The Mechanical Treatment of Hip Disease.* ByJjEYNOLD W. 
I Wilcox, A. M., M. D., Clinical Assistant at the Post-Graduate 
School of Medicine, Physician to the North-Eastern Dispen- 
sary, New York City. 
Among the mechanical appliances used in treating hip disease 
we may find almost any idea expressed in apparatus. The prin- 
ciple that rest is essential in joint disease is as old as the art of 
healing, but it is the manner of obtaining this rest that has ren- 
dered the solutions of the problem so varied. The modern me- 
chanical treatment falls under three divisions; 
1. Extension with more or less fixation, 
2. Extension with no especial provision for fixation, 
3. Fixation more or less complete. 
With the first class, extension with more or less fixation is 
attained with the weight and pulley. At once there comes up 
the question whether or not we can relieve the mutual pressure 
upon the articular surfaces. At the outset we are met by two 
objections : 
1. The weight and pulley usually, if not generally, are attached 
to the leg by adhesive plaster so that the pull is upon the skin 
and not upon the bones, except indirectly. The elasticity of the 
skin, then, certainly prevents the weight from putting its whole 
energy upon the joint. Again, the skin being freely moveable 
in some places,.at others, notably the line at Poupart's ligament, 
we find it firmly attached, so, this point of attachment being 
above the joint the weight again failsof exerting its whole energy. 
However it must be borne in mind that some pull is obtained 
from the condyles of the femur. 
2. The weight extension is usually applied in a line parallel 
to the long axis of the body and not in the line of the neck of the 
femur, this being another mechanical loss. In limited femoral or 
acetabular disease it is perfectly possible that the seat of the dis- 
ease might be directly in the line of the extension, especially if 
there be slight adduction, and this may be the explanation of 
those cases in which extension is followed by an increase of pain. 
Does extension distract the articular surfaces? In an adult cada- 
ver an extending force of one hundred pounds failed to separate 
two pins, one placed above the acetabulum in the ilium and the 
Reprinted from the St. Louis Medical and Surgical Journal, December, ISSf 2 
other pin driven into the neck of the femur. On section of all 
the muscles and tendons, it was found that the head of the femur 
was held by a firm fibrous band or rather ring. In the foetus 
this ring is said to be not so well developed. In a child, by ex- 
periment, it was found that when the pins were similarly placed, 
they could not be separated, the same result as before. As the 
extending force used was far beyond the ordinary weight that is 
used for extension, it would appear that we do not get distrac- 
tion in healthy joints, although it can not be denied that after 
long continued extension and in chronic disease the above men- 
tioned collar may become softened and slight distraction may be 
produced. On the other hand so long as the joint is unruptured 
the atmospheric pressure, a no insignificant force, tends to act in 
the contrary direction, so then, in those cases where extension 
has been followed by relief of pain we must look in some other 
direction than distraction for an explanation. If, as is possible, 
increased intra-articular pressure will assist in the destruction of 
the joint certainly then, if distraction were obtained, our efforts 
would be far from conservative, for the extension ought to elon- 
gate the capsule, thus diminishing the capacity of the cavity, thus 
increasing the intra-articular pressure. On the contrary, we have 
extension diminishing of the intra-articular pressure, first because 
it stretches the ligaments and seco.ndly because we have increased 
absorption of the contentsof the joint from the primary increased 
pressure. As to what extension does, some things can be defi- 
nitely stated. 
1. It may overcome deformity when not due to true anchylosis. 
2. It overcomes muscular spasms. 
3. It. tends to allow the muscles to atrophy. 
4. It facilitates repair by giving the general condition an 
opportunity to improve. 
But, unfortunately, it only slightly fixes the joint, as one can 
readily demonstrate for himself if he will go through the wards 
of an orthopaedic hospital at night, when he will find the patients 
in almost every conceivable position. This method of treatment 
is simply confinement in bed plus a little more slight fixation of 
the joint. Patientswill usually improve under this treatment 
for a time but it soon becomes irksome and ceases to be bene- 
ficial. 
Extension with noattemptsat fixation has held an important 
place in the literature of the last few years. At the outset it 3 
should be borne in mind that any apparatus to be of any service 
whatsoever, should extend below the knee; various forms of 
apparatus have been devised but they all are practically the same 
in effect, the perineum being one point and some device for exten- 
sion being used, some portion of the leg being the other point 
for the attachment of the apparatus. Since we have no third 
point in the line we ought to get motion at the hip joint. Among 
the advantages of this method is freedom from confinement in 
bed and to the house, this advantage can hardly be over estima- 
ted. Again, the direction of the pull can be changed to meet the 
varied positions of the leg and so in the end perfect parallelism 
of the legs can be attained. Further, all jarring through the foot 
is prevented but not through the trochanter, and the apparatus 
can be applied to patients of any age. On the other hand, some 
drawbacks suggest themselves, supposing the extension to be ad- 
justed, the flexion of the leg upon the body changes the relation 
of the two bearing points to each other, this change as experi- 
ments show may be either in loosening or tightening the strap, 
depending upon the individual conformation and degree of nutri- 
tion. Further, any one who has adjusted a perineal strap will 
remember the bitter complaints that are made when the strap is 
tightened with any degree of efficiency. As without doubt this 
method will relieve pain in some cases, it has been said that it 
accomplishes this by rupture of the capsule. Considering the 
early excision to which so many joints treated in this way have 
come, this certainly in some cases may be the correct explana- 
tion. Without doubt, nlotion with friction is detrimental to a 
diseased joint and it is also true that motion with extension and 
without friction is a mechanical absurdity. Further, when the 
patients walk, the side bar bends and the perineal strap stretches, 
the effect of both of which is to reduce the extending force but 
on the other hand the weight of the leg goes to counteract this 
loss. Last of all comes a very important point, any one watch- 
ing a patient as he walks with this apparatus and a high shoe 
on the sound side, can hardly fail to notice that with each step on 
the diseased side the whole pelvis rotates about a point near the 
greater trochanter of the other side. In other words, it appears 
that the muscles have fixed the joint in spite of all efforts of the 
surgeon to the contrary. 
A second division of this method is the so called physiologi- 
cal one, namely, the high shoe on the well foot, the only other 
apparatus being crutches. Here again we get all the advantages 
of out-door exercise but the plan it only applicable to older chil- 
dren and must needs be under constant supervision. 4 
Although rest in the treatment of joint disease has been the 
keynote to all treatment, yet it remained lor the past few yehrs 
to see it emphasized in the sentence "enforced, uninterrupted 
and prolonged rest." If motion is the work of the joint then cer- 
tainly rest should be represented by fixation. As fixation is the 
chief end in view in this method of treatment, a few modes of 
attaining this result will be alluded to. G-utta percha splints, 
fixed bandages fail to meet the indications. Lateral fixation, as 
for fractures of the femur, if carefully adjusted, does very well 
but it has many objections on the score of adaptability. Poste- 
rior fixation by wire breechesextending below the knee are too 
cumbersome. Posterior fixation, as obtained by well covered 
bands of iron nearly encompassing the chest, mid-thigh and mid- 
dle leg, connected at right angle by a straight posterior bar of 
iron, seems to meet all the indications. This apparatus is cheap, 
light, easily moulded and requires but little supervision. This 
apparatus is that invented and used with such brilliant success 
by Mr. Thomas, of Liverpool. 
What, then, can fixation accomplish? It certainly reduces 
friction to a minimum or altogether abolishes it, thus preventing 
destruction in the joint and relieving pain. If the child is old 
enough to walk upon a high shoe on the sound side and crutches, 
we get extension as in the physiological method. With this 
apparatus we can obtain out door exercise, freedom from con- 
finement, and if recovery takes place it is usually without lum- 
bar deformity. The bugbear of this plan of treatment was the old 
idea that we would obtain anchylosis after long continued fixa- 
tion. It has been stated, and so far as I know correctly, that with 
perfect fixation anchylosis never takes place unless there be pro- 
found disorganization, and in that case even anchylosis would 
not be an unfortunate result. In the majority of cases the stiff- 
ness after the removal of the apparatus will disappear with the' 
continued use of the limb. 
Abscesses in. any situation need not, of themselves, prevent 
the application ofthis apparatus, as it can be applied to the sound 
side and the other limb bandaged with it. The great drawback 
to the employment of the posterior fixation splint has been the 
fact that the principle has not been carefully studied and simple 
as is the apparatus, its very simplicity is misleading. In general, 
surgeons have only partially studied the apparatus and finding 
themselves Jailing, have set out to modify the apparatus under 
other principles. Believing, as it seems just to conclude, that 
many of the failures have been due to an imperfect application 
and careless manufacture of the instrument, with increased care 
the principle of fixation will be as fully recognized as a necessity 
in diseases of the lower extremities as it has been, for many 
years past, in the joints of the upper extremities. 
November, 1884.