The most frequent localization of the carious portion is in the dorsal and lumbar portions of the cord, and the first symptom in this case is rigidity of the legs, ation of the reflexes, with weakness and paraplegia. To these symptoms are superadded in the subsequent course of the disease, diminution of sensibility in the legs, disturbance of the bladder and rectum, bedsores, and, in short, all the symptoms with which we are familiar in the adult as the result of a transverse myelitis. Fortunately, the disease in most cases does not progress beyond a spastic paraparesis. If the lesion causes great destruction of the spinal marrow in the lumbar enlargement, atrophic paralysis of the legs with diminution of the reflexes [nay result. If the lesion is situated in the vical portion of the corcl, all the extremities become involved in the spastic paresis; and again, if the mill suffers direet compression, a combination of atrophic paralysis of the arms with spastic paresis of the legs may be observed. Lesions of the sphincters are usually absent; on the other hand, paresis of the thoracic or abdominal muscles is not uncommon, and the plarenic nerve and diaphragmatic action may even be threatened. In those rare eases associated with destruction of the highest cervical yertebrce, rigidity of the neck and fixation of the head movements are more pronounced than in any other lesion. In such cases there is, in addition to spastic paresis especially of the arms, sis of the accessory nerve and of the hypoglossus, as well as other bar symptoms, and sudden death may result from compression of the medulla oblongata. To sun) up, the most frequent nervous cation of spornlylitis, aside from the localized pain, consists in spastic paresis of the legs or, possibly, of all four extremities and, in severe cases, the picture of a complete transverse lesion of the spinal cord.
The most important diagnostic sign of spondylitic compression paralysis is kyphosis; if this is absent, pain referred to, or elicited in the vertebral column is, in view of the frequency of caries of the verte bne in the child, an important diagnostic sign, provided disease of the muscles and of the peripheral. nerves and internal disease can be ex cluded. Sometimes, particularly if pain is absent, the rigidity- of the vertebral column inay lead to confusion with spinal meningitis, muscular atrophy or rachitis, particularly as: the peculiar manner of rising from a stooping to the erect posture, which is so characteristic of muscular atrophy, may be observed in the initial stages of spondylitis. X-ray examination very often gives quite satisfactory results, the diseased vertebra, appearing pale in the photograph, although I have occasion ally been disappointed in early cases. Hysteria may have to he con sidered in the differential diagnosis of vertebral caries in childhood. As a rule, however, the rigidity of the back disappears on rapid move ment, and the general appearance and behavior of the patient usually suggest the correct diagnosis. In doubtful cases the presence of fever,
emaciation and other signs of scrofulosis and tuberculosis are of eourse in favor of spinal caries.
The severity- of the paralysis in sponclylitis is not always dependent upon the intensity of the spinal caries. Quite often very severe or even fatal tuberculous disease of the vertebra, is observed to run its course without producing any marked symptoms of paralysis.
The prognosis so far as the paralysis is concerned is not altogether unfavorable. In many cases a decided improvement and ultimately complete restoration of normal function occur (disappearance of (edema). 'When spondylitis proves fatal, death is much more rarely the result of vertebral disease (dccubitus, cystitis) than of general tuberculosis such as tuberculous meningitis or amyloid disease. The mortality of sponcly litis is according to Reinert GO per cent., according to Hugelshofer 57.(I per cent. and according to Billroth 52.1 per cent.
The treatment of spondylitic paralysis or spinal caries has been made the subject of much study in orthopedic surgery. It is impossible to discuss the details of treatment in this place; suffice it to say, that absolute rest in bed with extension, supporting apparatus and plaster jackets are the means employ-ed in the treatment (Glisson sling, Rauch fuss' suspensory apparatus; plaster of Paris bed after Lorenz).
Many attempts have recently been made to treat spinal caries by operative means. The most radical procedure consists in directly attacking the kyphosis (laminectolny), removing of the abscess or granular tissue compressing the spinal cord. or cieatricial or thiekened portions of the meninges and scraping away the carious bone. The first operation of this kind was performed by Macewen, who was so fortunate as to get good results from his first cases because they were in process of recovery. Later operators, however, satisfied themselves that in florid active tuberculous processes of the vertebrw, radical removal of the diseased tissue is frequently impossible and that, after a temporary improvement in the paralysis the original state of affairs soon returns. From an analysis made by Chipault, it appears that, of 103 cases of lamineetomy only 15 ended in permanent recovery— reason recent enough for extreme conservatism in deciding upon such an operation (Schlesinger). Measures directed to the gradual straighten ing of the prominent vertebrm are more encouraging, although their object is rather to improve the patient's appearance than to exert any influence on the paralysis which ultimately- develops. Forced compres sion of the kyphosis, was recommended by Calot a few years ago, for a time attracted a great deal of attention, but has since been abandoned as too dargerous.
General supportive treatment such as is indicated in any- form of tuberculosis must be resorted to in spondylitis also.