Diseases of the hip, knee, and ankle, joints, with their deformities, treated by a new and efficient method

Front matter

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Med

Excision of Wounded Joints. — Or suppose one of the larger joints — the shoulder, the knee, or the elbow — to have been injured and so lacerated as would have compelled the surgeon in former days to amputate the limb ; have we not, in a- carefully performed excision, a vastly more hopeful method of dealing with the case ?

Preface

TO THE THIRD EDITION.

Consequent on the publication of the previous editions of this treatise, many of my appliances 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 profession* and that it requires a long period for others to realise the conclusions at which time and observation alone have enabled me to arrive.

*1 am frequently told that “Rest is the right thing ” and an ancient principle 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.”

But that these conclusions will at length be accepted, and the theory will be one day acknowledged, 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 of what I 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 lor 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 England. I cannot better introduce him than in

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Dr. Sayre’s eloquent but not over-drawn portrait.

“ 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 instruction 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

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 mercifully 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; the first gives relief from pain ; the second, added to the first, enables the case steadily to progress to a cure ; the third secures that which has been gained. However 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.

11, 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 P'fficient 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, arc frequently not followed by resolution, ajid it is no exaggeration to assert that the majority of cases are benefited with remaining defects.

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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

VI 1 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 compassed in a written account which does not cover far more ground, and perhaps display more numerous illustrations, than this book attempts, and can otherwise 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 priori agreement, 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 criticism 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 gratefully 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 1 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 system 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 conelusions 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 Therapeutics, an Art based, like every other, upon empirical observation, though not indifferent to the support of applied science/^ The work was undertaken upon a plan chosen by the author, whose clinical facts and assertions, accumulated during years of observation, together with the explanations 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 necessarily of contact. These are the only forms of rest applicable to a joint ; though a constitution, jaded by prolonged disease, irritated by the painfulness 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 treatment vastly different to that demanded by inflammation 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 treatment of articular affections, though the most certain means of attaining this end may not be so well known or uniformly agreed upon. But the principle 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 therest-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 bedn about in not regarding them. Every department of our art owes 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 doctrine, there are three points which deserve mention : —

1. — The limits which are supposed to be required 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.

1. — Prevailing doctrine, though advising Rest, deprecates an excess of this condition, lest stiffness be induced by its means. In this work the Rest insisted upon is, as far as possible, 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 sufficiently 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 permanent 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 from 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 bv 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 inflammation 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 whetheror not there be any adhesions between the surfaces. Further, I know from moderate experience in pathological 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 oedema, or collateral inflammation. The only effect that an artificial inflammation of the skin over a joint can 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 consequently 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 vd±t±a an injured (sprained or inflamed) 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 treatment in early stages of inflammation is also one of the novel features of the work. The various items of treatment here given are mainly based upon and confirm theory which can be found in the literature of Surgery — 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 1 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 surgery, 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.

Rushtox Parker.

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 constructed 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 prolonged the upper portion of the instrument, causing it to embrace the trunk — an important improvement. See (plate 1, fig. 1.) 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,” (plate 1, fig. 2.) It is arranged with the intention that the patient should not remain at rest, but that he might continue to perform all the movements of his joint. The designer of this instrument supposes that 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, (Opiate 1, fig. 4,) again, is a modification of Sayre’s appliance, the difference consisting principally 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-Sayre design.

We have also Washburn’s Splint (plate 1, 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 instruments 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 dejsign 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 docs 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-resolution 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 description 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 advocate 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, 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 1, 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 reclination 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 arrangement 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. Instruments, 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 g to himself. But Charriere has converted Bonnet’s instrument into an admirable appliance, by continuing the body portion up to the scapula, as shown in the figure. It is possible, with great care and attention, 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 advantage 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.