DEFORMITY AFTER HIP-JOINT DISEASE FOLLOW- 
ING THE EXTENSION TREATMENT; 
OSTEOTOMY FOR ITS CORRECTION; RECOVERY 
WITH A USEFUL EXTREMITY. 
CLINICAL LECTURE DELIVERED AT THE COLLEGE OF PHYSICIANS AND SURGEONS, ST. LOUIS, MO. 
BY JOSEPH L. BAUER, M.D., 
Late Professor of Materia Medica, Therapeutics, and Genito-Urinary Surgery ; Late 
Assistant Professor of Orthopaedic Surgery, etc. 
[Reprinted from International Clinics, Vol. II.,'Second Series.] DEFORMITY AFTER HIP-JOINT DISEASE FOLLOW- 
ING THE EXTENSION TREATMENT; OSTEOTOMY 
FOR ITS CORRECTION; RECOVERY WITH A USE- 
FUL EXTREMITY. 
CLINICAL LECTURE DELIVERED AT THE COLLEGE OF PHYSICIANS AND SURGEONS, 
ST. LOUIS, MO. 
BY JOSEPH L. BAUER, M.D., 
Late Professor of Materia Medica, Therapeutics, and Genito-Urinary Surgery ; Late 
Assistant Professor of Orthopaedic Surgery, etc. 
Gentlemen,-Through the courtesy of Dr. Grundman, of this 
city, I am enabled to present to you a most interesting case, which you 
have seen in the early part of our session, and which I now show you 
after the operation for the correction of the deformity has been per- 
formed. It gives me an opportunity of saying a few words to you 
upon the general treatment of chronic joint-disease. As you will re- 
member, this patient was discharged from a local hospital, after having 
l)een under treatment for one year, according to a plan which has 
been designated " the American method," or the treatment of hip-joint 
disease by extension. This treatment, originally devised by Crosby, 
consists in attaching a certain number of pounds of shot by means of 
adhesive plaster, in such a way as to exert continuous and moderate 
traction on the affected limb for the purpose of relieving the joint in- 
flammation by separating the articulating surfaces one from the other. 
Quite a difference of opinion exists even at this day as to the proper treat- 
ment of hip-joint disease in its initial stages. Surgeons are divided 
into two classes ; some believe in the principle of rest and position 
alone, others believe that rest and position cannot be secured without 
fixation and an extension apparatus. If you were to glance at the 
numerous articles on orthopaedic surgery that have been written within 
the last ten years by different authors of repute, you would be struck 
with the remarkable number of appliances which have been suggested 
to accomplish the results of those who advocated the latter view. This 
227 228 
INTERNATIONAL CLINICS. 
fact alone is sufficient to assume that the extensionists themselves are 
not satisfied with the net results which they have achieved from their 
particular methods. That the extension treatment is not so radical a 
method as one would suppose is evidenced by the case before you, be- 
cause this boy has been under the treatment of a very competent gen- 
tleman, and one who is an enthusiastic advocate of the extension treat- 
ment in hip-joint disease. He has been converted to the method of 
treatment advocated by Hugh Owen Thomas. 
Now, in order to draw a comparison between the method which I 
shall advise you to follow7 in the majority of cases of this kind and the 
above-described treatment, it will be necessary to understand upon 
wrhat the most rational plan of extension treatment should depend. 
Let me summarize the claims of the extensionists : 
1. That the application of, say from five to twenty pounds of, shot 
in the line of the deformity will draw asunder the articular surfaces of 
the affected joint, thus relieving intra-articular pressure and intra- 
articular friction. 
2. That the application of a sufficient amount of weight acts as 
the best means of relieving pain, which is, as you know, a notable 
feature of the second stage of hip-joint disease. 
3. Its usefulness in preventing luxation of the head of the femur 
out of the cavity of the acetabulum. 
Lastly, that this method is the best for the purpose of relieving 
most certainly the contractions of muscles around the hip-joint. 
Now, let us examine these claims advanced by the extensionists, 
and determine wThether or not the same principle of treatment cannot 
be reached by the ambulatory treatment of hip-joint disease. The 
main essential in the treatment of any disease in which inflammation, 
acute or subacute, is a factor is rest. Where such rest cannot be ac- 
complished by recumbency alone, the part affected must be fixed so that 
all motion is prevented. Could we attend any case of joint inflam- 
mation in its very incipiency, wre wTould soon be satisfied that the simple 
immobilization of the joint would be ample to check, if not entirely 
relieve, every symptom of which the patient complained. Need I refer 
you to inflammation of the ankle-joint as a result of sprain ? Is it not 
known to you that after a wrench of the ankle-joint, and subsequent 
to our application of ice for the purpose of checking intra-articular 
hemorrhage and oedema, the immediate immobilization of that joint 
will at once stop any further inroads of the inflammatory process; 
and that if we allow that patient to move the joint, if we permit fric- 
tion of the opposing articular surfaces, whether it be a tubercular or DEFORMITY AFTER HIP-JOINT DISEASE. 
229 
a pyogenic process, the joint will ultimately be destroyed, and this 
destruction will have been due to nothing more nor less than mobility 
plus friction ? All surgeons are aware of this fact, and why, therefore, 
they are not satisfied with simple rest of an inflamed joint, without the 
addition of mechanical encumbrances, seems to me incomprehensible. 
But the advocates of the American method claim that it is impos- 
sible to prevent intra articular friction or pressure without the fixation 
supposed to be connected with the extension treatment This assump- 
tion suggests another supposition : intra-articular pressure per se is 
inimical to the welfare of a diseased joint when the opposing surfaces 
are affected by the localized pathological process. That this is not 
always the case need not be stated. That the disease originates at the 
epiphyses, in the cancellous structure of the bone, and even in the 
synovial membrane, is too well known to admit of any question. And 
besides, having no data to determine without a doubt that either the 
head of the bone or the opposite portion of the acetabulum is always 
affected, in every case, the result of the simple fixation treatment 
shows that the symptoms and conditions peculiar to hip-joint disease 
may be produced by other causes than the contact of diseased surfaces. 
Intra-articular tension, whether as a result of synovial or purulent col- 
lection, is as much responsible for the contraction of the muscles, for 
the pain, and for the distortion of the joint, as the affection of the 
articular surfaces themselves. The subcutaneous division of the cap- 
sule of the hip-joint, with marked beneficial results following the re- 
lief of intra-articular tension, is sufficiently evidenced by the experi- 
ence at hand. In these comments I exclude, those forms of osseous 
tuberculosis in which wedge-shaped sequestra with large cavities develop 
as a result of the tubercular process. Such cases, as a rule, do not get 
well, whatever form of treatment we may devise short of radical sur- 
gical methods. No one who has had the opportunity of seeing these 
patients in any stage, where the capsule of the hip-joint is still intact, 
and has witnessed the remarkable results which follow the administra- 
tion of an anaesthetic, and the ease with which such a limb is placed 
in its proper position, all contracted muscles relieved, and the deformity 
of the limb immediately reduced by the simplest possible methods, 
will seriously doubt that extension is the only means by which such a 
beneficial result is to be attained. 
Remember that the treatment which I have just criticised claims 
that fixation is an impossibility without the extension treatment, and 
that this method of fixation is the sine qua non for the relief of pain 
and of deformity. We have shown that the movement of any joint 230 
INTERNATIONAL CLINICS. 
pathologically involved produces pain; that intra-articular tension, 
or, when that is absent, inflammation of the joint per se, producing a 
deleterious effect upon the nerves which supply the components of the 
joint, and which at the same time distribute themselves along adjacent 
muscles, can be equally responsible for both the pain and the deformity. 
It follows, therefore, that the principle of rest, which means the abso- 
lute cessation of all motion, checks the inflammatory process, and that it 
therefore mitigates, if not entirely relieves, the symptoms connected 
with the special process in question. Why the treatment which im- 
mediately checks an incipient hip-joint disease will not produce identi- 
cally the same results in the later stages, has been to me a problem 
easily solved. Because the later stages of the disease are simply an 
increase of inflammation and an increase of pressure, producing an in- 
tensification of the symptoms, and this is why we have the night cries 
of joint-disease, due to the spastic contraction of muscles fed by nerves 
which also supply the joint affected, and by the juxtaposition of the 
muscle itself to the inflamed area. Reduce the inflammation by putting 
this joint at complete rest, so that every attempt at mobility is anni- 
hilated, and all symptoms are relieved as if by magic. 
It is known that deformity, excluding dislocation or ankylosis in a 
false position, is produced by the influence of the inflammatory condi- 
tion upon the nerves which supply the joints and adjacent muscles, and 
the spastic contraction of the muscles upon which the deformity de- 
pends, is either temporary or organic. The spastic contraction is tem- 
porary in the early stages of the disease, and if the irritation is per- 
sistent, continuous, and unrelieved, organic changes in the muscles take 
place at the expense of their elasticity and contractility. Under those 
circumstances it matters not whether we apply one pound or one hun- 
dred pounds as a means of extension, no effect whatever will be pro- 
duced upon the muscles, and nothing short of myotomy will serve to 
correct the deformity. Where, however, the luxation of the head has 
ensued, or where deformity has resulted as a sequence to ankylosis in a 
false position, brisement force, osteotomy, or osteoclasis must be per- 
formed to correct it. 
Let me detail to you the average treatment which has been followed 
in our clinic. A child is presented manifesting the symptoms of the 
first stage of the disease ; it is placed upon a table and a plaster-of-Paris 
bandage applied, completely encircling both the knee- and the hip-joints, 
and reaching above the umbilicus; a pair of crutches is supplied, so 
that the child may be aided in its locomotion. This bandage is kept 
on for two months and removed. If then full range of motion is Fig. 3.-Showing the line of incision and the result 
of the osteotomy. 
Fig. 2.-Lateral view of the same case, showing the 
appearance of the sound and the affected limb. 
Fig. 1.-Deformity after hip-joint disease. DEFORMITY AFTER HIP-JOINT DISEASE. 
231 
possible, and at no point does pressure upon the joint-environs or pedal 
concussion cause a manifestation of pain, the child is permitted to use 
its limb, as if nothing had occurred. Should pain still persist, the 
bandage is reapplied for another period of two months and similar tests 
are made. If a patient is presented in the second stage of the disease, 
in which I contend the deformity is due to intra-articular tension, a 
tenotome is introduced subcutaneously and the capsule of the joint 
divided. Relief of deformity follows immediately, and a similar fixa- 
tion bandage, whether it be plaster of Paris, poro-elastic felt, silicate 
of sodium, Stillman's metallic splint, or the Thomas hip apparatus, is 
applied; so that I can secure all the advantages of the ambulatory 
treatment. I do not consider rest in bed an essential requisite to secure 
rest for the joint. When the patient presents all the features of the 
third stage of the disease, such as flexion, adduction, and internal rota- 
tion, the anaesthetic test is at once applied. Now, I do not mean by 
anaesthetic test the first stage of chloroform anaesthesia, nor the second 
stage of anaesthesia, but I contemplate the full effect of complete an- 
aesthesia, by which the reflexes are sure to be controlled. If then the 
organic changes which result from persistent spastic contraction and 
non-use do not exist, no difficulty whatever will be experienced in plac- 
ing that limb in its correct position, and by immobilizing, by either 
of the methods which I have suggested, there will be no question 
whatever that no further treatment will be necessary to control the 
disease, provided that the tubercular process per se has not completely 
annihilated the bones of the joint. Even then pain will cease, de- 
formity will be corrected, and in many instances, if the destruction has 
not been far-reaching in its results, the case will proceed to recovery. 
And let me emphasize the necessity of complete anaesthesia, because if 
complete anaesthesia will not relax the spastically contracted muscles 
under the influence of manipulation, any number of pounds which 
may be attached to that diseased limb by any method whatever will 
not reduce the deformity or relieve the pain. And why ? Because 
the muscles have lost their physiological function; because they have 
been organically changed; because they have lost the property of 
elasticity and contractility, as all physiologists have shown, notably 
Cohnheim. 
It is not my intention to-day to say anything further to you with 
reference to the treatment of the disease where abscesses have developed, 
and so on. That may be a subject for future discussion, though I 
agree in this particular with the suggestions thrown out by Dr. Judson, 
of New York, who makes a reasonable attempt to secure the organ- 232 
INTERNATIONAL CLINICS. 
ization or absorption of such abscesses without resorting to surgical 
measures. 
Now to our case. In order to understand the excellent results 
achieved by the operation performed upon this patient, let me refresh 
your memories by calling attention to these two photographs, which I 
have designated as figures 1 and 2, and which show the character of 
the deformity which suggested the operation I performed. Looking at 
Fig. 1, which is a rear view, you find that the thigh is flexed upon the 
pelvis and rotated externally, and that the head of the bone is fixed in 
the cotyloid cavity. The position of the head of the bone and the 
flexion has materially shortened the limb, as can be evidenced by the 
compensatory lateral curvature, which the photograph shows, so that 
when the boy attempts in walking to bring the heel level with the 
ground, there is a material drop on that side of the body, producing a 
very awkward and cumbersome gait. Fig. 2 represents a lateral view 
of the same patient, and shows the relation of the deformed to the 
healthy limb. 
The mother's consent was secured to perform any operation which I 
deemed necessary for his relief, and, accordingly, he was placed under 
chloroform, and the only unyielding muscle, the tensor vaginae femoris, 
divided. Believing that I felt some slight motion of the head in its 
abnormal position, I felt that brisement force might be attempted, its 
attachments dislodged, and then, by a forcible extension, the correc- 
tion of position accomplished. This, however, failed, and I there- 
fore determined to perform osteotomy. Osteoclasis was discarded, on 
account of its uncertainty, while no objection could be raised against 
the operation of osteotomy, as practised by Gant, Maunder, and other 
surgeons. Accordingly an incision was made, as appears in Fig. 3, 
and the bone chiselled at right angles to the longitudinal axis of the 
femur, and then the limb placed in a straight position. The operation 
was performed under antiseptic precautions, and the limb fixed in a 
plaster-of-Paris bandage, which was not removed for six weeks. At 
the end of that time the bandage was taken off and the patient per- 
mitted to walk on crutches. Fig. 3 represents the result attained by 
the operation, and while the curve in the back indicates that the out- 
come is not what might be termed perfect, yet when we compare it 
with the condition he was in before the operation, we have reason to 
congratulate ourselves upon the result, as we have given the patient a 
much more useful extremity, and relieved him of a deformity which 
would have tended to seriously modify the future usefulness of his life.