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Rip Joint Disease 


WITH CASES, 


U V 

/ 

Stewart LeRoy McCurdy, M. D., 
DENNISON, 0. 

MKMHKK INTEKXATIOXAU MEDICAL COXGRESv^ ( 9 tH ) ; 
AMEKICAX MEDICAL ASSOCIATIOX ; XATIOXAL ASSO- 
CIATIOX OF RAILWAY vSURGEOXS ; OHIO STATE 
MEDICAL society; SURGEOX TO I*., C. 

& vST. L. railway; etc. 


Read before Tuscarawas County Medical Society, July 22, 1890. 



[Reprint from Clevelaed Medical Gazette, August, 1890.] 



HIP JOINT DISEASES WITH CASES.* 

BY STEWART LEROY M'CURDY, M.D., DENNISON, OHIO. 

One apology for using a portion of your valuable time 
in considering the subject of hip joint disease is to review 
the early and most prominent symptoms, and what 
appears to me to be the most successful mode of treat¬ 
ment, for my own benefit, as well as to present the same 
facts to you, so that we may be all more readily prepared 
to differentiate this most subtile disease in its earlier 
stages, and by the institution of a vigorous, mechanical 
and systematic course of treatment, cut short the affection 
that may be the incipiency of untold agony and cruel de¬ 
formity. 

Like many other obscure afflictions, we may not be 
watching for them, and possibly fail to locate ;the true 
trouble and subject our patient to an unnecessary course 
of treatment. 

Caxalgia or coxmum morbus has been divided by Sayre 

* Read before Tuscarawas County Medical Society July 22 , 1890 . 


2 McCurdy: Hip Joint Diseases ivtiJi Cases. 

into three stages : First, stage of irritation before effu¬ 
sion ; second, stage of effusion and apparent lengthening ; 
third, stage of shortening or ruptured capsule. 

The more prominent symptoms of the first stage may 
be summed up briefly as follows: Slight stiffness in 
the affected joint, especially in the morning, the ..thigh 
slightly flexed on the pelvis, and the leg fixed on the 
thigh, this position being that assumed by the patient 
while walking. To allow the foregoing position, it will 
be observed that the patient throws the body slightly 
forward and toward the affected side. The foot is slightly 
everted and the leg thrown forward. 

One of the earliest and most misleading symptoms is 
pain in the knee upon the affected side, which, owing to 
its remoteness from the real seat of the trouble, is fre¬ 
quently mistaken and treated for rheumatism or neuralgia 
of that joint. 

I .desire now to make indelible on the minds of my 
hearers this one symptom, which, if remembered, will be 
the first fragment to make a true diagnosis. Never allow 
a child suffering with pain in the knee, not accompanied 
with any apparent symptoms of disease of that joint, to 
pass your notice without suspecting this malady. To sus¬ 
pect will be to diagnose. The buttock upon the affected 
side will be found to be somewhat flattened and lower. 
The gluteo-femoral is less distinctly marked on the affected 
side. By laying our patient down on a table on his back, 
nude, every motion of the thigh will carry the pelvis with 
it. For instance, when the thigh is extended, the ilium 
will be thrown further from the table on the diseased side, 
and when flexed again, it is thrown down against the 
table. While there may be no pain in the affected joint 
in the earlier course of the disease, pain can generally be 
produced by gently tapping the bottom of the foot with 
the legs extended, and also by suddenly pressing the 
trochanter while the pelvis is being supported on the 
opposite side with the other hand. 

The second stage, or that of effusion or apparent lengthen- 


3 


McCurdy : Hip Joint Diseases with Cases. 

ing, is pretty much the same as that of the first. The position 
assumed by the patient while walking and flexion of the 
thigh upon the pelvis is as described heretofore. All 
symptoms are more marked, and the pain in the hip now 
begins to show itself more prominently. 

In all bone diseases the pain is more severe at night, 
and especially is this true of the so-called strumous dia¬ 
thesis, or syphilitic affections. The trouble beginning 
primarily either as a synovitis, or osteo-epiphysistis, pro¬ 
duces very much the same train of symptoms, the ex¬ 
ception or variation being in the earlier distension of the 
joint bag in synovitis, and the absence of the same in central 
ostitis. A further consideration of symptoms would be 
but to repeat what is known to you all, and a needless con¬ 
sumption of time, for after a case is made out our duty is 
not to arrange a tabular list of symptoms and make a 
dreamy comparison of the same with other cases, but 
rather take advantage of an opportune moment and insti¬ 
tute treatment that will give you a brilliant result. 

No form of hip brace thus far devised has given univer¬ 
sal satisfaction to its inventor, much less to those who 
endeavor to select, apply and carry out the demands in a 
given case, when he is lacking in mechanical ingenuity. 
From the fact that every stage demands certain variation 
in the form of splint used, no splint unless applied with 
a ripe knowledge of the case, and genius enough to adjust 
a brace, can expect to give satisfaction. 

Of the innumerable splints that haye been devised for 
this purpose, the Davis’, Andrews’, Sayre’s, long, short, 
infants, and night, Stephen Smith’s, Hutchinson’s, Wash¬ 
burn’s, Shaffer’s, Duncan Eve’s, Taylor’s, Roberts’ and 
Stillman’s, have been most successfully used. As a mat¬ 
ter of fact the Sayre, in the various modifications, has en¬ 
joyed almost universal supremacy with the country sur¬ 
geons, who found it most convenient to adopt some form 
of brace. All the foregoing braces differ in detail, but 
have for their main purpose the protection of the joint. 
Some of them secure fixation, others articular motion, 


4 McCurdy : Hip Joint Diseases with Cases. 

others endeavor to relieve enter-articular pressure, while 
others say such procedure is impossible, impractical and 
positively injurious. 

After making a pretty thorough inquiry into the various 
braces and devices now in vogue, I must say it is quite 
difficult to endorse the opinions of one orthopedist and 
reject the views of another equally as skilled and time- 
tried. 

In the first stage, or the stage of irritation and limita¬ 
tion of motion, per Sayre’s classification, Roberts advises, 
when the disease begins as a central osteo-epiphysitis, 
drill through the greater trochanter and neck of the femur 
to the supposed or suspected seat of the disease, and 
thoroughly ream out the morbid area and establish free 
drainage. 

Mr. Stokes of Dublin, advises early drainage of the dis¬ 
eased area and gives cases illustrating his success with 
the same. 

M. Boeckel, before the French Surgical Congress, ad¬ 
vocates the early resection of the head, holding that a 
case of hip disease cannot be cured until the head of the 
femur undergoes molecular disintegration and absorption, 
or resection, and the earlier resection is performed the 
more probable our patient is to escape tubercular infection 
of the more vital organs. 

Sayre and others of this country, who follow him, have 
performed early resection with very gratifying results. 

When the trouble is primarily a synovitis, surgeons 
have advised and practiced early drainage of the synovial 
sack. 

Without entering into a description of the various braces 
heretofore referred to, for all of which we must have great 
respect, I will at once proceed to describe a modification 
and combination of some of them, as illustrated here, 
which have given me greatest satisfaction in my limited 
experience in treating hip-joint disease. 

Verify your diagnosis, and then institute a course of 


McCurdy: Hip Jomt Diseases with Cases. 5 

treatment that will produce as near physiological rest to 
the joint as possible. 

Assuming that the trouble is, primarily, either a syn¬ 
ovitis or an osteo-epiphysitis, both being inflammatory dis¬ 
eases of the joint structures, and while they differ widely 
in their early course, they both produce pretty much the 
same impression upon the system. All the muscles cross¬ 
ing, or whose tendons pass over the affected joint, are in a 
state of spasmodic contraction, due to reflex nervous irrita¬ 
tion. As a result of this reflex nervous irritation and re¬ 
sultant muscular spasm, the bones entering into the form¬ 
ation of the joint involved are pressed more firmly to¬ 
gether, and if the interposed synovial membrane be en¬ 
gorged, the extent of the lesion will be increased thereby, 
which in turn increases the muscular spasm, again increas¬ 
ing inter-articular pressure, and so on, until dislocation is 
the result. 

If the trouble be primarily a synovitis, it can be readily 
seen that to lift these bones from each other (if such be 
possible), and allow the inflamed membrane to rest, it will 
have more chance to repair; while on the other hand, to 
allow this pressure to continue will be but to allow the 
inflammation to increase, and a consequent destruction of 
all structures involved. 

Or if the trouble be primarily a central ostitis, even ad 
vanced to where the head of the bone must dissolve and 
undergo absorption, according to Boecker of Paris, the 
duty of the attendant is to arrange a course of treatment 
that will allow our patient to go on to recovery with a 
minimum of deformity. 

To obtain the foregoing results, one must apply a 
brace that will hold the limb in its normal position, and 
retain it there throughout the course of treatment. This 
is best done, it appears to me, by the brace herewith pre¬ 
sented, which, as you see, is composed of a double sys¬ 
tem of bars extending from a belt around the pelvis on the 
outside and a perineal crutch upon the internal side of 
the thigh down to a stirrup fastened to the bottom of a 


6 


McCurdy: Hip Joint Diseases with Cases. 


neatly fitting shoe. These double systems of bars are so 
arranged that they slide upon each other and are held to¬ 
gether by a collar from the proximal ends of the bars. 
You will also observe a button projecting from the collar 
at the proximal ends of all the bars. If an elastic is 



thrown about these buttons, you can readily see they are 
thrown closer together, which increases the distance 
between the distal ends, one fixed point being at the 
sole of a neatly fitting shoe and the other at the peri¬ 
neum and pelvis. These points being fixed, the elastics be- 















McCurdy: Hip Joint Diseases with Cases. 7 

ing thrown about the pins, the traction made upon the 
femur’s head as it rests in the acetabulum can always equal 
the demands of the case as thought desirable by the sur¬ 
geon, and the interposed synovial membrane in a state of 
congestion will be relieved of, at least, a portion of its 
pressure, which will, theoretically at least,fallow the in¬ 
flammation to subside. 

The objects to be sought in the adjustment of this brace 
are two-fold: First, secure fixed points for the brace; 
second, avoid rigidity. 

The Gurdon Buck weight and pulley extension has been 
used for this trouble in all stages, but it has been unsatis¬ 
factory, principally for the reason that there is no 
definiteness in the degree of traction, A definite degree 
of traction must be secured and at the same time 
avoid the iron-clad encasement of the member. Braces 
secured to the member by adhesives are not as 
satisfactory as those adjusted to fixed points. Adhesions 
must be used in wrist and phalangeal affections, but in hip 
cases they should never be used. Elastic traction, early 
applied, not only affords rest to the inflammed synovial 
membrane of the affected joint, by overcoming muscular 
spasms, but it also holds the head of the femur in its nor¬ 
mal position during the stage of destruction and absorp¬ 
tion of the head of the femur, and allows the patient to 
recover with very little deformity. 

Case I. —O. C., girl, aged 6; fell and sustained a con¬ 
tusion of the left hip. In a few months she complained 
of a pain in the knee, which was treated for rheumatism. 
In about six months the mother noticed a perceptible 
atrophy and redness of temperature of the affected side. 
I saw her eighteen months after injury and had no trouble 
in making out a case of morbus coxaris. There was one- 
half inch of thigh atrophy and one-fourth of leg - atrophy. 
The member was practically useless and had been for 
months. She had been using crutches for months. I took 
measurements and had a brace made for her, similar to 
the one I show you. From this time on she began to 


8 Robinson : Gastro-Enterostomy. 

improve, and went to school the entire nine months after¬ 
wards, being one of the honor members. Sleep was im¬ 
possible before application of the brace, and after the 
application she never spent a wakeful night, appetite im¬ 
proved, and in every way she went on to a good recovery. 
She had an abscess on the anterior surface of the thigh, 
which was aspirated, and afterward a small sequestrum 
was removed. With the brace she went through the 
course of the disease with comparative comfort, and came 
out with little deformity, and about an inch of shortening. 

Case 2.—J. E., male, aged 5, now under treatment; 
was treated for months for rheumatism, finally fell into 
the hands of a doctor who diagnosed hip disease and sent 
the patient to a neighboring city for treatment, and while 
there he was in a hospital with Gurdon Bucks extension 
tugging aimlessly at his diseased member, without effect 
however, for while under this treatment the head of the 
femur underwent molecular disintegration and spontaneous 
dislocation. When I saw him he was suffering great pain 
in the hip, with extreme emaciation and deformity. I 
adjusted a brace as per illustration and he began to 
improve, and was soon about on crutches. As this case 
is still under treatment, I cannot report more than pro¬ 
gress, but hope to be able to give you the results of further 
treatment at our next meeting. Other cases might be 
given, but as our time is limited, I defer reports until some 
future occasion. 






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