The abduction frame of Sir Robert Jones has to a considerable extent done away with the Plaster of Paris jacket in the treatment of spinal caries.
Small children can be nursed in a Phelp's box or any extemporised flat wooden structure with shallow sides in which they can be carried about from room to room or out into the open air and sunshine. This contriv ance may be combined with the wheelbarrow splint, which tends to correct deformity and allays muscular spasm by extending the spine.
The use of tuberculin in spinal caries is still a moot point. Gauvain claims to get better results without than with tuberculin, but where the other forms of treatment cannot be perfectly used (as is difficult in all large towns) the cases seem to do better with small doses of tuberculin given once a week.
Poroplastic Felt Jackets, ready-made, of various sizes and shapes, may be obtained from any instrument maker, and rapidly adjusted to the patient's body when suspended. The Felt Jacket is put into a steam oven, and in a few minutes it becomes quitelsoft and pliable, in which con dition it is moulded to the chest and abdomen, fastened with buckles, and the setting process is complete in 5 to so minutes, during which time the suspension is to be kept up. It can, every 4 or 6 weeks, be reheated and applied again, as it yields a little with the heat of the patient's body. It has the great advantage of being easily taken off and put on, and allows of daily inspections if abscesses are feared.
When already some prominence of the spine has developed in the early stage, an attempt should be made to lessen it by carefully adjusting a firm cushion or sand-bag under the curve, so that the weight of the upper and lower parts of the trunk may be utilised as a slowly extending force. The wheelbarrow splint meets these requirements. The use of any form of extension apparatus should only he entrusted to an experienced surgeon, and the plan of forcibly straightening out the angularity under anxsthesia is reprehensible.
When the cervical vertebrae are involved the neck must be rigidly sup ported; if the disease affects the first and second vertebrae a dislocation forwards of the atlas may speedily cause death. Sand-bags should be placed on each side of the head, so as to effectually prevent all rotatory or lateral movements. In the presence of acute symptoms of threatening paralysis immobility must be further procured by attaching a band to the chin and occiput and passing the cord from this over a pulley at the head of the bed, a small weight being used as an extending force. Later on, a leather or poroplastic support may be moulded; seldom does the jur• mast apparatus prove of any use. but it may be employed in disease of the lower cervical region. In young subjects the best mechanical appliance for high cervical caries will he afforded by an abduction frame, the upper extremity of which bears a leather head rest.
Paralysis usually passes off when prolonged rest has been strictly carried out; when, however, the power seems to he steadily getting less, the opera tion of laminectomy may be undertaken. The pathology of tuberculous
spondylitis must be always kept in mind : the symptoms of paralysis are very rarely caused by mechanical compression by the displaced seg ments of the spinal column. hut by a low form of arising from the presence of granulation tissue inside the osseous canal. Hence lamin ectomy (or removal of the diseased posterior arches) or transyersectomy (removal of transverse processes) should be undertaken more with a view of clearing out the tuberculous detritus than of removing bone deformity. Where severe pain arises from pressure on the nerve roots the operation of costo-transversectomy may be demanded and a portion of the rib removed.
For the spastic condition which sometimes remains after recovering from the tuberculous process the operation of resecting the posterior roots of the second, third and fifth lumbar nerves has given excellent results.
When suppuration occurs, the resulting spinal abscess should be opened under strict antiseptic precautions without waiting for the skin to he involved, the abscess cavity should be thoroughly scraped. flushed, and pressed empty, after which iodoform emulsion may be injected and the skin sutured without drainage being provided for. as in the treatment of carious bone described in the previous article. (See also Psoas Abscess.) Where old sinuses have already become established an attempt may be made to heal these by the injection of Bismuth Jelly with or without previous curetting, and the removal of diseased laminae and spines, trans verse processes, or necks of the carious ribs.
The treatment of retropharvngeal abscess will be found under Pharyngitis.
The treatment of spinal caries has in recent years been revolutionised by Albee through the introduction of his method of employing Bone Grafts cut from the tibia down to the marrow. Haying exposed the affected vertebra by suitable incisions and splitting of the interspinous ligaments, the spines are incised down to the osseous tissue and each is split with the chisel, causing a greenstick fracture on one side; into the gutter so formed the graft, inch broad and of the required length, is inserted with its medullary surface touching that of the unfractured spines. A series of kangaroo tendon sutures passed through the split interspinous ligaments fix the graft. This procedure, by preventing the separation of the spinous processes, checks the crushing of the vertebral bodies, thus removing or preventing deformity and accelerating the healing process, which is usually complete in six months. Several hundred patients have been treated by this method in the hands of different surgeons, and F. Jones has secured success in 96 per cent. of his cases. Finkelstein has applied this method to the treatment of spondylitis deformans.