When we have once learned to recognize the early stages of coxitis the later ones will give us no difficulty. The correlation of the patho logic changes, together with the anatomy of the normal movements in the hip region, helps us to understand and analyze these.
The radiogram is an excellent aid. In the beginning it shows us the swelling of the joint cavity, indistinct contours of the bones in compari son with the unaffected side, considerable atrophy of the femur, and in some cases a peculiar protrusion of the bottom of the aeetabulum towards the abdomen. In the later stages we observe on the plate the faulty position, the abduction, the rotation of the pelvis from flexion, the destruction of the bones, and perhaps a change of relation of the head to the acetalmlum as an explanation of the true shortening (Fig. F25e and Fig. 50, Plate S).
In making a differential diagnosis we have to consider lesions near the joint and diseases of neighboring joints, though these latter will not interfere with the motions in the hip itself.
Diseases of the vertebra' (spondylitis) may simulato a contraction in flexion in the hip-joint through the gravitation abscesses which proceed along the psoas muscle and appear below Poupart's ligament (painful contraction of psoas). But this will permit all motions in the hiu-joint except extension.
Diseases of the knee-joint are found on examination, and the flex ions of the hip in these are proved to be caused only by the flexion con tracture of the knee, and that all other motions are free.
Osteomyelitic and pymnic affections of the hip run a much shorter course. Aspiration of a few drops of pus and their examination under the microscope will explain their pathogenesis.
Traumatic affections are cleared up through their history and their course.
Rheumatic affections are multiple and deforming processes are rare in children, as are also gonorrMeie ones.
Luxations of the hip-joint are shown by the absence of the head from the acetabulum and free motility. Pathologic hip luxations arc shown by the skiagram (Fig. 50, Plate S).
In paralyses of the hip znuseles, we miss the fixation and spastic conditions are not confined to the hip-joint.
True hysterical eoxalgize are made probable by the general condi tion; should the diagnosis be difficult then the skiagram or examination under narcosis will aid us.
have stated above that coxitis usually gets well. A small percentage only succumb to general infection. (In our poll clinical material 10.5 per cent. of the cases.) The earlier the child is brought for examination the sooner we can recognize and arrest the disease at its initial stage by treatment, and the better will be the prognosis, not only as far as the general health is concerned but also as to the function of the joint. Hydrops and the dry granulating type are benign. Night-cries, abscesses or high fever indicate a progress of the affection.
The duration of the disease is hard to determine; rarely in less than two years, often only after from four to six years, may we regard the disease as cured when we no longer find pain on pressure nor difficulties in bearing weight. Even after all other symptoms have disappeared, night crying and restless sleep in those children will indicate that the disease is still present (lack of muscular fixation during sleep).
Treatment.—First in importance comes systemic treatment of the tuberculosis, of which the hip disease is only one symptom. The splen did results of Calot and Bowlby are mostly due to the favorable social conditions. Bowlby has treated 900 eases without a single resection or other major operation, and with only 4 per cent. mortality. (Hospitals at the seashore.) For the local treatment we must figure upon a long duration. The physician, the child, and, last but not least, Ids parents must be endowed with the necessary patience. Children of the less intelligent and lower social classes should either be placed in institutions or the treatment should be so arranged that their care is possible and within the means of poor people.
Here, as in all other treatments requiring a long time, the social factor is of the greatest importance, and the percentages of cures must be looked at from this standpoint. Liberally supported, well located hospitals at the seashore or in the mountains or woods will give better results than hospitals in large cities, where treatment has to be carried out in the policlinic, and where the children, as soon as they have their splints, are returned to the surroundings where they caught the disease in the first place.