Pain.
—Pain is rarely absent. It may be misleading, but is usually referred to the terminal distribution of the intercostal nerves, and thus may be complained of in the chest, the abdomen, or the legs. Many a “stomach-ache” in children is of this character and origin, and a complaint of frequent “growing pains” should be carefully investigated. Even in sleep these pains are characteristic, and have been previously described as “starting pains.” Children cry out with them in the night. They tire easily and tend to seek rest instinctively. Pain is always aggravated by excessive pressure upon the upper spine or by jars, such as may be received in jumping. It is not necessarily constant. Vertebral tenderness may sometimes be detected by pressing upon the ribs. This will especially aggravate symptoms when respiration is of a groaning character or when there is any expression of dyspnea. There may be vomiting or dysuria. A sudden increase of these painful features means a fresh focus of infection, impending abscess, or a danger of paralysis.
Muscle Spasm.
—It is by muscle spasm that we account for the attitudes and postures of Pott’s disease. It is a constant feature, but will vary in its expressions with the location of the disease. In caries of the cervical spine the chin is raised, the head is balanced somewhat backward, while the lower spine is straightened and given a backward curve. In the stooping posture the head is supported by the patient’s hands in the instinctive effort to protect it. In caries of the mid-dorsal region there is elevation of the shoulder, with marked tendency to support the weight of the upper part of the body by placing the hands upon the knees or thighs. Lumbar caries often produces perceptible backward curve in the lower portion of the spine.
In all cases there are stiffness and rigidity of the spine, and patients resort to all sorts of instinctive expedients to avoid motion in the affected area. When that part of the spine which is in relation with the psoas muscle is involved there is more or less psoas contraction, with characteristic flexor deformity at the hip, which is usually bilateral. This will give a peculiarity to the gait and cause it to be not only stiff in appearance, but it will be seen that the patient walks more upon the toes and with slightly bent knees, which are thus made to act as springs. An attitude assumed in stooping or in the effort to lean over as if to pick up an object from the floor is characteristic; the spine will not be curved forward and the patient will not stoop as usual for the purpose, but the spine will be more or less erect and stiff and lowered to the floor by flexing both knees and hips until the squatting position is assumed. In rising the same effort will be made to protect the spine from any motion between its component parts. (See [Figs. 253] and [254].)
During sleep this muscle stiffness becomes even more pronounced, so that in the morning patients are “stiffer” than later in the day. The existence of muscle spasm can often be detected by palpation of the spinal lesion. Some lateral deviation or asymmetry of signs may often be noted, according as the muscles of one side are more pronouncedly influenced by the location of the disease focus, and it is the more common in proportion to the greater severity of the case.
The confinement caused by the disease will naturally be followed by more or less atrophy of the body muscles, but, in addition to that, those immediately involved about the centre of the disease undergo an atrophy due to it and often apparent on inspection.
Tenderness.
—In numerous distinctive ways the patient constantly evinces tenderness and makes invariable efforts to protect against movement or even jar. Tenderness can also be evoked by pressure upon the head or shoulders, which will cause severe pain, or by causing the patient to jump down a step or to rise upon the toes and then come down abruptly upon the heel. Pressure upon the spines of the affected vertebræ or upon the ribs which connect with them will also cause complaint of pain.