THE RADICAL CURE OF- HIP-JOINT DISEASE. 
By REUBEN A, VANCE, M. D., Cleveland, 0. 
Professor of Operative Surgery and Clinical Surgery in the Medical Department of the University 
of Wooster ; Consulting Surgeon to Charity Hospital ; Honorary Member of the 
•Cincinnati Academy of Medicine, etc. , 
Extracts from a Lecture delivered at the Joint Session of the N. E. O. and the N. C. O. 
Medical Associations, Akron, O., 1882. 
In introducing the subject of “The Radical Cure of Hip-joint Disease,” I do so, well knowing 
that in order to state my conscientious convictions, I shall have to enunciate principles diametrically 
opposed to those advanced by the leading authorities on articular affections. Educated under the 
eye of one who to-day enjoys a world-wide reputation in this branch of Surgery, it would be far 
more agreeable for me to dilate upon the acknowledged skill of this admirable surgeon, than to place 
myself in opposition to him. For years his faithful follower, and as a medical teacher the zealous 
exponent of his peculiar vie\ys, it was only when I could no longer blind my eyes to the connection 
between the measures adopted and the unsuccessful results I attained, that I ventured to test the 
sufficiency of his principles and the merits of his practice. Then I saw, but too clearly, how incor- 
rect was the pathology I had believed in, and how erroneous the treatment I had adopted. 
Hip-joint disease commences in inflammation either of the joint, or of the osseous tissue near 
the articulation,—occasionally in both. These lesions are readily curable. The hip-joint, like every 
other articulation in health, is admirably fitted for the performance of its function—the resistance of 
pressure and the facilitation of motion. With disease of the hip comes inability to perform its nor- 
mal offices; motion and pressure are as much restrained by voluntary effort as by reflex muscular 
contraction. If the joint be in any way moved, the nerves in and near the articulation are irritated, 
and irregular but powerful muscular movements are evoked. These muscular contractions force the 
diseased articular surfaces together and give to the extremity various characteristic positions. In a 
few cases synovitis of the hip-joint, or ostitis near the articulation, recovers spontaneously. In these 
cases one fact is always apparent: The joint is kept motionless with the leg and thigh fixed in one 
position—in these patients there is no muscular spasm, and none of the phenomena so common in 
cases where motion of the joint is permitted. If motion be permitted at the diseased joint, the 
evidences of synovial inflammation or bone disease are speedily supplemented by muscular spasm 
and excruciating pain. The various groups of muscles that unite the extremity to the trunk are 
called into action; the thigh is fixed in one position and flexed on the pelvis; and the head of the 
femur is violently forced against the upper and back part of the socket. With sleep comes an inter- 
ruption of the control previously exercised over this part; spasmodic, intermittent contractions ensue, 
and develop the night pains so characteristic of progressive disease of the joint. In this way motion 
and pressure produce absorption of the opposed surfaces and cause purulent arthritis. Unfor- 
tunately, the foregoing phenomena are not limited to cases of morbus coxarius, running an unre- 
strained course—they may attend any case of hip-joint disease, during the treatment of which 
motion is permitted at the hip-joint. 2 
Professor Lewis A. Sayre has identified himself with a system of articular therapeutics, in which 
motion of the inflamed joint surfaces, during treatment, is a cardinal principle, and his extensive 
attainments, great reputation and known ability, have caused this system to be adopted not only by 
the medical men of his own country, but by the profession in almost all parts of the civilized world. 
In view of this fact, I would ask you to consider Sayre’s pathology of hip-joint disease before 
reviewing the treatment he advises for this affection: 
Professor Sayre divides hip disease into three stages : one of irritation; a second of effusion ; 
and a third of rupture of the capsule. In the first stage he says there is lameness, with flexure of 
thigh on pelvis; in the second, the capsule is distended with fluid, and, as a consequence of this 
distension, the limb is flexed, abducted, everted and apparently lengthened; while in the third, the 
capsule having ulcerated, or the acetabulum become perforated, the fluid is either effused into the 
tissues of the thigh, or discharged into the pelvic cavity—the limb becoming at once adducted, 
inverted and apparently shortened. Here certain positions of the extremity are ascribed to given 
anatomical conditions of the hip-joint. Is this correct? Isay, most emphatically, that it is erro- 
neous.—that these different positions are not due to the presence or absence of fluid in the hip-joint, 
but are wholly due to the influence of irritated nerves acting upon powerful the 
upper end of the thigh. How can you test the truth of my statement ? Readily enough : by 
aspirating a distended hip-joint the exact condition is produced that Sayre declares to be the essen- 
tial element in converting his second into his third stage of hip-joint disease. If Sayre is correct, 
by aspirating the distended joint, the abducted, flexed, everted and lengthened extremity of his 
second stage should instantly become the adducted, flexed, inverted and shortened limb of his third 
stage. But in my hands aspiration has been demanded for the relief of a distended hip-joint, when 
the limb was flexed and everted, without causing any change in the position of the extremity; and, 
finally, I have resorted to it for the purpose of removing the fluid from the hip-joint of a patient 
whose thigh was flexed, adducted and inverted. In view of these facts—and, fortunately, they are 
such that any surgeon can test their accuracy himself—I am compelled to pronounce Professor Lewis 
A. Sayre’s explanation of the mechanism of the physical phenomena of hip-joint disease demonstrably 
untrue, and his division of the stages of the affection contrary to the plain facts of Nature ! 
Every attentive student of pathology is aware that the joint structures of the body in health are 
non-sensitive ; in disease, however, they are exquisitively sensitive. In health they are adapted for 
motion, and can withstand pressure; when inflamed the slightest movement induces excruciating pain. 
When a joint becomes diseased, Nature exerts all her powers to keep that joint absolutely motion- 
less. The only machinery at her command is the muscles ; these contract and hold the limb firm 
and the joint still. The position the limb assumes depends upon the relative strength of the 
various groups of muscles, and the extent to which the joint is implicated. A knowledge of 
these few facts furnishes invaluable aid in both diagnosis and treatment. By observing the 
course of cases in which no treatment—or what is exactly the same, a treatment that permits 
the joint surfaces to move upon each other—is adopted, it is seen that the joint becomes more 
and more flexed; that, up to a certain period, the angle of flexion corresponds with the dura- 
tion of the disease; and that, although the apparent shortening and lengthening are due to the 
groups of muscles called into action, and the period they continue contracted, still it can be 
stated, as a fact of observation, that flexion of the thigh upon the abdomen, slight adduction 
and eversion accompany apparent lengthening of the extremity, and precede marked adduction, 
inversion and apparent shortening, just as in the order of clinical phenomena, apparent shorten- 
ing precedes real shortening. 
The diagnosis of Hip disease, after it has persisted for a length of time, is a very simple 
affair. Its recognition in an early stage is occasionally a difficult problem. It is a matter of 
vital moment to the patient to have the disease recognized early in its course, for in the hands of 
surgeons, guided by true principles, its cure is then a certain and simple matter. Fortunately, 
the rules for diagnosis are as easy of application, and as sure of success, as the principles of 
•treatment are fixed and immutable. The manner in which the surgeon should proceed is as fol- 
ws: Strip the patient, and place him flat on his back on a hard table covered with a sheet- 3 
Arrange him so that the line which marks the junction of knees and feet, when the lower ex- 
tremities are extended and in contact, if drawn upwards should bisect symphysis, navel and 
sternum ; then, if one limb be flexed more than another, elevate the knee of the latter until both 
knees are together, and the two feet side by side. This done, note the position of the lumbar 
spine, and observe the effect of alternately depressing each knee until its popliteal space is in 
contact with the table, while its fellow remains flexed. The knee on the healthy side can be 
depressed without increasing the space between the spine and the table, but whenever the knee 
corresponding with the diseased hip is depressed the lumbar spine curves, and makes the space 
between it and the table greater. This points out the site of the disease, and indicates beyond 
question the hip affected. Then the surgeon grasps the healthy limb and flexes it so that the 
knee is in contact with the chest—this places the sacrum, the lumbar spine and back of the chest 
in the same line; while this position is maintained, the patient is urged to extend to the utmost 
the diseased limb—this he will be able to do in exact proportion to the length of time the disease 
has lasted, provided it has not been in existence more than one year. The angle the partially 
flexed extremity makes with the longitudinal axis of the body is a very important one, inasmuch 
as by simply measuring it the surgeon can approximate with great accuracy the course of the 
affection, and estimate with precision the duration of the malady during the first year of its 
existence. 
While Nature aims to fix the joint and hold it as nearly motionless as possible—a procedure 
that effects a cure in a small minority of cases, it matters not what the surgeon does so he leaves 
the part at rest—yet the advantage gained is complicated, to a perilous degree, by dangers arising 
from the pressure together of the diseased surfaces. Nature strives to fix and hold in one position 
the diseased surfaces ; the only mechanism at her command consists of groups of muscles varying 
in power and relative excitability, and agreeing in but one thing—in the degree of force 
with which they can make the femur press against the acetabulum. Consequently the longer 
Nature, unaided, is permitted to contend against synovitis, or ostitis and synovitis of the hip, 
the more will the articulation suffer, and the greater the danger of caries and prolonged suppur- 
ation. Until the joint gives way before the powerful compression of the irritated muscles—a 
lesion readily explicable when the influence of local inflammation is added to the effect of absorp- 
tion from constant pressure—the position of the extremity will depend upon the comparative 
power of the opposing groups of muscles. Experience shows that for the first nine months the 
thigh becomes more and more flexed upon the pelvis ; that the area of greatest disease passes 
from above gradually downward over the posterior superior quadrant of the circle of the 
acetabulum. 
Nature here, as in so many other regions of the body, plainly indicates the character of the 
treatment that must be adopted to secure success. Let the surgeon do what Nature is vainly 
trying to do—fix the limb firmly in whatever position it chances to occupy—and at once all 
irregnlar muscular action ceases. With efficient fixation comes a tendency to extension of the 
thigh, for it is kept flexed by but two agencies, the action of the muscles and the ensheathing-callus- 
like influence of inflammatory exudation about the joint, and in a few days, with little effort, and 
no pain, the thigh is brought iniu line with the body and the extremity straightened. This done, 
but one other thing is needed for a radical cure; that is, to give the diseased part rest until 
resolution occurs. Fixation of the extremity and rest of the inflamed parts, are the principles 
upon which Nature cures hip-joint disease. Motion of the joint, by irritating the diseased sur- 
faces, not only prevents repair, but by evoking excessive muscular action, may cause destruction 
of the articular structures. 
H ow fare the various popular systems of treatment for hip-joint disease, when brought to 
the bar of Nature and tested by Nature’s principles? Look at the hip-joint appliances known by 
the names of Davis, Sayre, Bauer, Hutchinson, Andrews or Taylor. The splints devised by 
these surgeons are all designed to favor that which Nature strives to check—motion at the hip. 
How is it with extension by weight and pulley, the foot of the bed being elevated and the weight 
of the body acting as a counter-extending force ? Nothing could thwart Nature more effectually 4 
unless it be the above splints; the latter permit the diseased surfaces to move, thus exciting 
muscular spasm; the former acts directly upon the muscles and evokes reflex contractions ; in 
both, Nature’s endeavov to fix the joint is foiled. In one respect extension by weight and pulley 
is less disastrous than splints permitting motion—the application of the former necessitates con- 
finement to bed, and despite the injury arising from constant stimulation of the muscles, the 
recumbent posture and incidental rest in a measure counteract the harm done. In so far as the 
popular mechanical treatment of the day permits motion at the hip, or employs extension, its 
.effect is injurious to the patient. The appliance of greatest benefit to the patient is one that 
fixes the extremity and holds the joint motionless. What a diseased joint wants is just what a frac- 
tured bone needs—efficient, enforced and sufficient rest! 
This all-important rest can die obtained tor the hip by appliances based upon the principle 
.of either lateral fixation, or posterior fixation—preferably the latter. In apportioning apparatus 
to an extremity, and determining the kind of fixation and the degree of rest necessary for the 
cure of hip-joint disease, each case must be judged upon its own merits. Take a patient with 
morbus coxarius at any stage, and treat him upon the principle just set forth and he will recover 
with a rapidity unknown to any other method. Not only that: this treatment will cure patients 
whose cases will resist all other therapeutical procedures. 
In order to secure such results, certain details that can only be briefly alluded to here, must 
be carefully attended to. If the synovial cavity contain fluid, it must be removed ; if the leg is 
flexed on the thigh and the thigh on the body, the deformity must be relieved , and, finally, the 
fixation must be maintained and the rest continued, not only until all tenderness disappears and 
all inflammation subsides, but until all the callus-like induration about the joint has been absorbed. 
Tn order to dispose of fluids that accumulate in the joint, the aspirator can be resorted to. 
There is but one rule to guide the surgeon in this matter; the joint is to be kept free from liquid 
effusions, and the aspirator should be used sufficiently often to attain this end. The influence of 
reflex muscular contraction in producing the deformity characteristic of this affection has been 
Sufficiently dwelt upon; the surgeon who will apply a posterior fixation splint to one of these 
extreme cases, will have an opportunity of noting the fact that, so soon as his apparatus relieves the 
THE WEIGHT OF THE LIMB AT ONCE TENDS TO STRAIGHTEN THE EXTREMITY AND 
relieve the deformity. If his splint is one that can be moulded to the part as the extremity 
extends itself, no other influence than fixation and rest will be required to restore the parts to an 
extended position. The joint freed from effusion and the limb relieved of deformity, the poste- 
rior fixation appliance should be worn bv the patient until all pain has disappeared from the 
joint. The recumbent posture that the patient assumed when the apparatus was first applied, 
#nd which has been continuously maintained thus far, should not be deviated from until no 
reasonable amount of manipulation of the diseased articulation excites pain in or around the joint. 
When this state has been attained the splint can be removed, but the patient should still keep 
his bed. It will frequently happen that even after the joint has recovered, a certain amount of 
the inflammatory induration—one of Nature’s conservative provisions to limit motion in cases of 
articular disease—early effused, still remains and demands the stimulus incident to commencing 
motion of the joint for its absorption. If the joint has recovered, a few weeks of recumbency 
without fixation-splint suffices for the removal of the induration about the joint and the restora - 
tion of motion at the hip. Should the induration persist, or should it disappear without the 
articulation recovering its freedom of motion, ?nore or less disease of the joint remains and the splint 
should be reapplied. 
Above all things, do not call this “Fibrous Anchylosis,” or “ False Anchylosis,” and try to 
cure it by passive motion. As well endeavor to cure vascular keratitis by putting sand in the 
eye! The “stiff” joint that follows articular inflammation is an uncured joint, and the only true 
method of relief is to reapply your fixation-splint, and give it that rest which Nature demands 
as the condition of its cure.