Dr. Lewis A. Sayre Casebooks

From Clinical Notes Vol. 2, pages 193-194. Additional materials attached to page 192.

The patient is a seven-year-old boy from New York City. He is being treated for second stage morbus coxarius (hip disease). Sayre first applied weight and pulley traction to relieve S.C.H.’s pain. On January 10, 1874, Sayre brought the patient before his students at Bellevue Hospital Medical College and applied a short hip splint. Following the application of the splint, S.C.H. sent Sayre a thank you note, which Sayre preserved along with his notes on the child’s case. Through January of 1875, Sayre monitored the progress of S.C.H.’s treatment.

Sayre recorded two later visits from S.C.H. once he reached adulthood. During the first visit, on January 22, 1886, the patient returned the crutches and splint from his childhood treatment and was examined by Sayre. S.C.H. returned again for an examination in 1890 and asked for Sayre’s advice about joining a bicycle club.

To page through Sayre's clinical notes and read the transcribed patient narrative for S.C.H., use the arrow icons to scroll through the gallery.

Sayre treated morbus coxarius, or hip disease, at different stages and with differing levels of intervention. In his lectures on the subject during the Bellevue Hospital Medical College session of 1874-1875, Sayre described hip disease as the result of trauma to the hip joint that affected the bones, cartilage, and ligaments as it progressed and could lead to severe inflammation and necrosis. He understood the disease to have a vascular component "interfering with the nutrition of the head of the femur."

Sayre identified three stages of morbus coxarius. In their article “Lewis A. Sayre and Lessons in Orthopedic Innovation From 170 Years Ago,” Pakdee Rojanasopondist, Joseph D. Zuckerman, and Kenneth A. Egol describe the characteristics of the three stages:

Stage 1 was characterized by a stiffness around the joint and a limping gait that improved over the course of the day, atrophy of the thigh or entire limb, tenderness, and pain. Stage 2 was characterized by the affected limb appearing longer, abducted, everted, and flexed with more severe pain, tenderness, swelling, atrophy, and limited motion. Sayre believed that the symptoms of this second stage were caused by the effusion of liquid, synovia, or pus into the hip joint. Lastly, Stage 3 was characterized by perforation of the acetabulum and ulceration and rupture of the capsule of the hip joint that caused the affected limb to appear shorter, adducted, inverted, and flexed at the hip with decreased pain.

Sayre’s treatments for morbus coxarius varied depending on the stage of the disease. In his lectures on the subject, he reminded students that nutrition and hygiene were the first line of treatment as “you cannot expect to succeed in the face of adverse hygienic surroundings and insufficient and improper food.” Like other physicians of his day, Sayre drained fluid buildup in the joints with blistering techniques, setons, or aspiration. He also prescribed saltwater baths, massage, and outdoor exercise.

As described in the case of S.C.H. above, Sayre frequently used a weight and pulley system to provide traction and relieve pressure on the hip joint. The short and long thigh splints Sayre developed also allowed the patient’s leg to be held in a pose he referred to as "fixation with extension" that relieved pain while making motion possible during the healing process. The splints were combined with plaster bandages to hold the leg in position.

Exsection was the most dramatic and controversial intervention for morbus coxarius. A surgical operation with only one other successful practitioner in the United States prior to Sayre’s adoption of the technique, it consisted of opening the diseased hip joint and removing dead bone. The patient then wore a pair of wire breeches which kept the hips and legs immobile as the patient healed.

Image: Sayre's short thigh splint. From Sayre's Lectures on Orthopedic Surgery and Disease of the Joints, 1885.