Coincident with the change of posi tion from abduction to adduction, there comes a change from apparent lengthen ing to apparent shortening of the limb. If the disease has been in existence some time, there may be actual diminution in the length of the leg from absorption of bone, as well as the apparent shortening due to the adducted position in which the limb is held.
Diagnosis.—The diagnosis in hip-joint disease should only be difficult in the early stages. If a child is brought, com plaining of a limp, an obscure pain in the toe, calf, or knee, do not be satisfied with finding something in the toe, calf, or knee which may account for its limp and pain, because it may possibly have disease of the hip in addition to its other ailments; but strip it, and watch its posi tion with great care, allowing it sufficient time to become composed and assume its natural attitude, as quite frequently, under the influence of excitement, slight disturbances of function may easily be masked. After noting any of the ab normalities of attitude which have been just described, place the child upon its back upon a hard surface,—a table cov ered with a shawl, for instance. It is important that the surface be not so thickly covered as to leave a yielding surface for the back to rest upon, as slight alterations in the position of the pelvis may then pass unobserved. With the normal child lying on its back, with its pelvis in such a position that a line drawn from the centre of the sternum over the umbilicus through the symphy sis pubis is at right angles to a line join ing the two anterior superior spines of the ilia, the entire back should rest upon the table while the lower extremities are in a straight line with the trunk, and also rest upon the table. If there is any arching of the lumbar spine, raise both legs until the entire spine rests upon the table, and then lower the side which you believe to be the sound one until the back of the leg rests upon the table. If the joint of that side be unaffected, there will be no change in the position of the trunk and pelvis, and the spine will re main in contact with the table. Now lower the other leg gently to the table, and if there is involvement of the hip, the psoas and iliacus or rectus femoris them from consideration, while careful examination of the spine should clear up the diagnosis between disease of the hip and disease of the spine, though in some cases both exist simultaneously, and the mistake of recognizing only one is some times made even by men of experience.
Case of hysteria in which there was an absolute increase of measurement from the anterior superior spine to the internal malleolus. After a prolonged and careful study the diagnosis of hys muscles will be sufficiently contracted to tilt the pelvis before the leg comes in contact with the table, and a slight arch ing of the lumbar spine will result. This tilting of the pelvis does not necessarily mean the presence of hip-joint disease. It means a contraction of the ilio-psoas muscle, which may be caused by inflam mation of the spine, by appendicitis, or by salpingitis; but the previous history of the last two affections would exclude terical hip disease was made. Marked thickening in the region of the affected trochanter was noticed after the patient had been under observation for fifteen months. This swelling was believed to be due to hysterical cedema. Upon pressure tenderness was present. The patient improved greatly under treat ment, but did not recover entirely. J. J. Putnam (Jour. Amer. Med. Assoc., May 4, 1901).
Both legs lying flat upon the table should then be moved to and fro, to ascertain, if possible, the presence or absence of muscular spasm.
It is frequently advised that an aims thetic be administered, in order that the condition of a diseased joint may be thor oughly investigated. As far as diagnosis is concerned, this is absolutely unneces sary. The administration of the anes thetic, by the removal of the sensitive ness from the joint, removes the neces sity which Nature feels for establishing the involuntary muscular protection which she gives all inflamed joints, and muscular relaxation, as a child will, in many instances, voluntarily stiffen its muscles when first examined, and thus mask the presence of a slight involuntary spasm. The joints should then be moved through all normal ranges of motion, beginning with the sound side, and slight involuntary twitches taken into account. It is usually quite unnec essary to manipulate the joint so vio lently as to cause pain, in order to arrive at a correct diagnosis, and, in the major ity of cases, pain will not be elicited thus removes from the surgeon a most valuable means of diagnosis. If the rigidity of the joint is due to adhesions, and so persists after the anwsthetic has been administered, the case has been of such long standing that there should be no difficulty in reaching a diagnosis even by an inexperienced observer.