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I S E A S E S 



OF THK 



jf4ip, Knee, and Ankle Joints 



WITH THEIR DEFORMITIES. 



TREATED 



By a New and Efficient Method. 



ENFORCED. UNINTERRUPTED AND PROLONGED REST. 



"A man born to live through a given cycle lives through 
it free of disease, unless he be stricken from without. If 
he be stricken, and by the stroke the natural functions, by 
the exercise of which he lives, are not so disturbed but that 
they can swing back again in due order, he may recover; 
if he be stricken beyond this, he will die. Nature will per- 
sue hex course undisturbed by either event. She will make 
no special effort to kill, and assuredly she will put out no 
special hand to save. A man may intervene, and may, by 
knowledge, put the stricken body into such a. condition that 
it may swing back into natural course whereby .he will have 
put it into a condition in which it will not die. This is 
the very highest development of medical art resting on 
science. But it is not cure, in the common meaning of 
that term." — Dr. W. B. Richardson, F.R.S., in Nature, 
July 5th, 1877. 



DISEASES 



OF THl 




if, Itn^e, ani glnlil^ Joints, 



WITH THEIR DEFORMITIES, 



Ti\EATED BY A NEW AND EFFICIENT METHOD 



BY 



HUGH OWEN THOMAS. 

WITH AN INTRODUCTION BY 

RUSHTON PARKER, F.R.C.S., 

Zjtcturer on Surgery at the School of Medicine ; Assistant Surgeon to 

the Royal Infirmary, Liverpool. 



THIRD EDITION. 



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LONDON : 
H. K. Lewis, Gower Strket. 

1878. 



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Page 33» M "Plate i, fig. i"" read "Hate 5> fifi^ 4." I 

»> 45* y^ ''joint be sound" rnoi/ ''joint be apparently 
sound'' 

70, /{ft "saspected'' rmd ** suspected.** ^P^ 

211, yfer " seven". fwttf "severe:" 

212, >fcr "dry point" read "dry joint." 

„ 212, y&r "chapter fourteenth" /««</ 'y«venteenth." V* 



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:MY FltlEITID J^TSTD I^^ESFECTEID FEXiXiO"W* 



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THOTJO-H ^IT I2jTJ^3DE(^TJJ^TE ODiTE, 



OF 



3^-AJiTir VA-IiTJA.T^Ti-F. SEI^^VICES ItETSr3DEI?,EI> 



TO THE 



-A-TJTHOK. 



I 



C02iTTElTTS. 



Preface to Third Edition. 
Preface to Second Edition. 
Preface to First Edition. 
Introduction. 

CHAPTER I. 

Page. 

Previous Hip Joint Apparatus... ... ... 1-15 

CHAPTER II. 
Diagnosis of Inflammation of Hip Joint ... 16-26 

CHAPTER III. 
Treatment of Hip Joint Inflam.mation ... 27-86 

CHAPTER IV. 

Diagnosis and Treatment of Knee Joint 

Inflammation 87-129 

CHAPTER V. 
Inflammation of Ankle and Tarsal Joints ... 130-138 

CHAPTER VI. 

Etiology, Casualties, and Therapeutics of In- 
flamed Articwlations ... ... ... 138-173 

CHAPTER VII. 

The Method of Relieving Articular Disten- 
sions BY Aspiration and Incision ... 174-196 

CHAPTER VII. 

A Review of the Past and Present Treatment 

of Inflamed Joints... ... ... ••• 196-283 



PREFACE 

TO THE THIRD EDITION. 



Consequent on the publication of the pre- 
vious editions of this treatise, many of my ap- 
pliances have been used by surgeons in the 
treatment of inflammation of the articulations, and 
also in the treatment of other lesions, such as 
fractures of the thigh and leg» (knee appliance) 
fractures of neck of femur (hip appliance), for which 
purpose they are undoubtedly very useful, though 
not equal to the special instrument I have devised 
for fractures, and over which I have spent much 
time and labour. 

But while the models have been well received, 
very few have adopted the theory, nor is this to 
be wondered at, seeing that it is at variance 
with principles so long believed in by the profes- 
sion* and that it requires a long period for 
others to realise the conclusions at which time 
and observation alone have enabled me to arrive. 

*I am frequently told that "Rest is the right thing " and an ancient prin- 
ciple in the treatment of articular inflammation. If, therefore, the 
ancient practice was based on the principle of so-called Rest, then my 
practice must be based on the principle of "arrest." 



11 



But that these conclusions will at length be 
accepted, and the theory will be one day acknow- 
ledged, just as the practice has been already 
adopted, I have not the slightest doubt. 

Some have admired the form of my splints 
and have complimented me as though I 
were only an ingenious blacksmith, a matter 
satisfactory, so far as it goes. Such a compliment 
was not anticipated by me. So very few 
have understood the principles of the treatment, 
as I have endeavoured to explain them in 
previous editions, that I am induced once more 
to propound and amplify the details x)f what 
J hold to be the correct theory, for, assuredly, 
the surgeon who is guided by a knowledge of the 
right theory of treatment — though his mechanical 
aid be limited to a broomstick and a bandage — 
will be more successful than he who is deficient 
in this knowledge, though backed by the arsenal 
of a Weiss or a Charriere. 

This Volume is devoted solely to improving 
the treatment, and the elucidation of the principles 
which are supposed to guide it. It will, probably, be 
my last contribution to this department of surgery, 
as I hope to see more able workmen enter a field in 
which there is scope enough for the highest ability. 

I am but too conscious of the literary defects of 



Ill 



this volume. The reader will regard them leniently. 
Ill health, indeed, would have much delayed its 
appearance, were it not that the proofs were 
supervised by my friend Dr. Canavan and my 
nephew Mr. R. Jones. 

During the period that has elapsed since the 
appearance of the first edition, which I was induced 
to publish by the friendly coercion of Mr. 
Rushton Parker, we have together verified most, 
if not all, the conclusions arrived at by myself in 
previous years. 

There has been added to this edition a review 
of the past and present published treatment of the 
lesions here considered, and in it I have endeavoured 
to point out the vital difference between my practice 
and that of others, both past and contemporary. 

In criticising Dr. Bauer s published opinions in 
justice to him, it is here acknowledged that I 
had no access to his teaching later than 1868. The 
doctrine then taught may have (probably has) 
undergone important modifications. Dr. Bauer 
has done so much and so well for this department 
of surgery that it is only fair here to acknowledge 
his work, as he is not so well known as he should be 
in Enorland. I cannot better introduce him than in 
Dr. Sayre's eloquent but not over-drawn portrait. 



IV 



" Professor Louis Bauer, of Brooklyn, (now of 
St. Louis), a German surgeon of very scientific 
attainments, with an energy that knows no limit, 
has devoted his* time almost exclusively to this 
department of surgery. In fact, the professional 
mind of this country has been attracted to this 
particular branch of surgery through the various 
articles of this able author in the different medical 
periodicals more than from any other source, and 
his lectures on this subject are very valuable in- 
struction to Orthopedic literature." 

All those surgical appliances which I have 
designed and use in my practice can be had from 
'Mr. Critchley, 59, Upper Pitt Street, Liverpool, 
and Krohne and Co., London. 



PREFACE 



TO THE SECOND EDITION. 



In this, the Second Edition of my Treatise, I have 

again limited myself to an attempt at rationalizing the 

diagnosis and treatment of diseased articulations of 

the lower extremity, and amplifying some details 

which appeared obscure. Many of the statements 

may appear to some readers dogmatic and strained, 

but, after careful consideration, I am satisfied that I 

have understated my success in the practice of my 

theory by the method herein advised. I particularly 

urge the discontinuance of specific constitutional 

treatment, and especially that which is usually known 

as counter-irritation. This practice is curiously and 

exhaustively advocated by Mr. Furneaux Jordan, of 

Birmingham, who, in his remarkable Treatise on 

I 



u 



Surgical Inflammation, unintentionally confirms my 
views, that the farther the counter-irritation is from 
the joint, the more rapid and satisfactory must be the 
result. It is but a step further, too. If we carry out 
the "sympathetic" treatment of our forefathers, and 
gravely anoint the offending rapier with the specific 
of the period, and allow the patient's wound merci- 
fully to have the benefit of an " expectant " method,* 
the ** Vis medicatrix naturae." 

I have made special reference to the views of some 
few gentlemen who have advocated principles which 
I decidedly believe to be retrograde as regards 
articular therapeutics. Since the first edition was 
published, many suggestions have been made, some 
of which would have diminished the utility of the 
machines employed ; others I had already tried and 
set aside at some period during my practice. Some 
improvement, probably, will be made in the practical 
parts of my methods, and by strict adherence to the 
details I have indicated, the innovator will probably 

* See John Bell, vol. i., page 25. 



Ill 



avoid trying designs that have already been improved 
upon. The success that has followed the use of this 
method in my practice, others can achieve. The 
treatment introduced to the notice of the profession, 
in this volume, may be summed up as a combination 
of enforced, uninterrupted, and prolonged rest; die 
first gives relief from pain ; the second, added to the 
first, enables the case steadily to progress to a cure ; 
the third sectu'es that which has been gained. How- 
ever much my mechanical appliances may meet with 
the approbation of the surgeon, they will rarely be of 
value if the theoretical principles herein inculcated do 
not guide their use. 



II, Nelson Street, George Square, 
Liverpool, January, 1876. 



PREFACE. 



TO THE FIRST EDITION. 



It is proposed in this Treatise to introduce to the 
notice of the Profession a Theory and an Efficient 
Method of treating Inflammation of the Hip, Knee, 
and Ankle Joints. The application of this Theory 
by my method, (judging from the results, after many 
years experience and very frequent opportunities of 
trial in practice upon over one thousand cases,) is, I 
feel confident, a vast improvement on all the modes 
of treatment hitherto practised in this department of 
Surgery. 

The means usually employed by Surgeons, in 
treating Inflammation of the Hip, Knee, and Ankle 
Joints, are frequently not followed by resolution, and 
it is no exaggeration to assert that the majority of 
cases are benefited with remaining defects. 



VI 

The attention of the reader will be drawn to 
surgical appliances and details, which involve radical 
changes of treatment, and are now for the first time 
made known to the Medical Profession. 

I feel assured that my method will reclaim this 
class of diseases from the domains of excision and 
amputation. I shall not enter into the pathology 
of the various stages of these diseases, as this has 
been already so minutely described by abler writers. 

By following the treatment now counselled, the 
practitioner will be agreeably surprised at the absence 
of many of the usually recorded symptoms. Even in 
those cases where the disease has run a course of 
some severity, recovery is attained with but little 
perceptible defect. 

I fear that these pages, written as they have been 
during hours which should have been devoted to rest, 
will be found faulty in many respects ; but an anxiety 
that the Profession should test these methods has 
induced me to submit this Treatise to their judgment 



Vll 

without further delay, now that I have crucially tested 
the theory by a practice extending over many years. 

I cannot omit this opportunity of thanking the 
Artist, Mr. Lewis, for his care and fidelity in copying 
the original Photographs. 

Messrs. Krohne & Sesemann, Duke Street, 
Manchester Square, London, have made themselves 
practically acquainted with my practice, and can 
supply the appliances. 



II, Nelson Street, Great George Square, 
Liverpool, July, 1875. 



INTRODUCTION. 



About three years ago I first saw Mr. Thomas s 
appliances for the treatment of joint affections, and 
sought a brief explanation of them at his hands ; on 
which I set myself to persuade him to publish an 
epitome of his practice and opinions. 

This step was taken, because it was plain that the 
matter in hand had only to be understood to be at 
once adopted ; and feeling, as I did, that these 
devices quite eclipsed other efforts in the same 
direction, I thought they might as well issue direct 
from their contriver ; knowing that I should myself 
have to adopt, and might any day publish, nay, 
hoped one day to be privileged to teach, practices 
and doctrines so copiously borrowed from the 
studies of another. He has made his own apology 
for the literary dress in which the work appears, in 
reference to which I need only remark that the 



details involved in a due appreciation of the method 
as applied to the case of joints, and as applicable to 
an almost infinite extent to fractures and other 
injuries of the lower limb, cannot possibly be com- 
passed in a written account which does not cover far 
more ground, and perhaps display more numerous 
illustrations, than this book attempts, and can other- 
wise only be acquired after prolonged and repeated 
failure, in the absence of direct practical exposition. 

Since the appearance of the first edition (which 
was suggested, written, and published within three 
months), the opportunities afforded me of testing 
in every way the author s teaching have so greatly 
exceeded my anticipations, that instead of merely 
expressing, as I could then have done, a mere a 
przorz Sigrcementy I can now add practical testimony 
to every item, I suppose without exception, upon 
which the author lays any stress. 

It is unnecessary to go into any detail as to the 
means we have together adopted in the attempt to 
work out this subject, further than to say that 
during this period Mr. Thomas's practice has been 
open to my constant observation and criticism, 
that we have been intimately associated in the 
whole argument, and have debated, I might almost 
say haggled over, every point which either of us 
has thought of the least practical importance. 



Besides this, my present and former colleagues, 
and other surgical friends, have, without stint, 
permitted me to avail myself of the invaluable 
resources presented in the observation and critic- 
ism of their hospital, and often of their private 
cases ; opportunities which have been of value to 
me beyond the possibility of due return on my 
part, but for which my best thanks are here grate- 
fully recorded. Lastly, my own hospital practice 
has throughout that period been well furnished 
with every variety of case illustrating the subject, 
the elucidation of which I have been thus enabled 
independently to prosecute. 

We have thus worked it out, step by step, 
and verified the theory to an extent enabling 
us to hope that an approach to precision has 
been attained in a much mismanaged though 
fascinating study. On these grounds, among 
others, I have gladly contributed to the present 
volume an Introductory Note in support of the 
position adopted by Mr. Thomas, and of the sys- 
tem he has worked out. So far as it goes, this Note 
attempts a critical estimate of the subject, a sort of 
scanty review, which is perhaps not altogether 
out of place, since the few notices which have 
appeared in periodicals have been mainly abstracts 
of the work, or have regarded the author s con- 



elusions in the light of opinions which he has set 
himself to refute, rather than in the light of a 
practical test of his treatment The mechanical 
part, indispensable, yet not to be learned in a day, 
is, after all, only the threshold of a subject, which is 
itself nothing if not a system of Rational Thera- 
peutics, an Art based, like every other, upon empi- 
rical observation, though not indifferent to the 
support of applied science. The work was under- 
taken upon a plan chosen by the author, whose 
clinical facts and assertions, accumulated during 
years of observation, together with the explana- 
tions deduced, are 

I . Partly confirmatory of traditional opinion. 

II. Partly antagonistic to prevailing doctrine. 

III. Partly undoubtedly new. 

I. — For instance, the advisability of Rest has 
been preached for ages, and has been more or less 
successfully attained by a variety of means ; but 
the word has been too often taken for the deed, and 
*' the complete immobility of the joint " freely 
spoken, even when no such state has been either 
secured, or, under the circumstances, possible. 
The old doctrine of rest is more than ever insisted 
on here, but considerably furbished up, and, in fact, 
realized. The rest required for an inflamed joint 
is a rest from duty, a relief from the accustomed 



articular movements (flexion, extension, rotation, 
&c.) ; and, under many circumstances, also a relief 
from a share in supporting the weight of the body; 
in precise language, the abolition of intra-capsular 
friction, and of linear pressure, though not neces- 
sarily of contact. These are the only forms of 
rest applicable to a joint ; though a constitution, 
jaded by prolonged disease, irritated by the pain- 
fulness of an acute inflammation, may require the 
temporary comfort of the recumbent posture — a 
rest of the whole body — but the rest for a joint 
is obtained by immovable fixation. 

It may be thought that the joints require treat- 
ment vastly different to that demanded by inflam- 
mation of other parts* This is not really so. 
The means necessary to keep a joint at rest differ 
somewhat from those advisable in the case of a 
skin wound or abcess, except either of the last be 
situated on the convexity of a joint, when the 
treatment most appropriate is identical for each, 
as regards fixation, while other items such as relief 
of distension, by tapping or incision, cleanliness of 
dressing, &c., are equally identical. 

It is not necessary to be at much pains to show 
that all modes of treatment which profess to 
prosecute the cure of an inflamed joint, while yet 
permitting the occurrence of its movements, are 



totally repudiated here. The so-called Sayre^s 
method was for a short time nearly countenanced 
by the surgeons of Great Britain, whose fairness 
in adopting it has been equalled only by their 
fairness in casting it aside. 

Every surgeon now knows the efficacy, and 
consequent necessity, of immobility in the treat- 
ment of articular affections, though the most certain 
means of attaining this end may not be so well 
known or uniformly agreed upon. But the prin- 
ciple has the stability and unalterableness of a 
law of nature. How then can the very contrary 
be true, when the reverse of demonstrated and 
daily demonstrable fact ? 

The arguments here advanced in favour of 
rest, immobility, and fixation, also appear in the 
voluminous treatise (on Orthopaedic Surgery and 
the Diseases of Joints) issued by Dr. Sayre of 
New York, who has made himself the Apostle of 
the extension-movement-and-subsequent-excision 
treatment. In that work are found, often on the 
same page, the dual advocacy of the rest-and-fixation 
method, and of the extension-movement method. 

The contradictions are so numerous and so 
transparent that the wonder is what the reviewers 
have hitherto been about in not reorardinor them. 
Every department of our art ov;es much to 



American Surgery, of which, however, that work 
can only be regarded as an utter perversion, and 
unworthy to be considered in the slightest degree 
representative. 

II. — As regards antagonism to prevailing doc- 
trine, there are three points which deserve 
mention : — 

I. — The limits which are supposed to be re- 
quired to the employment of rest. 

2. — The position here assigned to what is known 
as passive motion, and the causes and prevention 
of stiffness and anchylosis. 

3. — The discussion of counter-irritants, or what 
may better be called Artificial Inflammation. 

I. — Prevailing doctrine, though advising Rest, 
deprecates an excess of this condition, lest stiff- 
ness be induced by its means. In this work 
the Rest insisted upon is, as far as possiblci 
perfect, uninterrupted, and almost indefinitely 
prolonged. Its very perfection is a measure of 
its value ; its uninterrupted continuance is another 
essential feature ; while its prolongation for a suf- 
ficiently lengthy period is an equally important 
item which varies with each case, and ceases to be 
regarded only on the perfect recovery of the case. 

2. — Under the method here advocated per- 



-1 



manent stiffness of a joint is seldom met with, and 
this assertion is based upon practical observation. 
Cases, previously untreated or only imperfectly 
fixed, are found, under this method, to lose the 
stiffness they had acquired. The practice of 
passive motion, if carefully enquired into, is found 
to invariably aggravate cases in which any trace 
of inflammation still remains ; while the cases in 
which it has seemed to do good are those in which 
resolution has actually occurred, but in which 
muscular weakness or some other passing infirmity 
still remains, and has led Surgeons to mistake for 
advisability the impunity which has followed passive 
motion. But although the majority of cases 
treated by the methods here advised, in any stage, 
(and all if undertaken early enough), may be 
guaranteed free Ircftn eventual stiffness, there are 
cases, some of great severity, and others undertaken 
late, in which occasionally permanent stiffness, 

• 

must ensue. Of passive motion it may be said, 
then, that, when it does no harm it is not wanted. 

The slackening of a stiff joint under immovable 
linear fixation is an axiom which follows from 
the successful practice of the author's method. 
By this I do not mean that bony anchylosis is 
converted into mobility by prolonged rest — this is 
absurd. Neither do I mean that every case of 



fibrous anchylosis is slackened by linear fixation : 
this would be at once an unfounded assumption, 
and a pretension to knowledge which no one can 
possibly have. When a joint is stiff from inflam- 
mation it commonly becomes slack and moveable 
under prolonged successful fixation ; it occasionally 
does not. I know of no means, without looking 
inside a stiff joint, of forming even an idea whether or 
not there be any adhesions between the surfaces. 
Further, I know from moderate experience in path- 
ological anatomy, that great stiffness of a joint in 
any position, may be accompanied by a total 
absence of adhesions, whether of lymph or of fibrous 
tissue, nay by a total absence of morbid change 
inside the capsule ; so that in every such case part at 
least of that capsule must have lost its accustomed 
suppleness. 

3. — This book makes no peace with counter- 
irritation by firing, blistering, or any other means. 
These practices being sources of inflammation, 
such inflammation is necessarily artificial. Every 
inflammation, whether artificial or otherwise, has 
an area proportionate to its own intensity, and 
involves adjacent parts accordingly, more or less — 
hence what is known as collateral cedema, or 
collateral inflammation. The only effect that an 
artificial inflammation of the skin over a joint can 



1 

possibly have, is, if it be itself intense enough, to 
aggravate the existing inflammation of the joint, 
or to create it if not already there. Physicians, 
by their blisters on the chest, are able to convert 
a simple sticky pleurisy into an unlimited effusion. 
Surgeons, by blistering and firing, may irretrievably 
ruin, or indefinitely prolong the cure of, inflamed 
joints ; may, fortunately, sometimes fail to do so ; 
but can never do them any good. The practice is 
contrary to true clinical experience, and conse- 
quently to common sense, but its abolition is 
antagonistic to prevailing doctrine. 

III. — The chief novelty in the book is the 
recognition of resolution. I have not yet learnt 
from any other source, even the faintest suggestion 
which indicates- when an injured (sprained or in- 
flamed) joint can be tested as to its fitness for use. 
The systematic straightening of bent hips and 
knees by the same splints as are used for their 
trciatment in early stages of inflammation is also 
one of the novel features of the work. The vari- 
ous Items of treatment here given are mainly 
based upon and confirm theory which can be 
found in the literature of Suri^crv — but as a tout 
ensemble the system is a practical novelty. I am 
not concerned to attempt the task, which belongs 
rather to an historical essay, of trying to prove or 



advocate either the mere novelty or originality of 
Mr. Thomas s, or of any other method; my sole 
concern is with their truth or the reverse. They 
are either the best methods ever devised, or they 
are not. At present I think they are, and I am 
not alone in this opinion. 

A word in conclusion about the practice of 
*• excision" (of bone), which is here repudiated in 
favour of " incision'* (of soft parts.) Much might 
be made of this greater step in conservative sur- 
gery, but I feel that it would be unfair to the 
labours of distinguished men in London, and no 
doubt elsewhere, not to notice a disposition in 
many quarters not only not to perform excision 
with eagerness, but positively to rely upon incision 
even with the use of appliances offering mechanical 
aid of a vastly inferior description. 



RusHTON Parker. 



JiLvr:, 1878. 



\ 



CHAPTER i; 



PREVIOUS HIP JOINT APPARATUS. 

During the last twenty years, various designs in 
wood, iron, wire gauze, leather, gutta percha, gypsum, 
silicate of potash, solutions of shellac, plaster of Paris, 
and their combinations have been used in the 
treatment of hip joint disease. I have used very 
many of these in practice during my early career, have 
well considered every known method and appliance 
in use both in Europe and America, and I trust it will 
not be deemed presumptuous if I point out what I 
consider to be the merits and demerits of these 
various appliances ; many of them having been con- 
structed at the suggestion of gentlemen well qualified 
to do so. 



In France, Bonnet seems to have designed the 
favourite appliance ; but in vol. ii. of his " Traite des 
Maladies des- Articulations," page 327, he does not 
report well of it, for the reason, I believe, that it 
extends no higher than the pelvis. Charriere pro- 
longed the upper portion of the instrument, causing 
it to embrace the trunk — an important improvement. 
See f plate* i, fig. i.) This machine is an efficacious 
one, but very cumbrous ; and owing to its high price 
(250 francs), is only attainable by wealthy patients 
and the larger charities. We may describe this 
instrument as one of *' posterior fixation." 

Our professional brethren in the United States 

have been most prolific in the invention of means for 

treating this disease. To Dr. H. S. Davis, of New 

York, is accorded priority in the invention of the 

" Perineal and Side Splint with Counter Extension," 

rplate I, fig. 2.) It is arranged with the intention 

that the patient should riot remain at rest, but that he 

^^ght continue to perform all the movements of his 



by Its use the weight of the trunk is removed from 
the joint, and the surfaces relieved from pressure. 

Following in the wake of Dr. Davis, we find Dr. 
Louis Sayre, of New York, whose appliance, (plate i, 
fig. 3,) is the same in principle as the last named, but 
designed as an improvement upon it. 

Taylor's, ("plate i, fig. 4,) again, is a modification 
of Sayre's appliance, the difference consisting princi- 
pally in the extension of the steel bar down to the 
ankle. This is also advertised as permitting the limb 
to be adducted or abducted, an objectionable feature 
superadded to the other faults of the Davis-Say re 
design. 

We have also Washburn's Splint (plate i, fig. 5J, 
designed for poorer patients. This appliance is 
devoid of such complications as screws, racks, and 
pinions, which mar so much the usefulness of in- 
struments employed in this department of surgery. 
It consists of a pelvic band, outside steel bar, and 
knee cap ; the end of the steel bar being attached by 
adhesive strap to the ankle ; and is, in principle. 



identical with that of Davis'. 

Another variation met with is the instrument of 
Dr. J. C. Hutchinson, of Brooklyn, U.S., (plate i, 
fig. 6.) This is a dei^ign similar to Taylor's, but it 
possesses an inside as well as an outside steel bar, 
the bars being attached by means of an iron joint to 
the sole of the shoe. 

The last five appliances are variations of one type, 
and may be called " perineal extension instruments," 
illustrating alike the erroneous principles which led to • 
the construction of the original splints of Davis and 
Sayre, each equally possessing their practical defects. 
These gentlemen have attempted to cure hip joint 
disease by relieving pressure, while yet permitting 
movements of the joints. 

I hold that for mechanical reasons, this relief of 
pressure must be infinitesimal, if at all, and I know, 
from practical experience, that a cure, free from defect, 
is impossible with the use of these appliances. I 
admit that, when applied, some relief from pain may, 
and often does occur, (whatever be applied,) and not 



as a result of the application of this instrument ; and 
I do not regard such relief to be of benefit to the 
patient under the circumstances. 

I know that often when rupture of the joint takes 
place, some relief follows, and I am disposed to offer 
this as an explanation of those instances in which 
marked relief follows the application of this irrational 
method. I confidently believe that the non-resolu- 
tion of the inflammation is due to pressure and 
friction of the inflamed joint surfaces, which these 
machines increase rather than arrest. 

In the year 1863, Dr. Davis published a descrip- 
tion of his instrument. I became acquainted with 
it in the same year, but on rational grounds I 
was opposed to, and did not venture to use it. 

Since the visit of Dr. Sayre to England, and the 
exposition of his method to the London surgeons, I 
have seen several instances in which his apparatuses 
were skilfully applied, and from personal knowledge 
I am satisfied that in not one of these cases was the 
disease arrested or even benefited. 



The best commentary upon this method is the 
remarkable frequency with which its principal ad- 
vocate has had to perform excision of the joint. 

The next class of instruments are those we find 
designed upon the principle of ischiatic support, and 
to Dr. Andrews, of Chicago, is ascribed the merit 
of having designed an ingenious contrivance — (plate 
I J fig' 7') This consists of the ordinary crutch- 
head, attached to a steel stem passing down the inner 
side of the thigh, and fixed to the heel of the boot, 
and is supposed to support the body effectually by 
counter-pressure against the tuberosity of the ischium 
and groin. This may take a fraction of the weight 
of the body off the hip, but makes no provision for 

controlling the joint movements, and consequently 
it is of no practical value. 

Dr. Bauer, of New York, has also adopted a 
modification of this design, which consists of the 
inside stem and crutch-head, with the addition of an 
external stem, both stems being attached to the shoe. 
(Plate I, fig. 8.) 



Another method, which has occasionally been 
made use of in this country, is that practised at the 
Verral Institution, and consists of an anterior reclina- 
tion of the whole body upon a double inclined plane : 
much the same position as that used for treatment 
of spinal curvature in that establishment. 

Another instrument, partaking of the perineal 
type, is that designed by Mr. Barwell, of London, 
and which consists of an outside wooden splint, 
perineal band, pulleys, and pelvic band, with an ar- 
rangement for elastic extension. (Plate i, fig. 9.) 

Appliances which are intended to effectually fix 
the hip joint must be attached to the Thoracic portion 
of the trunk, as well as to the lower limb. Instru- 
ments, however ingenious, which extend no higher 
than the pelvis, seldom attain the desired result. 
When the patient is disturbed, the length of the 
splint, attached to the lower extremity, acts as a 
lever, to resist the force of which leverage the pelvic 
portion and band are not sufficient. Owing to this 
defect, Bonnet's original design was not satisfactory 



8 

tx) himself. But Charriere has converted Bonnet's 
instrument into an admirable appliance, by continu- 
ing the body portion up to the scapula, as shown in 
the figure. It is possible, with great care and atten- 
tion, to obtain some benefit occasionally with Mr. 
Barwell's apparatus, and I admit, that with the 
exception of the old-fashioned long splint, it has 
been, for years, the best instrument at the surgeon's 
disposal. Mr. Barwell's appliance possesses an ad- 
vantage over all the American designs, in that it 
has some little control over the movements of the 
joint. Painless nursing of the patient, however, is 
impossible with his appliance, or with any "side 
splint," a fault possessed alike by all the others to 
which I have referred. 

Professor Hamilton's apparatus for hip joint dis- 
ease, as described in Tineman & Co.'s Catalogue, 
seems constructed to control the movements of the 
joint, but is not long enough, and so is of very little 
value, and I can best convince the reader of this 
by referring him to plate i, fig. lo, which is taken 



from the above catalogue ; allied to the last two is 
Mr. Hilton's appliance, a drawing of which is given 
in his essay on " Rest and Pain." 

Finally, we come to the old-fashioned long 
splint, which, when applied from the axilla down 
to the ankle, is an instrument possessing merits 
beyond any of those I have previously discussed; 
yet, it has its faults, as, being applied laterally, it 
can only partially control the movements of the joint, 
and the nursing of the patient is not performed 
lyithout pain, while, where deformity is present, it 
cannot be applied. 

I will conclude by referring to the method of 
treatment by weight and pulley, which amounts to 
no more than confinement to bed. Dr. H. G. Davis, 
the author of the perineal system of treatment of 
hip joint disease, is credited with having suggested 
the use in hip affections of this useless, and, worse 
than useless, injurious method of treatment, when 
applied in hip disease, and in its application, decep- 
tive and irrational ; for surely if relief of pressure be 

B 



lO 

required^ the only direction in which this is possible 
is clearly in the axis of the neck of the femur ; any 
method of extension in the axis of the body merely 
transfers the pressure from the upper part of the 
acetabulum to its lower quarter. Continuity of ex- 
tension, " per se," is not a remedy in joint disease, 
as I shall subsequently show ; in its application it 
involves unavoidably a fractional degree of fixation 
which is sufficient to mask the evil -of this ridiculous 
mal-practice. The idea of practising extension in 
joint disease has originated, no doubt, from observing 
its effect in the treatment of fractures,, under the 
supposition that it is the best antidote for muscular 
spasm. I assert that a fractured thigh, if treated by 
extension only, would be accompanied with vastly 
more muscular irritability than if the . same case was 
placed in a modern appliance with retention in 
which the limb was retained and fixed immoveably, 
in the strict meaning of the term fixation. Then 
we should not have the slightest muscular excite- 
ment. Traction is a very inefficient sedative in joint 



II 

disease, as well as in fractures, compared with the 
effect of the immobility modem surgical appliances 
place at our disposal, while I admit that continuous 
extension is next in value to retention as an aid in 
the treatment of certain fractures, though of second- 
ary value compared with an immobility that places 
the limb at perfect ease. 

Our Transatlantic brethren deserve praise for 
having studied diligently to improve the treatment 
of these joint affections, but by ignoring in all their 
designs the fact that friction is a greater evil than 
pressure, they have devised methods of less efficacy 
than those previously in use. Frigtion may be 
defined as a combination of motion and pressure, 
consequently it is to be specially avoided in joint 
disease. Efficient enforced rest in joint disease, as 
well as in fractures, is the infallible remedy for 
quieting the irritated muscles; not extension. 

In confirmation of the correctness of my opinion 
as to the evil of friction in joint inflammation, I 
refer to the lower jaw articulation. In this joint we 



12 

rarely have inflammation, but when this does occur, 
it is more liable to be followed by anchylosis than 
in any other joint, in consequence of the fact that 
the patient is obliged to make some use of this joint 
daily. 

In chronic inflammation of shoulder joint we have 
an illustration of the continuous extension method 
readily provided for us, by the weight of the limb 
Itself, yet, when the movements of the joint are not 
effectually arrested, which they seldom are, we have 
anchylosis to that degree, that even the great mobi- 
lity of the scapula .cannot mask. Any practical 
surgeon will recollect the marked relief in some cases, 
given to the patient by supporting the upper ex- 
tremity, the reverse of continuous extension. 

The various mechanisms to which I have referred 
may be described as of two classes: first, those 
models which are intended to permit the joint to be 
in action, and are supposed to relieve pressure; 
secondly, those that are constructed for the purpose 
of attempting' an arrest of the joint's movements. 



13 

The first I shall dismiss as useless and injurious ; it 
includes all the American models, Hamilton's design 
excepted : this last is a step in the right direction, 
but has no value in practice. The second I regard 
of some value, and can be subdivided intn lateral 
and posterior fixation. 

The first includes Barwell's instrument and the 
old Long Splint, single and double. The second 
includes Charriere's model of Bonnet's "grand ap- 
pareil." As to the lateral fixations, I have already 
stated my opinion when referring to the instrument 
of Mr. Harwell, that the long splint is an useful means 
to success when skilfully and frequently adjusted, and 
when the patient lies still ; but that its palpable 
defects are the readiness with which it may fail, for 
instance in nursing, or should the patient endeavour 
to rise, or not remain contentedly still, as is often 
the case Avith children, who continually attempt to 
flex the L'mb, or especially to turn in bed, thus 
causing the splint to rotate from its position towards 
the front. I have already expressed my approval of 



14 
Bonnet's apparatus, and only take exception to its 
cost and cumbrousness. My method illustrates the 
superiority of posterior fixation over all other meth- 
ods, and is the only one by which, efficiently, friction 
and concussion can be arrested, pain alleviated, and 
a cure secured and that without deformity, no matter 
to what stage the case has progressed, conditionally 
on a strict observance of the principles and details 
which I have found essential, and shall explain in 
the following chapters. 

The design that I shall submit to the profession 
is free from the defects of all the previous appli- 
ances ; is cheap, and within the reach of the poorest : 
is light, and can be applied under the cbthes 
without much disfigurement to the sufferer's appear- 
ance, and enables the attendant to nurse and handle 
the patient, as though he were a toy, without pain ; 
and can be applied for the purpose of rectifying 
cases of hip-joint deformity, though they may have 
existed twenty years. (See Plate 2.) 



15 
I have not entered into the demerits of the 
shellac, silicate of potash, and other solutions, as 
they are not usually applied beyond the pelvis. 





OHAPTBB II. 



DIAGNOSIS OF INFLAMMATION OF THE 

HIP JOINT. 

We have hitherto had no method of determining 
with certainty the existence of this disease at a 
very early period, except in very rare cases, 
where, for example, acute inflammation is very 
rapidly developed without the usual premonitory 
warnings, such as lameness, pain round the 
patella, disturbed sleep and wasting of the nates. 
We have also to guard against the possibility of 
mistaking abscesses, (connected with the spine, or 
arising within the pelvis), sciatica, or hysterical 
simulation of this complaint, for Morbus Coxae, the 
method of diagnosing which is here detailed. I have 



17 

tested it during ten years, and never once has it 
failed in enabling me to detect the disease at even so 
early a stage as the first week or day, if there is any 
effusion into the joint. 

The diagnostic method which I shall demonstrate 
is of value to the surgeon in the cases of children 
in particular, as he can get all information in defi- 
ance of the struggles of the patient, and without 
administering an anaesthetic, and it enables him to 
estimate how long a time the patient has have been 
suffering, whether one week or twelve months. 
For all practical purposes the symptoms are often as 
well defined in twelve months as they are in as many 
years. Plate 3 illustrates the manipulation in this 
diagnostic method. 

Having undressed the patient and laid him on 
his back upon a table or other hard plane surface, 
the surgeon takes the sound limb and flexes it, so 
that the knee joint is in contact with the chest. Thus 
he makes certain that the spine and back of the pelvis 
are lying flat on the table ; an assistant maintains 



i8 

the sound limb in this fixed position ; the patient 
is then urged to extend, as far as he is able, the 
diseased h'mb, and this he will be able to do in 
a degree varying with the previous duration of 
the affection. While the patient is retained in 
this position the operator will be able readily to 
note a rigid cord corresponding to the origin' of 
the adductors, which ^are invariably the first to 
shorten. 

In fact, this method demonstrates two invariable 
symptoms of hip joint inflammation, flexion of the hip. 
joint, and curve of the spine, in a greater or less 
degree, so early as the first or second week, limiting 
the normal range of extension,* which not only is 



* Dr. Taylor, of New York, in a paper read before the New York Jkledi- 
cal Library and Journal Association, discusses *' constant, excessive, and unre- 
laxing tonic contraction, varied or not with spasms, but always present when 
there is any disease in the joint. The latter may exist so slightly as not to 
prevent the extremest flexion and extension." The above quotation I hold to 
be a contradiction. How is it possible to have contraction of a muscle, and 
its utmost extensibility, coexisting ? Indeed, our transatlantic brethren, 
having adopted during the Davis-Sayre period the wrong premises of these 
gentlemen, have set aside the little good that was in the practice of our 
predecessors. We are told that the continuous extension is carried so far 
that weights, nearly as heavy as the sufferer, are attached to the diseased 
limb, with, in my opinion, the effect of masking one pain by another; and I 
can not perceive that such would be any benefit to the patient. 



19 
the patient unable to overcome by his own efforts, 
but which will not yield to the forcible manipulation 
of the surgeon without the production of some degree 
of pain. However, on releasing . the sound limb 
from its flexed position on the chest, the patient 
may, if not an extreme case, be able to apparendy 
extend the limb, but a compensatory curve of the 
spine is formed, as shown in Plate 4. This diagnostic 
manipulation" enables the surgeon to note at a glance 
the amount of flexion. The degree of flexion is an 
important symptom during the first nine months of 
the affection, if the case has been uncontrolled. By 
noticing the amount of flexion, the surgeon will, 
with practice, soon be able to guess the previous 
duration of the disease. For instance, I consider 
that an angle of about 1 70 degrees is reached in six 
weeks, and one of about 1 00 degrees in nine months. 
Thus, in Case No. 4, when the child's parents 
asserted that he had been two or three weeks lame, 
I was able to correct them. As soon as a right angle 
is nearly approached this rule is no . guide, indeed by 



20 

that time there are changes within and around die' 
joint appreciable to digital examinati<m. 

This flexion explains the peculiar limp diese 
•ufferers have at the commencement of this disease. 

* 

ThuSi if we suppose the pelvis to be represented by 
A, (Plate 5, fig. i,) the ground by BC, and that FE 
represents the lower extremity extended, then cm any 
movement of the limb FE, forwards to G, FG will 
•represent FE flexed, and would be too short to reach 
the ground BC. To make FG reach the groimd, die 
pelvis is tilted forward, and this can only be done by 
an extra curving of the lumbar spine, hence the 
necessity of fixing the spine and pelvis to detect this 
flexion. This diagram exactly shews the cause of 
the apparent shortening in the disease, before 
absorption of the head of the bone, &c., has taken 
place. Then we may have actual shortening at an 
advanced period. 

Plate 4 represents the patient's spine as curved 
when the leverage of the sound limb is taken off the 
pelvis. The flexion here shown indicates a period 



21 

of many months. Plate 6 shows the same case with 
the leverage of the sound limb fixing the pelvis, 
and so controlling the spine. In cases of abscess 
connected with the pelvis or spine, this curving of 
the latter is absent when the patient makes an 
attempt to extend the limb, though the hip may 
be flexed to a greater or less degree. Here we 
have contraction of the flexors without hip disease. 
In simulated or hysterical affections of the hip joint, 
the patient is able, though the pelvis is fixed with 
the leverage of the sound limb, to extend the simu- 
lated one. I have frequently successfully diagnosed 
cases in this manner that were judged serious, the 
subsequent termination of the case confirming my 
diagnosis. The supposed lengthening of the limb, 
which is sometimes noticed in this affection, arises 
from obliquity of the pelvis, which may at an early 
stage be sufficient to hide the slight flexion and 

apparent shortening that always co-exist.. As- the 

fl 

inflammation progresses, if uncontrolled by any 

appliance, the flexion increases, so that the obliquity 



32 

m 

of the pelvis is masked', though often even then 
present This method of diagnosis will demonstrate • 

■ 

the existence of slight flexion and contraction as co- 
existing with the apparent lengthening. This obli- 
quity of the pelvis, and deceptive elongation of the 
limb, is sometimes present in knee joint disease, 
when the complaint has advanced to a chronic con- 
dition, and the joint is deformed by fixed flexion. 

Extreme flexion, with thickening and enlaige- 
ment of the acetabulum and head of the femur, in 
disease of the hip joint, is, even now, frequently 
described as dislocation of this joint, an occurrence 
which I have never yet observed, and which must be 
extremely rare. There may be displacement of the 
trochanter, as far as the tubercle on the outer lip of 
the crest of the ilium^ causing a shortening varying 
with the age of the patient and proportion of the 
parts, when the head of the femur has been destroyed. 
This certainly cannot correctly be called dislocation 
of the hip joint, and to attempt its reduction would 
be absurd. In nearly every case reported, and in 



23 

those I have observed, the so-called reduction has 
only been a diminution of the fixed flexion; and 
many cases simulate dislocation even without any 
displacement from destruction of the epiphysis of the 
femur. For example, when inflammation of the hip 
joint progresses to the suppurative stage, there is 
thickening around the joint and inversion of the limb, 
with rupture of the capsule posteriorly, if the case 
has not been treated in the fixed extended position. 
The last calamity allows of an increased inversion 
combined with thickening at this aspect of the joint, 
which closely resembles dorsal' dislocation of the 
femur. All these local symptoms of luxation can be 
removed by simply inviting the limb into the ex- 
tended position,^ with the adoption of the means I 
have recommended, without immediate violence. 

Mr. Hilton, in his Essay on " Rest and Pain," 
reports several cases of this so-called dislocation, and 
describes their reduction ; yet there is no evidence, 
to my mind, of dislocation in any one of the cases 
reported. 



24 

A remarkable instance of this error in judgment 
is published in Sir ' Astley Cooper's volume on Dis-. 
locations, page 91.. The patient had been under 
the care of Mr. Cline for traumatic injury of the hip 
joint, in all probability accompanied with inflamma- 
tory action. At the expiration of the treatment, 
some defect remaining, he consulted Sir Astley 
Cooper, who judged it to be dislocation. Some- 
time afterwards, this patient, whilst on a sea voyage 
was " lurched '* during a storm, so effectually tteit 
his deformity suddenly ceased, and the so-called 
luxation was reduced, though it had existed many 
years. I have no doubt that positioning the case of 
this man, and fixing him in a suitable appliance, 
would have removed the supposed dislocation, as 
was done in case No. 6, which had existed fifteen 
years, and presented all the signs of a so-called 
dislocation. 

A practical question, and one of interest to the 
Surgeon, is : What is the value of an early diagnosis 
of this disease ? In the volume on Rest and Pain, 



^5 

page 323, Mr. Hilton thus writes: — 

'* If we succeed in an early diagnosis of disease of the 
" hip joint, I am confident that it will not fall to the lot of 
*' surgeons to see those sad, and sometimes hideous cases 
" which we so frequently observe in private practice." 

With this I cannot ag^ee, since from my own 
observation the defective results, in the majority of 
cases, had been in-patients of Public Charities, 
neither cart I confirm the Author^s view as to the 
value of an early diagnosis. With the appliances 
which were at that time at the surgeon's disposal, 
inclusive of that which Mr. Hilton recommends in 
his volume, combined with the erroneous theory that 
has hitherto directed the treatment, an early diag- 
nosis seldom benefited the patient in times past. 

It is to be noted that many cases have a strong 
tendency to recover. These are the cases that some- 
times recover spontaneously (an extremely rare oc- 
currence), or are a long period in a passive condition, 
and jnay recover but with defect, never reaching the 
destructive stage, though neglected. Another class 



26. 

of cases are those we meet with which have a 

« 

tendency to non-resolution of the disease. 

I have supposed the above classes of cases not 
to have been under treatment. But the first class of 
cases, with careful treatment, recover rapidly, though 
diagnosed late ; and the second class of cases, 
although diagnosed early, may proceed to the sup- 
purative stage, yet, with my method a patient of tfiis 
class may be in fair health, have little pain, and 
ultimately recover perfectly. Cases belongfing to the 
first class may have been neglected for one or two 
years, yet, under treatment, may recover, rapidly and 
without defect, nor have any complication during the 
treatment. 

My observation convinces me that the practitioner 
is by no means to be discouraged by the advent of 
suppuration, as I have very frequently had recovery 
without the slightest defect, though the patient did 
not escape the suppurative stage. 



CHAPTER III. 



TREATMENT OF HIP JOINT INFLAM- 
MATION. 

There is an opinion prevalent, that only gentlemen 
on the staff of our public charities can treat, with 
any chance of success, this affection ; and certainly, 
hitherto, they have had advantages not possessed by 
the general practitioner, having at command the 
wealth of the charity to which they are attached, and 
being thereby enabled to order the costly appliances 
at present in use. 

Persons living at a distance from -large towns 
rarely receive professional assistance, as the one thing 
upposed to be needful cannot be obtained at home. 
This has induced me to describe such details as will 
enable any surgeon to treat his cases at home, with 



o 



28 

no more mechanical assistance than can be rendered 
by the village blacksmith and saddler, and the poorer 
class of sufferers will, at a small cost, be assisted as 
effectally as the wealthier classes. 

We will suppose the patient, a boy of about ten 
years of age, having been examined, and the affection 
diagnosed as disease of the right hip joint ; the 'sur- 
geon then proceeds to measure him for the instru- 
ment, suitable for a case in the early stage. He 
requests the patient to stand on the left limb (the 
one supposed to be sound), and places under the 
sole of his right foot a block or a book, one inch 
thick, telling him to rest the foot of the affected limb 
on it. If the spine is then straight, he is ready to 
have the contour of the sound limb and portion of the 
trunk taken. If the spine be not of normal line, then 
another block is added, or several blocks, if considered 
necessary, until the sound limb is raised sufficiently 
to allow the spine to resume its natural form, as in 
Plate 7. Now, take a long flat piece of malleable 
iron, one inch by a quarter for an adult, and three 



29 

quarters of an inch by three-sixteenths .for children, 
and long enough to extend from the lower angle of 
the shoulder blade, in a perpendicular line downwards 
over the lumbar region, across the pelvis slightly 
external, but close to the posterior superior spinous 
process of ilium, and the prominence of the buttock, 
along the course of the sciatic nerve to a point slightly 
internal to the centre of- the extremity of the calf of 
tlie leg. The iron must be modelled to this track, to 
avoid excoriations. In neglected and extreme de- 
formities, then under such conditions, the patient 
being in the position represented in Plate 7, the model 
is taken from the deformed limb, and, as the muscles 
relax, the appliance is altered at G, fig. i, Plate 9, 
by aid of the wrenches, Plate 8, figs. 2 or 3. The 
lumbar portion of the upright must be invariably 
almost a plane surface, Plate 9, figure i, F to G, 
and rotated on its axis in the direction of the 
arrows (in Plate 5, figure 4,) more or less in pro- 
portion to the plumpness of the patient. This iron 
forms the upright portion seen in Plate 5, fig. 4. 



30 

It is also very necessary that the upright dbodd 

« 

come below the knee, to enable the sui^eon to fix 

* 

this joint; otherwise the patient would flex the 
knee, and strain the hip joint Then measure round 
the chesty a little below the axilla, deducting,, in the 
case of an adult, four inches from the chest cir- 
cumference. This latter will be the measure for the 
upper cross piece, which is made from a piece of 
hoop iron, one and a half inch by one eighth of ao. 
inch. The hoop iron is firmly jointed with a rivet 
to the top of the upright, as shewn in plate 5, fig. 4^ 
at one third of its length from the end next to the 
diseased side, as plate 5, fig. 2 s. Fig. 2 in plate 5 
shews the upper ring modelled to the outline of the 
trunk, which is oval in shape. It is important to 
give the upper crescent this oval shape, to assist in 
arresting the machine from rotating from its position 
behind the body ; and inversion of the limb. An- 
other strap of hoop metal three-quarters of an inch 
by one-eighth of an inch, and in length two-thirds of 
the circumference of the thigh, is fastened to the 



31 
upright, at a position from one to two inches below 
the fold of the buttock, as in plate 5, fig. 4 B, plate 5, 
fig. 2 D C, according to the age of the patient ; 
then another piece of metal of like strength, equal 
to half the circumference of the leg at the calf, 
is firmly rivetted to the lower extremity of the up- 
right, as in C plate 5, fig. 4, and plate 5, fig. 2 E G. 
In the sectional diagram, plate 5, fig. 2, the forms 
of the cross pieces there given should be carefuUy 
noticed, especially the points of junction with the 
upright marked at S^ as being out of centre. The 
short portion of the top half circle is next to the 
diseased side, with a space intervening, while the 
long portion must be closely fitted to the sound 
side. If the machine should tend to rotate from 
the diseased side, then daily contract the long wing 
of the crescents, and expand the short ones ; or 
should it tend towards the spine too far, then 
reverse this manipulation until the appliance be- 
comes set in the correct position. In my earlier 
experience a second crescent embraced the pelvis, 



32 

but I found it painful to wear. In appl;^g an 
instrument with two uprightSi care should be taken 
to measure the distance between the tip of right and 
left posterior spinous processes, and then to set the 
uprights parallell and apart^ one inch more than sudi 
measurement, or it cannot be tolerated by the patioit* 

• 

The two uprights should be connected by a cros^mrj 
as shown in plate 13, fig.' i A, when practicable^ 

« 

which is not possible when the double instrument is 
used for reduction of deformities, as in plate 15; 
this crossbar when used, will be found useful fdr the 

attendant to grasp in nursing. This appliance, with 
two uprights, is indispensable when both joints are 
affected, and, if the patient or his friends do not 
object, will be found easier of application, and there- 
fore of more certain efficacy, even in cases where 
only one articulation is affected. 

The instrument is now ready to be padded and 
covered. The former is conveniently done with 
boiler felt, (No. i thickness,) which should not be 
used in more than a single layer ; the latter is done 



33 
by a saddler with basil leather.* However correctly 
it may have been modelled, it will often occur that 
some slight alteration will be demanded, when it 
comes to be applied to the patient, either on the 
first day, or at some period during the progress of 
the case ; or the case may have been one of long 
duration, uncontrolled, and consequently attended 
with much deformity : then the surgeon may, for a 
few weeks, occasionally have to alter the curve G, 
plate I fig. I, of the appliance. . This modification 
the surgeon should be prepared to perform himself, 
as the workman can only make the apparatus. To 
enable the former to do this, I have devised and 
used the instruments and wrenches shewn in plate 8. 
For instance, it may happen that the upright por- 
tion of plate 5, fig. 4, may require a little more 
rotation outwards, which can be done by the hooked 
ends of the instruments shown in plate 8, or the 
concavities may require to be increased or decreased, 

♦ I recommend this quality of leather as it never becomes offensive with 
the patient*s secretions, &c , which is the case ^vith chamois leather, so 
frequently used in the construction of surgical appliances. 

E 



34 
which can rapidly be done with the extremities B 
B of the instruments Nos. i and 4. The two lower 
short crescents can be altered with end B of die 

figs. I and 4, plate 8. Fig. 3 and 4, plate S^ re- 

• " 

present a triple ratchet wrench for bending, and hook 
for rotating. This wrench will enable the siu^eon 
tx> alter the apparatus while on the patient These 
are very convenient, though more expensive than 
the simpler form^ fig. i, plate 8. By the aid of 
these the surgeon is always independent of any 
mechanician's aid until the case has terminated, or 
he may remodel an old appliance to use again. 
The patient being placed in the machine, a strap 
and buckle close the upper circle round the chest, 
and the limb is bound with flannel from the calf up- 
wards, beyond the small crescent B, plate 5, fig. 4. 

Fig. 2, plate 5, shows how the splint should fit, 
when applied correctly; the long portion of the 
upper crescent being close to the trunk, and exer- 
cising some pressure on the sound side, the short 
portion a space from the trunk. This is necessary to 



35 
hinder rotation of the instrument, and the upright 
stem should have a perceptible rotation outwards, as 
shown in fig. 4, plate 5, from F to G, and be fitted so 
that it shall pass to the inner side of the popliteal 
space as indicated by the arrow in fig. 2, plate 5 ; 
this will avoid rotation inwards of the limb, a defect 
easily avoided by attending to these details. 

Should the instrument rotate towards the diseased 
side, and so become a side splint, the surgeon should 
contract. the longest wing of the upper crescent and 
expand the shorter one ; or if the instrument does 
not rotate, yet the stem is not over the prominence 
of the buttock and well behind the thigh, then the 
upright requires more twisting with the hooks, plate 
8, figs. I and 4. Or should the trunk portion of the 
upright threaten to ulcerate the skin, the angle at G, 
plate 5, fig. 4, and .seen at plate 9, fig. i G, should 
be diminished, untill the portion from F to G is a 
plane surface. It is preferable to place the patient in 
a soft bed, during the first stage, rather than on a 
mattrass, which is objectionable granting that the 



36 

surgeon has not selected the iron of too slight propor- 
tion, an error I notice many are inclined to commit 

The hip appliance if not moulded by the siirgeon 
so as to remain continually behind the trunk, and 
painless to wear, then it requires more of the sur- 
geon's skill and perseverance, or it would be useless 
to the patient. A few minutes of interruption is as 
great an evil as so many days, and would not be 
uninterrupted rest, which is so essential to success. 

Since the publication of the first edition, several 
gentlemen have suggested the making of these ap- 
pliances of steel, instead of iron, so as to reduce the 
weight ; others have recommended the substitution 
of lighter iron : their so doing, in the construction of 
either the hip or knee instruments, would make 
upracticable models. If the hip appliance were made 
of steel, it could not be moulded by the surgeon with 
his wrenches in the reduction of deformities, and 
consequently could not be used except in a very early 
stage, and further the surgeon could not excercise 
his skill in fitting, which, though sometimes success- 



37 
ful in one visit, may at other times occupy many 
days. This is the duty of the surgeon, not the 
mechanician. And the surgeon should mould by 
reducing or increasing the various curves, until the 
instrument ceases to tend to rotate, and at none of its 
angles irritates the patient. What I can infallably do, 
must be possible to others. As regards the forming 
of the hip appliance of lighter iron, the nursing would 
not be painless. The instrument must be so strong 
as to be free from tremor, in nursing in particular, 
or the stage of inflammation would be prolonged. 
Again the knee appliance if made of steel could not 
be altered without unnecessary expense. In the case 
of children, their growth, wear, &c., necessitate the 
repair and elongation of the machine frequendy, and 
again the iron is not so liable to fracture ; it rather 
bends, and a stroke of the hammer will directly 
restore the correct line. 

As to constitutional treatment, the local inflamma^ 
tion if of traumatic origin, and the patient suffering 
from local lesion only ; then no therapeutic remedy 



38 
may be indicated, or the case may have been of 
diathetic origin, as rheumatism, or as the sequelae of 
blood contamination. If at the time the surgeon is 
consulted, the constitutional defect has been reme- 
died, prescribing may here not be required. Or, the 
surgeon may find the patient under constitutional, as 
well as local irritation ; in this condition, I have no 
faith in any benefit from the internal administration 
of specific remedies, as Mercurials, lodidies, &c., 
the contrary is my conviction derived from practical 
observation. And that the practitioner should pre- 
scribe what he rationally judges fit for each individual 
case to restore health : as to local treatment, nor do 
I believe in the efficacy of counter irritation, rather 
the reverse. At an early period in my professional 
training, I began to doubt the correctness of its use, 
and practical observation has confirmed, what at one 
time I only surmised. I well recollect that the late 
Professor Syme, in his Clinical Lectures, when dis- 
cussing the method of treating loose " bodies " in the 
knee joint, taught that blistering this joint caused 



39 
collateral inflammation within the articulation. Pro- 
fessor Spence, of Edinburgh, also in his volume on 
Practical Surgery corroborates Professor Syme, and I 
am inclined to believe from practical observation 
that a potent counter irritant is a feature in prolong- 
ing the inflammation and consequently tends to the 
condition of anchylosis. Should suppuration occur^ 
repeated aspirations are necessary, and this practice 
is usually successful, if performed early, and efficiently 
carried out. Aspiration, repeatedly practised, is 
usually successful ; but at times this fails, especially 
if practised late, and the case becomes complicated 
by an abscess, With communicating sinuses. I fre- 
quently note, even in these days, that it is the 
practice with many to cover the opening of the 
sinuses with the vile filth, known as linseed meal 
poultice, or some other glutinous and irrational cata- 
plasm, which does not permit the abscess to drain 
and contract, and greatly increases the quantity of pus 
formed. The application I have found to be useful, is 
either moist carbolic tow, or coarse floor cloth flannel. 



40 

which can be had at any draper's estaUishment 

It is veiy advisable that the sufferer should be 
confined to bed for a period, at the commencemeiA 
of the treatment This preliminary reclination, I • 
have never noticed to injure the general health, but 
invariably improves die patients condition, sEnd 
shortens the acute stage. During' the first stage of 
the mechanical treatment, die surgeon being satisfied 
that suppuration has been avoided, he permits the 
patient to proceed on to the second stage. The 
patient is then allowed to go about with the as^sfr 
ance of crutches, the frame continued, and an iron 
patten at least four inches in depth is placed under . 
the shoe of the sound limb, as in plates i o and 1 1 . 
These must be continued until the limb is well 
atrophied around the great trochanter ; the outline of 
which should be more discemable than that of the 
sound side. 

Ngw we come to the third stage. The patient 
takes off the framework in bedj and replaces it 
during the day, still using the crutch and patten for 



41 
a certain period. 

We now arrive at the fourth stage. The patient 
totally discards the frame, and uses the crutch and 
patten only. These he sets aside after the surgeon 
is well satisfied with regard to the permanence of the 
cure. If the case does not progress to the surgeon's 
satisfaction, some of these stages must necessarily be 
prolonged. 

The weight of the lower extremity is equal to re- 
ducing any angular deformity of the hip or knee joint, 
not resulting from true anchylosis, and is capable 
also in some degree, of diminishing any shortening, 
should absorption of the head of the bone occur, — 
provided a suitable mechanical arrangement be ap- 
plied, and continued during a sufficient period. 

The splint ought to be applied at once, whatever be 
the stage of the disease. Forcible flexion, extension, 
tenotomy, or chloroform, &c., are to be avoided as 
imnecessary. In the presence of my method, these 
operations are undesirable, though they were essen- 
tial at one time. Even should the deformity be an 



F 



42 

extreme one, no violence must be attempted; the 
Iknb should be gently persuaded to come batk horn 
the arring positioiH and as it assents, die wroidies 
^ewn in plate 8 should be used to alter the hip 
kistnunent towards the pormal lines. 

I 9ball f^trict m3^1f to a few instructive case^ 
which will be useful to the suigeon in his 6sAy 
ipractic^ illustrating the complications and di£&eul<ie$ 
to be encountereid, rather than the success of this 
^^e&od, or my personal skilly as it would ma^d: m 
pnuitiau purpoise to burden the treatise by a multitiKle 
4»f cases, mdst of than being but repetitions. 

Case No. i. — On the 17th of April, 1872, one of 
the siste« of a neighbouring convent, accompanied 
by a child, aged 12 years, (Miss D^ — ) consulted me 
regarding some pain which the latter suffered in 
her right thigh. On making an examination, by 
the previously explained method, I was convinced 
that she had some slight inflammation of the hip 
joint, and advised a delay of two weeks while 
the patient's guardians were written to; the 



43 
patient being confined to bed in the meantime. 
In the course of a few days I received a message 
stating that the patient was much wor^, and on 
calling I found that her joint was in a state of 
acute inflammation, and very painful, accompanied by 
a good deal of constitutional disturbance, and noticed 
the local symptoms, usually present, intensified. I 
counselled no further delay, but with the consent of 
the Superioress of the convent, applied the frame, 
and fixed the joint, retaining the patient in bed for 
twelve weeks ; at the expiration of this period, the 
local symptoms subsided, and could not be detected 
on rough manipulation. During the first three 
weeks the febrile condition was treated with salines, 
&c., in addition to the mechanical treatment. At 
the expiration of the twelve weeks she was taken 
from bed, much improved in health, and stouter than 
she had been previous to the attack. For the next 
six months she went about with crutches, frame, and 
patten, as in plate lo. Afterwards, for a further 
period of three months, she continued to use the 



- F" ■♦■ '. 



44 
frame in the daytime only, at the c^d ci whidb t»ie 
the patten and crutches were used during the wb^ 

m 

mainder of .the period that she was tmder my mgiiL 
It is very essential that the patten should be Bt lea^ 

four inches in depth ; if made less than four iml^ 

« 

a careless and unruly youth would be able to i^eadi 
the ground so readily as to delay his recovery, it 
is preferable to increase the depth of the pattm hy 

4, 

one or two inches, than to lessen its elevation^ 

This patient progressed well, and reo^vered 
perfectly ; and at the expiration of the treatmaEit shfe 
was in better health than at any previous perkxl c^ 
her life. During the progress of this case, there was 
neither inversion, nor eversion, abduction, shortening, 
nor lengthening, at any time ; nevertheless at one 
period in the treatment, I feared that there would 
possibly remain some amount of adhesion, and conse- 
quent stiffening of the joint, impeding its future action, 
as the inflammation was more rapidly developed 

• • • . 

and more acute than any I had ever before witnessed 
in this class of cases. But it did not occur> and it is 



45 
my opinion — and this is quite consonant with reason 
— that the more effectually an inflamed or irritable 
joint is fixed, and the sooner this is done, the greater 
is the certainty of its future freedom of motion and 
absence of defects. 

No rule can be laid down as to how long a joint 
ought to be kept under treatment. The surgeon 
must judge, by the disappearance of the symptoms 
of disease, when to modify or discontinue it. • 

Stiff joints are not the results of too long confine- 
ment in an immovable position, but are caused by 
inefficient or interrupted control of the diseased arti- 
culation, and by permitting its use too soon ; it may 
be too soon even if the joint be sound. 

It matters not from what causes these affections 
arise, whether from an injury, rheumatic attack, or 
constitutional defect, the main thing needful, espe- 
cially in the chronic stage is, that the joint be mecha- 
nically fixed, the general health being attended to, if 
necessary. The fact of a person suffering from 
chronic articular inflammation is not of itself any 



46 

f€ason for nauseating the saffek& vnA iatenai 

* 

remedies. 

Case No. 2. — On the 18th of Fdbfuaiy^ iSfJ^ 
Mr. ]^ p.| of Cumberland, brought his soOt ^ boj^ 
eight years of age, to consult me' res9)6Cttng a bme-^ 
ness affecting his left limb. On examinatk»t I Ibund 
flexion of the hip joint to an angle of 150 degree!!^ 
I considered this to indicate that the joint had hem 
unsoimd for at least five months, and I advised lim 
use of my hip appliance, with the patient's confine* 
ment to bed. This was done, and had the effeolk iot 
removing the flexion of the thigh by the end of the 
second week. He remained in bed twelve weeks, at 
the expiration of which period I found the affected 
joint had become normal in appearance. He was 
now permitted to get up, using the frame, patten, 
and crutches, as in plate 10. These were continued 
for another five months, when the frame was set aside, 
and his recovery was, by the end of another four 
months, completed. In .this case no constitutional or 
local medical treatment was adopted- 



47 



This patient did well, although his early treat- 
ment had been very unsuitable, as he had been 
treated for dislocation by a bone-setter in the neigh- 
bourhood of his home. 

Case No. 3. — In July, 1867, Mr. J. G., of 
Aberayron, consulted me concerning his son, a boy 
six years of age, whom, on examination, I found 
suffering from morbus coxae, with an amount of 
flexion 150 degrees, indicating to my mind, an 
inflammation of five months' duration, with some 
amount of thickening around the joint. I adopted in 
this case my previously described treatment, carefully 
^shioning the frame to the trunk and sound limb, 
but applied it to the diseased limb, and sent the 
patient home, directing him to be confined to bed, 
and to return in three months. At the expiration 
of that time I again examined him, and found the 
deformities, usually present at the fifth month, 
gone, the health moderate, but some thickening re- 
maining around the trochanter ; consequently, I 
feared suppuration would occur. I again sent him 



48 
home, and advised his continuing in bed Icxr tuo 
months longer, and(m his return aftar that tiin% ( 
found that the limb had continued u>mjpt(xvt,mik 
no sign of suppuration. I. now albwed him fta g0 
about with frame, crutches, and pattai, desira^ him 
to return again in three mcmths ; and on hfe i^etum 
I allowed the fram^ to be removed in bed, an4 
replaced in the daytime, with crutches aiid patt^; 
and on his last visit, in 1869, 1 ordered the reniovid 
of all apparatus. This boy was efSsctually cured*^ ; 

In the above case we have a patient treated at t 

long distance from the surgeon — which course I have 
often had to adopt — yet, notwithstanding this dis- 
advantage, the case did well. 

It is very advisable when the patient resides at 
a distance from the surgeon that his return home be 
delayed a few days, as frequently an appliance that 
apparently fits well on its first application, may re- 

* The upright portion of the hip appliance was modelled from the contour 
of the sound limb in this case, which course is only advisable when the 
deformity is not extreme and of recent date. 



49 

quire some subsequent rectification during the first 
few days. 

Children from the ages of one to ten years can be 
very successfully treated, as travelling at this early 
age is not such an obstacle to their progress towards 
recovery as it often proves in the cases of adults. 

The patient ought never to be allowed out of the 
frame, except under surgical supervision ; should the 
patient be taken out of the frame, and happen to 
assume a sitting posture, thus moving his trunk from 
the straight line with his limb, he would retard the 
recovery, and, possibly, may in a few minutes undo 
the repair of months, and cause suppuration, a disaster 
he might otherwise have avoided. 

At one period in this case I feared suppuration, 
yet, from the absence of persistent pain, I judged he 
might escape this evil. A notable sign of suppura- 
tion is, that at some period during the third to the 
sbcth month of treatment, a rapid increase of pain is 
manifested, lasting from seven to thirty days, with an 
almost sudden cessation, in one or two days, through 



5<*' 
rupture of die joint on erne or bodi sides of the ilio- 
femoml ligament. ■ The contents of the joint -esca^Mi^,- 
in this direction, in most cases, when the limlKl^- 
befen retained immovably in a line with tiie tnu^ " 
Case Na 4. — In January, 1873, I was conaiheii-. 

by Mr. N , B— — R , of this. town, ■cone- - 

ceming a slight lameness of his son, a hoy ei^t 
years of ^e. The lameness only, had attracted^ the 
parents' attention ; but, on applying my dragnostie . 
' method, I concluded that he had had hip disease for 
titi'ee months. The parents denied its having been - 
so long ; but on careful consideration concurred after - 
a few days, with my view of the matter. . I com- ■ 
menced the treatment of this case by applying -the 
frame as usual, and by confining the patient to bed 
at night, and to a couch during the day; and as 
there was some amount of thickening around the 
joint, with pain continuing for a long period, I 
was convince^ that suppuration would occur, and 
directed that the patient should be retained in a 
horizontal position during six months. He required 



51 

occasional constitutional treatment. At the expira- 
tion of SIX months the night pains, which had not 
previously troubled him, commenced to disturb his 
rest, and during the seventh month I detected fluctua- 
tion, and aspirated the abscess, which lay under the 
skin over the anterior aspect of tl^e hip joint. ' I 
aspirated a second time in two weeks afterwards, 
which operation was repeated every month; in all, 
SIX operations, after which the abscess ceased to 
refill. Then he commenced to go about orh 
crutches, with th^ frame and patten. Gradually the 
joint became atrophied; and he progressed favourably 
to recovery, without any defect. I advised however 
the continuation for a longer period of the mechanical 
aids, so as to ensure the avoidance of a relapse. 

•This patient, though requiring some medical at- 
tention to his general health during the early period 
of the complaint, became possessed, in the latter part 
of his recover)', of most excellent health. 

Since practising this method of fixing the joints, on 
no occasion have I had to give the patient an opiate. 




■ Case No. 5. — In the early part of 1873, Mr. 
p , reading in Cheshire called, desiring me 

^ to vi»t and examine his son, a boy of about seven 
years old. On doing so, I found him suffering 

' from inflammation of the hip joint of four months' 
dutation^ general ill-heal^, much emaciation, and 
want of sleep from' night pain. I proposed im- 
' mediately to fix t"he join^ telling the parents that 
this wjiild of itseJf res&re sleep and appetite. The. 

-, parents- consented, and I applied the frame on the 
18th of February, 1873. In three \*eeks time the night 
pain had gone, the appetite improved, and the boy 
rapidly gained flesh. But the local tumefaction around 
the joint did not subside, and as some tenderness 
remained, what I expected occurred, viz. : an abscess 
formed on the anterior aspect of the thigh, which I 
aspirated once a fortnight for six weeks, afterwards 
once a month for three months. The repeated form- 
ation of the abscess, necessitated his confinement to 
bed during the long period of nearly nine months, at 
the. expiration of which time he commenced to go 



53 
about with the patten and crutches, which I advise in 
the second stage of treatment. This case also re- 
covered without any defect. 

Case No. 6. — In July, 1874, Miss M. R. con- 
sulted me, being desirous to have a deformity of 
her hip joint improved. On examination I found 
that the angle which the thigh formed with the 
pelvis and spine was a right angle, so that she could 
only reach the floor with her toes by arching the spine 
considerably and leaning to the affected side. I also 
noticed, thit there were several cicatrices, indicative 
of abscesses, at a previous period. The integument 
between the ribs and the pelvis formed several folds, 
caused by long inclining to the deformed side. She 
had suffered at an early age from hip disease, and 

was now beginning to have a return of the acute 
symptoms. She was much emaciated, and appeared 
in general ill-health. I advised her to undergo a few 
months' treatment, especially as she had at times 
much pain, which was the 'principal cause of her 
deteriorated health. Acting on my advice, she en- 



S4 

tered my ho^Mul on the isib of August, 1S74. As 
the cue was one of many ycan^ axaaditig, I deddcd 
to model a frame to the dcibnned ade as plate 9, 
fig. j, (which 1 do not advise in recent cases,) and as 
tfic case progressed, the spine str^ighteoed aod the 
Innb became nwre extended. I itsed the wrenches— 
pbte 8 — ^to alter the lunn of the upright portion of 
the frame. This rtKxliiication is absolutely necessary 
in cases of long standing. In sixteen weeks the: 
apparent shortening was corrected, and the spine 
Straight. I then advised a change to her native sat 
in the Principality. 

My hospital assistant having mislaid the notes 
of this case, I wrote to the patient, and requested the 
Wstory of her suffering. I lay before the reader her 
note: — 

" Dkws 'Refail, 

"Aberwch, A/n'i 15, 1875. 

"Dr. Thomas, 

"Dear Sik,— I am happy to say tliat my hcallh 
"in better than it has been for a long liir.e. I am getting to 
" look so well that you would not lliiiik I was the same person 



i 



55 

** that entered your .hospital on the 15th of August. My back 
"is not so painful now. The creases in the left side have 
" almost disappeared. My back is quite flat on the splint now, 
" The doctor could not push his fist, as heused to do, between 
*' my back and the splint. I can put the other knee up to 
" the chest quite easy now. I am still wearing^ a thick boot, 
" and using crutches. I was afraid of leaving them off without 
"your permission. You wished to know, siri how long it 
" is since I have been bad. Mother says that an abscess 
"formed in my hip about twenty years ago, after scarlet 
" fever ; and then I had a fall about three years before I 
" came to you, sir; and after that I had more pain than I had 
" before, when walking. I do not think I caii explain myself 
"any better. 



" With kind regards from. 



f> 



When I examined this case in October, 1876, 
I found all def9rmity gone, and no symptom of 
unsoundness. 

In my early practice I often placed the patient 
under chloroform, as I believe it is the practice of 
others in cases of this character, then divided the con- 
tracted tendons, and forcibly extended the limb — a 
process which, though not very risky to the patient, is 



ytry painfitL Since however I have practised this 
me d iod of allowing the body to become unfolded by 
mere pontkm, the patient has had no pain, and the 

■ result has been all that the surgeon could desire, and 
has not necessitated as much time as the previous 
practice. The deformity here was great, and had 
existed fifteen years, at least ; this case was certainly 
a crucial test of my method. 

Practically, we anay class this case as one of 

' reduction of a deformity which had existed for twenty 
years. I totally differ with previous writers as to the 
causes that determine the direction of deformities of 
limbs affected with inflammation of the joints. I be- 
lieve that they are the result of the patient's voluntary 
efforts by muscular action to arrest friction, pressure, 
and tremor of the diseased part, and in so doing 
calling into action, simultaneously, muscles that are 
antagonistic in their action, and these usually belong 
to the two actions of flexion and extension ; and as 
these two classes of muscles are not possessed of 
equal power, whichever set of muscles possesses 



57 
the greatest force^ the limb thus being unequally 
balanced, must be drawn by those muscles which 
possess the maximum power. 

In those cases where an exception to this rule is 
noticed, the weaker muscles are in possession of some 
mechanical advantage, securing to themselves the 
balance of power; as, for instance, in the case of 

the elbow. But in the case of the ankle joint, we 
have the greater muscular power as well as mecha- 
nical advantage in the extensors ; consequently, early 
and rapid deformity, and corresponding difficulty of 
reduction exist. 

We have a very noteworthy tfest of this theory .in 
deformities of the hip joint. At first, we have the 
deformity of flexion, caused by the greater muscular 
force of the flexors, and their accessory muscles the 
adductors, predominating over the force of the ex- 
tensors ; and continuing their action usually up to a 
right angle. This is also often accompanied by 
rotation outwards, corresponding to the extra force 
possessed by the external rotators over that of 



• 58 
the internal tmes, this eversion Icing some timqs 
the last deformity "noUced. Upon rare occasions, 
this state is succeeded by ioversion, which occurs 

. when the joint has been long in an acute and irri- 
tate condition. ThSs inversion comes on by the 
action of the hanistring muscles at the period when 
the previously affected muscles have become paralysed 
from long action, and i^ik inversion results from the 
predominating force of the inner hamstrings over the 
external ernes, the latter being weaker in power. 
Indeed, we may look upon the muscular contractions 

. as nature's attempts at the resolution of the disease, 
and by no means ' can I see that tlie muscles are 
oifenders. I am aware that the opposite view has 
been maintained, and that an eminent United States 
Surgeon, Dr. Bauer, has proposed division of the 
tendinous insertions of all these muscles with 
the object of relieving spasm and pain ; but I 
should say that by that means the destruction of 
the joint would only be allowed to progress more 
rapidly. 



59 

We have a parallel in Veterinary Surgery, where, 
by unnerving a horse affected with joint disease, pain 
is eased and spasm, relieved, but with the result, 
that the joint is destroyed more surely and rapidly. 
Night spasms and pain are caused principally by the 
patient's inabiltiy during sleep of closely engaging his 
mind and by his deficiently directed efforts to steady 
the limb. Again, pain is aggravated by night, to 
some degree, by altered atmospheric pressure, giving 
rise to more or less irritation of the joint. Atmos- 
pheric pressure has more influence on inflamed joints 
and tissues than is generally supposed. No symptom 
is so frequently complained of by patients than what 
is popularly termed " Rheumatic pain " from approach 
of night and " change of weather." 

Case No. 7. — J. P., fourteen years of age, was 
brought to me by his parents, in May, 1875, suffer- 
ing from inflamed hip joint, in the destructive stage, 
abscesses having formed, and sinuses communicating 
with the joint. 

Plate 12 is a carefully copied engraving of the 



spine, widi large 
trochanter, and 
three inches. 



patients photograph taken after eight months' 
treatment m a lat^ hospital, previous to my ex- 
aminatkn of him. On examination I found the 
piUient in the condition which is so well illustrated by 
the artist, namely, that of flexed thigh, and curved 
abscess and ulceration over the 
inability' to reach the ground by 
This boy had had skilful advice 
for eight months. The disease had existed about 
one month previous to his admission into the charity. 
The treatment he had received was, according to his 
own report, the long splint, at first, and latterly the 
weight and pulley. 

This patient was placed in my appliance, and in 
the short space of three weeks all deformity had 
been removed, and he was free from pain, but will 
require a long period to become sound. 

I admit that abscesses, and some amount of 
destruction, may occur under any method, but I also 
assert, that to whatever stage the patient progresses 
with my method, his recovery will be at least without 



6i 

angular deformity ; an unsightly and crippling defect 
and a serious obstacle to the patient's future use- 
fuUiess. • 

Case No. 8. — In the early part of 1874, I was 

requested to visit Miss D , 14 years of age, who 

resided in this toym, and who had suffered from 
lameness for five years. 

On making an examination, I found that she had 
been suffering from inflammation of both her hip joints, 
which had terminated in the * formation of abscesses 
and sinuses on both sides. The joints were acutely 
tender, and flexed to an angle of about 140 degrees, 
the spine was greatly curved, and she was unable to 
stand upright. Her history was, that five years 
previously she had slipped in the street, injuring her 
left hip, and from that time had commenced to 
limp slightly — gradually more so. In one month 
. after this slight accident she consulted a surgeon In 
this town, practising as a specialist, and supposed to 
possess hereditary skill in this, department, who 
advised rest and medical treatment; (not surgical 



e.) Not satisfied ^vith this advice she 
consulted another surgeon, ^ho advised rest with 
linamentSa codliver oil, &c. In nine months after the 
accident, the right limb b^;an to sufl'er. At about 
the twelfth mopdi she was jJaced under the care of a 
homoeopathic practicumer,.but the deformity, which 
had been increasing, now became stationary, and 
continuecl so for four years. At the termination of 
tliis period^ a Uttle oirer exertion brought on the 
acute sympt(»ns again, when she consulted me, 
and I advised her being ' placed in the horizontal 
fixed position, and in- twelve weeks both her limbs 
became unfolded and in a direct line with the trunk. 

In this case, during five years, there was no 
attempt at any mechanical assistance, tliougli she 
consulted a specialist. When I saw the patient she 
was much emaciated, and the parents at first were 
not willing to have her confined to bed ; but confine- 
ment to bed, and fixation of the joints, had the usual 
effect of giving her undisturbed sleep, increase of ap- 
petite, freedom from pain, and a rapid gain of flt-sh. 



63 

In this case I had to place an upright on to each 
limb instead of on to one, and I have always found 
it much easier to fit and retain the hip instrument 
with two uprights to it, than with one (as in plate 
13, fig. I.) It is of importance that the two uprights 
should pass to the outer sides of the posterior superior 
spinous processes of both hip blades, with an inch of 
space from the processes, or the machine cannot be 
tolerated by the patient. When an instrument with 
two uprights is applied, and both the hip joints are 
affected, then it is necessary to prolong the first stage 
of treatment, as crutches can only be used in the 
second stage, there being no sound limb to attach 
the patten to, and take the weight of the body off the 
diseased one. My experience informs me that cases 
of disease of both hip joints, are of more frequent 
occurrence than double affections of the knee joints, 
and that twin affections of the ankle joints are rarer 
than the latter. Double inflammation of joints are 
usually of diathetic origin. 

Case No. 9. — In May, 1868, I was consulted by 



64 

O. E., a timber merchant of Utica, United StatesT 
He had 1>n)t^ht his son over to have assistance in a 
case c^ flexed bip joint, the result of inflammation, 
l<^wed by suppuration, and the sinus formed had 
not yet'c^sed discharging pus. 

In diis-case. I put the patient tlirough my usiul 
treatment and he remained in town for two months 
by my advice. He was then taken to the Principality 
for some mmtths, and again consulted me on his way 
home to the United States. 

I instructed him how the treatment was to be 
continued, during certain periods, and his report to 
me in 1871, was that he had recovered perfectly. 
He had had skilful assistance from United States 
surgeons, previous to his being brought over to 
this country, but the disease resulted In deformity. 

Case No. 10. — James H , Dalton-fti-Fumess, 

aged eighteen years, suffering from pain, lameness, 
and deformity of the left hip joint, consulted me on 
July ist, 1874. On examination I found also the usual 
symptoms of formation of formation of abscess. The 



I 



65 

history of this case was, that two years previously he 
had met with a slight accident to his hip joint, and, 

• • 

as some lameness remained, he consulted a qualified 
specialist in this town, who advised alkaline fomentii* 
tions, cod liver oil, and other remedies prescribed by 
sui^eons who take a diathetic view of nearly all 
chronic joint affections. This treatment he had con- 
tinned for two years. I advised that' he should enter 
my hospital, and be placed in the horizontal fixed posi- 
tion, which treatment had the usual effect of improving 
his health and appetite. As soon as he had become 
well fixed, and settled in the instrument, his joint was 
aspirated at intervals of two weeks, until the loth of 
September, when, perceiving that aspiration would not 
succeed in controlling the formation of pus and drain 
on his constitution, .1 laid open the abscess by an ex- 
tensive incision. It, however, continued to discharge 
more or less until the latter part of November, when 
the patient became decidedly hectic and exhausted; 
from the drain of pus. I then decided to excise his 
joint, which operation was performed by the method 



I die bip of t)ie 

I to die rotator 

r BK^ imgt.1 MtoAe depths of 

», I 

: wegea «f Ac femur, jost 

r throogfa the 

1 Ac had md neck and a 

• *g- 3. pbte U)- I 
£■■■1 dbe head trf" the fcavr carioB, wah perfbfatkm 
of Ac irrtA J—, tfcnM^ «Ucfa about ten ounces of 
pnscsc^ied. Hieopentioa was successfiil in tem- 
porarily icfievn^ the cnos tituti ooal irritation, but did 
not arrest the drain and iDacastp^ depressioa, and 
the patient succumbed in twraty days after the 
excinoD. 

In this case the operation was imperatively 
demanded, and I was prepared for a very extensive 
smount of disease, as the patient had had no rational 



67 
treatment for nearly two years previous to his con- 
sulting me, and had made use of the limb to some 
degree daily, though not in any employment. 

I performed the operation on this occasion, devi- 
ating from the methods hitherto practised, by leaving 
the upper portion of the great trochanter. The usual 
justification for removing the whole trochanter and 
head of the femur, is that it facilitates drainage from 
the wound. This modification of the usual operation, 
leaving part of the great trochanter, would not inter- 
fere with the drainage from the joint, and I judged it 
to be quite as rational a course as that of leaving the 
calcaneum in Pirogoff 's operation, and calculated to 
assist in developing more bone in the place of that 
removed, and finally to unite with the femur. 

Plate 13, fig. 2, shews the course of the saw 
through the bone. My limited experience of excision 
of the hip joint, derived mainly from what I have 
observed in the practice of others, convinces me that 
it is not an operation desirable except* as a last re- 
source, where all other means have failed to control 




jht dweiie, and when the patient is suffering an 
■BKNint of irritation, that must be iatal to him 
* if oot rdievecL This operation, which, by surgeons 
of ^ United States, is looked upon as involving 
bat litde riidc, has been performed, according to 
dieb own evidence, upon patients whom I should 
. cooaide r amenable to treatment, with a fair presump- 
tim c^taccesk, which accounts for their dictum, that 
die openttion involves no risk, for doubtless their 
patients were operated upon long before the disease 
had reached an advanced stage. In fact, ex cision was 
not indicated. 

Since publishing the above, I have perused a very 
instructive treatise on the Pathology and operative 
treatment of hip disease, by Mr. Thomas Annandalcj 
of Edinburgh, in which he reports a series of 22 
cases of excision of hip joint with a - result, cer- 
tainly not encouraging to those who incline to this 
operation. I find, on analysing these cases, that in 
seven out of the 22, the results were fatal. In one 
out of the non-fatal cases, the operation gave no 



69 

relief; whilst the remaining 14 cases» were what is 
usually termed a success; that is, they recovered 
with a shortening varying from two to f^ur inches, 
according to the age of the patient. A shortening of 
two inches at the age of six would of course become 
four inches of shortening at the age of 2 1 . This 
explains why in the case of adults the shortening 
was so much greater than in the youthful period. 
In the practice of my method, even if the head of 
the femur has been • destroyed, the shortening would 
not exceed two inches in an adult, and scarcely one 
inch in a youth ; a result worth some trouble to 
secure. I notice that out of the seven fatal cases in 
only one case is it reported that the symptoms were 
urgent, and necessitated an operation ; and out of the 
remaining fifteen cases, only one is reported as 
having been accompained with urgent symptoms, 
calling for an immediate operation. 

Certainly to my mind, 14 out of the latter cases 
could in all probability have been successfully treated, 
and I have reasons for asserting, that there was a 




f tfau aoDK of the seven £aial cases might 
Ab lave recovered, as I find that the padents 
«CR ■AjacteJ 10 no efiective mechankal control, 
tBifc IB voidd have a definite purpose towards 
mola&in of cbe tnfamnm ion cxistiog in the joint ; 
mA even where the poaabiBpf of a fractional aoMHint 
<f nrt m-crc poasifafe xo the patient, it is reported 
Am Means were empioj-edi sodi as the weight and 
prikf, whicA D^ativcd the rest the patient is 
sqipoaed to have bad b}* mere reclioation. 

h Buny of these cases that recovered after the 
c^ienition, th^ reooveiy Qani]Hed so loi^ a period 
that I cannot see any occaskn for its advocacy CMi tiie 
sc(»c oi time, as sudi a period would hare 5u£B(^ to 
dire the msLjanty <£ them, and certainly with less 
defect. In no one of these cases was the joint aspi- 
rated, an important omissiom in the tieatmait of joint 
disease when efiiisicm or suppuraticm is suspected. 

With regard to the reported state of the excised 
pcHtions, there is nothing to be leamt in tus treatiseat 
I with my finn convicti<»i. Without enter- 



71 
ing into minute anatomical details, I 'assert in general 
terms, that the pathological conditions met with in 
joint diseases (excluding of course tumours) are the 
results of motion and pressure in an articulation 
which has become inflamed, and is unfitted to sub- 
mit to the exercise of its normal functions (motion and 
pressure) so long as any inflammation remains. And, 
as attending circumstances, variable symptoms of 
exacerbation are frequently present, due to the var- 
ious constitutions of patients, but in no way necessi* 
tating any departure from strictly mechanical treat* 
ment, and still necessitating an adherence to the 
principles taught in my treatise. Again, I note at 
page 48 of Mr. Annandale's volume, the explanation 
of the delayed recovery of some of these cases, even 
after excision. The author advises, as. do other 
writers indeed :— 

** Movement of the new joint should be commenced 
*' at the end of three weeks, unless there is painful symptom 
" or condition of the wound, then the movement should be 
" employed as soon as this condition has passed off.*' 



72 

Thus we see that after excision, the dread of pro- 
longed inacUon even here haunts the Surgeon, and 
the patient too frequently loses again a chance of 
recovery, when he has had excision performed. 

Some of my readers might, however, put the ques- 
tion, " Then do you think excision never required r" 
My answer would be, that, if carefully applied, effi- 
cient and constantly watched, mechanical treatment 
had failed, and the patient had commenced to suffer 
the sympathetic fever, then the operation oitght to 
be performed, I have, however, very frequently seen 
cases where all the constitutional sympathetic irrita- 
tion was present, and which had existed a long period, 
and where the patient had all the appearance of 
succumbing to the prolonged local irritation, speedily 
relieved and finally cured by mechanical control 
alone, without any constitutional or local appUcaticni 
beyond ablution of any saneous discharge — with a 
piece of coarse floor cloth flannel. Excision should 
be the exception, not the rule. I have never excised 
a case of knee joint, and only one of hip joint, and 



73 
this was the only case I ever met with, that urgently 
demanded this operation, and had the patient been 
efficiently treated at an earlier stage, his case pro- 
bably would have been a successful one. I refer to 
Case lo, which for two years had been treated only 
with medicine internally, and local irritants externally. 
Better he had never had any advice. 

On three occassions, I felt, certain I would 
have to excise the shoulder joint, but the patients 
lecovered. It is my opinion that the carpal and 
tarsal joints are the most tedious in recovering and 
require operative interference most frequently. 

This year, Dr. Sayre has also published some 
valuable data concerning excision in his volume, 
" Orthopedics and Diseases of the Joints." I find 
that he gives, in tabular form, a history of 59 cases 
of excision, extending over a period of 21 years; 
and, interesting as the information he gives us is, it 
would have been more useful had he described the 
treatment of each patient previous to his operation. 
Dr. Sayre has ^Mtsedixpon an average 2| cases per 



K 



74 
, whilst Mr. Annandale has averaged 3^- per 
but I must do Dr. Sayre justice, and 
admit that his cases, (though he omits all history of 
prenous tnechanical treatment, if there had been 
any*) q^Kar to have been nearer the conditions 
nqiuiii^ excision than those of Mr. Annandale ; in 
filct they were urgent, provided efficient mechanical 
control- had been tried ; though the symptoms which 
he relates as attending each case, justifies us in con- 
duding drat there was no treatment adopted which 
could be dignified by the title of " efficient control " 
of the joint. It is, however, a significant commentary, 
that many of the cases were judged to be beyond 
the reach of our art at periods varying from four 
to 21 months. For instance, on analysing the 
table of excisions, page 314, Cases 5, 8, 9, 33, 27 
and 56, had been 18 months diseased. Case 46 had 
been 2 1 months diseased. Granting that they re- 
quired excision. Cases 58, 43 and 21 had been 
respectively only 12, 10, and 9 months- diseased. 
Surely, if these cases had been treated with anything 



] 



75 

like efficient control they could not have arrived at 
such a condition of destruction as to necessitate 
excision so early ; but what value are we to set upon 
the efficiency of so-called mechanical treatment in 
the United States, when Cases 22, 28, 52 and 2 had 
been, the three first only four months, and the last 
one only, six months diseased, yet they were ready 
for excision at this eariy date P These last four cases 
are, to my mind, conclusive proofs that .the theory of 
treatment must have been utterly incorrect, and the 
appliances more harmful to the patient than leaving 
the case to the vis tnedicatrix fiaturce. With 
regard to shortening after excision, as recorded in 
this table, it appears to vary in proportion to the age 
of the patient ; yet, in the case of a girl only teft 
years of age, there is recorded a shortening of three 
inches. This was, I suspect, not actual, as Dr. Sayre 
remarks that the patient was wearing a high boot with 
a three inch sole. This was probably too high for 
her, and caused the patient to acquire a correspond- 
ing elevation of the pelvis of the diseased side. 




Sildi, profaatfyi will WOOtint for the extreme short* 
ening reocmled h C^e 18, Are we to judge from 
Ae remarics of Dr. Sayre, appended to Case 3 1, that 
die treatment and reduction of double hip deformity 
are not undeistood by Sorgeons ? 

- — , a boy seven years of 



Caseii.^W-' 



age, of very cadiecdc aj^arance, was admitted into 
my hospital SeptenAer aoth, this year, suffering from 
extreme dcfixmity and ilight tenderness of right hip 
joint, which was flexed to rather more than a right 
angle ; tibeie were several cicatrices indicative of pre- 
vious extensive suf^Diatiui and also actual shortening 
from absorption of the head of the femur, the so-called 
luxation. Plate 14, is a copy of his photc^raph taken 
previously to his admittance into my ho5|ntal; this a - 
a representation of his condition after four jreara 
surgical treatment in private practice, and also as 
an inmate of a large charity; during that time 
the long splint was mostly employed. Knowing 
that by reason of his early age he would not a 
willingly to treatment, I decided to place him in i 



77 
appliance with two uprights, so as to make it impos- 
sible for him to thwart my efforts. 

Plate 15, represents the patient placed in position 
fiM* the reduction of his deformity. The angularity 
of the right upright (as plate 9, fig. 3) was reduced, 
towards the horizontal line by the aid of wrenches 
every seven days. By the seventh week the deformity 
was reduced, and in the ninth week an appliance 
with a single upright was used, .with a patten to the 
sound limb, also crutches to enable him to go about 
during the confirmation of the cure, thus to gain fie- 
titious diminution of the actual shortening caused by 
destruction of the head of the femur. 

In this case there was anchylosis as £20* as absence 
of any motion at the junction of the femur with the 
pdvis, but it must have been fibrous, or the flexion 
ocmid not have been reduced so readily. 

Case No. 6, had been deformed for fifteen years at 
least, and when I commenced treating her I had not 
anticipated being so successful, or I would have ' 
secured a photograph of her case previous to my 



78 

commencing her treatment ; the deformity in case 
No. 6 was greater than in this latter one. 

Case 12. — July 21st, 1875, I was consulted by 

Mr. W. F., of B Street, near this town, whom 

I found suffering from Periostial Inflammation of the 
right Ulna, accompanied with fever. For this condi- 
tion I prescribed local and internal remedies. By the 
tenth day the constitutional symptoms were aggra- 
vated and the patient was found to be suffering from 
acute inflammation of the right hip joint, which had 
become intensely painful. I applied one of my splints, 
which gave immediate ease from pain. After three 
weeks had elapsed the inflammation over ^e Ulna 
terminated in suppuration. In the fourth week of 
treatment, the case became further complicated by 
inflammation of the left hip join^ upon which I re* 
moved the single splint, and placed him in a double 
. appliance, which had the same effect as before in 
all^v^ting all pain. In this appliance he remained 
for ten weeks. At this period, the nurse in charge 
allowed the lower extremity to be very suddenly 



79 
jerkedi and the right thigh was fracturedi thus further 
complicating the case, and as the accident was not 
reported to me, the lesion was not detected for ten 
days. I perceived that the thigh bone below the 
trochanter was enlarged, and on making a careful 
examination lest aspiration should be indicated, for 
I suspected fluid, and then detected the fracture. 
However, I enjoined more care in handling the 
patient, and applied an extra quantity of bandage ; 
and the fracture was firmly united at the end of six 
weeks. At this date, the existence of fluid in front 
of the right hip joint became apparent, which 
fluid was at once aspirated and did not reaccumu- 
late. The patient was kept in the double appliance 
for twenty-four weeks, when a single one was applied 
to control the right hip joint only ; for the left joint 
having completely recovered was, by the aid of a 
crutch, used for locomotion. 

Here we have a case of inflammation of the perios^ 
teum of the right Ulna, ending in suppuration and 
necrosis, wh^re the necrosed shaft of ulna exfoli- 



'Med and ms reproduced. Secondly, inflammation (/ 
Ihi ligbt hip joint. Thirdly, inflammation of the left 
hip jovit; aad lastly, fracture of the right thigh, and 
yH die [letient recovered mainly through mechanical 
tAebneat. After the symptomatic fever had sub- 
tided, be took continuously for a long period Tincture 
of iNft im. well diluted doses, no medicated local 
tnetment nor irritant was applied ; yet the patient, 
iriK^ wkbdut this mechanical fixation, would very pro 
hid)ty not- hurt lived over the first six weeks, finally 
IMOVered. During the treatment of this case, the 
wlue of efficient mechanical assistance was tested in 
this maimfcr. The nurse persuaded the patient and 
his friends that the appliance was uncalled for, 
painful, aind injurious to the sufferer, and that some 
Other method such as , she had observed elsewhere 
was better, the result of her interference was that the 
appliance was taken off, but the patient's experience 
of its omission for twelve hours (though he was on a 
water mattress) was such, that he was delighted to 
have it replaced, and ' he dismissed his officious 



{ 



8i 

attendant as he dreaded she should interfere with 
what he thought was a pleasant bedfellow. 



SUMMARY. 



I.— Inflammation of the hip and other joints is sometimes 
of diathetic, at other times of traumatic origin, but is. generally 
continued by traumatic causes— pressure and friction, whatever 
may have been the primary origin. It may also be caused 
by the patient's indulging in prolonged and unaccustomed 
exercise. 

2. — There are three deformities which may occur in hip 
joint disease — apparent lengthening, apparent shortening, and 
actual shortening :— 

Apparent lengthening is caused by the patient's effort to 
keep all weight off the diseased limb by placing it fonivards at 
a period when the flexion is not extreme enough to keep the 
foot of the diseased side off, and a degree of apparent length- 
ening may be actually acquired after the occurrence of resolution, 
by wearing a shallow patten on the sound foot for a sufficiently 
long period, when actual shortening has occurred. Under such 
circumstances the deformity is an advantage, as it serves to 




'ODMMI tba'ted Adricning, so as to avoid a roll in walking. 
TUl dw tWgeOB Aqnld instruct Ihc patient to attain. 

)>«>Appinnt ibbrtening is produced by muscular action 
(flniOB,) or Aon > tilting up of the pelvis on the diseased side, 
tbk htter ibte it Vnallj found in cases where an unnecessarily 
hl|^ wded boot hw been worn. This phase of shortening may 
banet witb in mj one of the so called "stages of inflara- 



4.— Actual thottening is often caused by erosion of the 
boUM COnpoilllf the joint, and though usually noticeable in 
CCOjutictkiD iritb Mppu ration, it dot?); however often occur 
Vben ao mpiMiiBtioa has taken place. 

' 5. — Tbt hip jd|it should always be cured witb the lumbar 
eoncavi^ strictly corrected ; that is, with the thigh and spine 
ill Une, wbether anchylosis be present or not, so as to avoid 
ncanlng tionbles in the future, and to eventually insure in the 
non-aochylosed condition the utmost range of aciion. 

6. — If the hip splint be not so fitted as to remain 
contiDnonsly in its proper position, it must not be expected to 
give ease from pain or to benefit the joint. So to avoid 
pain and eversion or inversion of the thigh, and to bring on 
early resolution, the upright portions of the splint must be so 
fitted as to remain, uninterruptedly, close to the body and limb, 
but external to the posterior superior spinous process of the 
ilium of the affected side, and over the prominence of the- 
buttock, and so as not to shift towards the diseased side. 

7.— Should the splint shift outwards when on the patient, 
and turn round the great trochanter, the body wing of the soumj 



83 

side, and the inner wings of the limb portion, should be tamed 
up so as to grip the patient more closely, and the twist in 
the stem must be increased at that point which lies behind the 
upper margin of the ilium. These manoeuvres must be per- 
formed without removing the splint from the patient, and they 
demand the use of the wrenches, by means of which all the 
necessary alterations in the shape of the splint are eflfected with 
accuracy, facility, and speed. 

8. — Should the splint shift inwards towards the spine, and 
cover or tend to cover the anus, the inner wings must be 
extended, (and the outer, of course, turned up if necessary,) 
while the rotation of the upright portion must be decreased. 

9. — ^The rotation of the upright portion is effected thus : — 
The plane of the trunk portion is inverted, so as to lie more 
aptly on the convexity of the thorax. This twist is generally 
imperative in the case of thin patients, but is required in a 
less degree by stout ones, in whom alone it may, if ever it can, 
be dispensed with. 

10. — If pain be not efficiently alleviated after the first three 
days, the surgeon may conclude either that the fitting is not 
accurate, or that during his absence the patient is able to rotate 
himself within the splint, consequently the appliance requires to 
be more carefully adapted to the body. 

11. — The less padding there is on the iron of the appliance 
the more tolerable it is to the patient. During the period of 
treatment, a soft feather bed or water mattress is to be 
preferred, but a firm mattress is the most convenient in the 



reduction of deformities if no inilammation exists. Deformities 
are reduced with less pain and more rapidly in tlie unsound 
than the sound stage. 

12.— Aspiration of fluid should be practised as soon as it can 
be detected, whether within or external to a joint, and repeated 
as often as it may re-3|)pear. Tliis operation is attended with 
no risk. 

13.— When open suppuration exists, with direct or indirect 
apertures (sinuses), it is of importance that the part be treated 
with simple ablution, and without any form of dressing. By 
this means alone, if the aperture or apertures be also free 
enough to permit easy eiit of fluid, perfect antiseptic condi- 
tions arc ensured. 

14. — Abscesses may be opened by incision with but little 
risk, if for a time previous to, during, and after this operation, 
the joint be kept well fixed. 

75. — Abscesses that have arisen within the hip joint and 
have existed long enough to travel some distance down the 
thigh, have often ceased to be connected with the joint. Such 
abscesses are often "curdy," and practically cannot be aspi- 
rated ; but they may be safely opened without risk to the joint. 
Thus the practice of our piedecessois> who, before the introduc- 
tion of aspiration, advised delayed incision, was occasionally 
good, 

16. — The gradual increase of pain without extraneous cause, 
and its sudden cessation, frequently indicates a mptnre of the 
joint, though there may be no appreciable increase of heat or 



I 



85 

17.— Occasionally, absorption of the head of the femur may 
occur without suppuration in the practice of this method, and 
should shortening take place from absorption it may be 
practically diminished if the use of a shallow patten under the 

• 

foot of the sound limb be persisted in for a sufficiently long 
period after recovery. Under these circumstances, a lateral 
spinal curve is acquired without alteration in the normal level 
of the shoulders. 

18. — A correct application of the appliance prevents pain, 
eversion or inversion, and angular deformity of the hip joint. 

19. — It is essential that the first stage of treatment of hip 
disease should be strictly uninterrupted in principle. 

20. — When the acetabulum is ulcerated through and its fluid 
communicating with the pelvis, this method may, but will 
not always, arrest constitutional irritation, and the same may be 
said of excision. 

21. — The indication of permanent cure of hip joint disease 
in those cured with anchyloses and with the thigh in line 
with spine, is the nonrecurrence (after a period of use) of the 
flexion and lumbar concavity. If cured with partial anchyloses, 
or what is termed stiffness (a temporary condition) and the 
thigh in line with spine, my diagnostic method should not 
indicate any angle with the spine (after a period of use.) 

22, — The consulted may have occasion to apply the hip 
appliance to a case where, from the omission of aspiration to 
accumulated pus, and where sloughing has occurred, there exists 
a surface of ulceration corresponding to the parts covered by the 
instrument. In such a case, let the hip appliance be adapted 



86 

to Lhc aound tide, then placing a pad bctvreca the two limbs 
bukdkgc them fitm\y together. 

ij.— FrofD obKrvation, I an inclined la believe that in bip 
Joint disease, when fluid i* itwlicatcd close to Poupait's 
ligament, and sllghlljr citcmal to the femoral arteif, it denotes 
that the acetabulum has been prinarily affected, and its floor 
nlccnued thnragh. ThiK occurrence requires the practice of 
aspiration as I have already advised. 

1+.— The casualties of bip excision arc of like character to 
those met with in disease ofthis joinL 

15. — Tht; deformities of inversion and eversion usuaity 
become correctctl by use after resolution, consequently they niaj 
be ignored during treatment. 



■!? 



J 



CHAPTER rv. 



DIAGNOSIS AND TREATMENT OF 
KNEE JOINT INFLAMMATION. 



The diagnosis of chronic or subacute inflammation 
of the knee joint is usually easy when somewhat 
advanced, but its existence at an early period is 
some times undoubtedly obscure. 

The earliest symptom which I have noticed is a 
tenderness on firm pressure over the internal lateral 
ligament. This symptom is very rarely absent in 
any stage of the disease. The external lateral liga- 
ment becomes tender on pressure usually at a later 
stage. There may be tenderness of the internal 
lateral ligament previous to any apparent eflfiision or 



■ 88 
perceptible distension of the joint This tenderness 
is, I think, generally due to efiu«on and consequent 
distention, though the quantity effused may be very 
small ; and the practice of aspiration, in cases of 
simple synovitis, lias shewn me that this tenderness 
of the internal lateral ligament immediately ceases 

^H aAer an aspiration of the articulation, for a short time, 

^^B but recurs if the fluid re-accumulates. 

^H Another symptom noticed at an early date is an 
inability to extend tlie knee to its utmost. I believe 
that in hysterical knee joint affections, if the condition 
of the internal lateral ligament of the side complained 
of be compared with that of the other, it is a useful 
guide to the formation of an opinion, inasmuch 
as firm pressure on both will give equal un- 
easiness to each, but if real unsoundness of die 
joint exists the patient will describe the pain there 
as being of a different character to that of the uneasi- 
ness produced by mere pressure on the sound one. 

I have frequently noticed • a form of simulated 
inflammation of the knee joint which occurs in 



89 

children from 6 to 12 years of age, the principal 

symptom being a spasmodic condition of the flexors 

and extensors of the knee, yet no tenderness or altera- 

tion in the form of the joint; and in these cases, 

I observed that they resolved themselves without any 

assistance beyond cold douche and confinement to 

their couch, and were cured in a period of two weeks 

at the most. This condition has always appeared to 

me to be more muscular than articular. 

The deformities to which an inflamed knee joint 

is subject are usually, flexion, dislocation of the head 

of the tibia backwards, rotation of the leg, and an 

enlargement of the condyles of the femur ; never 

can I /ecoUect having seen enlargement of the 

tibia. The inflammation is either of traumatic 

or diathetic origin, but I hold that whatever the 

origin, the surgeon should employ mechanical means 

ih every case, and attempt to correct any abnormal 

condition of the general health. In the mecha- 

nical treatment of inflammation of the knee joints 

I believe that the arrest of pressure as well as of 

u 





90 
Crktiaa b essential ; yd this double proviso ts not 

-sscotial in simpic sj-oovitis. The arrest of fiidioa 
alooe, is in this htlcr cociditioo, cnoi^fa. My attentioa 
was called to this hct by my friend Mr. Rusbton 
Paflcer, and J have frequently since verified it 
in piactice ; bat in chronic cases, a fractional 
degrc* of pressnn*, caused by the splint being too 
short and permitting a slight touch of the toe upon 
the grmioH, will thw-art a satisfactory result. 

My mechanical treatment consists in fitting an 
appliance as shewn in plate i6, and bandaging die 
limb to the machine, to secure it in position ; die 
bandage is to consist of two fUmnel rolls, one for 
the thigh portion and one for the leg portion, the 
former is to be firmly applied, so as to carry the 
splint with the thigh rather than with the 1^, in 
locomotion ; the latter less firmly so as to permit 
the leg to give way and not resist the downward 
pressure of the femur, and so to avoid risking an injuiy 
to the inflamed joint ; but yet not bandaged loosely 
enough to allow the leg to shake within the 



91 
splint. This detail I have found to be a necessary 
precaution. If fluid be detected, whether it has ex- 
isted one or twelve months— or m hether it be serous 
or purulent — it is better that Dieulafoy*s operation * 
of aspiration be performed at once, and repeated 
so frequently as fluid re-appears. If suppuration 
exists and the pus has become too condensed for 
aspiration the joint should be laid freely open, and 
the incisions treated by ablution only. Incision can 
be practised with but little risk to the patient if 
before, during, and after the operation, the joint be 
kept strictly immovable, with as little "after manipu- 
lation *' as possible. 



• This operation I have practised with perfect safety, and with marked 
benefit (as regards ease of pain and acceleration of cure), at all ages, from one 
month to 40 years. For many years I was much puzzled by noticing 
that, generally speaking, while inflammations of the hip, knee, ankle, and elbow 
joints were usoally accompanied by effusion, painfully distending their 
capsules, the shoulder joint was an exception, but that even an acute or a 
prolonged chronic stage of inflammation of the shoulder was often ac- 
companied by extreme atrophy and complete absence of efliision, the ex- 
planation of which I now suggest is, that the effusion probably escapes from 
the capsule by the side of the biceps tendon. Thus we seem to have in this 
joint a natural arrangement which prevents tension, and is called into action 
as soon as any excess of fluid commences to accumulate. This explains 
why cases of inflammation of this joint are so often mistaken for cases of 
paralysis— which they somewhat simulate— so extreme is the atrophy. 



F 



92 

The knee and ankle joints are frequently sub- 
ject to localised inflammation, which may appear in 
the case of the knee joint on either side of the 
ligamentum patellae or on either side of the hamstring 
tendons, beti\-een the hamstring tendons and the 
patcUje, or, in rare cases, in front of the leg between 
the tibia and fibula. The symptoms of this condition, 
which I have noticed, are, that patients who wece 
apjiarcntly doing remarkably well, with no tendeftess . 
and with but slight thickening of the joint, will 
suddenly feel great pain, with no appreciable indication 
of heat or effusion within the joint) and will become as - 
suddenly relieved by a rupture of the joint, diagnosed 
by the appearance of a small area of fluid elasticity — 
the product of localised inflammation. On attempting 
the aspiration of such collections, or if this be impossi- 
ble, on laying them open, the discharge seldom exceeds 
a drachm or two of pus. These collections rapidly 
resolve themselves if careful immobility is secured for 
a time previous, during, and after either incision or 
aspil^tiotl. 



1 



93 

Deformities of the knee joint are always more 
easily corrected in the inflammatory stage, even 
though suppuration with sinuses exists, as in this 
condition reduction can be accomplished with less 
pain and with more rapidity and eflfect, than when 
resolution has taken place. 

A correction of deformity that might occupy two 
days in an inflammatory or even suppurative state, 
w(Juld require, after resolution, probably ten times 
as many weeks, and be accompanied with some 
pain. 

The knee should always be cured in a strictly 
straight position, the Surgeon ignoring the condition 
which it may happen to be in when presented to him. 
In this way relapses and increased deformity are 
avoided in the future, should the joint become 
anchylosed, and the patient is enabled to progress 
without any roll of the body, whilst the joint is event- 
ually more certain to enter upon its utmost range of 
action. 

It is my practice to wait a few days after apply- 



94 

' {ng mechanical assistance, previous to prescribing for j 

i the constitutional state, as by that time it may be*| 
apjarcnt tJiat nothing is required. 

Specific medicines, as iodine, mercury, lime,! 
nlica, &c., administered with the intention of pro" 

. ducing local action in these complaints are, in my 
opinion, ridiculous. 

I hold that the improvement of the patient's as- 
similation is next in importance to mechanical treat- 
ment, and it is also my belief that a too frequent 
or a too liberal allowance of food is an evil, 

, whilst a slight deficiency of aliment is not ; for, in 
the former case, by over-taxing the stomach digestion 
is frequently deranged, whilst, in the latter, what 
is taken is well digested, and the patient gets the 
full benefit of what little he takes. 

Another remedy which is in my opinion, of 
litde value in these diseases is change of air,* it is 
however very rarely requisite, but a luxury neverthe- 



* Those of my patients who are the favorites ot fortune do n 
better than those who have not the meanE ot luxury at commaDtl. 



95 
less which those who can afford, may be allowed to 
indulge in. As to the frequent practice of applying 
compression, shampooing friction, passive motions, 
galvanism, injections of sulphuric acid, iodine, and • 
filthy poultices, or any other heavy or sticky forms of 
dressing, they are all, to my mind, only modes of 
prolonging the inflammation, and the patient has to 
get well in spite of them. 

As to the application of cold lotions, it is ideally 
correct, but, as the removal of friction, pressure, 
and tension cools the joint more efficiently, cold ap- 
plications are not necessary. 

So little has been attempted for the improvement 
of the mechanical treatment of inflamed knee joints 
that, in my opinion, there has not existed up to the 
present time any appliance worthy of special notice ; 
for, although many ingenious means have been devised 
to improve the treatment of hip joint affections it 
certainly appears as if this joint had monopolised 
the attention of Surgeons in the mechanical depart- 
ment. 



96 

: popularity of excisiMi of this joint explains the 
absence of any tendency towards true conservation of 
this articulation, i-'or example, Professor Spence, in his 
address on Surgcrjv delivered to the members of the 
British Medical Association at Edinburgh, in review- 
ing the Surgery of the Articulations, remarks : 

"A wide field opens before tne. but I must limit nayself to 
"one or [wo points. In regard to excision of joints, now 
"so firmly established as a conservative measure, and so 
" obviously an advance in the tight direction." 

Mr. Spence evidently has but little hope for itn- 
proved treatment, except by excision, for chronic 
diseases of joints. 

Excision of the hip joint has not been a popular 
operation amongst surgeons in this country, but 
they have made up for their abstinence in this par- 
ticular by a much too frequent practice of excision in 
affections of the knee joint. 

When Mr. Filkin, of Northwich, Mr. Park, of 
Liverpool, and Mr. Jeffray, of Glasgow, ('the designer of 
the chain-saw,) the Moreaus in France first pnaposed 
and practised this operation, they selected only 



97 
those cases where destruction of the articulation had 
occurred, but their modern successors have fre- 
quently excised joints which have only just entered the 
chronic stage, and are not what is popularly termed 
^* diseased." 

Many cases thus condemned, which certainly had 
not arrived at the chronic stage, but which could have 
been successfully treated, have come under my notice. 

The apparatus here advised for fixing the knee, 
taking off all concussion, and arresting friction, in 
diseases of this joint, is more satisfactory and re- 
markable in its effects than the hip appliance. By it, 
we are enabled to control the joint more effectually, 
the patient is able to go about at a much earlier period 
than in the case of hip disease, and is frequently 
competent to attend to his usual avocation long 
before the knee has recovered. 

As in hip joint disease, so in this, position and weight 
of the limb are sufficient to remedy any deformity, not 
the result of true anchylosis, and to reduce deformities 
which cannot be removed by immediate force. 

N 





1 fitffc i> S^ 4 aad & and aic applied as 
m ffa>e >^ ffaae 17 B k a reprcsentatkn 
id snagcaBtt to be ap^icd temporarily ? 

Ac fBBOK hvtokeoMiBed to bed fcr aig' period. 

lai k c^ he ca^ — *— ^^ It oo nsisfa cf a bar d 

and 



s to 09 Ac <ad «r Ac bi 






by dae ! 



^appbanoe. 
in phic 13, fig. 4, 
lidans as the hip 



t is fonned of an iron 
rii^ Jths of an inch in dudmess, varying according to 
tbe ^e and w^ht of the patient ; the ring is nearly 
ovoid in shape and is covered with boiler felt and 
basil leather; from its upper and lower portioiis 
two irwi rods pass down to the lower end of 
the machine, where may be noticed a small staple for 
retention purposes, only used for the reduction of 
6exion. 

TTie ovoid ring should join the inner stem, forming 
an angle of 55 degrees, which, when correctly padded, 



99 
becomes reduced to 45 degrees. This arrangement 
of the splint will be the most acceptable for wearing. 
The staple can be cut off at a subsequent stage, and 
replaced by a patten, — as shown in plate 16, — which 
is welded on in its place, for the use of the patient in 
locomotion. 

Across the two bars is stretched an apron of basil 
leather to support the limb, and in the leather 
are two slits for the insertion of the bandage — plate 
^3> %• 4- The patten which is worn under the shoe 
of the sonnd limb when the patient walks in 
locomotion is shown in plate 13, fig. 5. An exact 
diagram and side view of the nearly ovoid ring is 
shown in plate 5, fig. 3 ("for left side), by which the 
reader will perceive that the anterior crescent E is 
much straighter than the posterior one D, and that the 
inside stem G is connected anteriorly to the centre of 
the nearly ovoid ring, the stem A being connected 
to the central and uppermost portion of the ovoid. 
The stems of the machine should extend several 
inches below the foot so that the toe of the diseased 




t mAAmt^ icachng the 

tf Ae kMc ijiiii iliii » Adm (vkn 
^pfied> ii {fate ifiC aad Ihe cania- at&dxd pbte 17 
B6r HK iabeddHaf asf pMUpmod or redncdoB 

of dtimiuttj. 

I do DOC wish it ID be aappcaoi that tbe retentka 
jiijtii^>«>nt IS always rajntred m a recent case d 
dmnic mftamcH kne^ wben tbeic is nooe or ciily a 
dight defonniQ' ; it is (xily essential whoi the case 
has been of long duiatioD and is accompanied by 
much deformit}-. This " retention " may appear 
to be a method of extensicui ; it, however, is only so 
in appearance, as it only answers the purpose of retain- 
ing the limb in the splint during the progress of 
reducing any deformity. It is occasionally impossible 
to retain an extremely deformed limb between the bars 
without this application, and its continuance may be 
required for a few weeks ; the deformity being re- 



lOI 



duced, this retentive arrangement may be discontinued. 
This retention need not be pushed to any extreme 
extension, as it would thereby interfere with the pa- 
tient's ease and comfort. I have always observed that 
the hip, knee, and jaw joints at the termination of treat- 
ment, enter more rapidly upon their functions if cured 
in the position of extension, while the elbow and ankle 
joints recover their action the more readily if cured when 
flexed ; yet the hip, knee, and jaw, when inflamed and 
imcontrolled, tend to flex, whilst the elbow and ankle 
joints tend to extend when not controlled. 

In the use of the knee appliance the surgeon 
should note carefully whether the cutier has his details 
correct, or, in the case of an adult patient it will not 
be tolerable to wear. A youth may do with an 

ill-fitting appliance, but an adult must be carefully 
fitted. 

The surgeon may meet with a neglected case, in 
which the knee is much larger than the thigh at the 
groin ; consequently the ring of the appliance which 
will pass over the knee may be too large to grip 




<a^ m Ac ULjaiJit c£ At cziW st3ge of s^-novids. 
The iH^ih of the acncr stem A 6g. i, pL 24, can be 
Tsiied, ID avoid f iress ure oa the trocfaanter, I^ means 
cf die set scTcvs. 

I win bere ^am inliDdnoe a few ty{Hcal cases 
of ^lectal intenst, they hxvii^ been crucial tests of 
dK efficiency cf this ro^faod of cure, and will be guides 
to the treatment c^ the varieties usually met widi. 

One or two ai my critics have found &ult with 
my not having giv^ more numerous instances of 



103 

the successful results of my method of treatment in 
this class of diseases. But I beg to intimate that 
my object was rather to guide my fellow-practi- 
tioners than to gain credit for any personal skill; 
consequendy I have selected cases of varying 
complications, some not having been primarily sub- 
jected to my method of practice, and upon which other 
methods had failed — certainly a very trying test of my 
method. With this mechanical treatment of knee joint 
affections, as I remarked of my application in hip joint 
disease, the surgeon will note the absence of many 
symptoms, both local and constitutional, that have 
hitherto been supposed to usually accompany this 
disease. 

Case No. i. — In May, 1872, I was consulted by 
M. P., of Dalton-in-Fumess, twenty-six years of age, 
who was suffering from chronic inflammation of the 
knee joint. He had been a sufferer and unable to 
work for nine months previously. There were the 
usual symptoms of chronic inflammation, but no 
effusion ; the knee was contracted to an angle of 



104 

about 160 dcgiccs- Tbe symptoms not being acute, 
the knee midline, 6g. 4, plate 15, was fitted, with a 
patten end attached, as in plate 5, fig. 7, and the 
usual patten under the foot of the sound limb. From 
the date upon which the appliance was fitted, the 
patient went about daily, with do treatment other than 
an occasiooal aperient, togedier witli finn bandaging 
to the macfatne. wWch he retained mght and day for 
twelve months. This man's recover)' had continued 
when examined in October, 1875. 

Case No. 3. — On the loth October, 1873, 
Mr. S — , of Workington, brought his son, a child 
four years of age, to my hospital for examinati(m 
and advice. I found him suffering from disease of 
the knee joint at the destructive stage. Suppuration 
existed, and there were several sinuses discharging 
pus, and the leg was contracted to a right angle 
with the thigh. The hamstring tendons were teno- 
tomised under aether, and a safe amount of force was 
used to extend the knee, but without success in 
totally removing the angularity. The patient was 



I05 

then placed in the machine. Plate 5, fig. 6. A very, 
gentle fixed retention in the machine was continued for 
four weeks. At the end of this period, the limb was 
perfectly straight, and the child ultimately recovered. 

In this case the adhesions were so strong, that a 
justifiable amount of force was not sufficient to tear 
them, but four weeks of uninterrupted retention 
between the parallel rods, without any posterior 
leather support, sufficed to straighten the limb. 
Tenotomy was performed in this case, for the 
purpose of shortening the period required to diminish 
the deformity. In this opinion I was wrong, and 
the case convinced me, that it made no practical 
difference, whether the tendons were divided or not. 
After this experience I totally laid aside the opera- 
tion. This case was last examined by me in January, 
1876, and his recovery was confirmed. 

Case No. 3. — In March, 1872, I was consulted 
by Mrs. H., thirty-two years of age, residing in 
London, concerning a chronic inflammation of her knee 
joint, the joint being contracted to an angle of about 



o 



io6 
oae hundred and forty d^rees. She could make 
very Uuic use of the limb, and suffered continuous' 
pain, night and day. 

■This patient's history was, that when about 
eleven years of age, she fell and injured her Icne^ 
and was piao^ under the care of a bone setter in 
tbe neighbourhood of Wakefield, who pronounced th6 
case one of dislocation. She was under his care up ta 
the age of nineteen, when she consulted a celebrated! 
bone setter in this town, who advised the countw 
I irritants in vogue in those days, but which did not 
benefit the patient. In the year 1 862 she consulted me. 
I prescribed the usual remedies taught in our schools, 
but with no beneficial results. Soon after, having 
removed to London, she had the assistance of a 
professional gendeman of the highest reputation and 
skill, and who deservedly stands at the head of the 
profession. His advice, however, was followed by no 
improvement in the limb, nor any diminution of the 
pains or other signs of local irritation. 

I was consulted by her again in the early part of 



107 

1872. At this time I was practising my new method 
of treating such cases, and had used it successfully for 
some years. I advised a trial of this method of 
treatment. The machine was applied with the patten, 
as shown in plate 16. No retention arrangement was 
used, but merely posterior support with leather across 
the bars, and flannel ^bandages. The limb, Avhich had 
been flexed, to an angle of one hundred and forty 
degrees for several years, in four weeks Was perfectly 
straight in line with the thigh. With the aid of the 
machine she was enabled to go about, and attend to 
her duties, &c., and at the expiration of her third year 
of wearing it, the joint became perfectly sound ; she 
set it aside, and its disuse has not been attended with 
' any signs of relapse. A slight degree of stiffening 
remains, which is an advantage towards her recovery ; 
moderation however, in the use of the limb will 
remove the stiffness. Had passive motion been 

employed to overcome this, I feel assured that it 
would be an invitation to a return of the disease. 
Case No. 4. — In June, 1875, E. W — , residing 



'^ in London, was brought to me by his parents, for 

advice- He suffered from chronic inflammation of 

die knee, accompanied by an enlargement, and 

1 angular contraction nearly lo a right angle with 

! thigh. There was neither effusion nor suppura- 

4ion, but tenderness on manipulation. 

From the history of the case, I found that he had 
been a sufferer for nine months, and had had skilful 
assistance from a surgeon in one of the hospitals 
in the* metropolis specially devoted to this subject. 
It had been decided to excise the joint. I applied my 
new instruments with the staple end for retention, and ^ 
bandaged the limb, but omitted posterior support 
The result was that the limb became perfectly straight 
in ten days, and quite free from pain. By this time the 
child was able to walk about, with the additional aid of 
a patten under the sound foot, although he had not 
walked for nine months previously. 

Without wishing to reflect upon the earlier 
treatmertt of this childj the new method proved of ■ 
More benefit to the limb in ten days than the old 



|09 

method had in nine months. It enabled the child 
in a few days, without pain or distress, to go about, 
and this without the aid of crutches or walking- 
stick. The termination of this case I cannot record, 
as the child and parent removed to another di$trict. 
Case No. 5. — In October, ,1872, Miss H — , of 
Bootle, nine years of age, was brought . to me by 
her mother, suffering from inflammation of the knee 
joint which had existed for twelve months. There 
was a good deal of effusion, and tenderness of the 
joint, with flexion to an angle of one hundred and 
forty degrees, and consequent lameness ; she 
did not seem to be suffering constitutionally. The 
patient had been for twelve months in this' condition, 
though she had had skilful assistance. I advised 
the use of the instrument, and the application was 
followed by the limb becoming straight in six 
weeks. The effusion diminished but slowly, occupy- 
ing a period of nearly three months ; there was no 
retention practised in this case. From that time 
up to the present all trace of the disease has dis- 



I to, 

appeared, leaving no stiffening. I advised, 
however, a continuation of the appliance a little 
longer, to confirm the recover^'. 

This patient's knee was placed in the appliance 
■when partially anchylosed, and retained in it for four 
years continuously ; yet was found at the expira- 
tion of that period with the movements of the knee 
restored. 

Case No. 6. — In February, 1871, whilst making 
a professional visit to Mr. H — , of L — Street, in 
this town, I noticed that his daughter. Miss A. J. 
H — , twelve years of age, was a cripple, and on 
inquiry was informed that when only 12 months 
old she had had a fall, and from that time commenced 
to be lame. This lameness continued to increase 
until she was twelve years of ^e. Upon 
examination, I found that her knee had suffered for 
a long period from chronic inflammation. There 
existed at this time a partial dislocation of the 
head of the tibia, from the condyles of the femur, and 
excruciating pain on slightest manipulation, togethei 



•in 



with a right angkd flexion. Although this case had 
riot gone on to suppuration, yet during the whole of 
that time it had been more or less tender, so as to in- 
capacitate the sufferer from even the use of crutches. 
I volunteered to do what I could to relieve her, and 

applied one of my instruments. Her condition at 

« 

present is represented in plate i8, taken from a 
photograph. The left knee, although not perfect, 
she is able to use with some defect of motion. 
During the time the patient wore the machine, she 
attended to her household duties. Some defect must 
ultimately remain in this case, as twelve years of 
neglect one cannot expect to totally remedy. 

Case ^ No. 7. — In January, 1869, a patient, 

M. J — , ^ame from Palestine to consult me. 

■ 
She was suffering from a long standing chronic in- 
flammation of the knee joint. The joint was 
enlarged,' slightly effused, very tender, and . angular 
flexion to onie hundred and twenty degrees had 
occurred. The patient was much emaciated, in 
depressed spirits, and in ill health. The history of her 



|[3 

^tSSk », Aat ia the wimer of 1856 she fell on the ' 
ice and injtired her knee. She received no pro- 
frliirwn! aaasance far six mooths, and on consuldng 
a doctor be p na n o uo ced it a dtslocatioa of the 
knee <a:p, but that it was cot possafale to reduce it. 
After this she coosulod sevml doclocs and bone 
setters in search of re&ef, but in vain. In i S59 she 
was taken to the Queen ^s Hospital, Binningham, 
from whence, after a period of two months' treat- 
ment, she was discbaiged much relieved, but not 
quite free from pain. This improvement continued 
for three years. In 1864 she went on the Conti- 
nent, and whilst there, in that year, was laid up 
for three months with a return of her previous 
^mptoms. She was again relieved, ^d able to 
travel for twelve months. 

In 1857, while at Jerusalem, she had a return of 
all the previous symptoms, intensified. This attack 
continued for four months, and not being able to 
get sufficient relief to enable her to look after her 
duties, she returned to Eng^d for the purpose of 



"3 

consulting me. I applied the machine with a patten 
attached; no retention was used, but leather was 
placed across the bars and flannel bandaging. I also 
prescribed certain details to promote her general 
health. She was so much improved in six months 
that she commenced to travel about the country as 
a public lecturer in connection with the Canaan 
Mission, and continued to do so for three years, at 
the expiration of which time her recovery was 
complete, though with a stiff limb. She tells me, 
that she can now walk many miles per day, without 
feeling in the least distressed. 

The improvement in her general health was rapid 
after the first six months. There remained an unusual 
amount of stiffness in this case> which is not to be 
wondered at, when the many repeated attacks of acute 
inflammation she had suffered from during the 
previous fifteen years are taken into consideration. 

This was the first time I applied this machine 
to an adult. I had been using it for children 
for many years previously. 



p 



"4 

No. 8.'— !n January, 1865, Master J. W-^ 
of Boollc, seven years of age, was brought to 
me by his parents, suffering from a diseased knee 



pf: 



On examination I fiund that suppuration had 
occurred, and that there were several sinuses 
communicating with the joint, one through the 
popliteal space, and others on either side of the 
joint. I had never before seen so much apparent 
destruction of the articulation. There was also flexion 
to a right angle. 

The history of the case was, that in consequence 
of a fall the knee became attacked by acute inflam- 
mation. The patient had been placed under the care 
of a bone setter in this town, and also under that of 
his son, a surgeon, who professes specialism in this 
department. 

The usual methods of treatment had been 
adopted up to the period when I examined him ; and 
I decided to place him in one of my new appliances 
with retention, cutting out from the leather stretched 



"5 
across the rods an opening sufficient to admit of 
drainage from the knee. The limb soon became 
straight and the leg (inclusive of the machine) was 
bandaged with flannel, up to the knee and from 
thence to the thigh, but leaving the knee exposed. 
The only treatment applied to the knee was frequent 
swilling with water, and a little oil to prevent the 
opening into the joint from scabbing, and the 
joint itself to become distended by pus. It is, even 
now, too frequently the practice to surround the joint 
with a poultice, a mercurial ointment, or some other 
specific, a proceeding very injurious, being a remnant 
of the effete surgery of the middle ages. 

The patient was under my treatment for five 
years ; during this period he had first an attack of 
kidney disease, and then fever. 

This case ultimately attained a perfect recovery. 
Plate 19, taken from a photograph, shows the boy 
standing ; plate 20 shows him with his knee ex- 
tremely flexed. These two plates enable the reader 
to see what amount of action the knee possessed, and 



li6* 

the extent of its recovery. This case was very 
comijlicated at one period of the treatment, owing to 
kidney disease and typhus before adverted to. This 
did noi, however, induce me to interrupt the treat- 
ment of the knee. I have always objected to 
removing the appliances in cases that have become 
complicated, as the additional irritation of the second 
complaint, superadded to the existing disease, 
would much diminish the patient's chance of recovery. 
Here we have a case of knee joint disease with 
ulceration of the articular cartil^e and partial 
anchylosis, placed under enforced, uninterrupted, and 
prolonged rest for five years, at the end of which 
penod there was no anchylosis, and finally at this date« 
1875, the patient recovering, with perfect motion. 

Case No. 9. — Miss McG , from near Kirkinner, 

Wigtonshire, consulted me in April, 1872, suffering 
from splay foot of the right side. I noticed, 
that she also suffered from some lameness of the 
left limb, concerning which, however, she had 
no intention of consulting me. Perceiving that she 



117 

was seriously lame on that side, I advised her to 
allow an examination of it. On thus examining, 
I found that she suffered from an angular deformity 
of the knee joint with an extreme curve inward, as 
in the ordinary knock knee. The joint was much 
enlarged and abnormally sensitive and stiff. So I 
advised that it should be placed under surgical 
treatment, to which, after some persuasion, she 
consented. The splay foot was first completely 
remedied and then her knee was placed in my 
usual knee appliance with patten under the foot of 
the sound limb, &c. The thigh and leg were so 
much diverted (krock-kneed) from the straight line 
that I had great difficulty in getting them into 
the appliance. T he patient was in excellent health, 
and required no prescribing. 

The mechanical treatment was continued for 
two years, the lady returning to consult me at inter- 
vals of three or four months until January, 1875. 
The limb, which she had thought was beyond all 
remedy, had been so far relieved, that she was 



i8 

dedrous of making use of it. It had become 
peifectty straight, the joint being nearly normal in size, 
painless, and free from the stiffness which had 
characterized it when first placed under control, 
though it had not been released from the restraints, 
even for a moment, for two years. I advised her to 
continue the appliance for some portion of this year, 
to confirm the cure, after which I have no doubt 
diat the abs«ice of restraint will, during the fol- 
lowing twelve months, restore motion of the joint 
to its extreme radius. 

Case No. lo. — Master R , of Pwllheli, Car- 
narvonshire, was brought to me, suffering from 
chronic inflammation of the knee joint, accompanied 
by a great amount of constitutional disturbance; 
the joint was enlat^ed with efliision, together with 
flexion to a right angle, and much pain, from which 
there was but slight remission day or night. 

The history of this case is, that m April, 1874, 
the sufferer had received a slight injury, and not 
recovering at the expiration of three months, his 



119 

parents consulted a bone setter, now practising in 
the Principality, who pronounced the joint luxated, 
and who subjected the patient's knee to manipulations, 
(so severe as must have satisfied any of the 
distinguished modem surgeons who are converts to 
this antiquated barbarity,) with the result of adding 
greatly to the patient's local distress, and producing 
the constitutional disturbance under which he 
laboured. 

These manipulations were followed by the 
standard local remedies, rubbing with oils, baths, 
iodine, and other trifles, ad nauseam. 

He was brought to me three months after this 
maltreatment, and six months after the injury. 
This was in October, 1874. I first placed his 
limb in one of my knee appliances, and then 
attended to his general health, and he was taken 
home ; when brought for examination again in 
three months he had greatly improved. I then 
advised the discontinuance of constitutional treat- 
ment, and the use of the limb (^controlled by the 



190 

fcnieV^T^'"°*'*'"- ^ ^"'^ return on the third 
occasion, in six months from the second visit, I 
found the knee sound and free from defect, normal 
in function, and healthy in appearance; yet I 
advised a continuance of the appliance for six 
months longer to confirm the cure, as experience 
has convinced me that six months, though apparently 
in excess, is no evil, but a too restricted period of 
restraint, may result in imperfect recovery, or no 
recovery at all. 

Case No. ii. — In June, 1874, Mrs. B , 

residing at Saniander, in Spain, brought her 
daughter, a child ten years of age, to have my 



The child suffered from chronic inflammation of 
the knee joint, and right angle flexion, with acute 
tenderness and constitutional irritation. She had 
been a sufferer for nine months previously. The 
limb was placed in one of my appliances, and the 
knee joint aspirated, removing about one ounce of 
fluid. In the fourth week she was going about 



121 

Without assistance even from crutches, though her 
previous sufferings rendered "the crutch" indispen- 
sable when taking exercise. 

This patient stayed at my hospital four months, at 
the expiration of which time her joint was painless ; 
there was no deformity, and no effusion. When she 
left the hospital she returned to Spain, and Mrs. 

B reports her daughter as doing well, and not 

requiring any further medical or surgical assistance. 

In this case I was convinced that the pain was 
the sole cause of the constitutional disturbance, 
and I was confirmed in my view, for as soon as 
complete mechanical rest was established, the 
general health rapidly improved without my pre- 
scribing, and the angular deformity gradually 
disappeared, by my adjusting the limb/ as in plate 
1 6. In this case aspiration was performed; an 
operation in my experience not merely harmless, but 
one which can be resorted to early with benefit to 
the patient. 

I am glad to be able to add independent testi- 

9 



132 

many to the value of the treatment here advocated, 
in the following case attended by my friend, Mr. 
J. P. Harris, of this town, who has kindly furnished 
me with the following particulars : 

"Elizabeth H , aged 30, consulted me about" 

" six months ago for an affection of the knee " 
"joint. Her history is as follows : About eight " 
" years ago she fell in going up some steps," 
"and slightly bruised the left knee. She did" 
" not experience much inconvenience at the time," 
" as she used the limb afterwards, though " 
'' attended with some little uneasiness and slightly " 
"impaired motion." 

" Six months later she obtained a situation " 
" as a school teacher, where she took some ad- " 
" ditional exercise and was exposed to cold and " 
" damp. The knee became inflamed, and was " 
" treated with leeches, blisters, &c., rest being in- " 
*' sisted on. From this time the joint became more " 
" stiffened, and nine months later an abscess " 
" formed on the outer side of it, which discharged " 



123 



(6 



tc 



for twelve months. The joint now became fixed " 
in a semi-flexed position, allowing her to walk *' 
very imperfectly on the points of the toes with " 
" the aid of a stick. Attacks of recurrent inflam-" 
" mation of the joint continued to trouble her, and " 
" these deteriorated her general health very much." 
" On the nth of May, 1876, Mr. Thomas' splint" 
" was applied according to his method. In about a " 
" month the limb resumed its natural straight " 
*' position, the joint becoming less in sfze and free " 
" from all tenderness, though somewhat larger " 
" than the opposite joint. The splint continues to " 
" be worn, and by the use of the patten for the " 
" opposite foot, she is able to move about with " 
" comparative comfort." 

Case No. 13. — In April, 1872, Mr G. D , 

residing at Hanley, Staffordshire, brought, (at the 
recommendation of my late friend Mr. Tillet) his 
daughter, a girl eight years of age, to have my 
advice for a chrcnic inflammation of her right knee, 
the joint having been in an impaired state for seven 



124 

nionlhs. VVtien I examined the joint,' there 
cfTusion, (endemess, and angular defc*nnity with 
partial dichylusis. The h'mb was placed in one of my 
appliances, with a patten under the sound foot as 
usual. 

This was the only treatment she received for three 
years — care being taken lo lengthen the machine 
when required ; which was attended to every three 
monthii. The lestraint was continued uninterruptedly 
for three years, at the expiration of which time i 
dismissed the patient, possessed of perfect movement 
of the joint. 

The reader will have noted that in remedying 
defurmitics of the articulations, the force I advise 
is never continuous, but interrupted by a few days 
rest, after each diminution of angularity. This 
is the secret of the force being so easily tolerated 
by the patient. Three days of non-interference at 
least should be allowed, but in cases much deformed 
double that time is . requisite between each cor- 
rection of the machine, and with a correctly fitting 



125 

appliance, any deformity, however extreme, if not 
anchylosed by bone, will* be corrected more easily and 
with vastly less pain by this, than by any of the prior 
methods, such as tenotomy, forcible rupture, or 
continuous extension. 

No. 14. — T. H., Everton. This case was a boy, 
who, when brought to me was eight years of age. 
He was of a very unhealthy and strumous appear- 
ance, and had been suffering for two years from 
disease of the knee joint. The joint had already 
suppurated and there were sinuses communicating 
with it, and it was flexed to a right angle. The patient 
had lost one eye from disease, and during the time 
I attended him he suffered from albuminuria with 
general dropsy. He had two immense abscesses, 
one in the loin and the other in the thigh. This boy 
was under my treatment for two years. At the com- 
mencement of, and many times during, treatment, I 
felt confident that I should save neither joint nor life, 
but I was astonished to see him recover with a very 
useful knee, though with defective mobility. 



Cases of pure synovitis can be treated with success 
by the use of my "calliper foot splint," shown in 
plate 24, fig. 6. This is to arrest motion in the joint 
only; the lower end being inserted into an iron tube 
in the heel of the patient's boot. As an example, a 
persona! friend of mine lately consulted me, suffering 
from simple synovitis, without any pain, only slight 
stiffness. The calliper foot splint was applied, and 
the joint aspirated every third day on four occasions. 
During this time he attended to his duty as superin- 
tendent of extensive masonry works ; and after 
wearing the splint for six weeks he laid it aside, 
having quite recovered. This splint may be used in 
the early stage of knee joint inflammation, where, as 
I know, arrest of friction alone is often sufficient. 
It is astonishing how much fluid the knee joint will 
accommodate itself to, without subcutaneous rupture. 
As an instance, my friend, Mr. Rushton Parker, 
assisted me in one case, when we aspirated from the 
knee joint no less than three pints of non-purulent 
fluid. The elbow seems to come next in disten- 



127 

sibility ; and though I have but seldom had occasion 
to aspirate this joint, I not long ago removed in this 
way as much as ten ounces of liquid from a case of 
huge enlargement of the elbow produced apparently 
by chronic rheumatic arthritis. 



SUMMARY. 



I.— The student who has acquired a knowledge of the 
casualties and correct treatment of knee joint inflammation 
will find that this knowledge will always qualify him for effi- 
ciently treating inflammation of the other articulations, inasmuch 
as the knee joint is subject to the general inflammation 
common to the other joints, with the addition of a feature 
peculiarly characteristic of itself, i.e., localised inflammation. 

2. In this joint as in all others there is no. position of 
ease, whether straight or flexed, in the absence of efficient 
fixation. The extended position msures the utmost future 
usefulness. 

3. — The deformities of the knee joint are flexion, luxation 
of the head of the tibia backwards, accompanied occasionally 
by slight rotation, and sometimes by the deformity known as 



128 

genu valgum. 1 have noticed this last tJerormitv on several 
occasions in knee cases, though not connectt-'d with the joint 
inflammation, yet corrected spontaneously while the joint was 
simply retained in the knee appliance without the addition of 
any retentive arrangement. 
K 4.— The knee joint appliance should be so fitted that after 
wM few days' wear it may be easily tolerated by the patient ; 
again, a space of at least one inch shoald be allowed between 
the extended tob and the ground in the case of an adult, whilst 
in the case of a child a space of two inches is preferable. And 
the length of the splint and patten shoulti be so adjusted that 
the shoulders of the patient are level. 

5.— If the patient complain of too much pressure on the 
groin, the depth of the patten on the sound side should be 
increased. If complaint is made of pressure on the itium the 
patlen should be decreased. 

6. — As the patient grows (supposing he is under the adult 
age), he must grow from the patten on the sound side and 
/sKMri^j the lower end of the splint on the diseased side; con- 
sequenlly, while the depth of the patten never needs to be 
increased, the splint has to be watched, and lengthened as the 
toe nears the ground. 

7. —If the patient be able to touch the ground when the 
ankle and toes of the affected limb are well extended, the 
appliance should be lengthened, as a very slight touch of the 
extended toe on the ground during progression will delay re- 
solution and cause flexion, except in some cases of mere 
synovitis. 



129 

8. — It is of the utmost importance that pnemnatic aspira- 
tion, so fully expounded in the masterly work of M. Dieulafoy, 
should be practised (and repeated daily if necessary, which it 
seldom is), as the distension of the articulation with fluid, how- 
ever small the quantity, is very frequently the sole cause of the 
irritative fever often present. 

9. — ^All counter-irritants, applications of heat, shampooing, 
passive motions, should be avoided. Under this head is in- 
cluded that venerable relic but "strange device" "Scotts 
dressing,'* the undoubted occasional advantages of which I 
hold are in exact proportion to its rigidity. 

10. — When the joint has been laid freely open on both sides 
(2 to 3 inches incision) aspiration not being practicable, it is 
better to abstain from all dressing and avoidable manipulation, 
and occasional ablutions should only be practised. 

II. Incision of the joint may be done with but little risk if 

for a period before, during, and after incision, the joint is 

efficiently fixed. 

12. — The signs of resolution of all inflammation in the knee 
joint are : — 

Absence of unusual tenderness on applying moderate 
pressure over the ligaments around this joint, especially the 

internal lateral ligament. 

• 

The absence of all evidence of eflusion. 

The tolerance of concussion without discomfort. 

The power, after use, of fully extending the knee, to the 
straight position acquired while in the splint. 

The non-recurrence of flexion, after use, in cases of un- 
avoidable fibrous anchylosis. 



CHAPTER V. 



INFLAMMATION OF THE ANKLE ANDil 
TARSAL JOINTS. 

The diagnosis of inflammation of the ankle joint is 
not so easy as that of other joints, the symptoms, on 
manipulation, simulate so closely those arising frcm 
a simple sprain of the articulation. It will be noticed 
that the ligaments around the joint are equally abnor- 
mally sensitive in both conditions, but when the joint 
has been in a chronic state for a long period, then it 
may be observed that the joint has ruptured, and its 
contents point to the outer side of the tendo Achillis, 
or on both sides. The patient at this period is 
also unable to flex the ankle, which has a tendency to 
become fixed in the extended position, and he is dis- 
turbed by nocturnal pain, and by symptoms deno- 
ting constitutional sympathetic irritation. It is my 



^3^ 
practice, in an advanced case of chronic inflammation 
of the ankle, occasionally to ignore the accompanying 
deformity, and correct it after resolution, especially 
if the patient is not close at hand, so as to be readily 
watched. It may occur that the surgeon cannot see 
the patient except at long intervals, in which case the 
ignoring of the deformity and securing resolution first 
is the more convenient practice. The principles 
followed by myself in the treatment of these and of 
all other joints are identical, with merely variations 
in mechanical detail. For the ankle I usually use 
the knee appliance simply ; but when I wish to 
keep the foot at a right angle to the leg, there is 
added a foot piece, (plate 2 1 , fig. i ,) to which the 
foot is bandaged. This slides up and down on the 
rods, which must be strictly parallel between D. C. ; 
or if the patient be confined to bed, the angular 
splint, fig. 2, can be applied. The application of 
this (if the surgeon can watch the case daily for a 
few days,) will rapidly correct deformity of the 
ankle. 



133 

Though the knee appliance Is not so effectual in 
restraining the use of the ankle and tarsal joints, as 
it is that of the knee, yet the cases which follow 
shew the benefits of the method. 

Case No. i. — Elizabeth J. residing in G s 

Street, in this town, two years ago, while alighting 
fr»m a chair on which she had been standing, fell 
and twisted her ankle, which caused her great pain 
and swelling, so that it prevented her using it. 
Cold douche was applied immediately after the acci- 
dent, by the continued use of which she improved so 
as to be able to go about at the expiration of two 
weeks after the accident. But its use in locomotion 
was followed by a relapse of the previous symptoms. 
At this period she consulted myself, when I applied 
a method of stiffening only, and advised her to dis- 
continue the use of the joint. However, she, being dis- 
satisfied with my advice, sought admission into one of 
the public charities, where she remained about twelve 
weeks. During the first five weeks, " Scotts Dress- 
ing" was applied, and retained uninterruptedly for 



133 
five weeks; on the removal of which it was dis- 
covered that the ankle joint had suppurated. This 
causualty was treated by linseed meal poultice for 
seven weeks, during which time sinuses formed, com- 
municating with the joint, and amputation was urged 
by the surgeon in charge. This she declined, and 
left the Hospital. #When she consulted me again, 
on examination finding the condition of the ankle 
joint such as I feared might not recover, or occupy a 
very long period in resolution, I also advised ampu- 
tation, and took her into my Hospital for the purpose 
of performing the operation. But previous to operation 
I showed the case to my friend, Mr. Rushton Parker, 
who remarked " that as no mechanical method had 
been tried, it would be well to test its efificacy before 
removing the foot. " 

To this I assented, and after detaining the patient 
in the hospital long enough to fit her with the knee 
appliance, she was dismissed, and directed to apply 
pieces of coarse flannel, " floor cloth flannel," wrung 
out of cold water, slackly around the joint, changing 



'34 

this many times a day. This treatment was continued 
for nearly eighteen months, and the joint became sound 
during the first seven months' wear of the machine, 
but with the deformity of fixed extension; this I 
corrected in the fourteenth month. This patient 
recovered, with perfect motion at the ankle. 
I I frequently permit the use ef cold water douche 
in the treatment of inflammation of the ankle and 
foot joints, being easily applied ; not so with the 
knee or hip : the use of the cold douche in the latter 
would soil the appliances, these again would irritate 
the patient's skin. 

Case No. 2. — In October, 1872, Mrs. D — , of 
Ridgway, Iowa County, Wisconsin, U.S., came over 
to England to consult me concerning a lameness of 
her left foot. On examination, I found slight 
tenderness, with a little swelling and stiffness of 
several of the tarsal articulations. She was totally 
unable to place any weight on her foot. The ankle 
joint was healthy and in no way affected. 

The history of her case is, that she had strained 



135 
her foot some seven years previously, and had 
consulted several doctors in the States ; most of the 
gentlemen consulted concluded that there was 
a displacement of the tarsal bones. Various 
remedies were advised, and on one occasion she 
was subjected to violent manipulation, for the 
purpose of reducing a displacement which was 
believed to be present. She also had applied a 
remedy (which luckily has not as yet found favour in 
this country), the Junod boot, but with no beneficial 
result. 

On finding that her ankle joint was inflamed, I 
decided to apply the knee apparatus and patten, 
which treatment was continued for two years. In 
the last communication received from her, which 
reached me this year, she represented herself as 
having completely recovered, and that she had laid 
aside the appliance after two years' use. 

The kind of appliance worn in this case is shown 
in plate 1 6, but without the " retention." In diseases 
of the foot joints, a very excellent method is 




•3* 



tt ^ mm 



1*0= ■* %- S. 
ifacmg the bed 
kdcalgr oT the 
HicBtlD^ abool 



Ok ita. 3.— Ms. D— ^ of Dcnii^ cmailted 
: m Ae mtmA c£ HiMiBiiii. 1S73. coaoaraag a 
' r • • ' rfkx tKsd htws. wliidi had 

. ia dKB CMC X adviscsd cxu- 
ker 

asan vitt ThcImc <■ BDnoHy to pRiteLt it fitm 
the nritatkn whidi, in her case, the water alwaj-s 
produced. Under the bed of tbe afiected foot was 
l^aoed an iroa dogy plate 5, fig. 5, with the usual 
patten under tbe soond foot. My instructions and 
mecbankal af^iliances were continued for six months 
with tbe result erf" perfect recovery. 

Case No. 4. — Miss R , near Llanrws^ 

amsuhed me in Fdvuary, 1868, sulfering from 
long standing chrcuic inflanunadoa of ber tarsal 
articulations. In this case tbe only application was, 



137 
strapping for the purpose of stiffening by ad- 
hesive plaister, spread upon paper, with the foot 
appliance, plate 5, fig. 5. This treatment was con- 
tinued for seven months, when the patient recovered, 
Plate 22 shows a very useful method of relieving 
the metatarsal and phalangeal joints from both 
pressure and friction. 

The reader will have noted that in none of the 
cases reported did I practice counter-irritation. Mr. 
Cline, in the past, and Mr. Fumeaiix Jordan, in the 
present time, have taught that counter-irritation is 
best applied at some distance from the joint. I am 
convinced that its total omission is the correct pro- 
cedure. I believe the local application of cold water 
though not essential, to be not objectionable, and that 
the application of heat ought always to be avoided ; 
the arrest of pressure and friction being the indispens- 
able remedy for gradually diminishing the inflamma- 
tion present in the articulation. 



CHAPTER VI. 



lETlOLOGY, CASUALTIES AND THERA- 
PEUTICS OF INFLAMED 

ARTICULATIONS. 

There are several difficulties which beset the surgeon 
in his attempts to treat chronic inflammation of the 
joints rationally. 

In the first place, an extended experience has 
convinced me, that as a rule, it is easier to cure the 
disease than to remove the doubts of the patient 
and his friends, prompted as the doubts too often are, by 
members of our profession, who ascribe to a faulty 
constitution the origin of nearly all joint inflamma- 
tions, and advise partial, or ignore all, local restraint, 
and trust to counter-irritation, with so called rest, and 
specific medicines ; or they believe that prolonged rest 



139 
is the principal factor in the production of anchylosis, 
and especially dread rest continued beyond the acute 
stage for any prolonged period. This error is very 
general even in this country, but more so among our 
Transatlantic brethren, and has culminated in the 
maturing of the " Portative-extension " appliances of 
the Davis- Say re type. As illustrations of the opinions 
held by them, I quote some of their principal author- 
ities. Bauer, in his " Orthopedic Lectures," published 
at New York, 1867, page 57, says: — 

" Gentlemen, absolute rest of inflamed joints however 
•* beneficial for a time, has likewise its therapeutical restriction 
"and experience teaches that if the immobility of healthy 
" articulations is unduly prolonged, they will become stiff, dry, 
«* and even anchylosed by fibrous bands.** 

Another quotation from the same page shows 
clearly to me how ridiculously inefficient this so-called 
absolute rest must be : — 

"Do not expect to mitigate the frightful nocturnal pain 
** and convulsion and muscular quiver by anodynes ; they have 
" very little effect in large, and none in small doses.** 

Again, in Barwell on Diseases of the Joints, page 



I40 I 

324, we have the above r»pinions re-iterated : — 

"It U of great importance to anntil, ot at least to 
" mitigRte these spssms, not only on their own accoont, bat 
" also becansc they accompany tasting contraction of the muscles, 
" anil becansc tbcir amonnt corresponds sufficiently closely 
"with the rapidity of the destructive process. Now, no opiate 
" which our art supplies annuls these p^s : it has been allowed 
" me to watch patients, thus suffering, who have taken a heavy 
" dose of laudanum, and in one or two instances it has seemed 
"to me that they slept more through the pain ; but, that it was 
" still there, was evidenced by their starting up momentarily and 
'■ falling back again to sleep, or by sudden sharp cry or groan ; 
" in fact, opium may dull the perception a little, bat does not 
"check the spasm, if, indeed, it does not increase it ; for the 
" limb, in cases I speak of, has jerked with much force, and 
" while this lasted patients were bathed in sweat. The 
" pathological condition of the nerves, already described, is not 
" one which could be diminished by an opiate, or by any means 
'■tending to decrease the controlling action of the nervous 
"centres." 

These quotations satisfy me that their authors 
have never been able to secure for their cases more 
than a fraction of the needful rest, or they would 
have observed that an anodyne is very rarely required. 
Yet some of my critics assert that my theory and 



141 

method of rest, which abolish all these horrors, is 
not new. 

It is remarkable^ as I show by quotations from 
authors who have made this department their 
speciality, that their treatment is certainly specially 
irritational ; for instance. Dr. Sayre thus teaches : 
(American Clinical Lectures, Vol. I, No. i, Diseases 
of Hip Joint, page 14.) 

** When this instrument is employed, it is necessary that the 
** child should be taken from it very frequently, and have all 
" the joints carefully moved, otherwise, too long continued rest 
" of the joints may end in anchylosis. In moving the diseased 
''joint, care must be taken to hold the pelvis, and to make slight 
** extension upon the diseased limb when motion is given 
** to the joint. Perfect rest, long continued, even of the diseased 
** joint is decidedly injurious, as there is danger of its resulting 
** in anchylosis.*' 

No method can be devised, in my opinion, 
to more effectually thwart any tendency to resolution 
than the practice which the advise — it may be 
characterised as Rest simulated, interrupted, with 
prolonged suffering; no wonder Dr. Sayre judges 
anchylosis to be a favourable termination, (see page 



17 of same lecturcsj. 

" In fact, Btichylusb should be considered in this stage or 
" the iiistASf! a very favourable termination." 

I 1 maintain that such treatment would produce 
anchylosis in any stage of joint inflammation. 

In the " Clinical Lectures and Essays," by 
Sir James Paget, Vol, I, page 93, article " Bone 
setting, &c," he says: — 

*'With rest too long maintained, the joint becomes and 



itiff and weak, over sensitive, even though there 
"be no morbid process in it, and this mischief is increased if 
*' the joint have been too long bandaged, and still more if treated 
" with cold douche. I need hardly say that it may sometimes 
" be difficult to decide the time at which rest after having been 
" highly beneficial may become injurious." 

The foregoing quotation is utterly at variance 
with my own personal observation, — that treatment 
may be continued beyond a necessary period is very 
possible, though surgeons usually err by the 
practice of a too restricted period of rest : the former 
is certainly, in my opinion, no evil, but the latter 
occurrence might thwart the resolution of the disease. 



H3 
Another writer lamentably instruct us, Mr. Wharton 
Hood, in his treatise on Bone-setting, page 113: — 

** It is also manifest that if permanent anchylosis be the 
" result arrived at by the surgeon, rest must be a necessary con- 
** dition for bringing it about." 

Certainly not; for in support of this he reports 
cases of partial anchylosis, the result of what is 
usually mis-called rest. 

Most of the evidence contained in Mr. Wharton 
Hood's treatise is second hand, derived from an un- 
reliable source; consequently not deserving of the 
serious consideration of practical surgeons. This 
author has been cited by me inasmuch as his treatise 
has been judged deserving of special consideration 
by some who ought to be well able to judge of its 
value. Nevertheless, I believe that joints treated 
according to the doctrine laid down in this treatise 
cannot, with very rare exceptions, have any chance 
of relief, without permanent defect. 



* This treatise is principally devoted to an exposition of the purely 
imaginary merits of the practice of one Hutten, who practised a method 
oi manipulation of joints. 



144 

A £iUacy with the public, and a growing one 

nong the profession, of late years, has been that 

some unqualified practitioners are in possession of an 

occult art in this branch. 

I I have, after extended observation, ventured to 

r declare this a fallacy ; having been during the early 

portion of my life in the confidaice, for years, 

of as many as seven of these manipulators, male 

and female, in various parts of England and 

Wales ; and, Indirectly, watched the practice of six 

such others, distributed over England, Wales, and 

Scotland. 

In the sanctum of one I had the pleasure of 
meeting (incognito) one of our metropolitan profes- 
sors of surgery in search of knowledge. 

These opportunities have given me the right, and 
in the interests of the progress of rational surgery, 
I feel it my duty, to record the experience thus 
gained, which experience amounts to this : that this 
class of practitioners are not in possession of 
methods "not dreamt of in our philosophy," 



145 
Frequently I have heard patients express them- 
selves relieved in twenty-four hours, when, as a 
practical suigeon, I could plainly see that they 
were sufferers. I never met with one of these 
practitioners "but loved his trade rather than his 
art." Many of them are only successful competitors 
. with shrines, relics, and other nervine remedies ; 
and I certainly would not advocate the addition 
of even a genuine relic to the surgeon's arma- 
mentum. 

Mr. Barwell supplies me with another quotation 
which plainly indicates the prevailing dread of rest 
even if prolonged to that indispensable period, 
necessary for resolution to take place, but not by pro- 
longed fixation secured beyond possibility of relapse. 

** Yet in strumous synovial disease, all inflammation having 
" ceased, my recommendation that passive motion might be 
" used, is often met by the question—* Had we not better wait 
'* till the tissues are consolidated ? ' What a strange query 
" that is. Wait till the joint is all but immovable before we 
** try to establish mobility ? Wait till the house is burnt down 
** before we attempt to extinguish the fire ! " 

T 



^m 146 1 

My answer to this is, that the practice he 1 
advocates is more like rushing into the house and J 

I attempting to occupy it whilst the fire is ra^g, 
or we might object to play the hydrant on a burning ! 
jbouse lest the contents m^t be damaged by the I 
■water, though this is the only method of saving some 
of its \'aluable contents. 
In iKMie of the cases reported by the two last 
authors was there complete rest of the joint. I 
believe consequendy that the cases were not in a 
condition fit to enter gradually upon their normal 
functions, even if sound. 

Again at page 274, of Dr. Sayre's recent Volume 
on Orthopedics and Diseases of joints, we are warned 
of the im^inary evils of fixation. 

" Bat I must again warn you of the danger of pemiitting the 
" patient to wear such fixed dressings too long. If employed 
" at all they must be frequently removed and passive motion 
" employed, else anchylosis, more or less complete, will take 
"place, and the last state of the patient may be worse than the 
*' first." 



H7 
Indeed I In this last quotation we are warned 
against a remedy most preventative of anchylosis, and 
urgently advised to practise the main cause of 
anchylosis, i.e., motion of articulations while in an 
inflamed condition. 

Again, at page 399 of the same Volume, he 
reports thus : — 

" I have seen one case in a gentleman under thirty years of 
•* age, from Providence, Rhode Island, on which both hips, one 
" knee and both ankles, were apparently completely anchylosed, 
" as the result of rheumatic inflammation. I have seen another 
" case in a young lad of fifteen, from Kentucky, who had disease 
** of his right hip joint, and for the purpose of procuring rest of 
" that joint, was put by his attending surgeon into a fixed 
" apparatus, embracing the trunk, pelvis and both lower extremi- 
" ties, and so retained for several months. At the end of 
'' this time the diseased hip was cured by anchylosis, and the 
" knee and ankle of the diseased limb, as well as the 
" hip, knee, and ankle of the opposite one, completely anchylosed 
" and still remain in the same condition. In this case there 
" had been no inflammatory action in any of the diseased joints, 
" except the right hip, and he had never complained of or suffered 
" pain in any of them. This case is of importance, showing as 
** it does that anchylosis can take place, even in a young person, 
** on a perfectly healthy joint, by long continued rest." 



148 

This case and its interpretation, involves, the whole 
question in dispute between myself, contemporaries 
and predecessors. That these cases are correctly 
reported, I will admit; but that the extra 
articulations mentioned became anchylosed, and that 
without any abnormal condition pre-existing beyond 
rest of the par^ I hold to be impossible. As 
regards the first case, it Is given as one of rheumatic 
inflammation of all the joints that recovered with 
defect ; the second, It is highly probable, was also 
of rheumatic origin, and was so carefully and skilfully 
" put up " by the surgeon in attendance that the 
implication by inflammation of the other joints was not 
felt by the patient, nor noticed by the surgeon. 

Had this case not been so well treated (fixed) he 
possibly would have recovered with hideous deformity 
and would be fit to earn a livelihood at a street comer. 

During the period I was qualifying myself for the 
profession, I was asked to go and see a case of 
general Rheumatism, where every joint in the body 
was completely anchylosed as regards any motion, and 



149 
the patient could be handled by the nurses as though 
he was a plank, yet beyond reclining in bed he had 
had no method of fixation applied to him. 

For many years I believed and practised the 
principles of treatment of joint difficulties, as laid 
down in our Surgical Text books, and special treatises, 
until their imperfect results induced me to attempt 
some improvement in the practical part, during which 
period I discovered, that it was the Theory of treat- 
ment that was the cause of non-success and had for 
ages relegated the majority of these casualties as 
incurable. After many years of labour devoted to 
constantly improving the details of mechanical treat- 
ment, gradually I observed that inflamed joints re- 
covered, as regards time and freedom from after 
defects, just in proportion to the efficiency of their 
fixation (arrest of motion j, and freedom from concussion 
with the application of certain practical details 
required by the accidental variations of each case. 
With my theory as his guide, the surgeon can with 
confidence treat these difficulties "in suche wise that 



"50 
knowinge the nature of the infirmity there may 
thereby through natuial reason (ye though there were 
no practicej be procured a speedy remedye."" Joints 
not controlled, or when placed in what is usually 
termed " rest " if in a state of inflammation, become 
theseatof a degree of stiffness ; which I confidently 
state is not usual when joints have been fixed 
immoveably. 

The conditions tending directly to anchylosis are 
continued friction and pressure, while the joint is in 
a state of inflammation ; absolute rest is not a factor in 
causing anchylosis, but the means of avoiding this 
casuallty, and my observations convince me that rest 
cannot be too long maintained nor ever become 
per se, an ailment. 

At page 206 of Sir James Paget's Clinical Essays, 
&c., a very interesting case is reported, as described 
by Professor Flower, which confirms my theory as 
to the effect of rest on healthly joints. 

"A man, whose skeleton is at Marburg, was encased bj' 
•John Halle. A.D. 1565. 



" his relatives for 20 years in a space in which he could only 
"sit with his limbs doubled up, and in which he could have 
** had only very narrowly restrained movements of his joints, 
" yet his limbs did not become deformed, and his joints retained 
•' their normal textures." 

The Professor quotes this as an instance of 
exception to his own belief, but he omits to inform 
us whether the man's relatives wished to kill him 
or merely to stiffen him. If the latter, they certainly 
tried it according to the commonly supposed means, 
but failed, as there was wanting irritation of them 
this would have assisted in stiffening his joints, 
but granting that he had this irritation or 
inflammation of the joints, and had also been 
compelled to roam about, the anchylosis would have 
been a certainty, and instead of the experiment 
occupying twenty years, stiffening the joints of the 
tortured person would only have occupied one thirtieth 
of the above term. 

Two years agC I operated upon the feet of a lady 
suffering from contraction of the Achilles tendons, 
caused by the weight of the bed clothes during a long 



"52 

period of confinement to bed. The contraction had 
existed five years, and totally prevented any locomot- 
ion, and she was consequently confined to a couch or 
bed during the whole of that period. 
■ Ten days after the operation she walked from 
^my hospital, a distance of 800 yards, yet this joint 
had been fixed for a period of five years ; there was 
not the slightest stiffness or adhesion in it. The 
stiffness was confined to the Achilles tendons only. 

I had occasion during the same year to operate 
upon the feet ol a young lady who had been confined 
to bed for three years from the same condition of the 
Achilles tendons. As in the previous case, she was 
totally unable to walk or to place her feet upon the 
floor. In six days after the operation she went about. 
There was no evidence of anchylosis. Anchylosis 
will occur in a degree always relative to the Inflam- 
mation present, and the imperfect fixation of the 
joint prolongs this inflammation. Whatever stiffness 
occasionally remains, after the fixation of a joint, that 
stiffness would have been still greater after deficient 



153 
fixation. It has been my practice in certain cases of 
paralysis of the extensors of the hand, to place the 
hand at nearly a right angle with the forearm, in the 
position of extension, and to keep it fixed for six 
months, without a moment*s relaxation or intermission. 
Yet this amount of fixing alone, has never in any case 
produced permanent stiffening of the articulation, as 
the one thing needful was absent, namely : — internal 
irritation of the joint. Articulations that were stiff- 
ened, inflamed, and falsely anchylosed, when fixed and 
retained so without interruption for one, four and five 
years, became relaxed as knee joint cases, No. 5, 8, 1 3, 
previously reported ; the more an inflamed joint is 
efficiently fixed, the sooner does the inflammation 
subside, and consequently, the less damage will be 
done and the better the result ; a certain amoimt of 
mere stiffening, remains for a time, which assists in 
confirming the cure by preventing the patients' 
making a too free use of the limb on removal of 
restraints. Once resolution has been secured beyond 

a possibility of relapse, let the restraint he removed, 

u 



154 

and the limb will regain its utmost range of usefulness 
by use alone; it may happen that the inflammation 
has been so severe and prolonged, that anchylosis 
may remain limiting the limbs' usefulness ; in these 
cases the surgeon can boast of having saved the 
limb> and perhaps the life of the patient, by having 
finnly continued a course of treatment that r^son 
dictated, and which my experience indicates to be 
correct.* 

My experience compels me to disbelieve the possi- 
bility of anchylosis, where there has been complete 
mechanical rest, and not an inordinate degree of 
inflammation. 

What is usually meant by " Rest " is confinement to 
bed, without any fixing of the joint. In the case of 
the hip joint such rest is of no value, as the patient 
sits up in bed many times during the day, and so 



■while insisting on the importance of arresting friction and pressure in 
unhealtliy aiticulafions, and also tliat tust cannot of itself anchylose a joint; it 
must not be forgotten that prolonged or unuaual friction or pressure in the 
use of healthy joints will produce inflammatioa in them which may go on to 
anchylosis. Many cases illustrative of this could be cited but as this has 
no doubt been frequently noted by other surgeons, such reports would not be 
of any value and they require no special treatment. 



»55 
flexes his limb more effectually than he would have 
done had he been going about. Confinement to bed, in 
the case of the knee joint, may be called partial rest ; 
and in the case of the ankle joint it is more effectual. 
If this so called rest is tolerated ; some stiffness must 
ultimately remain in the majority of cases, as anchy- 
losis will occur in proportion to the inefficiency of the 
immobilization of an inflamed articulation. The 
preceding quotations, represent the opinions held by 
representative men in this department of surgery, 
and show unmistakeably, that the profession hold 
tenets at variance with the views taught by myself, 
regarding the effect of rest on both healthy and 
inflamed joints, we differ also as regards the possible 
result of over friction and pressure on even healthy 
joints at times. 

As a general rule both in surgery and medicine 
the " rest " prescribed is only hypothetical, inas- 
much as, that in the generality of cases where rest is 
advised, means are prescribed that effectually nullify 
any benefit that could be gained by it, for instance, in 



■56 

affections of joints, llie weight and pulley, Sayres' 
apparatus, counter-irritants, rubbing, unguents, sham- 
pooing, and last of all there are indications of a 
desire to popularise the most irrational of all so called 
aids, viz. : Dr. Bauer's suggestion that the tendons 
controlling the inflamed joint should be divided, ere 
they become affected by prolonged action. From the 
volume of the 'Lancet' for 1876, is extracted the 
following paragraph by a Professor of Surgery, on 
the treatment of knee joint inflammation. 

Trealmejil. — " Good diet, change or air, and tonics, including 
*' preparations of iodine, are indicated by reason of the chronic 
'■ natute of the complaint, implying a serious constitutional error. 
" Perfect rest to the joint must be ensured by splints, with an 
" occasional counter-irritant in the shape of allying blister; and 
" when heat and tenderness have nearly subsided, strapping and 
" bandage, to support the cell-mas and prevent venous con- 
"gestion, nmst be applied— when all danger of resuscitating 
"inflammation appears to have ceased, friction and passive 
" motion will much avail. Thomas' splint, such as I show you, 
" as used by one of the above children, — with a patten attached 
" to the boot of the sound foot — will allow the patient to take 
" csLTLiae in the open air ; will provide extension, and yet secure 
" ;i c» rtiiin amount of repose to the joiiif. 



157 

There is one very hopeful feature in this formula, 
the absence of the traditional " linseed meal poultice " 
and " mercurial unctions." Most of my critics assert 
that there is nothing new in my theory or method, yet 
It is in every particular the reverse of the mode here 
counselled. In the first place we have here *' good diet 
change of air and tonics," though they are not so 
valuable as securing ease from pain, because the dainti- 
ness of the patient's appetite and digestion, as a rule, 
disappears in proportion to the relief of pain and 
local irritation ; when this relief has been achieved, 
the patient seldom requires special attention or stimu- 
lation of his appetite. 

As to the use of the " preparations of Iodine " they 
have not in my opinion, any curative value in these 
difficulties, and I do not believe that any surgeon will 
be able to demonstrate, that Iodine has any beneficial 
effect in producing resolution of inflammation of 
joints. 

Again the chronic condition of the complaint is 
attributed to a "Constitutional error," and not to 



I >58 1 

im'talion caused by friction, pressure, and tremor of 
parts not tolerant of such, which I assert to be the 
case. 

" Perfect rest," is also enjoyed by means of so called 
" splints," which are very inadequate for their intended 
purpose, and that this fractional rest may be still de- 
tracted from in value, an occasional "counter-irritant" 
is added in the shape of a " flying blister," and " when 
the heat and tenderness diminish, or have nearly 
subsided," in spite of all this treatment, then strapping 
and bandaging are urged, and when " all danger of 
resuscitating inflammation appears to have ceased, 
friction and passive motion will much avail." Certainly, 
but only to bring back the difficulty. And finally 
Thomas' splint is applied at a period, that had a more 
rational mode been practised, the sufferer would have 
been able to dispense with surgical aid. 

Again in the same lecture is contained the follow- 
ing commendation of a practice that I had hitherto 
thought was confined to Transatlantic surgerj'. . 

Tcnoloniy. — " You will have rematked thai, of my three cases, 



•159 

" in that of the Jad, the disease is in its first stage, while in the 
" two girls the malady has terminated in anchylosis with deformity. 
" Now as prevention is better than cure, I would suggest, as a 
" rule of practice, that an attempt be made to prevent that 
"deformity that you have witnessed in these children by a 
" subcutaneous section of one or more hamstring tendons— at 
"any rate the biceps, the power of which to rotate the leg out- 
" wards, you can readily appreciate on your own person. I 
" adopted this plan in the case of a child of a professional friend 
*' and I believe with marked benefit. I propose to do the same 
" in the instance of the lad above mentioned." 

The adage here applied to illustrate this 
operation, most certainly does not indicate its value, 
though it may express one of the principles of 
conservative surgery. How any surgeon who has had 
a moderate experience of Tenotomy can urge or 
practise it in these cases is to me inexplicable ; as it 
is well known that division of healthy tendons only 
suspends the action of the muscular fibre for a very 
short period, sometimes not for more than three 
days, consequently, this practice, if done on limbs 
efficiently controlled, can answer no end — nor tem- 
porary purpose ; but if done upon an extremity not 



controlled (granting that such division of tendons 
were not followed by rapid union — which is not the 
fact) then the joint would rapidly retrograde as the 
patient would have lost the ability to secure rest even 
in a slight degree by the action of his will, and thus 
fail to imitate what art should) and can, do effectually. 
"Dr. Bauer's suggestion is only an imitation of 
the operation practised by veterinary surgeonsj 
i.e., unnerving a horse for navicular disease, which 
enables the animal to be free from pain for a short 
period at the expense of a rapid retrogression to 
destruction of the foot, that otherwise would have 
lasted a long period. The operation of unnerving is 
certainly the less irrational of the two, though 
there is sense in neither — if conservatism is the aim of 
the surgeon. The operation of tenotomy, as pro- 
posed by Dr. Bauer can relieve no pain nor answer 



•From (he reports of cases published in the Metropolitan Journals this 
year, iS^C, it is apparent that this hitherto Transatlantic procedure ha^ now 
been tried in London with reputed benefit. It would lake a very high 
numerical evidence of success to induce me to try it— an operation in my 
opinion the most irrational item ever introduced info the treatment of 
diseased joints and which "out bids" all other suggeationa in the wrong 
direction. 



i6i 

any purpose I know of, but the operation of un- 
nerving does make the inflamed part painless for 
a time at least, and makes its use tolerable until it 
is ruined. With the action of the tendons, the sur- 
geon need not concern himself, for as soon as the 
limb is placed at rest, their action ceases ; as soon as 
immobility is attained by art, nature, the irregular 
practitioner, disappears from the scene, in the treatment 
of joint diseases as well as in that of fractures. The 
more skilful the surgeon, the less we see of nature's 
rude surgery. 

Several examples confirmatory of this occur in 
both Medicine and Surgery as well as in the Veter- 
inary Art. 

Dr. Sayre's views as given in his recent Volume, 
convince me that he has never observed the effect of, 
nor secured for any of his cases a curative amount 
of, rest; for at Page 199, he thus informs us. 

" You may keep the limb perfectly still, and locked up in 
" every conceivable way, and yet you do not overcome the 
'* tendency of the muscles to contract, you do not prevent reflex 
" action." 

v 



1 62 

It is astonishing the attention that many siugeons 
give to the muscles, and to thwarting their eflbits at 
conserving the articulation, all this correcting of 
muscular action is wrong, for as soon as sufficient 
fixation of the articulation has been attained, their 
action ceases, in fact their "occupation's gone." 
I " Pasnve motion " so generally insisted upon in 
6ur Surgical text books, as a necessary item to gain the 
utmost usefulness of the joint, is I believe attended 
with danger to the patient, and often undoes that which 
the surgeon liad well achieved, never have I seen a 
case of recovery where it was required, and deny that 
it is indicated except in extremely rare cases, such 
as never came under my observation. Once the arti- 
culation is sound beyond relapse, let the restraint be 
removed, and the part will usually regain its utmost 
usefulness through use alone, but to enable the 
recovered joint to resume its utmost extent of action, 
it is necessary that it should have been retained 
during treatment, and to be on the occurrence of 
resolution, in the posture which theory and ex- 



1 63 
perience indicate as the right one to permit 
the patient to use the limb more and more in the 
direction of its usual purpose, as for instance, in the 
hip joint, the thigh must be in line with the body ; 
the knee joint, the thigh, and leg, should be also in 
line while the ankle joint should be, if possible, cured 
square to the leg or corrected by tenotomy after the 
occurrence of resolution and previous to its use by 
the patient. 

There is yet one more feature of joint disease that 
requires notice, naniely : wasting of the affected 
limb. And as evidence of the opinion held by the 
profession, I cannot do better than quote from the 
6th chapter, vol. I, page 209, of Sir James Paget's 
Essays, &c. 

** It seems dependent on disordered ner\'ous influence, and 
** often appears proportionate to the coincident pain." 

From this opinion I feel compelled to differ, and 
hold that the absence of pain, especially if combined 
with effective rest, favours wasting. 



164 

Atroph)', in these diseases, I believe (contrary 
to the usual teaching) to be an advantage, for the 
more the muscular tissue becomes atrophied, the less 
will there be of spasm and consequent irritation of 
the joint, and the less power the patient will have to 
put his joint to an excessive strain at the commence- 
ment of use, and so he will be prevented from invi- 
ting back the irritation. 

It has been my lot to meet with several cases of 
hip joint disease, in which this symptom of wasting 
as well as that of lameness were wanting, and had I 
not applied my new method of diagnosis, I should 
not have detected the existence of any disease in the 
hip. The patients had only complained of obscure 
pains at night in the Hmb. In one such case, where 
I had been consulted, I informed the parents of the 
patient that hip joint disease existed. They doubted 
me, and two other surgeons were called in consultation, 
but through not having had sufficiently early notice, 
I was not present. The parents judged themselves 
slighted, and I was set aside. My successors did 



i65 
not judge it a case of serious import, yet it ended 
fatally. 

The absence of wasting is no good omen to the 
sufferer. Rapid and early atrophy of the muscles 
often coincides with early relief of the local irrita- 
tion. I know of no degree of muscular atrophy the 
result of joint disease, which is not recoverable, once 
the joint is well. 

In the acute stage of articular disease, or when 
reducing deformity, it is advisable to confine the 
patient to bed, and I cannot do better than quote 
Mr. Holmes' excellent advice in his volume on 
the Principles and Practice of Surgery, page 

445: — 

" But prolonged rest in bed is the main agent in the cure 
**of the disease, and the confinement to bed, far from being 
'^deleterious to health, is generally attended with considerable 
** improvement in the general health." 

This is in conformity with my own observations. 

A second difficulty that frequently meets the 
surgeon is the solution of the question. What 
duration of time do these cases require for recovery ? 



l66 

A month may be sufficient in the case of A, while 
the case of B, commencing with the same symptoms 
and under almost the same conditions, might demand 
forty months. It is the duty of the surgeon to 
give no heed to the duration of the difficulty, but 
to ascertain if the limb is sound and beyond probable 
relapse, before pronouncing it fit for use. The period 
of treatment can of itself be no guide to the 
formation of an opinion as to whether or not resolution 
has been arrived at ; the surgeon need have no 
anxiety of any resulting evil should he, through over 
caution, prolong the rest unnecessarily. 

I admit that a vast number of acute cases 
arising from rheumatism, gout, and other constitu- 
tional disturbances, recover with but little or none 
of what I would term rest; but enforced un- 
interrupted and prc'.onged rest, Is a necessity for 
the joints that may have entered upon the chronic 
stage. 

The signs of recovery usually to be noticed are, 
that the soft parts around the joint nppcar and feel well 



16; • 

atrophied, and that there is an entire absence of pain 
or tenderness in the part, for instance, as to pain, the 
patient should awake from sleep in perfect ease, even 
though he may have been reclining on the affected 
limb, again when pressure is applied to the ligaments 
between their attachment, or when percussion is 
performed on the limb unawares, the tests should 
give no pain, but the most crucial and infallible 
test is the ability of the patient, after using the limb, 
to return it at will to the posture it was maintained at 
during treatment ; or if a case of anchylosis it should 
remain after use, in the posture it was retained in 
during treatment. 

I assert that this is an infallible test, which may 
be tested and used only when all other guiding 
symptoms are not possible of being detected this 
is an unerring test, like the " Mariner's Compass " 
when all landmarks are out of sight to the navigator, 
so the surgeon by this test can get to know for 
certain whether a joint that appears sound is 
genuinely so. 



As regards the excision of joints, my experience 
will not allow me to endorse the opinion of Prof. 
Spence, that this operation is " so obviously an ad- 
vance in the right direction ;" but I have been con- 
vinced that it is a step in the wrong direction, and is 
too frequently an excuse and a ready way of disposing 
of the difficulty to the neglect of sufficient attempts 
at saving the articulation; joints when treated by 
f the ancient method or by some of those recently 
introduced by some of my contemporaries may, nay 
do, frequently arrive to a condition when no, 
alternative remains except excision. From the 
testimony of their advocates and my own personal 
observation of results, this is very apparent. Again 
joints, not subjected to art, but permitted to remain 
in charge of the " irregular practitioner " known as 
nature, which usually acts through the medium 
of muscular action, these may occasionally require 
operative interference by excision of the joint. But 
articulations early diagnosed and treated by 
rational principles and by efficient mechanical control. 



169 

these as a rule will never so deteriorate as to require 
excision.* 

An exception to this rule will be found an 
extreme rarity, the exact value of the mechanical 
aid advised in this treatise is not to be judged from 
its effect in cases already neglected or mistreated, 
valuable as it is even in these difficulties. While 
granting that the hip, knee, ankle, and wrist joints, 
may some times, though rarely come to excision, 
I feel constrained to say excision of the shoulder, 
and elbow, joints, are still more improbable and 
should be an extreme rarity, though since Prof. 



* Accompanied by my friend, Mr. Rushton Parker, I visited the Rhyl 
Convalescent Home when there was under the care of the medical ^taff a 
great number of cases suffering from diseased joints, sent to the Institution 
from all parts of the country. After a careful examination of the cases we 
observed that those which had been subjected to no assistance from art 
were in a much better condition as regards soundness, i.e., freedom from 
inflammation and its stages, but there was present more deformity in this 
class than existed in those that had been perseveringly assisted by modem 
surgery. This latter class had but a very slight deformity, but a serious amount 
of destrjction of the parts composing the joint and a peculiar sodden oedematoug 
condition of the articulation and surrounding tissues and this discouraging 
feature existed just in proportion to the amount of traction or extension 
employed Mr. R. Parker and myself here acknowledge our indebtedness to 
Miss Vizard, the matron, and Dr. Tumour, Denbigh ; Drs. Roberts, 
Girdlestone, and Lloyd of Rhyl, with whom we carefully examined and 
" noted " 18 cases, which fully confirmed our previous experience in private 
practice. 

W 



r ■7^' 

i Syme popularized excision of the elbow, it is a 
L frequent procedure. 1 never saw occasion for 
[ excising this joint in my own practice, but I have 
seen the operation performed by others when not 
I accessary, in cases that were amenable to resolution 
I ■ by rational treatment, and with a cure securing a more 
\ useful limb than could have resulted from the operative 
[ interference by excision. 

1 With confidence I maintain that if the methods 
and details I have counseled, in this Volume, 
which is the result of the closest daily personal, 
supervision and scrutiny of the cases submitted to me 
during a period extending over twelve years (this 
surely a sufficient time amply to test the value of 
anything that might be considered an innovation on the 
principles of a time honored practice) be accepted by 
the profession, most of the deformities and deficiences 
caused by inflammation of joints, will be rareties in 
the practice of our successors. To the younger prac- 
titioners of Surgery 1 especially appealed and expect 
that they will make themselves proficient in this 



171 

department, and I would urge them to be adepts 
practically, before introducing alterations, which too 
frequently in the absence of experience must be either 
useless or injurious. 



GENERAL SUMMARY. 



I.— The following conclusions have forced themselves on 
my mind, in the application of my theory and method in 
practice. 

That, like all other lesions, however early we may detect 
diseases of joints it does not follow with certainty, that difficulties 
and prolonged treatment can be avoided ; yet an early diagnosis 
is of great value in the majority of cases. Again, by the 
practical application of my theory, there is a greater certaifity of 
success, there are lesser and rarer difficulties, prolonged treat- 
ment is not an evil, deformities are avoided while the 
operations of excision and amputation are set aside for rare 
cases. 

2. — That the main cause of joints entering into the chronic 
stage is imperfect immobilization of the articulation ; friction 
and pressure being permitted in a greater or less degree. 

3. — The causes of the variability of the symptoms in diseases 
of the joints, do frequently arise from variations in treatment. 



4- — That the mosl cfTcclual inclliod or a\-oMiiig anchylosis, 
is the practice of uninlcrniptcd and jirolonged immobility. 

J. —The niAiii olwUcles to the cure of an inflamed joint are, 
]>rinci{KiUy friction, and secondly, pressure on its surfaces ; conse- 
quently the attainincint of rest, i.e., immobility of the articulation 
ought to lie the jirimar}- principle, which should guide us in the 
treatmcnl, Pressure and concussion are less to be feared than 
friction, 

t).— Tlic correct use of proper appliances arc followed by 
resolution of inflammation in most ca-ses— the avoidance of 
deformity when applied at a later stage ; the position of the limb 
is not an item in producing resolution, but requires attention to 
secure future usefulness, 

7.— This mechanical treatment when applied early, and when 
well adapted, always litnofils every case of joint disease, and the 
p!iin may be so great that no anodyne drug in less than toxical 
doses would alleviate it, yet, the mechanics of this method 
correctly applied, will invariably give ease. Emaciation usually 
[irL-si'iil in llicsf cases is the direct result of cynlinucd pain, but 
it is llius prevented at an early stage and arrested when present 
in a later stage. 

H. — To insure permanency of cure the control should be 
maintained for a period beyond the time when resolution has 
taken place. This prolonged immobility of the joint's 
movements even for an unnccccssarily long period can be 
productive of no harm. 

1).— The more an inflamed joint is uncontrolled the stiffer 
docs it become, while the more effectually it is fixed the sooner 
and tlie more complete is its capability of movement restored. 

10. — Temporary stifTiiess docs, and must, always occur 
after resolution, but is equally certain to wear off without 



173 

interference such as passive motion, ^^hich is highly objection- 
able. 

II. — ^True anchylosis after correct mechanical treatment is 
extremely rare. 

12. — That previous to pronouncing the articular inflammation 
resolved beyond probability of relapse, the joint should be care- 
fully observed after removal of restraint, and notice taken, 
whether after use it can be restored by the will of the patient 
without any supplementary force, to the position it was in 
when under treatment. This is a crucial and unerring test. 

13. — ^The arrest (or more strictly immobility) here advocated 
must be enforced so that the patient's ordinary movements 
will not materially disturbed the joint, it should be 
uninterrupted not even momentarily, and prolonged so to 
secure beyond any probability a return of inflammation. 

14. — No joint ruptures when distended by simple non- 
purulent fluid. 

15. — The symptoms that indicate the presence of articular 
inflammation, difier in accordance with the degree of fixation 
secured. 



CHAPTER Vn. 



THE METHOD OF RELIEVING 
ARTICULAR DISTENSIONS BY ASPIRA- 
TION AND INCISION. 

The first consideration of the operator should be the 
selection of a useful and safe aspirator, if he is not 
already in possession of one. That made by Weiss 
& Co.j of London, and consisting of a three way tap, 
attached to a bottle, which is exhausted by means 
of an air pump, is certainly the safest, inasmuch 
as it is impossible to make any mistake with it ; but 
it has its disadvantage, being liable to leakage, in 
consequence of which there is defective vacuum 
power after it has been some time in use ; but, where 



175 
the surgeon has time to prepare it for use, its defects 
can always be made right before operating. 

My own aspirator depicted in Plate 25, fig. is 
the simplest and least liable to get out of order of any 
that has yet been designed ; and where the surgeon 
has occasion to aspirate many times in a day, it has 
decided advantages over all others hitherto placed 
before the profession. 

The successful treatment of articular inflammation 
is so far dependent upon the correct and early practice 
of this operation, that aspiration merits special notice, 
and in this chapter I purpose recording my own ex- 
perience in its practice. 

It must, in the first place, be borne in mind that 
articulations are liable to accumulations of fluid 
though there be present no inflammatory action; 
while, on the other hand, inflammation may exist 
unaccompanied by any perceptable distension of the 
articulation. 

While thus recording my experience of articular 
distension, and its relief by aspiration, I would ask 



»7« 

I die reader to presuppose that the limb under treat- 
[ awnt is already fixed and uninterrupted in the 
|MTWtion and manner advised in the previous chapters ; 
inasarodi as many of the symptoms which are referred 
to, cannot be noticed in joiats trea te d by the so-called 
(but only firactiooal) resL 
I The joint, abo\*e all others, from which thy 

surgeon can gain most experience as to the value of 
aspiration, is the knee joint. 

This join^ on the front aspect, is so thinly covered 
that many of the physical changes can be early seen 
and felt. Accumulations of fluid, in this joint when 
treated by my method may become localisedj so that 
the joint may contain t\vo or three seperated collec- 
tions, which cannot be pushed by manipulation from 
one, to any other part of the joint. 

These localised collections of fluid I have always 
found to be purulent, and that aspirating one doth not 
relieve the others, though they be in the immediate 
neighbourhood and on the same side of the joint. 
As a notable instance of this I can recollect the case 



i 



177 
of a lady, who had a localised purulent collection in 
the right side of the right knee joint, just above 
the patella. This I successfully aspirated after 
several operations, after which the patient absented 
herself for six months, in the meantime retaining 
my appliance, but being able to go about in the 
discharge of her duties. On her coming to me at 
the end of that time, I found fluctuation and disten- 
sion above and below the patella on the inner aspect, 
and that aspirating the lower collection, had no effect 
upon the upper one, which had to be subjected to a 
special aspiration ; as however they repeatedly 
reformed, it was decided to lay them open; this was 
done ; and a digital examination fully convinced me 
that these two collections were independent. 

On another occasion I aspirated a boy's knee on 
the left side of the ligamentum patella, with success ; 
yet in nine months afterwards a small collection 
formed on the outer side, above the patella ; v/hich, 
having failed to successfully aspirate, I laid open. 
These two cases are reffered to as typical of many 



wfcicll hnc GOOis aader my nodce. 

Gfaadi^ dot die operadoa of aspcradoa has been 
cuiruttlv pcHbnncd. aoA that pcDper means to fix the 
joint have been oiide use of. 1 know of no mishap to 
have occurred to the joint after this operation, but 
more than ones I have noticed the formation of extra- 
articular abscesses occunii^ in the track of the needle. 
In those cxses where I noticed this complication the 
aiticulattons were successfully aspirated, but the extra- 
articular abscess (which much simulated articular 
distension) had to be treated by free incision, 
aspirauon having failed. An exploration with the 
finger confirmed my diag^nosis. 

The knee joint may be aspirated with special 
benefit as soon as it is distended, either with simple 
fluid, pus, or with blood, as immediately after an 
injury ; a couple of aspirations usually suffices to relieve 
pain, and shortens the time neccessary for recovery in 
traumatic cases. Aspirating this joint is an operation 
attended with absolute safety, if carefully performed, 
and an efficient control is maintained over the motion 



I 



179 

of the limb by my ordinary knee appliance or, if an 
immediate traumatic case, then the knee can be 
controlled by the calliper foot appliance. I am 
aware that fatal cases of aspiration of the knee joint 
have been reported, but I firmly believe that- the 
disaster in such cases, granting that no 
mistake was made in the operation, arose from 
the omission early to repeat the operation, as in 
some cases the first operation is followed by rapid and 
painful distension in a few hours. To abstain from an 
early repetition of the aspiration, and thus fail to relieve 
the distension would be serious ; as extreme distension 
like undue pressure would give rise to suppuration. 
Aspiration should be repeated every twelve hours, if 
the fluid reaccumulates so as to distend the capsule. 
I have frequently noticed that the first aspiration has 
given rise to irritation and rapid refilling of the joint, 
this might alarm the inexperienced, and cause him 
to abstain from a renewal of the procedure though it 
is urgent, as irritation is sure to subside if the joint- 
is kept relieved from distension by the repetition of 



the operation in time. I have myself in urgent cases 
relieved the joint twice in twelve hours, but once 
every two daj-s, tor three or four occasions, Is the 
usual indication. 

Two very instructive cases occurred lately in 
my own practice illustrating the correctness of this 
policy. Both of these patients consulted me at my 
surgery, suffering from Simple synovitis. Their joints 
were aspirated and partially fixed, not being judged 
as requiring complete immobility. The following 
day their joints were acutely painful and had refilled 
with extreme distension. Aspiration was repeated 
in one case every twelve hours for five or six days 
when the fluid ceased to accumulate and the difficulty 
subsided widiout any after defect of the joint. 

In the other case I had to aspirate twice in one 
day, and daily for two or three daj-s. Had I 
not persisted in the repeated aspirations, no doubt 
these cases would have been accompanied by surgical 
fever, extreme distension, destruction of the joint, 
&c. 



i8i 

When the joint is suspected of containing, or 
known to contain, pus the aspirating needle should 
equal in ^* bore " Nos. 3 or 4 catheters, but needles 
of the " bore " No. i and No. 2 catheters will do 
when the articulation is distended by non-purulent 
fluid. 

My observation justifies me in asserting that 
distension of the articulations by simple fluid or 
healthy pus can always be relieved permanently 
and safely by aspiration, combined with efficient 
fixation. Again, joints distended by purulent fluid 
and of recent formation are frequently got rid of by 
the same process ; but where the collections are old 
and dense, failure is a probability, though after failure 
they are more amenable, and with greater safety, to 
the treatment by incision and the practising of other 
details when aspiration has failed. 

Frequently cases are presented to the surgeon 
for treatment where the joints have been distended 
with pus for some months, and the collections have 
become condensed and flakey, this condition, may 



l82 

sometimes be successfully aspirated, while on other 
CKcastons, though the fluid remo^-ed ceases to appear 
purulent, and though it has become serous 
in appearance it may persist in reforming. Purulent 
collections in articulations can nearly alw'ays, by 
repealed aspirations be made serous, yet this may 
persist m rdbrming and finally necessitate the 
opening of the articulation by free incision.* 

When the condition of the joint is such that the 
accumulation cannot be permanently corrected by 
repeated aspirations, and the surgeon has reduced 
the quantity as well as qualitj' of the articular 
contents, there is no alternative but to make an 
incision into the joint and the question which 
naturally presents itself is, — What should be the after 
treatment of the opening r He has to chose whether 
he will make use of the traditional filthy poultices, 
lotions, and supposed specific linaments, or carry out 



•In this condition I would snggest a trial of some method of <:< 
aspiration, i.e., to leave the needle in the joint puncture and attached to a: 
eihauater and receiver, having only tl]ouf;lit or this but receiitly I have no 
had an opportunity of practically tesfing this plan. 



i83 

Professor Lister's antiseptic method, or practice an 
open method. That the first mentioned is now quite 
out of the question ought I think to be the opinion 
of the majority of modem surgeons. I can see no 
benefit attached to it, but on the contrary believe 
it to be highly injurious, and therefore I think it 
is only a question whether we ought to follow 
Professor Lister's method or an open one. Much as 
I admire the antiseptic method, it yet seems to me 
to be but the old method made safe and harmless, 
in fact a correct method of ritualistic surgery, and I 
venture to assert that had Professor Lister's ability 
and zeal been expended in perfecting an open method, 
we should have now been in possession of a method 
more simple, easy, and safe, than the antiseptic, 
great as its merits are. 

For some years previous to the introduction of 
the antiseptic method I practised the open method 
and was well satisfied with the results obtained, but 
on the publication by Prof. Lister of his successes 
I at once commenced the practice of antiseptic 



_ ry and continued to practise it for three years 
■with the result of being perfectly satisfied that its 
merits have not been overstated nor the trouble 
necessary for carrying out the details exaggerated. 
I returned, however, at the end of that time to the 
open metliod and have since laboured to improve 
it, so much so, that I am emboldened to assert 
that by the open method, results and successes, equal 
if not superior, to anything to which antiseptic treat- 
ment has yet attained, can be arrived at. 

My usual method of treatment in the case of joint 
accumulationSj where aspiration has failed, and where 
there is continued redistension, is to aspirate and reduce 
the area of the cavity (whether an abscess or a joint 
collection) as much as possible and then to incise, lay- 
ing the joint freely open so as to obliterate any cul-de- 
sacs which are often allowed to remain at either end of 
the incision. (Here I presuppose that the limb is 
well fixed, and the patient kept reclining ; with all 
other precautions to render him immovable and free 
irom tremor and concussion.) Then I instruct 



1 85 
that the part is to be frequently washed with water 
and oiled. The oil is to be applied to the surface of 
the wound to hinder it from closing by scabbing, 
and so from the possibility of retaining fluid. This is 
all I usually do after incision into articulations or 
abscesses, and I hold this to be sufficient. As I am 
obliged to allude here to the " open method," it may 
not be out of place to append a few examples as 
evidence of the value of a systematic open method 
of treatment. 

In cases of compound fractures, it is my custom 
to place the limb in an apparatus which retains 
it immovably fixed, so that there is no occasion to 
disturb its immobility for the purpose of changing 
bandages or dressings, until it has recovered. 

Having fixed the limb, I treat the wound in this 
way : — 

Supposing that the bone is projecting thrqugh the 
skin, the wound is enlarged before reducing the 
fracture, then the finger is passed in, and the wound 
explored for any cul-de-sacs which may have formed 

Y 



1 86 

during the accident, and if present they are laid 
open, the blood clots removed, bleeding arrested, 
and such drainage secured as to make retention 
of any fluid an improbability if not an impossibility ; 
then direct the attendant to simply wash the wound 
with water, or salt and water, pouring in every 
three or four hours a little oil to prevent 
scabbing. 

If the case is one of compound fracture not 
complicated by protrusion of bone, then the opening 
is always enlarged, cul-de-sacs searched for and if 
present, laid open in all directions, then the simple 
ablutions are practised with the addition of 
applying a little oil at intervals until recovery. 

In the case of large incisions for the removal of 
tumours, &c., the wound is left gaping, being sponged 
and oiled and assisted gradually to come together. 
Again in cases of amputation, the flaps are never 
brought together earlier than after 24 hours, and then 
they are " put up " immovably, and treated by 
simple ablutions, and oil, until recovery. If after 



operation or injury, any portion of the wound, 
especially the skin, be much detached and appears of 
low vitality, it may be necessary to cover for a time 
such portion with tin foil or gutta-percha-tissue to 
ensure its vitality, or it otherwise might from loss 
of heat and moisture become gangrenous. In cases of 
Lithotomy the after treatment of the operation by this 
open method, consists in passing into the viscus, 
through the wound, a glass tube, and in retaining it 
there a few days until all post-operative irritation has 
passed away, when a rubber catheter is to be passed 
into the viscus per urethram, so as to continue an 
efficient drainage after the removal of the glass tube 
from the perineal wound. Operations involving 
abdominal section present difficulties which require 
special attention, but which I am informed surgeons 
have surmounted, as for example drainage by tube 
through '* Douglas's pouch," or by a suitable arrange- 
ment at the abdominal wound ; again many operations 
on the upper and lower jaws, are unavoidably treated 
by the open method and usually do exceptionally well. 



iftS 

As examples of the success of an open method as 

by myself* appended are reported a few 

; that were so treated. 

No. I. — A case in nrliici] a ftactnred leg was placed in a 
jtermanent imiBorable appliance, two indies of the front portion 
of the Tibia was removed, and " pot up " witb [he open method 
simple ablution and (Hling, with the icsolt of no suppuration, 
nothing bnt a continual mnning of serum ; the bone was renewed, 
and the lecoven- was so complete that there is no deformity or 
defect of the tibia, and bat a slight scar upon the skin. This was 
the case of one Wallace, a shipwright, of this town. 
^B No. 1 . — On another occasion, last year, I was called to attend 
^M old gentleman, aged Si, who, while on a visit here from the 
Is!e of Han, had indulged rather too freely in spirits, and on 
leaving a friends' house he had a fall and sustained a compound 
dislocation of the tibia inwards. On my arrival at the house I 
found him slill under the influence of drink, and he commenced 
to swear at me and otherwise misconduct himself, and 
it was with difficulty he could be kept under control. I incised 
the skin, enlarged the wound, replaced the bone, and searched 
for cul-de-sacs or bagging spaces, laid them open, placed 
the limb in an immovable appliance, and instructed the nurse 
simply to wash and oil the wound. There was no suppuration 
and in the ninth week the patient was walking about. 

No. 3.— On another occasion during this year an engine 
driver in the employ of a corporation was just leaving his 
cmiiloymcnl, when, there being a heavy gale at the time, he was 



t89 

thrown down by a gust of wind and sustained a compound fracture 
of the leg. There was no protrusion of bone. I made the 
necessary incisions to obliterate bagging spaces, placed him in 
a permanent immovable apparatus, no dressing being applied, 
and sent him home in a cab. He was placed on the bedroom 
floor where he remained for two hours awaiting my arrival. 
On reaching the house I ordered him to be put to bed, and 
gave instructions that the wound should be simply washed 
and oiled. This case made an excellent recovery, no surgical 
fever or any diflSculty occured. 

No. 4, — A gentleman, living in Denbighshire, whilst riding 
home sustained a compound fracture of humerus by his horse 
jumping into a railway cutting. On the third day after the 
accident I visited him, in conjunction with Dr. Pierce of 
Denbigh. I placed the limb in a permanent fixed appliance. On 
exploration it was found that there was no occasion for incising 
the wound which was treated by simple ablution and oil. The 
treatment resulted in an excellent recovery with no suppuration. 

No. 5. — The case of a young man who had got entangled 
in the hoisting gear of a Warehouse and sustained a compound 
fracture of the humerus, &c. The limb was placed in a 
permanent fixed appliance, explorations were made with a 
probe, and several extensive cul-de-sacs laid open. It was 
treated by the open method ablutions, and oil, and resulted 
in an excellent recovery. 

No. 6. — The case of a Cabman, who, having occasion to 
remove the head gear from his horse, while on the " stand," the 
animal took fright, and in attempting to arrest it, he was thrown 



I atul the cab passed over his foreann, vhich sustained a 
conpoond fractote. The limb vas pat op in a peimanent 
immovable appliance suited to iTich an ioJDTf, the wound 
was explored with a probe pointed knife and all bagging spaces 
obliterated. It was treated b/ the open method and resolted in 
an excellent recoreiy with no sapparatioo. 

No- 7.— The case of a Carter, who, whilst in attendance npon a 
vicious horse was seized by the foreann which was consequently 
much crushed. He was taken to a public charity where amputation 
was decided upon, but his friends objecting to this he was 
afterwards brought to me. I extensively incised his arm so as 
to obliterate all spaces where fiuids might accumulate, put the 
limb into a suitable appliance and it recovered, with no 
suppuration. 

No. 8. — A female, residing in Seacombe Street, having 
occasion to go into a back passage where there was a quantity of 
refuse, and decayed vegetable matter, placed her foot on a portion 
of it and fell, sustaining a compound fracture of the leg. The 
limb was put up in a permanent immovable fracture appliance, 
and as there was no protrusion of bone the wound was explored 
with a bistoury and opened in several directions. I advised simple 
washing and oil. There was no suppuration and the case 
recovered in the tenth week. 

No. 9. — The case of a Railway Porter, from South Wales, 
suffering from a loose cartilage in the knee joint. The joint 
was distended also with synovial fluid. The limb was placed in 
a permanent fixed apparatus, the joint aspirated and the knee kept 



191 

in the appliance for a week, then incised through the skin and 
subcutaneous tissue, and when the bleeding had ceased the 
loose cartilage which was fixed between my two fingers, was cut 
at through the capsule, grasped with forceps, and drawn out. 
The wound was afterwards treated by simple ablution and oil. 
There was no suppuration. No surgical fever, no rise of temper- 
ature and no symptom indicative of the procedure. 

No. 10.— The case of a foreigner in the employ of E. Holt, 
Esq., who consulted me, having a shortening of four inches 
of the right thigh bone, which had been fractured abroad while 
away at sea. Having failed to refracture the bone with the 
aid of two powerful iron wrenches, I decided, assisted by Messrs. 
Parker, Williams & Owens, Surgeons, to sub-cutaneously incise 
the femur with chisel and hammer. An incision was made square 
to the thigh on the outer side, the chisel introduced, and the 
bone which was as thick as an ordinary man*s wrist was cut 
halfway through, and finished by forcible fracture. I then 
introduced my finger into the wound, found a large chip portion 
of bone the size of a thumb, which I removed and then passed 
my finger into the wound again and found one large cul-de-sac 
corresponding no doubt with the splinter which I had removed. 
This I laid open, thus converting the wound into a T shape. 
Extension was kept up steadily for six weeks, during the 
supervision of this case on no occasion was there the slight- 
est elevation of temperature, no suppuration, nor any other 
evidence of surgical interference beyond the local wound. 
This case recovered — without any shortening though it was over 
3 inches short previous to operation. 




for a ipace of fovt iaci«s- This Tono-i was coinptrcalsd br 
the tbigb being fractsced at the same time. This was a 
cofuoltation case, and I advised enlarging the pmnaiT woood 
irbicb oalj admitted the index fieiger ; the gentleman in charge 
coQcnmng with mj Tier, ve enlarged the voond to neailjr 
three inches, tnmed out a qoantitj of dot, placed the lirab in an 
immovable appaiatns with retentive — extension, and tieated the 
lesion bj ablution with water and occasional oiling, tfae patient 
never bad any surgical fever or pain, nor rise of tempeiatoie, 
snppnratlon or any other symptoms indicative of the serions 
nature of the accident. 

No. 13.— Daring May, this year, a yoong girl from the 
countiy, and an inmate of my hospital, had a tamoor removed 
from the neighbourhood of the carotid artery, which involved 



193 

dissection and much in<inipu]ation of the wound, and after the 
removal of the adventitious growth, there remained a gaping- 
wound, into which the fist could have been buried, yet the 
treatment by this open method was not followed by any symp- 
toms indicative of operative interference. 

No. 14. — Being present at the Stanley Hospital, when my 
friend. Dr. J. K. Smith, removed a large tumour from the neck» 
which necessitated the exposure of important blood-vessels, at 
my request, he tried the open method of after- treatment, and 
the operation was not followed by any constitutional sympath- 
etic irritation, indeed the patient was perambulating the wards 
on the second day, wound gaping wide, the flap of which was 
only gradually allowed to come together. 

No. 15.— Sometime during 1876, I was called to one of the 
filthy courts in Vauxhall Road, to see a patient with compound 
fractured leg, a travelling crane having fallen and killed some of 
the workmen and injured this man's leg. This patient had been 
taken to a public charity, and had refused to submit to amputa- 
tion, consequently he had come to what he termed "a Lome,'' 
though it contained only a bed and that was but so in name. I set 
the leg— fixed it in an immovable apparatus, enlarged the wounds^ 
reduced the protruding bones, &c. This was one of the most 
serious fractures of leg ever presented to me for treatment, yet 
with a systematic open method, sympathetic irritation was 
avoided, only a slight degree of suppuration occurring, several 
pieces of bone coming away by exfoliation. Here there was na 
convenience it being a case of surgery under difficulties, with 
viled smells, dirty utensils, filthy rags and sheets on the so-called 



194 

1 and Impure water to vash the wound, but I must admit 
that hix wife was vciy attentive in attending to the 
instructionf given. Inadeqaate as her means were to assist (he 
nirgeon, ^hc ga^~c the open method a fair trial and it 
triumphett, as it must do, under conditions where the antiseptic 
method wonld fail. This case, after the third day was not 
visited more frequently than once a week. By the open method 
m anKkilled assistant, as in this case, if he acts as instructed can 
Bbss veil as a skilled assistant for a lime. 

^' The advocates of the antiseptic method are able 
to assert that with it success is more insured than 
"by the open method ; but hitherto, the open method 
has been in all recorded instances, and probably in 
all cases, only a do-nothing method. To insure 
success by an open method, details of practice 
consistent with certain principles must be observed, 
as immobility, the avoidance of irritation, 
whether in the form of accumulations causing 
■distension, or, pressure fatal to the vitality of the 
part, and lastly frequent ablutions with oiling to keep 
the part clear and free from undue scabbing. 
Immobility both facilitates healing, and is an important 
item in avoiding or diminishing suppuration, again 



I 



195 

distension should be guarded against as it is well known 
that it will lead to suppuration, surgical fever, &c ; 
these may be guarded against by securing an efficient 
drainage. As to the evil of pressure some in the 
profession must have noticed its injurious tendency 
when allowed to act upon parts of abnormal vitality, 
as we see in chronic inflammation of the knee joint 
compression is injurious ; but in my opinion the most 
notable example is to be observed in the practice 
of tenotomy ; however well the subcutaneous operation 
may be performed, three to four days tight bandaging 
afterwards will cause suppuration in the track of the 
knife ; removing the dressing on the second day, and 
re-applying it with less firmness is an infallible 
preventative of suppuration after tenotomy, no matter 
how clumsily the operation has been performed. Here 
we have an example of pressure causing suppuration, 
and under conditions, least likely for It to occur. 
Ablutions and oiling, are very useful in dimin- 
ishing the tendency to scabbing, as neglect In 
attending to them would permit the accumulation 



und, of discharges that might 



or near the 
become botli injurious and offensive. 

To carry out the details of the open method, 
certain surgical appliances are of great assistance. Ali 
the splints I have designed for use in injuries of the 
upper and lower extremity have been constructed 
with the special intention of improving of the 
open method of treatment of wounds, which occur in 
connection with such injuries. 



A REVIEW OF THE PAST AND 

PRESENT TREATMENT OF 

INFLAMED JOINTS. 



** The Other method whereby, in ray opinion, the art of medicine may be 
advanced, turns chiefly upon what follows, viz., that there must be some 
fixed, definite, and consummate mf.thodus medendi, of which the com- 
monweal may have the advantage. By FIXED, DEFINITE, and CONSUMMATE, 
I mean a line of practice which has been based and built upon a sufficient 
number of experiments, and has in that manner been proved competent to 
the cure of this or that disease. I by no means am satisfied with the record 
of a few successful operations, either of the doctor or the drug. I require 
that they be shown to succeed universally, or at least under such and such 
circumstances. For I contend that we ought to be equally sure of overcom- 
ing such and such diseases by satisfying such and such intentions, as we are 
of satisfying those same intentions by the application of such and such sorts 
of remedies ; a matter in which we generally (although not, perhaps, always) 
can succeed. To speak in the way of illustration, we attain our ends when 
we produce stools by senna, or sleep by opium. 

I am far from denying that a physician ought to attend diligently to par- 
ticular cases in respect to the results both of the method and of the remedies 
which he employs in the cure of disease. I grant, too, that he may lay up 
his experiences for use, both in the way of easing his memory and of seizing 
suggestions. By so doing he may gradually increase in medical skill, so 
that eventually, by a long continuance and a frequent repetition of his ex- 
periments, he may lay down and prescribe for himself a METHODUS 
MEDENDI, from which, in the cure of this or that disease, he need not 
deviate a single straw's breadth. 

Nevertheless, the publication of particular observations is, in my 
mind, of no great advantage. Where is the particular importance in just 
telling us that once, twice, or even oftener, this disease has yielded to that 
remedy ? We are overwhelmed as it is, with an infinite abundance of 
vaunted medicaments, and here they add a new one. Now, if I repudiate 
the rest of my formulae, and restrict myself to fhis medicine only, I must 
try its efficacy by innumerable experiments, and I must weigh, in respect to 
both the patient and the practice, innumerable circumstances, before I can 
derive any benefit from such a solitary observation." — Sydenham. 



Since the publication of the first edition of this 
volume on Diseases of the Hip, Knee, and Ankle 
Joints, the subject has engaged the special attention 
of surgeons, and the merits and demerits of various 



198 

methpds have beeo debated more fully Chan before : 
and as one of the geatJemen I dissented from 
expressed the opimon in a communication to 
myself, that my notice of his views and means was 
too limited (which 1 now believe), I therelore deci- 
ded to review more fully than I had hitherto done 
the various methods championed by gentlemen 
whose views are worthy of being well considered. 
One notable feature is prominent in the discussion 
of the last three years, namely, that it has 
principally concerned the treatment of the hip joint 
Why this joint should be referred to as though its 
treatment involved special theoretical principles I 
have failed to perceive : indeed, the press reports 
of lectures and discussions amply confirm my former 
assertion, that those who have devoted special 
attention to the surgery of the articulations are also 
specially wrong in their theories, and. consequently, 
in their practice. The methods advocated in 
and out of the surgical profession, may be sub- 
divided into two classes, namely, those believed 
to be based on scientific principles and pro- 
fessional experience, advocated by surgeons 
trained to practise their profession scientifically, 
and, again, the other methods heralded by un- 
qualified practitioners, who generally claim to 
have arrived at their knovi'Iedge from intuition, or 
accidental experience ; while some even credit them- 
selves with a special mission to relieve mankind. 



199 

In the first class may be included these authors: — 
The Coopers, Ford, Beale, Coulson, Little, Hug- 
man, Wildberger, Bauer, Prince, Harwell, Coote, 
Brodhurst, Taylor, Sayre, and others who have 
insisted upon principles of treatment diametrically 
opposed to those I inculcate. In fact, I find that 
the writers have not attained, or even wished to 
attain, but that all have rather dreaded enforced, 
uninterrupted, and prolonged rest. 

In the second class may be placed the late 
Grosvenor, of Oxford, (flour cure) ; Evan Thomas, 
of Liverpool, (pitch plasters) ; Taylor, of Man- 
chester, (issue peas) ; Hutton, of London, (mani- 
pulation) ; Clucas, (manipulation) ; the Penrith bone 
setter, (manipulation), and a number of others, 
(male and female) whose names I cannot now 
recollect, but whose treatment and its results 
I know too well. To me it seems inexpli- 
cable how educated men'"* can seriously discuss 
evidence not verified by unbiassed witnesses. 
Having had exceptional opporturtities of watching 
the practice of many of these individuals, and having 
seen its results I assert with the utmost confidence 
that there is nothing to debate, and I never yet met 
with one case, relative to which, on my making a 
careful analysis, there remained a single fact worth 

* See Sir James Paget, article on bone setting. Mr. E. R. Bickersteth's 
Address on the recent Progress of Surgery, page ii. Bauer's second edition, 
page 303. 



notify as an addition to surgery. Frequendy 
I have seen cases in which the patient asserted that 
he was cured by so and so, when it was only too 
appareot that he was unconsciously attributing an 
effect to a wrong source. Ignorance of the first 
principles of treatment of this form of inflammation 
is the true explanation of the unwarranted opinion 
of even members of our own profession regarding 
this class and their practice. * 

Before noticing in detail the treatment of 
articular diseases of the lower extremities in vogue 
during the last thirty years, I shall show from 
authors that up to this time all writers of authority 
differ from my views : — 

" One thing, almost esscnlial to the production of aQdorlcsis, is the put 

being kept motionless ; and is M. Sanson we!1 obscr^-es, this condition has 
such influence that il will of itself bring on the changes which wili terminate 
in a joint becoming incapable of resuming its functions, in consequence of 
trae or false anchylosis." (A.scHYLOsrs, Coopek's Dictionary of Sur- 

" In additon to the direct effects of inflammation in the production of an- 
chylosis, a variety of other circumstances facilitate its progress and augment 
its severity. Among these are the long-continued rest of the limb in one 
position." (Little on Anchylosis.) Page z. 

Dr. Prince devotes five pages lo quotations from authors expressiye of 
their opinion on the evils that arise from immobility (so called). 
(Dr. Prince on Deformities, &c.) Page 51-9. 

" On the contrary motion of the joint without pressure is not only not in- 
jurious, but it is highly beneficial." (Taylor on the Mechanical Treat- 
ment OF THE Hip Joint). Page 15. 

• This opinion refers oidy lo the treatment of inflamed joints by 
these unqualified professors ; that some of them may have skilfully treated 
other lesions I am not prepared to deny. 



20I 



it/ 



'Gentlemen, absolute rest of inflamed joints, however beneficial for a time, 
has likewise its therapeutical restriction, and experience teaches that if the 
immobility of healthy articulations is unduly prolonged they will become 
stiff, dry, and even anchylosed by fibrous bands." Bauer Orthopedic 
Lectures, 1864). Page 57. 

**The treatment which prevents either of these contingencies (anchylosis) 
and establishes mobility of the joint, is passive movement, with shampooing 
and pressure." (Harwell). Page 379. 

** Sayre thus teaches : — When this instrument is employed, it is necessary 
that the child should be taken from it very frequently, and have all the joints 
carefully moved, otherwise too long continued rest of the joints may end in 
anchylosis. In moving the diseased joint, care must be taken to hold the 
pelvis, and to make slight extension upon the diseased limb when motion is 
given to the joint. Perfect rest, long continued, even of the diseased joint is 
decidedly injurious, as there is danger of its resulting in anchylosis." 
(American Clinical Lectures). Page 14, 1875. 

At page 157, Sir B. Brodie on Diseases of Joints, 1850, also refers 
to a case which he judged as indicating that long rest would produce 
anchylosis. 

(1568). ** The growing together of the joint surfaces may be produced in 
various ways. It is usually consequent on inflammation of the parts com- 
posing the joints, especially when if long standing and when the joint has 
been long at rest." (Chelius's Surgery). 

** It is also manifest that if permanent anchylosis be the lesult arrived at by 
the surgeon, rest must be a necessary condition for bringing it about." 
(Wharton Hood, page 113.) 

These extracts express the opinions maintained 
by past and contemporary authors, as to the effect of 
prolonged rest of diseased joints. My teaching is 
the reverse of the theory advanced in these quota- 
tions, and it is my conviction that the principles 
inculcated by these my predecessors and contem- 
poraries have been the cause of the minimum 



s anmrfmg tbc creatinent of ankruiar taaam- 
YeC 1 am infonncd constantly that my 
theory aod method of treatntent is ooi original. 
One critic aSrm?d that the appliances have been in 
use sixteen >"cars in America ; another, that they 
have existed "• from time immemorial in this 
countn'": others, ere they had had a day's experience 
of their use. not understanding hov they should be 
nude or applied, commenced to make innovations 
to suit their own defective knowledge. 

Firmly convinced that my theoretical principles 
arc correct, and that the appliances are suited to 
the application of these principles, and that they 
have not been improved in efKcacy by any other 
surgeon up to this date ; and that better, quicker. 
and more useful results are obtained by my method 
than by any other; holding this opinion |at the 
snme time inviting a practical demonstration 
of the contrary), it is not possible for me to be 
tolerant of methods which must be wrong if mine 
are right. To me it appears an anomaly that the sur- 
geon should have to make a choice of theories. 
the principles of treatment should not be left 
to the discretion of the surgeon, but should be 
unalterable. No doubt ere long it will not be a 
qut^siion. " How shall we treat this patient ? Shall 
it be by Bauer's, Barwell's, Sayre's, Taylor's, or 
Thomas's principles ?" The theory must first be 
scttleil, and the mechanics will " right themselves," 



203 

and at no distant time after. It is the desire to 
assist in this settlement that has induced me to 
review those incorrect methods which have been 
received with such acclaim during the last fifteen 
years. I will also attempt to answer the objections, 
advanced since the publication of my view, and also 
point out the mistakes of the crowd of tyros 
who have taken the field and given forth their 
limited experience with the confidence of veterans. 
The writers on this subject are many, but I 
shall notice only those who have influenced the 
practice of surgery in latter years. Some have 
deviated but little from ancient principles and 
practice ; as, for example, ** Dr. Little on the 
Stromeyrian method (tenotomy) in anchylosis ;" 
Brodhurst on ankylosis (a method of tenotomy and 
passive motion), Wildberger (a mere manual of 
so-called orthopraxy). Dr. Louis Bauer, of St. 
Louis, late of New York, on the publication of 
his lectures in 1864, became entitled to priority in 
attempting to improve the mechanical means of 
treatment of inflamed joints. Some of the appli- 
ances were designed by himself, whilst he adopted 
others designed by Dr. Davis, and modified by 
Dr. Sayre. In his writings, the ancient theory of 
rest is taught, as shown by his warning his 
readers of the supposed evil of rest. He, like all his 
predecessors, is ignorant of the one fact upon which 
all treatment should be based, namely, that rest is a 




xpcricncc of those who have practised aspiration 
of this joint. The mechanicaJ appliance designed 
to fix llie knee joint is shown at pages 290-1 and 
Is very inefficient, bcingbut a mere sheet iron gutter. 
In this (latter) edition, Dr. Bauer still adheres to 
the practice of tenotomy and forcible rupture in 
the reduction of deformity of the knee, and there is 
no evidence that he has ever had reduction of 
deformities of this articulation by simple fixation ; 
nay, at page 308, he expresses his doubts of the 
possibility of its being attained, except by tenotomy 
and forcible rupture. Chap, third, first edition, is 
devoted to disease and deformity of die hip joint. 
Deformity of this joint is due, he says : — 

"Chiefly fiuiu the presence of effuied liquid of some kind within Ihejoinl," 
attended milli "peripheral anJ noclumal pains, culminating in Ionic contrac- 
tion of certain muscles and deformities." 

Andatpages5i-2 nocturnal pains are said to arise 
from : — 

Anlagomi.Iic directions of forces, muscles inclining one way, liydraulic forces 
another. 

And in the same paragraph he attributes the in- 
clination of the so-called deformity of the third stage 
to the diminution of distension of the joint, and 
the consequent increased control of the limb from 
muscular action. At page 54 his treatment is pre- 
scribed, and he also reviews that of Sir B. Brodie, 
Bonnet, and Physick, and complains that though 
their treatments were good, yet they "were not 



1 



207 

heeded by the profession." He fails to perceive, why 
the long splint and its modification were set aside, 
namely, that the results gained by the appliances 
of Brodie, Bonnet and Physick were seldom secured 
to the patient both from a dread of prolonged rest and 
from the absence of any means to allow a prolonga- 
tion of the period of repose after the patient was 
removed from bed. At page 54, he insists on the 
importance of rest and " suspension of all locomo- 
tion," and also prescribes the antiquated local 
applications : — 



(< 



By leeches, cold and other appropriate applications." 



But, at page 57, he delivers an eloquent tirade 
against complete prolonged immobility ; and in the 
same page proves his treatment to be sadly defec- 
tive in efficient rest by reporting that : — 

"Nocturnal pain, &c., cannot be relieved by even opiates" or the " wire 
breeches," 

Except aided by powerful extensions ; yet in the 
same page we are told that : — 

"Extension can prevent, but not cure active contractions of the muscles, 
and its indiscreet application will certainly stimulate the disease." 

My observation of the practice of others amply 
bears out this observation, and I can add that those 
cases treated by the addition of or by (continous) ex- 
tension alone do not do so well as when they are 
even left to the method of nature (muscular action). 



Al pagt 59, the D^vis — Taylor — Sayre type of 
applianft' b discussed ; and he reports that : — 

** tlM*«M* (mM Hkd tiliipumiible llw tip iplint ubviously is, its applie- 

tlim ill biff ilmmm i> iwiltuli 111 li in liln il " And only fit in those 

caM*«( "ndpiiW Up&sB^ whitQ the inflannnzljon and le&ei BcLiacs 
■!• wluMii : tBOtadif. alba actiir syapComs hair subsided ; thirdly, s.hii 
ihrcoMncicd nweln hSTE be^n fOFMfaUy ireai«l." 

At page 60, we are informed of the effect of 
extensioa by Sayre's splint. 

"n* anal «AeCt oldcti iW sfUta txtnit-n is the alleviaiion of pain," 

But. he also adds, that the pain may increase by 
its use, and — 

" To peniu in cilnuioa ikhiIi) br to ^tggravate the disensr, " 

In the second column of page 60, he gives his 
opinion that Idiopathic diseases of joints are not 
amenable to mechanical treatmenL 

•■■niat a n'nsJiliili.iii il iliwase is equal!)' unamenable to mechanical 
remedies need no proof." 

With this I cannot agree, as those diseases of 
Idiopathic origin require mechanical aid just as 
much as those of traumatic origin, and those in- 
flammations that occur from malaise are quite as 
frequent as those that arise from injury. 

In the second eiiition of Dr. Bauer's volume, the 
treatment of hip joint disease commences to be 
discussed at page 2S4, and in the first paragraph he 
lays down the rule that more fixation is required 
during the second stage than during the first, and re- 



209 

commends his wire breeches, which extend only to 
the pelvis and lower limbs. This apparatus is in my 
opinion defective, not being of sufficient length 
in the trunk portion, and, consequently, it cannot 
possibly give the joint that amount of immobility 
which it would have done had it been carried up to the 
angle of the scapula. I n the last paragraph, page 285, 
he gives cogent reason against using the pulley 
extension method. At page 287 is to be seen a 
pictorial illustration of his own Portative-Appliance, 
which he extols as able to effect that which Sayre's 
modification of Davis's apparatus cannot. The 
practical difference between the two (Bauer s and 
Sayre's) I fail to perceive, as the arguments he 
advances at page 206 against Sayre's are equally 
applicable to his own invention, which he says also 
resembles the apparatus of Dr. Andrew's, of Chic- 
ago — the ischatic crutch. This similarity does not 
exist in practice ; for Dr. Andrew's instrument can 
be regulated to undoubtedly take the weight of the 
trunk from the hip, though it cannot fix the 
limb ; and as the arrest of friction is of more impor- 
tance than the arrest of pressure. Dr. Andrew's 
appliance is thus very defective. These are 
Dr. Bauer's views regarding the treatment, &c., 
of the hip and knee joints ;- in his first edition 
the general treatment of articular inflammation is 
not discussed ; but in this edition the omission is 
supplied in a chapter specially devoted to its con- 



r 



sideration. Chapter thirteenth is devoted to the 
" Causation of joint disease," in which he attributes, 
to all articular innammation a traumatic origin ; 
and in pronf of this relies (page 238) upon the fact 
that mechanical treatment benefits all cases. That 
the majority of cases arise from traumatic causes 
few will deny, but many cases too plainly indicate 
during the process of the after treatment that 
they are of Idiopathic origin, such have occurred 
in my own practice, where the local lesion has re- 
solved but where the patient has died from a consti- 
tutional fault. 

I fail to perceive what the cause of the disease 
has to do with the mechanical details of treatment, 
neither can I understand how, as Dr. Bauer says, 
it would fail if the disease was of Idiopathic origin. 
Mechanical aid appears the one thing needful 
above all others, whether the difficulty arises from 
rheumatism, prolonged use,''' injury, scrofula, or as 
a sequelae to some zymotic disease. 

• Unusual prolonged use (rriction oi concussion) of a joint will produce 
inflammation of it, and is not a rare occurrence. At p^e 315 of the second 
edition. Dr. Bauer reports a case of friction producing the lesion ; and I was 
consulted during this year by an omnibus driver who attributed the inflam- 
mation (chronic) of his knee joint to the continual (concussion) jar of 
his limb, which he kept on the pedal ol the omnibus break all day. We 
have no reliable evidence of prolonged rest producing inflammation in anchy- 
losis. The Fakirs of India are sometimes referred to as examples ; but I am 
of the belief that they produce stilTness only by prolonged disuse, and as 
they have no desiie to use again the sliffeneii joint, it remains stiff. This 

on tlie iierson's Bill. 



21 I 

Chapter fourteenth is devoted to anatomical 
changes, &c., of inflamed joints, and contains much 
interesting original information. 

Chapter fifteenth contains his views of the "Clini- 
cal character of joint disease;" and when referring to 
the general symptoms of articular inflammation, 
he says — 

** Pain is the most prominent, usually the first to appear, and the last to 
disappear." 

Except in seven traumatic cases, I have always 
noticed that a feeling of weakness was the 
initial symptom and the final one to disappear. 

Pages 250-54 are devoted to the symptoms in 
general, which indicate articular inflammation, and 
here he unfolds a tale of horror and mentions symp- 
toms, showing beyond doubt that in the treatment of 
these difficulties, he has not been able to attain a 
modicum amount of curative rest by his methods 
of fixation. From the first paragraph, page 250, 
it is apparent Dr. Bauer does not think that the 
will of the patient, calling the muscles into action 
to steady the extremity, decides the direction of 
deformity. I cannot endorse his assertion that — 

** In affections of the tibio-larsal and tarsal articulations, the peronei 
muscles are retracted." 

This contraction of the peronei in disease of the 
ankle or foot joints is extremely rare in my 
opinion. Again, he says — 

**In affection of the elbow joints, the biceps, muscles and prpnator-tercs 
'are involved." 



With this I also dissent. It were weff 
were involved. 

At i>iigc 256 the wi!I of the sufferer is admitted 
to sometimes affect the position and mobility of the 
limb, at other times "hydraulic pressure," " osseous 
material," and " muscular contractions." At page 
258 the author very properly says — 

" To speak of & dry poinl in these Bflections a ui absurdit}." 

Chapter sixteenth is devoted to prognosis and 
ireaiment of joints, and commences with a sum- 
mary of symptoms and conditions which, luckily 
for sufferers, do not occur where correct treatment is 
undergone. He also warns (very properly) the 
reader that the primary symptoms are not a reli- 
able barometer of the actual difficulties which the 
surgeon may have eventually to grapple with. At 
page 273 we are informed that the therapeutics 
of joint disease 

" Is infinitely better to day than il was firiy years ago," 

Certainly not in the United States. Their 
theory is ancient though their practice is new, but 
they have omitted what was good in the old prac- 
tice, and held on to that which was bad. At page 
-274 the cause of articular disease is again discussed, 
and Dr. Bauer asserts that they are all of traumatic 
origin, — to myself it would matter little whether 
idiopathic or traumatic. I anticipate, however, few 
among those who have had an extensive field 



213 

observation, will agree with the author that all 
these do arise from injury. In page 275 diagnosis 
is discussed, where all those antiquated signs, which 
are of little value to any except experienced 
practitioners, are enumerated. 

At page 277 the treatment of joints in general 
is laid down. 

** The very first therapeutical axiom in the treatment of joint disease is 
rest, absolute and unconditional ; and the next proper position of the affected 
articulation. The efficacy of the'se two is greater and more reliable than the 
entire antiphlogistic apparatus, and they generally suffice to meet the 
exigencies of the first stage. 

This quotation shows that since the publication 
of Dr. Bauers first edition he has materially 
changed his views, and, in my opinion, has consider- 
ably progressed ; yet, at the end of the second para- 
graph, page 277, it is apparent to me that he still 
prescribes local medication. Again, discussing the 
position of the affected joint, last paragraph, page 
277, he says : — 

"The position of the affected joint should be that in which the patient is 
most comfortable and at rest." 

This, again, is proof of his methods being defec- 
tive in obtaining rest, inasmuch as all positions are 
those of ease, provided a curative degree of fixation 
is secured, but all positions are not such that the 
utmost future use can be obtained. 

At page 278, he says : — 

"Some surgeons advise to give the extremity such an angle as will be 
most conducive to its usefulness." 




i{t»d««(;hi%(t abi«;iu Dm jaacisrs; <wr object b 
fel thai pet^n-: Ih> otas utMam of He jiMiit : xhat 
aMcS It ta pbes w&es A* Jaini is atnot asdirtona^'* 

The policy laid down here is. in my opinion, 
exactly the reverse of the proper method. It is 
in the diseased condition that deformities can 
be corrected quickly, safely and with least pain, and 
he seconds my dissent from the above at page 28a 

" If tlu aS^cEsl oiEi&bcr iaa slindj b?ea placo] in atl'posalioQ, fon 
lure pctiEi|i:l7 in teiiici t!i; same to iasjre utKa!u nf." 

This contradicts the last paragraph in page 
277- Again, at page 281, second paragraph, he 
insists on the necessity for reduction of deformity in 
the inflammatory condition. This latter statement 
again is adircct contradiction of paragraph 278, com- 
mencing with " We have nothing to do, &c.," which 
has bi^tn previously quoted by me. At page 2S2 
the value of extension (continuous) is summarized 
thus : — 

"I.— Eilsnslon cannot part ths in^anjJ art'.c-jlar surfacss, for which it 
has bcfn eiion^ausly de^iTofj by it; author. 

J. — Powerful exl;ns:on is parhipi th; promptisl rimedy against an eph- 
emiral mjsciUi spis;n, a; evsry on; ha; e.tij^rleii^^d hirasilf if hi has 
happsosd to be suJdjnly attackfd by spasm of the musclss ol' the calf ; 
but it cannot b= r;H>d on In p;rsisle:it spastic ajUalions of th: miisclss. 

3. — In m any iastancas extension will not fail to relieve the spasms, but 
will riact unfavourably upon the violenc; of the existing joint disease, if per- 

4, — The divis'.on of the contracted muscle is the surest oad unfailing 



" The most violent periods ia the course of joint disease I have observed 
in consequence of keeping a restricted muscle on (he Etretch." 



215 

I most cordially agree with all he reports against 
the practice of continuous extension in joint inflam- 
mation. At page 296 it is satisfying to note 
that he protests against the application of blister- 
ing or any other derivant to the region of the 
joint 

Chapter fourteenth is devoted to the treatment 
of the sequelae of joint disease, and commences 
with a paragraph which might cause some to doubt 
that Dr. Bauer ever saw a case of genuine resolu- 
tion (secured soundhess). 

The second and third paragraphs in this chapter 
are devoted to the treatment of stiff joints, and mani- 
pulation is commended with passive motion, and 
the lumber, known as emollients, are advised, also 
cold and hot douche, or a visit to Germany. The 
remainder of this chapter is devoted to teaching 
that " Brisement force," combined with myotomy, 
will correct deformities which continued extension 
cannot correct, and his teaching appears to coincide 
with that of our countryman, Mr. Broadhurst, 
the special advocate of tenotomy, " Brisement 
force " and passive motion. My experience will not 
permit me to endorse the opinion of the author as 
regards the purpose of these last three items of 
treatment, viz.. Tenotomy, "Brisement Force," and 
Passive Motion. 

The two first procedures in my opinion are 
very rarely required. I have repeatedly seen 



3l6 

reduction of deformity- b\- simple rctentiaa : 
Oiilure by ■* Bri^Kment force." ihoi^'h this latter was 
emploj-cd while the piticnt was under asther As to 
" passive motioQ," thi& U a phrase, that in this year 
of grace, conveys to my mind no information. 1 
cannot see a place for it in the art of sui^ry. 

Whatever difference of opinion may exist as 
n^ards the treatment of these lesions by the 
methodsadvised in this volume. I havegreat pleasure 
here in acknowledging that surgery is much in- 
debted lo Dr. Bauer for his labours as an innovator 
in the treatment of inflamed joints, and he has given 
courage to others to \'enture on a vo)'age of 
discovery in the treatment of these difliculties. 

Dr. Bauer's labours have been the means of in- 
spiring several surgeons in the United States to 
allempt the improvement of the mechanical treat- 
ment of articular indammation, and among others. 
Dr. C, F. Taylor, of New York, lias appeared as 
an exponent and practitioner of the theory, but 
his method of practice varies Irom that set forth by 
Dr. Bauer. His opinions have been published in 
the"Ni-:w York MEoicAi. Record," Sept. i, 1867, 
and May S, 1875, and in a treatise "On the 
Mechanical Treatment of Diseases of the Hip 
Joint," Ward and Co., New York, 1873. I find 
also lliat tie is patentee to a form of hip appliance,* 



217 

also Surgeon to a Hip Hospital in which establish- 
ment (if there is the same mania for specialities in 
the United States as exists in this country), he has had 
sufficient opportunities to test his speculative views 
as regards hip inflammations. Dr. Taylor s writings* 
contain many clinical observations which I am glad 
to find corroborate my own notes ; and judging 
from his writings, had he simply made deductions 
from clinical observations of cases while treated by 
simple fixation, he would have evolved the same 
theory as myself, but starting with his mind stocked 
with the opinions of" the fathers," together with an 
additional idea that the muscles are at the root of all 
the evils attending hip inflammation, he has made 
his appliances to enable him to apply this idea in 
practice. This he informs us in page 289, vol. li, 
" Medical Record,*' — 



it 



" An apparatus, like a remedy, should be the embodyment of an idea.' 

With this none can dissent if a maximum amount 
of success follows the application in practice of the 
idea, otherwise we are called upon, as the navi- 
gators term it " by sounding," to feel our way to 
correct principles, and try by a method of deduction, 
to gain a correct theory. 

In the commencement of this article (Medical 



* To Dr. Taylor I am indebted for his collected writings, and here ack- 
nowledge his courtesy in sending them to me, and at his request I now 
more fully notice his views. 



2l8 

Record, Sept. i. 1867), Dr. Taylor discusses the 
causes of failure of cure by the use of his appliance, 
which he attributes — 



" To Ihe In eS tkncT cf th» iastrameM employed, and to a pcaclicol dis- 
Kfud of ibe true cod lo be tonstiX bjr its use." 

And he further objects to " elastic extension," and 
condemns Dr. Sayre's appliance, which he claims 
as his own design a model of which he had laid aside 
after using it only once. In last paragraph, page 
289, when referring to the advisability of preventing 
motion at the knee joint in hip inflammation, he 
writes : — 

•■ Piiooiily il is an adTactige when the counter eitension is complete, but 
Dol olhcivriH, lo caose the molina of pit^ression lo be at the hip instnd 
of ihe knee, u it nould be U the lutlei were not coofined- 

The meaning of this quotation is better ex- 
pressed at page 23 in his treatise on the " Mechanical 
Treatment of the Diseases of the Hip Joint." 

" But motion at the knee is a decided disadvantage. It prevents, or at 
least diminishes, motion at the hip joint." 

This is not correct as anyone can observe that 
fixing the knee limits the friction and motion at the 
hip joint, while permitting motion at the knee in- 
creases friction, and allows more action at the hip. 
An anchylosed knee always diminishes the 
extent of the radius of action and friction at the hip. 
At page 290, Dr. Taylor expresses his disbelief 



219 

in the possibility of drawing out the head of the 
bone by extension, and very properly remarks — 

" It would be harmful if it did occur." 

On the same page he expresses his opinions on 
the necessity that — 

** Muscular tonicity must be temporarily destroyed." 

This, to my mind, is inexplicable. I should 
rather say, place the limb at ease, and the muscles 
will be (Jliiescent and remain so until wanted by the 
patient to resume duty. Again, when discussing 
the" supposed destruction of muscular "tonicity," 
we are informed that it may be, and generally is, 
followed by weakness of the muscles about the 
joint, which may require special treatment to restore 
their tonicity. 

" This is a sacrifice we must make to the greater good of arresting the 
diseased action in the joint." 

We have never noticed that atrophy of the muscles 
after the treatment of lesions of joints required 
special attention to induce them to resume their 
functions, for as soon as the articulations are 
sound, they are certain to regain their action 
and power, and the more they are delayed, the more 
certain the surgeon is of securing his resolution 
beyond the possibility of a relapse. 

In the same paragraph v;e are told that — 

** On the other hand, if contractions accompany or follow disease, we may 
be sure our counter extension has basn efficient, and therefore worthless, and 
that the improvement, if any, is due to the quiet fixation of the joint, which 
the splint has been a convenient means of accomplishing, and I suspect this 
is very oftea the case in the use of both splint and pulley." 



When expressing my conviction of the incorrect- 
ness of the treatment of joint infiammation by any 
system of extension, I have always expressed 
myself in the sense contained in the above para- 
graph, that all these injurious methods of treat- 
ment, — namely, those of extension treatment, in- 
volve inseparably in their application, a certain 
amount of "quiet fixation," which is the remedy, 
which benefits the patient despite the extension he 
is too frequently tortured with. 

At page 291, Dr. Taylor reports that he has 
advised a clog under the sound foot, but evidently 
with neither method nor success, as he says — 

"The difficuUr is incairymg the pian inlopraclke ." 

From this it is apparent that since I introduced 

this addition to the treatment of hip affections. Dr. 
Taylor had become acquainted with the method, 
as he informs us that — 

" In<leed manj' have advisfd, as I sometimes have when circumstances 
were such that nothing belter could be done — patients to wear a thick sole 
on the foot of the well leg, and use crutches, letting the lame leg hang. The 
only dilficulty is in cattying the plan into practice, with sufficient persever- 
ance and uniformity.'' 

This article concludes with testimony to the 
injurious tendency of the extension methods. 

"1 have seen several legs irretrievably spoiled by applying the straps on 
t)ie leg only, neglecting to include the thigh, This has been generally done 
vt hen the ttealment had been by the weight and pulley, force enough to 
relax llie ]iowerful muscles aliout the hip joint must be liable to pull asunder 
the wealier ones at the knee and anhle if traction be made only Ironi the 
f,H.tandleg." 



221 

If all this damage can occur from extension 
applied to a sound joint, what may be the amount 
of damage done to an unsound articulation, the 
structural surroundings of which are softened by in- 
flammation ? 

• 

Again, we are informed that — 

** With the best appliances disease of the hip joint is not easy to cure." 

I dissent from this, as the hip joint presents 
no difficulty which does not also present itself 
in diseases of other joints of the lower extremity. 

Dr. Taylor concludes by very properly drawing 
attention to the fact that the treatment of joints is 
not so much a question of splints as of principles. 

"There is no magic in surgical apparatus, let them be ever so cunningly 
devised. They should have a function corresponding to our idea of the re- 
quirements of the case.'* 

In the New York " Medical Record,** issued 
May 8, 1875, is a further exposition of Dr. Taylor's 
views, the paper is entitled, ** On some of the 
elements of Diagnosis of the different stages of 
Diseases of the Hip Joint," and he commences by 
asserting : — 

** The importance of an early and correct diagnosis of disease in the hip 
joint must be apparent to all. But diagnosis implies much more than a 
recognition of existing disease. It embraces, or should embrace, such a 
careful analysis of the existing facts, as to resolve the condition into distinct 
and well-defined elements, which are separately comprehended, and which, 
being correctly interpreted, are the indications to which our tieatment 
ought directly to respond." 



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This ia a dec.;cuoii from Dr. Taylors own 
exiy-riencis : if so. i: is by no means creditable to 
his method. 



223 

Page 323 is principally devoted to the considera- 
tion of the value of flexion as a sign of joint inflam- 
mation, but nowhere does the author give a method 
(beyond the rough one of digital manipulation) by 
which one can measure this flexion which he admits 
always exists from the earliest period, and he con- 
cludes his remarks with an opinion which demon- 
strates beyond doubt that he has not a correct 
appreciation of the value of this very symptom. 
He says: — 

** A very slight injury of the joint, the merest trace of inflammation resulting 
from such injury will cause an immediate response of muscular action, 
which can be appreciated by the examiner for the purpose of diagnosis, still 
while the disease must have advanced to a considerable degree before the 
patient becomes mentally conscious of anything wrong. Of course, I reject 
Etherization as being utterly valueless as a means to assist diagnosis, and am 
simply amazed that it has ever been used for that purpose. To relax the 
muscles is to destroy the most delicate evidence of suspected disease." 

This latter paragraph certainly amazes me, as no 
amount of Etherization would relax joint flexion 
caused by inflammation so long as no violence was 
used. 

Also at page 323 Dr. Taylor gives an illustra- 
tive case of reduction of flexion, when the inflam- 
mation was only of two weeks duration ; yet it 
required six weeks for his method to reduce the 
flexion ; even if the inflammation had existed 
four weeks, my splint, by obtaining mere fixed recli- 
nation, would have succeeded in reducing it in 
one or two days at the utmost. 




Kt page 524 the author enunciates his own views 
as regards the muscular contraction which accom- 
panies and indicates articular lesion. 1 1 is here given 
in extenso, 

"The mialakea ra Jiagnosis arise from confounding as identical iwocondi. 
tions which ue enlirely diSerenl and wholly sepa.[:ible. A condition of so- 
callrd contmcluic is a pennanent shortening of the aiusdes. It is cbaiacter. 
iied bf increased rigidily and diminished contractility. The DiMiniSKED 
CONTKACTILirV and diminished initabilily arc important to be remembered. 

This condition of the muscles may result from various causes. Il if 
ipecially likely to be found afier long disease accompanied with the absence 
of all direct or reRen nervous excilalion to Eiction ; as after librous or bony 
ankylo^ and disuse of the joint. 

But this coodilion of the muscles must not be confounded with not mis- 
taken for the constant, excessive, unrelaxing, tonic contmction, in greater or 
less decree, varied or not with spasm, but always present when there is any 
disease whatever in the joint. The latter may exist so slightly as not to pre- 
vent tha exireraest dexion and extension, or it may exist to such a decree as 
to arrest all motion as completely as true anhyloss ; but it can always be 
JelectciJ when ive have a clear conception of its liislinguishlng characteristics 
In the earliest stages of any injury to the joint, supposing such inju^ to be 
so slight as to produce the least possible inflammatory action, there may be 
a mere stiffening of the muscles, not enough perhaps to prevent motion, but 
always enoj^h, when one is looking for it, for the educated touch to deled 
what I have named A reluctance to relax. It is quite independent of 
the patient's volition, though it often requires careful management to prevent 
the voluntary efforts from mingling with and obscuring this condition, which 
is independent of the will. It is the first feeble involuntary intimation of an 
effort to arrest motion, which, further along, and after the disease have in- 
creased, becomes palpabie enough to the most ordinary observation. It is 
chiefly in the earlier and later stages when mistakes of diagnosis are most 
likely to be made. In the beginning this symptom, being less pronounced, 
may be overlooked ; and later, when it has increased to its greatest degree 
it may be mistaken for contracture or permanent shortening ; and it is also 
often mistaken for ankylosis when it is sufficient to arrest motion. In the 
stage of its higher activity there are two conditions by which muscular con- 
iraction — the increased, constant, tonic contraction here meant — may bedis- 
(inguished from so-called contracture, or the muscular shortening for which 



225 

it is so often mistaken. There is increase of irratibility (independent of 
muscular power), accompanied with what may be called a relaxibility, while 
muscles in a state of contracture or permanent shortening are characterized by 
want of irritability and by inelasticity. The former relaxes on the applica- 
tion of force. The latter stretches by its physical elasticity, or by the rup- 
turing of inelastic fibrous tissue.*' 

Here are defined two abnormal conditions of the 
muscle — one contraction, which relaxes on the appli- 
cation of force; the second where the muscle stretches 
from physical elasticity, or ruptures from inelastic 
tissue. 

Although the writer maintains the existence of 
two characteristic changes in the contracted muscles 
he mentions three — first, relaxing by application of 
force ; second, stretching by its physical elasticity ; 
third, rupturing of inelastic fibrous tissue. 

This classification is not warranted by any clini- 
cal observation given us by the author or any 
other writer on this subject ; and as soon as Dr. 
Taylor has mastered my diagnostic method for 
detecting recovery of inflamed joints, the in- 
correctness of this classification will become appa- 
rent. The conditions he seperately defines are but 
degrees of the same abnormality of the muscles. 

At page 325 is given the history of a case of 
hip joint inflammation which had existed fifteen 
months, and at the time the patient consulted Dr. 
Taylor his joint was evidently in a condition of in- 
flammation ; yet to correct the deformities present, 
the author s splint, with counter-extension was used 



226 

together with weight and pulley as extra tractors. 
This latter item was equal to a pull of fifty pounds ad- 
ded to that of the counter-extension apparatus, which 
equalled in all one hundred and fifty pounds, and 
all this had to be continued uninterruptedly for six 
weeks, whilst simple fixed reclination would have 
succeeded under ten days. I make this assertion, 
basing it on the history given, viz., that the disease 
was active ; this being the easiest, quickest, and 
safest period for reduction of deformity. 

Another case is related at page 325, a perusal of 
which shows a poverty of diagnosis — 

" PecuUoi qualil; of muscular action and the educated touch " 

appear to have been the signs depended upon ; 
and there is mentioned in the history of this case 
rupture of the joint and burrowing of the pus 
dov/n the thigh, which is referred to as^ — 



" Showing how extensive disease of the thigh may depend on previous 
disease of the hip joint ; and, secondly, how the former may go on while the 
latter is recovering". 

This is a misinterpretation of a casualty that 
sometimes occurs in hip inflammation. Dr. Taylor 
has evidently not noticed what others have namely, 
that the hip joint distended with pus after 
rupture, forms a collection external to the joint, 
which collection may travel downwards, and by the 
time it has got below the middle of the thigh 
cease to be connected with the joint. This is not 



- 227 

always the case. This progression of the joint 
contents down the thigh cannot be correctly termed 
disease of the thigh. Page 326, first paragraph, Dr. 
Taylor says — 

**I hope I have been successful in satisfying those who have followed me so 
far, that it is never safe to dismiss a case as cured, no matter what may have 
been the method of treatment employed, merely because the pain has been 
relieved or that there is no hurt in locomotion.'' 

With this opinion and useful hint I quite concur, 
but of what value is it in the absence of some test 
to enable the surgeon to end his treatment. Dr. 
Taylor has here made an omission which cannot 
be explained, except by the supposition that he has 
no method of testing the genuine recurrence of 
soundness. What are here wanted are the signs of 
resolution. At Page 328 the author gives another 
of his clinical deductions, as regards indications of 
treatment, which he says depend — 

** On delicate shades of muscular conditions," "imperceptable amounts 
and qualities of motion." 

If this were correct, none but the experienced 
veteran could treat these cases with any reasonable 
chance of success. 

In a treatise " On the Mechanical Treatment of 
Diseases of the Hip Joint," published in 1873, Dr. 
Taylor further explains his peculiar views and 
mode of treatment. Although this volume is men- 
tioned in the preface as "The completer system of 



Mechanical Treatment-" He evidently does not 
think mechanical treatment applicable to all cases. 

'■ Thtre be cases in which the mechanical (rtatment on accouni of Palho- 
logical conditions, is nol applicable, lei such be left oat of considetatioii. ' 

Knowing of none such myself, it would have 
been instructive to have had this class of cases 
specified. Chapter first contains statistics of cases 
occurring in the New York Orthopaedic Dispen- 
sary and Hospital, and deductions therefrom. 
In chapter second, the cause of hip joint inflamma- 
tion, he attributes to a traumatic origin in the 
majority of instances. And at page 1 2, the crusade 
against muscular action commences, 

"But the muKcular rigidity made necessary to diminish the immediate 
pain and injury of motion, Increases Ihe ultimale damage to the joint, not 
only on account of the steady pressure from the increased muscular action— 
itself sufficient to destroy the vitality of the parts — but every movement and 
the weight sustained are transmitted directly to the joint, because of the 
rigid and inelastic condition of the muscles. So that, on the very first inti- 
mation of a diminished ability to bear pressure — which is the great obstade 
to a spontaneous arrest of any morbid process within the joint — the exigency 
of arresting motion to save the joint from immediate pain, causes the muscles 
to take on a contraction of such a rigid and permanent characlerastobeacsn- 
dition of perpetual wounding of the parts. Their own excessive action as 
well as their inelasticity constitutes a continual source of severest injury. 

Hence, there is established a self-continuing traumatic condition calculated 
to increase and prolong any diseased action once commenced in this joint; 
the more the disease, the more the muscular contraction and rigidity to avoid 
motion, and the greater the pressure on and injury to the affected tissne. 
The purely mechanical force of pressure — that which is due to ihe confine- 
ment of the disease within inelastic walls and Ihe vastly increased muscular 
action which expends its force on already inflamed and sensitive structures- 
is sufficient to'prevenl, one would think, any diseased movement, once ever 
so slightly set up, from term inaling by resolution while the pressure con- 



229 

tinues. But add motion to a diseased and compressed joint, and can 
we wonder at the destructive course disease of the hip-joint ordinarily runs. 

We find, then, from our premises as well as from clinical experience, that 
it is pressure or motion under pressure, which is the destrustive agent in 
disease of the hip-joint. Hence we derive our two prime indications for 
mechanical treatment. 

1st. To relieve the pressure in the joint due to muscular contraction, 
by temporarily destroying the muscular irritability and contractility. 

2nd. To protect the joint from weight and concussion. 

The indication for arresting motion in the joint, which is well met by the 
gypsum bandage and similar expedients, pertains only to a condition of rigid 
muscular contraction, and consequent increased constant pressure in the 
joint. But no such necessity exists after the muscular rigidity has been 
overcome to the degree of entirely removing all pressure within the joint. 

On the contrary, motion in the joint without pressure is not only not 
injurious, but it is highly beneficial. " 

From the last paragraph in this quotation, it is 
apparent that its author, judges motion in an 
inflamed joint to be less injurious than pressure ; as 
to the first portion of this quotation the best 
illustration of its fallacy is to imagine ten cases of 
hip-joint inflammation identical in degree &c., with 
the exception that the muscles controlling the joint, 
in five out of the ten cases are paralyzed. Which 
of the two sets of cases would go to destruction or 
spontaneous resolution first ? If art does not 
interfere I should say that set paralyzed, to the des- 
tructive stage, and that set with muscles unaff*ected 
to resolution first. Had Dr. Taylor given as much 
attention to what he designates ** quiet fixation " as he 
has spent in torturing the muscles, he would at this 
date have held very different ideas, and such that 



2iO 

when embodied in an appliance, would have had a 
most gratifying result, with a saving of much un- 
necessary trouble to him and time and pain to the 
sufferer. Chapter iii commences with a compli- 
mentary reference to Dr. H. G. Davis, who first 
applied counter-extension with locomotion in the 
treatment of hip-joint inflammation (better I say that 
he had never entered the profession,) as far as 
articulations are concerned ; he also refers to Dr. 
Gordon Buck as having introduced " extension and 
counter-extension in fractures for overcoming muscu- 
lar action," this is incorrect as J, H. James Esq., of 
Exeter was the originator, and first practised this 
method, and published it to the profession in July, 
1839, at the Meeting of the British Medical 
Association at Liverpool ; Dr. G. Buck published 
his description &c., in 1867, and on a comparison of 
the two pubhcations, that of J. H. James's is the 
better, and has the more detail, namely — arrange- 
ment to diminish the friction of the limb on the 
couch. 

What is most remarkable to me in the writings 
of Drs. Bauer, Taylor, and Sayre, is their emphatic 
protest against the extension treatment, yet they 
all advise some form of extension — for instance 
in this chapter. 

"The painfulness usual during activity is lessened by Ihe quiel of the 
palieni's posUion, and this is wrongly credited to (he effect of extension ; 



231 

while the muscular contractions are still not overcome, the pressure in 
the joint continues practically the same, and while the surgeon may fancy 
that his patient is being cured by extension and counter-extension, he often 
is really getting only a certain amount of temporary relief from fixation." 

"In careful, experienced hands, the weight and pulley may be made 
a valuable means : as frequently employed by the careless and inexperienced, 
my observations in this country and in Europe satisfy me that it is inferior in 
practical results to the plaster of Paris bandage, which does not seek 
so much and generally accomplishes the anchylosis which it seeks, 
and with the leg in a better position than is generally obtained 
by carelessly employed extension." 



At page 22, the author condemns Dr. Davis s ap- 
appliance, and at page 23, Dr. Sayre's appliance 
meets with the same fate, and on carefully perusing 
chapter iv, which describes the Taylor appliance, I, 
also feel compelled to pass an adverse sentence on 
Dr. Taylor's apparatus, which, as he tells me, was 
made to suit an idea, for after a careful consideration 
of his opinions set fourth in his publications, it is only 
too apparent that his errroneous principles, which his 
appliance represents, makes it unnecessary for me 
to consider the value of the appliances made to 
apply those principles in practice, as to the 
treatment of some of the casualities which com- 
plicate the mechanical treatment Dr. Taylor 
makes but imperfect reference. 

The next gentleman whose advocacy of the 
"American Methods," deserves special notice is Dr. 
L. Say re who is certainly the "great apostle'* of 
this system. Drs. Bauer and Taylor have hitherto 



232 

filled the position of clinical labourers in this 
department while Dr. Sayre has taken the part of 
missionary; indeed his incessant zeal has (much 
t to his credit and honour) induced him to visit other 
• countries to instruct surgeons, in what he judges 
to be a valuable addition to the treatment of 
articular inflammation and orthopedics, and so 
his name has become known among the many in 
connection with the "American Method," this 
combined with the publication last year of his 
I volume on Orthopedic Surgery and Diseases of the 
I Joints has brought him to the front so prominently 
that on the publication of his volume it was re- 
viewed in most of our professional periodicals with 
unqualified approval and in such a manner com- , 
mended, that indicated to me that insufficient 
knowledge on the part of reviewers accounted for 
no dissenting comments. 

*^The first twelve chapters of Dr. L. Sayre's 
volume are devoted to Orthopedics. With the 
practically Orthopedic portion of the volume I note 
no advance on the traditional treatment. It may 
represent the condition of the mechanics of 
this department of surgery in the United States, 
and, if so, It is behind time compared with British 
Orthopedics as I understand it. I exclude the so- 

'Lectures on Orthopedic Suigery and Disease of the Joints, by Dr. 
Louis Savbe, published by Churchcll, London, 1876. 



233 

called orthopraxy which seems to be much in the 
same condition in the new world as in the old. 

The author begins the discussion of articular 
inflammation in lecture xiii, with inflammation of 
the ankle joint, the symptoms of which appear to 
to me, as recorded in pages 156 and 157, to be 
obscure. 

At page 156, the symptoms of sprained ankle 
are enumerated and a method of manipulative 
diagnosis is advised such, that if practised in this 
country, would "stamp" the surgeon in the opinion 
of the patient as been "a novice," and "at sea" in 
the matter; granting that the questionable dis- 
tinctions he makes can be detected, then detection 
is here mere curosity, which injures the sufferer 
and gives no aid to treatment. In page 158 
also is enunciated Dr. Sayre's favourite theory 
" Blood Blister," which, I believe, is a pure 
speculation as no where in his volume does he 
refer to any actual proof supporting this " Blood 
Blister" theory. 

Let us, then, next consider how such disastrous resuhs may be biought 
about. We will take, for example, a simple sprain of the ankle, which is 
very common, and from which all of you, it may be, have suffered. As I 
have already told you, a ** Blood Blister," or extravasation, is first produced. 
Such a " Blood Blister," is considered as insignificant under ordinary circum- 
stances, if it be allowed immediately to heal. If, however, the " Blood 
Blister," is constantly irritated by friction, an ulcer is formed which rapidly 
increases in size, and involves the deeper tissues. 

This, I believe, is exactly the morbid process going on in one of these 
neglected sprained ankles. The small quantity of blood effused behind the 



=34 

■jmovial menitniLDe, oi lielween the cartilage and bone, would be speecU^ 
■IxoiboJ, iTnufKcient lesl were allowed to the part ; but thete tsoaswelliog 
anil iittlo psin, ilmaybc, lo give wamiDg of ihe mischief doce^ indche 
ptlienl doc* not ttop hii usual walks luul exercise. The " Blood Blister," 
becomes inilnted and increucs in size, and finally, onaccouct oflhedii- 
tuibanee praduced, he is obliged to lay by for a short time. 

This "Blood Blister," theory as laid down in this 
quotation, refers to joints in general, and the only 
way to give my grounds as to the incorrectness of 
this teaching is to discuss that which usually takes 
place in sprains of the knee joint in particular, 
(this is the joint that gives us the best field for 
observation and deduction). I will suppose a 
Mr. B. who has (during the hour previous to his 
consulting me) fallen whilst alighting from an 
omnibus while in motion, and twisted and rotated 
inwardly his knee, (this is usually the history of 
knee accidents short of not involving fracture) he 
is able, in a few minutes after the accident, to walk 
a short distance, two to three hundred yards, but 
the joint becomes more painful, distension rapidly 
occurs until at the expiration of an hour the joint 
is acutely painful and extremely distended, the 
history and appearance of the knee induces me to 
introduce, without delay, a No. 3 aspirating needle, 
and to aspirate the articular contents, which, in 
the majority of cases, is fluid blood, and coagulates 
into a firm clot as soon as removed, patient now has 
much relief, and the joint is fixed, he is sent home 



235 

and about the third day the same distension of the 
joint recurs, this is aspirated, and is usually composed 
of bloody serum, a third aspiration is seldom re- 
quired ; how this hemorrhage within the joint occurs 
I am not prepared to say, certainly a blood effusion, 
which equals four fluid ounces, often more, cannot 
come from "behind the synovial membrane," or 
" between cartilage and bone," and be referred to 
as a " Blood Blister." 

With the author's views as to the cause of inter- 
mittent night pain in joint distension, with its evils 
and the unnecessary dread of joint incisions, so well 
stated at page 159, I concur, but with many of his 
details of treatment, pages 160-3, of inflamed or 
sprained ankles, I am obliged to dissent, such as 
"hot water", "elastic compression," " friction with 
the hand," manipulation and friction," all this, "when 
the injury is first received," and, he adds, at the 
conclusion of lecture xiii, 

"could such treatment be faithfully carried out in every case from its earliest 
commencement there would rarely be need of the mechanical appliances and 
surgical interference to be described in our next lecture." 

In my opinion these items of treatment when 
practiced are a " Royal Road " to the so called 
" disease of the joints," the sufferer has to recover 
despite this malpraxis v/hich has been in vogue 
from time out of memory, and which I am glad to 



236 

say surgeons have surely but slowly begun during 
tile last thirty years to lay aside. 

Lecture xiv is devoted to the consideration of 
inllanimation of the ankle and joints composing 
the foot, and the reader is introduced to a new 
appliance which is advised as the best form of 
mechanical aid in the treatment of ankle joint in- 
flammation, and is designed so that it may and can 
take a little of the weight of the body off the ankle, 
and, it is evident from its construction, that it 
effectually arrests motion of this articulation, why 
he should here arrest motion, and not advise its 
limitation but advise the reverse in inflammation 
of the hip-joint I fail to perceive, 

"By the splint I prevent motion which WQuM be the cause of relapse." 

I should do well, I think, to explain to you when motiou is injurious, 
and when it is demanded. 

So long as there is active inflammalion in a joint, motion is injurious, 
and rest absolutely necessary. In the first stages of inflammalion of any 
joint, rest is also imperative, and, in fact, is the essentia] element of the iteat- 
ment ; and, as long as acute pain is produced by pressing the synovial surfaces 
and articular cartilages together, rest must be enjoined ; or, if motion of (he 
joint is requisite, in order to prevent anchylosis, then this motion must be al- 
ways accompanied with extension, in order to relieve this pressure. But, 
when pressure can be borne without pain, and the diiliculty in motion depends 
upon the contraction of tissues around the joint from want of use or from 
deposits, as the result of an antecedent inflammalion, then motion — passive 
motion — applied with discretion, is just as much a part of the treatment as 
rest was in the earlier stage of the disease. 

I hold that neither here or in any other portion 
does Dr. Sayre explain how we are to detect that 



-'o7 



motion is injurious, he certainly informs us under 
what conditions, he would allow the patient to use 
the limb ; (though what he says on this point 
contradicts his teaching in the "American Lectures.") 
I hold that in the case of the ankle joint the 
condition of soundness would be indicated thus ; 
after moderate use there would be increase of power 
to flex the joint, and an equal ability on the part of the 
patient, by the exercise of his will only, to extend 
the joint, and these two motions of the articulation 
should increase, by exercise and by volition, 
not by passive motion, which would give needless 
pain and trouble. The cases of ankle and foot-joint 
disease reported in this volume are to me of no value, 
as with two exceptions, all occurred in patients at 
an early period of life, 3 to 7 years of age ; my 
experience informs me that at this early age the 
sufferer can recover from an extensive destructive 
inflammation of the joints of the foot with very little 
aid from art even despite a method of prolonged 
fallacious treatment beginning by poulticing, with 
linseed, cow-dung, bread, sea tang, oatmeal, marsh 
mallows, and other filth, whose name is " legion." 

In pages 18 1-4, are given details of the mechanical 
treatment of the Tarso-Metatarsal articulations 
which is a mode by extension such as will be 
highly prized by the anti-muscle and extension 
practitioners in America and this country. 



"The patient shonlil ol ooct be placed upon bis back in bed, and ex- 
Inuion made ftom the toei by Blipping an Indian Ju^le on each toe, and 
attaching them to a card fastened in the ceilii^.'" 

Chapter xv is devoted to the anatomy and 
diagnosis of the abnormal conditions of the knee- 
joint ; at pages 186-7, ar'e described the symp- 
toms and mode of diagnosing, acute and chronic 
inflammation of tliis joint. The symptoms 
given as attendant on the acute stage are those 
generally accepted by surgeons, but when he in- 
structs us as to the manner of diagnosing the 
chronic condition he informs his clinic that — 

rtie erosioQ can be veiy easily detected by crowding the atticnlar sur&cea 
together and slightly twisting them upon each other, when the most inteme 
f |nin will be produced." 

This is certainly an injurious degree of manipu- 
lation and might do more harm in ten minutes 
than the surgeon could undo in ten days, and is 
needless if the surgeon has any acquaintance 
practically with his art, as the condition he here 
refers to is such that the unqualified can almost 
detect at sight. 

•J recollect a. teamed professor, when testing the knowledge of his 
students, asking an impertinent fellow what he would do if suddenly called to 
2 case of bleeding from a varicose vein of the leg, this occurring in the public 
street, he answered that he would elevate the limb and tie the patients foot 
to the neatest "dooi knocker," a proceeding quite as reasonable a« the 
Indian Juggle extension treatment. 



239 

In this chapter IS also described a condition of the 
bones comprising the knee-joint, which I have 
never met with and consequently cannot comment 
upon — indeed some of the casualities indicated by 
Dr. Sayre appear from a perusal of the lecture to be 
purely speculative, for in pages 190-3 are given 
supposed pathological explanations of some of the 
symptoms of articular lesion. This is a subject 
I must confess my unwillingnes to debate, holding 
as I do the opinion that the pathology of articular 
lesions requires much correction. Dr. Bauer in 
his writings has furnished the profession with much 
valuable information in the pathological department. 

In lecture xvi, the treatment of the knee-joint 
is laid down and is divided into two-heads, 

*' Treatment for the earlier stages of the disease, and treatment when the 
disease has become so developed that the case requires extension and counter- 
extension operative interference &c." 

For the first stage ''posterior splint,'' "confinement 
to bed" "until recovery is well advanced," "hot or 
cold water" "after a few days have elapsed write 
for a linament" " a liberal amount of hand rubbing 
and passive motion" "firm compression," no wonder 
the author adds, "these cases are slow in recovering" 
this is the treatment when the ligaments alone are 
involved, but when "synovial membrane becomes 
involved" "an active plan of treatment" is sketched. 



This active plan of treatment is appended here in 
extenso, it almost reminds me of John De Vigo 
and the good old times gone by. 

** When ihe mjtaj hoi been toDomtA bf diison into the joint, next lo, 
>L»&liilj tea,Autic cowjiwaaon i» the maal entntnl danenl in the treatmept. 
Placa ll>e palical in bed at once. It aaj be, and quite ptobably will be, 
ni Tf i ij . i> \hr isigontf at rasa, to nuke some loaJ deplelioo bf meani 
«f leeche* or vet atpt before resortiDg lo my measures far the pnqxMe of 
promodof slwKptkii] of Ibe Said. The Dccetut; of local depletion, and its 
inKnoil, will be dedded by the ligor, geneia] health of the patient, and the 
dq;iec of iDBuniiiBtoiy action pteant, u aunifested by increased heat sboat 
the joint, incieasod frequency of pulse, pain, and general constitutional 
dittntbance. Afiet local depletion, hot fomeDlalioDs and elastic compression, 
KCUted eilliei by means of a fine India-rabber bandage, or, still better, by 
the doable India-rabbet bi£ before lefened to'(iee Fig. 131), will be of tlie 
greatest possible service. 

If ahsoTptlon of the fluid does not take plaoe ra{ndly under this tieatmeot, 
coonter-ination may be resorted to by applying blisters above and below the 
joint. Never apptj joat hUMen Erectly ovei the knee-joint, bnl apply than 
abcive the capsular ligamenl. and below Ibe ligamentum pnteH:K. In addition, 
iodine-ointment may be applied over the joint, and covered with 
oiled'sillt. Never use iodine locally in the fonn of tincture, for the reason 
that it is painful, (he alcohol is soon evapoia.ted, thereby leaving the iodine 
as a coaling upon the skin which permits only a very small quantity to be 
absorbed. After the first application, succeeding applications are of no 
service as far as absorption goes ; for they simply facilitate the destruction of 
the cuticle, and until this layer is removed further absorption of the iodine 
cannot take place. The objection to iodine, therefore, in (he form of tincture, 
is that it renders but little service except when its effect as an escharotic is 
desiredl; but, used in the form of an ointment, scarcely any pain is produced, 
no exfoliation of the cuticle follows, and therefore absorption can go on, and 
in this manner the remedy renders continuous service. 

When the acule symptoms have subsided, great benefit may be derived 
by freely shampooing the parts, slightly rubricated with cosmoline, vasolioe, 
or any substance which will permit Ihe hand to glide over the surface Ireely 
without producing loo much irritation to the skin. Friction should be 
applied in this manner with very gr^t freedom for from twenty minutes to 



241 

half-an-hour at each sitting ; and, while one hand is made to do rubbing 
around the joint, the othei hand should rub up and down upon the limb 
above the joint, thereby greatly facilitating the absorption of the efiused 
fluid. If the case does not jrield to this treatment, and the effusion increases 
so as to make tension sufficient to paralyze the absorbent vessels, it may b^ 
necessary to aspirate the joint and remove all the fluid possible. In many 
instances, if only a small quantity of the fluid is removed, the tension upon 
the absorbent vessels will be relieved to such an extent that the remaindei 
may be absorbed by the means already mentioned. This is an application 
of the same principle that governs us in the management of certain cases 
of ascites ; mamely, first, removing a portion of the fluid from the abdomina^ 
cavity in cases where great distention is present, and then resorting to 
diuretics, hydragogue cathartics, etc. , for the removal of the remainder." 

What labour to the Surgeon and annoyance to the 
patient consequent upon pain and delay, is here 
shadowed forth when with an aspirating needle the 
joint can be relieved in a few seconds, ease secured, 
and time economized. Aspiration of joints is evidently 
an unexplored field to Dr. Sayre, for the contents of 
page 197 unmistakably point out dangers and prac- 
tical difficulties which, I say without the slightest 
hesitation, do not exist in practice. In the last 
paragraph of the same page he advises the making 
of a fine incision if the joint contains pus ; this is 
not as conservative item of treatment. I have 
frequently succeeded in making a perfect and rapid 
cure of knee joints distended with pus, by the 
practice of repeated aspirations with efficient 
fixation, that such joints may sometimes have to 
be incised I admit, but aspiration and fixation 
usually succeeds and much shortens the treatment. 



and with vastly less risk than incision. Incisim 
"demier ressort" and an excellent one at times when 
the joint contains verj' old collections of condensed 
pus &c, but this will not occur unless mismanage- 
ment or neglect has extended over at least twelve 
months. At page 199. Dr. Sayre when discussing 
the treatment and the modus operandi of his pro- 
cedure, makes this, to me, extraordinary statement — 

" For ibc ttmloot trill beal bj Lhe Imie the snicularsiirfkces have icsnmed 

Now, tendons are usually only a few days 
healing; surely it is not meant here that they will 
take as long a period as the inflamed joint which 
may take weeks. In the same page commenting 
on Sir Benjamin Brodie the lecturer says ; — 



" In looking over Sir Benjamin Brodie's works, I find he ri 
positive rest, ami that is all. IJut you ni.i)' do this— you may rest the joitit 
in splints — but you do not do all thai is required. Vou may keep the limb 
perfectly sllll, and locked up in every concei\-able way, and yet do not 
overcome the tendency of the muscles to conltact— you do not prevent 
the reflex action." 

Here Dr. Sayre is certainly mistaken, for in page 
i39of Sir Benjamin Brodie's volume on dlseaseof the 
joints, fifth edition, 1850, he will find that the 
extension method (or counter-extension) is advised, 
and details for its practical application are given, 
but I must admit the arrangement would not 
allow of the application of a hundred and fifty 



243 

pounder as Dr. Taylor reports, but this, Dr. Sayre 
says, is not essential, 

** simply enough extension to overcome the reflex contraction of muscles.' 

Sir B. Brodie's mode of applying extension was 
I judge, such as would, if required, permit double 
this amount of traction, but he does not report well 
of it, and the veterans in the medical profession in 
Great Britain, will readily vouch for Brodie^s acute- 
ness of Clinical Observation, and, had there been 
any merit in extension, it would not probably have 
escaped his observation, interested as he was in 
this department. 

On page 200 is a diagram of the Sayre knee ap- 
paratus, and both the drawing and text inform us 
that while it is intended to diminish pressure (take 
it off altogether it cannot) it is also designed to arrest 
friction, although Dr. Sayre is an advocate for 
fricton in other joints while yet in the unsound state. 
On the same page we are informed that, 

"When the joint is filled with liquid acting like a foreign body, as in the 
ankle-joint,' it is advisable to give the patient the benefit of the doubt as 
regards being able to secure absorption, trusting that fixation of the 
joint in such a manner as will relieve the patient of all pain and remove all 
pressure from the diseased surfaces, will diminish the amount of irritative 
fever, and give us the opportunity to build up and invigorate the general 
system, so as to render the absorption of fluid practicable." 

This again shews that its author is a novice in the 
aspiration of joints, "to give the patient the benefit 



of a doubt" here is to delay the aboonnal condili 
and in many cases the delay would be fatal to 
success. 

At page 20t is a pictoiial Ulustnuion of a case of 
tnlLiiticd knee-joint with angular deformit)-, and 
posterior luiution of the he^d of the tibia. On 
page 206 is a like exhibition of the same patient 
after the application of the knee support, and the 
accompanying text is so worded that it may be sup- 
posed that the deformity and luxation had been 
corrected in one hour. Now this was in this case 
impossible, and I base my criticism upon the 
contents of pages 202-4, where details are given of 
a tedious process which the patient must un- 
dergo previous to having the knee splint applied. 
A perusal of pages 202-204 convinces me that 
days, not an hour, would have to elapse before that 
patient could have been exhibited as free from 
deformity. 1 n the preface to this work Dr. 
Sayre informs the reader that it contains — 

"Many eipressions which I would like to change" 

It was Dr. Sayre's duty as a public teacher to 
change anything of the correctness of which he had 
a doubt. 

He continues to discuss treatment in lecture 
xvii, and he advises that — 



245 
And he advises us that : — 

** The instrument must be worn until the joint is well ; until concussion, 
produced by bringing the tibia and femur together, does not cause pain, and 
until pressure over the coronary ligaments is painless. When this can be done, 
you may remove the instrument and commence the passive movements and 
manipulations that are to restore motion to the joint, and complete the cure ** 

Here are given symptoms, supposed to indicate the 
sound state, and that the limb is fit for use, but, 
these are not infallible criteria of the soundness 
of the joint. Again "passive movements and 
manipulations" are not required "to restore motion 
to the joint." The whole of page 208 is devoted to 
the recommendation of manipulative details which 
at pages 209 and 211 he warns his listeners are 
dangerous — 

"There are some cases in which the disease progresses reasonably well 
until passive motion is resorted to, and then there is at once an almost 
constant tendency to new inflammatory action, in consequence of such 
movements, however careful they may be made. 

In these pages also, the success of pretenders 
he professes to divine, and their means he extols. 

At page 210 is introduced an illustration of a 
knee machine made by Mr. Darrach, New Jersey, 
which, from its appearance, might have been taken 
from "Scultetus armamentum." In referring to 
anchylosis of the knee joint, Dr. Sayre strongly 
advises the " straight position," and I have much 
pleasure in seconding his opinion. At page 211a 
series of illustrating cases are given, and, when 




rcLuinff the history of case No. i, he refers to the 
marked relief from pain on extending and counter- 
extending the boneH of the joint. 

"When Dr. Ck-vdan'l look held of hci foot to move her in pix^iljon for 
th« uporalion, she teizcti him bjr the nnn with her teeth, and held on with 
Ihc grip of a tigress, unlil I grasped her lim^ above and belovi the knee, and 
by firm exlepsion and counter-extension, to separate the bones from each 
otiicr, gave her such relief ibnt she let go her hold upon his aim." 

That immediate relief followed Dr. Sayre's 
manipulation I feel confident, as his procedure 
involved in its practice that "quiet fixation" which 
Dr. Taylor points out as inseparable from extension 
and counter-extension. 

Any surgeon who has had moderate experience, 
must have occasion at times to raise from a 
Mclntyre splint a compound fractured leg, for 
the purpose of cleaning beneath the limb, and he 
will admit that the way to do it with least pain, is 
to grasp the ankle and knee of the injured extremity 
and counter-extend it, raising the leg at the same 
time ; but, no surgeon would be so unreasonable as 
to throw away the Mclntyre and take to extension 
only. Extension per se is an evil, and, in serious 
cases, every item must be carefully considered, and 
that method with least defect should come into 
general use. What is the very best method? Clinical 
observation alone, can solve this question. After a 
careful perusal of Dr. Sayre's typical cases of knee- 
joint disease, I fail to note anything specially 



247 

instructive in them. They were treated by the usual 
routine of treatment common among specialists here 
and abroad, viz. : — ** Tenotomy/' ** Brisement force," 
" passive motion," ** manipulation," and " imperfect 
fixation." There was no stated theory, yet they 
all did remarkably well. That Dr. Sayre is not 
usually so successful, I gather from the prominence 
he gives to "exsection or amputation" in this 
lecture. 

In exsection Dr. Sayre is almost without an 
equal; and, as the exponent of a method of treatment 
of joint disease which I hold is a straight way to 
exsection, his opportunities of operating may have 
been many. During twenty years I have been on 
the look out for a case to excise, but have had the 
ill luck not to succeed in securing more than one. 
My last disappointment occurred about two years 
ago when after I had judged a knee which for 
15 years had suffered chronic inflammation with 
suppuration as one fit for exsection, I asked the 
opinion of Mr. Rushton Parker, who differed from 
me on the ground that as no mechanical treatment 
had been tried, it would be well to try it. We did 
so, and the patient did well. Excision is also argued 
in lecture xviii., the mechanical treatment of which 
is "poor indeed." 

In lecture xix., inflammation of the hip-joint 
is expounded, the anatomy, pathology, etiology, and 




24S 

symptoms of the first stage, of this disease are given 
and with Dr. Sayre as with others, the treatment of 
hip-joint intlammation is looked upon as being 
the best test of methods. In my opinion the knee- 
joint is the best field for clinical teaching. 

The discussion of the causation of this complaint, 
and the views held by Dr. Bauer are repeated ; at 
page 234, the symptoms are given of the first stage, 
this is continued in patjes 235-40, where are 
enumerated ver>' many useless and fallacious details. 

He informs me at page 241 thus: — 

" We have thus dwell Upon them at some length, becaiuie many of them 
differ from Ihusc of more advanced stages only in dfjree, coneeqnenllj 
requite only one description ; but more especially because it is in this, Mage 
that tlie diagnosis is most difficult nnd important." 

I hold the diagnosis by a method now at our 
service to be just as easy, in an early, as in a later, 
stage. 

At page 240, a means of manipulative diagnosis 
is prescribed, which, if practised would do more harm 
in five minutes, than could be undone in five months ; 
he also asserts that no one symptom is diagnostic 
of this lesion. 

Referring to the explanation of knee-pain 
symptoms, the author appears to have forgotten 
Dr. Bauer's very conclusive explanation by reference 
to the anatomy of the obdurator nerve, as given in 
his works. 



249 

In the beginning of lecture xx., is an attempt to 
solve the causes of the deformity of the so-called 
second stage of hip inflammation, and all is attributed 
to hyperdistension of the capsule with fluid. That 
this may occur in the dead subject I am willing to 
admit, but I think it does not in the living 
subject, on the contrary the deformity arises from 
muscular action, and this Dr. Sayre partly admits at 
page 244, first paragraph. The first of the author's 
typical cases is given at page 245, and he informs 
me that all the symptoms were aggravated by 
weight and pulley, which had been persevered in for 
ten months at St. Luke's Hospital. 

At page 247 the signs of the third stage are given, 
and the variation of deformity is referred to rupture 
of the capsule. With this I do not concur. A 
rupture of the capsule may take place without the 
variation of deformity supposed to be characteristic 
of the third stage, the variation depends upon the 
fact that another set of muscles are sometimes called 
into action, namely — those that are inserted into 
the Tibia, (hamstrings) Dr. Sayre in a very able 
manner disposes of the ancient theory of dislocation 
of the head of the femur from disease.* 

* My fellow townsman Dr. Macfie Campbell informed me that in one 
case of exsection that he performed at the Northern Hospital after making the 
usual incisions to expose the joint he found the shaft of the femur separated 
from the articular head, the separation had taken place at the neck, the 

articular head he found in the acetabulum, with its vitality unimpaired, 

and the ligamcntum teres intact. 





At p^cs 354-5 the prognosis of this compU 
is indicated, and may be summarized thus — first 
stage, good resuh, second stage doubtful, third stage 
hopeless, and fit for exsection. Referring to 1 
treatment of the second stage he says, that— 

" To decide vku b ;W bes tnabaat dot cxa be jda 
pcaun (kin and fodcBeiU qb iIif pBl of tbe ^ijeon." 

That some knack, genius, or long experience iS 
necessary to treat this or any other stage, is 
ridiculous. In reality nothing more is required than 
consistent principles, and the exercise of common 
sense* in applying those principles to practice. 

I n lecture xxi, treatment — we find that mechanical 
apparatus, for hip-joint disease and their appli- 
cation, are considered. Treatment is divided into 
local, and general, whilst tonics, with oil and 
stimulants, are prescribed, and excellent hygienic 
rules are insisted upon, together with sea bathing 
in warm weather. With this latter remedy, is the 
steel splint taken off ? 

At page 250 he gives his readers another of 
his theories of treatment. I say another, for it may 
be noticed that Dr. Sayre's theory varies according 
to the locality of the disease, the principles he 

•The late Prof. R. Knox the anatomist when instructing hisclass, always 
(jocularly) included this among the special senses, hut also remarked that it 
was this one that was frequently absent in many persons. 



^51 

advises in treating one joint he sets aside when 
treating another, nay, he even varies his theory 
whilst treating the same articulation. 

In this case, then, I have accomplished what ? By my excavation I 
have removed the essential morbid cause ; by the splint I prevent motion, 
which would be a cause of a relapse." Page 167. Ankle. 

" So long as there is active inflammation in a joint, motion is injurious, 
and rest absolutely necessary." Page 169. Ankle. 

'* In all these cases, no matter in how favorable condition the joint may 
be when the instrument is removed, it is necessary for a time to apply some 
kind of apparatus to protect the joint against accidents, such as falls, trippings, 
etc., and also to prevent too free motion of the joint." Page 209. Knee. 

" Again, firm support may be given to the limb, and at the same time 
motion of the joint allowed within the limits of safety, by the use of the 
instrument which I now show you, made by Mr. Darrach, of Orange, 
New Jersey." Page 209. Knee. 

" Motion is much more painful than rest, even when rest is accompanied 
by pressure produced by muscular contraction. Hence the patient, naturally 
choosing the least of two evils." Page 246. Hip. 

"The local treatment which has grown into favor during the past few 
years, but which I have advocated earnestly for the past twenty five years, 
depends upon the necessity of giving absolute rest and freedom firom pressure 
of the parts involved in the disease, without materially interfering with the 
mobility of the joint." Page 259. Hip. 

** Bonnet's method — fixation without extension — for local treatment has 
been the plan abroad. In this country, however, fixation with extension 
has been chiefly employed, and to afford an apparatus that would meet these 
indications, leathern splints, gypsum and starch bandages, and strong wire 
gauze, moulded to fit the limb, have all been employed with more or less 
benefit, but all these plans prevented mobility." Page 259. Hip. 




II nUch ihr influnnutioD is sa rioUnt, uid 
o intcnic, thai absolute resl is requisite 
s tbc Hxed Jressiog alluded to answeis i, most 
Uoder Ibese OKMunituice t emploj miisl coramonly 
(See Fig. 190I Bui motion is ss essential in 
1 besltfaj condititni orf the xlincluie about s joint as light is 
essentia inrelaiiuagmbciJtllf coadiliooartheeTei for Ibe ligaments around a 
joint will becocue CbnveaititacMUNis, 01 even oG&eous, if motion is denied them, 
paiticulaily iT* cbivcic inflammation is going on wjthin (he joint with which 
ihej arc coAtieded. It v^ in Cfmspquence of such accidents occuriog ifl 
several iostaoces that I wss led lo contiive some plan by which eitension 
coatd be muntaioed that would cemove p7e>^re fiom the acetabulum and the 
bead of lb* femur, and al the same lini'.- permit motion ofthe joinl, therebj 
reiaimng the capsukrligameois ill nhcoiihy condition." Page 26a Hip. 



"Il was (lesigaod thai the motions of the jinnls should be free, 'and no 
harm will attend this fledom of motion, unless the joint itself becomes the 
scat of disease ; but on the contrary, testi^t will give rise (0 mt>re or lea 
anchylosis and defonnity." Page 270. Hip. 

"If left lo itseUi the lest which is so essential to the joint is proeored l>y 
the firm muscular ctmtraclion which prevents motion, and this is so perfect, 
in many instances, as lo assume the appearance of genuine bony 
anchylosis." Page 274. Hip. 

" If employed at all, they must be frequently removeii, and passive 
motion employed, else anchylosis, more or less complete, will take place, 
and the last stale of the patient may be worse than the tirsl." Page 274. Hip. 



"The patient should ihen tie secured in some apparatus — the wire cuirass 
(Fig. 169) is most convenient— which will prevent the possibility of 
. motion." Page 277. Hip. 

"This plan is lobe pursued until the more acute symptoms have subsided; 
but as it is a disease chronic in its nature, long confinement in a bed is 
injurious to the general health, and we must, therefore, contrive some 
mechanical appliance which will give extension and counter-extension, at the 
same time admitting motion of the joint while it permits the patient lo lake 
exercise in the opim air." Page 13. American Lecturci. 



253 

" In some cases, where the disease is ver^ acute and the children very 
small, this is best effected by placing them in a wire cuirass ; a modification 
of Bonnet's grand appareil will be found very useful. When this instrument 
is employed, it is necessary that the child should be taken from it very 
frequently, and have all the joints carefully moved, otherwise too long 
continued rest of the joints may end in anchylosis." Page 14. American 
Lectures." 

" Perfect rest, long continued, even of the diseased joint, is decidedly 
injurious, as there is danger of it resulting in anchylosis.*' Page 14. American 
Lectures.'' 

From quotations such as these the reader has to 
evolve a theory of treatment, for the author appears 
to have no method beyond a "rule of thumb"; and 
"the greatest possible skill and judgment" on the 
part of the surgeon are required, if he depends 
on these contradictory principles to guide him. 

Again what can be the meaning of the quotation at 
page 260, Hip ? How can the comparison between 
an inflamed joint, "and a healthy eye," illustrate the 
matter ? There is no similarity of function or state. 
It reminds me of the stupid remarks that ignorant 
and senseless people frequently make to their 
medical attendant. When the patient is prevented 
by disease from leaving bed, they say, " he cannot 
possibly get well if you keep him thus in bed," 
not considering that rising from bed means con- 
valescence. 

Further, what is meant by the following ? 

**It (the appliance) was designed that the motions of the joints should 
be free, and no harm should attend this freedom of motion unless the joint 
itself becomes the seat of disease." 




maed vkcic bo joaat in&m- 

saad OS 
L arc fftraL, sad die iarentor 
C be osed durii^ the 
mi^M,saA3sAema^3mdpJkj7 tfacsbtterbe 
dta^gB^es * hed-aOBammT Al page 268, ifae io- 
fa n tttf ioQ if gTTPi dot Ac a r f fonrc cannot support 
tbe •c^fac erf" the faodij', and cnttcfa e s are adrised as 
xrcBDries. Utt3 Ifaadicaddnsp^cl tmdeis&xxl 
i dta ga e r taogfal tbat his spCnt pceveoted 
' pvcsBHC. bitf if it cannot sustain ihe 
we^ht. it oertainly cannot relieve inlra- 
anicular pressure. 

From tbe bst and foDowii^ pan^Ta{As of page 
269, it is apparent thai Dr. Sa\Te. like Dr. Taylor, 
has not found the value of the simple but very 
important anltice in the mechanical treatment of 
this affection, viz : — locking the knee-joint ; which 
alone, I suspect would, in the treatment of very 
early inflammation of the hif>-joint, give results quite 
equal to those obtained by the use of their own very 
expensive and illusive machines. The treatment is 
continued in lecture xxii; and at page 273, the non- 
mechanical details are discussed, which consist of 
change of air, leeches, ice, mild mercurial internally 
and externally, " energetic antiphlogistic," and 
prc:isure by strapping. In my opinion Dr. Sayre's 



255 

mechanical treatment is a puzzle, the surgeon being 
introduced to so many appliances, all for the hip- 
joint, each of which is very complicated as well as 
very expensive. 

The first stage, he says, can be treated by the 
Sayre or Taylor appliance, but when 

" There is a great deal of tenderness around the joint, and other evidences 
of inflammatory action are present." * 

Then he advises weight and pulley, but 

*' If the patient is uneasy, restless, irritative, and does not bear the 
extension apparatus well," 

it is advised to place him in a wire cuirass, or other 
fixed apparatus. Much as Dr. Sayre has advocated 
the extension treatment, more emphatic testimony 
than he gives here to the superiority of posterior 
fixation, could not possibly be borne. 

The above amounts to this — That if the patient 
cannot tolerate the irritation of extension, then 
give him plenty of fixation and ease his pangs. 

The second stage is also advised to be treated by 
extension to reduce deformity, then the hip appli- 
ance, and the " wire cuirass." Hyper-distension of 
the joint, by accumulated fluid, is to be aspirated, or 
removed by canula. In the performance of this 
operation, we are instructed in the details of a 

* Is there no inflammatory action in the commencement of this lesion ? I 
should say yes. 



2S6 

ore injurious to the patient than the 
n of the accumulated Biud ; in fact a repetition 
two or three tiiDcs of the procedure here counselled 
wo€iid in most cases oecessitate exsection of the 
anicuhtkui. Those accustomed to posterior fixation 
aod to the use of tlie aspirator, know thai the latter 
iDSCniment can be eiiq>lo)~ed with perfect safety, 
and wjdi such littJe pain to the patient that 
anaesthetics aie rightly deemed unnecessar)', 

At page 378, when discussing the treatment of 
die third st^e, the author informs us — 

"I only laBC^ '^^ Naiw ihflil be iiniiiiil t^ mcdiuiic^ uppliancei 
te hn eSo(b to facos abort ikiB ipsauiMioai care, " 

"It h fan Ibtmttk McAo^ hoBCrttt tbn we aie 10 deduce the 
ptincipla tbU are to gD««ra si in ihc^trotiDent (Jdiese cases." 

What is the method of Nature ? She attempts 
to arrest motion, both by muscular action and by 
the deposit of plastic matter around the joint How 
can the Davis method of encouraging motion be 
termed assisting Nature's efforts ? For as soon 
as art slips in witli an efficient method of fixation, 
which includes arrest of motion and pressure, 
Nature takes away her rude mechanics, without 
showing any signs of being offended ! 

At page 208, the description and discussion of 
the mechanical treatment of hip-joint inflammation 



257 

terminates, and it is obvious that Dr. Sayre has 
recourse to several machines, appearing to have 
least faith in his own invention. Then the 
Taylor splint, or if the case does not progress v/ell ; 
the weight and pulley are tried by him, and should 
these means fail to give satisfaction, the "wire 
cuirass" a method of posterior fixation, is, as a 
forlorn hope, pressed into the service. 

And, although the "wire cuirass" is such a 
trustworthy remedy, Dr. Sayre frequently warns 
his readers of the dangers attending it, which 
dangers, I hold, are purely imaginary and originate 
from a theory of treatment which is other than 
correct. Dr. Sayre, I learn from his lectures, 
resorts to the " cuirass " in severe cases only ; but 
had he employed it in the early stages of the 
affection, the grave apprehensions which afterwards 
impel him to the " cuirass," would in all probability 
have been spared him. 

The accompanying cases given as illustrative of 
his treatment of hip-joint inflammation, are cases 
wherein Nature had struggled on to the third stage, 
when Dr. Sayre interfered and corrected the known 
deformities that accompany her method. They do 
not illustrate the correctness of any principle ; and 
he closes his lecture by informing us at the same 
time the operation of exsection may be unnec- 
essary — 




■awi tfau vtit obrtHc Ik 



Evidently Dr. Sajie has but little hope of the 
future successful treatment of cases that have been 
treated by his method in so-called second stage. 

Lecture xxiii is devoted to the history and 
description, with illustrative cases, of exsection of 
the hip-joint This operation, as I have previously 
asserted, is one of which I have not and hope will 
ne%-er have much persona! clinical experience ; 
consequently my opinion of its dangers, success, 
&c., cannot be of value. I have witnessed several 
of these operations in various joints, and seen many 
patients some years after they had been operated 
upon, and from observation 1 am convinced thai 
those cases of joint inflammation which did well 
after exsection, would have done better had they 
been treated by a correct method. I also believe that 
some cases are met with, which a correct method 
may benefit but cannot save : in such cases exsection 
is in vain. I have seen cases in which the patient 
having no store of vitality, the disease com- 
menced with inflammation of ankle-joint, then hip- 
inflammation ; and after the accession of brain, 
kidney, or lung disease, the sufferer succumbed: as 
the Turks would say "his time had come." Correct 



259 

treatment is no warrant that the sufferer must 
recover, but granted that the subject when he 
consults the surgeon, has a fair amount of stamina, 
then, if treated by a correct method, he must recover, 
and does so with the aid of art. But if treated by a 
method based upon erroneous principles Jie recovers, 
which many do and " excellently well,'* then his 
recovery was despite the surgeon's interference. 
This all experienced practioners well know may 
occur. Sydenham wrote as an experienced observer 
when he asked the question — 

What is the particular importance in just telling us that once, twice, or 
even oftener, this disease has yielded to that remedy."? 

A cure does not always commend the reputed 
means. 

While admitting Dr. Sayres undoubted skill 
in the department of hip-joint exsection, it is not 
possible as yet for him or any other surgeon to 
give exsection its real value until a correct theory 
has become more general among surgeons, as the 
treatment both here and on the Continent is some 
times some aid, at other times an obstacle to 
resolution. 

Even among those who have hitherto sanctioned 
and frequently performed hip-joint exsection, dis- 
senters have presented themselves. Not to 
mention others, Mr. Timothy Homes, of London, 



26o 

has given us his views in the Lancet, Nov. 3rd., 
1877. His lecture is a very interesting addition to 
the recorded opinions on this subject, and Dr. 
Sayre's special teaching is therein ably and fully 
discussed. 

In lecture xxvii, the author commences to 
illustrate his views regarding the etiology and 
treatment of anchylosis. A perusal of his volume 
shows us that this is a casuality, the advent of 
which he specially dreads, and this special lecture 
equally shows that when he meets the difficulty he 
has abundant courage to grapple with it. In fact 
his deficiency in the knowledge of his subject, is 
almost compensated for by his untiring zeal In 
correcting. In this lecture we find no informadon 
which 15 not contained In the treatise by Dr. Little, 
and also in the works of other surgeons both past 
and contemporary. 

There are cases reported, from which Dr. Sayre 
deduces special Information, but as they have been 
called In question by so able a clinical observer as 
Dr. Bauer* this Is in my opinion, a very strong 
argument for me to withhold my comments. 

What is meant by anchylosis ? Generally that an 
articulation has been in an unhealthy condition and 

* In the Saint Louis Clinical Record, May, 1877, Dr. Bauer givei a 
very able resume of the hbtory of operation for relief of true anchyloui and 
other matters pertaining to this difficulty. 



26l 

has recovered with permanent or temporary stiff- 
ness. Now, all writers, myself excepted, teach 
that this is the result of rest, and that the more rest, 
the more certain anchylosis, and they so tone their 
teaching as to impress the student that recovery 
with anchylosis is in some way blame-worthy. 

But it should be remembered, that patients 
suffering from other diseases, such for instance as 
smallpox, scarlatina, and diphtheria, recover from 
the disease, though they ever afterwards bear upon 
their persons traces of the malady which afflicted 
them. Yet no sane person ever thinks of blaming 
the medical attendant for the pits and scars which 
his patient presents. Nor should it be otherwise 
with cases of joint-inflammation. Recovery with 
anchylosis will ever and anon occur, but it should 
be the Surgeon s aim to diminish the chance of 
anchylosis remaining, when the inflammation in the 
joint has undergone resolution. 

Now, it is my opinion that permanent stiffness 
too often accompanies cases otherwise cured, 
because of the absence of a correct theory of 
treatment, and of the failure to recognise the 
varieties of anchylosis. 

To succeed in the surgery of joint-inflammation, 
I believe it imperative to recognise at least four 
varieties of anchylosis. 

First — True anchylosis: Bony union of the 



bones comprising the joint, the result of a high 
or erosive degree of inflammation. It may result 
with or without efifictent treatment. 

Second — Fibrous anchylosis : A deposit in, and 
around, the joint capsule, of much plastic organ- 
izable matenal, the result of a high degree of 
inflammation. h nray occur with or without 
efficient aid. 

Third — Latent anchylosis : That is, a condition 
maintained by a fractional degree of inflammation. 
not to be detected by any digital or manipulative 
test, but by use simply, and this condition may 
result cither from ill treatment, or from the want 
of sufficient prolonged treatment by a correct 
metlioti. 

Founh — Simple stiffness : A condition remain- 
ing for a time only, after genuine resolution, 
which will priss away quickly or tediously ; its 
progress being stimulated by the will alone. 

The first form of anchylosis is usually permanent, 
and lest any attack of inflammation should termin- 
ate in this condition, that position, allowing of 
the utmost possible use to the joint in future, 
must be secured at the onset of the treatment. 
Once consolidated however, the joint is not very 
liable to have periodical remissions of tenderness. 

The second form may become permanent even 
when genuine resolution of the articulation has 



263 

been attained, and is liable (though rarely once it 
has become sound), to recurrent inflammatory 
action, such as may not incapacitate the sufferer 
from attending to his duty; but at this point if 
aid from art is not secured, a limb that has been 
cured in a correct position, is very apt to vary from 
that position.* 

The third form of anchylosis is that which most 
puzzles the surgeon,'who, on examining the affected 
joint, detects nothing but stiffness, and therefore 
orders his patient to exercise the articulation. This 
the patient cannot do. A consultation follows, 
the patient is put under the influence of ether, 
passive motion is employed, twists and turns are 
performed, but in vain ; for the patient is unable to 
make any use of his joint, as his adviser would wish. 
It would indeed be as reasonable to attempt to cure 
a fever patient by kicking him out of bed, as to 
benefit joint disease by wriggling at the articulation, 
in fact neither the one method nor the other will 
succeed, until convalescence is well established. 

This form of stiffness can always be demonstrated 
by my method of testing the advent of res- 
olution. At page 2 1 1 of Dr. Sayre s volume, the 

* I have not included in this class of anchylosis contraction of muscles, as 
this may or may not exist with joint stiffness, for cases occur when, after 
division of tendon or tendons, perfect radius of normal action is at once 
secured for the joints. 




IS at a loss 
how to explain it. 

" Tlieic are some cases in which the disease progresses reasonably well 
UDtil passive inovenaents are resorted to, and thea Lbere is alonce anahnost 
coBiUnl tenvlencj to new i<i9ainm>torr action, in consequence of inch 

lis, however caiefulljr Ihey may be miiie." ^ 



Such cases do require to be managed with the 
greatest caution, if this the third form of anchy- 
losis is unknown to the practitioner ; but once 
recognised, it is not without promise in regard to 
final results concerning motion. It is the attendant's 
want of knowledge as to the exact state of the 
articulation, that obviates a successful issue. I find 
that Mr. H. Marsh, has noticed what I call the 
latent form of anchylosis, but has not attributed to 
it any clinical value, nor has he recognised the 
lesson which I hold it teaches us. At page 98, 
British Medical Journal, vol. 11, for 1877, Mr. 
Marsh says — 

"This use of weight at night is a mailer of g^eat importance. If it be 
neglected, you will find in many cases that allhough all active disease has 
ceased, the limb will, in the course of a few months, become flexed upon 
the trunk, so that the child walks more and moie upon his^toe, and with 
more and more lordosis. 

The fourth form of anchylosis is that condition of 
joint stiffness in which Bathers, Rubbers, Sham- 
pooers. Movement curers. Muscle Thumpers, 



265 

Huttonists, Hocxlists, and Galvanists, acquire 
and maintain a reputation for knowledge and 
curative skill. When a case of this class is 
transferred to one of these special practitioners, 
time, and some deceptive ceremony, complete 
the case, which the surgeon has previously 
brought to genuine resolution, yet not to perfect 
use. When the surgeon learns the result, even he 
too frequently from an imperfect knowledge of the 
signs of resolution, at once concludes, that here is 
something "not dreamt of in our philosophy/' 
For example, at page 303 of Dr. Bauer s second 
edition, is given a case of joint disease successfully 
treated by the author, yet from his non-recog- 
nition of the fourth form of anchylosis, a female quack 
with neither knowledge, nor skill, secures the credit 
due to Dr. Bauer; because, if the joint had not been 
already made genuinely sound by Dr. Bauer, 
motion could not have been restored by any 
amount of scrubbing &c., even if all the Huttons 
and Hoods, et id genus omne, since the days of 
Adam, had been engaged in the case. 

Some of my readers may reasonably ask : — 
Will no amount of rest stiffen a joint where 
ther eh as been none, or only a slight degree, of 
inflammation ? For all practical purposes, I say 
certainly not. No surgeon need fear to err from 
over caution. W. J. Little, M. D., the founder of 



266 

apartment of surgery in England, at p 
ill his volume on anchylosis, gives (though in 
his published views he dissents from myself) mqst 
important evidence corroborating it. ^H 

" We SIC credibly informed, Ihat ia India religious devotees, *ilef 
Ivtmly yeait' duiation of voluntary contortion of the limbs, aie lestoied to 
synimeliy end activity by the eneigclic manipulations of the native medical 
pnuttitionen. ll appears not improbable, thatagreaternaturaJlooieiiessof 
ihe uticulatioTu in the inhabitants of warm climates, and some influence 
exertiied by an elevated temperBloie, in rela^ng the contracted tissues, 
mty favcnii this remit of oriental sltill and perseverance ; but the practitioner 
who would expect similar good forlune in out climate would be 
■llsappointed." 

Here we are informed that after "twenty years 
duration of voluntary contortion of the limbs" 
motion is restored by treatment and favourable 
conditions of climate. But Dr. Little, ignores the 
very evident factors which render the restoration 
of motion possible, viz : first — A joint which though 
stiff is perfectly sound, and second — a change of 
ideas on the part of the patient who has become 
willing to exercise his joint and tries his utmost 
to do so. The joint being sound, his endeavours are 
successful and motion is restored — This is the 
explanation of the result, not manipulation, unctions 
or warm climates. 

Dr. Sayre's work is entitled " Orthopedic Surgery 
and Diseases of the Joints," yet it is confined ex- 



26; 

clusively to the joints of the lower extremity, 
with their treatment by the Davis mechanical 
method, together with additional novelties taught 
by Dr. Bauer. Indeed the book reads like an 
elaborated copy of Bauer s second edition. I fail 
to note in the treatment of the inflamed articula- 
tions any originality that can be traced to Dr. 
Sayre. Even the Sayre splint Dr. Taylor lays 
claim to. Neither have I noticed any new truths 
in the work, in fact nothing but the reiteration of the 
ancient doctrine, dread of prolonged rest, with ap- 
pliances so constructed as to enable the surgeon 
to carry this doctrine into practice. 

The fact of their being adapted to the require- 
ments of this ancient and well known doctrine, ac- 
counts for the popularityof Sayre's splints. Although 
the recorded teaching of a professor of surgery 
Dr. Sayres book contains more contradictions, 
and errors, than any treatise yet published on this 
subject. Dr. Sayre has christened his method 
the "American method:" it has been extensively 
used in this country and, from personal experience 
I can confidently assert its utter failure. 

It has been said by our transatlantic friends that 
their method has not been well tried by us. The 
profession can judge for themselves, by consulting 
Mr. Howard Marsh's interesting paper, published 
in the British Medical Journal, page 20, 1877. 



258 

We appear from his evidence to have carried out 
the details of the extension method with more care 
than even its originators: this can be seen by refer- 
ence to the illustration, in the British Medical 
Journal, fig. lO, page 98. Extension is so ap- 
plied that it almost reminds me of the " Charge of 
the Light Brigade " Extension to right, above, 
below; splint to the right and left and, a hard mat- 
tress underneath ; in fact the patient like a warrior 
of old is encased in mechanism, all of which is in 
my opinion ridiculous. Mr Marsh reports well of 
this extension for reducing deformity— but we know 
that the patient need only remain in a supine 
position with the knee stiffened, when reduction 
must take place, even if no appliance is worn. 

Concerning the supposed merits of the Davis, 
Taylor and Sayre form of Portative splint, Mr. 
Marsh shews so conclusively its defects, that I 
have reproduced that portion of his lecture; at 
page 99 he says — 



" The lime al my disposal does not allow me to do more than thus very 
briefly to describe the principle of Ihese instruments and the method of 
their construction ; and in so short a notice it is not possible to do them 
justice. But you may find a fill] account of them in Professor's Sayre's 
recently published Lectures on Orthopofdic Surgery, (Churchill, London), 
or in Dr. Taylor's essay on the treatment of Disease of the Hip-Joint, 
(New York). The object al wbicb they aim is undoubtedly most important, 
and they are constructed with great mechanical skill ; yet I confess 1 have 
found it extremely difficult to obtain satisfactory results by their use. I 



269 

suppose the greatest amount to which the suiface of the head of the femur 
can be separated from that of the acetabulum cannot be more than about the 
tenth of an inch. And it is very difficult to preserve efficient extension and 
counter-extension within this range ; for the parts cannot be acted upon as 
if they were parallel metal plates to be adjusted by a screw ; they must be 
controlled through the agency of perineal bands and strapping fixed upon 
the skin, and all these are apt to give when they are subjected to constant 
traction ; and, if they yield, though it be but slightly, they soon, in the 
aggregate, lose this tenth of an inch of extension which they should maintain, 
and then the articular surfaces come again into firm contact. Besides, I 
may refer to what has seemed another difficulty. Both Dr. Sayre and Dr. 
Taylor allow to move the thigh upon the trunk by bringing it towards flexion, 
and it has always appeared to me that, if the perineal band be adjusted, 
according to their direction, when the limb is extended, it will become 
loose when the limb is flexed. However, I have not had the good fortune 
to see Dr. Taylor carry out his treatment (though I once saw Professor 
Sayre apply his splint to a patient in the hospital) ; but the results 
published both by him and Professor Sayre are very striking, and are such 
as all may envy. Still, I cannot help thinking that, with either instrument, 
extension and counter-extension can only be maintained by such an amount 
of incessant watching as cannot be secured in the usual course of practice ; 
for, so far as I have observed, the perineal band requires readjustment — 
when the child is up and about — several times in an hour, and it always 
grows loose in the course of the night. Again, perineal bands must always 
be very troublesome appliances in young children, especially in girls." 

Mr. Marsh is of opinion that the results pub- 
lished by Drs. Taylor and Sayre "are very 
striking and such as all may envy." For many 
years I was a witness of the treatment of joint 
disease, by methods sometimes purely expectant, 
at other times consisting of fractional fixation, and 
the results in some instances were certainly so 
striking as to excite my envy. But these very 
cases I now know would have recovered, some 




I but imperfect 
I my admiration, 
terminating the 
atcellent recovery 
g. what is wanted is 
If Ac past writers and 
xaic coosulted, do they not 
tei IB iktt Dr. A. ewcd many cases by mercur)-, 
B liy caMber, C bjr leeches, D by repeated blisters, 
E by fbaa^ F by hadts. &c ? M^ny practition- 
ers bad a »o ad eifal run of apparent successes — 
bat it vas ^aai by a pftxess of "natural selec- 
tkn~. Dr. A. Ibc inssaoce favoured by circum- 
daacesbooasuliod by ahundred sufferers, and ten of 
these, even with taethcient treatment get well, the 
ninety receive no benefit, and the diseases of these 
noa-successful cases being charitably attributed to a 
faul'.v cons'.itu'.inn. p.re re yarded by all as hopeless. 
and become neglected. Dr A, now having gained 
a reputation for skill is consulted by patients from 
distant parts, who, of course, suffer from but a 
slight degree of inflammation and therefore do well. 
Extreme cases could not be transported, owing to 
the want of efficient fixation to ease their pains, 
during the journey. 

Mr. W. Adams, of London, has become a con- 
vert to the treatment of hip-joint disease by exten- 
sion with or without motion. He delivered an 



271 

address on this subject to the Manchester meeting 
of the British Medical Association, which is pub- 
lished in their Journal, Jan. 5th, 1878. 

''On the treatment of hip-joint disease by extension with motion, as 
practised by the American Surgeons, instead of long continued rest and 
immobility. " 

This (extension with motion) Mr. Adams refers 
to in the first paragraph as — 

" The recent advances which have been made in the treatment of hip 
joint disease by the American Surgeons." 

"The first principle is that of extension, as a means of relieving the 
most acute pain in joint-diseases, especially applicable to the knee and 
hip-joints. 

The second principle, is that of extension combined with motion during 
the progress of disease, the patient being allowed to walk about, so as to 
promote recovery with free motion in the joint, instead of the ordinary 
result of ankylosis obtained by long-continued rest and immobility. 

There can be no doubt that the discovery and practicable application 
of these two principles have completely revolutionised the treatment of joint 
diseases, and changed our opinion with regard to the pathological condition, 
existing, especially as to the production of acute pain which, formerly was 
believed to depend upon acute inflammation, requiring active local, as well 
as general antiphlogistic treatment, such as leeches, blisters, calomel and 
opium, etc. It has now been proved to depend upon undue articular 
pressure and contact of inflamed surfaces, produced by reflex muscular 
contraction, and capable of relief by mechanical means alone, producing 
extension, whether this be applied by means of the weight and pulley, or 
by the screw and cogwheel. 

The object of extension is not, as generally supposed, to separate articular 
surfaces, but to overcome reflex muscular contraction, and, by relaxing the 
muscular rigidity, to prevent undue pressure of inflamed articular surfaces 
or their margins, when the joint is held in a flexed position by muscular 
contraction." 



Prom these quolalions it is evident that iff. 
Adams has '■ thrown overboard" the "rest and 
immobility" of our predecessors. Indeed sur- 
geons from want of confidence in, and means to 
attain, rest and immobiUty, have utterly failed to 
perceive their value. Notwithstanding this, 1 hold 
that our forefathers were on the right path to a 
correct treatment of diseased articulations, and 
that this so-called "American method" Is a stray 
path. 

Paragraphs 6, 7, 8, 9, and 10, are devoted to a 
short history of the extension method, and in par- 
agraphs II, 12, and 13, we are told that — 

" The English icka has always been test and immoUilily lo (he joinl. 
The American idea, dioins die Ia«t tea •/teat, has baes -extaBmoD inik 
inollun. r'.^., preserving motion in the joint whilst the pain is relieved bj 



In the tieatment according to the English system, itnmobility of the 
joint is obtained by various mstrnments and splints ; from that piece of 
surgical antiquity, the long straight splint, reaching from the axilla to the 
foot, necessitating the confinement of the patient in the horizontal position 
for many months, and many other contrivances, such as metal and leather 
splints to the joint, which permit the patient to move about on crutches, to 
the now fashionable Thomas's splint, invented by Mr. Tnomas of Liverpool, 
and described in his recently published noik. 

All these means succeed, more or less, in relieving pain and promoting 
recoveiy, although ankylosis is frequently pi-oilucd, and this has gener.illy 
been regarded as the most desirable termination ; but in many cases they 
all fail in relieving pain, for want of the American extension principle, and 
also they do not prevent the occurrence of dislocation or partial dislocation 
the effect of which is to produce shortening of the limb with permanent 



There appears one special topic about which 
the American surgeons are unanimous ; it is, that to 
one of their countrymen is due the credit of having 
introduced to our profession the uninterrupted 
method of extension. Among them I notice with 
astonishment that Professor Hamilton, who should 
be well informed in the history of extension, wrote 
to the Philadelphia Times, Nov. 24th, 1877, as- 
cribing the invention to an United States surgeon. 
The credit of the invention is due to the late J. H. 
James, of Exeter, who described the details far 
more completely than did Messrs. Josse, Crosby, 
Buck, Davis, or any of his followers. *At the time 
that Mr. James published details of his treatment 
of fractures of the thigh by continuous extension, 
so great an authority, as the late Professor 
Syme, asserted that Hildanus had also practised 
the method ; this however is not the fact. Those 
who consult John BelFs famous volume on His- 
torical Surgery can there see figured **The Jack 
Stone of Hildanus." John Bell surmised that cer- 
tain illustrations in Hildanus's work represented a 
strap and buckle, two hooks, and a rope,to which 
was attached, he thought, a stone. In reality, this 
supposed stone is only an ingenious method in- 
vented by Hildanus to cover the pulley blocks of 
his apparatus, which he only used for the purpose 

* See his address in surgery delivered at Liverpool, July 24th, 1839. 



of reducing dislocaUons and fractures. His illffi 
iratton certainly looks very like a stone. 

There is nothing in the text to warrant John 
Bell's descripUMi of the "jack stone," which 
indeed is but an invention of the great historian. 
The mistake can only be accounted for by sup- 
posing that Beil simply gazed at the illustrations 
and never read the explanatory text, A method of 
retention was well known to surgeons at a very 
early date, but must have been difficult to bear 
and far from satisfactory in its results, for at page 
132, book ii, chap. viii. paragraph 8, Heister's 
surgery. 1745, we are informed that — 



n tlul would keep the fracraied ibigb p[op«il]r 
entendcd, lod of iht ume leiifth with tlie sound one, fat alHKjL fouitcen 

ttayj. or till the case w»j perfect, we could go on iritti mote certainty »ad 

J. H. James's method of continuous extension 
was original, and 1 do not believe that he had 
any suggestion from the published opinions of his 
predecessors, 

I cannot help protesting against Mr. Adams' 
contemptuous reference to the long straight splint. 
In my opinion it has been a very simple and useful 
appliance for many lesions of the lower extremity, 
and if well applied, can do more for hip-disease 
than any one of the complicated American impor- 
tations that have supplanted it in the practice of 



275 

many surgeons. Apropos of Mr. Adams remark 
" the now somewhat fashionable Thomas splint," it 
exactly expresses my opinion, as most of my splints 
which have been supplied to the profession are 
more ornamental than useful, and are practically 
worthless, becasuse of the impossibility of correctly 
applying them. 

In paragraph 14, Dr. Adams gives an isolated 
case illustrative of the defects of " Thomas splint,** 
and although Dr. Sayre confirms the opinion of 
Dr. Adams, it cannot but be apparent to any 
observant and experienced surgeon that the case 
in question illustrates neither the merits nor faults 
of any method. The case is denominated one of 
" slight flexion. What evidence have we that the 
shortening, which was apparent after reduction of 
flexion, did not already exist whilst the limb was 
in a flexed position ? A state which makes the 
detection of luxation (unless it be extreme) most 
difficult. 

Again we are informed that nine weeks after the 
application of my appliance there was ** the occur- 
rence of pain,** and that this was relieved by the 
addition of extension. Now the explanation of 
this may be that the joint was on the eve of 
rupture — a statement warranted by the interval of 
ease — and whether extension had been applied or 
not ease must inevitably have followed. In fact, 



27b- 

the reported case gives some details of the natural 
course of hip disease, and these are erroneously 
attributed to peculiarities of treatment. Those who 
desire to apply an injurious detail of treatment 
viz. — extension, to my appliance, can do so by 
applying straps to the thigh, and connecting them 
to the lower cross bars, then casting off the 
shoulder braces. 

I notice in Dr. Adams paper on extension, the 
fault that pervades all the writings of the exten- 
sionists ; they praise it here, and warn us of its 
evils somewhere else, 

Mr, Adams, I notice, does not confine himself to 
extension, but at times advocates immobility; 
he says — 



" I ajvise ihe palient u> walk aboul with tlie assistance of crutches, 
WEiiriii^ al the 5[inie time a firm leather splint moulded to the hip^ reaching 
from the waist to the knee, this secures rest and immobility of the joint." 

Despite this, at paragraph 1 7, Mr. Adams affirms 
rest and immobility to be factors in the production 
of anchylosis ! In fact it is an utter impossibility 
to find out from the writings of the so-called 
extension gentlemen, what they mean by extension; 
sometimes it is uninterrupted, sometimes continuous 
{as the weight and pulley,) or again it may be a 
method of retention — as the Taylor and Sayre 
machines shew. Again Sayre's method of treating 



wrist joints is a plan of retention. In hip joint 
disease again he advises a combination of fixation 
and retention, (wire cuirass). In spinal disease 
he advises temporary extension and permanent 
fixation. 

" My own experience in the use of these instruments i6 very limited; but 
during my visit to America last year, I had the opportunity of seeing them 
applied in a large number of cases, and as it appeared to me with great 
advantage. In one case, that of a young lady, who was residing in Dr. 
Taylor's private establishment in New York, where patients are received for 
the treatment of various deformities, the hip-joint disease appeared to be in 
a more active stage, judging from the pain she suffered, than I should have 
thought the walking instrument could have been applicable still, when the 
extending force was applied pretty nearly to its full extent by Dr. Taylor, she 
was etiabled to walk without pain, and therefore it seemed to be a test-case 
of the value of extension. Children with hip-joint disease in a more chronic 
form are frequently seen walking about the streets of New York wearing 
these supports, and are enabled to get in and out of the tramway-cars 
without difficulty. 

Mr. Adams* experience of Dr. Taylor s practice 
derived from observation during his visit to 
America, strongly recalls to my memory what I 
observed some twenty years ago in the practice of 
another person, who also had a reputation for skill 
in the treatment of joint disease. Many cases have 
I observed enter the consultant's surgery, lame 
and in pain, who after being well fitted with 
several layers of stiff adhesive paper plaster, over, 
and around, the affected articulation, left the 
surgery less lame, and in less pain ; sometimes 
without even any pain. A great number of these 
patients having repeated their visits from week to 



27S 

week recovered, and even to lliis day, I frequent 
meet them in the streets of this town, per- 
manently sound. This is the history of some ; 
others indeed had a very different termination. 
And if we read the writings of the extensionists, 
it is only too evident that their experience coin- 
cides with the above. Indeed they plainly say: 
that some patients recover with but slight assistance 
such as, the Taylor and Sayre appliances ; that 
other and more severe cases require more efficient 
means. If this is so I ask, why not try the very 
best means at first .'' By so doing, after regrets 
may be avoided, for none can predict with certainty, 
at the commencement of the difficulty, whether 
it will at once progress to resolution, or retrograde 
to a stage which involves a cure with defects. 

There are certain qualifications that are of assis- 
tance, in enabling the surgeon to weigh the pros 
and cons advanced on behalf of methods, they are 
I St. observation of cases not treated, 2nd. obser- 
vations of those aided by slight treatment, 3rd. 
observation of cases treated by the supposed most 
efficient aid. Practitioners of any of these three 
varieties, can refer to cases of recovery at times, 
while it must be admitted, that the most correct 
treatment must fail in a certain sum of cases. 
We know that there is no disease, however trivial 
but has attached to it a "death register." 



2/9 

In the February copy of the London Medical 
Record, there is introduced to the notice of 
surgeons another eccentric theory said to be ap- 
plicable to injured joints. This doctrine is embodied 
in the words *' compression, motion, use." * 

* Compression is a mode of practice frequently resorted to in the 
treatment of diseased joints under the misapprehension that pressure is a 
means conducive to resolution. In estimating its position in the treatment 
of these difficulties we must take into consideration the fact, that its practical 
application (like continuous extension) involves an unavoidable amount of 
"quiet fixation." This ** quiet fixation" is the actual remedy which in 
mild cases may be enough to complete resolution. But pressure per se in 
any form (like friction) would thwart recovery. Indeed advanced cases 
notably will not tolerate the slight degree of pressure necessarily induced 
by the method of compression frequently practised in surgery. That which 
is meant by ** compression" in the surgery of articulations is-a combination of 
fixation (itself a remedy) which fixation is inevitable, in the application of press- 
ure (itself an evil. ) We have an example in Scott's dressing. It is my opinion, 
based upon experience, that compression — even when combined with efficient 
fixation, if used in the advanced stages of articular disease— is a hindrance to 
resolution. In my practice, therefore, for some years back, I have carefully 
avoided applying any form of fixation which involves the least pressure on 
the inflamed joint. The sound parts of the limb are alone used as points 
for securing fixation, and the unsound joint is not to be interfered with. In 
fact, motion, concussion, and unnecessary manipulation must be avoided. 
A case, which came under my notice recently, demonstrates the evil of 
treatment by pressure. The case is already referred to in the foot note, 
at 2IO of this volume ; the patient, an omnibus driver, consulted mesuflfer- 
ing from slight inflammation of the knee joint, caused by the continual jar 
of the pedal of the omnibus break. As he could not ascend to his *' box" 
on the omnibus with any of my appliances attached to his limb, I treated 
thekneeby a method, of slight fixation, withsome benefit, but I perceived that 
he must abstain from his avocation, and undergo treatment by absolute 
fixation. I advised him to that end ; but as he had no means of maintain- 
ing himself, he became the inmate of a l^ublic Charity, when he was treated 
first, by simple pressure in the form of a bagful of lead •* shots;" then a 



28o 

The " American " — or rather I should say the 
Sayrc — method would have us believe in the pos- 
sibility of motion without friction. This last theor}- 
introduced by Dr. Pilcher. is based on the supposi- 
tion that motion can occur without friction and 
pressure without force. It has been dubbed the 
" Hood method ;" the name is sufficient comment 
when I recollect that even the "elect" have been 
led astray. 

My own inventions for the treatment of in- 
flammed articulations of the lower extremities, have 
now been used for only a short time by surgeons 
generally, yet most of the machines have been what 
I would designate modifications ; modified indeed 
to suit what are in my own opinion incorrect theories 
of treatment held by these several innovators. 

Plate 25, fig. I to 9, represents models of these 
innovations with their modes of application as 
observed in practice at a number of public 
institutions both metropoHtan and provincial. 

Fig. 1, is a hip appliance with two trunk cross 
bars, showing that the surgeon had some difficulty 
in getting the appliance to remain uninterruptedly 
posterior to the body. He argues that if one 
cross-bar is an assistance, two are doubly 



conllniulion or press 


ire nn.l fisatif 


n known 


as "Scott's Dressing;" and 


List of oil, )h.il vene 


-il«l lillh kro 


wr as lir 


see.1 pontlice. with Ihc result 


tliat the knee vlo,-, so 


n rtfui) foi e^ 


ci'ii.jn. 





28l 

so. He is wanting however in that experience 
which informs one that this second bar is most 
irksome to wear. Fig. 2, is also a modification, 
introduced by one who must have been unable to 
fix the hip splint posterior to the trunk. He has 
consequently added a foot piece ; thus making the 
most injurious modification of all I have noticed, as 
the splint, instead of being fitted to remain in 
correct position, is thus attached to the limb which 
it rotates inwards, causing increased articular 
pressure which, should the shoulder braces slacken 
results in traction also. Figs, i and 2, are indicative 
of ignorance in the method of fitting. 

Fig. 9, is a sketch of a splint where the trunk 
portion of the stem is too long, and the chest band 
unnecessarily wide. The maker supposed it would 
be easier to wear, but it is not. I have seen 
several modifications of my appliances that are 
not figured on plate 25. Some had the cross bars of 
the thigh and leg portion made to encircle the limb, 
opening and closing with a hinge, a modifica- 
tion rarely of use as it does not admit of 
modelling with the wrenches. Such a modification 
is figured at page 129, British Medical Journal, 
Aug. 4th, 1877. This model is notable, as it has 
many defects, amongst which are — first : — incorrect 
shape of upper cross bars — second — two mistakes 
in the upper two thirds of the upright, viz : — no 



382 

Citation, and a curve instead of a straight lir 
Aj^ain the two lower cross bars do not admit of 
being moulded, and the patten figured in the sketch 
is useless for children, although it might do for 
adults, because, besides being too low, it can easily 
be set aside by children, who will not give the 
surgeon that co-operation which can be had from 
adults. An adult will do very well with a rise of 
from one to two inches where a child requires 
from four to six. There is another fault this 
modification possesses, namely, too much padding ; 
much is an evil, none is a luxury. Iron and 
simple basil leather are alone most comfortable, 
or, one layer of flannel or felt at most, on the 
anterior surface only. 

Fig. 8, is the concoction of some thickheaded 
mechanic who did not know how to fix the upper 
cross piece without the stays B and C. 

Figs. 3, 5, 6 and 7, are diagrams of modes of 
application practised at four separate Public 
Charities, not one of the splints being so applied as to 
secure the utmost possible benefit from it. Fig. 7, 
shows a cavity in the bed to allow motion of the 
knee-joint lest it should anchylose ! This model 
does not extend below the knee, a matter, combined 
with other defects, rendering the appliance of 
very little value. 



There is one defect that is noticeable in nearly all 
the modifications in my appliances for both hip 
and knee. I allude to a determination to ornament 
them until their usefulness is much diminished. 
This involves expense, and it almost appears that 
instruments are valued not in proportion to there 
usefulness but in proportion to the labour and time 
spent upon their construction. They add 
screws, hinges, padding, morocco, or Russian 
leather additions positively detracting from their 
usefulness, if making them "fashionable.'* Again 
practitioners I have observed will persist in 
specially providing hard mattrasses for hip cases 
and they are equally neglectful in not allowing the 
limb to rest on the couch on knee inflammation. 
Both these points are defects in treatment. 

Furthermore, in the majority of cases reported 
and observed, with the use of my appliances, are 
associated Poultices, Ointments, Blisters, and 
Leeches, all which should be positively adverse to 
resolution. 



♦•» 



T. DoBB, Printer, 69, Gill Street, Liverpool. 



\ 



Plate 1 . 



Fig. 1, Bonnet's Grand appareil. 
Fig. 2, Davis' Hip appliance. 
Fig. 3, Sayre's Hip appliance. 
Fig. 4, Taylor's Hip appliance. 
Fig. 5, Washburn's Hip splint- 
Fig. 6, Hutchinson's, of Brooklyn, Hip splint.4 
Fig. 7, Dr. Andrew's, of Chicago, I^cliiatic 

crutch. 
Fig. 8, Bauer's Hip appliance. 
Fig, ro, Hamihon's Hi]) splint. 



Plate 1 





Represents the mode of handling the patienT 
with splint applied 




Diagnostic method for detecting fixed flexion of 
Iiip joint. I 



w > 





howing compensating curve, when limb i 
extended. 




Pl-ATI:: 0. 

Fig" I. Diagram illustriiting diagnostic method, * 

Fig 2. Section of trunk and lower extremity 
showing application of tiie hip splint cross bars. 

Fig 3, Shape of upper portion of knee appli- 
ance when not covered with padding. 

Fig. 4, Hip appliance to show rotation of 
upright portion. 

Fig. 5, Patten for heel In tarsal or metatarsal 
disease. 

Fig. 6, Staple for retention with knet appliance. 

Fig. 7, Patten end of knee appliance, — -for loco- 
motion. 

Fig. 8. An useful form of fixation, for acute 
infiammation of ankle joint. 



Plate 5 




•■1 




li'l 




I.ATF 7 

Showing line of application and fitting of hip 
appliance. 



J 



Plate 7 




""^te1/-lr 




Fig. I. Cheap wrenches. 

Fig. 2. Another form of wrench. 

Fig. 3, & 4. Another and more efficient form 
of wrench, which enables the hip appliance to be 
fitted while in situ. It is made by the Lowel 
Wrench Co.. Mass.. U.S., modified at my suijrres- 



^LATE 8 



B 





B 




1 



y 



B 



S 




B 




B 





Fig. 
Fig. 



Platc 
, Correct lines fcr Iiip appliance. 
. & 3, For reduction of deformity. 



Fig. 4, Incorrect and intolerable forms ofliip 
appliance. 



Plate 9 



^Reeufy /br a r^cenir cttse. 
J/uie of upriff?^. 



/7g.A 



£5^H^I5^ 



i 



J 



^or reduciUfTv of cl^fo/Trai^ 
.^Ti^Je of al^nt JIO> 



F/G 2. 



JFor TedudioTi^ of tiefhiTiv^. 




F/G.S. 




J^worr^p^ ?rtode^ u^itld irrilale 
F/G.¥. 




Pl.AI 

Posterior view of hip appliance witli patten 
and crutches (iron) for locomotion ; the splint must 
sling on the sound side to avoid rotation. 



Plate 10 




. 




Jiterior view ol Hip appliance with patten, 
and crutches, as uicd for locomotion. 



Plate 11 





Case of hip disease in third 
reduced deformity (flexion). 



^LATB " 12 




Pl\te 13. 
F^ t. Twin hip appliance. 
F^ 3 and 3. Fetnur vrith lines showing direction 
of same id the case of excision. 

Fig. 4. Knee appliance for locomotion. On the 
parallel rods of this appliance "split zinc " tube 
is to be placed, and then the leather stitched over 
the iiibes ; this will reduce the concussion and pres- 
sure to a inininuim, 

l-i:; 5. I'.ULcn lor soiuiJ limb to be used with 



Plate 13 



^# 




Pf-S. 



AN ANGLt OF 55" OR IT WILl 
NOT B£ EASY TO «EhR 



Plats 13 



^■rt 







) 




^ij ^ Plate 14. 

Case of sound hip joint, but unreduced deformity 
y _(flexion.j 



14 




I 



li 



I :| 




Plate 15. 
Case in progress to reduce flexion. 




Plate IIS. 



Anterior view of jinee appliance ready for 



locomotion. 



LATE 16 





F'g- A' Quadrant for correcting eversion or 
inversion in hip disease. 

Fig. B, Wheel carrier for use in bed with knee 
appliance to make certain that the posterior 
aspect of the limb will not come in contact with 
the bed, as this is often a source of aggravation 
of pain and other symptoms. 

Fig. C, Knee appliance. 

Fig. E. The four- way aspirator. D. India 
rubber exhauster. 



="1.115 17 





• or resolution of inflammation of knee 
joint and reduction of flexion, but slight posterior 
luxation remaining. 



LATE 18 




Plate 19 





Plate 20 . 
See plate 19, same case recovering with 
utmost radius of action, after ulceration of carti. 



^LATB 20 




Plate 21 . 

Fig. I, Locomotion appliance for disease of the 
joints of the foot. 

Fig. 2, 4, Splints for use in acute cases and 
while confined to bed. 

Fig. 3, Double hip appliance for single hip 
disease. The complete portion is to be applied to 
the; sound side and the incomplete portion to the 
unsound side when the parts around are per- 
for;it(jd by m.iny sinuses. 



Plate 21 



*AN ANflLE OF S£* 
ILL NOTSE EASTTD WUH 



-—^jrg^ 



Fi^.S 



riq. 2. i 




Plate 22 




I Improved diagnostic method. The forearm of 

I the sound side is used as a means of fixing the 

sound lower hmb on to the trunk during ex- 
amination of diseased side. 



ir> 



Plate 24 . 
Open knee appliance in cases when J 



the knee is so enlarged that the 



ring 



of the 



km 



lee apparatus 



is too small to 



B semi-circle is applied to the inner aspect of the J 



thi-jh close t 



The length of the stem c 



) groin. 

be regulated by the screw; the semi-circle A is to 
be applied just above the great trochanter, both 

scmi-circles being softly padded. 

Figs. 2, 3, 4 and 5, represent shoes for splay 
feet before or after operation. 

Fig. 6, Caliper splint for knee joint. 



Plate 24 




Plate 25. 
Incorrect models and appliances. 



1 I 




Plate 25. 
Incorrect models and appliances. 



iTATE <:3 




Plate ; 



This is a representation of a modification of Dr. 
Andrews' Ischialk Crutch, modified so as un- 
doubtedly to take all concussion off the neck of 
lemur but to relieve friction, consequently, of no 
use in articular inH;immation, but I have found use- 
ful when there i^, delnyed consolidation in case of 
ir.icture of the neck of the femur, my hip appliance 
will be found a \'ery ufficii.-nt aid in securing l)on\- 
union in fractures of the neck iif femur. 



Plate 26. 




h\ TIIK SAME AUTHOR— 

Fractures of the Lower Jaw, Treated by a New Wire Method. 

Five Shillings. 



Intestinal Obstructions, and their Rational Treatment Indicated. 

Ten Shillings. 



Diseases of the Joints of the Lower Extremity (with Twenty-six Plates.) 

Twenty-tive Shillings, 



In the Press, and will shortly be Published — 
Diseases of the Joints of the Upper Extremity. 



Also will shortly be Published — 
A Manual of Orthopedic Surgery. 



I* 



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