ON THE 
MECHAETCAL TEEATMEET 
OF 
SYNOVITIS OF THE KNEE-JOINT. 
BY 
SURGEON TO THE NEW YORK ORTHOPEDIC DISPENSARY AND HOSPITAL, ETC., I|TC. 
C. FAYETTE TAYLOR. NL D., 
[.REPRINTED FROM THE NEW TORE METrtOAL JOURNAL, JULY, 1873.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 55 1 BROADWAY. 
1873. PROSPECTUS FOR 1873. 
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D. APPLETON k CO., 549 & 551 Broadway, N. Y. ON THE 
MECHANICAL TREATMENT 
OF 
SYNOVITIS OF THE KNEE-JOINT. 
BY 
C. FAYETTE TAYLOR, M. D., 
SURGEON TO THE NEW YORK ORTHOPEDIC DISPENSARY AND HOSPITAL, ETC., ETC, 
{REPRINTED FROM THE NEW eWHESSHBSiCai JOURNAL, JULY, 1873.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1873. ON THE MECHANICAL TREATMENT OF SYNO- 
VITIS OF THE IvNEE-JOINT. 
If the mechanical treatment of all diseases of the joints 
has its conception in a conservative idea, this is especially 
true in regard to synovitis of the knee-joint. Here, if any- 
where, our first and last idea must be protection. Neither 
careful nor vigorous management, under a single idea in the 
treatment of this disease, can compensate for the omission of 
other ideas which go to make up the conservative whole in- 
volved in the term protection of the joint. A correct com- 
prehension of the mechanical requirements involved, appro- 
priate mechanical means for realizing our conception, and a 
patient persistence which does not tire nor attempt short pas- 
sages to the end, till it is fairly reached, are the requirements 
needed in the successful treatment of this disease. I use the 
word protection with a purpose. Synovitis of the knee-joint, 
like inflammations everywhere, requires rest. But the idea of 
rest alone is but a feeble conception of the requirements neces- 
sary to meet all the indications which this disease presents. 
The gypsum bandage gives rest from motion and partially 
from pressure also; so that, for a time, and to a certain ex- 
tent, there follows a subsidence of the inflammatory process. 
But there comes a time when, after a certain degree of subsi- 
dence of the inflammation has taken place, the want of mo- 4 
TIIE MECHANICAL TREATMENT OF 
tion in the joint is injurious, because it is the withholding of 
the natural stimulus to the healthy nutrition of the synovial 
membrane, and is a direct cause of irritation ; and, after that 
point is reached, rest from motion is no longer protection, but 
the reverse. All, who have had any experience in the treat- 
ment of this disease, must have observed a persistent irrita- 
bility and long-continued sub-inflammation in the later stage 
of treatment by rest alone, precisely similar to what we find 
in a healthy joint which has been, from any cause, for a 
long time deprived of its power of motion. Motion, then, 
under certain circumstances, as w5ll as rest under other cir- 
cumstances, is protective. But there may be an indication 
for motion, so far as the synovial membrane and the ligaments 
of the joint are concerned, and such motion at a certain period 
maybe the best and only healthy stimulus to the normal secre- 
tion of the synovial fluid; while neither the synovial mem- 
brane, the cartilage of the joint and, perhaps, the epiphyses 
of the bones, may yet be in a condition to bear pressure ; not 
even the pressure caused by the tonic contraction of the mus- 
cles, and still less can they bear pressure accompanied with 
weight and motion. It becomes, then, the surgical-mechanical 
problem to make these two otherwise antagonistic conditions 
harmonize. 
There are other problems equally important to those just 
mentioned, and equally antagonistic without mechanical inter- 
ference, which require solution; such as confinement of the 
leg without confinement of the whole body, involving protec- 
tion with locomotion as against total confinement of the per- 
son ; progressive changing of the angle at the knee, at the 
surgeon’s option, with a view of preventing or removing dis- 
tortion ; motion or rest, or both alternately, under the same 
control; complete relief from pressure in the joint or partial 
pressure, according to the degree of recovery and consequent 
increased ability to bear it, at different stages of the process 
of resolution ; in a word, to be master of the situation, and to 
be ready and able to respond to any and all indications, sepa- 
rately or at the same time, constitute the problem of the me- 
chanical treatment of synovitis of the knee-joint. 
The following is a description of tlie construction and use SYNOVITIS OF THE KNEE-JOINT. 
of an apparatus which is designed to solve the mechanical 
problem above mentioned, and, through this means, to place 
all the indications presented by the inflammations of the syno- 
vial membrane of the knee-joint directly under the surgeon’s 
control. In the first place, it is necessary to grasp the limb 
easily but firmly, so that it may be held without motion or 
jar. 
The apparatus consists of a steel bar, A (Fig. 1), above, and 
another, B, below the knee on the outside, and other similar 
bars on the inside, which are united by several bands which 
pass under the leg. 
These bands which unite the inner and outer bars are im- 
portant. They should be entirely unyielding, so that the in- 
ner and outer parts of the instrument cannot spring apart in 
the least; and, that they may not be too heavy, a vertical sec- 
tion ought to be concave. Inside the upper and lower por- 
tions of the frame are placed strong leather linings securely 
riveted. They exactly fit the thigh and leg, and are laced in 
front. 
This arrangement grasps the leg and thigh as securely and 
with as much ease to the patient as a plaster-of-Paris bandage. 
Hence the first indication is answered. By a peculiar con- 
struction of the joint at E—to be hereafter more particularly 
described—the instrument is made to take the angle assumed 
by the leg, or whatever angle the surgeon desires, with mi- 
nutest adjustability. 
The knee is left free for the application of an elastic or 
roller bandage with opportunity for changing, with increased 
or diminished pressure, or with local applications, as may be 
desired. Thus motion in the joint is effectually stopped, and 
■with a material which is not frail and liable to be broken, but 
entirely uninjurable in bodily movements. 
But it is desirable to remove also the pressure within the 
joint. To that end four pieces of adhesive plaster are pre- 
pared in the same manner as for dressing for extension and 
counter-extension in disease of the liip-joint, and applied in 
a similar manner on the inner and outer aspects of the leg 
and thigh, from the knee upward and downward, with the 
ends, to which pieces of webbing are attached, reaching near- TIIE MECHANICAL TREATMENT OF 
Fig. 1. SYNOVITIS OF THE KNEE-JOINT. 
ly to the ankle below and to the upper part of the thigh above, 
where buckles are placed on the instrument to receive them. 
By drawing the several ends of these adhesive straps applied 
as above described, effectual extension and counter-extension 
are made at the knee and the pressure in the joint wholly or 
partially removed, at the surgeon’s discretion. The knee is a 
true hinge-joint, very strong to resist ordinary force, but whose 
ligaments are easily overcome in relieving pressure in this man- 
ner. The forcible drawing of the straps and buckling the ends 
at the upper and lower extremities of the instrument afford 
sufficient extension and counter-extension without the inter- 
vention of screws or means of elongating the instrument. 
But, another important indication is, to make available 
the hygienic influences of fresh air and exercise. Many cases 
of synovitis in the knee-joint, which are simple and incipi- 
ent, improve for a time under total confinement, but, after 
a while, become worse as the patient sinks for want of fresh 
air and exercise. Hence the tendency with every partial 
subsidence of the inflammation to get the patient off from 
his bed and out into the air, at the risk of redeveloping 
the disease by premature use of the only partially-restored 
joint. It is a constantly-recurring question in cases treated 
by total confinement, which is the greater risk : to keep the 
patient longer confined, to the certain deterioration of his 
general health, with its deleterious effect on the disease; or to 
take the chance of too early use of the knee. 
This difficult dilemma is avoided in the following manner: 
The lower portion of the instrument—which may be length- 
ened or shortened at B, to get exactly the proper length— 
extends to near the sole of the foot, where it is jointed on 
both sides to a foot-piece of steel, C, which rests beneath 
the foot and about half an inch below it; or, so far that 
the sole of the foot cannot reach it to rest upon it when 
the patient steps in walking. Ho part of the weight of 
the body rests on the adhesive straps, they being used solely 
for the purpose of obtaining extension and counter-exten- 
sion, as previously described. But, for the purpose of sup- 
porting the weight of the body on the instrument alone, a 
thin plate of steel is fastened to the outer portion of the frame 8 
THE MECHANICAL TREATMENT OF 
of the instrument, extending to above the trochanter major, 
curved to fit the thigh, and of a width equal to about one- 
fourth of its circumference. To this the leather lining, which 
laces around and firmly holds the leg, is attached. A piece 
of thick steel is riveted across the top, to add strength, and 
from the posterior upper corner the strong webbing band D 
is fastened, which, after being incorporated with the upper 
edge of the lining, cut to fit the part, passes under the ischi- 
um and around the thigh, and is fastened to a buckle on the 
upper anterior corner of the plate. 
The arrangement is in such a manner as to receive the 
whole weight of the body without yielding. The instrument 
thus becomes itself an ever-present crutch for the purpose of 
supporting the weight of the body during locomotion. The 
foot-piece, C, occupies so little space that shoe is put on 
as usual, and the fact that the foot does not rest on the sole of 
the shoe is not observable. In very sensitive cases, arm- 
crutches are first given to the patient. But after a while in 
all cases, and from the first in most cases, the patient can 
walk with ease and impunity on the instrument alone. The 
extension of the instrument far enough beneath the foot to 
prevent contact adds about half an inch to the length of the 
leg. To compensate for this difference, the sole of the shoe 
on the other foot is made thicker, and, to still further save 
the diseased leg from accidental jars, this sole is usually made 
about one inch thick, so that the well leg is rather longer 
than the affected one. The patient can then walk with 
perfect ease and comfort, and the surgeon has the immense 
practical advantage, in employing this conservative treat- 
ment, of not being restricted as to time. In ordinary cases, 
during the later period, the patient can often pursue his busi- 
ness with impunity from injury and independence in regard 
to the time necessary for complete subsidence of the inflam- 
mation. Besides, he can graduate the use of the joint, either 
in regard to its motion or the weight it may bear, from time 
to time, as the case proceeds toward recovery. As a rule, mo- 
tion is indicated before pressure can be tolerated; that is, mo- 
tion with no pressure in the joint is found to be beneficial long 
before either motion with pressure or pressure alone would be SYNOVITIS OF THE KNEE-JOINT. 
9 
borne. To meet the requirements indicated above, the joint 
(E, Fig. 1), has now to be described. In the description hereto- 
fore given, this joint has been supposed to be locked at an an- 
gle to accommodate the degree of flexion of the leg. But this 
peculiar joint has other uses. It is constructed (Fig. 2) with 
a semicircular plate, E, resting between the ends of the upper 
and lower portions of the instrument, where they are united 
by a rivet at the knee. The lower edge of this disk is firmly 
fastened to the lower bar by a screw, K, which can be moved 
to any of the numerous holes prepared for it in the lower edge 
of the disk, and with a corresponding alteration of the angle 
at the joint. The upper part of the instrument is held in 
place by means of a strong pin, G, in the end of the spring F, 
which the latter forces through corresponding holes in the 
steel bar and disk whenever they are op- 
posite each other. By depressing the 
spring F, the extremities are made to rise 
on the inclined planes on either side, and 
thus the pins are withdrawn from the holes 
in the disk, leaving complete freedom of 
motion in the joint. These pins are still 
retained in the holes in the steel bars, and 
are pressed against the face of the disk by 
the spring F, till they are carried opposite 
the holes from which the act of depressing 
the spring withdrew them, when the latter 
forces them in and the apparatus is fixed 
again. The usual method is to unlock the 
joint while in the act of sitting down. This 
is accomplished with a slight and generally unnoticeable 
movement of the hand. 
Fig. 2. 
This occasional bending of the knee, more or less—always 
without pressure—after the inflammation has subsided to a 
certain degree, is often quite sufficient to entirely change the 
character of the secretions in the joint. At a much later stage 
free motion at the knee during locomotion may be admissible, 
but not wffiile there is much flexion remaining. 
In regard to the flexion at the knee, wThich usually accom- 
panies inflammation of the lining membrane of the joint, no 10 
THE MECHANICAL TREATMENT OE 
forcible extension of the leg upon the thigh is necessary or ad- 
missible. Forcible straightening or any thing approaching it 
Fig. 3. 
is not necessary, because we find that, during the conservative 
treatment here described, a gradual relaxation of the muscular 
contraction takes place with the subsidence of the inflammation. 11 
SYNOVITIS OF THE KNEE-JOINT. 
But there should be no haste to realize the straightening 
of the leg. It is sure to take place voluntarily, after a while, 
when the treatment is carefully and steadily pursued without 
regard to the time it takes to arrive at the point of relaxation. 
As we find a gradual increase of motion in the joint, with in- 
creased ability to straighten, we have only to adjust the instru- 
ment to a different angle corresponding to the improved con- 
dition of the leg, by changing the position of the screw K, as 
previously described. If by accident the instrument is made 
too straight for the comfort of the patient, it should be at once 
changed to a position perfectly easy to bear. 
But, after the inflammation has subsided, and the muscles 
have relaxed till there is little or no flexion at the joint, and 
motion is tolerably free and without pain, we are not yet ready 
to allow the patient free locomotion with the whole weight of 
the body on the joint. We And, in synovitis of the knee-joint, 
that it is generally a long time after all active inflammation has 
subsided, before there is the same ability to bear the pressure 
in the joint, which free locomotion would inflict, that there 
was before the inflammatory process was set up. So that, if 
we would carry out our conservative idea to the end, we must 
still seek to protect the joint from the deleterious influence of 
pressure till it is fully able to bear it without injury. But per- 
fect freedom of motion is safe long before the joint is capable 
of sustaining wreight. In still further adhering to the conser- 
vative, protective idea with which we began, we at this point 
adopt the plan designed for relieving the whole leg—including, 
of course, the hip- and knee-joints—from weight in locomotion, 
while at the same time allowing perfect freedom of motion in 
every joint. With this apparatus the patient may walk about 
without the least restriction on his movements in every joint, 
while the whole or any portion of the weight of the body may 
be sustained by the instrument. 
“ This apparatus,1 intended to sustain the weight of the 
body from resting upon the hip-joint—it answers equally well 
for the knee—without restricting in any manner the move- 
ments of the limb in locomotion, is shown in Figs. 4 and 5, 
and is constructed and used in the following manner: 
1 From a work in preparation on “ The Mechanical Treatment of Dis- 
ease of the Hip-Joint.” 12 
THE MECHANICAL TREATMENT OF 
“A strong upright bar of steel (Fig. 4) is jointed at A in 
such a manner that, when vertical, the rivet of the joint is be- 
hind the vertical line. It is evident that, with such a joint, 
Fig. 4. 
vertical weight would not only be sustained, but would add 
firmness to the supporting power. 
“ D D are steel plates about one-fourth of the circumfer- 
ence of the leg, to which are attached the broad bands of leath- 
er which lace around the leg and thigh. The lower steel plate 
is riveted to the upright, but the upper one is fastened by 
three ‘ keepers,’ which enable it to be raised or lowered, 
in adapting the instrument to the length of the leg. 
“ B is a foot-piece intended to rest under the foot inside 
the shoe. The broad hand of leather, C, is cut down at the 
top, where there is a firm pad, F, terminating in the strap, Gr, 
which, when the instrument is applied, fastens in the buckle SYNOVITIS OF THE KNEE-JOINT. 
13 
Fig. 5. 
H. The leather, C, has the thin metal plate, E, riveted to it 
to give it more firmness. 
“ The instrument is seen applied in Fig. 5. It is adjusted 14 
THE MECHANICAL TREATMENT, ETC. 
at such a length that the heel does not reach to the foot-piece, 
but there is a little space beneath the loot. So that the padded 
strap, G F, as will be seen, passing under the ischium and rest- 
ing close against the perineum, is arranged in such a manner 
as to sustain the entire weight of the body while the patient is 
standing or walking. But care should be used, in applying 
the instrument, that it is not laced too close. The leg ought 
to move freeely in it, so that the whole weight will rest on 
the padded portion at F, and not any on the leg and joint. 
The foot is dressed in the ordinary manner, the space between 
the bottom of the foot and the foot-piece being too little to in- 
terfere with applying a shoe in the ordinary manner, and the 
shoe itself is sufficient to keep the instrument in place. But 
a small piece of adhesive plaster properly applied to the leg, 
and the lower end fastened to the buckle near the bottom (B), 
is generally preferred for sustaining the instrument. It will 
be seen that, by the peculiar construction of the joint at A, the 
leg, when lifted, bends freely at hip, knee, and ankle; but when 
straight, as in standing, the joint is forced backward, and the 
instrument becomes firm and unyielding, and neither pressure 
nor concussion can be sustained by the joint. A person wear- 
ing such an instrument, properly applied, walks about with 
perfect freedom of motion, and with no appearance to others 
that he has a contrivance beneath his clothes which protects 
the hip-, knee-, and ankle-joints from all pressure or concus- 
sion. And while no injury can come to the healthy articula- 
tions from the absence of the accustomed weight upon them, 
so long as their motions are not interfered with, the impor- 
tance of affording protection to a joint, susceptible from previ- 
ous disease or in the incipient stages of an inflammation, can- 
not be oyer-estimated.” 
This instrument is generally made use of during the last 
months of the treatment of synovitis of the knee-joint, and, if 
its use is prolonged to several years as a precaution against pos- 
sible injury, no harm can come from such use. It is far better 
to carry out the conservative idea to an unnecessary extreme, 
than by too great haste to jeopardize a cure. 
Mild and incipient cases are often treated with, complete 
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IJppincott's Magazine, the Atlantic Monthly, Scribner's Monthly, or the Galaxy, for one year, on 
receipt ol $, ; Appletons" Journal and LittelTs Living Age, for $10; Appletons1 Journal and 
Oliver Optic's Magazine, for $5: the Journal and Popular Science Monthly, for $‘f 
D. APPLETON & CO., Publishers, 
549 & 551 Broadway, N. Y„