ON THE 
TREATMENT OF UNUNITED FRACTURE 
/ 
BY MEANS OF 
ARTIFICIAL LIMBS, 
WHICH 
COMBINE THE PRINCIPLE OF PRESSURE AND MOTION AT 
THE SEAT OF FRACTURE, 
AND LEAD TO THE 
FORMATION OF AN ENSHEATHING CALLUS. 
ILLUSTRATED BY THE 
HISTORY OF FOUR CASES OF FALSE JOINT IN THE FEMUR, EIGHT IN THE 
LEG, AND TWO IN THE HUMERUS. 
BY 
HENRY H. SMITH, M. D., 
CONSULTING SURGEON AND LECTURER ON CLINICAL SURGERY IN THE 
PHILADELPHIA HOSPITAL, 
AND SURGEON TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA. 
V7ITH EIGHT WOODCUTS. 
Extracted from The American Journal of the Medical Sciences, for January, 1855. 
PHILADELPHIA: 
T. K. AND P. G. COLLINS, PRINTERS. 
1855. ON THE 
TREATMENT OF UNUNITED FRACTURE. 
The function of the bones of the extremities being to sustain the weight 
of the body, or aid in locomotion and prehension, any destruction of their 
continuity impairs the action of the muscles which are attached to them, and 
destroys the usefulness of the member. In accomplishing these functions, 
the bones are passive, and, therefore, resemble levers which are acted on by 
forces applied throughout their length. As when a lever is broken the 
splicing of the fragments may restore its usefulness, so, when a bone is frac- 
tured, the temporary and artificial union of its fractured ends may enable it 
to perform its functions nearly as perfectly as before the occurrence of the 
accident. Under ordinary circumstances, the reparation of the injury is the 
result of a natural action; but when this fails, no means of treatment seem 
more reasonable than that afforded by the application of such a constricting 
band as will afford artificial support at the seat of the injury. Saw a bone 
in two, and surround it at the point of division with a ferule, and it will again 
prove a lever of sufficient strength to sustain certain powers. Carry out the 
same ideas in an ununited fracture, and modify the means of support at the 
fracture, so that they may act properly on flesh and blood, and the nearly 
normal condition of the limb will be restored, or the patient, at least, will 
be enabled to use it for a great variety of purposes. 
In the ordinary treatment of fractures, nature furnishes the bond of union, 
and, therefore, but little aid is required from the surgeon-rest and the appo- 
sition of the fragments being sufficient to enable her to accomplish the cure. 
But, when she has failed in the performance of this important action, surgery 
has always been ready to step forward and interfere, and, in some instances, 
has done so with a rudeness that has terminated either in the loss of the limb 
or the life of the patient. 
In inviting professional attention to a successful plan of treating false-joint, 
which embodies the principles of pressure and motion in the part, I hope to 
induce surgeons to admit that a less dangerous and inconvenient method than 
the seton, resection, caustic, or wiring of the ends of a fracture, may do as 
much, if not more, than either of these well-known surgical means of treating 
false joint. With a view of showing the defects of many of the plans of 
treating this affection, heretofore recommended, I shall briefly enumerate 4 
them, and then, after referring to the pathological conditions of the parts, as 
well as to the more recent physiological views of the formation of callus, cite 
a few cases, as illustrative of the advantages of pressure at the seat of fracture, 
when combined with the stimulus of gentle and frequent motion of the ends 
of the broken bones. 
The formation of callus being due, under ordinary circumstances, to in- 
creased vascular action in the part, the means of treatment generally suggested 
for the cure of false joint have assumed the necessity of stimulus as a funda- 
mental point. With the view of hastening nature in the formation of the 
much desired bond of union, and in some instances without much reference 
to the difference in the state of the bones in a recent fracture, and in one 
which has existed many weeks, surgeons have urged the employment of local 
stimulants to all cases, without specifying the conditions which demanded it. 
Of course, means which were useful in one period of a fracture, could not be 
equally so in another; yet, but little distinction has, in many instances, been 
made between the treatment of a false joint of three, or of eighteen months' 
standing. Thus, friction might be useful in the first, but of no service in the 
last; whilst resection might be attempted in an old case, and yet not be justi- 
fiable in a recent one. The following plans of treatment, which have been 
suggested from time to time, sufficiently illustrate the views of surgeons in 
the pathological condition of false joint, as well as the ingenuity of each sur- 
gical period, and its dissatisfaction with the means of treatment previously 
recommended. 
The most ancient of the plans of treatment proposed for the consolidation 
of a false joint, was friction of the ends of the bone. This was advised by 
Celsus, and subsequently recommended by John Hunter and others; and when 
followed by rest, sometimes accomplished the cure of cases in which union 
was rather retarded than entirely absent. It is generally regarded as espe- 
cially applicable to the very recent cases of fracture in which the so-called 
callus does not harden, or is not sufficiently abundant. Next to the direct 
excitement of the local circulation by irritating the bone, was its development 
by indirect means, such as blisters and caustic issues, applied to the soft parts 
around the fracture, as advised by Dr. Joseph Hartshorne, of Philadelphia, 
in 1805; Walker, of England, in 1815; and subsequently by Wardrop and 
Brodie, as well as by Velpeau. The use of the tincture of iodine, as an in- 
jection into the fracture, and of stimulating liniments and plasters, also belongs 
to this class; whilst electricity, galvanism, and acupuncturation, are only modi- 
fications of the same idea. These means, like friction, necessarily develop a 
certain amount of vascular action; but can only prove useful in the recent cases 
of delayed or tardy union, rather than in the more ancient forms of false joint. 
As a more certain and permanent stimulant, we have next the suggestion of 
the introduction of a seton between the ends of the bones, as advised by 
Winslow, and urged, with especial reference to the humerus and jaw, by the 
late Dr. Physick, of Philadelphia. The employment of this means of ex- 5 
citing action was, however, far from being invariably followed by consolidation, 
though the patient wore it as directed for four or five months; and, in accord- 
ance with recent views, does more harm than good.1 In the case of false joint 
in the thigh, it generally failed so completely that it was admitted by Dr. 
Physick to be a very doubtful remedy in the treatment of this condition of 
the fragments in fracture of the femur.2 
In more obstinate cases, it was proposed by White, of England, and subse- 
quently practised by others, to resect the ends of the bones which constituted 
the false joint, establish a new surface, and then, by rest, attempt a cure; but 
so dangerous has this operation been deemed, from the severe constitutional 
excitement it often produced, that the celebrated French surgeon, Sanson, was 
induced to think that 11 all prudent surgeons would agree that it was better to 
leave the patient with his infirmity than to attempt to cure him by this opera- 
tion. " As illustrative of its dangers, I would refer the reader to the details 
of a case in which I performed it on the bones of the leg,3 and in which the 
patient barely escaped with her life. Where the surgeon has not wished to 
saw off the ends of the bones, he has endeavoured to create a new surface by 
the application of caustic or the actual cautery; whilst, in order to insure the 
rest and apposition of the fragments, when thus freshened, either by caustic 
or the saw, they have even been wired or tied together, and yet the operation 
has failed in accomplishing a cure. The development of a new action in the 
part, by inserting ivory pegs into the bone, near the fracture, as suggested by 
Dieffenbach, or by subcutaneous drilling of the ends of the bone, as recently 
advocated by Dr. Brainard, of Chicago, together with a variety of similar 
means, are additional instances of the difficulties and defects of preceding 
plans, and of the efforts of surgeons to remedy the evils of the other methods 
which have been suggested. 
In all these varied plans of treatment, it is important to remember that the 
patient has either been confined to bed for many weeks, at the risk of losing 
his general health, or, after suffering from the performance of an operation, 
been exposed to excessive suppuration, phlebitis, hectic fever, or purulent ab- 
sorption, especially when the bones were resected. They are, therefore, not 
only attended with great inconvenience, but often with great danger, whilst 
frequently their failure has necessitated the amputation of the limb. 
In most of the means of treatment thus briefly alluded to, it is easy to 
notice the effect of the pathological description of the condition of parts in 
false joint or ununited fracture, as furnished by Boyer, to wit, that, in unu- 
nited fracture, a true joint, or a condition approaching it, is usually found, in 
which may be noted the rounded surface and smooth face of an articulation, 
as well as a capsular ligament with synovial fluid. The fact that this descrip- 
1 See Transact. Am. Med. Assoc, vol. vii. p. 557. Prize Essay of Dr. Brainard, 
of Chicago, 1854. 
2 Dorsey's Surg. p. 135. 
3 Am. Journ. Med. Sci. vol. xv. N. S. p. 84. 1848. 6 
tion has been so generally received as correct, might be supposed to be proof 
of its exactness; yet more detailed and extended observation has shown that, 
though frequently existing, this condition is not invariably seen, the bones 
being sometimes joined by a fibrous tissue, and often deficient in anything 
like a capsular ligament, synovial membrane, articular cartilage, or fluid. 
As it is essential to a correct plan of treatment that we should possess a 
correct knowledge of the pathological condition which is to be relieved, a 
reference to the varied changes of structure found in an ununited fracture, 
and often modified both by time and position, will prove useful; whilst an 
allusion to the ordinary steps of reproduction in bone, may tend to elucidate 
the modus operand! of certain plans of treatment. 
The most ancient theory of the formation of "callus" was that the new 
bond of union was due to an exudation of a gelatinous or viscid fluid (like 
glue) around the seat of fracture; that it was the product of effused blood, 
and that this viscid fluid kept the bones in contact, and gradually hardened 
into an osseous condition. This doctrine seems to have prevailed from an 
early period, and to have continued in an indefinite state until the experiments 
of Duhamel, Dupuytren, Breschet, and others, showed the agency of the 
periosteum in causing the formation of the mass, and the analogy existing 
between the repair of injury in a bone and that seen in the repair of a wound 
in the bark of a tree. 
After following for many years the opinions of the French school in rela- 
tion to the growth of bone and the formation of callus, physiologists have 
recently had their views materially changed, and their ideas enlarged by the 
developments of the structure of bone, as made by (that great modifier of 
physiological doctrine) the microscope. The existence of the Haversian 
canals, spaces, and ossicles, as well as of the osseous granules and cartilagin- 
ous cells, having all been thoroughly demonstrated, the study of the forma- 
tion of the bony tissues has been pursued with an accuracy that has done 
much towards the advancement of a more correct knowledge of osteogeny, 
and with it of the process pursued by nature in the production of callus. 
As the results of a minute and extended observation by microscopists, and 
especially of the opinions expressed by Mr. Paget,1 it is now admitted, " that 
in the fracture of a long bone the injury is seldom limited to the bone, but 
that the adjacent tissues participate in it; that the periosteum, though rent, is 
rarely much damaged, and seldom stripped off the broken ends; that the ex- 
travasation of blood about the fracture is not only uncertain, but unequal in 
the different tissues, being often very slight in the periosteum; that the cel- 
lular tissue in and near the seat of the injury, is soon infiltrated with lymph, 
or a serous-looking fluid, which contains cells like those of granulations; and 
that the so-called callus, in its early stages, does not differ materially from 
the material formed for the repair of other subcutaneous injuries; that the 
* Paget's Leet. Surg. Phathol. Phil. edit. p. 160, et supra. 7 
bones are ultimately united by the formation of granulations, in which are 
found nucleated cells as the embryo forms of fibrous tissues, and that this 
structure becoming subsequently the seat of granular osseous deposit, leads to 
the formation of an intermediate bond of union, rather than an "ensheathing 
callus," the latter being, in Mr. Paget's opinion, rarely found in the fractures 
of the human subject, though often seen in animals. When seen in man, it 
has been in the ribs, clavicle, and humerus, and was due, in his opinion, to 
the disturbance of the proper mode of repair by motion. 
In a case of ununited fracture of the femur in a hale man of 20, recently 
placed under my care, the condition of the ends of the bones exhibited in a 
very marked degree the effect of motion in inducing the formation of this 
provisional or ensheathing callus, there being a mass around the end of each 
fragment, as felt through the soft parts, which created a tumour nearly of 
the size of a child's head at two years of age. In this case, there had been 
imperfect rest throughout the treatment, and nature had, therefore, apparently 
acted in this man in the manner often seen in the experiments on animals, 
and thrown out an amount of new material capable of sustaining the bones 
under these circumstances. 
It is an inquiry worthy of note in passing, whether, in the treatment of 
fractures, very perfect rest may not be one cause of the deficiency of the new 
bond of union, and consequently lead to the formation of a false joint. In 
the cases of false joint, hereafter reported, moderate motion has certainly in- 
duced union, and this question should therefore receive attentive consideration, 
especially in treating cases of tardy union not actually resulting in false joint, 
lest it prove that rest in the treatment of fractures has been too strongly in- 
sisted on. 
In studying the formation of the " intermediate," or, as it is more fre- 
quently termed, " the definitive callus," Mr. Paget says, that the course of 
nature in its formation is well exemplified in the condition of the end of a 
bone after amputation. In this case, as well as in compound fractures, gra- 
nulations, he remarks, "are always seen to form within and on the medullary 
canal, and gradually to protrude like the rounded head of a mushrooma 
description which every surgeon has doubtless verified in the delayed union 
of stumps, and there is, I think, no doubt that in old fractures, as in ampu- 
tations, the ends of the bone are disposed to take on a similar action, and that 
the granulations formed on the ends of the fracture lead sometimes to the 
development of bone in the cancellated portion of the fracture without the 
formation of any fibrous or cartilaginous deposit. At the same time, the 
vascular action in the lacerated edge of the external periosteum creates granu- 
lations on the edge of the compact matter of the bone, so that the granula- 
tions of the centre and of the circumference of the bone being gradually 
approximated, a bony convex cap is formed, which closes the surface of the 
bone whether as left by the saw in an amputation, or by nature in an ununited 
fracture; thus creating a round, solid extremity, devoid of external periosteum, 8 
yet having this membrane extending as far as its circumference-that is, up 
to the original point of division of the fibres of the compact structure. Such, 
at least, is the condition which I have more than once seen upon a careful 
examination of the ends of the bone removed in an old and well-marked case 
of false joint. Of course, in this state of the parts, we cannot anticipate union 
from the capped extremities of the bone, though we may, as will be hereafter 
shown, obtain it from the periosteum on each side of the fractured ends. 
When, instead of the formation of granulations and osseous granules upon 
the fractured extremities of a bone, there is only the fibrous or cartilaginous 
cell, it will be found that the bone will be closed by the attachment of a 
fibrous or cartilaginous structure, which, as Mr. Paget suggests, is the ordinary 
state of the parts in fracture of the patella, olecranon and intra-capsular neck 
of the femur, and which, it is well known, is the condition seen in certain 
recent forms of false joint, the union being either fibrous or cartilaginous, as 
in the false joint of the radius, and some of the other bones. As the deposit 
of osseous granules and the formation of bone is hardly probable in this form 
of ununited fracture, except in very recent cases, or those which are more 
correctly instances of retarded union, we must here look to some other point 
than the ends of the bone for a bond of union, and again find it in the perios- 
teum which surrounds the bone up to the seat of the fracture, this periosteum 
being capable, under proper excitement, of uniting the ends of a fracture. 
To prove this, I now urge the employment of the following plan of treat- 
ment in ununited fracture, believing that when, in any false joint, whether 
recent or ancient, the two fragments are permitted to overlap moderately, 
whilst, at the same time, such action is excited by the pressure of one perios- 
teal surface against the other, as may be obtained by gentle and long-con- 
tinued motion in using the limb, a growth of callus will be often induced and 
accomplished with much less local and constitutional disturbance than it can 
possibly be by friction and rest, pressure and rest, the seton, resection, drilling, 
or the use of ivory pegs, as heretofore recommended; whilst the patient will 
escape confinement, free suppuration, phlebitis, hectic fever, and the serious 
effects which have often resulted from these plans of treatment. 
That pressure and friction of the surface of the external periosteum will 
lead to the formation of bone, has long been known to surgeons, and exem- 
plified in the formation of a new acetabulum in cases of luxation of the head 
of the femur upon the pubis, two specimens of which are now in the Wistar 
and Horner Pathological Museum in Philadelphia; and other instances from 
the head of the humerus are doubtless well known, as the result is not a 
rare one. If, then, a rounded, smooth bone like the head of a femur, can, 
by pressure, lead to the absorption of the edge of the iliacus internus and 
psoas magnus muscles, then of the periosteum on the ilium and pubis, until 
it exposes the compact matter of the surface of the pelvic bones, and then 
induce an osseous deposit around the free edge of the ulcerated or absorbed 
periosteum, why should the same results not follow the application of similar 9 
forces when the two periosteal surfaces are in apposition near the seat of a 
fracture? It most certainly does so, and leads to the development of an 
amount of provisional or ensheathing, as well as of intermediate or definitive 
callus, fully equal to the support of the body. 
How this pressure and motion, acting on the external periosteum, lead to 
the growth of new bone, or callus, is fully explained by the recent observa- 
tions of histologists. From the remarks of Mr. Kolliker on the histology of 
the osseous system,1 it appears that in the growth of bone, the elementary 
processes in the layers of the periosteum are as follows: The periosteum of 
the primary cartilaginous bones being proportionally very thick and vascular, 
consists, as early as the fifth month, of common connective tissue and fine 
elastic ligament. On the inner aspect of this fully formed periosteum there 
is deposited an ossific blastema (4), firmly adherent to the bone (see Fig. 1), 
Fig. 1. 
Fig. 1. Transverse section from the surface of the 
shaft of the metatarsus of the calf, magnified forty- 
five diameters. 1,1. Rudiments of the Haversian 
canals of the compact substance. 2, 2. Area of 
the canals. 3. External periosteum. 4. Ossifying 
blastema. 5. Young layer of bone. 6. More de- 
veloped layer of bone.-After Kolliker. 
so that, when the periosteum is removed, it remains upon the bone as a mode- 
rately thick, soft, whitish-yellow lamella, in which the microscope shows 
fibrous tissue, and granular, oval, or round nucleated cells, measuring 
0.006.001 of a line, from which, after a time, the bone cells are formed, out 
of the formative cells of the blastema (page 325), the soft bone lamellae pass- 
ing into the blastema. The development of the ossifying blastema Mr. Kol- 
liker regards as due to the numerous vessels of the young periosteum, the 
origination of its fibres being from fusiform cells, as he has frequently observed 
it in man and animals. The formation of bone in this blastema occurs, 
he thinks, wherever it is in connection with bone. 
Although these observations of Mr. Kolliker are chiefly limited to the 
action of the young periosteum, there is reason to suppose that the adult 
periosteum continues to act in the same manner, although not so rapid in its 
formation. If, then, pressure of the two sides of the fragments of an ununited 
fracture lead to an absorption of the outer layer of the periosteum, and thus 
expose the blastema or structure described by Mr. Kolliker, as between the 
compact structure and the inner face of the external periosteum, it is easy 
1 Manual of Microscopical Anatomy. Phil. edit. p. 324. 10 
to understand how the periosteum may, under the stimulus of this pressure 
and motion, be enabled to create a sufficient amount of irregular bony deposit, 
or intermediate and provisional callus, to serve as the bond of union for the 
ends of a false joint. 
Without, however, enlarging on these physiological points, it may suffice 
to say, that it is evident from the action of the periosteum in old luxations, 
as well as in certain diseases and injuries of the bones, that it is capable, 
under stimulus, of throwing out a mass of new bone, and that it is only neces- 
sary to excite it properly to lead to the formation of such an ensheathing 
structure as will restore the continuity of the bone, and consequently of the 
action of the muscles attached to it; thus reproducing the usefulness of the 
limb. Such means, I think, will be found in the use of the apparatus here- 
after described, the formation of which is based on the following proposition. 
If a patient, after amputation of the leg or thigh, can sustain the weight of 
the body upon an artificial support, which is only a series of hollow cones, so 
adjusted as to play upon each other (at the joints), and thus facilitate pro- 
gression, why may he not obtain the same support with his limb on, from 
some similar mechanical contrivance, made sufficiently light to be moved by 
wasted and weakened muscles ? Surely, but little mechanical ingenuity is 
necessary to the development of such means of progression; and, in calling 
attention to those subsequently employed, I wish to lay no claim to originality. 
It is the surgeon's duty to suggest the principle for the construction of an 
instrument or apparatus, and the business of the cutler, or other mechanic, 
to develop it in the material most capable of furnishing the qualities required 
of the apparatus, and the credit of manufacturing a light and neat apparatus 
for the treatment of false joint, either for the upper or lower extremity, in 
accordance with my views and suggestions, is due to Mr. Rohrer, cutler, of 
North Sixth Street, Philadelphia. The application of the principle of pressure 
and motion is the result of considerable observation of the defects of the treat- 
ment of false joint by the ordinary plans, as well as of several dissections 
made by me of uncured cases. 
The results of my plan of treatment are shown in the histories of the fol- 
lowing cases, which I present as furnished to me, or as found in my notes of 
the patients as they were presented to me:- 
Case I.-False Joint in both Bones of the Leg, of ten 'months' standing, 
cured whilst walking about, by the use of the Artificial Limb.-Account 
furnished by Dr. Wm. Waters, of Frederickstown, Md.: "You request me 
to give my experience of an apparatus introduced by yourself in the treatment 
of pseudarthrosis. 
" In the first place, permit me to tender you my acknowledgments for the 
cases reported by you j1 as that principle has been completely successful in one 
case with me, of an aggravated character, and from report is acting very bene- 
1 American Journal of Medical Sciences, vol. xxi. N. S. p. 106, 1851. 11 
ficially in another, which has only been wearing for about a month the appa- 
ratus made by your ingenious cutlers, Messrs. Rohrer & Sons. 
"Mr. S , aet. 35, had received a compound comminuted fracture of the 
tibia and fibula, on the 4th of September, 1849. The accident occurred from 
the wheel of a tender to a locomotive passing over the right leg obliquely, 
about two and a half inches below the knee, comminuting somewhat the tibia 
and the fibula, and piercing the soft parts nearly opposite the injured tibia. 
The fracture of the tibia was obliquely inwards, about two and a half inches 
below the insertion of the ligamentum patellae. In passing my finger into 
the wound (it could be introduced opposite the spine of the tibia and carried 
around the face to the under surface of the bone), some comminution of the 
fracture could be ascertained in the lower shaft, but there was very slight dis- 
placement of the ends, as one slab or piece, which could be felt depressed 
slightly beneath the lower shaft, was raised with my finger to its place. The 
foot was of the natural temperature five hours after the accident; the dorsalis 
pedis and posterior tibial arteries were very feebly felt; but his pulse was 
pretty good and firm, though somewhat enfeebled. Drs. Gerry and Strong, 
of Harper's Ferry, near where the accident occurred, yielding in an effort to 
save the limb, he was brought, by return train of cars, to this place, where his 
family resided. He had some fever for a week or more, and suppuration, and 
a slough about the size of a large pear occurred over the fractured shafts of 
bone, which resulted in necrosis, exfoliation of the surfaces, and caries of the 
ends of the bone until April, 1850. In February, the immovable apparatus 
was applied, and subsequently a carved splint fitting the outside of his leg was 
fastened by a roller on the entire limb. Injections of nitrate of silver to the 
tibia were also tried. About twelve months after the accident, a seton was 
passed between the shafts of the tibia, the fibula having united in the early 
stage of the case. The leg was splintered for months; the seton was with- 
drawn, or rather it cut itself out in four weeks, on the principle of Lourme's 
modification of Physick's plan; this also failed. During November and De- 
cember, 1850, acupuncture was also used to excite inflammation in the part, 
the patient's health being good at this time, from previous generous diet and 
tonics. My patient now became anxious for excision of the fibro-cartilaginous 
ends. But the pseudarthrosis being near the knee-joint, the loss of bone 
from the block to be removed would have been at least from one and a half 
to two inches in width, and would have encroached upon the ligaments on 
the inside of the knee. I therefore prevailed upon him to try an apparatus 
like yours in the case reported in Vol. XV., New Series, of the American 
Journal of Medical Sciences, except that it extended some six or seven 
inches above the knee. As soon as this was applied, our patient, on the 26th 
of March, 1851 (about eighteen months after the accident), immediately, with 
a cane, walked across the floor with a pretty firm step. The mobility of the 
artificial limb at the knee and ankle had otherwise a twofold desirable purpose, 
as it permitted the exercise of the knee and ankle-joints, the latter having 
become considerably impaired in motion, from an injury he had sustained 
about a year previously. In from four to six months, the tibia became suffi- 
ciently strong to walk without the apparatus, and his ankle also improved. 
The fractured bone firmly united, and in six months after wearing it, he re- 
sumed his situation, in the employ of the Baltimore and Ohio Railroad Com- 
pany. I have not seen him for some time; but am credibly informed by his 
family, that he has had no occasion to wear the supporter for upwards of a 
year. Indeed, he might have dispensed with it earlier, but I advised him to 
wear it as a precautionary measure. 
" I feel every confidence in the success of the other case under treatment, 12 
who is a respectable physician of our county. I saw a brother of his to-day 
(April 28, 1853), who informs me that the leg is becoming more stiff, 
although the doctor has only been wearing the artificial limb about a month. 
This fracture was oblique in the lower third of both bones; the fibula readily 
united, but the tibia did not. The case Is only of five months' standing." 
Case II.-Pseudarthrosis of the Bones of the Leg, of five months' standing, 
cured by the Use of the Artificial Limb in nineteen weeks.-Reported by Dr. 
Wm. Waters, of Maryland. "On the 28th of November, 1852, Dr. J. W. 
J. fractured his left tibia and fibula, about the lower third of the leg; the 
fracture was simple, but oblique. His leg was placed in Roe's apparatus, by 
Dr. R. H. Thompson, of Urbana, and in a few days was changed to another; 
but, in three or four days, the shafts of the tibia were thrown out of position, 
and the spine of the tibia was rather more than half an inch out of line. He 
suffered considerably from the irritation of the fracture. I saw him with Dr. 
T., the attending physician, ten weeks subsequent to the fracture, and found 
the provisional callus only of a ligamentous character, and very soft, so much 
so that we endeavoured to reduce the shafts of the tibia to a rectilineal position, 
but failed, in consequence of the ligamentous union. We therefore proposed 
breaking up the slight union, and resetting the limb. This was not consented 
to by Dr. J. The knee of this leg had been anchylosed for many years, as 
it was injured during his boyhood, and had very properly been fixed at a 
slight angle to facilitate his walking with that limb. We now applied to the 
ununited fracture, the immovable apparatus of Suetin, and also advised tonics 
and exercise in his carriage, or upon crutches, with generous diet, as his 
general health had suffered from confinement to bed. About the twelfth 
week, the limb was examined, when but very slight, if any, improvement 
was noted, and the bone is still flexible. In consequence of erythema, and 
occasionally neuralgia in the limb, the apparatus had to be removed, and 
his sufferings were considerable for a simple fracture. This may be ascribable 
to two causes; first, the overlapping of the bones to some extent; and, secondly, 
his nervous temperament, he having suffered from dyspepsia previously; and, 
indeed, his great toe had some gouty thickening around the first joint. On 
the 6th of April, 1853, upwards of four months, we exchanged the apparatus 
of Suetin for that employed in the previous case. After wearing Dr. Smith's 
apparatus about five months, the tibia became firm, and since then our patient 
has been walking about with only a cane." 
February 20, 1854. 
CASE III.- Ununited Fracture of the Femur, of five months' duration, cured 
in seventeen weeks by the Artificial Limb, so that he coidd walk with only a 
cane.-Jno. K , aged 40 years, was admitted into St. Joseph's Hospital, 
in the fall of 1852, under the care of the late Dr. Wm. E. Horner, labouring 
under a recent fracture of the lower third of the left femur. After being 
treated by Dr. Horner, with Dessault's long splint slightly modified, the bone 
was discovered to be ununited, the amount of callus being very small and per- 
mitting free motion at the seat of fracture. Friction of the ends of the bone 
being freely practised, blisters were applied around the limb at the seat of 
fracture, and the patient took cod-liver oil freely, with full diet and porter; 
when, after a few days, the splints were again applied and the limb kept at 
rest for four weeks. A second examination yet showing no improvement, the 
limb was carefully bandaged from the toes to the groin, and splints of binders' 
board applied around the thigh, when he was placed on crutches and directed 
to walk about as much as possible. When I took charge of the wards, a short 13 
time after this, I found him unable to move the limb or bear his weight upon 
it, but continued the treatment of Dr. Horner for some time longer, whilst 
the artificial limb was being made. On the 17th of April, the dressing was 
removed and the motion at the fracture found to be free in nearly all direc- 
tions, the limb being shortened nearly three inches, except when extension 
was practised. The new apparatus being applied, he was at once placed on his 
feet with crutches, and walked across the floor, putting his foot to the ground 
and bearing some weight upon it. The apparatus requiring alteration, he was 
kept in bed for five days, at the end of which time he again applied his artifi- 
cial limb and walked about the grounds freely, spending much time in the 
open air as warm weather came on. When the apparatus was removed, after 
six weeks' trial, there was an evident firmness in the fracture, and on October 
3, 1853, seventeen weeks after its second application, the bone was so firm that 
he was permitted to walk without the splint, and in a few days walked freely 
with only a cane, and left the hospital. In December, he left the artificial 
limb at my office, being well able to walk with a high-heeled shoe, the short- 
ening measuring by accurate measurement two inches. 
Case IV.- Ununited Fracture of the Femur of six months' standing ; Sup- 
puration ; Great exhaustion; Hectic; Cured in nine weeks by the use of 
the Artificial Limb.-The history of this case is given as furnished me in the 
following letter, dated May 22,1854, from Dr. G-. Dock, of Harrisburg, Pa.:- 
"The bearer of this letter, Mr. Neelan, is desirous of having his brother 
placed in St. Joseph's Hospital, for the treatment of an ununited fracture of 
the femur. As a short account of his case will be of interest to you, I will 
give it to you, as far as I can. He is twenty-eight years of age. It 
appears his thigh was fractured by the falling of a bank of earth on him, 
whilst excavating a cut on the railroad. The accident occurred last fall. He 
was placed under the charge of a physician of this place; but, after he had 
been under his treatment for three months, the physician was discharged, and 
I was called in to attend him. 
" I found him in the following condition: first, his general health much im- 
paired; hectic fever; foul tongue and breath; pulse 115 to 120; irritable; 
slept but little; no appetite; and a torpid, depraved condition of the excretory 
system. The leg was in a long poplar box, in a state of extension ; the 
bandaging from the foot up to the thigh very tight, and he suffering much 
pain. I next took a survey of the limb (thigh), and at once saw it was crooked 
and much too short. I then applied a tape and measured the injured limb 
from the anterior superior spinous process of the ilium to the centre of the 
patella; then measuring the sound one, I found the fractured limb nearly 
three inches short. I then removed a mass of sheet-iron splints, about a 
peck of bandages, &c. &c., from the thigh, and found the bones, as I antici- 
pated, the upper fragment drawn up by the muscles of the pelvis, the upper 
end of the lower fragment being drawn backwards by the strong flexor muscles 
of the thigh, thus causing it to pass up under the upper fragment to the ex- 
tent I have mentioned. I took everything off, placed a nice Scultet's band- 
age on a padded double inclined plane, and flexed the thigh and leg. I then 
coaptated the bones (which I found ununited), reducing the limb to its proper 
length very easily, as the muscles were so soft and debilitated as to offer but 
little resistance. I then adjusted the bandage and placed splints on each side 
with an extending point and a buckskin perineal counter-extending band, all 
working pretty well for some days. 
"As I then discovered a spot of blood oozing through the bandage, under 
the calf of the leg, I removed the bandage and found a gangrenous ulcer 14 
about as large as a half dollar, and three or four lines deep at this point, the 
foot and leg being purple and with a low degree of vitality, several spots exist- 
ing on top of the foot and ankle, and threatening to slough soon. I was 
therefore obliged to loosen everything about the thigh that could obstruct the 
free circulation, and favoured the suppuration of the leg by gentle dressings 
and warm fomentations. 
"The next morning, the foot and leg were enormously swollen and oedema- 
tous, and sloughs were open on the upper and lower sides of the ankle and 
top of the foot. To these I applied warm poultices of flaxseed meal and yeast, 
gave him a grain of opium at night and wine-whey through the day, with an 
occasional dose of solution of quinine, and a little beef tea. But it is unneces- 
sary to detail my treatment. I succeeded in saving his leg and improving very 
much his general health, and as his thigh was a secondary matter then, and, of 
course, no deposit of plastic or osseous matter expected under the circumstances, 
I just retained the limb in as favourable a position as possible, and could apply 
no retentive means on account of the enfeebled condition of his system, his 
skin bearing scarcely the pressure of the weight of the limb itself, much less 
any firm splinting, etc. It is now about eight weeks since I first saw him. Any 
attentions he may receive from your hands in your official capacity will be 
gratefully appreciated by his friends, and be of no little satisfaction to me." 
The following history was furnished by Dr. Hoyt, the Resident Surgeon of 
St. Joseph's Hospital, after his admission :- 
"Michael Neelan, aged 29, was admitted into the hospital on the 23d of May, 
with an ununited fracture of the femur. He was at the time in an exceed- 
ingly debilitated condition; indeed, was almost in the last stages of hectic. 
He had little appetite, was extremely emaciated, and had decided night-sweats. 
His pulse was feeble, and ranged considerably above a hundred. His tongue 
was clean but pale. 
" On examining his leg, I found a small ulcer on the under side of the knee, 
which discharged healthy pus. The leg and foot were enormously swollen; 
the ankle was nearly anchylosed, and the toes possessed little motion. The 
muscles of the thigh were excessively attenuated. The bone was fractured at 
about the junction of the upper with the middle third. The upper fragment 
overrode the lower, and at the same time the two fragments formed an angle 
outwards of about thirty degrees. The limb was shortened three inches. 
There was a complete false joint at the seat of fracture. Moving the limb in 
any direction gave little pain unless carried to a considerable extent. He was 
put on good diet, with the use of tonics. His leg was bandaged every day 
with a flannel bandage; at the same the joints were freely moved. 
"On the 28th of May, as the leg had been much reduced in size, the bandage 
was discontinued, and Dessault's apparatus for fracture of the femur was applied 
in order to maintain extension until the appropriate apparatus should be pre- 
pared. Dessault's apparatus was continued until the 13th of June, when it 
was removed and the flannel bandage reapplied. The foot had become con- 
siderably swollen during its discontinuance. 
"The suitable apparatus (artificial limb) having been prepared, was applied 
for the first time on the 19th of June. He was able to walk with a little assist- 
ance on the same day. Though still weak and emaciated, his health and ap- 
pearance have much improved. From the time he commenced walking his 
improvement was rapid. He acquired new strength and vigour. A mass of 
callus was gradually formed, uniting the two fragments, until, on the 9th of 
August, it had acquired sufficient hardness to render it safe for him to walk 
with the assistance of crutches without his apparatus, which had been sent to 15 
undergo alterations. During the whole of this period, he gradually improved 
in the facility with which he walked. He at first required two crutches, and 
even then walked with difficulty; but as he grew stronger, a cane was substi- 
tuted for one crutch, and then for another. The broken limb measured, on 
the 19th of August, two inches and a half less than the other. We may 
certainly hope that, should he continue to improve, he will eventually have a 
highly useful natural leg in the place of the artificial one, which I firmly be- 
lieve he would have required but for this valuable apparatus." 
This patient soon afterwards recovered the use of his limb to such an extent 
that I returned him to the charge of Dr. Dock, at Harrisburg. 
Case V.-False Joint in the Femur, of twenty weeks' standing, cured in six 
weeks by the Use of the Artificial Limb.-Report furnished by Dr. R. J. Levis, 
of Philadelphia. " The case in which I advantageously applied the appara- 
tus, proposed by yourself, for the relief of pseudarthrosis, was that of an un- 
united fracture in the upper third of the thigh-bone, occurring in a heavy 
muscular man aged about fifty-five years, of general healthy appearance, but 
of rather irregular habits. The fracture had been treated with the long, 
straight splint; the apposition of the fragments seemed quite correct, and 
with no apparent shortening; but yet, at the end of about four months, there 
had evidently no bony union taken place, and there was an unimpeded mo- 
bility of the limb in all directions at the seat of fracture. No favourable 
change, for a month after, taking place in the condition of the parts, and the 
patient suffering much and becoming intolerant of the confinement, it was 
deemed advisable to make use of mechanical support, and, if possible, to place 
him on his feet. This indication was answered admirably by the appliance 
constructed by Mr. Rohrer, similar to others which had been previously formed 
after your direction by him, and fitted to the limb. The patient was at once 
placed in a walking attitude, and continued for some time moving about with 
the assistance of a crutch or cane. At this time the fragments had taken a 
permanent position, overlapping each other, and projecting somewhat out- 
wardly. The limb continued to acquire more firmness, until, after five or six 
weeks, he was able to dispense with the support of the apparatus entirely, and 
has now a somewhat deformed and slightly shortened, yet substantially useful 
limb." 
Case VI.-False Joint in the Humerus, of six months' standing, relieved, 
and permitting the use of the Arm in a type-setting."-From Dr. George Dock, 
of Harrisburg, I have recently received the following notes of a case of false 
joint in the humerus :- 
"A man, about fifty years of age, has been recently presented to me for 
treatment for a false joint in the left humerus, just above the insertion of the 
pectoralis major. The history of the case showing that the dressing of the 
fracture had been very imperfect, I was not surprised at finding a false joint 
of its character, and doubt whether anything short of a seton or Dieffenbach's 
pegs will bring about union; but if you can devise an apparatus that will 
suit him, be kind enough to write to me." The cost of the limb, $15, being 
beyond the patient's means, Dr. Dock writes as follows, October 24, 1854 : 
" My man with ununited fracture of the humerus was unable to purchase an 
apparatus. I consequently made one for him myself, and he is now at his 
daily work (type-setting), and bids fair to recover with an united bone." 
Case VII.-False Joint in the Humerus.-Treated by Dr. Ashby, of 
Alexandria. Another case of false joint in the humerus, of long standing, 16 
has been for some time under treatment by my friend, Dr. C. W. Ashby, of 
Alexandria, by means of an apparatus forwarded in accordance with the 
measurements sent. Although a combination of difficulties has retarded the 
treatment, yet Dr. Ashby in a very recent note says: "K wore the splint 
nearly three months, and although it was rather too short, it afforded him so 
much comfort and support, that at one time I anticipated a favourable result." 
This patient was subsequently started by Dr. Ashby for Philadelphia, to be 
treated by myself, but for some unexplained reason never got beyond Balti- 
more. 
Although these cases in the humerus cannot be cited as cures, they are 
sufficient to show, as Dr. Ashby has remarked, " the correctness of the prin- 
ciple," and may, I hope, induce others to try the same means (see Figs. 2, 3) 
when a false joint is presented in the humerus. 
In order to present a summary of the cases already treated by my method, 
I add the following recapitulation of those published in this and a preceding 
paper in this journal. (See vol. xxi. N. S. 1851, p. 108):- 
Case 1. Under the care of Dr. Win. Waters, of Fredericktown, Md. False 
joint in both bones of the leg, of eighteen months' standing, cured in five 
months. 
Case 2. False joint of both bones of the leg, of four months' standing, 
cured in nineteen weeks, by Dr. Waters, of Maryland. 
Case 3. False joint in the femur, of five months' standing, cured in seven- 
teen weeks, under my own care. 
Case 4. False joint in the femur, of six months' standing, cured in nine 
weeks, under my own care. 
Case 5. False joint in the femur, of twenty weeks' standing, cured in six 
weeks, under the care of Dr. R. J. Levis, of Philadelphia. 
Case 6. False joint in the humerus, of six months' standing, under treat- 
ment, and at present relieved, by Dr. Gr. Dock, of Harrisburg. 
Case 7. False joint in the humerus, under the care of Dr. C. W. Ashby, 
of Alexandria. 
In addition to these, I had previously noted a case of false joint in the 
femur of a man of upwards of seventy years of age, which failed to unite, but 
which was made so firm by the apparatus that the patient walked only with 
the assistance of a cane. One case of false joint in the leg failed, but though 
the bones did not unite, the patient is yet able to walk; and I have now from 
Mr. Rohrer, the cutler, reference to two other cases in the leg, cured by sur- 
geons at a distance, who have failed to respond to my communication respect- 
ing them. We have, therefore, a total as follows:- 
Cases. 
Cured. Relieved. Failed, but able 
to walk. 
False joint in the femur 
4 
3 1 
" " a leg bones 
8 
7 1 
" " " humerus 
2 
2 
Total 
14 
10 2 2 17 
The apparatus employed in these cases is represented in the Figures 2, 3, 
Fig. 2. Fig. 4. 
Fig. 2. A three-quarter view of the artificial limb applied in the treatment of false joint in the femur, 
and worn in the cases detailed above. A. A band and belt to surround the pelvis. B A padded crutch- 
head to support the weight of the body upon the perineum. If the portions of the apparatus are made so 
as to form a cone, the apex of which is towards the knee, this head may be dispensed with, as the support 
on the thigh will act as it does in the artificial limb worn after amputation. O. The back and upper half 
of the cone or splint which supports the thigh. The front half buckles around the limb, is formed of 
sheet-iron, well padded, and, by forcing the limb against the rest of the splint, gives firmness to the frac- 
ture, and acts as a ferule. D. A uother portion of the thigh support, which is sometimes continuous 
with that at C. E. A conical piece for supporting the leg. The front splint is here also to be buckled to 
the limb, and keeps the tibia directly in the line of the femur. Joints in the side-pieces of steel, 
to favour the motion at the ankle, knee, and hip, thus obviating the anchylosis so apt to result from 
long confinement and rest in one position. As there is always some shortening of the femur (say two 
inches), a false heel is placed inside the shoe. When the limb has united, the patient's shoe, if thus filled, 
will enable him to walk without attracting attention. 
Fig. 3. A buckskin piece to surround the thigh, and prevent chafing of the skin. 
Fig. 4. A three-quarter view of the artificial limb as applied. McNeelan walked with this apparatus 
whilst there was no union at the seat of fracture. In measuring a patient for this or any other of these 
artificial limbs, moderate extension and counter-extension is necessary in order to prevent subsequent 
shortening. When the artificial limb is well fitted, subsequent shortening is prevented, the chief support 
being above the seat of fracture, and the resistance below it. 18 
Fig. 5. 
Fig. 5. A three-quarter view of the artificial limb employed in false joint of the bones of the leg. A, A. 
Steel splints applied at the side of the leg and connected under and below the foot at C, so as to sustain the 
weight of the body. B, B A conical-shaped support attached to the side splints and made to embrace the 
head of the tibia, thus sustaining the weight of the body as in the artificial limb worn after amputation 
of the leg. D, E, F, H. The support furnished at the seat of fracture, and acting like a ferule upon the 
broken bones. This support steadies the fragments, and generally leads to the development of sufficient 
definitive and ensheathing callus to unite them. This shoe does not require a false heel, as the support 
is furnished by the ends of the side splints at C. Very little shortening has supervened on the use of 
this apparatus in false joint of the bones of the leg. 
Fig. 6. 
Fig. 6. A side view of the artificial limb applied to false joint in the humerus. In measuring the limb 
for this apparatus the humerus should be drawn as nearly as possible to its original length, and the arti- 
ficial limb should rise well over the shoulder and fasten by straps to the opposite axilla if the false joint, 
has followed a fracture of the surgical neck of the bone. 
Having thus shown the means of treatment and the results in the cases just 
related, it remains to exhibit the specimens which illustrate the method in 
which nature has accomplished the cure; and in the following drawings, taken 
from preparations in my possession, I think this will be readily seen to be due 
entirely to an " intermediate callus" produced at the expense of the external 
and internal periosteums, as exhibited in Figs. 7, 8. 19 
Fig. 7. 
Fig. 8. 
Fig. 7. A front view of the mode of union accomplished in an old fracture of the femur. The callus 
formed between the fragments appears to be chiefly due to the action of the outer surface of the bone, or 
rather to the inner surface of the external periosteum after its outer layer has been absorbed. 
Fig. 8. A front view of the union obtained in a comminuted fracture of the humerus of a turkey, show- 
ing the fusion of compact with the cancellated structure of bone. 1,1. Line of the saw in making a 
section. 2. Upper fragment of fracture. 3. Intermediate fragment. 4. Lower fragment. An end view 
of the section of the upper half of the bone is seen at the side of the drawing, and shows the perfect fusion 
of the cancellated structure of the intermediate fragment 3, with the compact structure of the fragments 
2, 4. This union has evidently resulted from the absorption of the outer layer of the periosteum, without 
which it could not have taken place. 
With the results thus given, I hope that others will be induced to repeat 
the treatment just advised, and give the profession the results of their expe- 
rience ; and that the more severe modes of treatment heretofore advised will 
be avoided until after the failure of the application of the artificial limb for 
six months. As the patient will have considerable use of the member during 
this period, the duration of the treatment and its inconvenience (if any) will 
hardly be complained of, whilst if it fails to accomplish the union of the ends 
of the bones, the patient will yet have a very good and useful member. 
The hopeless condition of the limb, after the trial of some of the means 
heretofore employed, has more than once been illustrated, both in the United 
States and in Europe, by the willingness of both patient and surgeon to con- 
sent to amputation. Very recently1 we notice the fact of an amputation of a 
limb for false joint, performed by Mr. Stanley, of London, whose work on The 
1 Med. News, Oct. 1854, from Lond. Times, July, 1854. 20 
Diseases of the Bones is so well known. In this case, the use of ivory pegs, 
as advised by Dieffenbach, and even wiring of the fragments, had failed to 
induce a cure. A case is also reported where Mr. Lawrence, after employing 
the immovable apparatus without success, has resorted to the seton, the case 
being under treatment at the last account; and amputation has more than 
once been performed in the Pennsylvania Hospital, after the failure of the 
seton in the femur. When a comparison is made between the use of a seton 
with confinement to bed for six months, or between the other means requir- 
ing confinement, and this, which permits free exercise of the limb in the fresh 
air, few will, it is thought, fail to give the preference to the treatment by pres- 
sure and motion, as accomplished through the artificial limbs. 
Philadelphia, October, 1854.