupefied him and  deadened sensibility for a time, but nar-
cotics,  arsenic, quinine,  iron, etc. never afforded  him any
relief.
  On the first of June following, the  pain being still referred
to the stump, I cut down at the upper part of the popliteal
space, exposed the ischiatic nerve,  and  took out about  an
inch of the trunk and a portion of  the popliteal and pero-
neal nerves, altogether about three inches in length.  The
nerves were all  enlarged, and,  no  relief  following, he  re-
turned home in despair.
  On 1st May,  1865,  he returned  to Mobile  to see me,
nearly twelve months after the last operation, still suffering, 
ADDENDA.
93
and having had no intermission except for a few hours at a
time.
  The pain was still, as it had been invariably, in the end of
the stump, and although there was perhaps no very good
physiological reason for so doing, I cut down upon  the
popliteal space and dissected out the two large nerve trunks
completely down to the extremity of  the stump.   Still no
relief.
  I may here remark, by way of parenthesis, that the reader
will find some excuse in Case 2, following this, in which the
function of the median  nerve  was perfectly preserved after
the excision of  five inches of its trunk.
  As may be well imagined, I  was at a loss what to suggest
next,  having lost all faith in surgical operations.   Still the
man called loudly for relief, and said he could not endure his
suffering.  I next  proposed, discouraging as  the  prospect
was, amputation of the thigh, to which he consented.
  The  amputation was done  about four inches above the
knee, on 21th May, 1865, by Teale's rectangular flap method.
The flap behind being short, gave me an opportunity of dis-
secting up the ischiatic  nerve about three inches above the
sawn  extremity of the  bone.   The nerve even  up to that
point was engorged and double its normal size.
  The stump was a little tedious in healing, from causes de-
tailed in Addendum  No. 1, but finally did well and made a
good cure so far as the amputation was concerned,  but with-
out any relief to the neuralgia.
   He still called for relief at any hazard, and I proposed, as
a dernier ressort, excision of the ischiatic nerve, at its point
of exit from the pelvis.   To this he consented, and on the
28th  August,  1865, I cut down behind the trochanter upon
the nerve midway between it  and the tuber  ischii, and re-
moved a little  more than an inch  of the nerve immediately
below the pyriformis  muscle.  The  nerve  here  is deeply
seated  but easily got at, the skin, areolar tissue, and gluteus 
94
BONE AND NERVE  SURGERY.
magnus being the  only  parts to be cut through.   There
was no vessel of any size divided, but there was continuous
bleeding from small  branches at the bottom of the wound,
which being difficult  to get at, it was stuffed with a wad of
cotton dipped in persulphas ferri, which arrested the flow
instantly.   The  cotton was removed a few hours after, but
healing by  first intention  was prevented  by the styptic.
The wound soon granulated and healed rapidly.
  For the first time in my various operations, I in this  last
one reached a part of the main trunk of the nerve which ap-
peared to be sound.   The piece removed  in this operation
was an inch and a  quarter long, and when examined, the
upper half  looked perfectly healthy in size, color, and text-
ure, while the  lower half had a diseased appearance; it was
enlarged and engorged with blood.  I was  much encouraged
too by the fact that on my visit the  next day, he expressed
himself as greatly relieved for the first time, and confident of
cure.
  The following day, however,  I found  he had  passed  a
horrible night and was  suffering as much  as ever, and  still
referring the pain, as he had done after every operation, to
the extremity  of the existing stump.  Even in the  two in-
stances in which I resected  the  nerve, the  pain was referred
to the stump,  as it had been in every amputation.
  The last operation was on the twenty-eighth of August,
and although after healing of the wound he left Mobile for
his home about the first of  October, a  month afterward,
asserting that he had experienced  no  relief from the last
operation, I am satisfied that he was much benefited by it;
his general  health, appetite, digestion, etc. were much im-
proved, and he no longer gave evidence to the nurses and
others of the  severe neuralgic  pains which had previously
tormented  him.  He had suffered so long and so severely
that he  had become an opium eater—taking as much as
twenty grains of morphia daily.  In order to procure the 
ADDENDA.
95
opiate, he would often make bitter complaints, when I was
satisfied he was  suffering but little.
   This  case  is  certainly one of the most remarkable on
record in several points of view.  The limb was first crushed
by a railroad car, he was afterward subjected to three ampu-
tations of the leg, one of the thigh, and three resections of the
nerve.  It is interesting too in a pathological and physiolog-
ical point of view.   It is unusual to see inflammation follow
up the trunk of  a nerve as it did in this case, and it is diffi-
cult to say why the pain should invariably be referred  to the
extremity of  four stumps in  succession.   The above history
extends over  a period of three years.
   Case 2.—The subject of  this  case, Mr. Wysinger, aged
about fifty,  of robust constitution,  lives  at the little village
of Citronelle, thirty miles above Mobile.
   He came  to consult me about twelve months  ago for a
tumor, which had been growing fifteen years on the front of
his forearm;  it  had never interfered with the functions of
the hand or arm, and had never given the slightest pain or
inconvenience until two or three  months  before consulting
me, when it commenced  giving him a good deal of pain in
the fingers, and  produced partial contraction of the little
and ring fingers.
   The tumor was  about the size of a cocoanut, oblong or
egg-shaped, and  extended from an inch  below the bend of
the arm to within an inch of the wrist; it was elastic, and
presented the "characteristics of an encysted tumor.
   He readily consented  to its extirpation, and in the pres-
ence of Dr. Henderson, Dr. McCleskey, and several younger
members of  the profession, I made an  incision  its  whole
length along a  line drawn  from  the tendon of the biceps
muscle to the center of the wrist.  On dissecting down care-
in !lv, I discovered, to my surprise, that it was a neuromatous
encysted tumor.   At its upper part the trunk of the median
nerve was seen  to enter it, and immediately to expand its 
96            BONE  AND  NERVE SURGERY.
fibers widely over the whole anterior surface of the sac; at
the lower border of the tumor  they were again collected
into a common trunk.   The expanded fibers were so com-
pletely incorporated with the sac that it  was impossible to
liberate them from it by dissection.   I therefore divided the
nerve above and below the tumor and  dissected out  the
entire mass.  The adhesions were  slight  and there was no
difficulty in turning out the sac, which had been punctured
and partially evacuated.  It is remarkable that the contents
of the sac presented  the appearance  simply of  grumous
blood, though  of fifteen years' standing.  Vidal de Cassis, in
his Pathologie Externe, reports a case very similar in every
respect, the only one I know on record.
   Though  interesting  pathologically, I have reported this
case mainly on account of its physiological bearing.
   Although at least five  inches of the  median nerve were
removed, its functions were not interfered with in the slight-
est degree.  The operation was followed by neither paraly-
sis nor loss of motion, and  the  neuralgic pains, which had
occurred two  or  three months previously to the operation,
disappeared entirely.   I have been in the habit of meeting
this gentleman frequently during the twelve months which
have followed the operation, and he assures me all the func-
tions of the fingers are perfect.
   The tumor had been growing slowly for fifteen years,  and
as the function of the median nerve was probably gradually
destroyed,  nature  made provision  to supply its place;  but
how it was done, I must leave to wiser heads than mine to
explain. 
 
 
 
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