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PROVINCIAL MEDICAL & SURGICAL JOURNAL.
DESCRIPTION OF AN APPARATUS FOR for carrying out the above measures, and at the same
INJURIES AND DISEASES OF JOINTS, / time to direct more attention than it appears to me WITH OBSERVATIONS AND CASES. has hitherto been done, to the quiet treatment which By BENJAMIN BARROW, Esq.,
| diseases and injuries of the joints in every stage require. Fellow of the Royal Medico-chirurgical Society, and
I believe it will be found that by the aid of the formerly Resident Surgeon at St. Bartholomew's splint, * represented in the cut, Fig. 1, the objects Hospital, London.
just named may be efficiently carried out, as also the The following observations are submitted to the
views and directions of Sir Benjamin Brodie most fully public in the hope that they contain some novelties,
complied with. These views and directions I cannot the knowledge of which will be found useful in the
do better than give in his own words,-be says, “Not management of diseased and injured joints.
only in cases of inflammation of the synovial membrane,
but in all other cases in which actual disease of a joint An almost constant attendance for ten years at St.
exists, the disease, whatever it may be, is kept up and Bartholemew's and other large Metropolitan and Con.
aggravated by motion and exercise, and whatever tinental Hospitals, and some years of private practice,
means can be employed so as to keep the joint in a bare afforded me in the first place, many opportunities
state of complete repose will go far towards the producfor comparing the various modes employed in the treatment both local and general of injuries and dis
tion of a cure. In the early stage of acute inflam. cases of joinis; secondly, the results arising from these
mation of the synovial membrane, indeed no inter
ference on the part of the surgeon is necessary for this various plans; and lastly, how the means and appara. tas in general use might be improved and deficiencies
purpose, the pain which the patient experiences, in supplied. I must premise that it is not my intention to
| every attempt made to use the limb being sufficient to
prevent him using it. But it is otherwise when the edier more minutely into the history of these cases,
inflammation has in a great degree subsided. At this either as regards the course they run, or the treatment
period the motion of the joint occasions little or no ordinarily employed, than may be necessary for the
inconvenience at the time, although it invariably tends clear explanation of the apparatus which I am desirous
to aggravate the symptoms afterwards. It is difficult of introducing to general use; for the valuable treatise
to persuade a patient thus situated to submit to a very upon the subject of the diseases to which joints are
rigid system of confinement, and if he should do so, liable by Sir Benjamin Brodie, precludes the necessity,
tbere is always danger in protracted cases that his I might say the possibility, of any subsequent writer,
general health may suffer in consequence. It is im. bowever great bis experience, adding to it any important information.
portant that he should not be altogether deprived of The prominent position wbich the joints, especially
the opportunity of taking air and exercise; yet it is ibe elbow and knee, hold in the human frame, augments
necessary that the affected joint should be kept in a
state approaching as near as possible to one of comconsiderably their liability to receive more frequently
| plete repose. This double object may be attained than other parts of the body external injuries ; no parts are so prone to inflame as the joints; in no part
by means of a proper bandage applied so as to
restrain the motions of the joint, at the same time berein inflammation has once set up, does it increase
that it makes no more than a moderate degree of 60 rapidly as in the synorial membrane, which renders it so much the more important that all motion in
pressure on it. As to the best mode of carrying this
plan into execution, the surgeon must exercise his own joint should be immediately restrained and altogether prevented after the first appearance, however slight, of
judgment in each individual case. If the disease be
far advanced, and there is davger of the cartilages inflammation, at the same time that all necessary local remedies are efficiently applied. To obtain this
• The Society of Arts of London awarded the silver end bas been my object, and to explain the requisites -medal for the year 1811, for this apparatus.
No. 2, Jangary 27, 1847.
being ulcerated, he will find it prudent to restrain the motions of the joint altogether.”
Upon these observations I must venture to make one or two comments. The first I would offer is, that there has always appeared to me to exist, even from the commencement of inflammation in the synovial membrane, the greatest necessity for keeping the affected joint perfectly at rest ; for although pain however severe, be present in the first stages of the attack, and to such a degree, as in a great measure to prevent all voluntary motion, still we must all be sufficiently conscious of the many involuntary morements as it were, to which our limbs are subject, whether waking or sleeping, not to trust altogether to this pain as a restriction from motion,-motion which must more or less aggravate and increase the irritation already existing in the joint.
The great difficulty of restraining motion in, and avoiding pressure upon, the joint, at the same time that the full and complete application of all remedies necessary for the prevention of inflammation and alleviation of pain is carried on, has been, I am weil aware, most frequently the cause of this part of the treatment being neglected; but I am in hopes that the
apparatus represented by Fig. 1, will be found calculated I to overcome, on future occasions, every similar obstacle.
Description of Cuts.
(cc)-The arc or bow. d d, the screws which bind together the two portions of the arc or bow. e e, the
from, one another. ff, the screws which confine the portions of arc or bow in the grooves e e. Fig. II.-Represents the screws or stops which allow of the two portions forming the arc or bow to move to a
certain extent one upon the other. Fig. III.-Represents one portion of the arc or bow removed from its groove. Fig. IV.- Represents the wooden splint, with its straps and buckles attached.
That air and exercise are highly necessary, especially | admit the small screws or stops represented by Fig. 2, for those persons who are so frequently the subject of and which allow of our giving to the diseased joints, (viz., the scrofulous,) no one will joint moderate and gradual motion and deny. This end can, by means of the splint in question, extension; the binding screws d d being
9 be most fully attained, during the whole progress of then removed, a strap may be fastened to cure of any disease or injury, allowing the requisite any of the brass buttons 0 00 00 0, fixed to the splints : remedies to be at the same time continued, no pressure and this being carried round the neck and shoulders being applied to the joint itself, a most prejudicial | answers the purpose of a sling. practice, particularly as regards the kneo-joint, where
In addition to the cases to which I have alluded as the patella pressing upon the articular surfaces of the likely to be benefitted by the use of this splint, I may femur and tibia must, by the consequent friction, very add that it is extremely serviceable in cases of fracture much increase the injury already inflicted upon the of the patella, fully answering the purpose of all joint by the previous inflammation, at the same time
bandages hitherto employed, and which more or less that it keeps up the irritation.
interfere with the application of remedies, and with the I may here remark that the apparatus I am about to joint itself. The two splints a a beiug brought as near describe has been invented some length of time, but I as required, one to the upper, the other to the lower, have delayed presenting it to my professional brethren end of the fractured portions, pressure as much as may until I had tested its utility in all those cases for which be necessary to keep them in apposition and close con I considered it peculiarly adapted. It will be well also
nection can be inost effectually accomplished, and kept to observe, that the arc or bow, (c.c., Fig. 1,) which pre.
ich pre up as long as there is that disposition to separate, sents an awkward appearance, but with which I cannot |
| which so frequently takes place as a consequence of discover the possibility of dispensing without very the strong action of the inuscles attached to, and surmuch impairing the value of the apparatus, may be
rounding the upper portion of the patella. unsighuy, but still not inconvenient nor unnecessary,
In like manner may the splint be most advan. affording as it does complete protection to the joint, tageously applied in cases of fracture of the olecranon, whether the patient be in bed, or op and about. A
especially when the triceps muscle is strong, and we blow upon it when the splint is applied to the arm con. find the fractured portion drawn upwards some distance veys no shock to the joint, the whole limb moving
from the ulna. No accident is so likely to produce together from the shoulder. The same applies to the mischievous consequences to the joint, and interfere kpee, when the splints are placed, one above, the other with its after utility, as fracture of the ulna, unless below, the joint. It will be observed, that the two properly attended to in the first instance. splints (a a, Fig. 1) are split, to allow of their close Contraction which so often follows inflammation of adaptation to the limb; they must be padded, and the joints, may be completely prevented by applying then firmly fixed, by means of the straps and buckles, the splint in the early stages of the attack; and even bb, bb, (or by what would be much better, a piece of should contraction hare taken place, it may be overelastic webbing, extending the whole length of either come by means of the splint, the angle being changed splint, and laced at the side, for the narrow straps are gradatim, the joint being at the same time fomented and very apt to act as ligatures, and to cause much pain and rabbed as may be desired. The great difficulty in the first uneasiness from their unequal pressure,) one to the place in preventing these coutractions, and in the second, upper, the other to the forearm ; or the one to the in overcoming them, has hitherto been the want of some thigh, the other to the leg, as the case may be. The apparatus which would leave the joint perfectly free, two splints are connected by the steel arc or bow cc, patients being unable to endure the pain consequent which is formed of two pieces, sliding one upon the upon constant pressure. I, in common with every one, other, in order to allow of the limb being brougbt to under whose care even a single case of contraction of any angle, or placed straight, as occasion may require. ( the elbow or knee-joint has fallen, have had many occaThis being accomplished, they are fixed by means of sions of observing, that unless the action be constantly the screws, d d. Thus the two divisions of the limb are persevered in, the limb, in a very short space of time, as it were connected, and consequently the joint kept regains its previously-contracted position. perfectly at rest; at the same time being, as I have The splint will be found a useful adjunct to the before stated, quite free for the application of all means already employed in the treatment of those necessary remedies. It will be farther noticed that cases in which the tendons of the hamstring muscles the two steel portions forming the arc or bow move in are divided, on account of contraction or partial anthe brass grooves e e, in order to allow of the splints chylosis of the knee-joint. being moved nearer to or farther from the joint, as I have no doubt but that this apparatus will likewise circumstances may arise; the bow being again firmly afford most important aid in those cases in which the fised in the grooves by the binding screws Sf. The extirpation of the articular ends of the bones may be boles observable on one of the steel portions are to necessary; not only will it be found useful in main.
taiping the limb at the required angle, and keeping the limb would have almost regained its right-angular it perfectly at rest after the operation, but it may be position. To obriate as much as possible this incon. applied before the operation, supplying the place of venience, and consequent retarding of the cure, an assistani, holding the two divisions of the limb
| whenever my splint was removed, I directed the foot much more steadily than can be done by the firmest
to be tied to a foot-board, and a straight splint to be hand, and not at all interfering with the surgeon's
placed against the patient's heel and thigh. This
plan had the desired effect of preventing the frequent manipulations, the joint being free in its entire cir.
CASE II By slight modifications in the shape and size of the Occurred in a boy of about seren years, who was splints, and length of the straps, any joint in the body afflicted with a diseased elbow, bearing in every respect may, by means of this apparatus, be kept perfectly at a strong resemblance to the knee-joint just described. rest, and guarded from external violence.
The left arm was almost disabled ; the swelling about It is well here to add, that the splints require most the joint was very considerable; the bones were discarefal padding and adjustment, for at some angles it tinctly felt to grate one upon the other, sbewing that will be found that either the apper one will be raised
| the normal condition of their articulating surfaces was
destroyed. Quietude, and a due application of proper and the lower one depressed, or vice versa. In such
local remedies, were the only chances of saving the cases, unless the padding be good, inconvenience will
limb. The rest was most effectually preserved by be experienced by the patient, undue pressare being
means of my joint-splint, and which allowed at the made on the soft parts.
same time of as complete an application of remedies as Thus hare I endeavoured to explain an apparatus could be desired. In this case the apparatus was kept most simple in its mode of action, easily managed, and applied for nearly five months, which perseverance made at a very moderate cost.+
was followed by the gratifying result of a fairly I have selected from many others the following useful arm. cases, in which I have employed my joint apparatus
CASE III. with the greatest advantage, and wbich I here recite A young man, of twenty.four years of age, whilst without any comments as to the general and local
walking, slipped and fell, striking bis elbow violently treatment specifically used, and which were of course
against the curb-stone. When I first saw him, about regulated in the various cases, according to their
two hours after the accident, the limb around the elbow
joint was enormously swollen and bruised, so much so requirements: CASE I.
as to preclude the possibility of ascertaining whether A boy, aged ten years and a half, came under my
there was fracture or not of either of the bones. I Dotice, being a fiicted with that condition of the right
immediately fixed upon the arm my joint-splint, applied kdee.joint, so common in scrofulous children. He had
cold lotions, and on the following morning, about
thirty hours from the time of the accident, the swelling suffered more or less from this affection for several years;
had much subsided, and I detected a crepitus, proving abscesses bad formed, broken, and healed, from time to
that the olecranon was fractured. I put the arm in time; the leg became bent at right angles to the thigh, and thus the lad was almost incapacitated from moving
that position best adapted for such an accident, and then about, except by hopping upon ove leg, with the aid
replaced the splint at the required angle. The lotions, of a crutch. The least pressure upon the patella caused
&c., were continued, and every thing went on most
prosperously, indeed there was not one drawback; the bim so much pain, and increased the swelling so considerably, besides inducing inflammation, that uny
union of the bone was perfect in about three weeks; plan for gradually extending the leg, which in any
the motions of the arm were not at all impaired. The way interfered with the joint itself, was obliged to be
perfect quiet, and the constant application of the
necessary remedies from the first, without any pressure abandoned. I recommended the use of my splint, which was
upon the joint itself, may in a great measure account accordingly employed for a lengthened period, at the
for the rapid decrease in the swelling, for the absence same time that fomentations and soothing applications
of all after inflammation or inconvenience, as also, for were constaotly used around the joint. The angle of
the speedy and perfect union of the fractured bone. the splint was changed at first about twice a week, and
CASE IV. then every other day, until the position of the limb! A little girl, aged eight years, was brought to me on was so much improved that the boy could walk tolerably account of a contraction at the bend of the elbow, folwell, at the end of three months, without the aid of lowing a burn. I loarnt that the accident had occurred trutch or stick.
some five years previously from her wearing-apparel The boy sometimes during the progress of this cure catching fire; that during the time the wound was. complained of so much pain that it was found neces. healing the arm became bent; that the cicatrix bad sary to remore the apparatus. In twenty-four hours been divided twice, and that on the last occasion a
• A much larger bow than is necessary in most cases Bartholomew's Hospital, has always manufactured my might be attached to the splints during the performance of splints, &c. I would advise all who employ this apparatus, the operation.
to have the bows made of steel and not brass, for the latter + Mr. Ferguson, surgical instrument maker to si, material adds much to the weight of the splints,
portion of the bardened skin had been removed ; tbat | THE LAW OF THE MORPHOLOGY OR META. considerable difficulty had been after each operation
MORPHOSIS OF THE TEXTURES OF THE experienced in keeping the arm extonded, during the
HUMAN BODY. progress of the healing of the wound, caused by the division of the cicatrix, and that a common straight
(Fourth Series of Experimental Researches.) splint had been fixed upon the back of the arm, but By William Addison, M.D., F.R.S., Malvern. from the pain and uneasiness consequent upon its
I. VegetABLE TEXTURES. constant pressure, it was found necessary to remove it very frequently, and at last to abandon its use altoge. The science of morphology, which treats of the ther. I placed upon the arm my apparatus, and with gradual transformation of the primary elements of & scalpel, just slightly divided the cicatrix upon the vegetable structures into the various special organs of first day, placing the arm at the angle which this division the species, has long formed an interesting and essential allowed, without causing pain, and there fixed it by department of physiological botany. The plan upon means of the joint-splint. Two days subsequently I
which the metamorphosis takes place, “is"-according again saw the child and effected another division of the
to Dr. LINDLEY—"notwithstanding the infinite variety cicatris, about an inch from the first, again altering the
observable, extremely simple, and executed by modifiangle of the arm, and at the same time that of the
cations of the leafy texture." splint. This operation I repeated at five different periods at
If the structure of a leaf of flowering plants be careabout three days' interval, and at each time placed the fully examined in very thin sections, with a sufficiently arm and splint at the angle which I found compatible high magnifying power, (750 diameters linear,) it will with the child's comfort; the arm had become perfectly be found composed of two distinct cellular elements, straight in about six weeks; the splint was, however, a fibrous tissue, spiral vessels, stomata, and an inmense still retained upon the limb, the straight position being assemblage of air-vesicles, or air-bubbles. On the occasionally changed for an angle more or less acute as upper surface of the leaf, is a thin transparent homo. the fancy took me, thus avoiding the chance of tiring my
geneous membrane, divided into a number of cellular patient. During this latter period I ordered friction and
compartments irregular in form and outline, and fomentations, whereby I succeeded in softening very
variable in size in different species of plants. On the much the cicatrized skin. The arm in about three
under surface is a similar membrane, in which the months had almost regained its natural appearance, and its usefulness is as great as that of its fellow
cellular compartments are thickly interspersed with
the stomata. The cellular compartments and irregular Case V.
outlines thus visible on the under and upper surfaces A man, thirty-six years of age, had the misfortune
| of the leaf, are the exterior outer portion of a very to fail and fracture his patella; he did not apply for surgical aid until soupe hours after the occurrence of
fine and strongly coherent cellular texture, running the injary, imagining that he had only bruised his
through the entire thickness of the leaf, and so disposed knee. Finding, howerer, that it became much swollen
as to form numerous divaricating air-passages connected and very painful, he thought it advisable to seek relief, with the stomata.* Within the meshes of this coherent and upon examination I readily discovered that the cellular texture, around the walls of the divaricating abore-named accident had occurred. I applied my intercellular air-passages, and in close apposition with apparatas, the upper edge of the lower splint pressing the air contained within them, is a less coherent cellular against the inferior portion of the patella, and the
element or texture, consisting of smaller and but lower edge of the upper splint against the superior
slightly adherent corpuscles or cells filled with the porion of the fractured bone. The two portions had
green granules of the chlorophylle, each granule con. become widely separated in consequence of the attempts
sisting of a number of minute molecules. made to walk and move after the fall, but this space was day by day much decreased by the gradual move.
The term cellular tissue or texture has been indisment of the wooden splints nearer to each other, and criminately applied to so many portions of vegetable which of course at the same time approximated the structure, that it is necessary to state prominently the fractured surfaces of the patella. Leeches, poultices, point which a careful microscopical examination of a and fomentations were during this period and until the leaf appears to me to establish between the coberent limb was restored to use, frequently and satisfactorily | cellular textures, the cuticle and supporting frameapplied; whilst the joint and fractured bone were kept | work, and the incoherent cellular texture forming the perfectly at rest and all muscular action overcome by
parenchyma. the constant application of ibe joint.splint.
If a thin section be taken from the main rib, or any I may mention that the limb was elevated in this
of the other ribs of a leaf, the cellular texture disclosed case, as is usual in such accidents, at the same time that ibe splint was employed. These two measures com
has the following properties and appearance. It is bined, caused the patient no inconvenience, but on the
strong and coherent; the spaces of the cells are contrary were a source of much comfort, and decidedly
* These air-passages when a section of the parenchyma tended to the rapid and solid union of the fractured
has been made, display oval foramina, similar to those seen patella.
in a section of a lung.