in walking and bearing the weight on the diseased side of the pelvis are the most prominent symptoms. On account of the undermining of the gluteus muscle and its insertion at the sacrum, we will frequently observe Trendelenburg's phenomenon, owing to painful insufficiency of this muscle (Spitzy). Pain can be elicited on deep transabdominal pressure against the synchondrosis, and still more pronounced on rectal palpation or when we examine bimanua]ly from the rectum and the back.
Pain on pressing upon both iliac crests or in trying to move these against each other is pathognomonic; should we further be able to find abscesses, then the diagnosis will be sure, even without swelling on the back over the synchondrosis (Fig. 127).
The differential diagnosis from eoxitis can only be difficult when an abscess traveling into the periartieular tissues makes motion in the hip-joint seem interfered with. (Careful analysis of motions and skia gram will clear the diagnosis.) When we find a psoas abscess we should always think of this affection, which also, without any doubt, causes many a periproctitie abscess.
Of the acute non-tuberculous infections of this joint we may mis take it for a perityphlitic abscess, and we should remember this when the ot her symptoms are not quite clear (author's observation of one case).
[Loosening or spreading of the saelo-iltac joint (Goldthwait) is more frequent in adults, but should be thought of; in this we will fail to find any signs of feet E TRANSLATOR.] The prognosis is worse than that of eox itis, which may be explained by the anatomi cal conditions. Years of abscesses and sup puration are liable to sap the (libi's vitality.
Treatment.—This must be restricted to removal of the pus, or in open fistulae to the prevention of secondary infection.
In the non-tubercular types it is impor tant to chisel the bone so as to give the pus the shorter route of exit through the back and thus to avoid further infection.
We were not able to note any good results in children from the major operations (partial resection of the pelvis according to Barden heuer). These are too exhausting for the child's system and secondary infections set in too easily in this region. In children we prefer conservative measures: aspiration of the abscesses, injection, fixation of the pelvis and the leg of the diseased side, walking with crutches, the sole of the sound leg being _elevated and that of the diseased side hang ing free without bearing any weight.
(f) Tuberculosis of the Knee-joint (Conitis tuberculosa) This is, next to coatis, the most frequent tubercular joint affection in children.
Pathologic Anatomy and Symptomatology.—We usually observe the granulating or suppurating type (fungus), the osteal, and the syn ovial forms.
In the osteal type the focus is usually located in the external eon dyle; skiagraphy is of great aid in determining the primary as well as the secondary foci (Ludloff) (Fig. 129, Plate S).
In this affection as in coxitis, the disease frequently begins with an exudation (hydrops) which may disappear and reappear, or the char acteristic doughy swelling will develop slowly; the knee-joint fills up with masses of granulations; all around the patella and on the sides at the ligamenta alaria the knee is puffed up, the skin covering it looks stretched and an:mule (Fig. 12S) (tumor albus). The knee returns to its biologic position in moderate flexion.
The child steps on the toes, avoids putting its weight upon the limb, and carefully keeps its knee fixed. As tne disease progresses, abscesses arc formed which will break through and the child will have high fever (Fig. 131a).
Tuberculosis of the knee-joint shows no other differenoes either in its course or in its prognosis front the other tubercular diseases of joints.
Each type may heal at any stage, and the final outcome and the change in shape depend upon the amount of destruction. Ilydrops may heal without affecting the function. The granulating and suppurat ing types leave the knee stiff from scars or rarely from bony ankylosis, and though small exclusions are possible the leg can rarely be stretched out straight.
The position of abduction and outward rotation of the leg which We frequently observe is caused by the attempt to remove the leg from the line of gravitation and thus to bear less weight. The fixation in flexion increases from the contraction of the stronger flexors and thus only is the joint assured of a painless quiet position. Following the anatomical structure of the knee-joint, the articular surface of the tibia moves backwards around the rounded eminence of the condyles, the free cartilage is now eroded and destroyed by the tubercular process; and the leg can no longer slide back for extension. Should either an active or a passive extension be attempted after the acute symptoms have subsided, then the tibia cannot slide forward, and even when the leg is straightened the anterior inferior circumference of the condyles will remain exposed, the tibia being in permanent subluxation.