Course and Prognosis.—The whole disease takes a very chronic course. The beginning is hardly noticeable and therefore often over looked. It runs its course for a number of years. Wullstein gives the mortality as 27 per cent. Death usually ensues as the result of systemic infection or from secondary affections (suppurations, paralyses).
The prognosis is absolutely unfavorable as to the retention of the shape of the body. A kyphosis almost always develops, and it fails to appear only in the rare cases of epiphyseal tuberculosis of the body of the vertebra or of tuberculosis of the arch. The more vertebrae affected the more pronounced will be the kyphosis (arcuate type).
Even this tubercular disease may heal at any stage. Fibrous or even osseous union of the remains of the bones, inspissation and calci fication of the cheesy and purulent masses, retrogression of the edema and granulations, as well as of the paralyses caused by these, may make a return to health possible.
Of the paralyses, those in the more resistant vegetative tracts will disappear first (bladder, rectum), then the sensory and last the motor functions.
Diagnosis.—This is especiallyimpo•tant in the earliest stages because by promptly recognizing the deformity we may prevent much damage and we may be able to prevent the extreme deformities as well as a fatal outcome by our treatment.
Once the kyphosis has formed and is painful to pressure, or when paralyses and gravitation abscesses appear, then the diagnosis is no longer difficult; but in eases of incipient spondylitis in small children in their second year, which is the favorite age for this affection, the recogni tion of the first stages may be extremely difficult, particularly before the kyphosis appears or in a child with a possible rachitic kyphosis.
The child is stripped and its attempts at walking are observed. Careful fixation of the trunk when walking should arouse our snspicion. This will be still more pronounced when picking things off the floor or when attempting to twist the body. An oblique carriage of the trunk must also be noted. Then we palpate the spinout' processes, as the protrusion of a single vertebra is detected quicker by touch than by sight. We should bear in mind, however, that in children the spinous processes frequently do not form a straight line.
The pain on pressure which is mentioned in the text-books is by no means reliable and cannot always be used for differential diagnosis, especially in young children. The examination for a passive lordosis gives better results. The raehitic kyphosis is fixed only when it is of a very high degree, and even then the arch is always flat. When we place the child face downwards and elevate the legs, the rachitic kyphosis of mild degree will be changed into a lordosis. The spondylitic kyphosis will always persist and attempts at correction will cause pain. When once the spondylitic kyphosis has reached the same size as a fixed rachitic one, differential diagnosis will not offer any difficulties. The diagnosis will be aided materially by the examination for nervous symp toms, increase of reflexes, lowered tone of the muscles below the kyphosis (fist pressure), disturbances of sensibility and motility, pains on motion, crying at night from involuntary motions (see Coxitis) and the appear ance of abscesses.
A sarcoma may simulate tuberculosis of the spine. Carcinoma need hardly be considered in children (von Pirquet's cutaneous reaction, proof of tuberculosis, absence of abscesses). The same may be said of the rare gummatous affections which can be diagnosed from the systemic disease (Wassermann's test).
Infections of the vertebrre other than tuberculous ones run a rapid course with high fever, while the tuberculous disease is without fever at first, or with only slight elevations of temperature (up to 37.5° or 3S° C.) (90° to 101° F.).
Lateral deviations (scolioses) arc shown to be tubercular by the painful fixation.
In cases of malum suboccipitale we frequently observe in addition to the fixation with the head bent forward a sideward twisting of the head and neck, especially when the next vertebrae arc affected as well, thus imitating a torticollis position. If we look for the total painful fixation we will rarely make a mistake in these cases, and if we further remember that in torticollis only the counter motion is interfered with, and in spondylitis every motion.