This condition is commonly called =Pott’s Disease= or =Caries=. It is
a chronic destructive process of the bodies of the vertebræ. The spine
bends at the weakest point and the compression and collapse of the
affected parts cause the characteristic posterior angular projection
at the seat of the disease. If one vertebral body is destroyed, the
projection will be sharp; if several are involved it will be less
angular and if one side breaks down before the other, there may be a
lateral as well as posterior distortion. The size of the deformity and
its effect upon the patient depend upon its situation; that is, if
either end of the spine is involved the angular projection is slight
because the area of the spine directly involved in the deformity is
small compared with that which is free from the disease. If the middle
of the spine is affected, the deformity is great, because the entire
spinal column may enter into the angular projection. In the latter area
the internal organs are compressed and, of course, the effect upon the
vital organisms of the body is disastrous.
=Pathology.=—The first indication of tubercular disease of the spine
is usually found in the anterior part of a vertebral body just beneath
the fibro-periosteal layer of the anterior longitudinal ligament. From
this point the foci may advance along the front of the spine following
the course of the blood vessels and invading the adjacent vertebral
bodies. The destruction may begin in the interior of the body itself,
more often in several minute foci near the upper or lower epiphysis,
which coalesce, gradually enlarge and form a cavity surrounded, for a
time, by unbroken cortical substances which finally collapse under the
pressure of the weight above. The intervertebral discs seem to offer
some resistance to the extension of the disease from one vertebra to
another but once the bone is destroyed on either side, they too quickly
disintegrate and disappear. Pedicles and articulations which come into
direct contact with the disease may become involved. Originally the
disease is confined to one or two adjacent vertebræ and may extend
in either direction, and the final area of deformity and rigidity
shows that from three to six bodies may be involved before a cure is
established. The infected granulations advance rapidly with the usual
retrograde change of shape and structure to a cheesy degeneration and
frequently liquefaction and abscess formation may follow.
=Symptoms of Pott’s Disease.=—There are three main symptoms of Pott’s
disease, namely the peculiarity of attitude and gait, limitation
of motion or muscular stiffness and the pain and referred pains.
In the cervical region, the chin is held somewhat raised and the
patient may have somewhat the same appearance as in wry-neck. In the
mid-dorsal region one will always find an elevation of the shoulder
besides the deformity. In the lumbar region, the patient nearly always
leans backward and has a sort of sidling gait or waddle due to the
contraction of the psoas and iliacus muscles. The patient in walking,
stooping, or lying down most carefully guards the spine against any jar
or motion, and always assumes attitudes which will relieve the strain
on the involved vertebræ. There is always present an unnatural mode
of standing or walking, especially when the dorsal and lumbar regions
are involved, as the patient walks more on his toes and with the knees
slightly bent, because in this posture all possible strain of the step
may be brought into play to diminish jarring of the spine. The child
becomes tired very easily and lies down or rests on the arms of a chair
or seat. The pain rarely occurs in the back, but is usually referred
to the peripheral end of the nerves and is thus felt in the chest,
abdomen or limbs. The abdominal pain passes sometimes as a stomach
ache and often times in the limbs, as rheumatism or “growing pains”.
I have noticed also a peculiar grunting respiration and sometimes
cough especially when the mid-dorsal region is involved. Muscular
stiffness is always present, all mobility being lost. The temperature
is not at all diagnostic, though sometimes in the afternoon it will
be one or two degrees higher than normal and does occur independently
of abscesses. About the only complication that occurs is paralysis or
abscess formations. Paralysis is given as a frequent complication,
though I have never seen it. It is usually flaccid and bilateral and
may exist from a mere muscular weakness to a complete loss of power.
It is certainly uncommon under proper treatment, and the prognosis is
favorable. Abscesses, though a very distressing complication, are very
uncommon in my experience and are certainly an evidence of improper or
incomplete treatment. They may subside in any region and be absorbed
without detriment to the patient, though if they increase in size there
is no tendency towards absorption. It is best to incise them and secure
complete drainage. It is hard, of course, to do this on account of the
depth. Abscesses occur always in close proximity to the disease.
=Treatment.=—Some authors recommend a brace for the treatment of this
condition, while others recommend a frame to which the patient is
strapped, and rest in bed. I have found nothing that gets results like
a plaster of Paris jacket applied with the patient suspended by the
neck and shoulders. I make no attempt at correction of the deformity
present other than the traction of the weight of the body at the time
the cast is applied. The spine is, of course, fully extended by this
and any undue pressure on the cord relieved. The cast should extend
over the shoulders and well down over the pelvis and sacrum. If the
disease is in the neck the cast should include the head as well. A
large window is cut in front and one must be cut over the involved area
of the spine behind. Ordinary absorbent cotton is used for padding
with, of course, extra padding over all bony prominences. From two to
five years’ time is required for a complete recovery. The X-ray is
invaluable in diagnosing this trouble, and each time a cast is removed
to see how much progress has been made. The casts should be changed as
often as they become soiled.