These symptoms increase, the limp beconies more pronounced and the pain more intense. In the daytime the are able to provide sufficient fixation, but when the children are asleep involuntary movements in their dreams will cause them to cry out with pain (night-cries). The patient usually avoids walking and either remains sitting or stays in bed. The hip-joint returns to its embryonal medium position (slight flexion). It sinks down in comparison with the other leg, following gravity (adduction), and is frequently supported by the other leg or fixed during the necessary motions of the body. The strong adductor and flexor muscles keep the hip-ioint fixed in this position (Fig. 124). When the patient attempts to stretch out the legs and place these parallel, the adducted diseased leg will appear shorter, because the equalizing motion has not taken place in the diseased and fixed joint, hut the sound leg has to be abducted to make it parallel to the other.
Thus the diseased side of the pelvis is elevated, and further, the pelvis is turned around on its frontal axis in order to equalize the flexion of the diseased leg.
When we make these patients stand up, the adducted and flexed leg will naturally seem ninth shorter than the sound one. Slight flexion may he corrected by twisting the pelvis, but if it should be increased the toes will reach the floor only when the knee is flexed.
At the same time the fever increases, especially at night ; it is high when an abscess forms. Temperatures above 39° C. (102° F.) usually indicate considerable absorption of pus.
The thickened region around the joint bulges in one place and fluctuation is soon found and the pus breaks through. This is followed by a long-continued period of suppuration which may last for years. When the pus begins to discharge the temperature will fall, but will rise again with the formation of a new abscess. Even in this stage the disease may heal after the elimination of the diseased parts.
In-about 10 per cent. of the cases a fatal outcome of the disease is caused either from general tuberculosis (meningitis, miliary tuberculosis) or from amyloiclosis in long-continued suppurations.
It is very easy to recognize the late stages of a coxitis or its conse quences, but the functional disturbances on which we must base our early diagnosis are very slight; still, only by early recognition and by instituting treatment quickly will we be able to shorten the duration of the disease and to improve our results.
Examination of an Incipient we examine the gait of our patient, stripped to the skin, and note any tendency to ease one leg by shortening that step. Next we note the position of the leg (abduction), whether the gluteal fold and the anterior superior spine are lower on one side (Fig. 123).
At this time we may sometimes be able to determine the lessened motion in one hip. We ask the child to stand on one leg, which he will
hardly be able to do on the diseased one, nor will he be able to hop on this leg.
Now we put the patient on a table (not upon a bed) and place the legs in a parallel position. When the leg is extended the loin will be bent forward in a lordosis on the diseased side on account of the equal izing rotation of the pelvis (Fig. 125a).
When we elevate this leg until the lordosis disappears we get the angle of flexion (Fig. 125b).
When the suspected leg seems longer, this will indicate a contrac ture in abduction (measurement) (Fig. 125a). In older patients we can easily prove this by asking them to lengthen the healthy leg; this they cannot do, owing to painful contraction, because they would have to adduct the diseased joint.
Now follows the examination of the voluntary movements. The child is directed to move both legs at the knees and the ankles, as well as in the hip-joints. The examination of the knee-joint saves us from making a mistake (localization of pain).
Inspection alone will reveal that in certain movements of the hip the suspected side of the pelvis is moved simultaneously, and that therefore the motion cannot take place in the hip-joint (see Tuberculosis of the shoulder-joint).
We now fix the healthy side of the pelvis and let the patient make motions (flexion, rotation, adduction, abduction). The motions on the affected side are limited and rotation and abduction are the first ones to fail. Any attempt to transgress these limits by passive motion will produce pain. Pressure upon the sole of the foot is equally painful when the leg is extended, also pressure upon the troehanter; pressure upon the bead underneath the artery is painful as well. In this stage we may observe a pronounced atrophy of the muscles. All these symp toms taken together tell us of a beginning coxitis.
The later symptoms are still more conspicuous. Just as easily as we can recognize the contracture in flexion when we place the patient in the right position, just so will it be important not to overlook the contracture in adduction. The seemingly considerable shortening of the leg when placed in parallel position will be proven to be mostly apparent when we measure from the anterior superior spine to the internal mal leolus; and the elevation of the diseased side of the pelvis (spina) will explain this. The actual shortening is caused by the destruction of the joint, though this will always form only a part of the apparent shorten ing. (L'inversion du membre dans Is eoxalgic c'est la source (le tour les matte.) (Kirmisson.) And truly these fixations interfere most with the functions and cause the disagreeable changes in shape.