The symptoms to observe in early diagnosis are: (1) stiffness of the joint due to tonic muscular contraction; (2) attitude of the limb in standing, walk ing, or lying. and either flexion, adduc tion, or abduction; (3) lameness; (4) atrophy; (5) pain; (6) swelling. These are in the order of their importance. In differentiating this disease in the early stage quite a number of affections at times present themselves, especially rheumatism, contusion, sprain, and neu rosis of the hip-joint. Infantile paralysis, acute synovitis, bur.kitis, and periostitis are a few others to be taken into con sideration. A. IL Shandy (Amer. Jour. of Obstet.. Aug., 1002).
The obturator nerve sends a little fila meat to the inner side of the knee-joint as well as to the hip-joint, and to this fact is due the characteristic pain in the knee which usually accompanies disease in the hip-joint, and which, in the great majority of cases, antedates the occur rence of pain in the joint itself. The obturator nerve often joins the long saphenous, which accounts for the fact that pain in the big toe is very frequently noted before pain in the knee, which, however, seems to have escaped the atten tion of a good many writers on this sub ject. Quite frequently children will be brought for observation because they limp and because they have complained of pain in the big toe, which the mother had supposed was due to some defect of the shoe or stocking or an ingrowing nail. Examination in these cases will fre quently reveal the presence of hip-joint disease.
One of the first things which is present in inflammation of any joint is spasm of the muscles controlling the motions of that joint. In hip disease efforts have been made to draw inferences, on ac count of the preponderance of spasm in a particular group of muscles, as to the location of the disease in the joint, but so far without having put us in a position to diagnosticate with exactness the loca tion of the focus of inflammation from the presence of spasm in certain groups of muscles. Not infrequently there may be noted, in addition to the spasm of the muscles immediately controlling the joint, spasm of the calf-muscles, although attention has very seldom been drawn to this fact. It often will be seen quite pronounced in the early stages of the disease, when deformity is very slight anti limitation of movement in the hip joint but slightly marked. It will usu ally be found in those cases where pain in the great toe has been noted instead of pain in the knee.
Hand in hand with muscular spasm comes atrophy of the muscles affected by the spasm, and this atrophy shows itself too promptly to be attributed wholly to disuse, and seems to be dependent on impaired nutrition. It is one of the
earliest and most important signs in con nection with joint spasm in the diagnosis of incipient and doubtful cases, being of vastly more importance than the occur rence of pain; but usually it is not present until the disease has been in existence for some time.
The position assumed by patients with disease in the hip-joint varies according to the progress which the disease has made. At the outset the almost invari able rule is that the patient bears the weight of the body upon the sound leg, the toes of the affected side being turned slightly outward, the thigh being flexed, the leg everted and slightly abducted; the buttock on this side is decidedly flat tened, and the gluteo-femoral crease lower down and more or less obliterated. On account of the abduction of the leg it seems longer than its fellow, but if accurate measurements be taken, with the limbs in the same relative position to the median line, this will be found to be an apparent, and not an actual, length ening. As the disease advances this dis tortion becomes more and more marked, until the thigh may be flexed almost to the point of striking the chest, and the leg everted and abducted to the limit of possible motion. If the capsule has been greatly distended with fluid, it may spon taneously rupture, or some sudden move ment may rupture it, and the leg may pass in a very short time from the posi tion of extreme abduction and external rotation, to one of adduction and internal rotation. Quite frequently this change accompanying the rupture of the capsule is followed by marked relief from the pain of which the patient had previously complained. This position of adduction was formerly spoken of as the "third stage" of hip-joint disease, that of marked flexion and eversion being called the "second stage," while the former position of slight flexion was denomi nated the "first stage" of the disease. And for purposes of explanation, it pos sibly may be well to retain these terms in some cases, though they do not repre sent invariably the different stages in the progress of the disease, as we some times find cases with marked adduction in the commencement of the disease, though in such cases we usually find the leg is rotated outward instead of being rotated inward, as it is when the thigh passes from the position of extreme ever sion and abduction to that of adduction.