DR. H. HOUSTON MERRITT 
 
 NEUROLOGICAL '^-^TrL-'E 
 
 710 WEST 163th STREET 
 NEWY0RK32;n.Y. 
 
 '^W' 
 
SPINAL CARIES. 
 
 (SPONDYLITIS OE INFLAMMATOKY DISEASE 
 OF THE SPINAL COLUMN.) 
 
 NOBLE SMITH, F.E.C.S.Ed., L.E.C.P.Lond. 
 
 surgeon to the city orthopaedic hospital ; 
 
 surgeon to all saints' children's hospital; 
 
 orthopa:dic surgeon to the British home for incurables. 
 
 Sovxboxi 
 SMITH, ELDEK k CO., 15, WATEELOO PLACE 
 
 1894 
 
■^s^c^rr 
 
 ■S7^ 
 
 7?/ 
 
PEEFACE. 
 
 \ In writing the following pages I have endeavoured to make 
 
 i< my remarks as practical as possible, recording my own expe- 
 
 . riences chiefly, but also referring, where I have thought it 
 
 At 
 
 desirable, to cases recorded by other surgeons. 
 
 The drawings I have made myself, in many instances from 
 
 photographs, and in others from sketches which I had pre- 
 
 ^ viously made in my note books. Nearly all the representations 
 
 '>^ of pathological specimens have been drawn by me during my 
 
 visits to the metropolitan museums, and I have further traced 
 
 and drawn in ink all these subjects for the ultimate blocks, so 
 
 that if any misrepresentation occurs, I alone am responsible- 
 
 However, having taken great care to follow the salient 
 
 points, I hope I have in all cases correctly represented the 
 
 subjects before me, whether these have been patients, or 
 
 morbid preparations found in museums. 
 
 Noble Smith. 
 
 Queen Anne Stkeet, 
 London, W., 
 Matj, 1894. 
 
 
CONTENTS. 
 
 PAGE 
 
 Chapter I. — General Description of the Disease . . . . l 
 Descriptiou of spinal column — Development of deformity — 
 Lateral curvature with caries — Alto-axial disease — The 
 progress of spinal caries — Etiology. 
 
 Chapter II. — Symptoms and Diagnosis . . . . . . . . 35 
 
 General symptoms — Pain — High temperature — Rigidity — 
 Nerve symptoms — Abscess. 
 
 Chapter III. — Other Diseases op the Spinal Column which 
 MAY simulate Caries 48 
 
 Cancer — Eickets — Syphilis — Aneurism — Hydatids — Osteitis 
 deformans — MoUities ossium — Osteo-arthritis. 
 
 Obscure Cases. 
 
 Absence of pain — Case unrecognised during life — Case mis- 
 taken for Hydrocephalus — Case mistaken for Croup — 
 Absence of deformity — Case of vomiting — Absence of all 
 ordinary symptoms — Necrosis of a lumbar vertebra — 
 Periostitis. 
 
 Chapter IV. — Treatment 79 
 
 Mechanical fixation of the spinal column — Adjustment of 
 the spinal apparatus in accordance with the progress 
 towards resolution — General rest of the patient — Modi- 
 fication of the bodily movements in accordance with the 
 severity of the case — Nursing — Clothing — Food and medi- 
 cine — Treatment of complications. 
 
vi. Contents. 
 
 Chapter V. — Treatment (Operations) . . . . . . . . 106 
 
 Laminectomy — Wiring the vertebrae — Bone drilling— Opera- 
 tion for abscess — Evacuation, antiseptic dressing of the 
 abscess walls and closure of the wound — Entire removal 
 of abscess — Scraping out the cavity — Simple daily syringing 
 with an antiseptic solution — Retropharyngeal abscess — 
 Sequestra of diseased bone. 
 
 Chapter VI. — The Period op Treatment . . . . . . . . 117 
 
 Period of consolidation — Period of time during which it will 
 be necessary to continue mechanical support. 
 
 Chapter VII. — Cases 121 
 
The influence of Actinomycosis upon the 
 production of Caries will be considered in a 
 subsequent edition. 
 
SPINAL CARIE8 
 
 (SPONDYLITIS, OB INFLAMMATOBY DISEASE OF 
 THE SPINAL COLUMN). 
 
 CHAPTEK I. 
 
 SPINAL CARIES (SPONDYLITIS). 
 
 In the following chapters I have discussed the nature of caries 
 of the spinal column and its treatment, and have also shown 
 that, in a great many instances of its occurrence, the symp- 
 toms are obscure and liable to mislead us in our diagnosis. 
 
 The most experienced surgeon may have a difficulty in 
 determining the real nature of the case, not only in the very 
 early stages, but even when the disease has made considerable 
 progress, for it sometimes happens that the signs commonly, 
 or exceptionally attributed to caries are absent, or that other 
 symptoms mask those pertaining to this disease. In the early 
 stages especially, there is often a difficulty in detecting the 
 nature of the case, and this applies both to children and 
 adults. 
 
 In the treatment of obscure cases it is well to act with 
 caution, and adopt a method of treatment which at least 
 is not calculated to increase the disease should it happen to 
 be that which we are now considering. In respect to this 
 subject I would especially refer the reader to p. 65 et seq. 
 
 There are several affections of the spinal column which we 
 1 
 
2 SPINAL CARIES. 
 
 may consider allied to caries — allied at least as far as symptoms 
 are concerned, and as being also of an inflammatory nature. 
 Various forms of traumatic injury; strains, contusions, partial 
 fractures, and inflammatory affections following severe illnesses 
 and causing much pain. The latter condition occurs so often 
 after typhoid fever, that Dr. Gibney of Nev^ York has de- 
 scribed such cases as "typhoid spines," considering that their 
 pathology is one of periostitis (see p. 78). Whether any of 
 these various conditions may eventually produce caries is a 
 subject upon v\^hich there are differences of opinion, but at 
 least we know that in patients thus affected pain may con- 
 tinue month after month unrelieved by medicinal remedies, 
 whereas they succumb to prolonged fixation of the painful 
 parts, or, in other words, to application of the treatment 
 suitable to caries. 
 
 In considering this point we must remember the many 
 instances, some of which I record in this volume, where the 
 history of the patients has been either of the character to which 
 I have just alluded, or even of a less definite form, and in 
 which after death a very extensive degree of caries has been 
 found. Dean Buckland, the author of one of the Bridgewater 
 treatises, and the father of the late Frank Buckland the 
 eminent and popular naturalist, suffered from symptoms which 
 were attributed by his friends to melancholia, but nevertheless 
 he died from caries (see p. 67). 
 
 Some of the cases recorded as obscure showed symptoms 
 which would, I think, have been recognised by the surgeon if 
 he had realized the variety of the characters which may 
 present themselves in caries. Some of these I have referred 
 to under " Cases." 
 
 There are other diseases of the spine which may simulate 
 caries, and which will be helped in their treatment by careful 
 mechanical fixation. Some of these are : — 
 
 Rheumatoid Arthritis, which may attack the spine and 
 cause great suffering. 
 
 Rickets, which may give rise to difficulties in diagnosis, and 
 even produce paralysis from direct bony pressure. 
 
 Cancer, Hydatids, Aneurism causing pressure upon the 
 spine ; and some other affections which are also mentioned 
 below. 
 
 In this consideration we cannot exclude Lateral Curvature, 
 from softness of bones and relaxation of ligaments, un- 
 
OR SPONDYLITIS. 3 
 
 associated with inflammation. This affection is one which 
 I discuss in the following pages very fully, showing how 
 difficult or impossible it may be to form a certain opinion, 
 and how important it is to adopt a careful treatment and 
 not jeopardise the patient by prescribing exercises and free 
 movements until the diagnosis is absolutely certain. In this 
 matter of diagnosis I would especially call attention to the 
 test of temperature — a test which is not always applied (see 
 p. 38.) 
 
 Other diseases affecting the form of the spine, such as 
 OsTEO-MALACHiA and Spondylolisthesis I have not dealt 
 with, fearing to enlarge the volume too greatly. 
 
 Caries of the Spine is very prevalent among children, is not 
 uncommon in adult life, and sometimes occurs even in old age. 
 It is an inflammatory disease of the vertebral bones, and of 
 the inter-vertebral fibro-cartilages, progressing to a process 
 of ulceration by which the affected parts are gradually dis- 
 solved away. An abscess is usually formed at the seat of 
 inflammation, and is at first out of sight at the front of the 
 spine, but it may extend in various directions according to 
 the part of the column affected, appearing externally at the 
 side of the neck or in the back, thighs, or elsewhere, some- 
 times opening internally into the bowels or other viscera. 
 
 If this inflammatory process is allowed to continue un- 
 checked, it will extend in time to the spinal cord, producing 
 at first weakness, and ultimately paralysis of the legs, or 
 even involving more or less of the body, but only including 
 that part which is below the seat of the disease. "While 
 these symptoms are developing, the general health of the 
 patient is deteriorating, and although, in the early stages, 
 he may feel comparatively well, and even have a robust 
 appearance, the strength of the body is gradually undermined, 
 until at last the patient sinks from exhaustion caused by the 
 continued pain, the incessant discharge of pus, or from 
 secondary disease of the liver, kidneys, or other organs. 
 
 This progressive downward course ought never to occur, 
 unless it be in the case of patients who are suffering from 
 some severe constitutional disease, or whose general condition 
 of vitality, irrespective of the caries, is too feeble to resist 
 any further strain. 
 
4 
 
 SPINAL CARIES. 
 
 Before the year 1779, all sorts of curvatures of the spine 
 were confused together, and Percival Pott was the first 
 surgeon to draw a clear distinction between curvature caused 
 by the disease under consideration, and other kinds such as 
 those usually denominated " lateral." So commonly did the 
 disease at that period progress unchecked, until paralysis of 
 the body below the part affected took place, that Pott en- 
 titled his work " Eemarks on Palsy of the Lower Limbs 
 
 Fig. 1. 
 A typical form of Caries of the Spine. 
 
 found to accompany Curvature of the Spine," &c. The de- 
 scription given by Pott, which described caries as a distinct 
 disease, was in time acknowledged as correct, and the term 
 " Pott's disease " has since been very commonly used in de- 
 scribing this condition. Another familiar term is "Angular 
 Curvature," and this is used in contradistinction to " Lateral 
 Curvature." The term " Angular Curvature " has been objected 
 to because an angle is not a curve, but I would rather object 
 to it because so many cases of the disease occur where the 
 deformity is not an angle. In the typical case, however, the 
 
OR SPONDYLITIS. O 
 
 spine ultimately projects in an acute angle, and we may then 
 without any difficulty form our diagnosis of the nature of the 
 affection. 
 
 But the spine may be bent backwards in a bow, as in lig. 2. 
 It may take a quadrilateral form, as in fig. 3. The projection 
 may be obscured by the disease being situated in the lumbar 
 region, when, instead of the natural incurvation of this part, 
 there may be simply an absence of it, and perhaps some slight 
 prominence of the spinous processes upon palpation, or in 
 
 Fig. 2. 
 General roundness of back in caries. 
 
 the cervical region where the same effect may be produced. 
 Again, there may be a lateral angle or curve caused by the 
 disease attacking one or other side of the spinal column, this 
 being distinct from the lateral deflexion of the spine in the 
 early stages, the effect of muscular spasm, a subject that is 
 fully dealt with at p. 14. There may be no deformity what- 
 ever, as occurs when the caries attacks limited parts of the 
 vertebrae, so that the spinal column is not displaced. Even 
 other modifications of form caused by this affection may 
 
SPINAL CARIES. 
 
 occur, SO that it is better to discard the name " angular," 
 notwithstanding its indicating the shape of the deformity 
 commonly found in cases of this disease. 
 
 Spondylitis is the term used in America, and it is un- 
 doubtedly a very good one. However, Spinal Caries is also 
 a scientific name, and clearly indicates the nature of the affec- 
 tion, and for these reasons I have adopted it as a title to 
 this volume. The illustrations given above are those of ad- 
 
 Fio. 3. 
 Quadrilateral deformity. 
 
 vanced cases of disease in which there is never any difficulty 
 in recognising the nature of the affection, but there are 
 a very large number of instances in which the diagnosis is 
 more difficult, either from absence or slightness of deformity, 
 slow progress of the inflammatory changes, or from the simi- 
 larity of the symptoms to those of other affections. I have 
 met with quite a notable number of patients who have 
 thought themselves to be suffering from rheumatism in the 
 
OE SPONDYLITIS. 
 
 form of lumbago, or from nem'algia, or from some functional 
 disorder, while their troubles have been entirely due to caries 
 of the spinal column. Before proceeding further it may be 
 
 Fig. 4. 
 Posterior view of the spine aud pelvis. 
 
 well to consider the general anatomy of the parts we have to 
 deal with. 
 
 The Spinal Column may be described as consisting of a 
 foundation formed by the wedge-shaped sacrum (see fig. 4,) 
 firmly fixed into the pelvis ((j). Erected upon this base are 24 
 bones, interlocked at their posterior parts, the arches, by 
 closely adapted joiats, and separated from one another an- 
 
8 
 
 SPINAL CAEIES. 
 
 terioiiy by elastic fibro-cartilages, all these bones being 
 strongly united together by ligaments. 
 
 The spinal column can be moved anteriorly, posteriorly, or 
 laterally, by the muscles which are attached to it, or these 
 
 Fig. 5. 
 The spine seen laterally, the natural curves being shown. 
 
 movements may be combined in circumduction The whole 
 spine can also be rotated upon its own axis.. 
 
OR SPONDYLITIS. 57 
 
 In rotation the front of the first cervical vertebra may turn 
 tov^ards one or other side; but the movement is chiefly 
 between the two first vertebrae, and those below move in a 
 much less degree. But to whatever extent the whole cervical 
 portion of the spine turns, the effect is produced by each 
 vertebra twisting very slightly upon the one below it. 
 
 The muscles of the spine are brought into action for a great 
 variety of purposes. Besides the varied movements of the 
 column itself, many actions, ordinarily supposed to belong 
 entirely to the extremities, take a direct basis from the spine ; 
 and in order to use muscles which have no direct communica- 
 tion with the spine, others, which are attached to this column, 
 must often be in the first place " fixed," i.e., set in action and 
 so retained. 
 
 It must further be remembered that the muscles of the back 
 are very extensive and complicated in their attachments, so 
 that all the varied movements, which have been referred to 
 above, can be carried out by them. In fact, the muscles, if 
 sufiiciently exercised, are capable of performing a greater 
 degree of movement than the ligaments of the spine will 
 ordinarily allow. 
 
 The Undeveloped Spine. — The foregoing brief description 
 refers chiefly to the fully developed spine — the spine of the 
 adult. As we meet with disease and distortion very often at 
 an early period of life, before the spine is fully developed, it is 
 desirable to consider the condition of the column during its 
 period of growth. It will be remembered that at birth each 
 vertebra consists of three bones, united by cartilage. The 
 osseous laminae unite behind during the first year, and the 
 body is joined to the arch about the third year. The centres 
 of ossification for the transverse and spinous processes do not 
 appear until the sixteenth year, and those which form the 
 thin plates at the upper and under surfaces of each body of a 
 vertebra not until the twenty-first. All these parts are not 
 thoroughly joined together, and the bones completely formed, 
 until the thirtieth year of life. 
 
 The spine, during this period of growth, is more susceptible 
 to injury and deformity than after it is fully formed; but it may 
 be reiterated that there is no age at which it is free from the 
 disease we are considering. Besides being the basis of support 
 
10 
 
 SPINAL CAKIES. 
 
 for the body, the spinal column has a very important function 
 to perform in surrounding that important nerve centre, the 
 spinal cord, and protecting it from injury. From the spinal 
 cord proceed the nerves, emerging between the junctions of the 
 vertebrae, to supply the whole of the body with nerve influence. 
 In caries of the spine, extension of inflammation from the bones 
 
 Fig. 6. 
 
 to the spinal cord, or pressure upon the cord or nerves from 
 the products of inflammation, are the causes of derangements 
 of the functions of the various organs of the body from inter- 
 ference with their nerve supply. This interference causes a 
 great variety of results, including pain, irritation, functional 
 disorder, and paralysis. 
 
DEVELOPMENT OP THE DEFOEMITY. 
 
 11 
 
 Development op the Deformity. 
 
 The projection popularly called "the growing out" of the 
 spine is the most obvious deformity of this disease, and 
 although there are many cases in which such deformity does 
 not exist, or in which it is very slight, yet it is characteristic 
 of the majority of the instances of caries, and therefore we 
 had better now consider the manner of its production. 
 
 Caries usually commences in the front parts of the column, 
 and extends backwards, but seldom attacks the arches of the 
 
 Fig. 7. 
 
 vertebrae. The superincumbent weight of the body is sup- 
 ported chiefly upon the parts of the bones which lie in front of 
 the spinal cord — the bodies of the vertebrae — and consequently 
 as the inflammatory process proceeds, and the bone is dis- 
 solved away, the trunk of the patient bends forwards, and the 
 ulcerated surfaces of bone fall together. Fig. 6 indicates this 
 condition. 
 
 The arches and spinous processes are not drawn, but the 
 figure shows the disposition of the upper part of the body to 
 fall forwards, and for the spine to project backwards. The 
 
12 
 
 SPINAL CARIES. 
 
 position shown in this figure is not maintained by the patient, 
 as the centre of gravity would be thus thrown too far forwards, 
 so that he must either bend his knees and throw the lower 
 part of the spine backwards, as in fig. 7, or he must hold his 
 
 ^' 
 
 rl?< 
 
 ^'' 
 
 ^ 
 
 Fig. 
 
 Pig. 9. 
 
 Fig. 10. 
 
 head more erect, and let the vertebrae above and below the 
 point of disease accommodate themselves to this position. 
 
 Kg. 8 shows the latter position, and when compared with 
 fig. 9, which delineates the natural contour of the spine, it will 
 be seen that the diseased part is thrown backwards to allow 
 
DEVELOPMENT OF THE DEFORMITY. 
 
 13 
 
 the diseased surfaces of bone to remain in apposition. As a 
 rule patients do not hold themselves quite so upright as indi- 
 cated in fig. 8, but they stoop somewhat while keeping their 
 heads sufficiently within the line of gravity. When even this 
 position is painful or insupportable, the patient stoops more 
 and keeps himself from falling forwards by resting on a chair 
 or other support (fig. 11), or by placing his hands on his knees 
 as in fig. 7. 
 
 When the disease attacks several bones in conjunction, the 
 projecting part is less angular, as shown in fig. 2 and in fig. 12. 
 
 The vertebrae that are involved (and when the disease is 
 severe there are several) are fixed to one another by inflamma- 
 tory adhesion ; but yet, during the period of active disease, 
 the carious surfaces can move to a certain extent upon one 
 another, and from and to one another, but the degree to 
 
14 
 
 SPINAL CARIES. 
 
 which separation of the diseased surfaces occurs is, as a 
 rule, sHght ; so that when a patient raises, or rather draws 
 backwards the upper part of the body for the purpose of 
 looking forwards and of equalising his equilibrium, the verte- 
 brae below the sea't of the disease are allowed to accommodate 
 themselves to the alteration in form, and an appearance of 
 incurvation occurs. I say " appearance " because the curve is 
 formed chiefly by an arching back of the vertebrae from the 
 perpendicular line of the body (fig. 8), and not by an arching 
 of the lower vertebrae forwards. In some severe cases, how- 
 
 FiG. 12. 
 
 ever, there may be a true incurvation as well as an arching 
 back, and the curves may appear as in fig. 10. 
 
 In the latter figure there is also an incurvation of the upper 
 part, especially in the neck, in order to allow the face to look 
 forwards ; but the bending is chiefly below the seat of the 
 disease. 
 
 Lateral Curvature with Caries. 
 
 The fact that irregularities of the spine in a lateral direction 
 sometimes accompany caries of the vertebrae has long been 
 known, but these deviations have generally been attributed to 
 a predominance of the disease upon one or other side, leading 
 to bony deformity in a lateral direction . 
 
LATEEAL CURVATUEB WITH CARIES. 15 
 
 Besides this kind of lateral deformity in cases of caries, we 
 also often meet with the ordinary appearances of scoliosis. In 
 the first edition of my work, " Curvatures of the Spine," pub- 
 lished in 1883, I referred to this subject, and in the second 
 edition, published in 1888, I described more fully the charac- 
 teristics of this complication of caries. I endeavoured to 
 describe the points of difference between the two affections, 
 and referred to cases in which mistakes had been made in 
 diagnosis, leading to very disastrous results, as follows :— 
 
 " The possibility of lateral deformity of the spine being de- 
 pendent upon caries should lead the surgeon to exercise great 
 care in making a diagnosis in doubtful cases. In caries, the 
 pain is usually of a different kind, easily increased by move- 
 ments, especially by stooping. In simple lateral curvature, 
 however severe the pain, I have never seen that extreme 
 caution in movements which generally accompanies caries. 
 There is, as a rule, more rigidity of the spine in caries as 
 regards flexion and extension, than in slight lateral curvature. 
 The angle of deflexion may be more acute, and there is fre- 
 quently some posterior projection, as well as lateral curvature. 
 There may be projection of spinous processes in the latter 
 condition, but there is a distinction to be made between the 
 two when the patient stoops. In caries the spinous pro- 
 cesses of the affected vertebrae do not as a rule separate 
 from one another, whereas this separation can generally be 
 felt when no ulceration of bones exists. I stated (in a former 
 edition of that work) that no exact rules could be laid down 
 for forming a diagnosis between these two conditions, but 
 that all the symptoms must be studied. I still adhere to this 
 opinion, and in offering the above suggestions for diagnosis, 
 I must urge that none of them are infallible ; that caries not 
 infrequently exists, and runs its course without producing the 
 usual symptoms of the disease, and that the knowledge of 
 the many anomalies of these cases should lead us to be very 
 cautious in forming a diagnosis. Sometimes it is necessary to 
 treat the case with, caution for a week or two, before coming 
 to a decision, 
 
 "In young children great weakness of the back may be 
 present, which, in the positions of sitting or standing, allows 
 the spine to bend in various directions, forming at one time 
 posterior curvature, and at another, one or more lateral curves. 
 
16 SPINAL CARIES. 
 
 Although this condition would probably lead eventually to the 
 formation of lateral curvature, yet in diagnosis a distinction is 
 to be drawn, for when this state of weakness exists, support 
 to the back, and rest, are more important at first than exer- 
 cise. In fact, in severe cases of weakness of spine, the 
 strength of the child is more rapidly and safely restored by 
 absolute rest at first than by attempts to exercise the muscles. 
 These curves are readily movable in any direction, the spine 
 being easily straightened or bent. 
 
 " I have met with cases in which the symptoms of this kind 
 of weakness of the spine predominated, but which ultimately 
 proved to be instances of commencing caries. An outline 
 of the history of one of them may be instructive. 
 
 "A. W., aged 8|, began to stoop about nine months before 
 I saw her. A few weeks before this visit, pain in the abdomen 
 was felt, and recurred frequently. Certainly this pain was 
 suspicious, but there was no other symptom of caries, the 
 child moved about quite freely, and did not complain of other 
 pain or discomfort. There was at that time no irregularity 
 whatever in projection of the spinous processes. I advised 
 moderate exercise, and treated the case upon the principles 
 described below. Nov. 6th, 1885, six weeks after the first 
 visit, the spine was much straighter, and the muscles were 
 developing. The child could sit up better, but the abdominal 
 pain was more troublesome, and as I could not detect any 
 local cause for it, I again examined the spinous processes in 
 stooping, when I found a slight but distinct projection of the 
 eleventh and twelfth dorsal vertebrae, which I did not hesitate 
 to attribute to the existence of caries. 
 
 " Other cases have been very similar. The possibility of in- 
 cipient caries being the cause of the general weakness of the 
 spine, is an additional reason for not advising gymnastic ex- 
 ercises in the early treatment of very weak backs. I have 
 known such a case treated by the Swedish Movement Cure, 
 and the caries developed soon after the treatment was com- 
 menced, and increased rapidly and severely before its nature 
 was discovered." 
 
 Since the volume above quoted was published I have met 
 with a number of instances in which this same mistake has 
 been made, and when cases of weak back, and slight lateral 
 curvature are treated by exercises, a great risk is run that 
 
LATERAL CURVATURE WITH CARIES. 17 
 
 some latent disease of the bones, which may be present, will be 
 rapidly developed by the treatment. 
 
 More recently the subject has received further attention. 
 In the year 1889, Dr. Bernard Bartow read a paper before 
 the New York State Medical Society, entitled "The Presence 
 of Spinal Distortion in the Early Stage of Spondylitis, and 
 its Value as a Diagnostic Sign." This paper was published in 
 the tenth volume of the "Annals of Surgery," and was illustrated 
 by very interesting photographs. Dr. Bartow is of opinion 
 that some degree of lateral distortion "occurs in almost every 
 case of caries of the spine, appearing even before any angular 
 deformity. When angular projection commences and gradually 
 progresses the lateral deformity becomes less conspicuous, but 
 still contributes in no small degree to the general deformity 
 of the trunk." 
 
 " Pathological spinal rotation," he states, "is always asso- 
 ciated with the early stage of spondylitis," occurring in the 
 dorso-lumbar region. He considers it differs from scoliosis 
 "in the greater variety of its forms, and in the presence of 
 phenomena of irritation, which may be referred to a vertebral 
 source." It is essentially a deformity of rotation. In the 
 early stage of spondylitis the deformity especially resembles 
 the deformity of scoliosis, particularly when the progress has 
 been slow. 
 
 Dr. Bartow's view as to the explanation of this complica- 
 tion of caries is, that in the attempts by the patient to rest the 
 inflamed part of the spine a lateral deviation takes place ; 
 the vertebrae rotate as a natural mechanical result ; the volun- 
 tary reflex contraction of the muscles immobilises the bones in 
 such position ; and subsequent destructive changes confirm 
 the malposition. 
 
 In the Bevue cVOrthophlie for November, 1892, Dr. le Kir- 
 misson writes upon the same subject. He gives many instances 
 of lateral curvature in Potts' disease simulating Scoliosis, but he 
 does not agree with Dr. Bartow that it occurs in every case. 
 Dr. Kirmisson refers especially to the American surgeons 
 as elucidating this important point. He quotes Dr. Henry 
 Taylor and Dr. Ketch, of New York, and also Dr. Lovett, of 
 Boston. He records twenty-four instances which he has met 
 with of lateral deviation in Potts' disease out of 123 cases. 
 Dr. Lovett has noticed in such instances, less of the rotation 
 2 
 
18 
 
 SPINAL CAEIES. 
 
 of the bones, and more of a bending en masse of the trmik to 
 one side. 
 
 It is a most serious matter that the importance of this com- 
 bination of lateral curvature with caries should be recognised, 
 and I think there can be no doubt that it has not received as 
 much attention in this country as it deserves. This' is especi- 
 ally the case so long as the fashion prevails for treating all 
 cases of weak spine and commencing lateral curvatures by 
 means of long-continued exercises. 
 
 As already stated, I have met with not a few instances 
 in which this " exercise " treatment has rapidly developed an 
 obscure case of caries, the lateral deviation which has been 
 present having unfortunately been considered conclusive 
 evidence that no inflammatory disease has been present. 
 
 That lateral deviation may occur in caries from structural 
 changes has long been recognised, but that lateral curvature 
 of the ordinary scoliotic form should accompany, and even 
 precede the majority, or at least a great number of the 
 
 Fig. 13. 
 
 Male, aged 20^ (April 2, 1889). The spine had suffered from a 
 fall, occurring six months previously. It seemed possible there might 
 have been partial fracture at the time of the accident, causing the mal- 
 positign of the spine iii this case. 
 
LATERAL CUEVATUBE WITH CAEIES. 
 
 19 
 
 ordinary symptoms of caries, has not been generally acknow- 
 ledged. The latter is a curvature with rotation which accom- 
 panies the caries, and which extends beyond the area of 
 inflammation, and it is chiefly the result of weakness and 
 discomfort. 
 
 In my own practice I have observed lateral deviation to ac- 
 company caries in the following varieties : — 
 
 1. From general weakness. 
 
 2. From spasmodic muscular action. 
 
 3. Occurring independently, as for instance in cases where 
 one leg is short. 
 
 4. From lateral loss of substance by the caries predominating 
 upon one side. 
 
 5. From some other unusual causes. 
 
 I have made drawings of some of the patients in whom 
 I have found caries to be thus complicated, and as the subject 
 is an important one I give several instances of this peculiarity. 
 
 Fig. 14. 
 
 Fig. 15. 
 
 Figs. 14 and 1.5 represent the back and side view of a male, aged 30 
 (July 10, 1BB9), who was in a very critical condition at this time. It will 
 be Been that there are several lateral irregularities. These were probably 
 caused by tubercular disease, attacking the spine laterally, in several 
 parts as well as chiefly in the region of tlie twelfth dorsal vertebra, as 
 ahown in the profile view. 
 
20 
 
 SPINAL CARIES. 
 
 Fig. 16. 
 
 Fig. 17. 
 
 Figs. 16 and 17 represent a boy, aged 5 (April 20, 1886). He was an 
 extremely feeble cbild, and was suffering from caries involving the vertebrae 
 from the sixth cervical to the fourth dorsal, and probably also the vertebrse 
 in the dorso-lumbar region. Under treatment he made very good progress 
 at first, but had not the strength to maintain it. He died about a year 
 subsequently from tubercular meningitis. The lateral curvature in this 
 case was undoubtedly caused by the general weakness. 
 
 Figs._ 18 and 19 represent a lady, aged 24 (July 10, 1890). There was 
 caries in this case, but it was complicated by there having been a spina 
 bifida, which gradually collapsed, until at the age of 13 it had disappeared. 
 At the time of her visit she was getting rapidly worse, but by means of 
 support and fixation she was almost entirely relieved from pain, and was 
 placed in a much more upright position, as shown in fig. 19. Some lateral 
 deviation, however, remained, and there was great bony thickening round 
 the involved vertebra?. 
 
LATERAL CUKVATUEE WITH CAEIES. 
 
 21 
 
 Pig. 20. 
 
 Fig, 21. 
 
 Figs. 20 and 21 represent the case of Miss H , aged 15 (May 3, 1892), 
 
 whose back began to suffer after a severe attack of typhoid fever three 
 years previously. The general health was feeble, and the patient felt very 
 tired after any exertion. 
 
 August 24, 1892. An abscess was found to be projecting in the left 
 inguinal region. 
 
 In April, 1893, the abscess was less prominent, and since the fixation of 
 the spine there has been no increase in the projecting vertebrae, and the 
 patient is now very well in general health. The lateral curve was probably 
 caused by the predominance of the disease on one side. 
 
22 
 
 SPINAL CAKIES. 
 
 Fig. 22. 
 
 Pig. 22 represents Miss B , aged 17 (June 25, 1892). The back was 
 
 first noticed to be bad eight years earlier, and it had been lately getting 
 worse rapidly. The pain was constant. There was a family history of 
 tubercle, and she had been treated by recumbency, which had given relief, 
 but had not stopped the progress of the disease. 
 
 She was soon benefited by fixation of the spine. The lateral curve, as 
 in the former case, was probaby due to the disease predominating on one 
 side. 
 
LATERAL CURVATUEE WITH CARIES. 
 
 23 
 
 Fig. 23. 
 
 Figs. 23 and 24 represent Miss W , aged 7 (October 24, 1892). A 
 
 year previously she first complained of pain in the right inguinal region. 
 She had lost the power of walking and suffered great pain from the least 
 movement. Caries in this case probably involved not only the dorso- 
 lumbar region which projected, but probably also some vertebrse above. 
 The lateral deviation was due to the general weakness, as the patient was 
 quite unable to sit up without supporting herself with her hands. 
 
 April, 1893. She had been quite free from pain dating from soon after 
 the spine had been thoroughly supported, she was very much better 
 in general health, and the spine was straighter. 
 
24 SPINAL CARIES. 
 
 Alto-axial Disease. — Caries occurring in the first two 
 vertebrae is apt to differ somewhat from the disease when 
 situated lower in the column. It has been stated that in 
 this situation the disease is rarer than formerly, and such 
 fact, if it be one, has been attributed to the caries, in this 
 situation, having been caused in former days, by syphilis which 
 had been allowed to "run on unchecked for longer periods, or 
 was treated too freely with mercury."^ It is quite conceivable 
 that syphilis of the throat might extend to the cervical verte- 
 brae, but I doubt if it has been proved that there is much 
 difference in its frequency in this situation. 
 
 The free mobility of these bones renders them less liable 
 to the sort of injury which is often the exciting cause of 
 caries, but I have seen many cases of disease, in this situation, 
 in some of which the symptoms have been rather obscure. 
 
 Alto-axial disease is more prevalent among adults, although 
 sometimes met with in quite young children. Destructive 
 changes may be very rapid in this part, and repair also may 
 take place more quickly than in other parts of the spine, yet it 
 is well not to depend upon this more rapid healing too con- 
 fidently. 
 
 The peculiar symptoms of disease in this situation may be — 
 pains referred to the throat in swallowing, torticollis (see page 
 40), projection of an abscess or of the body of a vertebra in the 
 pharynx, and pain in the occipital region. Great anxiety of 
 countenance may be present, but is not always so ; posterior 
 projection of the spinous process of the axis, and oedema of this 
 part are also frequent symptoms. When the patient turns his 
 head to one or other side, the whole body is turned also. 
 Should the disease get worse, and the head continue to glide 
 forwards, the odontoid process of the axis may eventually 
 press on the medulla oblongata, and so produce fatal paralysis. 
 Death may even occur quite suddenly from a giving way of the 
 transverse ligament. 
 
 The Progeess of Spinal Caries. 
 
 The inflammation usually commences in the anterior part 
 of the spinal column, generally in the bodies of the vertebrae 
 
 ' Holmes' " System of Surgery," 3rd edition, vol. ii. , p. 420. 
 
THE PROGRESS OF SPINAL CARIES. ZO 
 
 themselves, or at the junction between a vertebra and an 
 intervertebral cartilage. The disease extends backwards, 
 also upwards and downwards, and it eventually attacks, in 
 extremely severe cases, the articular processes, and also the 
 articulations between the ribs and the spine. 
 
 Caries sometimes commences in other parts of the bodies of 
 the vertebrae. Under such circumstances the symptoms may 
 be insidious and the progress of the disease slow ; fig 25 
 represents such a case. It is described in the St. Mary's 
 Hospital Museum catalogue (A. B., 142) as caries of dorsal 
 vertebrge in a male aged 21. He had been an athlete, ill only 
 
 Fig. 25. 
 
 one month before admission for ijleurisy. No symptoms of 
 the caries were complained of, and the diseased state of the 
 bones was only discovered at the post-mortem examination. 
 He died from croupous pneumonia. 
 
 A specimen in University Hospital Museum illustrates 
 another form of the disease in which the ordinary deformity 
 does not occur (see fig. 26). It will be obvious that in such 
 cases the diseased parts are not subject to so much compres- 
 sion or disturbance from the movements of the body as in 
 the commoner forms of the disease, and therefore the symp- 
 toms are less obvious. 
 
 In ordinary cases projection appears sooner and increases 
 most rapidly when the disease is situated in the dorsal region. 
 This result is the consequence of the natural curve of that 
 region backwards, the pressure upon the diseased part being 
 
26 
 
 SPINAL CARIES. 
 
 then greater. In the lumbar and cervical regions the natural 
 anterior curve has to be obliterated before a posterior projection 
 is formed. Therefore the amount of deformity is not a sure 
 indication of the extent of the disease, unless its situation be 
 taken into account. These remarks apply more to cases in 
 which the deformity is a curve, than to those in which it is an 
 angle. 
 
 Fig. 26 " Illustrates the effects of osteo-myelitis granulosa of the strumous 
 form acting upon the front of the bodies of the vertebrge, and leaving the 
 inter-vertebral discs intact. The latter are dried and shrunken in the 
 specimen, but normal. The ' pitting ' by pressure of bosses of granulation 
 tissue is well seen hollowing out the bodies, and starting underneath the 
 anterior common ligament. The surface behind [a a) is made by a 
 saw-cut removing the transverse processes." (From Holmes' " System of 
 Surgery," vol. ii., p. 404, A. E. Barker.) 
 
 If the disease is situated in the lower lumbar or upper 
 sacral region, incurvation of the vertebrae above the disease 
 may occur and be the most marked abnormal appearance. 
 This is especially the case in those peculiar cases called 
 Spondylolysthesis. When the disease is situated in the upper 
 
THE PROGRESS OP SPINAL CARIES. 
 
 27 
 
 dorsal or lower cervical region, the head subsides vertically, 
 and approximates to the upper part of the chest, the appear- 
 ance of the neck being more or less obliterated. Accordingly 
 the occiput may come in the way of an examination, pre- 
 venting the tips of the spinous processes from being felt by 
 the fingers, or the head may assume other positions. 
 
 In any case of weakness of the back causing posterior cur- 
 vature, even if it only amounts to a slight stoop, the chest 
 usually becomes flattened and the thoracic cavity reduced in 
 size. 
 
 Caries in any part of the spine may, by causing weakness 
 and consequent stooping, affect the chest in this manner, 
 
 Fig. 27. 
 Alteration in the form of the thorax. 
 
 and disease in which the dorsal vertebrae are alone, or chiefly 
 involved (figs. 27 and 11), as already stated, has the more 
 marked effect upon this part of the trunk. 
 
 Disease involving loss of substance of the front part of one 
 or two vertebrae in the dorsal region causes flattening of the 
 chest, but sometimes the front of the thorax comes to project 
 again while the angular projection of the spine increases ; the 
 
28 
 
 SPINAL CAEIES. 
 
 height of the patient then decreases, the ribs collapse upon 
 one another, and the chest becomes flattened laterally. The 
 sternum is then pushed forwards and a sort of " chicken breast " 
 is produced. It is, I think, only in the more favourable cases 
 that this development of the chest takes place, and especially 
 when treatment has helped in this development. The fol- 
 lowing instance (figs. 28 and 29) especially shows the effect of 
 
 
 Fig. 28. 
 
 Fig. 29. 
 
 treatment in this respect. The child was in a very critical 
 condition when I first saw her (described, p. 125), but is now 
 practically well. Fig. 28 is from a sketch I made of her 
 in April, 1884, and it will be noticed that the chest is much 
 incurved. Fig. 29 is from a photograph taken in October, 1891. 
 
 From compression of the chest by its collapse, and the 
 consequent lessened capacity of the thoracic cavity, the vital 
 organs therein contained are displaced, and more or less 
 interfered with in their functions. Impeded respiration and 
 circulation are marked symptoms of this condition, and 
 depend partly upon absolute compression, and also upon 
 interference with the nerve supply of the heart and lungs. 
 
The progress of spinal gabies. 
 
 29 
 
 When the upper cervical vertebrae are attacked, the head 
 is bent and protruded more or less forwards and downwards 
 in a " contemplative " attitude, which is very characteristic. 
 
 When the lower cervical and upper dorsal vertebrae are 
 affected, the deformity of the back generally assumes a 
 rounded lump-like projection, and the head droops downwards 
 (fig. 31), the patient often having a sad and painful expression 
 of countenance. 
 
 In other cases the head is held so that the face presents 
 more upwards, giving the patient a rather consequential look. 
 The exact position depends much upon the feelings of the 
 patient. In the active stages, if there is much pain, the in- 
 clination is generally to droop the head, whereas during 
 
 Fig. .30. 
 
 recovery or after ankylosis has taken place (should such a 
 result occur) then the head is held up with the object of see- 
 ing Straight forwards. This effort necessitates the position 
 which I have above referred to as giving a consequential look. 
 When the disease is in the lumbar region, the patient may 
 bend his body forwards, but sometimes he will hold himself 
 remarkably upright. 
 
 Movements. — In whatever part of the spine the caries 
 exists, the patient will, while the disease is in an acute form 
 
30 
 
 SPINAL CARIES. 
 
 in typical cases, move with extreme caution, support himself 
 in standing by placing his hands upon his knees (fig. 7), 
 inclining his body forwards, and bending his knees to give the 
 necessary prop to the body. In sitting upon a chair he will 
 prop himself up by resting the weight of his body upon his 
 arms, his hands resting on the seat of the chair (fig. 3). In 
 sitting at a table he will rest his elbows upon the table, and 
 support his head upon his hands. He moves with caution, 
 and avoids jolts and jars. If he wishes to pick up something 
 from the floor he does not bend his back, but stoops by 
 
 Fig. 31. 
 
 Fig. 32. 
 
 Fig. 31. — A. B., aged 9 (July, 1892). No previous treatment, having had 
 no pain whatever. He had been running about freely, but of late months 
 had been getting rapidly more deformed. 
 
 Fig. 82. — A. B. (April, 1893). Position of head had been gradually im- 
 proved by use of supporting apparatus. 
 
 bending his hips and knees, keeping the spine quite rigid. 
 Whatever he does, this care and deliberate action is observed. 
 I have stated that these characteristic movements occur in 
 typical cases, and I would emphatically urge that there are a 
 great many instances which are not typical, in which pain is 
 entirely absent or very slight, and in which therefore the 
 
THE ETIOLOGY. 31 
 
 postures which are assumed to avoid the production or in- 
 crease of pain are also not present, or in only slight degrees. 
 
 The Etiology of Spinal Caries. 
 
 The exact nature of the disease was, until comparatively 
 recently, a subject of controversy. It is so closely associated 
 with tuberculosis that the majority of writers have considered 
 it essentially or entirely a tuberculous affection, and recent 
 researches go to show that this view is probably correct in the 
 large majority of cases, but even in recent years there have 
 been surgeons who have thought that the disease might be 
 brought about by injury alone. The latter have admitted that 
 tuberculous individuals are much more liable to the affection 
 than those who are healthy, but they have urged that acci- 
 dental injury is generally the exciting cause, and may, in 
 delicate individuals, be alone responsible for the caries. 
 
 If we consider that modern researches have proved that 
 caries of the spinal column is essentially a tuberculous disease, 
 we have yet to draw a great practical distinction between those 
 patients who are so far affected by tuberculosis that they show 
 its influence in other and various ways, and those in whom 
 the disease of the vertebrae is the only obvious affection. 
 
 The explanation of these differences of character in various 
 cases is, probably, that tuberculosis is a local affection in the 
 one class and a general disease in the other. The localised 
 nature of tuberculosis in its early stages is now very generally 
 accepted as a fact, and great stress should be laid upon the 
 importance of recognising this local nature and of combatiug 
 it before it has become general. Tuberculosis may be over- 
 come so long as it remains local, and possibly, also even when 
 it has to some extent invaded the general system, but obviously 
 the latter condition is much more difficult to deal with than 
 the former. In the latter our greatest efforts will be needed 
 to contend with the general effects of the disease, whereas in 
 the former, although we must by no means neglect the general, 
 we may expect to effect a cure chiefly by local treatment. 
 
 In a patient affected by general tuberculosis, the disease is 
 not only a strong predisposing cause of Caries, allowing quite 
 
32 
 
 SPINAL CARIES, 
 
 a slight injury to set up this affection, but in some instances 
 it leads to the development of tubercular softenings in the 
 
 Fig. 33. 
 
 Drawn from a specimen in St. Bartholome-w's Hospital, No. 1064. 
 It consists of a vertical section of a portion of the spine, including 
 the fifth dorsal to the second lumbar vertebra. Between the tenth and 
 eleventh dorsal vertebrae there is destruction of bone leading to angular 
 deformity, but in other parts of all the vertebrae shown, hollow spaces, 
 more or less cup-shaped, exist. 
 
 vertebrae, which from their character and situation could not 
 have been in any v^ay induced by local injury. This is so 
 
THE ETIOLOGY. 
 
 33 
 
 when the surfaces of the vertebrae or central parts are hol- 
 lowed out in numerous places, as m fig. 33, and also in the 
 case already described, fig. 26. 
 
 When the disease is concentrated to one part, producing a 
 sharp angle in the back from projection of the spinous pro- 
 cesses, there is more probability that the active cause has 
 been an injury, whatever the constitutional condition may be. 
 In support of this opinion it should be noticed that the ulcera- 
 tion in Caries first attacks precisely that part of the column 
 which is chiefly injured in cases of fracture, and there is no 
 other apparent reason why one particular spot should be 
 attacked than that it results from injury (see figs. 34, 35, p. 42). 
 
 In support of the view that the disease in many cases of 
 caries of the spine is not the effect of general tuberculosis 
 (although it may be that disease in a local form) is the fact 
 that disease of the spine often occurs in children and older 
 patients who are otherwise robust and apparently healthy, and 
 in whose family history no record of tubercle exists, and whose 
 life prior to some fall has been especially free from ill health or 
 signs of constitutional weakness. 
 
 An apparently healthy child has a fall, more or less severe, 
 and complains of pain in the back. This pain may continue, 
 or it may cease in a few days and recur in about one or two or 
 three months' time, after which the pain comes on severely, 
 and many other symptoms of caries establish themselves, 
 while shortly afterwards a slight projection in the back is 
 noticed. 
 
 Should such a case continue inefficiently treated the disease 
 advances, and in the course of some months abscesses form, 
 and the general health at last breaks down, and then the tu- 
 berculous nature of the affection asserts itself, and general 
 tuberculosis is likely to supervene. 
 
 The condition of general health of patients differs widely, 
 and we meet with every variety, from the markedly feeble 
 and unhealthy to the markedly robust. Some patients are 
 from the first appearance of the affection undoubtedly tuber- 
 culous, whilst others show no other sign of tuberculosis than 
 the affection of the spine. It does not need any argument to 
 show that the latter are the more favourable patients to treat, 
 while at the same time it must be stated that in some of the 
 most unpromising instances careful treatment has been fol- 
 3 
 
34 SPINAL CARIES. 
 
 lowed by a perfect, or apparently perfect, restoration to 
 health, always excepting that after a decided degree of de- 
 formity of the spinal column has taken place, a return to 
 the previous condition of symmetry is impossible. 
 
 Syphilis. — Children suffering from inherited syphilis may be 
 affected with spinal caries, and treatment will probably fail 
 until we make use of mercury or iodides. These cases often 
 present other manifestations of syphilis, such as skin eruptions, 
 opacities of the cornea, syphilitic teeth, &c. A distinction 
 should be drawn between these cases and syphilitic (con- 
 tracted) disease of the vertebras in older patients (see p. 57). 
 
SYMPTOMS AND DIAGNOSIS. 35 
 
 CHAPTEE II. 
 
 SYMPTOMS AND DIAGNOSIS. 
 
 We may divide the symptoms into three stages : — (1) Those 
 occurring before deformity has appeared ; (2) those occurring 
 when deformity exists, and (3) those occurring when abscess, 
 paralysis, and subsequent general giving way of the health 
 are manifest. 
 
 I do not propose to follow this arrangement in describing all 
 the Symptoms, as such a course would not be convenient, but 
 the order should be kept in mind. The first stage is the least 
 accurately defined. There is always difficulty in diagnosing 
 the disease at this early period, whepeas much less exists in 
 the majority of cases at the other two. 
 
 The first symptoms are generally languor, listlessness, and 
 unwillingness to move much or quickly, all the actions indi- 
 cating, more or less, stiffness in the spinal column, but in cases 
 where movement does not cause pain, stiffness may not be 
 present. A stumbling or shuffling gait may soon appear, or 
 the legs may cross one another, especially when the patient is 
 sitting in a chair, and in walking the difficulty occurs chiefly 
 in attempts to hurry; also there may be stiffness, or spas- 
 modic movement, of the thighs. 
 
 In addition to the stiffness of the spine just mentioned, the 
 patient may keep his whole back rigid and supported by rest- 
 ing his hands upon something before him, or upon his knees, 
 or, while sitting, placing his hands upon the sides of the 
 seat, or in cervical disease, his elbows on the table and sup- 
 porting his head on his hands. In stooping to pick up an 
 object from the floor he will keep the spine rigid and bend his 
 knees and hips. By these actions he transfers the weight from' 
 the anterior diseased parts of the spine to the posterior healthy 
 parts, and lessens the nerve irritation which has caused the 
 discomfort. If the disease be situated in the lower cervical, 
 or in the upper dorsal region, upon slight efforts at exercise 
 
36 SPINAL CARIES. 
 
 the respiration will be unnaturally hurried, and a grunting 
 noise will be made, and there may be a hard dry cough. 
 
 Pain may commence early, either as a dull aching in the 
 back or in the front of the body. Pain will occur upon 
 sudden movements, especially in stooping or twisting, or in 
 stumbling. If this is the first symptom it may date from the 
 time of a fall or other traumatic injury. 
 
 Pain is often referred to a hip, knee, or ankle, and the affec- 
 tion has been mistaken for disease of one or other of these 
 joints. The supine horizontal posture usually affords some 
 relief to the patient, but the prone position is generally much 
 more effective in relieving this symptom. 
 
 As the disease progresses, cramps and convulsive move- 
 ments occur in the legs. A chilly feeling or a feeling of tension 
 in the thighs may be experienced, the appetite fails, the pulse 
 becomes rapid and feeble and sometimes irregular. Gradually 
 or suddenly the power over the legs is lost. Complete paralysis 
 may eventually take place below the diseased vertebrae, in- 
 volving the rectum and bladder, and causing atrophy of the 
 muscles of both legs, and the legs are generally cold. Or the 
 paralysis may extend higher in the body, even involving the 
 arms. Projection of the spinous processes of the affected 
 vertebrae will probably have occurred long before the advent 
 of inability to stand, the projection often being the first symp- 
 tom noticed. 
 
 When complete paralysis exists, the patient is liable to the 
 formation of bed-sores, but not to the same extent as in 
 paralysis from degeneration of the spinal cord. Disease may, 
 however, be very extensive in any region without causing 
 paralysis. 
 
 The peculiarities of the bony deformity have already been 
 described. 
 
 In acute cases there is frequently oedema of the tissues on 
 each side of the spine, in the region of the disease. 
 
 The symptoms naturally vary in accordance with the seat of 
 the disease. If the caries exists in the cervical vertebrae, we 
 may have pain in the throat, difBcult deglutition, or difficult 
 respiration and embarrassment of the action of the heart. If 
 in the lower cervical and upper dorsal regions, the movements 
 of the arms may be affected, and as the seat of disease de- 
 scends, indigestion, pain or feeling of tightness in the stomach 
 
SYMPTOMS AND DIAGNOSIS. 37 
 
 may be experienced. If in the lumbar region the pelvic viscera 
 may show symptoms of nerve irritation. 
 
 The discomfort at the epigastrimii is sometimes described by 
 the patient as resembling the sensation of a cord tied tightly 
 romid the body, or as a baud pressing firmly, but in very 
 young children the symptoms of pain are less definite — a child 
 may complain of stomach ache. Pain situated in the parietes 
 is usually symmetrical, but not unfrequently it is on one side 
 only. 
 
 Pain is a very uncertain symptom, for it may vary much in 
 degree. Exacerbation of pain commonly occurs suddenly in 
 the night, and this may cause the patient, if a child, to utter a 
 sharp cry. Pain may be entirely absent, or exist to such a 
 slight degree that it is very easily attributed to other causes. 
 The latter facts have certainly not received sufficient atten- 
 tion, for the opinion is very prevalent that the absence of pain 
 is positive evidence of absence of inflammatory disease of the 
 spinal column. 
 
 Pain is chiefly felt in the peripheries of the nerves proceed- 
 ing from the spinal column. Thus uncomfortable sensations 
 in the chest, abdomen, or pelvis, or legs, may be alone com- 
 plained of, or the pains in these parts may be severe, while 
 only a dull aching is felt in the back itself. 
 
 It will often be found that the pain proceeds in the line of 
 the spinal nerves, commencing near the spine and proceeding 
 downwards and forwards to the front of the body, commencing 
 to be more severe at the side or sides. A dull, aching pain in 
 the immediate neighbourhood of the diseased vertebrae is fre- 
 quently felt in acute cases, and this will often be increased by 
 the patient bending the body forwards. 
 
 If there is pain on firm pressure of the spinous processes or 
 in their immediate neighbourhood, it may be acute, and is 
 often complained of as a burning sensation. There is a pecu- 
 liarity as regards pain from caries which sometimes is met 
 with, especially with adults. Extra exertion will not produce 
 immediate pain, and a patient may even feel better for a brisk 
 walk, but a few hours afterwards the pain will occur and re- 
 main for several hours, and probably until prolonged rest is 
 obtained, such as rest in bed. Pain is usually relieved by 
 rest, and is often absent in the morning after a good night's 
 sleep, but commences soon after getting up and increases 
 during the day. 
 
38 SPINAL CABIBS. 
 
 The pain is especially increased by a stumble, or by twisting, 
 and by all sudden jarring movements, and in the second stage 
 may be described by the patient as a feeling "as if his back 
 would break." Firm but careful pressure with the hands of 
 the surgeon upon the patient's shoulders, from above down- 
 wards, may produce pain, but this test should be applied with 
 great caution, if at all. 
 
 Hyperaesthesia may be detected locally by passing a hot 
 sponge along the back, and electrical stimulus will produce 
 pain below the angle of deformity, passing downwards and 
 outwards in the lines of the spinal nerves. 
 
 High Temperature. — This is a very important symptom, 
 and is of especial value in cases where the diagnosis is, as far as 
 other signs are concerned, doubtful. In acute tubercular caries 
 there is very often, but not always, a rise in temperature. The 
 following case well illustrates this subject : — 
 
 Miss E. H., a very delicate-looking girl, aged 16, began to 
 suffer severe pain in the lumbar region in April, 1893, and had 
 gradually got worse. 
 
 When I first saw her, iVugust 9, she had recently recovered 
 from influenza, but the temperature had risen again to 102° in 
 the morning, and 108° in the evening. It had been so for the 
 previous fourteen days. There was at first a question as to 
 some specific fever. I found projection of the twelfth dorsal 
 and the first lumbar vertebrse, and great pain in that region 
 and below it. The spine was very rigid. The case was 
 obviously one of caries, and I thought that the high tempera- 
 ture was the effect of tubercular disease. Dr. Seton, who had 
 charge of the case, coincided with my opinion. I anticipated 
 a lowering of the temperature as soon as the spine was 
 thoroughly fixed. 
 
 The accompanying chart is worth studying, as it shows 
 gradual lowering of the temperature in exact accordance with 
 the gradual ■ perfecting of adjustment of the instrument. It 
 will be noted that the day following the application of the splint 
 the temperature dropped from 102° and 103°, which it had 
 been for eighteen days, to 2° lower in the morning, and to 1° 
 lower in the evening, gradually decreasing during the succeed- 
 ing days. After each fresh adjustment there was a small tem- 
 porary improvement in the temperature, but after the drop of 
 the first four days it remained practically the same for nearly 
 
August, 1893. — Miss H , 
 
 pain in lumbar region four months, 
 and gradually increasing. 
 
 This temperature for 14 pre- 
 vious days. 
 
 Instrument applied. 
 
 Readjustment. 
 
W^^M 
 
 
 
 August, 1893. — Miss H , 
 
 painialumbni-regiou fourmonths, 
 aud graduivUy increasing. 
 
 1 This temperature for 14 pre- 
 1 vious days. 
 
 Si.-pt ember. 
 
 1 
 
 
 11 
 
 
 
 
 
 
 II 
 
 
 
 
 
 H 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Reiidjustmeut. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 1 
 
 
 
 
 1 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Geuoi-al readjuBtments. Pa- 
 tient gradually improving both 
 iu health and in posture of 
 
 
 
 
 
 
 
 
 
 
 
 back. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 ^^^^^^B 
 
 
 
 ^^^^^^H 
 
 
 
 
 ^^^B 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 October. Roadjuatmont. Get- 
 
 
 
 
 
 
 
 position. Spino being equally aup- 
 
 
 
 
 
 
 
 [lortod in all positions. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Hh 
 
 
 
 
 
 
 
 Hb 
 
 
 
 
 
 
 
 IK 
 
 
 
 
 
 
 
 IBB 
 
 
 
 
 
 
 
 IBB 
 
 
 
 
 
 
 
 HI 
 
 
 
 
 
 Hj 
 
 
 
 
 
 
 
 
 
 
 
SYMPTOMS AND DIAGNOSIS. 39 
 
 six weeks, when a further improvement took place, after which 
 the temperature remained very steady, a fraction above the 
 normal, and a week later it became perfecily normal and has 
 remained so. 
 
 At the date when this practically normal temperature was 
 attained I had just succeeded in so arranging the apparatus 
 that it proved a perfect support in all postures of the body. 
 The spine had been gradually subsiding to a position in which 
 it now remained fixed. The patient had been also improving 
 in every other way — in healthy appearance, in gradual lessen- 
 ing of pain, and having a better appetite. The patient's list- 
 lessness and disinclination to do anything for herself, and 
 some other symptoms, had led the relations to consider that 
 some at least of her symptoms were hysterical. This view I 
 could not agree with, and the hysterical symptoms all disap- 
 peared with the disappearance of the high temperature, and 
 with the other improvements. 
 
 This seems a very characteristic case of active tuberculosis 
 of the spine, but from treatment by local fixation, and with 
 general medicinal and dietetic remedies, the patient continues 
 to improve, and there seems every probability of a cure being 
 effected. 
 
 The temperature should be regularly taken in all cases of 
 caries. I have found it a valuable diagnostic symptom ; a 
 slight rise perhaps of about one degree of temperature only, 
 often being present in caries when the diagnosis has been 
 otherwise doubtful. Certainly one meets with many cases 
 of caries in which no rise of temperature can be detected, 
 but upon more extended observation in this matter I have 
 no doubt very valuable statistics may eventually be obtained. 
 
 Rigidity. — There is usually more or less rigidity of the spine 
 in the neighbourhood of the disease, and this is an important 
 symptom in the early stages of caries. It is the result chiefly 
 of muscular spasm from reflex action, or voluntary muscular 
 action to prevent pain, but may also occur from the exudation 
 of the products of inflammation. 
 
 Eigidity in caries of the spine is not, however, so clearly 
 defined as it is in cases of inflammation of the more movable 
 joints, as the hip and knee, and in many cases it cannot be 
 very clearly detected. 
 
 If the disease be situated in the lower dorsal or in the 
 
40 SPINAL CARIES. 
 
 lumbar vertebrse, causing slight posterior projection in these 
 regions, it may be a question whether the projection is the 
 result of posterior curvature from weakness of the ligaments 
 of the spine or from caries. Under such circumstances the 
 presence or absence of rigidity should be determined. The 
 patient should be placed in the prone position, when, if the case 
 is one of weakness only, the projection disappears, whereas if 
 inflammation exists the projection remains more or less. Care- 
 ful elevation of the legs, while the patient lies in the prone 
 position, will intensify this result. Movement in other direc- 
 tions will also generally be found limited as a consequence of 
 the rigidity when caries is present. 
 
 In cervical disease the rigidity shows itself in stiffness of 
 the neck muscles, and this often affects the head laterally, 
 producing wry-neck. There is usually a great difference be- 
 tween wry-neck from caries and that from permanent muscular 
 contraction. In the latter it will probably have existed for a 
 long time, and there will be little or no pain, or at least of a 
 less distressing nature ; there will be firm and unalterable con- 
 traction of the sterno-mastoid alone, and the face may be 
 atrophied on the depressed side and the features distorted. 
 
 In caries, other muscles as well as the sterno-mastoid will 
 probably be affected, and the head will be held in a manner 
 more expressive of pain, and support of the head will relieve 
 the contraction and the pain to some extent. 
 
 In simple Torticollis the movements of the head are only 
 restricted in one direction ; in Caries the head is kept in one 
 position, but not commonly restricted in any if carefully 
 handled, because, in torticollis from caries, movements in any 
 direction are painful, whereas in true torticollis pain, if any, 
 only occurs from movement in one direction. Eest in bed for 
 a few days will often relieve the torticollis of caries. 
 
 In the latter affection there may be a condition of spasm in 
 the contracted muscles, and in adults it may be difficult to 
 distinguish between this disease and " Spasmodic torticollis." 
 
 I have known torticollis having all the characters of the 
 simple affection to exist in a child for many months before it 
 was recognised as a symptom of disease of the bones. Inflam- 
 mation of lymphatic glands of the neck alone may produce 
 torticollis, and this may be very difticult to distinguish in its 
 
SYMPTOMS AND DIAGNOSIS. 41 
 
 early stages. In caries of the cervical vertebrae there may, 
 however, be very free movement. 
 
 In caries occurring in the dorsal or Imnbar regions, rigidity 
 may be observed in the psoas muscles (or in one psoas only), 
 being perhaps associated with psoas abscess, and this may 
 produce lordosis instead of posterior projection. Such cases 
 must be distinguished from simple local inflammation of psoas 
 muscles, which is not always very easy ; however, the latter 
 condition is rare. 
 
 These cases also may be mistaken for hip disease. 
 
 In both instances other characteristic symptoms of the in- 
 dividual affection must be depended upon. In hip disease it 
 may be remarked that the stiffness of the joint exists in every 
 direction, as well as in extension, yet in some cases of lumbar 
 disease the hip is found very stiff, and the diagnosis may be 
 extremely difficult. Then again, the lumbar region may be 
 very stiff in hip disease. 
 
 There may be a certain amount of rigidity in lateral curva- 
 ture, especially in rachitic cases. In rachitic kyphosis, rigidity 
 may be very considerable and quite like that in caries. 
 
 Nerve Symptoms. — The difficulties in walking above re- 
 ferred to as occurring at a comparatively early stage of this 
 disease, the subsequent loss of power over the muscles, the 
 pain, and some other symptoms, denote lesions more or less 
 severe of the nerves. 
 
 The motor nerves are chiefly affected, commencing with 
 weakness in the legs and increasing until complete paralysis 
 of motor power takes place. 
 
 The range of these nerve symptoms depends upon the posi- 
 tion of the disease, almost always being limited to the nerves 
 proceeding from the diseased bones and below that position. 
 
 In paralysis from cervical disease the arms may be affected, 
 and all power of motion below may be lost. Herpes zoster 
 may occur. 
 
 Spasmodic movements of the limbs may become a troublesome 
 symptom, the legs jerking suddenly without giving the patient 
 any warning. The thighs may be jerked into a severely flexed 
 position, or spastic paralysis may take place. Exaggeration 
 of the reflexes is an early symptom of commencing paraplegia, 
 the knee jerk being especially increased, and ankle clonus may 
 
42 
 
 SPINAL CAEIES. 
 
 be found to exist. Although both legs are usually attacked 
 simultaneously, one leg may be affected before the other, or in 
 a greater degree, or even one leg alone may suffer. Paralysis 
 of the diaphragm may occur. When pain in the course of the 
 nerves precedes paralysis, this shows that irritation of the 
 nerve roots occurred prior to implication of the cord, and 
 precludes any supposed disease originating in the cord itself. 
 (Gowers). 
 
 There is not, as a rule, any pressure upon the spinal cord 
 from narrowing of the spinal canal in this disease, for even in 
 severe deformity the front wall of the canal being lost, the 
 lumen of the canal is not diminished when the upper part of 
 
 Fig. 34. — Fracture. Fig. 35.— Caries, 
 
 From specimens in St. Mary's Hospital Museum. 
 
 the column falls forwards. In this there is a distinct difference 
 from cases of simple fracture, when the vertebra below the 
 injury presses upon the cord by the gliding forward of the 
 column above (see figs. 34 and 35). 
 
 That severe injury to the cord is rare as the result of loss 
 of substance of the bodies, even when several of the latter have 
 been dissolved away, is attributed to the effusion of plastic 
 material in the locality, and to the quietness naturally observed 
 
SYMPTOMS AND DIAGNOSIS. 
 
 43 
 
 by the patient when so severe a condition exists. The change, 
 moreover is gradual, and therefore the structures have an 
 opportunity of accommodating themselves to the deformity. 
 
 I would now especially refer the reader to Case No. 1 (figs. 
 70, 71), where a considerable gap existed, and where, as a 
 consequence, very little force would have been necessary to 
 fracture the attenuated bones which remained, but where the 
 utter prostration of the patient, and the great pain caused by 
 the slightest movement, proved to be a safeguard against mis- 
 chief of this kind taking place. Had there been a sudden 
 movement . and fracture had occurred, irreparable mischief 
 would have ensued to the cord. 
 
 iPi^ 
 
 Fig. 36. 
 
 Very severe case in which no mechanical means had been used to pre- 
 vent deformity, but in vi^hich consolidation had eventually occurred with 
 very great distortion of the body. 
 
 Pressure upon the cord may however take place when no 
 effectual means are taken to fix and support the spine. The 
 inflammatory products, or the debris of bone may be pressed 
 backwards, as the upper part of the column falls forwards, 
 pressing on the cord, and similarly pressure may be produced 
 upon the nerve trunks, or a blood vessel may be ruptured by 
 an incautious movement, and pressure ensue. But the nerve 
 symptoms in caries are much more frequently the result of 
 the inflammatory process extending to the cord or nerves. 
 
 It is these inflammatory affections of the cord and nerves 
 
44 SPINAL CARIES. 
 
 which are the cause of most of the acute symptoms of the 
 disease as already described, and they differ according to the 
 locality of the affection. 
 
 It is the extension of this inflammation which ultimately 
 may cause paralysis of the legs, or even of the trunk, and in 
 some cases of the arms also. Dr. Buzzard ^ has described the 
 condition of the cord in caries. There is chiefly a degene- 
 ration of the axis-cylinders in the nerve fibres, and an increase 
 of the connective tissue between the fibres, and these changes 
 extend to a gradually decreasing extent both upwards and 
 downwards from the place of diseased bone. 
 
 Symptoms of compression of the cord may also be caused 
 by tumours or from the bones in rickets. In the, case of a 
 tumour, especially an osseous tumour, the symptoms are very 
 gradual, but when pain begins it is extremely severe, and 
 aggravated intensely upon the least movement, more so than 
 in most cases of caries. 
 
 Such symptoms will not be so entirely relieved by fixation 
 as in caries. However, it must not be forgotten that it is 
 possible to have pressure from a displaced vertebra or piece of 
 vertebra even in caries. Pysemic abscess in the bones has 
 been known to produce symptoms similar to caries. In caries 
 symptoms of compression may occur suddenly from displace- 
 ment of some of the products of inflammation, consequent 
 upon a sudden movement. Paralysis involving the sensory 
 nerves is much less common than motor paralysis. 
 
 Dr. Gowers suggests that when the sensory nerves are 
 affected this indicates that the damage to the cord is severe, 
 because both in the cord and in the nerves a greater degree 
 of damage is required to arrest sensory than motor conduction, 
 one explanation of this being probably that a slighter nerve 
 impulse suffices to excite the sensory centres in the brain, 
 than is necessary to stimulate the motor structures in the 
 muscles. 
 
 We see in severe cases of caries not only paralysis but a 
 perfect spastic condition of the muscles, and experience shows 
 that even in such circumstances recovery is not impossible. 
 This condition probably indicates degeneration of the lateral 
 
 " Diseases of the Nervous System," 1882, p. 120. 
 
SYMPTOMS AND DIAGNOSIS. 45 
 
 columns (pyramidal fibres), but as regeneration may occur in 
 the case of peripheral nerves, so there is no reason why it 
 should not take place in the lateral columns of the cord. 
 
 Abscess.— It is probable that in a very large majority of 
 all cases of spinal caries, an abscess forms at the seat of the 
 disease. Caries may exist without the formation of an abscess 
 (caries sicca), but for practical purposes we may assume that 
 an abscess, large or small, occurs in caries whenever there is 
 marked projection of the vertebrae backwards, and also even in 
 cases where no deformity exists. 
 
 The abscess^ is situated at the seat of the diseased bone, 
 more or less at the front part of the spine, and it may increase 
 gradually, but generally slowly, until it presents somewhere 
 outwardly. Or it may remain in the neighbourhood of the 
 disease, and never appear externally. In either case it may 
 eventually dry up and become partly or entirely absorbed. 
 
 If the disease is arrested before the abscess is detected out- 
 wardly, then the chances are greatly in favour of the further 
 progress of the abscess also being arrested, but this does not 
 necessarily happen. Although the disease of the bones is 
 stayed, and the abscess shut off from its source, yet the latter 
 may continue to enlarge, and may gradually burrow outwardly. 
 
 An abscess which presents outwardly, takes a course 
 dependent chiefly upon the seat of disease, and is influenced 
 by gravitation. 
 
 The majority of cases of vertebral caries being situated in the 
 dorso-lumbar region, the pus usually follows the course of the 
 psoas muscles and presents in the groin, and is called a psoas 
 abscess. A psoas abscess usually projects below and between 
 the outer and middle thirds of Poupart's ligament. The abscess 
 may not open in the groin, but descend down the thigh 
 inwards and forwards, being limited externally by the sarto- 
 rious muscle ; or it may turn inwards over the adductor longus, 
 or it may descend the leg to the knee or ankle. A psoas 
 abscess has been known to make its way into the spermatic 
 canal, and appear at the external abdominal ring like an 
 inguinal hernia, and it may enter the scrotum, or it may open 
 
 ' It has been Hhown that spinal abscess does not, as a rule, contain true 
 pus, but disintegrated cells suspended in fluid. Inoculation of guinea pigs 
 with this fluid has produced tuberculosis. 
 
46 SPINAL CAPilES. 
 
 in the perinseum, or it may pass over the crest of the iUum, 
 and appear over the gluteal muscles. 
 
 Spinal abscess may pass directly backwards by the side of 
 the spine and is then called a lumbar abscess. 
 
 Constant recumbency on the back favours the latter direction. 
 
 The abscess may burrow beneath the pleura, or may pene- 
 trate the cavity of the latter, or it may penetrate the lung. 
 Patients have been known to cough up pieces of bone. 
 
 An abscess in the thorax will either follow the course of the 
 aorta, passing through the aortic opening in the diaphragm into 
 the abdominal cavity along the psoas, or if the opening through 
 the diaphragm is not available it may pass upwards again. 
 
 Presenting in the lower abdominal region, an abscess may 
 burrow upwards again beneath the abdominal muscles. 
 
 An abscess may open into the bowel and be discharged per 
 rectum or find its way into the ureter and enter the bladder. 
 A piece of bone may enter the bladder and form the nucleus of 
 a calculus. (A remarkable case of this kind is recorded by 
 Buckstone Browne.) 
 
 A case is described^ of destruction of the two last dorsal and 
 two upper lumbar vertebrae, in which an abscess ascended 
 among the spinal muscles, and opened opposite the spinous 
 processes of the last cervical and first dorsal vertebra. 
 
 In considering this subject it is well to remember that in any 
 case a piece of bone detached from the diseased vertebrae may 
 cause special symptoms, and give rise to considerable pain and 
 irritation. 
 
 An abscess may find its way through the sacro-sciatic notch 
 and present at the nates. In the latter case the collection of 
 purulent matter will cause an obliteration of the gluteal fold 
 by accumulating below the gluteal muscles. This effect and 
 the resulting flexion of the hip joint may closely simulate hip 
 joint disease. Moreover, the abscess may even penetrate to 
 the hip-joint itself, ulcerating through the capsule, and may 
 thus set up disease in that joint. 
 
 In the cervical region an abscess may appear at the side 
 of the neck; often in the posterior triangle, in front of the 
 
 ^Pathological Society's Transactions, vol. vii., p. 290. 
 
SYMPTOMS AND DIAGNOSIS. 47 
 
 trapezius, or at the posterior border of the sternomastoid, being 
 directed by the position of the layers of cervical fascia. It 
 may present at the posterior wall of the pharynx, and open 
 into the throat. It may present directly backwards by the 
 side of the vertebrae, or pass downwards into the posterior 
 mediastinum, perhaps reaching the diaphragm, and opening 
 into the pleura or pericardium, or outwardly between the ribs, 
 or pass beneath the clavicle and open in the front of the chest. 
 
 Difficulty of breathing from direct pressure, or suffocation 
 from the abscess entering the lungs, or embarrassment of the 
 heart from direct pressure may occur. 
 
 When the abscess presents upon the posterior wall of the 
 pharynx it may open suddenly and suffocate the patient by the 
 matter entering the larynx. 
 
 A burrowing abscess may take other directions, and the 
 surgeon must be always on the look-out for unusual places for 
 its appearance. 
 
 The possibility of abscesses occurring independently of dis- 
 eased bone, and especially in tuberculous patients, must not 
 be forgotten. The following cases are examples. 
 
 Psoas Abscess from Tubercle of Kidney} — The patient was 
 aged 22 and had psoas abscess on the left side. He was in 
 hospital a year, and died from exhaustion. The abscess was 
 thought to be from disease of the spine. 
 
 Two or three of the lower dorsal vertebrae were carious, but 
 there was no communication with the psoas abscess which 
 came from the kidney and penetrated a few inches into the 
 right psoas muscle. 
 
 Lumbar Abscess from Ryegrass. — Mr. Nicholls^ recorded a 
 case of a large lumbar abscess in which was found an ear of 
 wild ryegrass, one inch and a-half long, which had been 
 accidentally swallowed by the patient a few months before. 
 He had vomited blood a fortnight before the abscess appeared, 
 but there was no other sign of gastric irritation. 
 
 The possibility of an idiopathic suppuration of the spinal 
 dura mater as recorded by Dr. Eobert Maguire" must not be 
 lost Bight of. 
 
 ' Pathological Society's Transactions, vol. xvi., p. 175. 
 
 ^ Brighton and Sussex Medico-Cliirurgicu, Society, February 3, 1887. 
 
 ^Lancet, July 7, 1888. 
 
SPINAL CARIES. 
 
 CHAPTEE III. 
 
 OTHER DISEASES OP THE SPINAL COLUMN WHICH 
 MAY SIMULATE CARIES —OBSCURE CASES. 
 
 The following diseases are those which are most likely to 
 resemble caries : (1) Cancer ; (2) Eickets ; (3) Syphilis ; 
 (4) pressm-e from an anem-ism ; (5) Hydatids ; (6) Osteitis 
 deformans ; (7) Mollities ossimii ; (8) Osteo-arthritis. 
 
 Some of these are rare affections, but any one of them may 
 give rise to deformity which may simulate caries. The most 
 important of these is undoubtedly cancer, and therefore I 
 shall describe several cases of this disease. 
 
 In rickets, although the deformity may appear like that of 
 caries, yet the general symptoms will, as a rule, be easily 
 distinguished. 
 
 Deformity of the spine from syphilis is a rare condition, but 
 the case quoted is an important one. 
 
 Pressure from an aneurism may cause deformity, which 
 possibly will give rise to some difficulty in diagnosis. 
 
 Hydatids is a rare disease in this country, but the cases I 
 am about to quote show the kind of deformity which may 
 occur, and should a patient present obscure symptoms, and 
 come from Iceland, Silesia, or Australia, or even India, one 
 might suspect the possibility of this disease. 
 
 Osteitis deformans causes a general rounding of the back, 
 but there would also be an affection of other bones of the 
 body, causing the characteristic bowing of the legs and arms, 
 &c. 
 
 Mollities ossium and osteo-arthritis, and allied disorders are 
 worthy of consideration. 
 
 Cancer. — Primary cancer of the spine is very rare. When 
 the vertebrae become affected by cancer, it is generally secon- 
 dary to cancer of the breast or some other part. In primary 
 cancer the diagnosis may be very difficult, but we should look 
 for cachexia, and there will probably be very acute local pain, 
 
SPINAL DEFOEMITY WHICH MAY SIMULATE CAPJES. 49 
 
 but the following cases will show that pain is not always a 
 marked symptom, nor does the occurrence of severe pain ex- 
 clude ordinary caries. 
 
 The body is liable to shorten by absorption of the bodies of 
 the vertebrae as shown in the case illustrated in fig. 37. 
 
 ' Primary sarcoma may occur at an early age, and then symp- 
 toms may be very similar to those of caries. In some cases 
 sarcomatous growths may give rise to swellings which may be 
 mistaken for abscesses. Dr. A. B. Judson, of New York, 
 records two cases, one in a child of 4 years 8 months old. 
 Pain in the back had existed two months, and this child died 
 ten days later. The second case was in a man aged 35, who 
 had suffered pain in the lumbar region and thighs for about 
 one year, and died five months subsequently. There was but 
 little deformity in these cases, yet the symptoms had been 
 attributed to caries. However, in the man Dr. Judson diag- 
 nosed malignant disease.^ 
 
 Cancer may also occur in old age. Mr. Laurence Humphry 
 narrated a case of primary cancer of spine ^ with slow compres- 
 sion of the spinal cord, occurring in a gentleman aged 72, 
 active for his age, and engaged at his profession until his last 
 illness. He had been under the care of Mr. Carter (Cam- 
 bridge), for many years, and he was in moderately good health 
 until June, 1882, when his first symptoms began. There was 
 some previous history of a slight accident in which his back 
 was said to have been jarred, the effects of which lasted for a 
 few days. His sister died of cancer of the breast. In June 
 he first began to complain of occasional pain in his back, and 
 his friends noticed that he stooped more than usual. In 
 October he went to London and consulted a physician, and the 
 opinion formed was that the liver was at fault. The pain 
 however became worse, and there was found to be an obtuse 
 bend in the lower dorsal region of the spine, with projection of 
 the spines of the five lower dorsal vertebrae ; here there was 
 also tenderness on pressure. The chief seat of the pain, how- 
 ever, was somewhat lower down in the lumbar region. In 
 December there began to be some alteration in the character 
 of the pain in the back. In addition to constant aching he 
 
 ' Transactions of American Orthopcedic Association, vol. iv., 1891. 
 '■^ " Cambridge Medical Society." —Lancet, January 5, 1884, 
 
 4 
 
50 SPINAL CAEIES. 
 
 was seized with paroxysms of a peculiar hind, coming on usually 
 at night or in the early morning, in spasms of the most severe 
 pain in the stomach (ind loins, qidte tinhearahle and causing 
 him to cry out and his back to become rigid, and then leaving 
 him pale, exhausted, and covered with profuse perspiration to 
 return again after an interval. Up to this time there was no 
 sign of paralysis, and sensation was normal, but the pain 
 extended down the legs and across the abdomen, as if the 
 nerve trunks were in some way irritated. He was seen in 
 consultation with Dr. Paget from time to time, and in Decem- 
 ber Dr. Bristowe was also called in, and the question raised 
 of a new growth involving the spine and nerves. At the end 
 of December the painful symptoms abated considerably, 
 although not entirely, and he got up and walked about, and 
 even went out of doors. The bowels were very confined, there 
 was a constant feeling of sickness with a troublesome secretion 
 of streaky mucus about the fauces. Now for the first time 
 he noticed some weakness in his lower limbs and his gait 
 became uncertain and unsteady. These latter symptoms in- 
 creased very rapidly, so that in a few days he was quite unable 
 to walk or turn himself over in bed. He was placed on a 
 water bed, and there was no particular change in his condition 
 for some weeks. The paralysis became more complete and 
 the muscles soft and flabby. Sensation began now to be 
 impaired and reflex action was slightly exaggerated. There 
 was no great tendency to bedsores. Emaciation ivas consider- 
 able, hut cancerous cachexia ivas not a marked feature. His 
 mind was perfectly clear to the last. He became gradually 
 weaker and died on July 1. The post-mortem examination 
 revealed a sarcoma occupying the middle and lower dorsal 
 region of the spine, and extending in and amongst the muscles 
 of the back. On section the bodies and spines of the vertebrae 
 were found softened and invaded by the new growth. The 
 body of the tenth being crushed in, had given way, so that 
 the spinal canal at this part was much narrowed, and the cord 
 tightly nipped just above the lumbar enlargement. The growth 
 had not attacked the meninges or nervous structures. There 
 was no evidence of malignant disease elsewhere. Mr. Laurence 
 Humphry drew attention to two facts of physiological interest, 
 the retardation of sensation, and the interference with micturi- 
 tion ; of the latter there was for the most part inability to pass 
 
SPINAL DEFORMITY WHICH MAY SIMULATE CARIES. 51 
 
 urine ; as the disease advanced downwards there was inabihty 
 to retain it. 
 
 At the Pathological Society (Novemer, 1891)/ Mr. Jackson 
 Clarke showed a specimen of lymphadenoma affecting the 
 spinal cord, vertebrae, and lymphatic glands, from a woman 
 aged 24, who first noticed a lump in the neck fifteen months 
 before death, death being due to exhaustion. There had been 
 slight pain in the back, and over the lower ribs of the left side. 
 
 Six months before death the abdominal prevertebral glands 
 were enlarged and adherent to the vertebrae. Paralysis of the 
 legs, pain and spasm also occurred before death. The affected 
 lumbar glands were found to be matted together and adherent 
 to the vertebrge which were infiltrated, and the body of the 
 first lumbar vertebra was destroyed. The growth had ex- 
 tended into the intervertebral foramina, along the nerve roots 
 implicating the dura-mater, the pia-mater and the spinal cord 
 itself. It was pointed out that the growth differed from a 
 sarcoma in that its vessels had walls of well defined structure. 
 
 Secondary Malignant Disease. — The following case illus- 
 trates the peculiar collapse and shortening of the spine from 
 absorption of the bones, which sometimes occurs in cancer. 
 
 In the Pathological Society's Transactions, vol. ix., p. 234, 
 a case is recorded of a man aged 28, who died from cancer of 
 the liver. He also had cancerous deposits in the sternum and 
 humerus of one arm and in the spine. At ihe jjost-mortem, "a 
 soft tumour was situated along the right side of the lumbar 
 vertebrae, and a section having been made in the mesial line, it 
 was found to protrude into the spinal canal, and produce com- 
 pression of the Cauda equina, having destroyed a portion of 
 some of the bodies and transverse processes of the vertebrae." 
 
 This patient had noticed a swelling in the abdomen and 
 arm about two months before going to Middlesex Hospital. 
 They had increased very rapidly. "He did not complain at 
 first of any pain, except a deep-seated aching in the spine. 
 Subsequently he had pain and tenderness over the enlarged 
 liver." (See fig. 37.) 
 
 " He sank gradually and died on April 28, 1856, less than 
 four months after he had first noticed the swelling of the arm." 
 
 In the following case the deformity was quite angular. 
 
 Lancet, November 21, 1891, 
 
52 
 
 SPINAL CAEIES. 
 
 Fig. 37. 
 Middlesex Hospital Museum, No. 783. 
 
 " A section of a spine in the dorsal region. The bodies of the vertebrae 
 have been infiltrated with cancer and have subsequently been removed by 
 absorption. This change has proceeded to such a degree that the inter- 
 vertebral discs which are scarcely affected have in two distinct places 
 come into apposition. Prom a woman, Elizabeth Hill, aged 45, who 
 suffered from scirrhus of the mamma which underwent atrophy. Lumbar 
 pains, paraplegia and angular curvature followed, later on pulsating 
 tumours appeared in the upper part of the sternum, in the cranium and 
 ribs. At the post-mortem examination the left femur was found to be 
 fractured, this probably occurred after death, but the bone was infiltrated 
 with cancer.— See Post-Mortem Register, No. 1170, December 3, 1860, 
 Series V., No, 638. 
 
SPINAL DEFORMITY WHICH MAY SIMULATE CARIES. 
 
 53 
 
 The patient died in St. George's Hospital and the deformed 
 part of the spine is preserved in the museum. 
 
 The specimen is described as follows : — 
 
 " This preparation was taken from the body of Jane H , 
 
 aged 55, admitted November 28th, 1828. There was a total 
 loss of sensation and of muscular power below the thorax; 
 the bladder, rectum, and lower limbs being all paralysed, but 
 the muscles contracted spasmodically when pinched and even 
 when not touched Violent pains in the abdomen and 
 
 Fig. 38. 
 
 St. George's Hospital Museum (B. B. v. 51). 
 spine producing angular deformity. 
 
 Malignant disease of the 
 
 limbs The urine was alkaline, and the temperature 
 
 of the lower limbs higher than that of the upper part of the 
 body. There was much pain on pressure being made along 
 the spine, especially in the dorsal region, where a bend for- 
 wards had taken place, as if from loss of muscular power. 
 
54 SPINAL CARIES. 
 
 There were several sloughs upon the nates. Pain had been 
 felt in the back eight months before her admission, followed 
 in two months by numbness and soon after by paralysis. She 
 had had the right breast removed for cancer seven years pre- 
 viously, and during the last six months, cancerous tubercles 
 began to show themselves in the cicatrix, and enlarged glands 
 in the axilla. She died from exhaustion caused by the slough- 
 ing, June 7th, 1829. Post-mortem. — All the bones of the spine 
 were softened so as to cut more easily, and were more vascular 
 and cellular than natural, and in cutting out the spinous pro- 
 cesses there were found in some places in the osseous texture 
 spots of yellowish substance. The sixth dorsal vertebra was 
 most changed, and from its body there projected a firm sub- 
 stance in the form of three or four oval prominences which 
 encroached upon the canal so as to compress the spinal 
 
 marrow." Three vertebrse in all were affected by the 
 
 cancer, " the abdomen contained a small quantity of serum, 
 but the peritoneum was almost everywhere covered by small 
 tubercles, not extending into the viscera. They were hard and 
 
 close-set, like grains of wheat, and a few rather larger 
 
 and many parts of the small intestines were quite matted 
 
 together by hardening and adhesion of the tubercles 
 
 The axillary glands were of well marked cancerous appearance, 
 very hard, and with bands going into the cellular membrane." 
 
 There is also a specimen at St. George's Hospital of primary 
 medullary cancer in the three upper lumbar vertebrae. The 
 body of the second lumbar vertebra has entirely disappeared, 
 but the intervertebral cartilages remain entire. The bodies 
 of the three inferior dorsal vertebrse as well as the lumbar were 
 soft and could be cut with a knife. 
 
 The symptoms in this case were very obscure. 
 
 It will be seen from the above records that it must be a very 
 difficult matter to diagnose cancer of the spine, in the early 
 stages, from caries. If, however, there should be a doubt in 
 the case, it is satisfactory to know that the treatment which 
 should be adopted for caries will also be the best for cancer. 
 The support will give some comfort to the patient, at least for 
 a time. 
 
 The symptoms we may expect in cancer compared with 
 caries are : — 
 
SPINAL DEFORMITY WHICH MAY SIMULATE CAEIES. 
 
 55 
 
 1. More acute pain. 
 
 2. Eapid development of the disease, and especially as 
 regards paralysis. 
 
 3. The failure of remedies to stop the progress (although 
 support makes the pain more bearable). 
 
 4. Should there be or have been malignant disease else- 
 where, this will add to the probability of the case being one 
 of cancer.^ 
 
 Fuj. 3'J. 
 
 Fig. 40. 
 
 o. Often there is httle or no angular deformity or kyphosis, 
 but in such cases we may observe shortening of the vertebral 
 column from absorption of the whole of one or more vertebrse, 
 as shown in the above drawing (fig. 37). 
 
 Rickets. — The spine in rickets is apt to curve posteriorly, 
 giving an appearance which might be mistaken for caries. 
 
 ' Sec also " Cases of Malignant Disease of Vertebrre with Paraplegia 
 Dolorosa," by K. T. Edcs. — Boston Medical and Surgical Journal, Juno 17, 
 1886. Also " Malignant Disease of the Spine," by K. W. Amidon.— i^^ew 
 York Medical Journal, Fcln-uary 26, 1887. 
 
56 SPINAL CARIES. 
 
 The presence of rachitic changes in other bones, and the general 
 characteristics of the disease, which are commonly present, 
 will help in the diagnosis. In those cases of rickets where the 
 patient suffers from pain (especially in scurvy-rickets) the case 
 may be easily mistaken for tubercular caries. Associated with 
 rickets is the following case which I have described in " The 
 more severe forms of Lateral Curvature.'" 
 
 Master B , aged 9, sent to me by Dr. Eussell Eeynolds, 
 
 April, 1890. The looseness of the joints is well shown in the 
 hands and fingers in fig. 39. He walked with great diffi- 
 
 FiG. 41. 
 Patient could walk ouly iu this way before treatment was commenced. 
 
 culty, supporting himself by his hands resting on his knees, 
 with his body much bent forward. He could not stand up- 
 right. I was informed that he was quite helpless in getting 
 in and out of his bath, and could not attend to the functions 
 of the body without assistance. 
 
 He derived a great deal of help from the use of an instru- 
 ment. Two months after his first visit to me I was told that 
 he could then manage quite easily for himself in every way, 
 while before he was " as helpless as a little baby." 
 
SPINAL DEFOEBIITY WHICH MAY SIMULATE CAEIES. 
 
 57 
 
 1892. — He had continued to improve in every way ; the 
 photograph (fig. 42) shows the alteration in his figure, and 
 also that he can now stand comparatively upright. 
 
 Syphilis may be the cause of caries, and is supposed to be 
 so in many cases of atlo-axoid disease. Personally I have 
 not recognised this cause in the cases of disease of these upper 
 two vertebrae which I have seen, and in fact in those cases 
 
 Fig. 42. 
 Appearance of Master B — 
 
 -, in June, 1892. 
 
 there has been no symptom whatever of syphilitic disease. 
 Upon the other hand, in an instance in which I attributed 
 the disease to syphilis, the dorso-lumbar region was the 
 part affected, and there was a peculiar irregularity of the 
 whole dorso-lumbar spine. The following illustration is after 
 Fournier.^ 
 
 It was in a man aged 56, who exhibited many other symp- 
 toms of advanced syphilis ; he was suffering from " syphilitic 
 
 ' Anal, (h TMrtvuklidngii: c.t <l,c Sijplt., January, 1881. 
 
58 
 
 SPIKAL CAEIES. 
 
 sarcocele, ten cutaneous gummata, as also in the muscles and 
 a gummous ulceration of the great toe, also a macula on the 
 thigh." This patient soon after died/ The case is referred 
 to in Holmes' " System of Surgery," third edition. After 
 death there was found "characteristic cicatrices on the spleen, 
 
 Fig. 43.- 
 
 " The deposit is softening" at its centre, and its products are working 
 towards the posterior common ligament. There was also gummatous 
 deposit in the roots of the nerves given off here." 
 
 gumma of the fourth lumbar nerve, multiple and considerable 
 lesions of Pott's disease affecting the lumbar column, espe- 
 cially the third, fourth and fifth vertebrae of that region. 
 These consisted of denudations of bones, thickening or de- 
 struction of the periosteal and ligamentous structures, sclero- 
 sing osteitis with caseous and purulent infiltration, almost 
 complete destruction of the intervertebral fibro-cartilage, and 
 
 ' See " Obscure Disease," p. 78. 
 
SPINAL DEFORMITY WHICH MAY SIMULATE CARIES. 
 
 59 
 
 a vast hollow mass in the lumbar column, also an abscess 
 in each psoas muscle." 
 
 " A careful microscopic examination showed the deposit in 
 these bones to be clearly gumma in various stages of degenera- 
 tion ; also that there were many gummatous nodules in the 
 nerves passing off from this region." In figure 43, it may be 
 
 fJ^v}j}^: 
 
 
 
 
 Pig. 44. 
 
 Part of the spine from a sailor, aged 36, who died in St. George's Hos- 
 pital after s3anptoms of rather more than two years' duration. 
 
 noticed, " that the disease lies on the posterior aspect of the 
 bodies where any injury would be most unlikely to affect the 
 bone. Nor was there any history of injury in this case, nor 
 any reason to suppose that such had taken place. The dis- 
 ease had manifestly originated in botli insta.ncesin the breaking 
 
60 SPINAL CABIBS. 
 
 down of a special deposit infiltrating the osseous tissue of the 
 part." 
 
 Pressure from an Aneurism. — Fig. 44 (on preceding page) 
 represents a specimen in St. George's Hospital Museum, which 
 well shows the great destruction of bone which may occur 
 from this cause. 
 
 Pain was prominent from the first, and was localised in 
 the hypochondria, the epigastrium and subsequently in the 
 shoulders. About a month before death severe pain occurred 
 suddenly in the left lumbar region, extending in all directions, 
 and was " excruciating " until the fatal rupture. 
 
 The erosion extends from the third to the twelfth dorsal 
 vertebra, but it will be noted that the intervertebral fibro- 
 cartilages remain intact. Two aneurisms were concerned in 
 the process. 
 
 In any case when deformity has been produced in this 
 manner, the presence of the aneurism will probably have been 
 clearly recognised long before, but in the early stages when 
 only pain is present, there may be some difficulty in diagnosis 
 as shown in the following instance. 
 
 A case was brought before the Clinical Society by Mr. 
 Spencer,^ which shows that aneurism may occur and press 
 upon the spinal cord without being diagnosed, and certainly 
 without producing any appreciable pulsation. It had been 
 previously referred to in volume xxiii. of the Clinical Society's 
 Transactions. The aneurism seems to have been caused by a 
 fracture dislocation of the spine at the junction between the 
 dorsal and lumbar vertebrae in a man who had fallen thirty 
 feet. 
 
 Hydatids^ (the cystic stage of taenia echinococcus). — 
 Hydatids are so uncommon in Europe that we do not often 
 meet with a case of this disease, unless the patient should 
 come from a country where it is more prevalent. There 
 would always be a difiiculty in diagnosis. 
 
 The following figure I have drawn from a preparation in 
 Guy's Hospital Museum (1029^=). 
 
 The case was that of P. P , aged 58, under the care of 
 
 ' Reported in British Medical Journal, December 5, 1891. 
 
 - Very well described by Mr. Bland Sutton, in bis recent work 
 
 Tumours." — Cassell d Co. 
 
SPINAL DEFORMITY WHICH MAY SIMULATE CARIES. 
 
 61 
 
 Dr. Wilks. Symptoms had lasted eleven months, and there 
 was severe pain followed by paraplegia. It will be observed 
 in this specimen that the curve produced by the disease is very 
 similar to that of an ordinary case of caries. 
 
 The eleventh and twelfth dorsal vertebrae are eroded by 
 hydatids extending into the tissue round the spinal column, 
 compressing the cord by bulging the dura-mater against it, 
 undermining the pleura. Some of the hydatids are to be seen 
 
 Fig. 45. 
 Hydatids of Spine. 
 
 under that membrane. They showed no booklets nor heads, 
 and they budded from each other's outer surfaces. 
 
 No other hydatids were present. Death followed paraplegia, 
 and sloughing of the bladder. 
 
 Fig. 46 (St. George's Hospital Museum, li'') represents 
 another case of hydatids. They had developed in the spinous 
 process of the seventh cervical vertebra, extending to the body 
 of the bone. The cavity formed in this part communicated with 
 
62 
 
 SPINAL CARIES. 
 
 another cavity situated on the side of the same vertebra ; two 
 of the foramina for the passage of nerves have been converted 
 into one. The cavities are Hned by a membrane which con- 
 tained more than 100 hydatids. In the cancellous structure 
 of the body of the vertebra there are also a few hydatids. 
 The bone around the cyst is perfectly healthy but the tumour 
 projected inwards upon the spinal marrow. For several years 
 the symptoms had been attributed to caries. 
 
 In this case I should, in consequence of the thickening of 
 the spinous process have drilled into it, and that would have 
 disclosed the nature of the case, and would have enabled one 
 to evacuate the contents, and possibly to have produced a 
 cure. See p. 109, under "' Drilling." 
 
 Fig. 46. 
 Hydatids of Spine. 
 
 Osteitis deformans. — This disease, first described by Sir 
 James Paget, is a chronic inflammation of the bones. The 
 deformities produced are very remarkable and characteristic. 
 The skull is enlarged, the spine bent, and the legs curved, the 
 patients assuming remarkably similar appearances in nearly 
 all the cases that have been recorded. 
 
 The cause of this disease is not known. In many of the 
 cases it has been associated with cancer. The bones are much 
 enlarged as well as bent, and are always extremely tender. 
 The general health does not suffer. 
 
SPINAL DEFORMITY WHICH BIAY SIMULATE CARIES. 
 
 63 
 
 The spines of these patients slowly curve and become rigid. 
 In Sir James Paget's first case "the whole of the cervical 
 vertebrae and the upper dorsal formed a strong posterior, not 
 angular, curve ; and an anterior curve of similar shape was 
 formed by the lower dorsal and lumbar vertebrae." The chest 
 became "contracted, narrow, flattened laterally, deep from 
 before backwards, and the movements of the ribs and spine 
 were lessened. There was no complete rigidity as if by union 
 of bones, but all the movements were very restrained, as if 
 by shortening and rigidity of the fibrous connections of the 
 vertebrae and ribs." 
 
 Fig. 47. 
 
 Sir James Paget's first case. Disease began at age 46, and he died at the 
 
 age of 68. 
 
 I wall now record a case of a lady who was sent to me by 
 Dr. Spender, of Bath, and Dr. Alfred Meadows, November, 
 1882. 
 
 Miss B., aged about 60. She lost the power of walking (for 
 more than a few paces at a time) twenty years before, in con- 
 sequence of an accident which caused sudden displacement of 
 tbe uterus. After a long treatment she was at last relieved 
 from the pain and discomfort three years before I saw her, but 
 still the inability to walk continued. This was attributed to 
 general muscular weakness from tlie long-continued inaction, 
 
64 SPINAL CARIES. 
 
 until the legs were examined, when the real nature of the 
 disease was discovered. Pains in the left knee commenced 
 about a year before. This patient was remarkably bright and 
 cheerful. 
 
 The spine was curved in consequence of the head sinking 
 forwards, just as in Sir James Paget' s case, but there was 
 not the incurvation of the lower part of the spine which he 
 described. 
 
 Miss B. complained of distress and difficulty in breathing, 
 occasioned by the bending forwards of the head. The general 
 health seemed good, and the urine was healthy. 
 
 Mechanical apparatus was not applicable, in consequence of 
 the tenderness of the bones, but a specially constructed chair 
 and couch to relieve the weight of the head from falling forward 
 was beneficial. 
 
 Osteo-malachia. — In this disease there is an osteo-porosis 
 or an absorption of bone, and the whole skeleton is generally 
 affected. It is said to occur chiefly in pregnant women, but 
 it is a rare disease and hardly likely to be mistaken for caries. 
 
 Osteo-arthritis and allied disorders. — The name osteo- 
 arthritis is sometimes assigned to the disease of the joints, 
 otherwise known as chronic rheumatic arthritis, formerly as 
 rheumatic gout. It will be useful to include under this defini- 
 tion all those cases in which an inflammatory process, either 
 rheumatic or gouty, or allied constitutional condition, occurs 
 in and about the joints of the spine, causing an outgrowth of 
 bone commonly described as a "liping" of the margins of the 
 joints, and" frequently terminating in ankylosis. Specimens 
 are not infrequent in museums of kyphotic spines in which 
 this condition exists. They are generally allied with old age, 
 but not exclusively. I have seen middle-aged and sometimes 
 quite young people, I mean about 30, the victims of gout or 
 chronic rheumatic arthritis, in whom the spine has been 
 rounded and rigid, but I may add that in such cases there has 
 not often been any difficulty in forming a diagnosis. I re- 
 member, however, the case of a lady, aged about 45, in whom 
 the kyphotic spine and the constant pain together with some 
 oedema in the mid-dorsal region gave at first an appearance of 
 caries, but her own history of gout, and the fact that her 
 ancestors and blood relations were an extremely gouty family, 
 helped me materially in forming what I think proved to \^ ^ 
 correct diagnosis. 
 
OBSCUEE DISEASE. 65 
 
 OBSCURE DISEASE OP THE SPINAL COLUMN. 
 
 Under this heading I am about to describe some cases in 
 which caries of the spine has existed, but has either not been 
 recognised during Kfe, or in which the symptoms have been of 
 an uncertain character. 
 
 In almost every case there have been some symptoms of 
 caries, but they have not been thought sufficiently characteristic 
 to lead to a definite diagnosis. The complete, or almost complete 
 absence of pain has often led the surgeon to ignore the pro- 
 bability of the cases being caries, and peculiarity in other 
 symptoms has also given rise to difficulties in forming a 
 decided opinion. 
 
 Some of these cases show that caries may progress to a 
 very advanced stage of destruction of bone, and that a patient 
 may die from its effects without the nature of the disease 
 being recognised. 
 
 Caries with absence of pain. — March 6, 1884. Child 
 aged 5. Angular projection of the spine, undoubtedly a case 
 of caries. Projection first noticed when the child was two 
 years old, and increasing ever since, but there had been no pain 
 luhatever. 
 
 I have met with a considerable number of cases of this kind, 
 some of which are recorded below under " Cases " (see espe- 
 cially case of December 2, 1884), but I would rather base my 
 observations upon the examination of morbid specimens in our 
 hospital museums, which prove the facts conclusively, and 
 also from cases recorded by other surgeons. 
 
 Extensive Caries unrecognised during Life.— In St. 
 George's Hospital Museum, 2a or V. 156, is a specimen in 
 which "the lateral masses of the atlas " — I quote from the 
 catalogue — " are extensively destroyed and the tubercles for 
 the attachment of the transverse ligament quite gone. The 
 superior articular processes of the axis are greatly, the left 
 almost entirely, worn away. The odontoid process is reduced 
 to half its natural size. The posterior ligament remains in- 
 tact, but the transverse and chock ligaments have been com- 
 pletely destroyed." 
 
 From a boy aged 8. — The report states: "This case is of 
 interest, as showing how large an amount of disease of the 
 atlas and axis may exist without giving rise to any of the 
 6 
 
66 
 
 SPINAL CARIES. 
 
 ordinary or characteristic symptoms of disease of the cervical 
 spine. The possibility of the existence of such disease was not 
 overlooked : but, on the contrary, was constantly," the writer 
 observes, "before my mind, and led to repeated and most 
 careful investigations, with a view to its discovery, but these 
 failed entirely to elicit any signs of its presence. 
 
 " There was no pain on rotating, or nodding or pressing the 
 head ; no difficulty in raising it ; none of the characteristic 
 fear of moving the head ; no thickening over the bones ; no 
 
 Fig. 48. 
 
 Second to seventh, cervical vertebrse, the atlas being considerably 
 destroyed by caries. Anterior view. 
 
 tenderness or swelling behind the pharynx ; in fact, until the 
 end of the boy's final illness nothing but wry neck." . . . 
 "I need hardly say," proceeds the writer, " that had I been 
 aware of this, I should not have allowed him to move his 
 head nor to leave the recumbent posture." 
 
 We ought to learn a lesson from this case ; and to consider 
 that although the symptoms were so unlike what we have been 
 taught to expect, yet the fact that they were so soon relieved 
 by fixation and recumbency, and rapidly recurred when the 
 patient began to move about again, were then relieved a second 
 time by recumbency in a fixed position, after six weeks of 
 which the patient was seen with " the head held straight but 
 stiffly, after the manner of one with cervical spine disease," 
 ought to have been considered indicatory of the nature of the 
 
OBSCURE DISEASE. 
 
 67 
 
 case. It was not, however, so considered, and the child was 
 allowed to get about. The disease consequently increased, and 
 death ensued. 
 
 Caries unrecognised during Life. — Another case in St. 
 George's Hospital Museum is that of No. 2b. There exists 
 caries " of the bodies of the upper four cervical vertebrae and 
 inter-verfcebral cartilages, communicating with an ulcerated 
 opening at the back part of the pharynx. The membranes of 
 the spinal cord were in this situation united to each other, and 
 to the posterior surfaces of the vertebrae. The upper part of 
 the spinal cord was softer than natural. The symptoms pro- 
 duced by the disease were so slight that the ulcer of the 
 pharynx was not, previous to the patient's death, known to 
 have any communication with the bones of the spine. The 
 patient died suddenly." 
 
 Fig. 49. 
 Diseased Atlas and Axis seen from above. 
 
 Yery extensive destruction by Caries unrecognised 
 during life. — A very remarkable case is that of the late 
 Dean Buckland, of Westminster, who died in 1856, aged 52. 
 The upper part of his spine is preserved in the Museum of the 
 Eoyal College of Surgeons (No. 2064a, old number). 
 
 The preparation consists of " The five upper cervical verte- 
 brae " (only the atlas and axis are here shown), "with a portion 
 of the occipital bone, affected at several points with carious 
 ulceration. The right transverse process and both upper and 
 lower articular surfaces of the same side of the atlas, are en- 
 tirely destroyed. The corresponding condyle of the occipital 
 
68 
 
 SPINAL CARIES. 
 
 bone is also diseased, and the articular surface of the axis, the 
 right transverse process of the third vertebra, and the left 
 occipito-atlantoid articulation." This description is taken from 
 the catalogue, which further records that "no other symp- 
 toms manifested themselves during life but those attributed to 
 melancholia." (See figs. 48 and 49.) A more detailed account 
 is recorded in the Pathological Transactions, vol. xv., p. 20. 
 
 Caries mistaken for Hydrocephalus. — In the Royal 
 College of Surgeons Museum, No. 2093, is the specimen 
 of a very remarkable case in a child about 6 years of 
 age, in whom " the symptoms were supposed to be those of 
 hydrocephalus. A swelling occurred at the side of the neck. 
 
 Fig. 50. 
 
 The first two cervical vertebra and the base of the occipital bone seen 
 
 from below. The displacement of the vertebra and their consolidation 
 
 after inflammation is clearly shown. 
 
 The child steadied its head with its hands, and moved very 
 cautiously. The symptoms gradually ceased, and the child 
 regained health, but died at the age of 12, from lumbar caries. 
 The post-mortem examination showed the great displacement 
 of the upper two vertebrae from disease. There had been no 
 hydrocephalus," Here were some of the characteristic symp- 
 
OBSCURE DISEASE. 69 
 
 toms of diseased vertebrae, but probably because of the absence 
 of other symptoms the nature of the disease was overlooked. 
 
 Caries Mistaken for Croup. — In Guy's Hospital Museum, 
 No. 1080^, is a specimen in which the fourth dorsal vertebra 
 is quite destroyed, and those above it partially so by caries. 
 The child was 6 years old, and was admitted with " urgent 
 symptoms of croup." He died, but the respiratory organs 
 were found quite healthy, whilst behind the oesophagus, and 
 opposite the diseased bones, there was a large abscess com- 
 municating with the diseased vertebrae. 
 
 Caries unrecognised during life. — Another specimen in St. 
 George's Hospital Museum (No. 3569, old number), is the spine 
 of a woman of 60, admitted for paraplegia of three months' 
 standing, and who died suddenly. Examination of the spine 
 during life failed to afford evidence of vertebral disease. The 
 
 Fig. 51. 
 
 From St. George's Hospital Museum. 
 
 (1b) Two lumbar verfcebrse, the inter-vertebral cartilage between them 
 having been destroyed by ulceration. The bones in this case are but 
 slightly affected by caries. Presented by Sir Benjamin Brodie. 
 
 contiguous portions of the bodies of the third and fourth dorsal 
 vertebrae are partially destroyed, and the inter-vertebral sub- 
 stance completely so. In regard to this case it may be 
 remarked that although pain may be present during the early 
 stage of the disease, its cessation is not necessarily a proof 
 that consolidation of the bones has taken place. 
 
 Caries with absence of deformity. — Very severe caries 
 may exist without any deformity being present. The cases 
 illustrated in figs. 25, 26, and 33 show degeneration of bone 
 
70 SPINAL CABIES. 
 
 to a very extensive degree without the production of character- 
 istic deformity. In the instances of this kind which I have 
 met with, the general giving way of the whole spine from 
 weakness, the pain, or some other symptom, have clearly 
 indicated the nature of the disease, and if the surgeon bears in 
 mind the fact of the spine being attacked in this manner he 
 ought not often to make a mistake. Figure 51 represents 
 a specimen in which probably there was no deformity, and 
 as the extent of the disease is so limited it is quite possible 
 there may have been an absence of pain. 
 
 Four Unusual Cases of Spinal Caries under the care of 
 Mr. James Allen in Wandsworth Infimary.^ These cases are 
 interesting and instructive on account of ; (1) The ages of the 
 patients ; (2) the small degree or absence of deformity ; (3) 
 the severity and peculiarity of symptoms which might have 
 been attributed to other causes ; (4) the necropsies. 
 
 Case 1. — Caries of dorsal spine, paraplegia. William S., 
 aged 69, was admitted on December 29, 1879. In December, 
 1878, after exposure to cold and wet, the patient felt pains 
 across the lower part of the back. This did not incapacitate 
 him from acting as a messenger until nine months later, when 
 the inferior extremities became weak and dragged slightly. 
 Sensation was impaired ; numbness, first noticed in the toes 
 and crept up both limbs simultaneously. He had slight 
 starting of the limbs, chiefly at night, straining on micturition 
 (urine passed most freely in the morning), and soon afterwards 
 constipation. Eapid increase of these symptoms took place 
 during the week preceding admission ; but he was not con- 
 fined to bed. On examination motor power and sensation of 
 the lower limbs were very limited and reflex action was 
 increased. There was pain in the lumbar spine ; the patient 
 could sit up in bed without difficulty. The urine was normal, 
 bowels constipated. On January 12, he had retention of 
 urine, necessitating the use of a catheter. On the 17th, he 
 had complete motor paralysis, with painful starting of limbs. 
 On February 1, incontinence of urine came on, the bowels 
 were moved only by enemata. On the 19th, the urine was 
 ammoniacal and there was a sensation of constriction round 
 the abdomen together with prominence of one of the lower 
 
 ' Recorded in the Lancet, June 25, 1881. 
 
OBSCURE DISEASE. 71 
 
 dorsal spines. On March 19, the skin over the sacrum had 
 given way; there was much pain shooting round the upper 
 part of the abdomen from the level of the two lower ribs ; 
 sensation in the limbs was quite abolished ; reflex action was 
 increased, anorexia. He was easiest when propped up in bed, 
 pain was relieved by opium and by small blisters applied near 
 the spine, temperature subnormal. On March 25, the patient 
 died exhausted. 
 
 Necropsy. — Eemoval of the thoracic viscera exposed at the 
 lower part of chest, two rounded tumours, one on each side 
 of the bodies of the tenth and eleventh dorsal vertebrae ; con- 
 tents fluid and communicating with each other across the 
 middle line. There was about an ounce of thick pus mixed with 
 bone fragments; the cartilage between the tenth and eleventh 
 dorsal vertebrae had disappeared ; the tenth vertebra was 
 ulcerated away in its lower surface, but to a much greater 
 extent anteriorly than posteriorly, and presented an irregularly 
 convex outline fitting into a corresponding concavity in the 
 upper surface of the eleventh vertebra, which was not much 
 wasted ; and the opposed surfaces were tolerably firm, 
 covered here and there with small patches of cartilage. The 
 tenth dorsal spinous process was slightly prominent ; on 
 removing the spinal arches the body of the tenth dorsal 
 vertebra was found projecting sometohat backivards inferiorly. 
 Above this projection the membranes and cord were normal ; 
 below, the dura mater was much thickened and adherent to 
 the spinal canal by means of an inspissated layer of pus, 
 mixed with bone spiculse ; the cord was slightly softened, but 
 not adherent. At the apices of the lungs there was evidence 
 of old cured lung disease, bladder hypertrophied ; pus in pelvis 
 of left kidney ; small granular kidneys. 
 
 Case 2. — Caries of huelfth dorsal and first lumbar ver- 
 tebra ; no pa7-alysts. — Henry C, aged 55, was admitted on 
 September 3, 1879. About four years before, he fell from a 
 considerable height on his back ; for the last two years he 
 had experienced weakness and pain in the lumbar region. 
 On examination the last dorsal spinous process was slightly 
 prominent ; pain on pressure or movement and rigidity of 
 the spine were also noticed. The urine was normal. While 
 under treatment he frequently had intractable pain in the 
 area supplied by the lateral branch of the last left dorsal 
 
72 SPINAL CAEIES. 
 
 nerve. The movements of the left thigh caused pain, and he 
 could not turn readily in bed. 
 
 No paralysis or difficulty v?ith bowels or bladder, occasion- 
 ally free from pain, not usually confined to bed. He was 
 relieved by chloral and by blisters ; his condition was aggra- 
 vated by opium ; died rather suddenly from pneumonia on 
 May 30, 1880. 
 
 Necropsy. — The right lung weighed fifty ounces, and was in 
 a state of red hepatisation. There were caseous nodules in 
 the apices of both lungs. There was prominence of the 
 twelfth dorsal spinous process, and slight displacement back- 
 wards of the twelfth dorsal vertebra. Over a limited area 
 anteriorly, opposite a large carious cavity in the contiguous 
 surfaces of the twelfth dorsal and first lumbar, the dura mater 
 was thickened and encrusted with a layer of thick pus and 
 bone spiculae, and adherent to the spinal canal. Cord normal. 
 On dissection from the abdomen it was found that no disc 
 existed between the above-mentioned vertebras, and that a 
 large portion of both bodies had broken down ; the space so 
 formed was occupied by thick pus and bone debris ; pus had 
 burrowed along each side of the spine in the psoas muscles as 
 far as the third lumbar vertebra ; the greater quantity of pus 
 was on the left side, tilting forward the left kidney. The 
 upper surface of the first lumbar presented a concavity ex- 
 cavated to almost the whole depth of the bone, and the under 
 surface of the twelfth dorsal was so fashioned as to fit into it. 
 The carious surfaces were soft and readily broken into. Large 
 white kidneys, 7 oz. each; liver, 4 lb., fatty. 
 
 Case 3. — Superficial caries of fourth and fifth lumbar ver- 
 tebrcs. Tuberculosis. — James W., aged 67, was admitted on 
 April 30, 1880, on account of a carious cavity in the shaft of 
 the right tibia, near the upper extremity, of ten years' duration. 
 While under observation he was feeble, appetite poor, lost 
 flesh, and complained of pain across the lower part of lumbar 
 spine. His chest was emphysematous, but nothing further 
 was detected until a few days before death, when crepitation, 
 dry and small, was heard all over both lungs ; resonance not 
 impaired. Ten hours before death on August 5, 1880, he had 
 a series of convulsive fits, and became unconscious. The fits 
 recurred frequently; consciousness was not recovered; con- 
 vulsions general and rather violent. 
 
OBSCURE DISEASE. 73 
 
 Necropsy. — Several minute haemorrhages were found in the 
 course of the vessels at the base of the brain, and especially 
 in the Sylvian fissures ; none in the cerebral tissue. Both 
 lungs free in the chest ; right weighed 29 oz., left 22| oz. ; both 
 throughout in a state of acute miliary tuberculosis. Heart 
 weighed 10 oz. ; right auricle contained a large firm white clot ; 
 valves competent. Liver, spleen and kidneys amyloid ; in the 
 liver and kidneys there were several minute purulent collec- 
 tions. Superficial caries of the fourth and fifth lumbar ver- 
 tebrae, an abscess situated anteriorly and connected with the 
 bare bone, containing about 3 oz. of pus, thick, not mixed with 
 bone fragments, entering each psoas muscle, and running in 
 the direction of the muscular fibres, causing considerable 
 , destruction of tissue. The carious cavity on the inner surface 
 of tibia reached deeply into the head of the bone. 
 
 Case 4. — Caries of dorsal spine. Paraplegia. — Mary H., 
 aged 68, was admitted December 8, 1880. For three weeks 
 she had felt ill, and on admission exhibited symptoms of 
 gastro-hepatic derangement, foul tongue, tenderness on pres- 
 sure over stomach and liver, nausea and constipation. The 
 urine was slightly alkaline. On December 14, she had neu- 
 ralgic pains in the left upper part of abdomen, relieved by 
 blisters applied near the spine. Two days later there was 
 pain on pressure over the lower dorsal vertebrse. On January 
 27, there was some loss of motor power in the lower limbs, 
 attended with cramp ; the bowels were confined. On February 
 2, there was complete motor paralysis of inferior extremities, 
 abolition of sensation, sole reflex subnormal, patellar reflexes 
 normal, painful involuntary flexions of the limbs (pain re- 
 ferred to spine, hips, and abdomen), and loss of sensation in 
 lower part of abdomen ; incontinence of urine ; bowels moved 
 only by enemata. On February 9, there was flatulent disten- 
 sion of the abdomen. The pain was relieved by opium. Later 
 the patient had a bedsore, and for a month before death the 
 bowels acted spontaneously. Death took place from cedema 
 of the lungs on April 24, 1881. A daughter died of hip-joint 
 disease and a son of haemoptysis. No history of injury. 
 
 Necropsy. — After removal of the spinal arches, on raising 
 the dura mater, it was found adherent anteriorly to the body 
 of the seventh dorsal vertebra, much thickened at this part 
 and encrusted with caseous pus. At the seat of this lesion the 
 
74 SPINAL CAKIBS. 
 
 cord was slightly softened and considerably lessened in bulk, 
 but not adherent to the membranes. There was a carious 
 cavity in the seventh dorsal vertebra. A small soft tumour 
 behind the descending aorta indicated the situation of the 
 affected vertebra, and was due to a local collection of thick 
 pus and bone fragments occupying the cavity in the body of 
 the seventh vertebra, and bulging anteriorly. With the ex- 
 ception of the upper and lower epiphysal plates, the body of 
 this vertebra was almost entirely gone ; the inter-vertebral 
 fibro-cartilages were not affected. Lungs emphysematous and 
 oedematous at dependent parts ; a multilocular par-ovarian 
 cyst on the right side, size of a large orange ; the left ovary 
 was implicated in a simple cyst of like dimensions. Fourth 
 ventricle of brain small ; central canal not patent at the 
 calamus scriptorius. 
 
 Caries in which vomiting was the most important 
 symptom. — At the Cambridge Medical Society, November 2, 
 1883, Mr. Stear, of Saffron Walden, " related the case of a medi- 
 cal man who died in June, 1883, aged 51. He had always been 
 a strong man, and worked hard at his profession, without ever 
 taking a holiday. During the last four months in 1882 it was 
 noticed that he was thinner and looked aged, but he could ride 
 twenty miles without fatigue. At the end of January he 
 caught cold and was confined to his bed with severe rheumatic 
 pains in the right gluteal region. After a brisk purge he was 
 better and able to get up, but he did not make much improve- 
 ment. On February 5th, he was seen with Dr. Latham, the 
 symptoms being vomiting after dinner and pain in the hip and 
 thigh. He left home for Ventnor, and afterwards went to 
 Clifton, and returned home much emaciated and very weak. 
 He was seen again by Dr. Latham, but no tumour or evidence 
 of spinal disease could be discovered. On April 8, Dr. Hum- 
 phrey opened an abscess which had been detected in the back, 
 a large quantity of laudable pus escaping. The disease con- 
 tinued until his death on June 25 from exhaustion. At the 
 post-mortem examination there was found to be extensive 
 disease on the right side of the bodies of the second, third, and 
 fourth lumbar vertebrse, and erosion of the transverse processes 
 of all of them, extending half way along the crest of the ilium. 
 The iliacus muscle had disappeared, and its sheath was filled 
 with pus. There was also pus in the psoas muscle. The car- 
 
OBSCURE DISEASE. 75 
 
 tilages were healthy. The stomach was dilated. All the other 
 organs were healthy. Mr. Stear thought it probable that the 
 spinal disease was caused by a fall from a horse, or at lawn 
 tennis in 1882. The case was of interest from the deceptive 
 nature of the cause of vomiting and emaciation, and from the 
 fact that although there must have been extensive disease of 
 the vertebrae, he was able to carry on his work." 
 
 Caries without ordinary symptoms. Sudden death. — 
 Mr. Samuel Buckley, Surgeon to the Manchester Clinical 
 Hospital, describes the case of John Isherwood, aged 7, who 
 was admitted into the Preswich "Workhouse Hospital "in a 
 debilitated condition and suffering from an attack of bronchial 
 catarrh." At the end of a month he was much improved, and 
 expressed himself as feeling quite well. "Whilst at tea with 
 the other convalescents, during somewhat boisterous laughter, 
 with his mouth full of food, he had a fit of coughing, followed 
 by symptoms of suffocation, apparently due to the irritation of 
 food having gone " the wrong way." One of the inmates 
 slapped him on the back with the idea of relieving him, when 
 the child fell down dead." 
 
 An inquest was held, and Mr. Buckley made a post-mortem 
 examination, and found that death was due to asphyxia, caused 
 by an abscess which was present behind the larynx and 
 pharynx . 
 
 "It was seen to bulge up from between the longus colli, 
 lying upon the anterior vertebral muscles, with a flattened con- 
 tour, and extending down to the fifth cervical vertebra. Its 
 walls were thick and unbroken in front, being formed by the 
 anterior vertebral ligaments, plus adventitious tissue. It con- 
 tained about five or six spoonfuls of thick pultaceous, cream- 
 coloured, purulent liquid slightly mixed with a gritty detritus. 
 It was found to arise from caries of the bodies of the second and 
 third and slightly of the fourth cervical vertebrse and inter- 
 vertebral fibro-cartilages. The axis was fractured. The 
 odontoid process was broken off from the body of the axis, 
 being partially eaten through with caries, and the atlo-axoid 
 ligament had separated from its attachment to the body of the 
 axis, the atlas, with the odontoid process below and the 
 cranium above, being dislocated forwards over the axis, pro- 
 ducing pressure upon the cord, and consequently fatal asphyxia. 
 The cord and its membranes presented a healthy appearance. 
 
76 SPINAL CAEIES. 
 
 The only symptom which had been observed was stiff-neck, 
 from which he seemed to have suffered at various times." 
 
 The report also states " the lad was of a strumous habit, 
 having had enlarged cervical glands in infancy, and a strumous 
 father." 
 
 Severe case, unrecognised during life. — A remarkable 
 case is recorded,^ which was under the care of Mr. Makins, 
 at St. Thomas's Hospital, in a woman aged 37, in whom 
 there was caries of the fifth lumbar vertebra, leading to 
 chronic rectal obstruction with extensive destructive ulcer- 
 ation in the perineum. It is stated " that no symptoms were 
 present to point to spinal caries except the perineal ulcer ; and 
 this from its shallowness, wide superficial extent, and general 
 unlikeness to the fistulse often giving vent to fseces usually met 
 with, together with the small amount of discharge, was of little 
 diagnostic aid. A thorough rectal investigation might, no 
 doubt, have thrown more light upon the case, but this, unfor- 
 tunately, was impracticable, as any examination caused extreme 
 pain, and the patient's general condition was so serious as to 
 preclude ansesthetisation unless absolutely necessary. 
 Vertebral disease being unsuspected, the main diagnostic in- 
 terest centred in the nature of the ulceration. The appearance 
 negatived at once the question of epithelioma, although the 
 ascites, the pressure of the left iliac vein, and the enlargement 
 of the superficial abdominal veins, still left the possibility of 
 internal malignant growth, even in the absence of a palpable 
 tumour, &c." 
 
 Necrosis of a Lumbar Vertebra. Rapidly fatal result. 
 — This case was recorded by Mr. James Y. Totherick, honorary 
 physician to the Wolverhampton General Hospital. A young 
 gentleman, aged 15, had been complaining for some days of 
 pain in the stomach, but was doing his school work as usual. 
 The next day, not feeling so well, he kept his bed. He then 
 complained of severe pain in the back, which was tender to the 
 touch, and in the abdomen, which was distended. His tem- 
 perature was raised, and his pulse quick. He could give no 
 history of any injury. 
 
 Abdominal distention, and the pain and tenderness in the 
 dorsal region increased. Temperature 102.5° ; pulse 100. 
 
 ' The Lancet, May 5, 1888. 
 
OBSCURE DISEASE. 77 
 
 Patient was restless, flushed, and moaning with pain, and im- 
 patient at being touclied anywhere. Extreme pain about the 
 abdomen, and in the lower dorsal region and the back for about 
 three inches on each side of the spinal coltimn. Leeches gave 
 temporary relief. Patient, the next day, became delirious, and 
 continued in that condition for two days. Temperature had 
 risen to 103°, but next day was 100°. The tympanites and 
 most of the tenderness of the abdomen had disappeared. 
 Bowels opened naturally. Urine had to be drawn off night 
 and morning. Swelling and tenderness appeared in the left 
 elbow joint. The next day a red painful swelling appeared in 
 the first two knuckles of the left hand, and in each place there 
 was fluctuation. "It was now evident that we had to do with 
 a case resembling pyaemia." Quinine and stimulants gave 
 temporary relief. Temperature again rapidly rose, and he 
 died quietly on the seventh day after being first seen. 
 
 Autopsy. — In the upper lobe of the left lung were numerous 
 small white lobules, some of which contained liquid pus. The 
 right lung was crepitant in the upper lobe, and emphysema- 
 tous. Yellowish soft patches, some purulent and some appa- 
 rently caseating, existed in other portions of the lungs. In one 
 spot of the liver was a collection of pus about the size of a 
 shot. The joints of the hand above referred to were found to 
 contain thick collections of pus ; there was also pus in the 
 elbow joint. " On cutting through the spinal muscles pus 
 welled up in large quantities. The periosteum of the spinal 
 canal was intensely inflamed, and the canal external to the 
 cord was filled with pus, which was also infiltrated amongst 
 the spinal muscles, but the visceral surface of the membranes 
 of the cord was free from inflammation, and healthy. 
 
 " The body of the first lumbar was found to be quite soft 
 and infiltrated with pus, presenting internally a marked con- 
 trast with the vertebra above it and the one below, both of 
 which were hard and of a dark, livid colour." 
 
 As regards the condition of the lungs, " during life the 
 breathing, beyond being a little hurried, was only shghtly 
 affected, and only a few mucous rales were audible on aus- 
 cultation, except on the last day, when some dulness was 
 discernible." The writer added, " What caused the acute 
 necrosis of the lumbar vertebra ? There was no history of a 
 blow or of a sprain, or even of a strumous tendency." 
 
78 SPINAL CARIES. 
 
 It is not at all unlikely that this patient may have been 
 kicked, or in some other way injured, by a schoolfellow some 
 time previously, and that the osteitis had progressed without any 
 very severe symptoms until septic absorption happened to 
 occur. School boys cannot be trusted to tell (what they con- 
 sider) tales of their schoolfellows. 
 
 A case of Periostitis of the Spine accompanied by 
 Tetanic spasms (probably Syphilitic).^ — Dr. William 
 Budd, of Exeter, records a case of a gentleman of active 
 habits who had suffered for nine months from symptoms 
 of periostitis. The spine and the bones of the pelvis were the 
 parts chiefly affected. Upon examination "there was much 
 tenderness in the spinous processes of the third and fourth dor- 
 sal vertebrae and also in the sternum. He had also suffered 
 severe pain in his limbs and trunk generally, which the least 
 motion aggravated; coughing, sneezing, or laughing produced 
 agonies of pain in the back and ribs. The pains were greater 
 at night." 
 
 A few days before being seen by Dr. Budd " he became 
 affected with sudden attacks of tetanic spasms, which fixed his 
 limbs and extended his trunk, throwing his head back. It 
 was a sudden shock, which relaxed again instantly. He found 
 that the best way to avoid their recurrence was to lie on his 
 back and remain perfectly still." 
 
 There was some history of syphilis for which he was treated 
 and was salivated. Upon this history Dr. Budd gave five grains 
 of iodide of potassium and five grains of Plummer's pill every 
 night at bed time. " After taking these for a fortnight, he was 
 greatly relieved in all his symptoms. The tetanic spasms had 
 not returned since taking the medicine. A fortnight later he 
 was entirely relieved from his symptoms, and had gained 
 strength and flesh." The next time Dr. Budd saw him he 
 described himself as perfectly cured. 
 
 ^British Med. Journ., September 6, 1885. 
 
TREATMENT. 79 
 
 CHAPTEE IV. 
 
 TEEATMENT. 
 
 The chief object of treatment is to obtain resolution of the 
 inflamed and ulcerated parts, with as little deformity as 
 possible. Whatever may be the condition of the health of the 
 patient, however advanced the disease, the object remains the 
 same ; to subdue the inflammation, and to obtain consolidation 
 of the diseased bones. 
 
 The chief items of treatment are : — 
 
 (1) Mechanical fixation of the spinal column. 
 
 (2) Adjustment of the mechanical apparatus, in accordance 
 with the progress towards resolution. 
 
 (3) General rest of the patient. 
 
 (4) Modification of the bodily movements in accordance 
 with the severity of the case. 
 
 (5) Nursing. 
 
 (6) Clothing. 
 
 (7) Food and medicine. 
 
 (8) Treatment of complications. 
 
 The chief symptoms which require special reference as 
 regards treatment are : — 
 
 (a) Pain. 
 
 (b) Paralysis. 
 
 (c) Abscess. 
 
 1. — Mechanical Fixation of the Spinal Column. 
 
 Efficient fixation of the spine can only be accomplished by 
 means of a mechanical apparatus. 
 
 Eecumbency in bed alone is a very ineffectual method of 
 affording rest to the spine. 
 
 Every movement of the head, of the arms, of the legs, 
 twisting in bod, attention to tbo functions of the body, all 
 
80 SPINAL CARIES. 
 
 necessitate disturbance of the spine. Of course the patient 
 can be strapped down tightly to the bedstead, so that a greater 
 degree of fixation is attained, thus converting the bedstead 
 into a splint ; but such a method is far more irksome to the 
 patient, and far less efficacious than the use of a properly 
 constructed apparatus. In the case of young children, it is 
 certainly, not infrequently, necessary to fasten the patient down 
 to the bed ; but even in such cases, we cannot dispense with 
 the splint, for fixing and supporting the spine effectually. The 
 effect of treatment by recumbency alone is so well expressed 
 by my friends, Mr. Eobert Jones and Dr. Ridlon, that I 
 cannot do better than quote their remarks. 
 
 " This method of treatment, in its effective application, is so 
 exacting to the patient, as to be well nigh impossible. It calls 
 for the most careful nursing, and hence, is totally unsuited for 
 the poorer population. It requires that the bed should be 
 flat, smooth, firm, and without a pillow, and the patient so 
 secured by straps that he cannot sit up, twist or turn. Thus, 
 pass a strap of webbing or strong canvas bandage, across the 
 bed, beneath the patient's shoulders, and fasten it to the bed- 
 frame, on either side ; upon this strap are strung two loops, 
 through which the patients arms pass, and these are connected, 
 the one with the other, by a strap across the chest. The 
 pelvis is secured by a broad belt around it, from the sides of 
 which straps pass to the sides of the bed-frame, and are there 
 fastened. 
 
 " The patient must not be once allowed to sit up for food, for 
 the use of the bed-pan, or for any other purpose ; nor must he 
 be taken from bed for bathing, for changing of sheets, or 
 clothing, or for the turning of the mattress, if the best effects 
 of recumbency are to be assured. To fail in strictly following 
 these directions may cause the breaking up of the new bone 
 formation about the carious vertebrae, a return or increase of 
 the deformity, or may prolong the paraplegia, if present, and 
 perhaps render it incurable. It will be readily seen that, 
 although the surgeon is saved labour, it is very difficult to 
 carry out this treatment for any considerable time ; in fact, 
 practically impossible to carry it to a successful result in any 
 but an exceptional case. ' So-called ' treatment by recum- 
 bency often means that the patient lies in bed when he 
 chooses, sits up when he pleases, or gets up and walks when 
 
TREATMENT. 81 
 
 he can. Under such conditions, it is not surprising that the 
 deformity increases, that abscesses are frequent, and the 
 duration of the disease prolonged." 
 
 I have elsewhere, and upon many occasions, explained the 
 method by which I am in the habit of producing fixation of 
 the spine, but there are a great many matters of detail which 
 I have not hitherto published, and which I propose now to 
 describe. To fix thoroughly the diseased part of the spine, it 
 is necessary to control the column, as far as possible above 
 and below the seat of inflammation. When the disease exists 
 below the third or fourth dorsal vertebra, the spine may be 
 supported sufficiently by an apparatus which extends from the 
 extremity of the sacrum below, to the level of the shoulders 
 above ; but if the disease is above this part, it is generally and 
 almost always necessary to continue the apparatus to the 
 head. I say " generally and almost always," because absolute 
 decision with regard to this point depends upon the case. In 
 very acute cases, the necessity for fixation being greater, it 
 will be more desirable to use the head piece, than in sub-acute 
 and more chronic cases. 
 
 In some instances, even when the disease is in the upper 
 three dorsal vertebrae (and especially in adults), the apparatus 
 without the head piece may suffice, but in every case the 
 instrument should extend to the level of the shoulders. 
 
 Principles of application. — To determine the principles 
 upon which the apparatus should be applied, it is necessary 
 to consider the objects to be attained in a typical case of 
 caries. 
 
 In fig. 52, we see a side view of such a case. The disease is 
 centred about the tenth dorsal vertebra, and probably extends 
 upwards and downwards to the extent of a few of the adjacent 
 vertebrae. The weight of the body above the disease is bending 
 the spine forwards, increasing the pressure upon the anterior 
 part of the bodies of the vertebras, that is, upon the part where 
 the disease is chiefly situated. The spine below the angle is 
 curved forwards, producing, by its incurvation still greater 
 pressure upon the diseased parts. This patient would probably 
 support herself by resting her hands upon the seat, and so keep 
 her head and upper part of her body more erect ; but I have 
 G 
 
82 
 
 SPINAL CARIES. 
 
 placed her in this posture to show the position which the 
 spine assumes when it is not being thus supported. To give 
 this patient comfort, one hand should be placed upon the angle 
 of deformity, covering as much of the back as possible, and 
 pressing firmly, but gently, in the direction shown by the 
 arrow A, and the other hand and arm placed across the 
 chest, supporting the shoulders very gently backwards in the 
 direction shown by the arrow B. If the patient is in much 
 pain this support, carefully applied, will be found very agree- 
 able. 
 
 
 
 If, while the patient is in this position, the hand supporting 
 the front of the body, be changed to the lower part of the 
 sternum, just above the region of the stomach, the sense of 
 comfort will be much decreased, or entirely removed. The 
 first kind of support represents that which is brought about 
 by the plan I recommend, and the latter is the kind of support 
 which is produced by an ordinary felt or plaster jacket. 
 
 In supporting the shoulders backwards, the less we press 
 upon the chest the better, and in applying the apparatus, it is 
 
TREATMENT.' 83 
 
 desirable to leave the chest absolutely free from pressure, 
 depending entirely upon the shoulders for fixation. Of course 
 this support with the hands is very incomplete, and does not 
 affect the lower part of the trunk, so that in many cases it will 
 not quite answer the purpose of testing the advantages of the 
 principles of support here advocated. These principles of 
 support can, more or less, be carried out by various apparatus. 
 Dr. Taylor, of New York, aims at this kind of support, and 
 M. Bonnet, of Lyons, and the late Mr. Thomas, of Liverpool, 
 used splints made of leather, which were also applied upon 
 somewhat the same principle, but by far the most manageable 
 instrument is that invented by my colleague, at the City 
 Orthopaedic Hospital, Mr. Chance. This splint I have now 
 used for many years with uniform success, and although I 
 have introduced modifications in its construction, yet the 
 principle in all parts is maintained, I call this apparatus the 
 " Adaptable Metal Splint." 
 
 The Adaptable Metal Splint. — Soft shoulder straps, 
 placed round each shoulder, are drawn back and attached to a 
 pad behind the shoulders. Light steel plates padded are 
 adapted to the spine at the side of the angle, a space being 
 allowed for the spinous processes to project between (fig. 53). 
 Two steel bars extend from the pad between the shoulders, 
 upon each side of the spinous processes, to the level of the seat, 
 where they are attached to a pelvic belt, the side plates also 
 being attached to them. The pelvic belt should be firm at 
 the back, so that by resting on the seat, it will support the 
 whole body from that point upwards. (See figs. 53 and 54.) 
 
 If this formed the whole of the apparatus, much support 
 would be given, but there would be a defective point. The 
 vertebrae below the angle of the disease would still tend to 
 curve forwards, as already explained, and it is necessary to 
 counteract "this tendency. For this purpose an abdominal 
 belt, as shown in fig. 53, is used. We now have the spine firmly 
 supported and fixed. The padded plates, at the sides of the 
 angle of disease, support that part in a forward direction 
 (arrow A). The shoulder straps fix the upper part of the 
 spine backwards (arrow B). The pelvic belt retains the 
 lower part of the instrument towards or in contact with the 
 sacrum (arrow C), and the abdominal belt supports, through 
 the abdomen, the part of the spine below the angle, back- 
 wards (arrow D). 
 
84 
 
 SPINAL CAEIES. 
 
 Eemoval of any one of these points of support would 
 diminish, more or less, or entirely take away the good effect 
 of the apparatus. 
 
 If the shoulder-straps were undone the upper part of the 
 body would fall forwards, and the same would happen if the 
 pelvic belt were unbuckled. The removal of the abdominal 
 belt would not produce so immediate an effect, but it would 
 very much lessen the benefits of the apparatus. 
 
 Pig. 54. 
 Posterior view of the "adaptable metal splint." 
 
 If the surgeon controls, as he should do, the construction 
 of the instrument, and understands all its component parts, 
 he will frequently be modifying his apparatus to suit the pecu- 
 liarities of individual cases. Every part of it should be 
 amenable to the surgeon's alterations, and I attach much 
 importance to the exact strength of the bars. These are so 
 tempered that by means of wrenches they can be bent into 
 any position, and yet are sufficiently strong to resist the effect 
 of the weight of the patient. One of the most important 
 modifications which I have introduced is the separate attach- 
 ment of the bars to the pelvic belt. Thus constructed, the in- 
 
TREATMENT. 85 
 
 strument when once applied to a diseased spine, can be moulded 
 with wrenches to the exact position necessary, and this posi- 
 tion can be modified from time to time without taking away 
 the support from the body. If it be necessary to change the 
 bars, or one of the bars, or to renew or change any single part 
 of the instrument, it can be done without interfering with the 
 progress of the case. In an acute case of caries it is a very 
 serious matter to have to remove the instrument, even for a 
 few hours ; in fact, generally it is very unwise to remove it 
 even for a few moments. We have an immense advantage in 
 being able to change any separate part in the manner 
 described. 
 
 (A description of the head-piece for disease in the upper 
 part of the spinal column is given below.) 
 
 It will be seen that the instrument should act by supporting 
 the spine from before backwards and from behind forwards, 
 and the only upward action should be that produced when the 
 patient is sitting, and allowing the lowest part of the instru- 
 ment to rest upon the seat. Its action should be quite different 
 from that of instruments which are built up upon the pelvis 
 with crutches under the arms. 
 
 The objection to these latter instruments is, first, the diffi- 
 culty of taking a sufficiently firm basis from the pelvis, it being 
 injudicious or impossible to apply them with sufficient tight- 
 ness for this purpose ; second, that, supposing this basis could 
 be obtained, it would then be found impossible to apply the 
 crutches so as to fix the upper part of the spine as thoroughly 
 as it can be fixed by means of the " adaptable metal splint," 
 the latter acting from before backwards ; third, that they press 
 upon the front of the thorax. 
 
 In considering the principles of support, we must not forget 
 that the disease is situated in the bodies of the vertebrae, that 
 is, the front part of the spinal column, and that the posterior 
 part of the column is in almost every instance free from 
 disease, or even in the worst cases is much less affected than 
 the bodies. Therefore the backward and forward pressure has 
 a more thorough effect in steadying and fixing the spine than 
 the upward support of crutches. 
 
 By the method advocated we can relieve the diseased parts 
 from excess of pressure more effectually than by attempts to 
 
86 
 
 SPINAL CARIES. 
 
 prop tip the arms ; and, moreover, such relief can be applied 
 with great accuracy and delicacy. If we realise the serious 
 nature of the disease ; if we consider that the bones which 
 should protect the spinal cord are partly or entirely dissolved 
 away, sometimes leaving the cord exposed, and that the pro- 
 ducts of inflammation approach or press on, or involve the 
 cord itself, we shall recognise the importance of possessing the 
 most accurate means of controlling, adjusting and re-adjusting 
 the position of the spine. Jackets of any kind, whether plaster 
 of Paris, felt, or any other material, are very inefficient as 
 supports. They do not take their points of resistance suffi- 
 ciently high or sufficiently low in the back. The point of 
 backward pressure to support the upper part of the body is 
 too low, and acts against the front of the chest, pressing on 
 
 Fig. 55. 
 
 the lower part of the sternum and upon the ribs. This posi- 
 tion of pressure is not efficient in fixing the spine, nor is it 
 desirable to press upon the walls of the thorax in patients who 
 are liable to be embarrassed, or are already embarrassed in 
 their breathing. The plan of supporting the shoulders back- 
 wards, which I advocate, tends upon the other hand to expand 
 the thorax, and to facilitate the respiration. 
 
 In discussing this matter with surgeons living in the country, 
 they have urged that however advantageous the use of the 
 apparatus as above described may be, yet that it is impossible 
 for them to carry out such a method, removed as they are 
 from the opportunity of having such an apparatus made, and 
 also if they could obtain the instrument, they might experi- 
 ence difficulty in making the adjustments. 
 
 This objection is undoubtedly reasonable, and I will now 
 describe a method of carrying out the principles which I 
 
TEEATMENT. 87 
 
 advocate, in a manner which can be effected anywhere. It is, 
 I think, the best that can be done under the circumstances. 
 
 The patient being placed in the prone position, with the legs 
 sloping downwards, at an angle of about SO"", or in other words 
 lying on an angle of 150°, and the patient feeling perfectly 
 comfortable and at rest ; a piece of stout gutta-percha or 
 leather is to be moulded to the back (see fig. 55), care being 
 taken not to press too much upon the spinous processes of the 
 diseased vertebrae. This splint should subsequently be lined 
 with some soft material, and strengthened by having two bars 
 of hoop iron, or sheet iron rivetted on from above downwards, 
 on each side of the position of the spinous processes. 
 
 A loop should be attached to the centre at the top, or a 
 large hook may be placed in that position, so as to retain a 
 figure of 8 bandage passed round the arms, or shoulder straps 
 may be attached. The lower part of the splint is to be fixed 
 by a roller bandage round the abdomen, the thorax being left 
 perfectly free. The addition of a firm pelvic band makes the 
 support more efficacious. For children under about 2 years of 
 age, this plan will generally act quite as efficiently as the in- 
 strument above described, and it will also do fairly well for 
 older patients, but of course it does not allow of very accurate 
 re-adjustment. 
 
 Fixation of the Head and Neck. 
 
 There is probably no part of the body the movements of 
 which are so difficult to thoroughly and effectually control as 
 the neck. There have been a great variety of apparatus 
 devised for this purpose. 
 
 I would, in the first place, remark that it is impossible to 
 control this part of the spine by apparatus unless they take a 
 basis from the whole length of the back of the patient. The 
 attachment of the arms to the spine is so unstable, that the 
 shoulders alone do not form a sufficient basis of support, or 
 in other words, the patient cannot keep the shoulders suffi- 
 ciently in one position in relation to the spine. 
 
 Apparatus supported on the shoulders may grasp the head 
 very firmly, but will allow of a moderately free movement of 
 the neck. When shown in an illustration, such instruments 
 
SPINAL CARIES. 
 
 may look very attractive, but in practice they are very inferior 
 to those which control the v^rhole spine. "Whatever instrument 
 is used to fix the spine, and I should advise that which I have 
 already described for the dorsal and lumbar vertebrae, the 
 head should be attached to this in such a manner that it can 
 be adjusted in any direction, fixed there, and be readily 
 altered into other position as required. The ordinary jury- 
 mast, passing in an arch above the head, is a very ineffective 
 machine. It is often made to project far backwards so that 
 the patient is unable to lie comfortably, if at all, upon the 
 
 Pig. 56. 
 Jury-mast, after Sayer. 
 
 back. The object of this kind of head support is to fix the 
 head by extension upwards, and it is endeavoured to attain 
 this object by means of a support from the lower jaw. This 
 plan is, to say the least, uncomfortable and irksome to the 
 patient. To be at all effective it must be so tight that it 
 produces considerable pressure, and interferes with the move- 
 ment of the jaw. Every movement of the lower jaw will 
 disturb the whole head, and if the disease is situated in the 
 first two cervical vertebrae, this movement will very seriously 
 disturb that part. 
 
I^beatmbNT. 
 
 89 
 
 Naturally the weight of the head is always borne forwards 
 upon the trunk, and the head is kept upright chiefly by action 
 of the muscles at the back of the neck. 
 
 In an illness of any kind where the head feels heavy and 
 oppressed, a patient will derive comfort from support applied 
 anteriorly, and it is well known that the most comfortable 
 way of supporting a sick person's head is by a hand supporting 
 the forehead. A child suffering from Caries or other affection 
 of the neck will frequently place the elbows upon a table, and 
 allow the forehead to rest upon the hands. We find in practice 
 that in using a fixation apparatus this kind of support is more 
 comfortable than support beneath the jaw. 
 
 ^ 
 
 Pias. 57 and 58. — Jury-mast applied, after Sayer. 
 
 Extension in a longitudinal direction, that, is by a process of 
 hanging, is neither so effectual, nor agreeable to the patient as 
 support from before backwards. The principles which I wish 
 to advocate can be attained as follows : — 
 
 The head is grasped by a band, which encircles the cranium 
 from the forehead to the occiput in the position of the brim of 
 a hat which is pushed well on to the head. The front part of 
 this band is flexible, the posterior half is firm, being made of 
 metal covered with some soft material. To the posterior part 
 of this band — that is at the central point of the occiput — a 
 metal stem is attached, which can be bent by means of 
 wrenches into the desired shape. This passes downwards, 
 and is attached to the upper part of the dorsal support. 
 Alterations in the exact position of this vertical bar may be 
 made either before or after the lower part of it is fixed, and as 
 
90 
 
 SPINAL CAElES. 
 
 a rule these alterations can be made with great advantage 
 while the instrument is being worn by the patient, and with- 
 out removing it. In acute and very advanced cases, where 
 very slight movements give great pain, and where we may do 
 serious mischief unless great gentleness is observed, this mode 
 of adjustment of the bar is too rough, and it is necessary to 
 have rack joints for the purpose. These rack joints are to be 
 made at the place where the vertical bar is attached to the 
 head-piece, and where this bar approaches the dorsal support. 
 The upper joints at the upper part of the neck permit the 
 surgeon (1) to move the head from side to side ; (2) to rotate 
 the head; (3) to move it backwards and forwards. In all 
 these cases the neck remains in one position. The rack joints 
 at the lower part of the neck allow us (1) to move the head 
 and neck together forwards and backwards ; and (2) to move 
 them from side to side. 
 
 Pigs. 59 and 60. — The head support recommended. 
 
 By one or other of these movements, or by a combination of 
 two or more of them, any position of the head may be 
 arranged, and such accuracy of adjustment is very necessary 
 in cases of acute caries of the cervical vertebrae. An almost 
 imperceptible adjustment will make a difference between pain 
 and comfort. 
 
 When the disease is situated below the third cervical 
 vertebra, rotation of the head, which occurs chiefly at the 
 axis, may be allowed to take place freely, and then the joint, 
 
WlEATMBNT. 9l 
 
 between the head band and its upright bar may be converted 
 into a free pivot-joint. 
 
 The vertical bar should be so arranged as to allow adjust- 
 ment upwards and downwards. The simplest manner in 
 which this can be done is by means of a longitudinal slot 
 passing over a screw fixed to the dorsal support, and made 
 firm in the desired position with a nut. The band which 
 surrounds the head may be varied in shape, and it is generally 
 advisable to have the posterior part wider than the band over 
 the forehead ; two inches deep at the occiput generally answers 
 the purpose, and it should be curved from above downwards to 
 fit the head. The band over the forehead should be from an 
 inch to an inch and a quarter wide, and soft leather is the 
 most agreeable substance for the head to rest against. 
 
 The part of this band which is flexible should be attached 
 by buckling upon one side to the firm part. Sometimes it is 
 well that this head-piece should extend downwards to grasp 
 the mastoid processes. 
 
 By means of this fixation apparatus a thorough control 
 of the parts is obtained, but there is no apparatus in ortho- 
 paedic surgery which requires more care, perseverance, and 
 accuracy in adjustment than an instrument for controlling the 
 head and neck. 
 
 Recumbency and Extension. — This plan of treatment 
 involves rest in bed. The head of the patient is extended 
 towards the head of the bed by means of a sling. This is 
 attached to the patient's head, and from it a cord extends 
 to the end of the bed and passes over a pulley and a small 
 weight is suspended (from half-a-pound to two or three pounds). 
 The feet are attached by bandages and cords to the foot of the 
 bed. 
 
 I do not enter into a detailed description of this treatment, 
 because I believe it is far inferior to the local fixation by a 
 properly-adjusted splint as above described. 
 
 Collars. — Although I have stated that apparatus applied to 
 the neck alone are not thoroughly effective, yet such appliances 
 may sometimes be found useful. 
 
 When the cervical caries is not very acute, or when we have 
 to keep the patient recumbent for a time, a well-adjusted collar 
 may be beneficial, used, perhaps, temporarily. In such circum- 
 stances Dr. Fleming's collar is a good one. (Figs. 61 and 62). 
 
 The. collar consists of two sets of three fusiform iudia- 
 
92 
 
 SPINAL CAEIBS. 
 
 rubber bags, connected by a narrow flexible but non-elastic 
 material, and having at the free ends flaps by which they can 
 be laced together. The bags are to be inflated with air. 
 
 Dr. Fleming's plan consisted in applying plastic felt round 
 the neck like a wide turned-down collar as shown in the 
 diagram, the lowest bag bearing upon the collar. 
 
 A neck support acting on the same principle as the above 
 was described in the British Medical Journal, October 31, 1886, 
 by Mr. Henry Clark, surgeon to the Glasgow Eoyal Hospital. 
 
 Disease in the Lumbar Region. — The apparatus as already 
 described does not control the lumbar region so perfectly as it 
 does the dorsal, and especially the mid-dorsal, but it is suffi- 
 ciently effective for the majority of cases. 
 
 
 Figs. 61 and 62. Dr. Fleming's Collar. 
 
 It is advisable to prevent much movement of the legs, and 
 the patient should especially avoid sitting on a low seat, as 
 this posture necessarily causes the lumbar region to project 
 backwards. Walking up and down stairs, and all actions 
 which flex the thighs are harmful. Action of the psoas muscles 
 is particularly to be avoided, as, from their attachment to the 
 diseased vertebrae, their use may do harm. 
 
 In severe cases it is necessary to extend the apparatus to 
 
TEBATMENT. 93 
 
 the thighs, as in hip-joint disease. Complete rest on a prone 
 couch helps in keeping the lumbar spine at rest, and then ex- 
 tension of the apparatus to the thighs is not always necessary. 
 
 When the "adaptable metal splint" is not obtainable, 
 Thomas's splint for double hip disease is a very useful one, 
 but the surgeon must be very careful in his adjustments of this 
 rather cumbrous apparatus, as, if he tries to use the heavy 
 wrenches while the instrument is in situ he will find it difficult 
 to make his alterations with sufficient gentleness, but he may 
 have the splint made with light, carefully-tempered steel bars, 
 similar to those used in the " adaptable metal splint." These 
 he can manipulate with very light wrenches, and make his 
 adjustments and re-adjustments with great nicety. 
 
 If Thomas's double hip splint be used, some pads should 
 intervene between the bars and the diseased part of the back. 
 A piece of gutta-percha moulded on the part, and afterwards 
 
 Pig. 63. 
 The back splint extended to the thighs. 
 
 lined with some soft material will answer very well. Although 
 I have mentioned this appliance, I do not think it is to be 
 compared in efficiency to the " adaptable metal splint" with 
 extension to the thighs. The latter consists in the apparatus 
 as already described, with troughs for the thighs which are 
 connected with the pelvic belt by steel rods which can either 
 be adapted by means of wrenches, or made with rack joints. 
 The rack joints are only necessary in extremely acute cases. 
 
 2. Adjustment op the Mechanical Appabatus in accord- 
 ance WITH THE PROGRESS TOWARDS RESOLUTION. 
 
 I have already stated that the surgeon should be able to bend 
 and mould his supporting apparatus without removing it from 
 the patient, and I should add that this adjustment is a 
 
94 SPINAL CARIES. 
 
 matter of the greatest importance. The surgeon who expects 
 to meet the requirements of the case without a great deal of 
 trouble, will probably meet with disappointment. Plaster and 
 other jackets are, in comparison, very simple to use, but, on 
 the other hand, they fail to provide the same degree of rest 
 and support, and they cannot be so accurately adapted as the 
 " adaptable metal splint." It must be clearly understood by the 
 surgeon who deals with these cases, and by the patients, that 
 if a good result is to be attained, no care must be spared to 
 adjust the instrument into an effective position, not only on the 
 first occasion of applying it, but upon as many other occasions 
 as may be necessary. It must be borne in mind that every 
 case of caries of the vertebrae in which the health of the 
 patient is not absolutely undermined, either by that or any 
 other disease, is not only curable, but curable without any in- 
 crease in the deformity. 
 
 Many a patient has been said to be cured by a plaster of 
 Paris jacket, but it. will be found that in such instances, where 
 resolution has really taken place, it has generally occurred at 
 the expense of a considerable amount of deformity. I would 
 even go further and say that, given an angle of any consider- 
 able degree produced by caries, there should be in the course 
 of time an improvement in the position of the whole spine, 
 not necessarily by a straightening out of the angle itself, but 
 by the accommodation of the vertebree above and below the 
 seat of disease. 
 
 "With regard to the question of stretching out the diseased 
 part, I may say that I have never aimed at such an effect ; I 
 have only extended the spine to a degree which was absolutely 
 comfortable to the patient, always with the object of relieving 
 pain as well as of curing the disease. But I do not think that 
 it is so certain as some surgeons assert, that it is impossible or 
 injudicious to separate slightly the diseased bones from one 
 another. 
 
 A case recorded below. No. 1, shows conclusively that a 
 great space may exist between the diseased bones, and yet 
 may be healed up by new bony growth. 
 
 In view, however, of the good results that can be obtained 
 by treatment without any attempt at forced extension, I am 
 not inclined to give the latter a trial until some greater reason 
 for doing so occurs than simply the improvement in appearance 
 of the patient. 
 
TREATMENT. 95 
 
 I meant to attempt to describe the details of adjustment 
 during the progress of resolution, but have found it quite im- 
 possible to do so. These details are matters of experience, 
 and every surgeon who treats a case must learn them for him- 
 self. The principles upon which the apparatus is constructed 
 should be acted upon, and I would strongly advise that this be 
 done in the surgeon's own way, rather than that he should use 
 an apparatus with which he is imperfectly acquainted. 
 
 In making alterations in the instrument I am guided very 
 greatly by the feelings of the patient, but not necessarily by 
 his suggestions as to the required alteration. These alterations 
 become more difficult in those cases where there is an absence 
 of pain, and, as I have already stated, such instances are not 
 so rare as it is often supposed. I have seen diseased spines in 
 every variety of deformity which have progressed without any 
 pain. In some instances, abscesses have formed without the 
 patient suffering in the least. Some of these cases are recorded 
 below. 
 
 It is of very great importance that the adjustments should 
 be made without removing the supporting apparatus from the 
 patient's back, both on account of accuracy and, in acute cases 
 because even momentary removal is dangerous. 
 
 3. General Eest op the Patient's Body. 
 
 Although rest of the spine is allowed by all surgeons to be 
 the most important factor in the treatment of spinal caries, it 
 is very rarely that rest is thoroughly carried out. I have 
 already remarked that recumbency in bed alone does not 
 afford sufficient rest, but that a well-adjusted apparatus (such 
 as I have described), is the most important means of attaining 
 this end. However, in an acute case even this means is not 
 sufficient. In acute disease we must bring to bear every 
 possible method of saving the spine from movement, and I will 
 now describe the details which I believe are desirable under 
 such circumstances. Absolute recumbency is to be insisted 
 upon. A very young child may be placed on a Jflat bed in any 
 position in which he is comfortable, lying either upon the back, 
 or upon one side, or in the prone position. If the child is two 
 years of age or older, the prone position on a properly constructed 
 prone couch is by far the best posture he can be placed in. 
 
96 
 
 SPINAL CARIES. 
 
 For the use of the prone couch, success or failure depends 
 entirely upon the manner in which the couch is made and 
 used. 
 
 As usually made in the present day it is of an entirely 
 different shape from that originally devised by Verrall, and 
 perpetuated by my colleague, Mr. B. J. Chance. 
 
 I have hardly ever had a patient with spinal caries in the 
 dorsal region, who has not expressed delight with the prone 
 couch, when it has been necessary to use one. Many children 
 will, of their own accord, assume the prone position by getting 
 
 Fig. 64. 
 In this couctithe angle is rather too acute ; it is 130°, whereas it should 
 be about 150°. This latter angle will produce about 160° of flexion of the 
 hips, because the patient generally raises the chest higher than the 
 abdomen. 
 
 on their knees and elbows in their bed, and one child (Case 
 No. 1) had remained in that position for months, and refused 
 most vigorously to be placed in any other posture. In the 
 prone position the patient should rest upon the abdomen, and 
 his chest be only very gently supported with a cushion. Not ■ 
 only will children assume the prone position of their own 
 accord, but the same inclination has been observed in animals. 
 Swan records a case of caries in a monkey, a Scamang 
 (Hylobatis Syndactylus). " This animal was first noticed to 
 be unwell during a cruise to Norway in the yacht of its owner. 
 
TREATMENT. 
 
 97 
 
 He constantly assumed the 'prone ijosition tvhen lying, and when 
 walking grasped his lower extremities with the paws of his 
 upper limbs in a manner painful, though ludicrous to behold, 
 and in faithful imitation of a child similarly affected. When 
 killed, the bodies of the fifth, sixth, and seventh dorsal 
 vertebrae were found to be almost obliterated, a collection of 
 cheesy pus occupying the situation." 
 
 Fig. No. 64 shows a patient resting upon a prone couch. 
 The feet are well supported by the foot board, in such a 
 position that the hip joints are above the angle of the couch. 
 The patient rests upon his elbows or with his arms upon a 
 pillow, and his head upon his arms. If the caries is situated 
 higher in the spine (or in fact in any case), be can have a head 
 rest to support his forehead. On this couch he should remain 
 
 Fig. 65. 
 
 Simple form of prone couch used at the City Orthopaedic Hospital, 
 having boards at the sides to prevent a young child from falling off. 
 Devised by my colleague, Mr. E. J. Chance. 
 
 as much as possible, but discretion must be used as to move- 
 ments. If the disease is very severe, it may be best, and most 
 comfortable to the patient for him to remain day and night 
 upon his couch, but it is often convenient to let the couch be 
 used only in the day, and the patient placed carefully upon 
 a bed at night. 
 
 4. Modifications of the Bodily Movements in accordance 
 WITH THE Severity of the Case. 
 
 The foregoing directions for rest of the body may be very 
 considerably modified in a large number of cases. The child 
 
 7 
 
98 SPINAL CARIES. 
 
 may be walking about and suffering a moderate amount of pain, 
 and yet be affected with acute caries, and the deformity may 
 be rapidly increasing. 
 
 Such a case, when the supporting apparatus is applied, may 
 be immediately relieved from all pain and discomfort, and 
 resolution may begin to take place immediately and continue 
 satisfactorily, without the patient being kept in a recumbent 
 position. Here again, experience teaches us to what extent we 
 may allow movements to take place, but we must always bear 
 in mind that it is far better to reduce the movements too much 
 than to allow the least excess. It may be impossible in such 
 cases to determine, upon first seeing a patient, the exact 
 amount of rest required. We must carefully watch the result 
 of our treatment, and be prepared to limit the movements in 
 accordance with the progress. 
 
 In advising the use of supporting apparatus, it has often 
 been urged in their favour, that the patient is by their use 
 enabled to obtain the benefits of fresh air and exercise, which 
 are said to tend materially towards recovery. 
 
 I cannot agree with this opinion. Fresh air every patient 
 should have, however much he is kept at rest ; but exercise 
 may be very harmful, and should never be allowed if it pro- 
 duces any discomfort or other signs of mischief. 
 
 Exercise is of no help towards recovery. It is, of course, 
 desirable not to impose all the trouble and expense of absolute 
 recumbency unless it is necessary, but in no case is exercise to 
 be looked upon as beneficial. 
 
 Children may be thin, anaemic, and showing other signs of 
 deficient general health while going about, and will quickly 
 gain flesh, colour, and vitality when relegated to absolute 
 recumbency, and it is only by keeping this fact in view that 
 success in treatment can be insured. 
 
 Even when the patient can be safely allowed to walk about, 
 it is desirable to insist upon very great restriction. His move- 
 ments must be made carefully ; he must avoid sudden exertion, 
 especially twisting his body. He must be taught to move with 
 his spine held as rigidly as possible, to get up from a chair or sit 
 down with the utmost deliberation, to walk gently, and especi- 
 ally to avoid tripping. In all cases, and especially if the 
 disease is situated high in the spine (above the sixth dorsal 
 vertebra), he must be very sparing in the use of his arms, never 
 
TREATMENT. 
 
 99 
 
 carrying or lifting anything at all heavy, and never using much 
 exertion with them. No patient suffering from spinal caries 
 ought to attempt to put on his own boots, and even drawing 
 on socks or stockings is decidedly harmful. 
 
 5. Nursing. 
 
 We cannot expect a nurse to understand the sort of care 
 required in handling a patient with caries of the spine without 
 special instruction. She must be made to understand some- 
 thing of the nature of the case ; that the diseased part is in an 
 extremely weak condition, and that if much strain is put upon 
 it, very serious injury will result. 
 
 Fig. 66. 
 
 Position of a healthy child's back in sitting on a flat surface with the 
 legs extended. 
 
 In carrying or lifting a patient the whole spine is to be 
 evenly supported, and this can only be thoroughly accom- 
 plished by lifting the patient on the supporting apparatus 
 as described below. The nurse must also understand that 
 separate movements of the arms and legs will influence the 
 spine, and that even the head must not be allowed to be 
 unsupported when the child is horizontal. 
 
 If the thighs are supported slightly flexed upon the body, 
 the legs may hang at a right angle to them, but the thighs 
 must not be bent up upon the abdomen. 
 
 Wbon the patient sits up (supposing he is well enough to do 
 
100 
 
 SPINAL CARIES. 
 
 so) it is important that the knees should be bent, as, if they 
 are extended, the spine is necessarily bowed backwards. 
 
 Figs. 66 and 67 show this. 
 
 Of course the instrument will prevent the back bending 
 posteriorly very much, but still the strain will be severe and 
 will do harm. 
 
 All twisting of the body is to be very carefully avoided. 
 "When recumbent the legs and hips must not be turned 
 laterally without the body being turned also. 
 
 Fig. 67 
 Position of a healthy child's back in sitting up with the legs bent. 
 
 Carrying a Patient. — Great care is necessary to carry 
 the patient safely. The arms of the nurse should support 
 both extremities of the instrument, or the right arm may 
 take all the instrument and the left the thighs, but it is 
 well that the ends of the fingers of the left hand should just 
 grasp the lower end of the splint. One arm should be placed 
 beneath the patient's shoulders, the head resting against the 
 upper arm, the other hand supporting the back of the pelvic 
 belt, and this arm should support the thighs. By this means 
 the spine may be prevented almost absolutely from movement. 
 
TREATMENT. 101 
 
 It is of the utmost importance that the nurse should observe 
 the greatest tenderness and care in moving the patient. The 
 slightest jolt should be guarded against, and every care taken 
 to avoid producing any pain. 
 
 Washing the Body and Attention to the Functions. — 
 Unless care be taken in washing the body, and attending to the 
 functions, our best efforts may be fruitless, and the symptoms 
 remain unsubdued. In very acute cases where the bodies of 
 one or more of the vertebrae may be entirely dissolved away, 
 where the child is possibly powerless in his legs, and where 
 there is incontinence of urine and difficulty with the bowels, 
 harm may be done in a few minutes which may upset all the 
 good which has been secured by a month's treatment- 
 General Washing of the Patieyit should be carried out with- 
 out disturbing the spine, and if the surgeon is not sure about 
 the carefulness of the nurse, it will be well that the washing 
 be considerably limited rather than subject the patient to the 
 risk of injury of the diseased part. Powdering the body 
 thoroughly with prepared Fuller's earth will take the place of 
 washing to a great extent, but still a certain amount of ablution 
 is absolutely necessary. 
 
 To wash the patient, we will assume that he is in the prone 
 position, lying thoroughly supported on his couch or mattress, 
 his arms resting on a pillow, and his head on his arms. Then 
 the instrument is to be unbuckled. The straps of both arms, 
 the straps on one side of the abdomen, and the strap of the 
 pelvic belt being unfastened, the instrument can be lifted side- 
 ways as if it were a lid, but not in any other way removed. 
 The back of the patient is then to be washed carefully, dried, 
 and the instrument buckled on again. Every buckle having 
 been carefully fastened, the patient is then to be lifted up, and 
 placed on his back on a flat bed or mattress, taking care that 
 he is comfortably supported. Then the straps should be again 
 unbuckled, and the front of the body exposed and washed, 
 and the straps again fastened. 
 
 The functions of the body are to be carefully attended to, 
 and if the nurse does not manage without disturbing the 
 patient unduly, the surgeon must tell her what to do. It is 
 not difficult for these matters to be attended to on the prone 
 couch, but it is sometimes preferred to attend to the bowels 
 while the patient is resting on his back in bed. 
 
102 SPINAL GABIES. 
 
 For that purpose an ordinary small bed-pan is available, and 
 it is a good plan to let the patient lie on two mattresses sepa- 
 rated slightly in such a manner that the bed-pan can be passed 
 between the two so that the patient need not be raised up 
 while it is being used. 
 
 6. Clothing. 
 
 Warmth is to be maintained, and especial care is required, 
 with the parts affected, in cases of paralysis. 
 
 Putting on and taking off children's ordinary clothing is very 
 liable to do harm by disturbing the position of the body. 
 Every garment should be made upon the principle of a dress- 
 ing-gown, i.e., open down the front or back, or both, so that 
 they can be put on and taken off without being passed over 
 the head or legs of the patient. No part of the clothes should 
 be tight, and the sleeves especially should be large. Flannel 
 should predominate. As the treatment with the adaptable 
 splint tends to develop the thorax, it necessitates more room 
 in the clothes in front of the chest than has been required 
 before the treatment commenced. This especially requires 
 attention when the patient is getting about, as when con- 
 stantly recumbent much looser garments are generally worn. 
 
 I have frequently found that clothes which were quite loose 
 upon the chest before the treatment commenced are from one 
 to three inches too tight soon after the application of the 
 splint. It must be further borne iu mind that as the chest is 
 continuing to expand for months after treatment has com- 
 menced, the space provided must not only be loose at the 
 onset, but be sufficient to allow for this further development. 
 
 7. Food and Medicine. 
 
 It is hardly necessary to state that plenty of good whole- 
 some food should be given. Meat and other nitrogenous food 
 should predominate. 
 
 Medicinal treatment must be based upon general principles, 
 but most cases of caries are benefited by some easily digested 
 preparation of lime and iron. 
 
 I prefer a neutral solution of lime, with a small amount of 
 ammoniate of iron. 
 
treatment. 103 
 
 8. Treatment of Complications. 
 
 (a) Pain, as already stated, is not a certain indication of the 
 severity of the disease. The pain may be very acute, or it 
 may be entirely absent, and we meet with every degree of 
 variation between these extremes. 
 
 The pain being caused by irritation of the nerves coming 
 from the spinal cord, and this irritation being a consequence of 
 the inflammation which exists, all treatment should be directed 
 to reducing that inflammation. One of the first symptoms of 
 the benefit of the fixation of the diseased parts is the subsi- 
 dence of pain. 
 
 Upon the first application of the supporting apparatus we 
 should be able to lessen, more or less, this symptom. Some- 
 times all pain will cease from the moment of putting on the 
 splint and never recur. At other times the pain is either 
 entirely subdued or very much reduced at the putting on of 
 the apparatus, and begins to get bad again in a few days, 
 when by readjustment of the splint it can again be relieved. 
 Thus the pain may recur again and again, but decreasing all 
 the time until perhaps in a fortnight all pain has been re- 
 moved. 
 
 Eecurrence of pain is a sign that alteration in the position of 
 the splint is absolutely necessary in consequence of an alter- 
 ation in the position of the diseased bones. These alterations 
 in position of the bones are probably caused chiefly by absorp- 
 tion of the inflammatory products. As a consequence of the 
 rest the spine falls into a different position from time to time, 
 until it settles into one in which it remains while resolution 
 takes place. 
 
 These recurrences of pain should be immediately attended 
 to, and this can only be done with an instrument which can 
 be accurately adjusted by the surgeon without being removed 
 from the back. I avoid as much as possible the use of seda- 
 tives, for the reason that I look upon pain as an indication for 
 re-adjustment, and because such re-adjustment very rapidly 
 gives the patient ease. In applying an instrument for the 
 first time the surgeon should persevere until ho has succeeded 
 in giving the patient relief, although in some cases it may be 
 a very difficult result to attain. 
 
104 SPINAL CAKIES. , 
 
 During the progress of treatment pain may be caused by 
 undue pressure of the instrument, and if this is not attended to 
 the skin will soon become abraded. If a sore place is once 
 allowed to occur, it is very difficult to get rid of, because 
 however much the pressure be reduced it will be enough to 
 keep up irritation and prevent the sore from healing. 
 
 However accurately adjustment may be made one day, the 
 instrument may be rubbing somewhere a few days later, and 
 if such is the case the surgeon should be summoned at once 
 to relieve it. All the varieties of pain described under the 
 head of symptoms are to be controlled by the treatment as 
 above described. 
 
 (b) Paralysis. — What has been written above regarding the 
 treatment of pain applies to a great extent to the treatment of 
 paralysis. That is to say, paralysis being caused by pressure 
 upon, or irritation of the spinal cord itself, or the nerves coming 
 from the cord at the seat of the disease and as a consequence 
 of that disease, so everything which tends towards resolution 
 will conduce to the relief of the paralysis. 
 
 In all cases of caries of the spine in which the health is 
 not thoroughly undermined, and in which, as I have already 
 stated, a cure should be looked for, we may confidently expect 
 relief from the paralysis. I have had no case of this kind 
 which has not recovered from the paralysis. 
 
 I have known patients, paralysed entirely as regards motion 
 in the lower extremities, including paralysis of the bladder 
 and rectum, and even paralysis of sensation, existing for 
 months and even years, to have perfectly recovered after 
 careful treatment. 
 
 In paralysis care is especially necessary to prevent rubbing 
 and irritation of the skin. 
 
 The depressed vitality of the parts paralysed, renders the 
 skin very liable to such irritation. A water-bed is often an ad- 
 vantage. The skin should be kept dry and clean and as free as 
 possible from contact with the excretions. The urine, which 
 is generally a much greater trouble than the faeces, can be 
 better carried away when the patient is on a prone couch than 
 in any other position. A urinal will be found useful for this 
 purpose, and a very simple one may be made with a rubber 
 funnel attached to a long tube. which can pass through a hole 
 in the couch. 
 
TBEATMENT. 105 
 
 As a rule, however, the patient can be kept dry by using 
 cloths or other absorbent material. It is only in severe and 
 neglected cases that bed-sores occur. 
 
 Complete paralysis of sensation as well as motion is rare, 
 and cases of caries do not present the difficulties which occur 
 in many instances of paralysis from fracture of the spine, or 
 disease of the spinal cord. 
 
 Counter irritation. — The use of moxas, setons, issues, and 
 the actual cautery upon each side of the spine in the neighbour- 
 hood of the diseased bones, belongs chiefly to a past age. The 
 pain and shock to a patient whose vitality is not of the best ; 
 the prevention, in consequence of the situation of the sores, 
 of efficient fixation of the part ; and the inefficiency of these 
 remedies are sufficient to condemn them, as a rule. In cases, 
 however, in which pain persists in the vertebrse, and espe- 
 cially in the spinous processes, notwithstanding careful treat- 
 ment as above advocated, the use of counter irritation may be 
 productive of benefit. However, a much less severe method of 
 giving relief in such cases is drilling into the spinous processes. 
 This operation will generally act most beneficially. This ope- 
 ration is described on page 109. 
 
 The Injection of a solution of carbolic acid (2 per cent.) 
 into the body of a vertebra, or in its close proximity by means 
 of Pravaz's syringe, as recommended by Hueter, is a remedy 
 which is not without danger, as it is almost impossible to be 
 sure that we shall not injure important adjacent structures. 
 
 I have not adopted this method, but I have injected a 1 in 
 40 solution of carbolic acid into the wound after drilling into 
 the spinous processes, in the same manner that I have dealt 
 with tuberculous inflammation of the joints by drilling into 
 the bones in their neighbourhood. 
 
106 SPINAL CABIES. 
 
 CHAPTEE V. 
 
 TREATMENT (OPERATIONS). 
 
 Laminectomy. — The safety with which operations can be 
 performed under strict antiseptic precautions, has rendered 
 the removal of the arches of one or more vertebrae a possible 
 procedure in cases where pressure upon the spinal cord has 
 given rise to symptoms which require immediate alleviation, 
 or which stand in the way of progressive improvement of the 
 patient towards recovery. 
 
 In all severe cases of caries of the spinal column, symptoms 
 of pressure and local irritation are apt to arise, and the 
 functions of the parts below the seat of disease are then 
 more or less interfered with by interruption of their normal 
 nerve supply, as already described. 
 
 Tubercular deposits in the membranes of the cord, abscesses 
 in the immediate vicinity, inflammatory exudation, or in some 
 cases displacement of the bones, or diseased portions of bone 
 surrounding the spinal cord, may produce pressure upon or 
 irritation of this nerve centre and give rise to more or less 
 serious symptoms. 
 
 We are accustomed to see the results of this pressure dis- 
 appear upon the careful application of the measures already 
 described, which include fixation of the spine in a good 
 position, and other treatment calculated to rest the parts in 
 conjunction with general hygienic improvement, and therefore, 
 it must not be too hastily assumed that because the patient is 
 suffering from severe symptoms of interference with the spinal 
 cord that the operation of laminectomy is necessarily indicated. 
 (See Cases.) 
 
 The temptation to resort to an operation which is very likely 
 to give immediately good results is very great, but we should 
 consider in the first place the disadvantages which are involved. 
 
OPEEATIONS. 107 
 
 I have already described the great value of the bony arches 
 of the vertebrae, in the treatment of caries ; how by supporting 
 the trunk backwards, so that its weight is sustained by these 
 arches (which are seldom themselves diseased) instead of by 
 the inflamed and carious bodies of the vertebrae, rest is afforded 
 to the latter parts. Now it must be obvious that if we remove 
 one or more of the arches, we remove sound parts upon which 
 we were relying for such valuable help. Certainly the articular 
 processes are left, and these being seldom involved in the 
 disease, serve to a great extent to sustain the body weight, 
 also in many cases we may depend upon utilising in the same 
 way the more posterior portions of the bodies of the vertebrae 
 themselves, but these parts are very limited in extent, and 
 therefore our efforts to fix the spine in a good position are 
 considerably lessened. 
 
 Another drawback is the immediate effect of the operation. 
 That it is comparatively free from danger as an operation is 
 doubtless true, but the disturbance of the diseased parts, 
 especially by the force necessary to cut through the bony 
 laminae is an element worth consideration, bearing in mind 
 how desirable it is, in these cases, to avoid all shock and 
 disturbance as antagonistic to that perfect rest which is so 
 essential to effect a subsidence of the inflammatory process. 
 True it is that bone may be re-formed, and in time the gap 
 may be filled up with firm osseous structure, but this takes 
 a considerable period, and it is always desirable, and some- 
 times a matter of grave importance not to increase the inflam- 
 matory process. Immediate rest is of the greatest importance. 
 Another bad result which has followed this operation has been 
 inflammation of the membranes of the cord, and even of the 
 cord itself. 
 
 Notwithstanding these drawbacks to the operation, cases 
 may occur in which such a procedure may be imperatively 
 demanded, or at least may be the least of two evils, or may, 
 perhaps, be the only remedy which seems possible to avert an 
 otherwise unfavourable result. 
 
 It has been stated by surgeons who have had recourse to 
 laminectomy that they have first tried the effect of other 
 remedies, and have not operated until the treatment by rest 
 alone has failed, and the patients have been getting worse. 
 The previous treatment by rest has been carried out probably 
 
108 SPINAL CAEIES. 
 
 by recumbency alone, or by means of plaster or felt jackets, or 
 possibly of some other inefficient support, and so I would 
 urge that the support has often not been perfect. This opinion 
 is based upon my belief that the fixation and support afforded 
 by the plan of treatment which I have advocated, is incom- 
 parably more effectual than that given by recumbency alone, or 
 by jackets. Therefore we may consider that the reasons for 
 resorting to the operation have not been in all such cases 
 sufficient. 
 
 I perfectly agree with the dictum that */, notwithstanding all 
 our efforts to cure by other means the patient is getting worse, 
 and the symptoms of pressure and nerve irritation persist, then 
 a resort to operation is called for, and it is only as regards the 
 carrying out of the former methods that I would urge a different 
 course. 
 
 Paraplegia persisting, notwithstanding the thorough rest of 
 the spine and' the relief of all symptoms of pain and irritation 
 by gradual adjustment of the supporting apparatus ; or other 
 symptoms of local mischief continuing, would denote pressure 
 either by a displaced vertebra, or displaced piece of necrosed 
 bone, or firm tuberculous material, or a circumscribed abscess, 
 and under such circumstances the operation of laminectomy 
 might be called for. 
 
 The Operation. — This consists in making a vertical incision 
 in the median line over the spinous processes, separating the 
 mass of muscles from each side of these processes, stripping 
 back the periosteum, cutting away the spinous processes, 
 cutting through the laminae on each side, and removing the 
 posterior portion of the vertebral arches. The membranes of 
 the cord are then exposed and any deposit thereon removed, 
 the cord can be drawn aside and the front part of the canal 
 approached, and it is possible to relieve an abscess in the 
 bodies of the vertebrse, or to remove carious or necrosed bone 
 from this part. The filling up of the cavity thus created with 
 glycerine and iodoform or other antiseptic, the insertion of a 
 drainage tube, and the careful closing up of the wound com- 
 pletes the operation. The tube can be left in for 24 to 48 
 hours or longer, according to the indications which present 
 themselves, and the further treatment of the wound should be 
 conducted on ordinary antiseptic principles. 
 
 After the operation the supporting apparatus should be 
 
OPERATIONS. 109 
 
 immediately applied, as at this time the apparatus is more 
 imperatively demanded even than before, because so much of 
 the bony column which would have afforded considerable help 
 towards supporting the part, has been removed. 
 
 The results of this operation have varied. The majority 
 of patients operated upon have been immediately benefited, 
 but there has been a tendency to relapse, and this points to 
 failure in the supporting apparatus, a failure which may in 
 some cases account for the supposed necessity of the operation 
 in the first instance. 
 
 Wiring the vertebrae. — Uniting the spinous processes by 
 means of stout wire after cutting down upon them by a ver- 
 tical incision has been proposed, the object being to fix the 
 bones together and to relieve the diseased parts from pressure. 
 The objections to this plan of treatment are : — 
 
 1. The inefficiency of the support, as it does not control 
 lateral motion, and it does not allow of the necessary adjust- 
 ments in accordance with the progress of the case. Moreover, 
 the great strain on the wire would cause either a breakage of 
 the wire or severe injury to the spinous processes. 
 
 2. The local disturbance of a foreign body. 
 
 3. The fact that properly arranged mechanical support as 
 described above is far more effective.^ 
 
 Bone Drilling. — It is now some years since I first tried the 
 effect of bone driUing in the neighbourhood of diseased joints 
 with the view of relieving tension. 
 
 The remarkably good results which followed this operation 
 in cases of chronic inflammation of hip, knee, and ankle led 
 me to adopt the same procedure in cases of persistent pain in 
 the spine, when unusual pressure upon one or more spinous 
 processes produced distinct and severe pain. The result has 
 been very satisfactory. 
 
 Fixation alone will generally relieve all pain in the spine in 
 caries, but in some instances of this disease, notwithstanding 
 general improvement, the local pain, greatly increased by pres- 
 sure, has remained persistent, denoting, I have thought, that 
 congestion or inflammation was present in the spinous pro- 
 cesses. 
 
 ' For operations performed, especially for abscess, see uext pa, 
 
110 SPINAL CARIES. 
 
 This pain is quite distinct from the deep-seated pain of 
 caries of the bodies of the vertebrae. I have always found 
 that perfect relief has been afforded by this operation, and as 
 it is a practically safe one, I have not hesitated to carry it out 
 v^henever the symptoms have denoted its desirability. 
 
 In some few instances a puncture to the bone with a teno- 
 tomy knife, and incision of the periosteum, has had the desired 
 effect, but generally it has been necessary to insert a fine drill 
 about one-eighth of an inch in diameter, penetrating the bone 
 until the cancellous tissue has been reached. 
 
 For two or three days subsequently a smarting sensation 
 has generally been felt by the patient, after which all pain has 
 ceased. When the pain has been very severe I have followed 
 the operation by injecting a solution of carbolic acid (1 in 40), 
 but I am not sure whether any extra beneficial effect has been 
 thus produced. 
 
 That drilling into the spinous processes is effectual in sub- 
 duing such pain, notwithstanding other treatment, is a fact 
 which I have been convinced of by repeated trials, and 
 although we know that caries only very rarely attacks these 
 processes of bone, yet it seems probable that they may be 
 frequently in a state of congestion sufficient to give the patient 
 considerable discomfort, and it is obvious that the operation is 
 capable of relieving such a condition by giving an exit to the 
 excess of blood pressure. 
 
 Operation for Abscess. — Until quite recent years the 
 opening of spinal abscesses was looked upon with great appre- 
 hension of evil results. The contamination of the contents 
 by the air, or in other ways, frequently produced septic infec- 
 tion, and the patients rapidly succumbed to the blood poisoning 
 thus produced. (Acute septic disease, or chronic septicaemia.) 
 
 If the patient escaped septic contamination, then it gene- 
 rally happened that prolonged suppuration occurred, whether 
 the opening was made by the surgeon or by nature, and the 
 patient became gradually exhausted from the constant drain 
 upon his vitality or from the effect of waxy degeneration of 
 the liver, kidneys and other organs. The advent of antiseptic 
 surgery first led to endeavours to exclude the air by local 
 applications to the external opening, but such precautions were 
 very uncertain in their effects. 
 
 To avoid the dangers which were once thought inseparable 
 
OPERATIONS. Ill 
 
 from the opening of these abscesses, aspiration was brought 
 into use. A fine tubular needle being passed into the sac, as 
 much as possible of the contents were removed, the needle 
 withdrawn, and the opening carefully closed and allowed to 
 heal up. This course is followed by some surgeons at the pre- 
 sent day, but it cannot be recommended as satisfactory or 
 desirable, except in the cases mentioned below. 
 
 In the first place, it is seldom that the contents are suffi- 
 ciently fluid to pass through the tube of the needle, and even 
 if a large, quantity of matter be thus removed, it is very likely 
 that some clots or pieces of carious bone will be left behind. 
 
 It has been stated that the injection of a few drachms of 
 tincture of eucalyptus will after a few days have liquified the 
 contents, but this can only apply to the solution of clots, and 
 not to pieces of bone. 
 
 After aspiration the pus, with a few exceptions, gradually 
 collects again, so that in the course of some weeks, or perhaps 
 months, the operation has to be repeated. 
 
 Sometimes pus re-forms very rapidly, so that the aspiration 
 has to be repeated in a few days, and so on again and again. 
 In a few instances, after one or more aspirations the abscess 
 has ceased to re -appear, and has apparently been cured, but 
 such a result is very uncertain and unlikely to happen, How- 
 ever, in the case of some very large abscesses, where the 
 contents are thought to be sufficiently fluid, the size of the 
 abscess may be diminished by aspiration some time previous 
 to a more thorough operation. 
 
 Pathology. — The most modern view of the pathology of a 
 chronic abscess is that it is quite different from acute abscess, 
 and that it is "a tuberculous tumour with a softened centre." 
 Upon this " theory," or we may perhaps say " knowledge," 
 modern treatment is based. 
 
 Eyacuation, antiseptic dressing of the abscess walls 
 and closure of the wound. — This plan of treatment consists 
 in washing out the cavity with a weak solution of carbolic 
 acid, or other antiseptic, after evacuation by a free opening; 
 the injection of a 10 per cent, emulsion of iodoform in olive oil 
 and glycerine, or iodoform in ether, and closure of the puncture. 
 This plan has not, however, proved quite successful, as the 
 walls of the sac remaining give rise to further secretion of 
 purulent matter which has to find its way to the surface. 
 
112 SPINAL CARIES. 
 
 Entire removal of abscess.— Any chronic abscess (or col- 
 lection of tuberculous material) that can be dissected out with- 
 out being opened, can be thus most thoroughly eradicated; 
 the wound made by operation is then closed up and heals by 
 first intention. Doubtless this is by far the best plan of treat- 
 ment where it can be carried out. In dealing with spinal 
 abscess, however, it is very seldom indeed that such a course is 
 practicable or advisable. An opportunity for operating in this 
 way may, however, occur in those very exceptional cases in 
 which the caries exists in the spinous processes, or in the 
 arches of the vertebrae. 
 
 The depth and extent of a spinal abscess, its situation, 
 often in close proximity to vital organs, and its connection 
 with the bodies of the vertebrae make the excision of the whole 
 abscess either impossible, or at least impracticable. 
 
 Scraping out the cavity. — The next best plan of dealing 
 with chronic abscesses, and one which is more commonly 
 applicable to spinal abscess, consists in removing as much of 
 the walls of the cavity as possible, by cutting away with 
 scissors, and by scraping with a Volkmann's spoon and freely 
 flushing out the parts removed. After removing as much of 
 the lining membrane as possible by these methods, dry rough 
 sponges, attached to long holders, should be assiduously rubbed 
 over every part of the abscess cavity, and this procedure should 
 be continued until the walls are denuded of their lining mem- 
 brane, and the cavity converted into the condition of a clean, 
 aseptic wound. Although there may be free bleeding at first, 
 this gradually ceases. Great care must be taken, when the 
 abscess is situated deeply from the surface, to avoid injuring 
 vital organs. 
 
 A post-pharyngeal abscess should be opened behind the 
 sterno - mastoid muscle, and care taken in scraping not to 
 penetrate into the pharynx. (See below.) 
 
 In deep situations, and especially if near a large vein, or 
 the peritoneum, a coarse sponge may be used exclusively to 
 remove the surface of the walls, and the Volkmann's spoon 
 omitted. Dealing with long sinuses — and these especially 
 occur in psoas abs.cess — a sponge on a probang is very useful. 
 I have adapted the bristle throat probang for this purpose, 
 the bristles being expanded after insertion of the probang, and 
 the apparatus then withdrawn. During any of these opera- 
 
OPERATIONS. 113 
 
 tions and afterwards, the cavity should be thoroughly flushed 
 out with a weak antiseptic fluid, such as 1 in 10,000 sublimate 
 solution, the fluid in the cavity squeezed out as much as 
 possible, and lastly, an injection made of one to two ounces 
 of a 10 per cent, emulsion of iodoform in glycerine, with 
 perhaps a small addition of sublimate solution and the ex- 
 ternal opening carefully stitched up. 
 
 If we have been able to thoroughly evacuate the cavity of 
 its lining membrane, then immediate closure will probably be 
 followed by a perfect cure; but it often happens that the 
 removal of lining membrane is only partial, and then some 
 collection of pus recurs, and necessitates either aspiration, or 
 a simple incision and flushing with the antiseptic solution, 
 followed by again reclosing the wound. This second inter- 
 ference will often be followed by a permanent cure. 
 
 Simple daily syringing with an antiseptic solution. — 
 About fourteen years ago I began to adopt the antiseptic 
 principle of treatment by opening the abscesses freely, and 
 injecting the cavity with antiseptic fluids, and with such treat- 
 ment I have never known any abscess to become contaminated. 
 
 I have freely opened all chronic abscesses, and have syringed 
 out the cavities daily with a solution of carbolic acid (1 in 40) 
 without producing anything but beneficial results. 
 
 Once only have I seen any symptoms of carbolic poisoning, 
 and that consisted only in a slight smokiness of the urine, 
 which ceased in a few hours after the substitution of another 
 antiseptic. 
 
 More recently I have used a 1 in 60 solution of the acid, 
 sometimes commencing by one injection of a much stronger 
 solution (1 in 30). This treatment has been followed by ex- 
 cellent results, the cavities closing up perfectly in a few weeks 
 and remaining permanently cured. 
 
 The evacuation of the lining membrane of these chronic 
 abscesses, as above described, is undoubtedly a better plan of 
 treatment, when it can be thoroughly carried out, but in cases 
 where it is doubtful whether we can remove the whole of the 
 lining membrane, it is a very good plan to follow our operation 
 by daily irrigation without closing the wound, in place of the 
 immediate closure. 
 
 There is another very important point for consideration in 
 deciding whether to close the external opening at the time of 
 
114 SPINAL CARIES. 
 
 operation, or whether to continue daily injections and allow 
 the cavity to heal up gradually. It is seldom that we can be 
 sure that the seat of diseased bone is so far advanced 
 towards recovery that no further debris sufficient to keep up 
 the secretion of pus will come away, and therefore, however 
 thorough our removal of the lining membrane may be, there 
 will be a great likelihood of re-formation of the abscess. In 
 many of the cases treated by immediate re-closure, the abscess 
 has re-formed, and further operations have been necessary. 
 
 In very many of the cases in which no second interference 
 was required, as well as in those where such a course was 
 necessary, it is likely, or we may say probable, that a certain 
 amount of re-formation has taken place at the seat of bone 
 disease, and has eventually gone through the process of 
 " drying up." 
 
 The antiseptic injection. — I believe that nothing is better 
 than carbolic acid, and this view has lately had the support of 
 Sir Joseph Lister, who, after years of experiment with a large 
 number of substances, has returned to a great extent to that 
 which he first advocated — carbolic acid. Corrosive sublimate 
 1 in 10,000 is also a safe and useful fluid. Eucalyptus oil is 
 also good as a change of injection. For a final injection in 
 cases in which it is thought judicious to close the opening, the 
 iodoform emulsion in glycerine referred to above is probably 
 better than iodoform in ether, a sloughing of tissue having 
 followed the use of the latter in some instances. 
 
 Retro-pharyngeal abscess. — An abscess at the back of the 
 throat may assume very considerable dimensions before it is 
 detected. It may cause serious dyspnoea, and even necessitate 
 laryngotomy. It may extend into the posterior mediastinum, 
 as already mentioned. It may open spontaneously at any 
 moment, and may enter the larynx, and produce fatal 
 asphyxia. The latter result may occur even if it be opened 
 surgically in the throat ; moreover there is great liability to 
 septic contamination of the contents. To obviate these 
 dangers and inconveniences, the operation first suggested by 
 Professor Chiene, of Edinburgh, is much to be preferred to an 
 opening in the throat. A longitudinal incision about 1| inches 
 in length is to be made at the posterior border of the sterno- 
 mastoid muscle from a little below the apex of the mastoid 
 process. The transverse processes of the vertebrae are then to 
 
OPEKATIOXS. 115 
 
 be defined, and it may be necessary to draw the sterno- 
 mastoid forward for this purpose. The deeper opening may be 
 made with a blunt instrument, such as a director or dressing 
 forceps. 
 
 Fluctuation may be detected by one finger placed in the 
 wound and another in the throat. 
 
 A certain amount of laryngitis and oedema of the glottis 
 may be present, and tracheotomy has sometimes been neces- 
 sary under such circumstances, to relieve the patient from 
 asphyxia. After opening the abscess behind the sterno- 
 mastoid, the general principles of treatment described above 
 can be followed. 
 
 Sequestra of diseased bone. — It occasionally happens, 
 although rarely, that a large piece of bone dies and becomes 
 separated from the body of a vertebra, and remains as a foreign 
 body at the seat of the disease. Such a sequestrum is a con- 
 tinued source of irritation as long as it remains in situ, and its 
 presence will considerably modify the course of the disease. 
 Small pieces of bone will in time become disintegrated, and 
 partially or entirely dissolve in the abscess, but larger portions 
 may remain for years, and give rise to a great deal of trouble. 
 
 The modern plan of freely opening an abscess enables us in 
 some instances to explore the seat of bone disease, and perhaps 
 to remove such a sequestrum. 
 
 Suggestions for operation with a view to remove this source 
 of irritation have from time to time been made. Furneaux 
 Jordan was one of the first who proposed cutting down by the 
 side of the spine with this object, and subsequently McEwen, 
 of Glasgow, introduced a plan of opening up a psoas abscess 
 both in the loin and groin, exploring the seat of disease, and 
 removing sequestra of bone. Treves performed the same oper- 
 ation, and inserted a large drainage tube from one opening to 
 the other. 
 
 The latter operation was performed as follows. 
 
 Details of operation. — A vertical incision is made near 
 the outer edge of the erector spinas ; the sheath of that muscle 
 and the quadratus lumborum are cut through ; the psoas 
 muscle is incised and the vertebrae reached by continuing the 
 operation along the deep aspect of that structure. Necrosed 
 bone can be removed through this opening, or an abscess 
 evacuated in its early stage. Should there be a psoas abscess 
 
116 SPINAL CARIES 
 
 extending to the groin, a counter-opening can be made there, 
 and a large drainage tube be passed between the two. 
 
 Such operations ought to be reserved for very exceptional 
 cases, and the continued drainage in this fashion has been 
 superseded by the more recent operations already described. 
 
 The locality which can be thus operated on with much 
 chance of success is limited to the lumbar region, for in the 
 dorsal the ribs seriously interfere with its successful per- 
 formance. 
 
 Yet even in the dorsal region operations have been per- 
 formed. 
 
 Dr. Boekel describes in Schmidt's Jahrbilcher, March 14, 
 1883, a case in which he removed portions of the bodies of 
 two dorsal vertebrae with good results. He stated that he did 
 not find it very difficult. Eesection of 1 to 1| inch of one rib 
 gave enough room to introduce a scoop. The abscess generally 
 makes a space lessening any danger of wounding large vessels 
 in front of the spinal column. 
 
 Laminectomy, or the removal of the arches of the bones in 
 the situation of the disease, seems to promise another means 
 of removing necrosed bone and tubercular deposits. I have 
 already described this operation above. 
 
THE PERIOD OF TREATMENT. 117 
 
 CHAPTEK VI. 
 
 THE PEEIOD OF TREATMENT. 
 
 The length of time during which treatment must be con- 
 tinued before we can expect the disease to be cured, and also 
 the time when the patient will be able to dispense with 
 mechanical support, are points of very great importance, in 
 which every patient, or his parents or friends are greatly 
 interested. 
 
 The decision upon these questions depends very much upon 
 the peculiarities of each case. 
 
 We may consider the subject from two points of view : — 
 
 1. Period of consolidation of the diseased hones. 
 
 2. Period of time during tvhich it luill he necessary to continue 
 mechanical support. 
 
 1. Period of consolidation. 
 The three chief items for consideration are : — 
 [a) General health of the patient. 
 (h) Extent of the deformity, 
 (c) Progress of the case. 
 {a.) I think it may be laid down as a rule that, given a 
 patient who is apparently robust, and in whom the disease is 
 presumably a local affection, and where the degree of deformity 
 is moderate (see fig. 1), the shortest time in which we may 
 expect complete consolidation of the diseased vertebrae is one 
 year, I would consider this year to commence at the time of 
 complete cessation of pain and all other active symptoms, such 
 as high temperature or spasmodic contractions of the limbs. 
 This is the most favourable result, as regards time, we can 
 expect in ordinary cases, the only exceptions being perhaps in 
 cervical caries and in some cases of lumbar caries. 
 
 In case No. 118 (cervical caries), a cure seemed to have 
 been brought about in six months, but I doubt the expediency 
 of acting upon such a result. 
 
118 SPINAL CAEIES. 
 
 Upon commencing treatment we depend much upon the 
 thorough carrying out of our directions, and it not infrequently 
 happens -that directly pain has been subdued, and all acute 
 symptoms have subsided, the patient believes himself nearly 
 cured and able to return, to a great extent, to his more active 
 occupations. 
 
 If this course be taken some of the former symptoms return, 
 and many weeks or a few months may pass before he realises 
 the absolute necessity of greater care. 
 
 Here, the commencement of the year must date from the 
 period when the patient has learnt how to modify his move- 
 ments, and to so adapt his habits that pain and other acute 
 symptoms are absolutely subdued. 
 
 In some instances, from the commencement of treatment, 
 notwithstanding our utmost efforts, and the utmost efforts of 
 the patients, it will be several weeks or longer before we can 
 subdue the active symptoms. 
 
 During progress towards recovery many things may happen 
 to retard the improvement, an illness, a sudden slip or fall, 
 a severe shaking in a carriage, or a sudden twist of the body, 
 as in turning round quickly. Any of these incidents may 
 seriously prolong the period. 
 
 There is a great difference in patients. Some will readily 
 adopt the principles of care, maintaining a rigid spine what- 
 ever they may be doing ; going about with caution and steadi- 
 ness ; doing everything in a deliberate manner ; never sitting 
 down in a chair suddenly with a jerk ; never looking round 
 quickly ; never bending forwards energetically. 
 
 These patients may take plenty of exercise, moving about 
 freely, but always discreetly and carefully, always keeping 
 their spines rigid, being guided by the action of the supporting 
 apparatus, and never trying to resist it. 
 
 Others do not take readily to these habits. They are too 
 graceful in their movements, too spasmodic in their disposi- 
 tions, and are frequently bringing back pain or discomfort by 
 their inconsiderate actions. Then we meet with individuals, 
 and they are numerous, who are ever wanting to test their 
 progress ; just trying if the pain can still be produced by some 
 particular movement, and never contented to keep from all 
 actions which have previously produced discomfort. 
 
 These irregularities may retard the progress of consolidation, 
 
THE PERIOD OF TREATMENT. 119 
 
 and thus prolong the period of cure. The patients with whom 
 we have the greater difficulty are those who suffer little or no 
 pain ; with them we must use our discretion as to their 
 actions. 
 
 If we consider the period of a year as the shortest time in 
 which a robust patient can get well, so we must increase that 
 time in accordance with the general deterioration of the 
 patient's health. When there is general tuberculous infection, 
 the ultimate result must obviously depend upon subsidence of 
 the general symptoms, or, in other words, upon the improve- 
 ment of the patient's constitutional condition. 
 
 Notwithstanding the truth of this assertion, we often see 
 carious spines consolidate, although tubercular disease is 
 progressing elsewhere. Tubercular meningitis may cut off a 
 patient in whom good progress has been made as regards the 
 caries, and we may even find consolidation of carious vertebrae 
 in patients who die from this or other tubercular disease. 
 When tubercular disease has become general, it is useless to 
 discuss the length of time necessary for consolidation of a 
 carious spine, the general health of the patient being of the 
 first importance. 
 
 (b) Extent of the Deformity. — If the spine is thoroughly 
 supported, and there is a moderately severe angular deformity 
 (other symptoms being favourable), we may consider a year a 
 fair time for consolidation, but if there be indications of a great 
 loss of bone, and especially if the rigidity has given place to 
 undue flexibility, then we know that a space exists which has 
 to be filled up (see Case 1, p. 121) ; then we know that several 
 years must elapse before the repair can take place, and the 
 new bone become perfectly consolidated. In such a case the 
 surgeon may consider it desirable to try and approximate the 
 diseased bones, but I do not think this would be a judicious 
 thing to do. Sometimes a patient has done this for himself, 
 and produced a terrible deformity, as shown by fig. 36, from 
 a specimen in St. Mary's Hospital Museum. 
 
 This apj)roximation of the diseased bones might expedite 
 the period of consolidation, but we can hardly suppose that 
 anyone, in order to save a few years of care, would submit 
 themselves to an increase of deformity, even to a much slighter 
 degree than shown in that figure. 
 
 (c) Progress of ihe Case. — Whatever our opinion as to 
 
120 SPINAL CARIES. 
 
 period of time may be, upon commencing treatment, we ought 
 to be always ready to modify it in accordance with the progress 
 of the case. Experience teaches the surgeon to be most 
 guarded in giving a prognosis as to time. In a very favourable 
 looking case there may be a large abscess existent which is 
 gradually approaching the surface, and which will ultimately 
 have to be opened. 
 
 Abscesses may greatly prolong the period of treatment, so 
 that no definite period can be safely depended upon. It may be 
 further stated that other complications, such as paralysis, will 
 necessarily prolong the period before a recovery can be 
 expected. 
 
 2. The period of time during which it will be necessary 
 to continue mechanical support. — This must depend upon 
 the degree of deformity. It is obvious that until complete 
 consolidation of the diseased bones has taken place, and all 
 symptoms have disappeared, the apparatus must be worn. 
 
 When perfect consolidation is assured, the further use of the 
 support will depend upon whether the spine is sufficiently 
 upright or not to support the body without the latter giving 
 way from its mechanical inefficiency. In such instances as 
 Case 142, p. 140, the deformity is so considerable that some 
 support will always be needed if an increase is to be pre- 
 vented. Under these circumstances, the patients feel so much 
 comfort from wearing the apparatus that they do not think of 
 giving it up. 
 
 It is not the part of the spine which was diseased which 
 would give way, but the sound parts above and below. 
 
 In slighter degrees of deformity it depends upon the strength 
 and activity of the patient, whether he can maintain his erect 
 position or not, without his support. Sometimes a partial 
 wearing of it, say every other day, or once a week, or when 
 laboriously employed may be desirable, or a more simple 
 apparatus may be used. 
 
CASES. 
 
 121 
 
 CHAPTEB VII. 
 
 CASES. 
 
 The following cases are selected from my list of patients 
 affected with caries of the spine. (In some instances I have 
 named the hospital where a plaster of Paris jacket has been 
 applied, the object being solely to show that the appliance 
 had been put on with due care and skill.) 
 
 Case 1. — January, 1882. Recovery from very severe and 
 extensive disease. The existence of a large space from 
 complete loss of the bodies of three vertebrae, and partial 
 loss of the bodies of several others above and below. 
 Repair, by deposit of new bone.^ 
 
 Fig. 68. 
 
 Eepresents the appearance of the patient (Case 1) in January, 1882, 
 ahnost lifeless, and with the lower extremities paralysed. 
 
 A. W., a boy, aged 8, who was so ill when I first saw him 
 that it seemed impossible he could live for more than a few 
 days. He was in an extremely emaciated condition, and 
 suffered great pain upon the slightest movement. He had 
 been getting gradually worse for five years. The disease was 
 
 Recorded in British Medical Journal, March 19, IS'Ji 
 
122 
 
 SPINAL CARIES. 
 
 attributed to a fall. He had been treated for six months by the 
 application of plaster of Paris jackets carefully applied at one 
 of the general hospitals, but this treatment ivas not successful, 
 and the patient had been in constant pain while wearing the 
 jackets as well as subsequently. 
 
 Abscesses, both lumbar and psoas, existed on both sides. 
 His legs were partially paralysed (it was twelve months since 
 he could walk). 
 
 He had been supporting himself day and night for six months 
 upon his arms and knees in the prone position, his mother not 
 being able to persuade him to rest in any other way. 
 
 Pig. 69. 
 
 Represents tlie patient (Case 1) improved in condition and walking 
 about, September, 1883. 
 
 On January 11, I fixed his spine in the manner already de- 
 scribed. At that time the slightest movement of the body 
 caused great pain, and the appearance of the back when such 
 movements were made, gave the idea that it would require 
 
CASES. 
 
 123 
 
 very little force to break the spine completely. I believe 
 there was little or no attempt at repair of the bones at that 
 time. 
 
 On January 13, I found the patient very comfortable and 
 able to turn in bed for the first time for a long period. T then 
 placed him on a prone couch, which he greatly appreciated. 
 Many complications arose which required attention and fre- 
 quent alteration in the adjustment of the instrument. He 
 gradually rallied. 
 
 My report, September 3 (eight months later), states : — "He 
 can now walk about comfortably, the abscesses are healed 
 up and the health has improved in every respect ; destruction 
 of bone seems to have ceased from the time of commencing 
 this treatment." 
 
 Pig. 70. Fig. 71. 
 
 Appearance of spine with new Shows the amount of destruction of 
 bone filling up the cavity formed bone, the new bony growth having 
 by the caries. been broken away during preparation 
 
 of the bones. 
 
 There was no record of tubercle in the history of the patient 
 or his relatives. 
 
 He continued to get about, and improved in health in every 
 way until September, 1884, when he died from tubercular 
 meningitis. 
 
 Fig. 68 shows his appearance when I first saw him. 
 
 Fig. 69 shows him as he appeared in September, 1883, 
 twenty months later and a year before his death. This patient's 
 health was evidently undermined from the long continuance of 
 
124 SPINAL CARIES. 
 
 the disease before his spine was thoroughly fixed, and it seems 
 probable that deposits in the membranes of the brain took 
 place during the period of extreme emaciation. 
 
 One important point elucidated by this case is the possibility 
 of the filling up of so large a gap as shown in Fig. 71. 
 
 It has usually been thought that such repair is impossible, 
 and that it is important in the treatment of caries of the spine 
 to allow the bodies of the vertebrae to sink together, and 
 so enable the repair to take place. 
 
 Fig. 70 shows the growth of new bone filling up the vacant 
 space, and yet not encroaching upon the spinal cord. 
 
 The diseased part of the spine appeared at the post-mortem 
 examination to be perfectly solid bone in a stalactitic form, 
 but upon its being cleaned by the museum porter most of this 
 new bone crumbled away, showing that it had not yet attained 
 perfect solidity, although it was sufficiently strong to support 
 the body and allow the patient to get about without dis- 
 comfort. 
 
 Fig. 71 shows the appearance of the bones subsequent to 
 maceration. 
 
 . This seems to prove that when such a severe case is restored 
 to health it requires several years before the new growth of 
 bone can be quite strong. 
 
 Case 23.— August 28, 1883. Miss T., aged 26, had severe 
 disease centred in the first lumbar vertebra. She had worn a 
 felt jacket, without which she could not walk, or sit up, but 
 even with this assistance she felt much pain, and was in a very 
 unsatisfactory state of health. 
 
 The application of the apparatus advocated above soon gave 
 perfect relief, and a month later this patient felt so well that 
 she returned to her work. 
 
 Case 30. — February 19, 1884. Master C, aged 15^. 
 Disease was centred in the twelfth dorsal and in the lumbar 
 vertebrae, and had been getting worse for two and a-half 
 years. A plaster of Paris jacket had been put on eight 
 months previous, and worn for four months, but abscesses 
 came, and it had to be discontinued. 
 
 Notwithstanding the abscesses it was quite easy to apply 
 the metal splint, which gave great relief at once, and by means 
 of this and other treatment, the patient made as good a 
 recovery as his tuberculous condition allowed; 
 
CASES. 
 
 125 
 
 Case 31 —April 5, 1884. Pain chiefly on one side. 
 
 Mrs. E.'s daughter, aged 7|-. Very healthy child until the 
 age of three, when in skipping she fell and her hoop struck 
 her back, from which time she complained of backache. 
 Eight months after the accident a small projection began (at 
 the twelfth dorsal vertebra), which was not thought serious. 
 The patient got gradually worse and the nature of the disease 
 became evident, and on November 7, 1882, a plaster of Paris 
 jacket was put on at Ormond Street Hospital, and this one 
 jacket kept on for ten months. When first put on the jacket 
 gave some relief to the pain, but it felt tight and interfered 
 
 Fig. 72. 
 Appearance at first visit. 
 
 Fig. 73. 
 
 Appearance in 1892, the chest having 
 been developed by the treatment. 
 
 with the breathing, and the patient felt distressed by it. She 
 soon began to get thinner. The appetite was always bad while 
 under this treatment, and she always complained of the weight 
 of the jacket. "When the plaster was removed it was found 
 that the deformity had greatly increased. Since then she had 
 continued to get thinner and suffered much pain, especially in 
 the left lumbar region. 
 
 On April 10 I applied the "adaptable splint," from which 
 
126 
 
 SPINAL CABIES. 
 
 the patient derived comfort immediately. All pain left her in 
 less than a fortnight, and she rapidly improved both in health 
 and as regards the position of the spine. 
 
 Case 35. — May 20, 1884. Caries centred in the lower 
 two dorsal and upper two lumbar vertebrse. 
 
 Miss M., aged 19, a very delicate, scrofulous-looking girl. 
 Eight years ago she first felt pain in the back, which had 
 gradually increased. The pain was worse when moving and 
 stooping, also upon lifting the left knee. Pain in the back 
 constant, except in the morning after a night's rest. The 
 
 Fig. 74. 
 
 patient was dependent upon her needle for her living, and 
 could hardly work at all. Was contemplating giving up work 
 and returning to her home in the country. I applied an in- 
 strument which gave immediate relief, so that her work was 
 continued in comfort. After three weeks all pain ceased. 
 
 The patient improved in general health and robustness. I 
 saw her occasionally up to September, 1886, and she continued 
 quite well and free from pain. 
 
CASES. 
 
 127 
 
 Case iO.- NoYember 6, 1885. Caries at birth. 
 
 Child, aged 13 years. Caries centred in the second lumbar 
 vertebra. A small projection in this region was noticed at 
 birth. The mother had had a fall downstairs a month before 
 the child was born. Projection gradually increased, and at 
 the age of three got rapidly worse. At the age of seven, an 
 instrument maker's support was put on which was uncomfort- 
 able, but served to lessen the rate of increase of deformity. 
 Upon adopting the plan of treatment here advocated the result 
 was satisfactory. I refer to the case chiefly as an instance of 
 very early caries. Brichsen mentions a case where he thought 
 that caries had been induced by slapping a newly-born infant 
 to make it breathe. 
 
 Pig. 75. 
 
 Case 42. — Yery severe case. Two years' paralysis. 
 No pain. Perfect recovery. 
 
 Master W., aged 10, was brought to me on December 2, 
 1884, with caries in the upper dorsal vertebrae. (See fig. 75.) 
 At the age of three he had suffered from disease of the left hip- 
 joint, following a severe fall. The result was ankylosis of the 
 joint in a flexed position, at right angles with the body. Con- 
 sequently, when he walked it produced severe lordosis. 
 
128 
 
 SPINAL CARIES. 
 
 At the age of 8| (one and a-half years before I saw him), a 
 doctor found a projection of the upper dorsal vertebras. The 
 patient was then getting about on crutches for the hip disease. 
 He had had a fall a few months previous. Two months after 
 the discovery of the dorsal projection he rapidly lost power 
 over his legs and ceased to walk. He had not been able to use 
 his legs since. He lost control over his bladder and subse- 
 quently over his bowels, hut he had never had any ]}ain in 
 connection with the spine. 
 
 There was an abscess on the right side of the neck. Sensa- 
 tion in the legs was dull up to the groins. His control of the 
 movements of the legs was absolutely lost, but the legs con- 
 tracted involuntarily. 
 
 December 9. — I applied an instrument, and the patient was 
 placed on a prone couch. 
 
 January 6, 1885. — He was better generally. 
 January 13. — Some slight power over the legs had been 
 regained. He felt the passing of a catheter, which he did not 
 on January 6. There was increased sensation in the skin of 
 the legs. 
 
 January 22. — Power over the bowels was increasing, also 
 sensation in the legs, and he felt the catheter more. 
 
 April 2. — Better in all respects. Abscess in the neck had 
 closed after repeated injections of solution of carbolic acid. 
 Power over legs had increased. He could raise his right thigh. 
 Knew for the first time when he wanted to pass water. 
 
 May 7. — Better. The left hip being ankylosed the move- 
 ments of the legs caused movement of the spine. I, therefore, 
 had the instrument extended down to the thigh as in hip- 
 joint disease. 
 
 June 24. — Finding the power in the legs so much in- 
 creased I placed the patient on his legs, and he was able to 
 stand unsupported, being the first time for more than ttvo years. 
 A few weeks after this I allowed him to take a few steps and 
 subsequently to walk across the room once a week. 
 
 September 6. — He was getting on well, walking a little every 
 day, having complete control over the bladder, but still not able 
 to wait long. Fairly good control over the bowels, but could 
 not wait. 
 
 He continued to improve, and I have seen him up to the 
 present time (December, 1893), walking about perfectly well, 
 with the exception of the disability caused by the deformity. 
 
CASES. 
 
 129 
 
 Case 59.— June 30, 1885. Caries centred in the tenth 
 and eleventh dorsal and first lumbar vertebrae. (See 
 fig. 76.) 
 
 Miss F. P., aged 10. Disease appeared five years previously, 
 after whooping cough and measles. Slight projection in the 
 back commenced four years previously. A felt jacket was 
 applied, and up to the above date three different jackets had 
 been made. The projection had been rapidly getting larger all 
 the time the jackets had been worn. No restraint was put upon 
 
 Fig. 76. 
 
 the patient's movements. The jackets were always uncomfort- 
 able. I applied an instrument which at once gave relief, and 
 remained comfortable. The child improved in every way, in 
 health and strength, and became quite upright, as shown in the 
 figure. She was quite well in 1888, and I have heard recently 
 that she continues well (1893). 
 
 Case 53.— October 5, 1885. A. C, aged 23. Four years 
 previously, while carrying a pail, this patient strained her back, 
 9 
 
130 SPINAL CARIES. 
 
 causing sudden severe pain. Had not been free from pain 
 since. Was getting gradually worse, and during the last 
 twelve months had not been able to work. Pain was chiefly 
 in the lumbar region. The fourth lumbar vertebra projected. 
 The pain was increased by walking, she was very weak, with 
 bad appetite and very short breath. The latter affected her 
 much when going upstairs. There was palpitation of heart, 
 pain in head, back, and neck, and inability to sit up. 
 
 October 12 I applied an instrument, and in a few days the 
 patient felt very much relieved. In a few weeks all the pain 
 had left her, and she made good progress, with the exception 
 of temporary intermissions from want of adjustment of the 
 instrument. About a year later she seemed to be perfectly well. 
 Case 55, Oct. 15, 1885. Yery severe case. Good 
 recovery. 
 
 Caries centred in the six lower dorsal, and upper two or 
 more lumbar vertebrae. 
 
 Master H., aged 13, had been suffering about six or seven 
 years. Had received very careful treatment, including several 
 appliances for the back. When I saw him he was wearing a 
 moulded leather splint, which took a fairly good bearing for 
 such an apparatus. He was thin, but healthy looking. 
 
 A psoas abscess on the left side had been continuously dis- 
 charging for five years. There were two lumbar abscesses in 
 the region of the twelfth dorsal vertebra. The right one had 
 been open for three and a-half years, the left one for two 
 years. He was lying in the prone position, but almost flat, so 
 that the lumbar region sank to an unnatural extent. Was 
 very carefully nursed, but moved in many ways that disturbed 
 his back. 
 
 Soon after I saw him a psoas abscess opened on the right 
 side, which was immediately, with the others, treated by 
 injection of solution of carbolic acid. An instrument was put 
 on and he was placed on a prone couch of proper form. (See 
 p. 96.) The profuse discharge which had come from these 
 abscesses was rapidly lessened, so that in six weeks' time, the 
 two lumbar abscesses had healed up. They subsequently 
 opened again, and discharged a much thinner and very much 
 smaller quantity of matter. 
 
 This tendency to close and open again has continued ever 
 since, but during the last few years there has only been a very 
 
CASES. * 131 
 
 thin watery discharge. The fact that these abscesses have 
 not healed up entirely, seems to me to prove the existence of 
 some necrosed bone at the seat of disease. This patient 
 improved gradually, and for the last few years he has been 
 walking about attending to his duties as a clerk. He plays 
 cricket, jumps and runs, and does anything he wishes. He is 
 very active and energetic, and does not trouble himself in the 
 least about the discharge, or the deformity. I proposed some 
 years ago to endeavour to cut down on the diseased part of 
 the spine and remove the necrosed bone; but, as in every 
 other way the patient was progressing satisfactorily, I did not 
 press my suggestion, and both patient and his father preferred 
 to put up with the small inconvenience. 
 
 Case 58.— Feb. 17, 1886. Sores caused by Plaster of 
 Paris jacket. 
 
 Master B., aged 10, Caries discovered in September of the 
 previous year. The following month a plaster of Paris jacket 
 was put on at Westminster Hospital. This was changed for 
 a second jacket, which latter had remained on ever since (three 
 or four months). He had emaciated since then, felt very 
 ill, had no appetite and suffered "just as much as ever." I 
 removed the jacket and found the disease centred in the fifth 
 lumbar vertebra. The surface was sore from the jacket, and 
 there were several sore places on the body, on both sides of 
 the back, and front of the chest. The whole skin was in a very 
 irritable state. He was very glad to get free from the jacket. 
 
 He soon realized the comfort of the adaptable splint, and 
 when I last saw him was rapidly progressing towards re- 
 covery. 
 . It should be noted that any appliance may cause sores if 
 not properly attended to, but such a result should not happen 
 with a splint which allows the back to be seen while it is being 
 worn, and which can at any time be modified in position so 
 as to relieve any part unduly pressed on ; but with a plaster 
 jacket such a result may be unavoidable, as very frequent 
 change is impracticable. Plaster jackets have often been kept 
 on for several months with the sanction of the surgeon. 
 
 Case 73.— May 30, 1887. Caries in advanced age. 
 
 Mr. C, aged 67, had suffered from asthma for many years. 
 About six weeks previous to above date, after very violent 
 coughing he felt pain in the back, about the position of the 
 
132 ' SPINAL CARIES. 
 
 third dorsal vertebra. This pain had rapidly increased, and 
 had extended from the situation named downwards and up- 
 wards and completely round his body, but it was always 
 worse at the part first attacked. Although he stooped 
 somewhat before, yet since the pain had occurred he had 
 become markedly more bent in the back. Had lately been 
 wearing a soft corset with lateral supports and crutches. I 
 applied a splint, but it required a great deal of adjustment 
 before it could be made comfortable. When, however, this 
 was accomplished, the patient derived very great relief from, 
 his pain. 
 
 There was gradual improvement until, in a week, the pain 
 in the back had quite ceased. He made steady improvement 
 in every way, and in February, 1888, 1 received a note from him ' 
 saying he had left off the instrument a few weeks and felt 
 quite well and strong. 
 Case 83. — March 20, 1888. Prone position by choice. 
 A. M., a little boy, aged 4, had been treated by means of a 
 plaster of Paris jacket, which he had worn for over six months. 
 It relieved him somewhat, but when it was taken off, the 
 deformity was found to be much worse. 
 
 This child adopted the prone position in bed of his own 
 accord. I have no further notes of this case, and, I believe, 
 I did not see him again. 
 Case 86. — June 5, 1888. Pain on one side only. 
 Mr. P., aged 28. This patient was a grocer by trade. Two 
 years and three months previous to my seeing him he had 
 strained his back lifting a heavy weight. The next morning 
 he felt ill, and only got with difficulty into the next room. He 
 felt acute pain in the loins directly he moved. The pain had 
 continued in this region ever since. Ten or eleven days after 
 the accident he returned to business and found himself quite 
 unable to lift heavy weights, and could only get about to 
 superintend his business. About three months before his visit 
 to me he found for the first time a projection in his back. The 
 pain was then chiefly in the left side of the spine. 
 
 On May 15 he had a plaster of Paris jacket put on, which 
 remained on up to a few days previous to my seeing him. 
 He looked ill and thin. His weight, which had been 142 lbs., 
 had decreased to 132 lbs. 
 
 He had a phthisical look. A younger brother died at the 
 
CASES. 
 
 133 
 
 age of ten from consumption ; two brothers and two sisters 
 were still living, and were in good health. There was no other 
 history of consumption in the family. The parents were both 
 •dead, ages 60 and 63. 
 
 On June 8 I applied an instrument with good effect. 
 
 On June 23 there had been no pain since wearing the instru- 
 ment. 
 
 On October 1 he was very much better indeed. 
 
 This patient made steady progress towards recovery, and is 
 now perfectly well. 
 
 Case 90.— January 15, 1888. Deformity produced by 
 disease earlier in life. ImproYement in figure and relief 
 of discomfort. 
 
 Pig. 77. 
 
 Before treatment, 
 
 sitting. 
 
 Fig. 78 
 
 Before treatment, 
 
 standing. 
 
 Fig. 79. 
 Position improved by 
 mechanical support. 
 
 Mr. K., aged 38. In this case there had been probably 
 active disease which had ceased, leaving the spine with a con- 
 siderable posterior curve. (See figs. 77, 78). The deformity 
 had commenced fifteen years previous to the above date, and 
 eight years subsequently he was made much worse by an 
 ■accident, a heavy cart-wheel passing over his back and loins. 
 
134 SPINAL CAEIES. 
 
 During the previous few years lie had walked a great deal and 
 played tennis, but felt considerable inconvenience from the 
 position of the back, which troubled him very much. Suffered 
 much pain in the stomach, which he attributed to indigestion 
 Standing made him feel very tired, but this position was 
 necessitated by his occupation. 
 
 On June 22 I applied an instrument with very good effect. 
 
 On July 19 he reported that he had no aching or pain of 
 any sort. General health was better. The pain in the 
 stomach had gone, and he could then stand at his work with- 
 out getting tired. He has since greatly improved in figure. 
 
 On July 31 he had attained to the position shown in fig. 79. 
 and felt in every respect better in health. 
 
 It will be observed that the centre of gravity of the head in 
 fig. 77 is in front of the anterior surface of the thorax, whereas 
 in fig. 79 his head is well behind this line. 
 
 Case 91. — July 3, 1888. Miss S., aged 7. This case was 
 brought to me in consequence of an inclination to stoop. The 
 symptoms then present were simply those of weakness, whereas 
 it afterwards proved to be commencing caries. 
 
 It was one of those cases which are often treated by severe 
 muscular exercises, and if that course had been pursued in this 
 instance, the patient would certainly have been made worse, 
 and disastrous results might have ensued. I considered the 
 child was so weak that she required recumbency as well as 
 a light support to the spine. 
 
 With this treatment she soon became perfectly upright, and 
 her health improved, but subsequently symptoms of caries 
 presented themselves, and she was treated for that disease in 
 the manner already described. In this case the use of a prone 
 couch was of very great assistance. 
 
 I have seen her from time to time up to the present, and she 
 is now apparently perfectly well and strong ; but as there is a 
 considerable scrofulous tendency, I had thought it wise not to 
 give up the support entirely hitherto, but have now (January, 
 1894) permitted this being done. 
 
 Case 93. — July 20, 1888. Caries mistaken for Hysteria. 
 
 Miss K., aged 17. Ten months previous she had twisted her 
 back at a gymnasium in taking a high jump. After resting a 
 few days she returned to the gymnasium, but every movement 
 hurt her back. She went again a few days later, but some 
 pain recurring, she gave up the gymnastics. 
 
CASES. 135 
 
 She suffered from constant pain in the lumbar region, but as 
 there was no projection of the spine the symptoms were 
 attributed to hysteria, and every attempt was made to induce 
 the patient to pay no attention to her feeUngs. After a time, 
 the pain not only occurred upon movement, but was felt at all 
 times, and especially after walking much or sitting up. 
 
 Previous to her visit to me she fell to the ground in trying to 
 sit down, the chair having been removed, and then the back 
 was considerably shaken. She was then taken to Dr. Guille- 
 mard, who diagnosed symptoms of inflammation, and sent her 
 to me. 
 
 The lower four dorsal vertebrae projected slightly. The 
 patient was in very delicate health. 
 
 On July 26 I applied an instrument, and on August 13 she 
 was very much better, the pain having left her. 
 
 On September 12 I learnt that no pain had been felt since 
 her last visit, until the day before, when some aching occurred 
 after taking a bath. After this, the pain was severe for some 
 days and then subsided. 
 
 From this date the patient made uninterrupted progress 
 to health, and about a year later gave up the instrument, being 
 perfectly well. 
 
 Case 102. — January 17, 1889. Severe Caries treated 
 by recumbency and a jacket, but the patient allowed 
 to carry out gymnastic exercises before the Spine had 
 become quite consolidated, with disastrous consequences. 
 
 Master B, E., aged 8|. Family history perfectly good, five 
 brothers and three sisters, all strong. 
 
 The patient was quite well until three and a-half years 
 previous, when he injured his back, and caries supervened. 
 He was laid up and treated by constant recumbency, and a 
 felt jacket for twelve months. Got gradually better with a 
 good deal of deformity. (This treatment often produces a 
 cure, but nearly always at the expense of increased deformity.) 
 
 After this he got about, and a few months previous to his 
 visit to me, he was allowed to do some exercises on a gymnastic 
 bar, which disturbed the repair of the bone, and set up active 
 caries again. When I saw him he had the peculiar grunting 
 respiration which I have already described, pain in the left 
 side only, in the course of the nerves from the affected 
 vertebrae. 
 
136 SPINAL CAKIES. 
 
 I applied an instrument, which he immediately realised 
 as very comfortable. There was some improvement in the 
 position of the vertebrae above and below the seat of de- 
 formity, and he seemed to be getting better. 
 
 Subsequently a psoas abscess appeared in the right thigh, a 
 large quantity of matter was evacuated, and small spiculse of 
 bone came away in considerable quantities. From this period 
 he got gradually worse. The cavity of the abscess was 
 thoroughly syringed out every day, the tube passing 14 inches, 
 apparently quite up to the seat of disease. During the long 
 illness which followed he suffered a great deal of pain, and 
 every few days pieces of bone came away. The surfaces of 
 these pieces were quite smooth, and not carious like the pieces 
 that usually come away in this disease. They were evidently 
 pieces of new bony growth, which had been broken down by 
 the exercises. He gradually got worse, and died from exhaus- 
 tion on Feb. 26, 1893. 
 
 The fatal result in this case I attribute entirely to the fact 
 that it was a secondary inflammation. The original inflam- 
 matory symptoms had ceased, and the repairing bone was 
 . broken down by the gymnastics commenced too soon. 
 
 The breaking down of this irregular mass of bone, must 
 necessarily be a much more serious matter than the original 
 caries, making it much more difficult or impossible to support 
 the spine in a satisfactory position. 
 
 In the few cases that I have met with, where there has 
 been a secondary inflammation of this kind, there has always 
 been far greater trouble, in fact, almost an impossibility of 
 obtaining a satisfactory result. 
 
 Case 105.— Feb. 12, 1889. Relief of inflammation by 
 drilling into the spinous processes. 
 
 Miss M., aged 23. In this case there was a lateral curve to 
 the left. The caries was centred in the sixth, seventh and 
 eighth dorsal vertebrae, the spinous processes of which were 
 much thickened and tender. 
 
 Mechanical support gave her great relief, but the pain in 
 the spinous processes remained, and so I operated by drilling 
 into these three bones, in the manner described on page 109. 
 
 There was considerable tenderness at the part operated 
 upon for a few days, but after that all pain ceased. In 
 January, 1891, this patient was quite well. She then married 
 
CASUS. 
 
 137 
 
 and went out to the Transvaal. I cautioned her against too 
 much hard work and rough travelhng, but I had a letter from 
 her subsequently stating that, although she had found the life 
 much more severe than she expected, her back was getting on 
 very well. 
 
 Case 110. — June 13, 1889. Severe bodily weakness from 
 the period of childhood. Very rapid growth. Extensive 
 range of the disease. Effectual, almost total removal of 
 deformity. 
 
 Fig. 80. 
 Miss M., June, 1889, 
 
 Fig. 81. 
 Miss M., June, 1892. 
 
 Miss M., aged 15|-. This was a very unusual case. She 
 suffered during infancy with severe bronchitis and congestion 
 of the liver, and was only reared with the greatest difficulty. 
 At the age of five she got weaker, and used to lose the power 
 of her legs when tired. She stooped considerably, and this 
 continued to increase during her growth. Eighteen months 
 
138 
 
 SPINAL CAEIES. 
 
 before her visit to me, however, it became much worse, and 
 she was then ordered three hours recumbency every day, and 
 seemed to get better. During the previous autumn she had 
 a severe attack of bronchitis. Fig. 80 shows the position 
 when I saw her. 
 
 The whole spine was very rigid, entirely so in the neigh- 
 bourhood of the prominent vertebrae, that is, from the sixth 
 dorsal to the second lumbar. 
 
 Fia. 82. 
 Miss A., July, 1889. 
 
 Fig. 83. 
 Miss A., Feb., 1892. 
 
 By the use of an instrument she was gradually, but very 
 slowly, brought to an upright position, until in June, 1892, she 
 appeared as shown in fig. 81. 
 
 She has gained a great deal of strength, and promises to 
 become quite strong in the course of time, but it will probably 
 take her at least another year (December, 1893). 
 
 This, I think, should be considered a very good result, 
 taking into consideration the history of the case from infancy. 
 She had long been looked upon as a permanent invalid, and it 
 
CASES. 
 
 139 
 
 was thought she must be a cripple for the rest of her life, which 
 it was supposed would only be a short one. 
 
 Her height was as follows : — 
 
 October 9, 1889.— 5 ft. 11| in. 
 
 March 7, 1890.— 6 ft. 0| in. 
 
 May 7, 1890.-6 ft. 0^ in. 
 
 June 11, 1891.— 6 ft. Of in. 
 
 May 17, 1892.-6 ft. 1 in. 
 
 She must have been much shorter when I first saw her. 
 
 Case 113.— July 26, 1889. -Figs. 82 and 83. 
 
 Miss A., aged 7. This child had a history of tuberculosis, 
 and there were many members of the same family who had 
 also suffered severely from the same disease. 
 
 She was quite paralysed in the legs when I first saw her. 
 She made very good progress, and when the activity of the 
 disease had ceased, and she had regained power over her 
 muscles she was unable to walk in consequence of the con- 
 traction which had taken place in the legs. 
 
 I divided the tendo achillis of each foot, and a few weeks 
 subsequently set her on her feet. 
 
 She has been walking daily since then up to the present time 
 (December, 1893). Considering her delicate constitution, great 
 care is yet taken that she should not do too much. 
 
 Case 118.— November 15, 1889. Spasmodic Wryneck 
 
 from Caries. 
 
 Mrs. P., aged 40. Six months previous she had first felt 
 spasms in the neck, and soon afterwards had an inclination to 
 turn the head towards the right side from contraction of the 
 left sterno-mastoid muscle. Treatment by tonics, blisters, and 
 other measures had done no good, and then she underwent 
 twenty-three appHcations from a galvanic battery which made 
 her feel much worse. The characteristic manner in which she 
 held her head, and the pain at the back of the neck, all 
 indicated a condition of caries. 
 
 The patient was quite unable to hold up her head, chiefly 
 from the feeling of weakness, and not from spasm. 
 
 When this patient first came to me I was watching a case 
 of spasmodic torticoUis without caries, and it was very 
 instructive to see the different appearances that the two 
 cases presented. 
 
 These differences have been already described on page 40. 
 
140 
 
 SPINAL CARIES. 
 
 After six months' careful mechanical support, the patient 
 felt perfectly well, gave up the instrument, and a few months 
 later was remaining quite strong and well. 
 
 Case 152. — April 11, 1891. — Yery seYere case. 
 
 Esther B., aged 19. This patient was quite well until twelve 
 months previous to the above date. Three months later some 
 one struck her on the back which gave her great pain at the 
 time, and the pain had never ceased. 
 
 Two months later the angle of deformity began to appear. 
 
 She had then great difficulty in breathing, but went on work- 
 ing in her mother's house, acting as general servant. At last 
 she became so ill that she could work no longer, and had to 
 take to her bed. 
 
 Fig. 84. 
 
 Menstruation had ceased about four months previously. Five 
 weeks after the injury, a plaster of Paris jacket was applied at 
 the Westminster Hospital, at which time she caught a severe 
 •cold and cough, which had remained with her ever since. 
 Prom the jacket she felt some slight relief to the pain in her 
 back, but none to the pain in her chest, and no other relief 
 whatever. 
 
CASES. 141 
 
 Had been rapidly getting thinner, and had entirely lost her 
 appetite. The plaster jacket being uncomfortable was re- 
 moved. 
 
 She had been laid up at home, and the journey in a cab to 
 my house increased her suffering very considerably. She was 
 so bad that I thought she would have died during her visit. 
 Her face looked like that of a corpse, the heart sounds were 
 scarcely audible, and she had to be propped up in her chair. I 
 gave her brandy and extract of beef, while I applied an old 
 apparatus that I had at hand. This at once reHeved her, and 
 her pulse soon returned. A few days later I put on a suitable 
 instrument. The legs became entirely paralyzed, both as 
 regards motion and sensation. There was no feeling below 
 the hip-joints and groins. She suffered from a great deal 
 of pain in the epigastrium. 
 
 This patient made steady progress towards recovery; and on 
 November 25 I noted that she had been free from cough for the 
 last four months. 
 
 The legs were improving in power, the patient being able to 
 lift both knees when sitting, and to move the feet. Sensation 
 was also returning. 
 
 The constant pain in the back and stomach from which she 
 had suffered had ceased soon after putting on the support. 
 During the last few weeks she had regained power over her 
 bladder, which she had also partly lost. 
 
 The spasms from which she used to be much troubled in the 
 legs had ceased. 
 
 Menstruation had returned in July. 
 
 On December 30 she was looking quite robust and well ; felt 
 well and free from pain. 
 
 She could now stand by placing a hand upon the table. 
 
 I have seen her at intervals up to the present time (Decem- 
 ber, 1893), and she is apparently perfectly well, able to walk 
 about and do anything that I will allow her, but I have advised 
 care for the present, and avoidance of lifting weights or doing 
 much work. 
 
 Case 152.— October 3, 1891. Yery severe and com- 
 plicated case. 
 
 Mr. r., aged 18. This was also an extremely severe case, 
 and one in which all hope of his recovery had been given 
 up, and the reason for having further advice was a question 
 
142 
 
 SPINAL CABIBS. 
 
 whether something could be done to relieve some of his severe 
 pain. Seven years previously he had suffered from rheumatic 
 fever, which occurred again a year later, leaving his heart in a 
 very weak condition. For two years after this he had to 
 be carried up and down stairs, and went out in a bath chair. 
 He then got about for nearly a year, not suffering from the 
 heart, except that it prevented him from running. Had 
 pleurisy in June, 1890, followed by influenza and congestion 
 of the lungs, then pneumonia. Supposed to have some affec- 
 tion of the liver. 
 
 Fia. 85. 
 
 I could find no signs of organic disease, either in the heart 
 or lungs, but the liver was much enlarged. I gave a favourable 
 prognosis, although certainly his health had been greatly under- 
 mined by the disease. 
 
 I attributed the trouble of the heart chiefly to the effect of 
 the caries. I applied an instrument with a head-piece. 
 
 On December 10 I note — " Has been very much better since 
 
CASES. 
 
 143 
 
 last visit.' The pains in the epigastric region have been almost 
 entirely absent, but he has had some pain in the right shoulder." 
 
 A readjustment of the instrument made him feel quite 
 comfortable. 
 
 This patient also made steady progress towards recovery. 
 In two months after the commencement of treatment all pain 
 had ceased, and when I saw him in November, 1892, he 
 seemed perfectly well, and able to get about, and do anything 
 he wished. 
 
 Fig. 86. 
 
 In September, 1893, I saw this patient again ; he seemed 
 quite well, and had not used the head-piece much for some 
 months. All active caries seemed to have ceased ; but from 
 the severity of the angle of deformity, the want of support to 
 the forehead had allowed the head to sink somewhat lower 
 (fig. 85). 
 
 Case 166.— June 13th, 1892. Miss E., aged 8. During the 
 last few months the spine had been noticed to be projecting 
 
144 
 
 SPINAL CARIES. 
 
 backwards, and gradually getting worse. Was very easily 
 tired. Stooped very much in sitting as shown in fig. 86. 
 
 By the appearance of the spine and the general symptoms 
 there could be no doubt this was a case of caries, but for some 
 months the diagnosis had been somewhat doubtful. 
 
 At the present time (September, 1893) she is perfectly 
 upright, apparently quite strong in the back, with no sign 
 whatever of any projection of vertebrae. 
 
 Case 168.— July 8, 1892. No Pain. 
 
 Master B., aged 9. Three and a-half years previous this 
 boy began to droop his head, and gradually got, worse. 
 
 Fig. 87. Fig. 
 
 Master B. — Before and after application of apparatus. 
 
 Two years ago he used to complain of some pain in the 
 shoulders when he came downstairs in the morning, but it was 
 very slight, and since then he has not complained of anything. 
 He was very active, running about all day. General health 
 excellent. His father is a very strong man, and has four chil- 
 dren younger than this one all well and strong. The only 
 history of an accident is a fall out of bed at the age of about 
 five years. 
 
 Case 188.— February 2, 1893. Miss L., aged 23. This 
 patient was a nurse. Two years previous while lifting a very 
 heavy woman she hurt her back and felt much pain for a week 
 afterwards. Then she felt all right until, (my notes state), " a 
 few months ago, when the pain began to trouble her again and 
 
CASES. 146 
 
 gradually became constant until the last few days, when she 
 has been obliged to lie up in bed, and that has given her great 
 relief." 
 
 By means of an apparatus I got her into a much straighter 
 position. The pain soon subsided, and when I last saw her 
 she was making rapid progress towards recovery. 
 
 Case 211. 
 
 Miss S., aged 26, came to me on October 12th, 1893. 
 She had suffered from her spine for about ten years, but 
 during the last two years it had been much worse, and her 
 whole health had given way. 
 
 She had had several plaster of Paris jackets applied, and 
 was wearing one when she came to me. Her chest was much 
 depressed from her head and shoulders drooping forwards, a 
 position which the plaster jacket does not prevent. She was 
 suffering very considerably from impeded respiration, and had 
 great difficulty in walking, and could never get about at all 
 without pain in the back. She described herself as feeling 
 (as she looked) very ill. She stated that she was quite unable 
 to hold herself up without a jacket. With some difficulty I 
 removed a very heavy plaster of Paris jacket, weighing over 
 four pounds. We were obliged to hold her up beneath the 
 arms, or she would have collapsed entirely. 1 happened to have 
 by me a support which I put on temporarily, and this enabled 
 me to examine the case deliberately. 
 
 There was a lateral sigmoid curve, the dorsal region bending 
 to the left and the lumbar to the right. There was no angular 
 projection. 
 
 Notwithstanding the absence of the characteristic deformity, 
 I thought from the general symptoms that this was a case of 
 active caries. I found the temperature nearly 100°, and this 
 fact strengthened my opinion. 
 
 A week subsequently the patient was relieved in every way ; 
 she had lost her anxious appearance, felt better than she bad 
 done for many months, could walk nmch better, and the tem- 
 perature had subsided to normal. 
 
 Case 204. 
 
 I was called to see Miss E. H., aged IG, on August 9, 1893. 
 
 She was a very delicate and tuberculous-looking patient. She 
 
 began to feel severe pain in the luml>ar region live months 
 
 previously, and had been getting gradually worse. She f(,'lt 
 
 10 
 
146 SPINAL CARIES. 
 
 better after a night's rest, and very much worse after walking 
 any distance. She had recently been attacked by influenza, 
 which had made her in every way worse. Temperature had 
 been ranging between 103° at night and 102° in the morning 
 during the fortnight previous to my seeing her, and Dr. Seton 
 had at first feared typhoid or some other severe fever. (See 
 chart, p. 38.) 
 
 I applied an " adaptable splint " upon August 16, and, as it 
 will be seen by the chart, the temperature began to improve 
 at once, the patient at the same time feeling less pain. 
 
 The patient gradually improved, pain left her, and, in 
 accordance with this improvement, it will be seen that the 
 temperature decreased. 
 
 Conclusion. 
 
 The chief points which I have endeavoured to show in the 
 foregoing pages are : — 
 
 That caries of the spinal column, although a disease which 
 endangers- life, is one which is generally curable if treated 
 with great care and patience before the health of the patient 
 has been undermined by the disease. 
 
 That if the treatment is effective there need be no increase 
 of deformity after perfect fixation of the spine has been 
 accomplished. 
 
 That the symptoms may vary greatly, and be obscure, so 
 that correct diagnosis may be difficult. 
 
 That the most important point of treatment is the me- 
 chanical fixation of the spine, and that considerable attention 
 to the details of this fixation is necessary. 
 
 That general rest of the patient, carefulness in nursing, 
 and assiduous attention to complications are necessary adjuncts 
 to the successful treatment of these cases. 
 
77/ 
 
 C> a