fix with the splint the joint above or below the fracture. In cases in which a splintering of the bone into a joint has taken place, more especially in those cases in which tendons have been injured, there may be a good deal of effusion into the joint and the tendon sheaths, and this may be organized into fibrous tissue leading to permanent stiffness. This is particularly apt to occur in old people. Care must be taken in such instances by gentle exercises, and by passive movement during the process of cure, to keep the joint and tendons free. To take a common example,—in fracture close to the wrist joint, it is necessary to arrange the splint so that the patient can move his fingers and thumb, and the splint must be taken off every day, in order that the wrist and fingers may be gently bent, straightened and exercised.
The treatment of fractures has undergone considerable improvement of late years. Simple fractures are not kept so long at rest in splints, but are constantly “taken down” in order that massage and movements of the limb may be resorted to. This, of course, is done with the utmost gentleness, and with the result that swelling, pain and other evidences of the serious injury quickly disappear, whilst a more rapid and complete recovery is ensured. Stiff hands and feet after fracture are much less frequently met with. By the aid of the X-rays it is now easy for the surgeon to assure himself that fractured surfaces have been well adjusted and are in close apposition. But if they are not in a satisfactory position, and it be found impracticable to assure their close adjustment by ordinary methods, the surgeon now, without undue loss of time, cuts down upon the broken ends and fixes them together by a strong wire suture, which remains permanently in the tissues. If the fracture be associated with an open wound of the part (compound fracture), and the broken ends are found incapable of easy adjustment, immediate wiring together of the fragments is now considered to be a necessary part of the primary treatment. The French surgeon, Just Lucas-Championnière, has done more than any one else to show the advantage of discreet movements, of massage and of exercises in the treatment of fractures.
Special Fracture in Young People.—The long bones of children and growing persons consist of a shaft with cartilaginous ends in which bone is developed. As the result of injury, the end of the bone may become detached, a variety of fracture known as diastasis. Such a fracture—however well treated—may be followed by arrest of growth of the bone or by stiffness of the neighbouring joint.
Delayed union means that consolidation is taking place very slowly, if at all. This may be due to local or constitutional causes, but provided the bones are in good position, nothing further than patience, with massage, and with due attention to general health-measures, is necessary.
An ununited fracture is one in which after many weeks or months no attempt has been made by nature to consolidate the parts. This may be due to the ends not having been brought close enough together; to the seat of fracture having been constantly disturbed; to muscle or tendon being interposed between the broken ends, or to the existence of some constitutional defect in the patient. Except in the last-named condition, the treatment consists in cutting down to the broken ends; freshening them up by sawing off a thin slice, and by adjusting and fixing them by a wire or screw. Ununited fracture of the leg-bones in children is a most unsatisfactory and rebellious condition to deal with.
There is still a difference of opinion as to the best way of treating a recent fracture of the patella (knee-cap). Many surgeons are still content to follow the old plan of fixing the limb on a back-splint, or in plaster of Paris splints, and awaiting the result. It is beyond question that a large percentage of these cases recover with a perfectly useful limb—especially if the fibrous bond of union between the pieces of the broken knee-cap is adequately protected against being stretched by bending the leg at too early a date. But in some cases the fragments have been eventually found wide apart, the patient being left with an enfeebled limb. Still, at any rate, this line of treatment was unassociated with risk. But after Lister showed (1883) that with due care and cleanliness the knee-joint could be opened, and the fragments of the broken patella secured in close apposition by a stout wire suture, the treatment of the injury underwent a remarkable change. The great advantage of Lister’s treatment was that the fragments, being fixed close together by the wire stitch, became solidly united by bone, and the joint became as sound as it was before. Some surgeons, however, objected to the operation—in spite of the excellence of the results obtainable by it—because of the undoubted risk which it entailed of the joint becoming invaded by septic micro-organisms. As a sort of compromise, Professor A. E. J. Barker introduced the method, which he deemed to be less hazardous, of holding the fragments close together by means of a strong silver wire passed round them vertically by a large needle without actually laying open the joint. But experience has shown that in the hands of careful and skilful surgeons Lister’s operation of openly wiring the fragments gives a perfect result with a comparatively small risk. Other surgeons secure the fragments in close contact for bony union by passing a silk or metal suture around them circumferentially. Many years ago Lister remarked that the careful selection of one’s patients is an antiseptic measure—by which he meant that if a surgeon intended to get the most perfect results for his operative work, he must carefully consider whether any individual patient is physically adapted for the performance upon him of any particular operation. This aphorism implies that not every patient with a broken knee-cap is suited for the opening of his knee-joint, or even for the subcutaneous adjustment of the broken fragments. An operative procedure which is admirably suited for one patient might result in disaster when adopted for another, and it is an important part of the surgeon’s business to know what to advise in each individual case. (E. O.*)
Industrial Applications of Bones.—By the increasing inventiveness of man, the industrial utilization of animal bone has been so developed that not one of the constituents fails to reappear in commerce. Composed of mineral matter—phosphates, &c.—fat and gelatinous substances, the phosphates are used as artificial manures, the fat is worked up by the soap-maker and chandler, and the gelatinous matter forms the basis of the gelatin and glue of commerce; while by the dry distillation of bones from which the gelatin has been but partially removed, there are obtained a carbonaceous residue—animal charcoal—and a tarry distillate, from which “bone oil” and bone pitch are obtained. To these by-products there must be added the direct uses of bone—for making buttons, knife-handles, &c.—when an estimate is desired of the commercial importance of these components of the animal frame.
While most of the world’s supply of bones goes to the glue and gelatin works, the leg and thigh bones, termed “marrows” and “knuckles,” are used for the manufacture of bone articles. The treatment which they receive is very different from that practised in the glue-works. The ends are removed by a saw, and the bones are steeped in a 1% brine solution for three to four days, in order to separate the fibrous matter. The bones are now heated with water, and allowed to simmer for about six hours. This removes a part of the fat and gelatinous matter; the former rises as a scum, the latter passes into solution, and the bones remain sufficiently firm to be worked up by the lathe, &c. The fat is skimmed off, and, after bleaching, reappears as a component of fine soaps, or, if unbleached, the oil is expressed and is used as an adulterant of other oils, while the stearine or solid matter goes to the candle-maker; the gelatinous water is used (after filtration) for making size for cardboard boxes; while the bones are scrubbed, dried, and then transferred to the bone-worker.
The glue-worker first removes the fat, which is supplied to the soap and candle trades; the bones are now treated for glue (q.v.); and the residue is worked up for manures, &c. These residues are ground to a fine or coarse meal, and supplied either directly as a fertilizer or treated with sulphuric acid to form the more soluble superphosphates, which are more readily assimilated by growing plants. In some places, especially South America, the residues are burned in a retort to a white ash, the “bone-ash” of commerce, which contains some 70-80% of tricalcium phosphate, and is much used as a manure, and in the manufacture of high-grade superphosphates. In the gelatin industry (see Gelatin) the mineral matter has to be recovered from its solution in hydrochloric acid. To effect this, the liquors are freed from suspended matter by filtration, and then run into vats where they are mixed with milk of lime, or some similar neutralizer. The slightly soluble bicalcium phosphate, CaHPO4, is first precipitated, which, with more lime, gives ordinary tricalcium phosphate, Ca3(PO4)2. The contents of
