Obrázky stránek
PDF
ePub

in obscure conditions. All cases of hematuria that we can not account for should be subjected to cystoscopy promptly. It is not painful or dangerous when properly done.

Dr. W. F. Westmoreland, Atlanta: One point that the doctor brought out should be particularly emphasized; that is, that papillomatous growths while originally benign may suddenly become malignant, and a curable disease may become one of the most malignant that we can have to deal with. The microscopic examinations of papillomata is now being more carefully carried out, and shows an increasing percentage of malignancy at the base of the condition. The tendency before has been to treat all papillomata as benign tumors and simply snip them off rather than do a more radical operation. So we have presented not only the conditions the doctor has mentioned, so far as danger is concerned, but the increasing danger of malignancy.

Dr. W. W. Battey, Jr., Augusta: I just wish to mention the use of glutol instead of adrenalin as an application to these tumors of the bladder where the growth has been scraped off. It is a German preparation of gelatin which has a very good effect in preventing hemorrhage.

SACRO-ILIAC DISEASE.

BY C. R. ANDREWS, M.D., AND MICHAEL HOKE, M.D.

In considering the sacro-iliac synchondroses, it must be remembered that we are dealing with true joints which are capable of distinct motion, but which, unlike the other joints of the skeletal structure, consist of flat, bony surfaces which are opposed in oblique axes. In consequence of this fact, the stability of these articulations is dependent upon the strength and tone of the muscles and ligaments which act doubly by preserving an anatomic relation and protecting them.

The pelvic girdle may be considered as the structural base for the skeleton, having attached to it the strong trunk muscles as well as all the important muscles of the thigh. Hence it is evident that any instability of the pelvic articulations must interfere with the proper action of the muscles thereunto attached, and conversely it is true that any lack of development or alteration in tone of the muscles and ligaments, which protect and hold in position the pelvic joints, must likewise render impossible their normal anatomic relation, and with change of anatomic relation we have impaired function.

ANATOMY.

syn

The articular surfaces of the sacro-iliac chondroses are broad and flat, the obliquity of their axes being in two directions, upward and outward and forward and outward. A consideration of the differences between the narrow approximation of bony surfaces forming the pelvic articulation, and the broad, extensive

apposition between the sacrum and the ilium will clearly demonstrate that the stability of the pelvic girdle is dependent upon the sacro-iliac articulations, and not the simphysis pubis. As a matter of fact, in cases of extrophy of the bladder, the pubic bones may be absent without seriously interfering with locomotion.

Motion is a normal function of the sacro-iliac joints and consists of a tilting of the sacrum on the ilia or the ilia on the sacrum. The axis of this motion is a transverse one, situated about the middle of the sacrum. It is obvious that in tilting, when the promontory of the sacrum moves forward, the tip moves backward, and vice

versa.

Certain physiological conditions bear a direct relation to relaxation of the sacro-iliac joints. It is a well-known fact that there is a demonstrable amount of relaxation during pregnancy, which becomes more marked toward delivery. This relaxation may not be sufficiently marked to deserve attention, while, on the other hand, it may be so great as to cause serious inconvenience as regards pain and discomfort, and materially interfere with locomotion, requiring treatment, both during pregnancy and after delivery.

During menstruation, which physiologically may be considered as a miniature pregnancy, there is often a relaxation of the joints in question. This unquestionably explains many of the backaches occurring at the menstrual period, which may often require mechanical support for their alleviation.

During pregnancy and menstruation, congestion of the pelvic viscera is present, and since these conditions may cause relaxation of the sacro-iliac joints, Goldthwait suggests that abnormal congestion of the pelvic organs might cause relaxation, and conversely long standing re

laxation of the sacro-iliac synchondroses might induce congestion of the pelvic viscera. It has been shown that these joint conditions often improve after plastic operations on the perineum and cervix, and removal of uterine

tumors.

From an obstetric viewpoint, the movements of the sacrum are of importance. If the upper part of the sacrum be tilted backwards, the anterior-posterior diameter of the brim of the pelvis is increased, and on account of the double obliquity of the articular surfaces, the lateral diameter is likewise increased. But, when in tilting, the axis of motion, passing through the center of the sacrum, as the diameters of the pelvic brim are increased, the tip of the sacrum moves forward and the diameters of the outlet are decreased correspondingly. A knowledge of these facts is often of value to the accoucheur, since the pressure necessary to produce these sacral movements is not at all unbearable by the patient.

Again, since the trunk muscles, which are attached to the pelvis, play such an important part in delivery, the auxiliary expulsive force contributed by the trunk muscles is greatly interfered with if the sacro-iliac joints be relaxed, because in that case the basal attachment of these muscles is insecure. This insecurity may be relieved at the time of delivery by a tight-fitting belt or bandage about the trochanters.

In the consideration of this subject it must be remembered that we are dealing with true joints, which are subject to the same diseases as joints in other parts of the body: tuberculosis, malignancy, injury, toxic inflammations, etc. But it is the desire of the authors to draw particular attention in this imperfect exposition of the subject, to the condition of relaxation and chronic strain, often due to faulty posture, associated with toxic inflam

mation. When we remember that these joints consist of flat, bony surfaces with articular axes in an oblique direction, with no bony projections, and held together only by muscles and ligaments, it is not surprising that chronic strain and relaxation are so common. Ligamentous and muscular support are quite less ineffectual than where the heads of bones are fitted into globular cavities, or the articular surfaces superimposed upon each other.

It has been observed by us many times that with an existing basal condition of excessive intestinal putrefaction, any injury or undue strain to a joint may precipitate a toxic inflammation. And since the sacro-iliac joints are liable to injury and strain, toxic inflammation of these joints is rather common. This superimposed toxic process is of greater importance, since, for the relief of the sufferer, mechanical measures must not only be adopted, but also due consideration must be given to the intestinal condition.

The mildest manifestation of disturbance in these joints is a slight strain or discomfort in faulty attitudes, as, for example, in stooping. The muscles protect the joints for a while, but as these tire the strain is put upon the ligaments, and as these begin to relax and become tense, discomfort is felt. This is usually relieved by stretching, as in so doing the lumbar spine is drawn forward, carrying forward also the sacrum into its normal position, the strain thereby being relieved. Downward strain of these joints is also possible from long standing, and is relieved by a change of attitude which brings other muscles into play. Strain may also occur in the recumbent position, the spinal muscles finally tiring and the lumbar spine sagging, carrying backward with it the upper part of the sacrum. After anesthetics where re

« PředchozíPokračovat »