Finally of all cases of Pott’s disease it may be said that each should be studied by itself, and for each a suitable method or apparatus devised, rather than to endeavor to apply indiscriminately unchangeable methods or forms of apparatus. Every apparatus has its disadvantages as well as its benefits. The more acute the case the more is absolute rest in bed, with traction, demanded. This is particularly true of disease in the upper spine. On the other hand, the more chronic and the lower the disease the easier it is to handle, and with such simple expedients as plaster corsets. When the sacral region is rigid, however, recumbency is usually necessary, because of the difficulty in securing adequate fixation within any apparatus that can be worn. The necessity for general constitutional, dietetic, and climatic treatment should never be forgotten, and the danger of possible acute dissemination kept ever in mind. This is particularly imminent when too much freedom is allowed. Time, patience, and discernment are the dominating factors beyond the general principles already inculcated.
SACRO-ILIAC DISEASE.
Under this name is included a tuberculous condition of the bony tissues on either side of the sacro-iliac synchondrosis, or of the cartilage itself, similar to that which produces the special caries described above. It is an uncommon expression of tuberculous disease occurring often in the young, identical in pathology with other tuberculous bone lesions, and giving rise to peculiar symptoms, mainly because of its location. Early in the course of the disease these may consist of mild discomfort in the lower abdomen, irritability of the bladder and bowels, disinclination for exercise, while, as the disease becomes more pronounced, there will be actual pain, intensified by standing, relieved by lying down, often severe at night, usually referred along the course of the sciatics. A most significant symptom is the tenderness and complaint produced by firm pressure made upon both sides of the pelvis, thus forcing tender surfaces against each other. In the later stages of the disease abscess may develop and present either externally in the lumbar region or internally, breaking into the pelvis and appearing perhaps in the groin or close to the perineum. The disease is usually unilateral, and will cause characteristic limping and aggravated pain upon standing on the limb of the affected side. Naturally this limb will be spared in every possible way. It is likely to be mistaken for sciatica or lumbago, in neither of which diseases is there any tenderness at the sacro-iliac joint such as can be evoked by pressure from the sides of the pelvis. It also has to be distinguished from hip disease by the fact that motions at the nip are not interfered with, and from Pott’s disease of the lower spine, which usually causes prominence of the spinal processes and local tenderness in a different region.
The surfaces and tissues involved are extensive and the disease is always serious. It is one of the most chronic of all such affections, and too often tends to suppuration, with its slow but inevitable consequences, or to dissemination. Thus of 38 cases with abscess reported by Van Hook only 3 recovered.
Treatment.
—Treatment should consist of absolute rest, with traction, so long as the symptoms are active, and avoidance of all irritation when patients rise from bed. Abscess due to sacro-iliac disease should be radically attacked, especially if this can be done early. Intrapelvic pus collections may require trephining of the pelvic walls or resection of some portion of the ilium, by which complete evacuation may be made and drainage be amply provided. When the joint itself is thoroughly broken down the case will have a hopeless aspect.
CARIES OF THE HIP.
Hip-joint disease, or, as it is often called, coxitis or morbus coxæ, is worthy of special consideration on account of its frequency, its importance, and the deformities which result from its existence. The most frequent site of the disease, which is of the usual type of tuberculous ostitis or osteomyelitis, is on the femoral side of the joint, usually in or near the head of the bone. In a small proportion of cases the first lesions appear upon the acetabular aspect of the joint, while in some cases the primary tuberculous lesion is of the type of a tuberculous synovitis. (See chapters on [Bones] and [Joints].) In addition to those changes already described in previous chapters there occur certain distinctive alterations about the hip-joint which are worthy of note. On the pelvic side the margins of the acetabulum occasionally become softened, and naturally yielding in the direction of pressure as the result of muscle pull upon the thigh toward the pelvis, cause, first, an elongation of the originally merely circular cavity, and, finally, considerable shifting of position, often referred to as migration of the acetabulum. Thus the head of the bone may be found in a socket thus formed on a level one inch higher than on the well side. So also perforation of the acetabulum may occur, with perhaps final escape of the head of the bone into the pelvic cavity. On the other hand, similar changes produce decapitation or marked alterations of shape in the head and neck of the femur.
Symptoms.
—When the symptoms and signs of tuberculous disease in this location are studied in accordance with what has already been stated in general about caries of the joint ends of the long bones, we have among the most significant features: