Spondylitis—A Submerged Entity in the Diagnosis of Obscure Conditions in the Abdomen

Abstract

IN looking over recent textbooks and other current medical literature, one is struck with the paucity of material bearing on spondylitis. It is only when the Index Medicus is consulted that one sees the amount of thought and effort that has been expended on the subject. My specific attention to spondylitis was caused by finding a case of the “Marie-Struempell” type in a patient where all the trouble was referred to the right kidney. This man, a lean individual of thirty-five, had been down to the cystoscopy room and had been catheterized three different times, radiographs being taken each time. The kidneys were visualized and were found to be normal, as was the urine. (I had paid no attention to the spine, for we were looking for a pathological condition of the kidney. ) Talking over the case with the cystos-copist, he remarked: “The man must have some pathology somewhere; if not in the kidney, where?” It was then that I looked for something else, and at once noted the spine, which showed a marked spondylitis. Following this case I was more careful in looking over plates taken because of gastric and kidney conditions, and was surprised at the number that showed spurs and other conditions of the lumbar spine. There is no doubt in my mind that in many of the cases it was these pathological conditions in the spine that led these patients to consult their physicians, who had been misled by the referred pain to some abdominal organ or viscus. The mistake is often made of inferring that spondylitis is always accompanied by rigidity or stiffness of the spine. A number of cases that I have looked over have had no perceptible stiffness, or at least not more than one would expect for the given age. Just what is the cause of spondylitis is still a mooted question. Some consider that it is just a part of a general rheumatoid condition that for some unknown reason has affected the spine rather than some other joint. If this be true, why does it nearly always select the lumbar vertebrae? The orthopedist, McCarthy, of Philadelphia, writing in the New York Medical Journal in 1905, considered it a distinct disease entity and pointed out what I also have noted—that the pain in these cases is usually referred to some distant point and seldom to the seat of the pathology. The studies and writings of Marie, Baumler and Struempell cite a number of possible causes for the condition, but unite on no one thing. In the last American edition of Struempeli's “Practice of Medicine,” he devotes only a few lines to the condition, and that to the terminal pathology, indicating that probably he was weary of the war of words and wanted peace. Bechterew approaches the subject from the rheumatic point of view entirely, and, I think, rightly attributes the pain to the pinching of the nerve roots by the new deposits.