ON THE 
MECHANICAL TREATMENT 
OF 
CHRONIC INFLAMMATION 
OF THE 
JOINTS OF THE LOWER EXTREMITIES, 
WITH A 
DESCRIPTION OF SOME NEW APPARATUS 
FOR PRODUCING 
EXTENSION AT THE KNEE AND ANKLE-JOINTS. 
BY 
LEWIS A. SAYRE, M. D., 
SURGEON, BELLEVUE HOSPITAL; 
PROFESSOR OF ORTHOPAEDIC SURGERY, BELLEVUE HOSPITAL MEDICAL COLLEGE ; 
RESIDENT PHYSICIAN OF JHE CITY OF NEW YORK J MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; 
N. Y. STATE MED SOC. J N. Y. ACAD. OF MED. : N. Y. PATH. SOC., ETC. ETC. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1865. ON THE MECHANICAL TREATMENT OF CHRONIC INFLAMMATION 
OF THE JOINTS OF THE LOWER EXTREMITY, WITH A DESCRIP- 
TION OF SOME NEW APPARATUS FOR PRODUCING EXTENSION 
AT THE KNEE AND ANKLE-JOINTS. 
The causes, pathology, and symptoms of the various diseases of 
the joints have been so accurately described by Brodie, Barwell, 
Guerin, Bouvier, and others, as well as in the numerous mono- 
graphs upon the subject, that it would be superfluous to repeat 
their description. The fact, also, that chronic inflammation of any 
joint produces reflex contractions, causing deformity and severer 
pain, by increasing pressure on the diseased surfaces, thus making 
extension and counter-extension a necessary part of the treatment, 
has been so fully proved by myself and others who have written 
on this topic, and is now so generally admitted, that no further 
comments are necessary. 
It is, in addition, acknowledged that the confinement, formerly 
necessary to produce the requisite extension and counter-extension, 
was so injurious to the general health of the patient, that the ad- 
vantages were sometimes overbalanced, and exercise in the open 
air became a necessity in order to save life, even at the expense 
of a deformed limb. Moreover, the immense advantage given to 
patients with disease of the hip-joint, since the introduction of 
mechanical appliances, which allow exercise without discontinuing 
the extension, is so evident, that no one at all conversant with the 
disease and its proper treatment, will attempt to deny it. 
The object of the present paper is, therefore, to show the prac- 
tical utility of this very principle of treatment to the diseases of 
the knee and ankle-joints, even when they have extended to suppu- 
ration and caries; and to illustrate it by the narration of some cases 
which have come under my personal observation. 
Before proceeding, however, with a description of the apparatuses 4 
ON THE MECHANICAL TREATMENT OF 
for the knee- and ankle-joints, it may not be inappropriate briefly 
to refer to the improvements made in the apparatus for the treat- 
ment of hip-disease, since the publication of my report to the 
American Medical Association, in 1860. 
In the first and second stages of the disease-when the limb is 
apparently longer, and the knee and thigh both flexed-extension is 
kept up at night by a weight and pulley fixed to the foot of the bed, 
which is elevated some inches, in order to make the body a counter- 
extending force, and thus avoid the necessity of a perineal band. 
The weight is fastened to the foot either by a buckskin boot, laced 
snugly around the ankle, or by strips of adhesive plaster placed 
on either side of the leg, carefully secured by a well-adjusted 
roller, with pieces of webbing sewed to their lower ends, which 
can be folded under the stocking during the day. If the thigh 
is very much flexed, another pulley is placed over the first, at 
such a height as to allow the force to be applied from above 
the knee, nearly on a line with the distorted thigh: this pulley 
is lowered by degrees as the patient can bear it, until the limb is 
brought to a straight line with the body, or as nearly so as may 
be, when the new force can be dispensed with, and the weight 
applied to the foot alone. In the daytime, or while the patient 
exercises, the extension is continued in this stage of the disease 
by means of an extension splint applied to the thigh only, and 
which allows free motion at the knee-joint. 
The instrument consists of a flange of very firm sheet-iron, three 
or four inches long, and one or two inches wide (according to the 
size of the patient), slightly curved, and which, when cushioned, 
fits directly under the crest of the ilium. At each extremity is a 
buckle to secure the perineal band, made in the centre, of buckskin 
stuffed with hair, and with ends of elastic webbing to attach to the 
buckles. On the outer side of the flange is a ball and socket or 
universal joint, to receive the head of the splint, which runs down 
the thigh to within three or four inches of the extremity of the 
femur, and is capable of being made longer or shorter by a cog- 
wheel worked with a key. Near its lower extremity is attached 
a branch, which, curving over the thigh, extends as far down as 
the main splint, and both terminate in broad ends with a roller 
over which the webbing attached to the adhesive plaster plays, 
and is secured to the splint by means of buckles near each lower 
extremity. (Fig. 1.) CHRONIC INFLAMMATION OF THE JOINTS, 
5 
To apply the splint, very strong adhesive plaster is required, or 
else two or three thicknesses of the ordinary plaster, cut in a fan 
Fig- 1. 
Sayre's splint for extension in morbus coxarius in the first and second stages. 
shape (Fig. 2), and long enough to reach, on the inner side of the 
thigh, from the perineum to within three or four inches of the con- 
Fig. 2. 
dyle of the femur, and on the outer, from the trochanter major, to a 
point directly opposite the end of the inner plaster. These plasters 
are secured by a well-adjusted roller, and after pressing them well 
with the warm hand, to obtain a firm adhesion, the instrument is 
laid over the thigh, and the webbing, which is attached to the 
plaster, firmly fastened over the rollers to the buckles on the lower 
extremities of the instrument;-the perineal band is then buckled 
on, and the instrument is extended, with the key, to just such 
degree as is required to make the patient comfortable, and then 
locked by the slide. 
This instrument should be worn as a guard for some months 6 
ON THE MECHANICAL TREATMENT OF 
after the patient is entirely well, as I have seen many cases return 
from very slight causes, after being perfectly well for a long time. 
In order to prevent the limb from swelling below the bandage, it is 
necessary to support the circulation either by an elastic stocking, 
or by a roller and a knee cap. 
These instruments are made with great perfection by Messrs. 
Otto & Reynders, Tieman, or Wade & Ford, of this city. 
In the third stage of the disease, when the limb has become 
shorter and the patient can, therefore, walk with the stiffened knee 
without difficulty-which cannot be done in the first and second 
stages, without a very awkward circumduction-the same principle 
can be much better applied by using the instrument first described 
by Dr. Andrews, of Chicago. It consists of a crutch in the peri- 
neum, with a wide flange curving around the gluteo-femoral fold, 
a ball and socket on its under surface opposite the tuberosity of 
the ischium, a rod running from it, to the heel, capable of being 
elongated at pleasure, and terminating at its 
lower extremity in two branches-the lower 
extremities of which are rounded or knobbed, 
to fit into iron cups or sockets which are well 
secured into the heel of a nicely-fitting laced 
boot; a thick buckskin tongue lies over the 
instep, before it is laced, for protection when 
the extension is applied. The boot being 
neatly laced without wrinkles, the fenced 
prongs are inserted behind the heel into the 
sockets, and the crutch then slipped into the 
perineum. The instrument can then be ex- 
tended by the cog-wheel and key, until the 
patient can bear pressure without pain. Its 
great advantage is, that force can be applied 
without girdling the limb with a roller, as must 
be done when adhesive plaster is used, which 
is a very great desideratum. 
I have used this instrument in many cases 
where the limb was shorter than the other, with 
very great advantage, and can therefore recom- 
mend it highly. Those I have used were made 
by Messrs. Otto & Reynders, 58 Chatham Street, 
after the annexed pattern, which, I presume, is so much like Dr. 
Fig- 3. CHRONIC INFLAMMATION OF THE JOINTS. 
7 
Andrews' splint, that I think he is entitled to the credit of making 
the suggestion. (See Fig. 3.) 
Of course, the mere application of mechanical force to overcome 
one of the effects of disease, viz., muscular contraction, is not in- 
tended to supplant or prevent the adoption of the well-established 
principles of treatment, but merely as auxiliary thereto; but as the 
object of this paper is simply to explain the construction and appli- 
cation of mechanical force, it is not deemed necessary to enter 
further into the general principles of treatment, and we shall, there- 
fore, proceed to the narration of some few cases where this prin- 
ciple has been applied satisfactorily to diseases of the knee- and 
ankle-joints. 
REPORT OF SOME CASES OF CHRONIC DISEASE OF THE KNEE AND ANKLE- 
JOINTS, AND THEIR TREATMENT BY MECHANICAL APPLIANCES. 
Case I. Thomas B. Clark, Fourth Street. Strumous synovitis of 
knee-joint; suppuration; luxation; anchylosis; operation; recovery. 
This patient had scarlatina when two years old, following which 
he had inflammation of the left knee-joint of the strumous variety, 
commonly called white swelling. After about eighteen months, 
contraction of the muscles took place to such a degree as to cause 
subluxation of the tibia backwards into the posterior inter-condy- 
loid notch. Eight or nine fistulous openings around the outer part 
of the knee led to carious bone and into the joint. Drs. R. K. 
Hoffman and R. S. Kissam had examined him, and pronounced 
amputation the only means of cure. 
I was called to see him in the spring of 1853, in consultation with 
Dr. Batchelder, who advised compression by means of sponge, and 
gradual extension: this was faithfully persisted in for some months, 
but with no appreciable improvement in the position of the limb. 
The sinuses on the outer side of the knee were then laid freely open 
-connecting with the joint-giving exit to a large amount of pus, 
and some carious bone which seemed to come from the external 
condyle of the femur and the patella only. The joint was freely 
injected with warm water, and the wound kept open by tents of 
oakum saturated with Peruvian balsam. Small pieces of bone con- 
tinued to exfoliate for some months, when the wounds gradually 
cicatrized, and the parts became perfectly healthy; but with no 
improvement in the position of the limb. All the constitutional 
symptoms improved from the time the joint was freely opened; 
his appetite increased, and his sleep was tranquil without narcotics. 8 
ON THE MECHANICAL TREATMENT OF 
In January, 1854, as his general health had become restored, I 
decided to attempt to improve the deformity by tenotomy of the 
hamstring muscles and brisement force of the knee-joint. Dr. Louis 
Bauer, of Brooklyn, saw him with me, and rendered me most 
valuable assistance in the performance of the operation. The boy 
was perfectly anaesthetized with chloroform, the tendons divided 
subcutaneously, the wounds carefully closed with adhesive plaster 
and a roller, and then the knee-joint forcibly broken-by flexion 
and extension, and internal rotation-until the limb was brought 
parallel with the other, and almost perfectly straight. A tight roller 
was applied from the toes up to near the knee; a large sponge 
placed in the popliteal space, and strips of adhesive plaster were 
applied over the sponge, and drawn tightly around the joint from 
the bandage below the knee, to some six inches above it. The 
roller was then continued over the plaster, snugly applied to the 
whole thigh. A piece of sponge about two inches in length, and 
about the size of the fore finger, having been placed over the 
track of the femoral artery-as is my usual custom in this opera- 
tion-the roller was carefully applied to cause partial occlusion 
of the calibre of the artery, and thus diminish the supply of blood 
to the joint, without being so tight as to induce its complete 
strangulation. Two pieces of firm sole-leather, cut to fit the foot 
and limb in its entire length, having been softened by soaking them 
a few minutes in cold water, were applied on either side of the foot 
and limb, and secured by a bandage. Great care was taken to 
model the leather, to all the inequalities of the part, while it was 
still soft and pliable, and the limb was forcibly held in its improved 
position until the leather became dry and hardened, when it re- 
tained it as perfectly as any plaster mould could do.1 
I wish to call especial attention to the principle involved in the 
dressing in this case, as I think it of cardinal importance, having 
witnessed its practical benefit in many serious operations. I mean 
the pressure on the main trunk of an artery leading to any part 
in danger of inflammation, in such manner as to diminish the sup- 
ply of blood, to prevent inflammation by partial starvation. Great 
caution is, of course, necessary not to produce gangrene; but a 
1 Subsequent experience has taught me that it is better to close the wounds and 
retain the limb at perfect rest in its abnormal position until the external wounds 
have healed (which will generally be done in five or six days), before proceeding 
to break up the bony adhesions. CHRONIC INFLAMMATION OF THE JOINTS. 
9 
little practice, and close observation, will soon give the necessary 
tact of knowing how to use pressure, without abusing it. 
In this case of young Clark, although the operation was very 
severe, and the force required to break up the adhesions very great, 
and continued for some time with rather rough manipulation in 
order to get the limb in good position, yet it was not followed by 
any constitutional excitement or irritative fever. 
The boy took an anodyne the first night only, and from that 
time had no pain or trouble whatever. The limb was kept im- 
movable in the leather splint, and was not disturbed in any manner 
for thirteen days. At the expiration of that time it was dressed 
and found perfectly satisfactory, the wounds all healed, with no 
inflammation about the joint. Our object being to obtain anchy- 
losis, the limb was again re-dressed, but without the sponge over 
the femoral artery. At the end of two weeks, on again examining 
it, it looked so favorably that I determined to produce a movable 
joint, instead of anchylosis. Passive motion was tried, with great 
care at first, but afterwards continued with much more freedom, 
and finally resulted in a very useful joint, having about two-thirds 
the motion of a natural one. 
The patella is very small-not more than one-third the size of 
the opposite one, the external condyle of the femur is very much 
reduced, there is paralysis of the peroneal muscles, from slough 
of the peroneal nerve, the foot is smaller, and the leg one inch 
shorter than the other. Yet, with a high heel, an elastic spring on 
the outside of the shoe, and an India rubber substitute for the pero- 
neal muscles-running from the top of the fibula to the ankle, 
where it terminates in a cat-gut cord, which plays around a pulley, 
and is inserted at the outer margin of the sole of the boot near the 
toe-the boy walks, dances, runs, and skates with his playmates 
without crutch or cane. 
Case II. Chronic synovitis of knee-joint, with angular contraction 
and probable ulceration of cartilages; tenotomy; extension by splint; 
recovery. 
Ann H , Jersey City, aged 14; father healthy, but mother 
died of phthisis; fell, when nine years of age, on the side-walk, 
striking her right knee on the curb-stone, producing a severe in- 
flammation of the knee-joint, which confined her to her bed for 
some weeks. Leeches, cups, poultices, and the usual antiphlogistic 10 
ON THE MECHANICAL TREATMENT OF 
treatment was adopted for some time, and finally resulted in a 
favorable recovery. For nearly a year she considered herself well, 
although she always had more or less pain in the knee-joint, after 
any very severe exercise; but it was not thought of'sufficient im- 
portance to call for professional advice, as it generally subsided by 
a few days' rest, although her father had applied a blister to it 
occasionally. When about twelve years of age she again sprained 
the joint, by slipping on an orange-peel, which produced the most 
intense pain, immediately after the accident, and which continued 
until the time I saw her, two years after. She had been cupped 
and leeched repeatedly; blisters and issues had been applied for 
some months, but all without any benefit, until the agony became 
so intense and the general health so much prostrated, that the 
disease was decided to be incurable, amputation advised, and I 
was sent for to perform it. Dr. Wm. K. Cleveland went with 
me to assist in the operation. We found the girl sitting on 
a chair, with her knee flexed at an acute angle, the foot rest- 
ing on a stool a little lower than the chair on which she sat, 
her body strongly bent forward, and both hands firmly clasped 
around the limb just below the knee, to prevent, as far as possible, 
any movement at the joint; at the same time she appeared to push, 
with considerable force, and stated that that was the only way in 
which she could get any ease. Her father stated that she had sat 
in that position most of the time-day and night-for the past three 
months; she would not let go her leg even to feed herself, and 
they had therefore to feed her. Whenever her position was changed, 
either to be put in bed or to attend to the necessary calls of nature, 
it produced the most intense paroxysm of pain, which frequently 
lasted some hours, and could not be relieved by any anodyne, 
although she took morphine in very large doses, constantly. Her 
knee was very much enlarged, almost transparently white, the 
irregular contours quite defaced by the general rounding out of 
all the parts. The leg below the knee, and the thigh above, were 
very much smaller than the opposite one. Her pulse was 160; 
her face very pale and emaciated, and her countenance bore the 
most marked expression of intense suffering that I have ever wit- 
nessed. It was impossible to walk about the room, or in any way 
jar the floor, without causing her to scream in agony. 
When Dr. Cleveland took hold of her foot, to move her in position 
for the operation, she seized him by the arm with her teeth, and 
held on with the grip of a tigress, until I grasped her limb above CHRONIC INFLAMMATION OF THE JOINTS. 
11 
and below the knee, and by firm extension and counter-extension, 
to separate the bones from each other, gave her such relief that 
she let go her hold upon his arm. So long as I continued the 
extension she seemed comparatively quiet, and said it gave her 
great relief; but the instant that I relaxed at all she screamed in 
agony. This fact decided me not to amputate, until she had had 
the benefit of extension fairly tried. It was impossible to do this 
efficiently without first dividing the hamstring muscles, as the leg 
had been so long contracted. I therefore held the limb still while 
Dr. Cleveland put her under the full influence of chloroform, when 
I divided the outer and inner hamstring tendons subcutaneously, 
covering the wounds immediately with adhesive plaster and a roller. 
By a very slight force the limb was brought immediately almost 
straight. A long strip of adhesive plaster, about four inches in 
width, was secured to both sides of the leg by a roller, for the pur- 
pose of making extension; and in the loop below the foot a board 
was placed, wide enough to remove pressure from either malleolus. 
To this board a cord was attached, and run through a hole made 
in the foot-board and over a pulley, and to its other extremity I 
attached a smoothing-iron weighing about five pounds. Two bricks 
were placed under each post at the foot of the bed, to raise it higher 
than the other end, so that the body, constantly gliding in the oppo- 
site direction, would make a proper counter-extending force, without 
the necessity of a perineal band. This was all accomplished before 
she had come from under the effects of the chloroform; and when 
she recovered her senses, she said she felt perfectly easy. As she 
had already taken a large dose of morphine just before we arrived, 
nothing more was given her; but instructions left to administer to 
her twenty drops of Magendie's solution in the night if necessary. 
She passed a more comfortable night than she had done for 
months, and from that time took no opiate nor other anodyne. 
Her appetite improved, and her bowels became regular, without 
the use of any cathartic medicine. Iron and quinine were the only 
remedies given, together with the most nutritious food that she 
could digest. A large coarse sponge, placed around the entire knee- 
joint, and secured by a very firmly applied roller, was thoroughly 
wet in cold water, and constantly kept so, by frequent irriga- 
tions day and night. The extension of the joint by the weight 
and pulley, and the compression by the wet sponge were continued 
about two months, after which I made extension by means of an 
apparatus I have been using for some years, and which allows 12 
ON THE MECHANICAL TREATMENT OF 
the patient to exercise in the open air at the same time that the 
extension is continued, which is so important in the treatment 
of all chronic inflammations of the joints. Although I have used 
this apparatus in many cases with most marked benefit, both in 
private practice and in Bellevue Hospital, for nearly seven years, 
yet I have never published or described it, except to the different 
classes of students in attendance at the Hospital. But having 
tested it thoroughly, I can commend it with confidence, in all cases 
where extension of the knee is required, and exercise at the same 
time necessary. 
The apparatus is constructed in the following manner: Two 
bands or collars of firm sheet iron, about an inch wide, embrace 
the limb-the one above the ankle the other at the 
upper third of the thigh-by means of a hinge on 
one side, and a lock on the other like a dog- 
collar, and connected, on either side, by a firmly- 
riveted steel rod, in the centre of which works a 
male and female screw, which can be retained at 
any given point by a small thumb-screw working 
in its side and fastening to the worm or thread of 
the larger screw. (See Fig. 4.1) 
To apply this instrument, adhesive plaster is re- 
quired, spread on strong cloth and cut in strips 
one inch wide, and long enough to reach from just 
below the knee to near the ankle, and also from 
the knee for several inches above the joint, upon 
the thigh, as seen in Fig. 5. 
These plasters are secured to within an inch of their extremities 
by a snugly-adjusted roller, as seen in Fig. 6. The instrument is 
then placed on the limb, the collars fastened sufficiently tight to 
be comfortable, and the loose ends of the adhesive plaster turned 
over them and secured by a roller. The connecting rods are ex- 
tended by means of the screw, the articulating surfaces of the tibia 
and femur separated from each other, and the limb brought nearly 
straight, as in Figs. 7 and 8, until pressure can be made on the 
Fig. 4. 
Dr. Sayre's apparatus 
for extension at 
knee-j oint. 
1 Since writing this paper I have made an improvement in this instrument by 
dividing the rings into two halves, which slide together in place of being hinged. 
The plaster has a strong loop of webbing sewed on each strip, and the separated 
ends of the rings can be passed through these loops before being locked, which is 
more neat than the former plan, and more easily readjusted. CHRONIC INFLAMMATION OF THE JOINTS. 
13 
foot without pain. A roller is applied over the foot and leg up to 
the instrument, to prevent oedema. A large coarse sponge is placed 
in the popliteal space, and other pieces of sponge completely sur- 
round the knee-joint; these are secured by a tight roller, and then 
Fig. 5. 
Fig- 6 
Fig. 7. 
Fig. 8. 
saturated with cold water. The cold water not only reduces the 
inflammation of the joint, but, by increasing the pressure of the 
sponge, promotes the absorption of the deposits that generally 
occur around and in a joint in this condition of chronic inflam- 
mation. 14 
ON THE MECHANICAL TREATMENT OF 
The instrument was applied in the case of Ann II , in the 
manner described, and when the extension was exerted, she could 
bear almost her entire weight upon the limb; but when the screws 
were shortened so as to remove the extension, the slightest pressure 
upon the foot gave her the most intense agony. With the instru- 
ment properly adjusted, she could exercise in open air upon her 
crutches,1 with the greatest freedom, and in perfect comfort. From 
this time her general health began to improve rapidly. After the 
first application she came to my office from Jersey City, a distance 
of several miles, every few weeks to have it readjusted, and each 
time showed evidences of most marked improvement. It was almost 
a year before she could bear much pressure without pain, when the 
extension was removed; but as this pain subsided, I became more 
free in my use of passive motion, and in about twenty months 
from the time of the operation, I had the satisfaction of seeing 
her walk without pain, and with tolerable motion of the joint. 
It is now nearly five years since this case was under treatment, 
during which time she has enjoyed uninterrupted good health, and 
at the present time the motions of her knee-joint are so perfect that 
no one but a critical observer would suspect that there had been 
any disease there. 
Case III. Suppuration and caries of both anklejoints from injury ; 
double talipes-equinus • operation; recovery, with motion. 
Elizabeth Bruen, set. 16. Admitted to Bellevue Hospital, Jan. 
29th, 1864. Her father died of phthisis. In 1862 she sprained 
her right ankle. The injury produced a chronic form of inflamma- 
tion, and in two months it had increased so much that she could 
bear no weight at all upon it. She now moved about by hopping 
on the well (left) foot, and in about six weeks, she had excited 
the same form of inflammation, in that one as in the other. Two 
years after the first injury, when admitted to the hospital, her ap- 
pearance was cachectic and miserable. The disease in her ankles 
had gone on to the formation of abscess, and several sinuses led 
into the joint, through which disintegrated bone had escaped. 
The gastrocnemii of both sides were so contracted as to extend 
the foot nearly to a straight line with the tibia. She could not 
1 Young subjects, who are not so heavy, can walk without the aid of crutches. 
But with adults, or very heavy children, there is danger of tearing the plaster, 
or breaking the instrument, and, therefore, crutches are necessary to take off the 
superincumbent weight. * CHRONIC INFLAMMATION OF THE JOINTS. 
15 
bear the slightest pressure on either foot, and could not use 
crutches, as she could not poise herself on the ends of her toes, 
which were the only points that could touch the floor when in the 
erect posture. She was, therefore, compelled to move about upon 
her knees, as seen in Fig. 9, which also shows the sinuses connect- 
ing with either joint. 
Fig. 9. 
All active disease about the joints had subsided; but the dis- 
charge from the various sinuses was considerable, and by probing 
them, several small pieces of bone escaped. 
On the 17th of February, 1864, in the presence of the class at 
Bellevue Hospital, I divided subcutaneously the tendo-Achillis 
on both sides, and restored the feet to their natural angle with the 
legs. Leather splints were then applied, to retain them in this new 
position until I could have a pair of instruments manufactured, 
which I am in the habit of using to extend the ankle-joint. 
This instrument consists of a firm steel, or hard rubber plate, 
made to fit the sole of the foot; at the heel is a hinge-joint, and 
attached to it a rod, slightly curved at the bottom, and extending 
up the back of the leg to near the knee. Over the instep is an 
arch, like the top of a stirrup, with a hinge joint at its summit 
from which springs another rod, which runs in front of the leg, of 
equal length with the one behind. These rods are made with a 
male and female screw, or ratchet and cog for extension, and con- 
nected at the top by a firm band of sheet iron, on the side of 
which is a hinge, and a lock on the other like a dog-collar. (See 
Fig. 10.) 16 
ON THE MECHANICAL TREATMENT OF 
The instrument is applied with firm adhesive plaster, cut in strips 
about one inch in width, and long enough to reach from the ankle 
to near the tubercle of the tibia, and placed all round the limb, as 
in Fig. 11. 
Fig. 10. 
Fig. Il- 
Fig. 12. 
The plaster is secured in its position, to within an inch of its 
upper extremity, by a well adjusted roller, as seen in Fig. 12. 
The instrument is fixed, and the foot firmly secured by a number 
of strips of adhesive plaster, as seen in Fig. 13. A roller should 
be carefully applied over this plaster to prevent its slipping, and 
the ends of the plaster at the top of the instrument turned over 
the collar, which has been previously locked, just tight enough to 
be comfortable, and secured by a turn or two of the bandage, as 
seen in Fig. 14. 
Fig. 13. 
Fig. 14. 
On the 24th of February, just seven days after the section of the 
tendones A chillis, these instruments were applied in the presence 
of the class at Bellevue Hospital, in the manner above described. CHRONIC INFLAMMATION OF THE JOINTS. 
17 
The sinuses were enlarged, and a seton of oakum drawn through 
the ankle-joint, as indicated in Figs. 11, 12, and 13. A wad of 
oakum thoroughly wet in cold water was placed over each ankle, 
and secured by a firm roller. The screws were extended, and the 
difference in the appearance of the ankle before and after is well 
represented by comparing Figs. 13 and 14. 
These drawings were taken from life by Dr. Henry C. Eno, 
House Surgeon of Bellevue Hospital, and are as accurate as any 
photograph could be. 
As soon as the instruments were properly adjusted, she stood 
upon her feet, without the aid of crutch or cane, for the first time 
in two years, and without any pain whatever ; but the instant the 
screws were shortened, the pain was most intense. 
She was directed to have the oakum around the joints kept 
constantly wet with cold water, and firmly supported by a bandage 
and changed as often as necessary. The seton was to be pulled 
through, and the soiled part cut off daily, and to be continued as 
long as any bone was exfoliating, until the matter should change 
from its sanious condition to a consistent pus, when it was to be 
removed, the wounds allowed to heal, and, if possible, passive 
motion made. If motion could not be attained, then the feet were 
to be anchylosed in their natural position, deeming that a stiff 
ankle was better than an amputation. 
The following notes of the case, copied from the hospital records, 
which were taken by Dr. Irving W. Lyon, House Surgeon, now of 
Hartford, Connecticut, will show the progress and the result of the 
treatment:- 
a February 28. She is very comfortable, and there is no pain 
about the ankles. 
" March 15. Has been out of bed most of the time since the 
operation; but remained sitting at the bedside until to-day, when, 
with the aid of crutches to balance the body, she walked about 
bearing her entire weight upon the feet; the extension made by 
the instrument being so perfect as to prevent pressure upon the 
joint surfaces. 
"A/m'Z 6. Apparatus removed from both feet, and motion 
made at the ankle-joints, which are perfectly free and movable, 
but pressure is yet very painful. The apparatus is reapplied. It 
should be stated that the patient was put upon the best diet the 
hospital could afford, together with cod-liver oil and iron, 18 
ON THE MECHANICAL TREATMENT OF 
" May 7. The adhesive plaster having become disarranged, 
necessitated its readjustment. It was now discovered that the 
sinuses had all closed completely; but pressure while extension 
was off' still gave her some pain. Her general health very mate- 
rially improved. 
"eThZ?/20. All extension being removed, she is able to stand 
erect without pain in either ankle; but attempts at walking occa- 
sion a considerable amount of pain and uneasiness. The motions 
of the ankles are all unimpaired. Her health is thoroughly re- 
stored, and she has not only grown taller since her admission, but 
has also grown much more fleshy, and will weigh at least thirty 
pounds more now than in February. The splints are reapplied, and 
will require to be worn a little while longer to complete the cure." 
In a foot-note I find the following record : "It should be men- 
tioned that since the 15th of March (the date of her commence- 
ment to walk upon the shoes) she has continued to walk upon 
her feet, bearing the entire weight of her body upon them, and 
only needed crutches to supply the place of the muscles of the 
leg, which, on account of being confined by the apparatus, were 
unable to balance the body." 
Dr. Lyon left the hospital about this time, and I can find no 
further notes of the case on the records of the Institution. She 
wore the instruments, however, until about the middle of January, 
Fig. 15. 
Fig. 16. 
1865, when they were permanently removed, and a plaster cast 
taken of both her legs and feet, from which Figs. 15 and 16 are 
copies. The motions are almost perfect, and she can walk without 
pain. CHRONIC INFLAMMATION OF THE JOINTS. 
19 
Case IV. Caries of the ankle-joint; seton; recovery. 
B. W., aged 7, of healthy parents, and whose brothers and 
sisters were all healthy, had himself always enjoyed good health, 
until in the summer of 1854, when he injured his left ankle by a 
fall. 
The joint swelled immediately, and was quite painful; but still 
did not confine him to his bed until after four or five days. It 
then became so painful as to prevent motion, and for a number of 
days he was treated by perfect rest, and alternate applications of 
hot and cold water. As he made no improvement, after a few 
weeks his ankle was blistered, and this was repeated every eight 
or ten days for a great number of times, but without any improve- 
ment in his ankle. 
His general health became much affected, with loss of appetite, 
and of sleep; he became greatly emaciated, and suffered intense 
pain constantly, which was greatly aggravated at night by fre- 
quent spasms, or "jerkings of his foot" as he described it. 
The development of the leg and thigh on the affected side 
became arrested, the ankle and foot very much swollen and shape- 
less, a number of sinuses formed leading into the joint, and the 
bones crepitated when the joint was moved. 
Dr. Valentine Mott saw him in July, 1855, and advised amputa- 
tion as the only means of saving his life. The mother, however, 
would not consent to the operation, and I was called to see him 
in consultation with Dr. David Green in October, 1855. Several 
sinuses then existed, leading into the joint, through which the 
probe was passed without difficulty, but coming in contact with 
carious bone in almost every direction. 
On the 21st of October, 1855, I opened the joint freely on either 
side by connecting some of the sinuses, and found the joint carious 
throughout. 
Two setons of oakum were passed through the joint, the one 
laterally, and the other antero-posteriorly; and the foot extended 
in the instrument as in the case of Elizabeth Bruen, above described. 
As the seton was pulled through, a number of small pieces of bone 
were drawn entangled in its meshes. 
When he recovered from the effects of the chloroform he could 
bear pressure on the foot without pain, and would permit it to be 
handled in any direction without complaint, although before its 
application he would not permit it to be touched, and it was im- 20 
ON THE MECHANICAL TREATMENT OF 
possible to move it in any direction, even in the most careful 
manner, without giving him the most intense agony. 
He slept quietly the night after the operation without any 
anodyne, although he had been compelled to use anodynes freely 
for many months, and never resorted to them again during the 
time he was under treatment. 
His general health began to improve almost immediately from 
the time of the operation and the application of the instrument, his 
appetite returned, and he was able to ride out in the open air with 
comparative comfort. The setons were pulled through daily and 
the soiled parts cut off; and the whole ankle constantly sur- 
rounded with oakum saturated in cold water, and sustained by a 
tight bandage. 
For two or three months small pieces of bone were frequently 
found entangled in the fibres of the seton, when pulling it through; 
but the discharge gradually diminished in quantity, became more 
consistent in character, and; as it did so, the setons were gradually 
reduced in size, 'until finally they were a mere thread or fibre. At 
the end of eleven months from their first insertion they were re- 
moved entirely, and the sinuses closed up in a short time after, 
never to be reopened. 
The extension was continued for nearly two years before it was 
removed permanently, although he had walked about for many 
weeks before the instrument was removed. As soon as the sinuses 
had become closed and he could bear moderate pressure upon the 
foot, when the extension was off, without suffering pain, I com- 
menced passive motions daily, by acting on the anterior and pos- 
terior screws alternately, thereby imitating the natural motions of 
the joint. In about two years from the first operation, the instru- 
ment was removed permanently, when he could walk without diffi- 
culty, having considerable motion in the affected joint. This motion 
has very materially increased, and is now (nearly ten years after 
the operation) almost as perfect as the other. The foot is smaller 
than the other, and about half an inch shorter, but he supplies the 
deficiency by a thick sole inside his boot, and can run and skate 
with any of his playmates without the deformity being detected. 
Drs. Mott, Stephen Smith, and other surgeons of this city saw 
this case when under treatment, and, therefore, know that the setons 
passed through the ankle-joint; but as there has been some question 
about it, by others who have not seen the case, I have had his foot 
daguerreotyped on both sides by Mr. Gurney, and the cicatrices on CHRONIC INFLAMMATION OF THE JOINTS. 
21 
either side, giving the entrance and exit of the setons, show con- 
clusively that they did pass through the ankle-joint. (See Figs. 17 
and 18.) 
Fig. 17. 
Fig. 18. 
Case V. Suppuration and caries of the ankle-joint; operation ; seton ; 
extension ; recovery with motion. 
In January, 1855,1 was sent for by Dr. L. C. Ferris to amputate 
the leg of Ella Stanley-aged 5 years-for disease of the right 
ankle-joint. In March, 1854, ten months previous, she had fallen 
from a chair, striking her right ankle against the sharp corner of 
a bedstead. The injury was immediately followed by considerable 
swelling and very great pain. The pain soon subsided, but the 
swelling continued. 
For two or three weeks she seemed tolerably well, but at the 
end of that time she began to limp badly. She was then put upon 
crutches, and various lotions applied to the foot and ankle. 
The disease, however, continued to progress, her general health 
became much affected, with loss of appetite and sleep, and she was 
greatly emaciated. The limb was much smaller than the other, 
but the foot and ankle were swelled into a shapeless mass. In No- 
vember she began to have repeated chills and hectic fever, and in 
the early part of December the ankle opened in several places, 
giving exit to a large amount of ill-conditioned or strumous pus. 22 
ON THE MECHANICAL TREATMENT OF 
Her general health became much impaired, and in January, 1855, 
I was sent for to amputate the limb. Her suffering was most in- 
tense; she would not permit the limb to be handled until she was 
under the influence of chloroform, when crepitus was readily de- 
tected ; several sinuses around the joint discharged quite freely a 
curdy pus mixed with a material very much resembling quince- 
jel]y- 
A probe passed into one of these sinuses, just posterior to the 
internal malleolus, went into and through the joint, making its exit 
at a point in front of the external malleolus. A strip of linen 
(in default of anything better) was torn from the child's dress, 
passed through the eye of the probe, and drawn through the joint. 
A piece of firm sole-leather, cut to fit the front of the leg, and 
dorsum of the foot, having been thoroughly soaked in cold water, 
was then applied over the top of the foot, and secured by a nicely- 
adjusted roller; the foot was firmly extended so as to separate the 
tibia and astragalus, and the roller then carried up the leg, oyer 
the leather, which, when dry, served to extend the joint and at the 
same time prevent all motion. This gave her great'relief, and her 
limb could be moved with comparative comfort. The child was 
put upon the most nutritious diet, with quinine, coddiver oil, and 
iron. 
The dressings were removed and changed as often as they became 
soiled with pus, and in the progress of the case, compression with 
sponges and cold water was resorted to. Her improvement was 
most marked and rapid. At the end of a few weeks the instrument 
was applied, as in the other cases, and with the same happy results, 
enabling the patient to walk with crutches and obtain the benefit 
of out-door exercise, which added materially to the improvement 
of her general health. 
The setons were retained nearly ten months, being gradually 
reduced in size as the bone ceased to exfoliate and the pus became 
more healthy, until for a number of weeks they were hardly larger 
than a single thread. When they were finally removed, the sinuses 
healed in a few days, and passive motion was commenced as in the 
other cases. The patient continued to wear the instrument for 
nearly a year after she was perfectly well, as a means of prevention 
against accident, and then left it off entirely. 
It is now eleven years since this case was operated on, and she 
is as well in the one leg as the other, and the motions are almost 
as perfect. The foot is one size smaller than the other, and the leg CHRONIC INFLAMMATION OF THE JOINTS.' 
23 
a little shorter; but the limb is perfectly developed, as represented 
in Figs. 19 and 20, which were taken from a plaster cast of her 
limb, and which also represent the cicatrices where the seton passed 
through the joint. 
Fig. 19. 
Fig. 20. 
I have treated fourteen cases of the ankle- arid nine of the 
knee-joint, where the disease had extended to suppuration, like 
those just described, and with equally satisfactory results, and have 
now under treatment two others, with setons through the joints, 
that are progressing favorably; but as they differ but little from 
those described, which I have selected as typical cases of the so- 
called strumous suppuration of the joint, I have not thought it 
necessary to report them in detail, as it is only a repetition of the 
same general principles of treatment, and adds unnecessarily to the 
length of my paper without conveying any new ideas. 
I have also treated an immense number of cases of chronic in- 
flammation of both the knee- and ankle-joints, that had not yet 
progressed to suppuration, by means of the instruments only, with 
the most satisfactory results, and have taught for a number of years 
that others should do the same. I will close this paper by quoting 
the report of a case furnished me by Dr. Robert Newman, of this 
city, who had treated it according to my suggestions, and, as it 24 
ON THE MECHANICAL TREATMENT OF 
represents many other cases treated in the same way, will save the 
necessity of further repetition. 
Case VI. " Chronic inflammation of the right ankle joint; talipes 
equinus; operation; recovery. 
"Kate Dooley, 279 West 39th Street, set. 17, single, presented her- 
self in June, 1864, wishing to be treated for rheumatism. She 
came upon a pair of crutches, and even with these could hardly 
move on account of sores produced in the axillae. She was suffer- 
ing from chronic inflammation of the right ankle-joint, which had 
caused contraction of the muscles to such an extent as to produce 
the extremest form of talipes equinus. This affection had existed 
nearly four years, the result of a severe sprain, and the deformity 
had lasted two years in the same position as at present. The 
patient was unable, herself, to move the foot, any effort on her part 
to do so causing severe pain in the ankle-joint. Pressure or rota- 
tion both aggravated the pain intensely, but firm, gradual exten- 
sion relieved it. Diagnosis: inflammation of the cartilages within 
the ankle-joint. A consultation with Dr. Sayre confirmed this 
diagnosis; and it was concluded to apply his splint for extension 
of the ankle-joint. 
" July 19, 1864. The general condition of the patient was 
bad, she was very anaemic, and suffered from loss of appetite, head- 
ache, and constipation; her right foot and leg were both atrophied. 
The contraction of the gastrocnemius had existed so long as to 
render extension of it impossible without first dividing the tendo 
Achillis, which was accordingly done by Dr. Sayre, subcutaneously, 
without the loss of any blood, and the wound covered with adhe- 
sive plaster. The foot was then brought to a right angle with the 
leg, and the splint applied? 
" After the application of the instrument, the patient could stand 
on her feet immediately in a natural position, without any aid. 
" For the next two days and nights she complained of soreness 
and some pain. There was scarcely any febrile movement present, 
" July 22. She had passed a comfortable night, and felt well. 
" August 1. She has been perfectly comfortable, and free from 
1 My usual custom is not to apply the instrument until several days after sec- 
tion of the tendon, or until the external wound has entirely healed ; but in this 
case I could not make a second visit, and therefore applied the instrument imme- 
diately after the operation. CHRONIC INFLAMMATION OF THE JOINTS. 
25 
pain since the last note, and to-day got up and walked about the 
room without any assistance, even of a crutch or cane. 
"27$. The instrument was reapplied. The patient walked to 
my office with the assistance of a cane, and the same day went to 
the country. 
" May 19, 1865. The patient has improved steadily since the 
last note. Great annoyance has been occasioned by the breaking 
of the instrument, which was not strong enough to bear her weight, 
and which once caused a slight relapse. 
"Since October last, she has done all her own house-work, and 
many errands. On the 15th of May, while the instrument was 
being repaired, I surprised her by an unexpected visit, and found 
her walking about at work, with not even a bandage upon her foot. 
She had not the slightest pain, though after being a long time on 
her feet she felt very tired. All the motions of the joint were per- 
fect; but it was thought more judicious to reapply the instrument 
for a few months, which was accordingly done. 
"The limb has regained its natural size, and her general health 
is perfect."