IMPROVED METHODS 
OF 
TREATMENT 
I N 
JOINT AND SPINAL DISEASES. 
BA 
E. ANDREWS, M. D. 
Professor of Surgery in the Chicago Medical College. 
CHICAGO: 
•M. HOFMAN, PRINTER, 218 LAKE STREET. 
186 5. 
*s IMPROVED METHODS 
OP THE TREATMENT IN 
JOINT & SPINAL DISEASES. 
E. ANDREWS, M. D., 
Professor of Surgery in the Chicago Medical College. 
Vert important improvements have of late been made in the treatment of 
diseases of the spine, the hip, the knee, and the ankle. So rapid and brilliant has 
been the advance in this department that, among the best surgeons, the treatment 
of joint and spinal diseases is already revolutionized, and vast numbers of cases 
are now easily curable, which formerly defied our utmost skill. It is to be regret- 
ted, however, that very many of these improvements are still unknown to the great 
mass of our profession. Even some of our most recent text-books are behind the 
times, and repeat the advice of ten years ago, in utter unconsciousness of any 
recent progress having been made. 
As the information has never been given to the public in any compact and com- 
prehensive form, there are many practitioners, who though aware of the existence 
of such improvements, have not been able to obtain sufficient knowledge of their 
details to apply them in the treatment of their patients. The mechanical difficulties 
to be overcome are considerable, for the apparatus cannot be purchased ready 
made, but must always be constructed by measure to fit the patient, making, of 
course, a constant tax upon the ingenuity of the surgeon; besides, the medical 
man, out of the cities, often has no mechanic at his command, with the skill 
required to execute his plans. 
For these reasons, it happens that the whole country is sprinkled with cases of 
neglected deformity and articular disease, which have never been taken seriously 
under treatment, many of which are susceptible of complete cure. 
The object of the present article is, to remedy this deficiency, by giving a care- 
fully condensed and illustrated synopsis of the best modes of treatment now known. 
I hope to make the essential points so clear that any surgeon, who has ingenuity 
and access to suitable mechanics, will be able to device and have constructed 
everything which the treatment requires; or if he does not wish to enter upon 
this branch of practice, he will at least, be made aware of the numerous cases 
which are now proved to be curable, and can direct the patient to some one who 
Will take him efficiently in charge. 2 
It being no part of rny object to make a special parade of my own improvements 
in tbis branch of surgery, nor to settle the disputed authorship of those made by 
others, I may be excused from all controversial remarks. Suffice it to say, that 
the advances which have beer made are the joint offspring of a number of different 
minds on both sides of the Atlantic. 
The diseases to which the late improvements are mainly applicable are the 
following : 
Curvature of the Spine, (Spinal Disease,) 
Hip Disease, (Morbus Coxarius,) 
Knee Disease, (Inflammation and Caries,) 
Club-Foot, (Talipes.) 
Our brief space forbids any more extended remarks upon the pathology of these 
diseases than will suffice to show the principle on which the treatment rests. 
SPINAL DISEASE. 
Spinal distortions result from inflammation, caries, rickets, chronic contraction 
of muscles, paralysis, wrong habits of position in study or work, and unequal de- 
velopment of the muscles on the two sides by the exclusive use of one set, as, for 
instance, in sewing girls. Inflammation and caries usually produce the backward 
distortion; and the angular variety, while the remaining causes result in the 
lateral deformity and the curved forms. Lateral curvature, is almost always 
double like the letter S. 
Constitutional Treatment. The most important modern improvements are 
of a local and mechanical character, but the correction of the general health must 
not on that account be overlooked. Thus, if paralysis, rickets, scrofula, or any 
other disturbance is present, the well-known standard remedies are to be used. 
Some special remarks, however, are required respecting the correction of the dia- 
thesis in inflammatory cases. Inflammatory spinal disease may be divided into 
two stages,—first, that of simple inflammation ; and the second, that of suppuration 
and caries. If the patient is of a very plastic diathesis, suppuration and caries 
occur with difficulty, if at all, and an excellent opportunity is afforded to effect a 
perfect cure. If, on the contrary, the diathesis at any time becomes aplastic, the 
inflamed vertebra; may become carious at once, after which the life of the patient 
is in extreme peril. It is of the utmost consequence, therefore, to maintain a uni- 
formly plastic diathesis by proper constitutional treatment. 
For the preservation or restoration of plasticity there is no medicine practically 
equal to the perchloride of iron. This should be given in doses of 20 to 40 drops 
of the muriated tincture, for an adult, every three hours. Quinine and mineral 
acids are also extremely valuable. 
The diet should consist largely of meat, and be in all respects rich and nutritious. 
The patient should also spend much time out of doors, and at night sleep where 
every breath inhaled will be of perfectly pure and fresh air. The windows of the 
bedroom should be kept open in all weathers, winter and summer, for “catching 
cold” is not to be feared in these cases. By acting thoroughly upon these princip- 
les the diathesis can usually be rendered and kept perfectly .plastic, and, if this is 
accomplished, caries will rarely supervene. 
Local Treatment. In al! inflammatory affections of the joints, the pressure 
of the weight of the body upon the diseased articulation is a most exasperating 
and injurious element in the disease. It is for this reason that the lower half of 
the spine, and the joints of the lower extremities far more frequently run on to 
destructive suppuration and caries than tiie upper. One of the most important 
discoveries ever made, therefore, is the recent one, that in treating diseases of this 
class, the weight of the body must be taken off, and the tension of the muscles must 
be overcome, so that all pressure shall be removed f,om the. affected articulation. 
The mechanical difficulties in the way of accomplishing this end, in diseases of 
the spine, have been very great, but by patient ingenuity they are now, in a great 
measure, overcome. 3 
If the disease is inflam- 
matory and is not higher 
than the sixth dorsal 
vertebra, I often make 
use ofan apparatus upon 
the plan shown inFig.l., 
which is constructed in 
the following manner: 
First, take a complete- 
cast of the patient’s hips 
in plaster of Paris, from 
the small of the waist 
downward to two inches 
below the trochanter 
major. Using the cast as 
a pattern, have a brass 
armor hammered to fit 
it, making it -wide on 
each side, somewhat nar- 
rower behind, and still 
narrower in front, so 
that the the thighs may 
not press against the 
lower- edge when flexed. 
This armor opens by 
hinges situated a little 
external to the sacro- 
iliac junctions and locks 
in front on the linea alba. 
It is, therefore, composed 
of three pieces; and, 
when clasped upon the 
patient, will be found to 
fit the hips nicely, and 
to bear any amount of 
downward pressure, 
without causing pain. It should be lined with cotton flannel. In children in 
whom the hips are usually narrow, it is commonly necessary to modify this by 
making the side pieces in such a form as to cap over more decidedly the crests of 
the ilia. A steel rod arises from the centre of the back of the armor and another 
from the front, each coming well up to the height of the shoulders. Their upper 
e xtremities are cut for eight inches into a screw, and carry an octagonal nut. A 
short and strong jacket of leather must be made to fit the chest snugly, and fast- 
ened at the top to the circumference of a steel ring which surrounds the neck. 
This ring has sockets before and behind, which slide down upon the screws to a 
distance regulated by the nuts. A cross arm before and behind may be used in- 
stead ot the ring. If now the two nuts be screwed upward the ring will be raised 
and by the tension upon the jacket the weight of the upper half of the body may 
be entirely taken off from the spinal column and borne by the steel rods directly 
upon the armor of the hips. The source ol initation being thus removed, the in- 
flammation will, in many instances, subside spontaneously without any other treat- 
ment. At the same time, the spinal column is drawn straight, exactly as if it 
were a string. The jacket mayr be advantageously lined with adhesive plaster in 
some cases. If the seat of the disease is not above the middle of the dorsum, the 
very excellent corset of serpentine wire, devised by Dr. Wood, is often the best 
•appliance. 
A simpler apparatus will accomplish the end desired in cases which are not in 4 
flammatory, because, in such it is not necessary to take off the weight of the 
trunk, but only to straighten it. Where a non-inflammatory curvature is lateral, 
winch it usually is, I advise the instrument shown in Fig. 2. This consists of a 
wide band of leather, fitted closely 
to the form of the hips, enclosing a 
large brass plate in the back and 
another in the front. From each of 
these plates rises a flat steel rod to 
the height of the seventh cervical 
vertebra behind, and of the top of 
the steruum in front. 
A half jacket connects the summits 
of the two rods passing around the 
shoulder on the same side as the 
concavity of the upper curvature. A 
broad “band” passes around the 
opposite side lower down, so as to 
press firmly upon the convexity of 
the upper curve. On the opposite 
side from this, still lower down pas- 
ses a second band which presses 
upon the convexity of the lower 
curve. Both should buckle to the 
front rod in such a way as to allow 
of strong tightening. This appara- 
tus is extremely light, simple and 
efficient. When desirable, the prin- 
ciple of Fig. 1 and Fig. 2 may be 
combined, by attaching the bands 
to the rods of the former. I formerly 
used “elastic” for the bands, but in 
practice the want of durability has 
proved so great an objection to that 
material that I now have them made 
of leather. 
Fig. 2. Instrument for Double Lateral Cur- 
vature without inflammation. 
In difficult cases of lateral, curvature the use of a supporter is not sufficient. 
Certain specific exercises must be resorted to in order to develop a greater power 
those of the spinal muscles which lie along the convexities of the curve and thus cause 
them to draw the spine into a correct form. For this purpose I have devised the 
chair of which Fig. 3 is a sectional view, and which must be constructed expressly 
for the patient so that it will fit his form. If, as usual, the convexity of the 
lower curve is to the left, and of the upper to the right, then the left arm of the 
chair must be stuffed so as to press upon the bulge of the lower curve just above 
the crest of the ilium. From the top of the right hand arm of the chair rises a 
strong iron bar carrying a broad pad hollowed to fit the side, and of such a height 
as to press upon the convexity of the upper curve. The pad must project far 
enough to the left, so that, when the patient sits down in the chair, the body will 
be forced strongly over to the left, in the position shown by the dotted outline. Then 
let her without any help from her hands, but solely by the muscles of the trunk 
flex her body strongly and suddenly to the right across the right hand pad, as 
shown in the engraving, endeavouring to carry the motion far enough to actually 
reverse the curvature for the moment and make it assume a direction opposite to 
what it had originally. This motion should be repeated from ten to twenty-five 
times successively, and then, after a few minutes rest, the same succession gone 
over again. Fifty motions will suffice for the first sitting. There should be four 
sittings a day, and the number of motions at each be increased to a number varying 
from 200 to 800 according to the vigor of patient. This has a powerful effect in 
all cases which are capable of muscular action. If the curvature is on the opposite 
direction the chair must be made with reversed sides. The outline in Fig. 3 and 4 5 
axe represented without the 
clothing,merely to show more 
clearly the action of the ma- 
chine. In practice, of course, 
the patient should wear the 
ordinary dress. Very obstinate 
cases require the apparatus 
represented by Fig. 4. It con- 
sists of a strong frame with a 
cushioned seat. On either side 
there is a large concave pad, 
one of which presses against 
the convexity of the lower 
curvature, and the other 
against that of the upper. A 
concave cushion also supports 
the shoulder opposite the up- 
per part. The. patient being 
seated in the chair, the pads 
are advanced against the con- 
vexities of the curves by 
means of screws, until they 
are pressed in and become 
concavities, thus reversing the 
deformity. The patient should 
remain in the apparatus from 
15 minutes to an hour three 
times a day. The use of the 
apparatus shown in Fig. 3 
must not be omitted on ac- 
count of the sittings in this. 
When the distortion is back- 
wards, an entirely different 
instrument is required. If 
inflammation still exists, ap- 
paratus No. 1 should be ap- 
plied, but if that stage is past 
and the deformity alone is to 
be treated, it can be ad- 
mirably managed by the 
principle represented in Fig. 
6. It consists of a steel spring 
enclosing the hips, shaped like those of trusses and attached to a brass cuirass in 
front, which distributes their pressure upon the lower half of the abdomen, and 
the front of the pelvis. From the back of the spring rise two strong elastic steel 
straps, set wide enough asunder to avoid pressing on the bony prominences of the 
deformity, and to make pressure upon the common mass of the erector spinae 
muscles on either side. The top is surmounted by a pair of elastic shoulter-braces, 
by which the spine is drawn back to the steel supports and thus made straight 
Unfortunately, many of the patients with angular curvature are already fatally 
exhausted by caries before they see the surgeon, and cannot, in that state, tolerate 
the annoyance of any apparatus whatever; but, if seen in time, some proper sup- 
porter should be promptly applied. The opinion advanced by many writers, that 
the spinal colum should be allowed to fall forward, so as to favor anchylosis, is de- 
lusive. The periosteum will produce new bone for anchylosis quite as well in the 
erect position as in the croaked, besides the falling forward keeps up the pressure, 
extends the caries, and insures deformity. ft 
If the deformity to be treated is in the neck or the upper fourth of the dorsum, 
Fig 3. Chair for exercising the deficient muscles 
of the spine. 6 
FIGURE 4. 
the before - mentioned instruments will not answer the purpose, as they do not 
reach high enough. In such cases it is necessary to apply the extension power to 
the head. For this purpose, an excellent splint may be made on the plan shown 
in Fig. 6. In this case we require the hip armor as in Fig. 1. From the back of 
this rises a steel rod to the middle of the neck, the last ten inches being in the 
form of a tube. In this tube slides a screw to a depth regulated by the nut upon 
it The top of the screw carries a brass headpiece, hammered to a concavity 
to fit accurately the who'e occipital region as tar forward as the ears. The hollow 
must be lined with some soft substance, and the head kept firmly in it by a band 
passing around the forehead. Extension is made by turning the nut so as to cause 
the screw and head-piece to rise. In this way, the cervical part of the spinal 
column is put on stretch. The patient will in these cases also require a “stretch 
bed’’ as described below, as the extreme difficulty of head extension renders this 
supporter less efficient than those used for lower curves. 7 
In adopting this treatment, the surgeon 
must not expect to buy his instruments 
ready made, and order them put on without 
trouble to himself. The ready made appa- 
ratus sometimes offered for sale for spinal 
disease always proves a miserable failure, 
owing to its total want of adaptation to the 
form of the patient. 
The case should first be thoroughly in- 
vestigated to ascertain what is needed. The 
form must then be carefully measured, and 
parts of it often copied in plaster of Paris, 
and the instrument constructed t > fit under 
the explicit directions of the surgeon. When 
put on, it must not be at first screwed and 
buckled to the utmost tension expected to 
be attained, but worn lightly and easily un- 
til the skin and other parts become accus- 
tomed to its pressure. Then it may grad- 
ually be made to draiv more and more until 
it accomplishes its purpose. Even old cases 
of deformity, of years standing, may thus 
be greatly improved and often entirely cured. 
The fact that the bodies of the vertebra; and the in er- 
vertebral cartilages have changed their form and be- 
come wedge-shaped, does not by any means condemn 
the patient to a lifelong deformity. The same agent, 
pressure, which, improperly applied, produced distor- 
tion, will, when correctly used, restore the original 
shape. Under the new influence, the thick sides of the 
bodies of the vertebrae receive the whole pressure, or, if 
extension is used, the shortened ligaments receive the 
whole tension; and, by a general law of the system, 
the corrected position at length becomes permanent. In 
some instances, the spinal column must be kept a little 
curved over for a time m the direction opposite to that 
of the deformity. The thicker borders of the vertebrae 
and cartilages will thus receive the entire pressure and 
be thinned by absorption, while the thinner sides, re- 
lieved from it, will grow thicker. In this way the forms 
may he quite restored. Yery great perseverance and 
patience will be required, however, in most cases of 
spinal disease. 
Pig. 5. Instrument for Backward” 
Curvature. 
THE STRETCH BED, 
The Orthopedists of Germany make use of an ex- 
cellent apparatus which they term the ‘ Siretch Bed”, 
hut which has rarely been tried by American surgeons. 
In many cases it is not sufficient that the patient be 
under corrective treatment when sitting or walking. 
They should also be under curative influence when 
lying down. For this purpose the Stretch Bed should 
be prepared. This apparatus is variously constructed. 
In case of patient’s remaining at home this may be extemporized in the following 
Fig. 6. Head Extension 
for High. Curvatures. 8 
manner : Take an ordinary bedstead and mattrass. Insert a hook at the head of 
the bed, and a screw pulley at the foot. The patient, when using the bed, must 
have the head or upper part of the body attached to the hook by a jacket, a head 
piece or by some other contrivance, varied according to the nature of the case. 
Extension must then be made in the opposite direction by means of a weight at- 
tached to a cord running over the pulley. The extension must be attached to the 
body by means of adhesive straps on the legs, or by a belt around the waist. The 
weight should be from five to fifty pounds according to circumstances, and the 
patient should go into the stretch bed, from one to three times a day, and in some 
cases sleep in it. 
HIP DISEASE, (Morbus Coxarius.') 
For the purposes of this article, hip-disease, like spinal inflammation, may be 
described as passing through two stages, viz .—lst, inflammation ; and 2d, sup- 
puration and caries. The brief intermediate stage of some authors is not, patho- 
logically, separable from the first, in some instances, and the second in others. We 
observe in this, as in spinal disease, that many cases recover in the first stage with- 
out ever proceeding to caries. The constitutional treatment for morbus cozarius, 
consists in the free employment of regimen, diet, and medicines adapted to in- 
crease the plasticity of the blood, exactly as was detailed above spinal inflam- 
mation, bearing always in mind that if plasticity is kept up, caries will not occur. 
The local treatment consists, in the first stage, in the use of a suitable splint, 
by means of which the weight of the body and the tension of the muscles may be 
completely taken off from the inflammed joint. This must be accomplished by 
such means as will allo w the patient to go about and preserve his health by ex- 
ercise. The disastrous effect of the pressure and friction, produced by bearing 
the weight of the body upon the diseased joint, may be rendered very obvious 
by a few remarks. The synovial membrane, when inflamed, becomes roughened, 
yet upon this inflamed and rough surface the entire weight of the body presses, 
rubs, and grinds at every step. Of course, under such harsh usage no tissue could 
be expected to recover without serious mischief, and especially the exquisite ma- 
chinery of a joint. The disease, therefore, being aggravated by the pressure and 
friction, grows daily worse, and seldom finds an interval of repose sufficiently long 
to permit a recovery. Hence, sooner or later, caries very commonly occurs, and 
abscess forms, and long and copious suppuration ensues, lasting for months and 
years, until the patient is exhausted and dies. In some cases,?! however, the en- 
durance of the patient is so great that the carious portions of bone are actually 
worn to sand and washed away with the pus. In this way the head of the femur 
and the walls of the acetabulum may be removed, and spontaneous dislocation 
occur, after which, recovery takes place with a 
deformed hip. Figure 7 illustrates of the 
cases which I resected. 
The part where the disease first commences 
is, naturally, where the pressure is greatest, 
viz.;—at the top of the acetabulum and the sum- 
mit of the head of the femu:. The shaded por- 
tion represents a mass of necrosed fragments 
which had been originally parts of the wall of 
the acetabulum. The black spot above is a fist- 
ulous channel in the bone through which the 
pus made its escape. The head of the femur is 
seen roughened and worn to a stump by con- 
stant attrition against the dead fragments of the 
bone. After the removal of the diseased bone, 
the patient recovered rapidly, and now walks on 
the limb with ease,— a ligamentous attachment 
of the femur to the pelvis supplying the place 
of the lost joint. 
Fig. 7, Sectional Yiew of a 
case of Hip -Disease. 9 
The local treatment of the hip-disease, in the first or 
inflammatory stage, consists in the application of some 
suitable instrument, by which the weight of the body 
and the tension of the muscles can be entirely taken 
ofFfiom the joint, so that the inflamed surfaces no longer 
press and rub against each other. Dr. H. G. Davis, of 
New York, was the first to construct an efficient appa- 
ratus for this purpose, and with it he has accomplished 
many excellent cures, 'there are some delects, how- 
ever, in the practical working of this instrument, which 
have led me to devise a modification, which, after much 
experience in these cases, I prefer. It is represented in 
Fig. 8, and consists of the following parts:— Ist, an 
iron crutch-piece modelled accurately to fit the peri- 
neum and nates. The engraving conveys an erroneous 
idea about the shape of this part. The principal curve 
is lateral, so as to embrace half the circumference of 
the thigh at the level of the fold of the nates. The 
posterior extremity is broad and hollowed to fit the 
nates, so that the patient, as it were, sits upon it. It is 
cushioned and covered with enamelled cloth or patent 
leather, to resist the moisture of the perspiration. The 
crutch piece thus made is supported upon the summit 
of a strong screw, twelve inches in length, upon which 
turns a nut. The screw slides into a tube, and this 
again terminates at its lower extremity in a rod which 
runs down along the inner side of the leg to the ground, 
and, by a cross-piece, rivets firmly to the sole of a stout 
shoe The top of the shoe carries a light buckle on 
either side for the purpose hereafter mentioned. 
In female patients the instrument is somewhat in the 
way of the urinary organ, and therefore I apply it to 
the outer side of the limb, supporting the body by a 
perineal band attached to the upper end of the screw. 
The instrument is applied to the patient as follows : Place it on the inner side 
of the limb, in such a position that the crutch-piece will press upward against the 
perineum, the broad end being backwards. The concave edge will now embrace 
about half the circumference of the thigh, and the perineum and nates will rest 
easily in the hollow of the upper surface. Buckle the attached strap lightly 
around the outer side of the thigh. Next cut two adhesive-straps, each two feet 
in length, and three inches wide at the one end, and one at the other, apply these 
on each side of the limb, broad end upwards, and confine them by winding spiral 
straps over them as in adhesive-strap extension for fractures. Place the foot in 
the shoe, and the lower ends of the adhesive-straps in the buckles at the top of it. 
Tighten the straps in the buckles until the foot rests firmly in the bottom ot the 
shoe. Next extend the screw, by turning the nut, until the crutch-piece rests 
firmly against the perineum, and until the patient, in walking, hears all his weight 
on the instrument and none of it on the hip-joint. This can be ascertained by 
seeing if the adhesive-straps are still tease when the weight of the body is thrown 
upon the instrument. The patient may then be allowed to walk about as much 
as he pleases, preserving his general health by exercise. He will not require any 
crutches. In the use of this instrument, the patient is soon conscious of great 
relief. Even little children discover in a few days that it greatly relieves their 
pain, and insist on keeping it on. It should be worn nights as well as daytimes, 
except in the milder cases. From the hour of its application, the patient generally 
begins to improve, and by degrees is perfectly cured. He should wear the splint 
fiom six months to two years. The cost of the instrument is $l5. 
In cases where the thigh has been drawn of at a right angle with the body, by 10 
tlie contraction of the flexors, it is sometimes necessary to divide the tendons an 
bring down the limb before the splint can be usefully worn. 
lire second stage of hip-disease is that of caries. When this has occurred, a 
recovery by simple subsidence of inflammation is no 
longer possible. The dead bone must be extruded by 
nature or removed by the surgeon. Great fear was 
formerly felt of undertaking an operation for this pur- 
pose, and the books which condemn it are still stand- 
ard works. There is, however, no part of the body 
whatever more benefited by the removal of carious 
bone than the hip-joint. The operation should be re- 
sorted to in all cases where the patient seems likely to 
sink from the exhaustive suppuration, as also incases, 
which after years waiting, snow no disposition to heal. 
It is best performed by a single straight incision along 
the trochanter major, through which the head of the 
femur may be turned out and sawed off. 11 the ilium 
is carious, it must be freely and unhesitatingly trim- 
med with the gauge until all dead portions are re- 
moved. 
After the operation, as before, the splint must be 
worn to keep the limb from shortening, until the 
femur has had time to contract a ligamentous adhesion 
to the ilium 
We often meet old cases of hip-disease, in whicn the 
carious bone hus already been removed by exfoliation, 
and the ulcerations have healed up; or, perhaps, the 
inflammation has subsided without producing caries, 
but, in which the thigh has become stiffened in the 
flexed condition, so that the foot cannot be brought doww to the ground In these 
cases, the hip-disease proper is already cured, and we have only to deal with the 
deformity, and if we succeed in rectifying that, so as to bring the foot to the 
ground, we shall give the patient a useful limb. 
for this purpose, I employ the apparatus shown in Fig. 9. It consists of a pair 
of strong close-fitting drawers, made of double brown drilling, and extending from 
the top of the abdomen to the knee. Enclosed in this is a brass curiass fitted to 
the front of the abdomen and pelvis, and a brass armor covering the front half of 
the thigh. The top of the thigh-piece is solidly hinged to the lower edge of the 
curiass. Erom one piece to the other passes an extension-brace, which, when the 
screw is turned, slowly pushes down the thigh and corrects the deformity. A 
slight additional extension should be made every day until the object is accomp- 
lished. The cost of the instrument is sld. 
Fig. 9. Apparatus for 
Straightening Flexed Hips. 
KNEE-JOINT DISEASE, 
The knee-joint is subject to precisely the same inflammatory and carious 
affections as the hip and the spine. The only notable difference in their history is, 
that hio-disease is limited almost exclusively to children, while spinal and knee- 
diseases occur at every age. The pathology of knee-disease is identical with that 
of tbe hip, and the tendency of carious spots, in one of the bones, to produce caries 
in the corresponding spot of the bone which rests upon it, is still more obvious 
than in the hip. F.g. 10 is a vertical plan of a knee-joint which I removed by the 
operation of resection; and the shaded portions represent the dead part of the 
bone. It is curious to note bow exactly each sequestrum is matched by another 
of the same size and position, facing it from the opposite surface of the joint. The 
two sequestra in the femur were, probably first formed, and by the constant irrita- 
tion which they kept up, they caused the death of those spots in the patella and 
tibia which rested upon them. It is noteworthy also that the disease has occurred 11 
exactly at the two points which, 
are subjected to the greatest 
pressure in the use of the limb. 
I have introduced this en- 
graving for the express purpose 
of showing the injurious effects 
of pressure, and of impressing 
upon the reader the importance 
of removing that cause of evil 
by suitable extension splints. 
The treatment, therefore, is 
identical with that of hip-dis- 
ease, and the same instrument, 
(see Fig. 8,) is required. The 
uniform conclusion, from the 
best experience is, that this 
treatment, applied in the first 
stage, is even more successful 
in the knee than in the hip. If, 
however, the case has already 
proceeded to the stage of caries, 
the splint is no longer appli- 
cable. There should then be 
an early resort to resection or 
amputation, before the patient 
is worn out by suppuration and 
pain. 
Pig. 10. Vertical Section of a Knee-Joint, showing 
that Necrosis in one surface causes Necrosis in 
the surface in contact with it. 
This condition results from inflammation, in consequence of which plastic lymph 
is effused upon the articular surfaces, causing them to adhere firmly together and 
prevent all motion. In a few cases, the cartilages are removed by ulceration, and 
a bony union is formed. Practically, the bony form is rarely found, ninety-nine 
cases out of a hundred being of the fibrous variety. During the inflammatory 
stage, the patient seeks a partial relief of his pain by placing the limb in a flexed 
position ; hence, we usually find the knee not only stiff, but flexed at an angle. 
ANCHYLOSIS OF THE KNEE 
There are two objects, therefore, to be gained by the treatment: fist, to 
straighten the limb so that the foot may be brought to the ground ; and, secondly, 
to restore the mobility of the joint. The resistance to the straightening process, 
in fibrous anchylosis, is maintained by three tissues, viz.: the flexor, muscles, and 
tendons, the shortened ligaments, and the new fibrous tissue connecting the inner 
faces of the joint to each other. All these obstacles will yield to steady tension; 
and, if the patient and surgeon think best, the limb may be perfectly straightened 
without any operative procedure. 
In all the more difficult cases, however, the flexor tendons oppose so much re- 
sistance that itns, practically, much the best to divide them at the outset with a 
tenotome. We have then simply to overcome the resistance of the shortened liga- 
ments and of the new tissue in the anterior of the joint. For this purpose, extend 
the leg until the tendons of the hamstrings are quite tense, and then divide them, 
taking care to avoid the peroneal neve by the tendon of the biceps. The patient 
should be well under the influence of an anesthetic; and, after the tendons are severed, moderate efforts may be made to straighten the limb by force. Great 
violence, however, should not be used, as serious and fatal results have followed 
such a course. If the adhesions refuse to yiled to a moderate force suddenly 
applied, we must next resort to gradual extension. 
For tills purpose, I use the instrument shown in Fig. 11. This consists of a 
half-armor, covering the posterior portion of the limb and extending from the 
ankle to the middle of the nates. An extension - brace, formed by a tube and a 
screw, passes across the angle, for the purpose of applying a powerful force in ob- 
stinate cases ; but, in more tractable limbs, the brace is removed, and the force 
obtained by means of the strong rubber springs on either side of the knee, attached 
to the upper edges of the apparatus. The knee must be kept in by a cloth knee- 
cap firmly strapped down, and the leg and thigh bound in by a band or two of 
cloth or adhesive-straps The principle of this splint has been in use a long time, 
bat one or two points are new. The prolongation of the thigh piece upward upon 
the nates is to get a firm bearing upon the ischium so as to avoid pressing the up- 
per end upon the sciatic nerve, which is apt to occur in the old form figured in 
the text-books. Care must be taken that the edge of the instrument on the outer 
border of the knee does not press upon the peroneal nerve and paralyze the dor- 
sum of the foot, If the brace is used for extension, the nut must be tightened a 
little three or four times a day, until the joint is quite straight. In milder cases, 
the brace may be removed and rubber springs left to work alone, simply being 
tightened a little once in three or four days. The best material for construction is 
sheet-brass ;|but, if preferred, ordinary sheet tin will answer, and a common tinner 
can construct every part of it, except the nut, screw, and rubber springs. 
The straightening may be accomplished cammonly within two months, mean- 
while daily motions of extension and flexion should be made as diligently as the 
sensitiveness of the joint will permit, in order to restore the mobility. This resto- 
ration of the power of motion is a slower and more tedious process than the mere 
straightening; but, nevertheless, if the passive exercise is continued long enough, 
the result is tolerably certain in favorable cases. If the anchylosis is bony, the 
straightening is still possible in the same way as before; but, practically, the 
difficulties are so great that operative interference is preferable. A wedge-shaped 
piece of bone may be removed in such instances, and the leg then brought down. 
Fig. 11. 13 
TALIPES, (Club foot.) 
The improvements in mechanical surgery have so much diminished the necessity 
of tenotomy, that some surgeons have almost ceased to cut tendons in club feet, 
it being found that the contracted parts will always yield to steady tension proper- 
ly applied. The fundamental maxim in these case3 
is this : Every distorted Joint may be made to re'' 
turn to its normal position by steady and lung con~ 
tinned traction. The principle of the management 
of talipes without tenotomy is, therefore, very 
simple ; but the successful application of it depends 
upon the patience, faithfulness, and ingenuity of 
the surgeon. There are also a few instances where 
the practical difficulties render the principle in- 
applicable. And in such the section of the l endo 
Achillas will still be found the best plan" The 
appliances must be prepared by the surgeon for 
each particular patient, and varied to suit the par- 
ticularities of the case ; and the materials for them 
consist mainly of adhesive plaster and elastic web - 
bing The following description may serve to 
convey the general idea. We will suppose it to be 
a case of talipes varus. The first thing to be done 
is to secure two firm points of traction, which will 
not hurt the patient. For the first, we envelope 
the foot in bands of adhesive-plaster, carefully ad- 
justed, bringing their free ends under the sole and 
up the outer side. The second point of tension is 
easily made by attaching broad adhesive-straps to the upper part of the outer side 
of the leg. It is convenient to arm the lower extremities of these with light buck- 
les. The upper and lower adhesive-straps are now connected by from one to three 
strips of elastic webbing, which, of course, pass over the outer maleolus and tend 
to draw the foot to its position. A small cushion should be placed upon the mal- 
eolar region to receive the pressure of the bands. Thus prepared, let the elastics 
be buckled to a very gentle tension f:r the first few days, until the skin becomes 
accustomed to the presence of the apparatus, after which they may be gradually 
tightened. The tension being moderately kept up day and night occasions very 
little pain, and the contracted parts slowly yield until the foot assumes a perfect 
position. Many weeks are often consumed in the treatment; but if the parents 
are intelligent, the surgeon need not see the child very often after the first twelve 
days. 
The engraver has, in the above cut, misrepresented the maleolar cushion, caus- 
ing it to look like a roller of solid wood. Of course, no one will be misled by the 
error. A good club-foot shoe can be made to accomplish the cure, but not so 
easily as the elastic bands. A very efficient application may be made to club-feet 
by means of the gutta percha casing to the foot by Dr, Prince. 
Fig. 12. 
BOW-LEGS. 
One of the most difficult and vexatious deformities ever brought up for treat- 
ment is bow-legs. It is caused by rickets, in some instances, and in others by too 
early efforts of the child to walk, by which the tibia is flexed with the convexity 
outward, and the whole limb assumes a bow form. The principal curvature is 
usually at the point where Ihe upper part of the tibia joins the epiphysis. There 
is often a slight degree of this deformity in young children, which disappears 
without treatment before the child reaches the fourth year of its age ; but in more 
aggravated cases, it continues and constitutes a permanent blemise. After a 
variety of troublesome experiments, I have devised the apparatus represented in 14 
3?1 g; 13, which answers the purpose perfectly, A 
spring-steel hand passes partly around the waist 
being left open in front where the vacancy is filled 
by straps and a buckle. On each side a projection 
of the steel extends downward until it overlaps the 
trochanter major. To each projection a steel strap 
is articulated, extending downward to the knee, and 
carrying an armor which embraces the outer half of 
the thigh. At the knee another strap articulates 
with a simular half-armor for the outer side of the 
leg. A narrow piece of armor is also made to fit 
the inner side of the leg The joints of the instru- 
ment must be made to come accurately opposite the 
hip and knee joints; and those opposite the knee, 
while they move easily backward and forward, must 
firmly resist any lateral flexion. For this purpose 
the rivet must have a broad, strong head The 
whole must be nicely covered and padded. If now 
the band is buckled around the waist and another 
be passed around the middle of each thigh, it will 
be found that while the limb applies very well, as 
far down as the knee, it there leaves the armor and 
curves inward. The proper pieces must now be 
placed along the inner side of the leg, and, by 
means of straps and buckles, be drawn outward towards the outside pieces. The 
spring of the steel keeps up a constant elastic tension ; and by daily tightening the 
straps, the limb will be slowly brought back to a perfect form. 
Care must be taken.not to apply the straps too tightly at first, otherwise the 
skin will abrade and ulcerate, and the whole treatment be delayed. It will be 
sufficient if, during the first ten days, the instrument be worn very lightly, —just 
pressing enough to accustom the skin to its presence, after which, it can be made 
to draw more powerfully, until the object in view is accomplished. 
Fig. 13,