Rip Joint Disease
Stewart LeRoy McCurdy, M. D.,
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¬
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
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-
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
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-
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
Mr. Stokes of Dublin, advises early drainage of the dis¬
eased area and gives cases illustrating his success with
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
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
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
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
s ?'. ' >