The mode in which to determine mus cular spasm in the early stages of the disease, at which time it is most impor tant to arrive at a correct diagnosis, is, first, to thoroughly gain control of the patient, and cause it to allow complete unless very extensive movements are made, and unless the limitation of mo tion which Nature puts to the joint is violently overcome. Pressure over the hip-joint proper may at times give rise to pain; it very frequently does, but in many cases pain cannot be so elicited.
The length of the two lower extremi ties should now be noted, the distance from the anterior spine of the ilium to the internal malleolus being taken as the most reliable measure; and in this con nection care must be exercised that both extremities occupy the same relative posi tion to the trunk at the time the meas ures are taken or they will be of no value, flexion and adduction causing much apparent shortening, while abduction causes apparent lengthening.
The relation of the trochanters to Nelaton's line should be noted, by pass ing a string from the anterior superior spine of the ilium to the tuberosity of the ischium. Normally this line should just touch the upper border of the great trochanter. If the latter lies above it, the cause may be fracture of the neck of the femur, congenital dislocation of the hip on the dorsum of the ilium, bend ing of the neck of the femur, absorption of the head or neck of the femur, or ab sorption of the upper part of the rim of the acetabulum, allowing the femur to glide upward; which cause is present in each case must be determined by the sur geon.
Atrophy of the muscles occurs early in joint disease, and the circumference of each thigh should be noted, both at the upper portion and also at a point rower down,—say, four inches above the knee,—care being taken to measure the thighs at corresponding points, or the results will be useless.
In noting muscular spasm care must be had not to mistake the flaccidity of a paralyzed muscle for the normal state, and suppose the healthy side to be the seat of muscular spasm by contact. The fact that the more relaxed thigh was the smaller ought to clear up any possibility of error, and it would seem that it hardly required mention save for the fact that such mistakes have occurred.
The temperature and pulse should also be noted, any elevation of the former above normal being taken, in a doubtful case of every incipient disease, as con clusive proof that disease is present, espe cially if.there is present in addition an accelerated pulse.
The amount of elevation of tempera ture is a fair index of the violence oi the inflammatory process.