Kirmisson calls attention to the fact that we may observe, by no means rarely, acute processes in the uppermost joints that are accom panied by swelling and fever (after angina, periostitis in that region). These begin like an acute "mal de Pott sousoccipital," but are easily distinguished from this through their benignity.
The treatment must keep in view many different points. Social conditions are here, as in coxitis, of the greatest importance.
The nature of the disease and the tendency of spondylitis in children to heal spontaneously will lead us to adopt conservative methods. We imitate nature in fixing the diseased spine. The weight is kept off as much as possible and the child brought under the most favorable external circumstances. The treatment is liable to extend over several years.
Hoffa, in his optimism, gave six months as the shortest time, while the author has never seen a case cured, i.e., all symptoms disappear, in less than two sears. In policlinic practice, however, the prognosis is considerably worse, because here not only the poor financial circum stances but also the low mentality, lack of education of the parents, will militate against a sufficiently long-continued treatment. As long as we cannot place these children in proper institutions, open-air sanitaria or floating hospitals, just so long will our true final results in the treat ment of spondylitis be far from satisfactory as far as the preservation of life and the avoidance of deformity are concerned.
Absolute fixation is the first desideratum which we can almost read in the anxious expression of the child's face. This is done in the best, the safest, and at the same time the cheapest way plaster bed, which forces the child to assume the dorsal position in which all weight is kept off the spine, and in which the internal organs do not suffer dur ing the long-continued treatment. This dorsal deenbitus must be kept up for a very long time, as it is the only way in which we can keep off the weight entirely and thus reduce the deformity to a minimum (Lorenz).
The child is placed face downwards in a lordotic position on a table in one of the many kinds of frames. The author prefers the ventral position advised by Fink, in which the head is supported upon the elbows, because we then do not frighten the little ones. We prepare, according to Klapp's advice, at another table a plaster mould about six or eight layers in thickness, according to the measurements of the patient, which we apply and is onto the child while it is in the proper position and the mould still soft, and mould it to the body and head. We can
thus prepare in a few minutes a useful plaster bed without being much disturbed by the struggles of the child. This method is better than that advised by Lorenz, who applies the bed direct to the body with bandages.
This mould may either be padded and used as the bed, or it may serve as a negative from which to prepare a shell of celluloid or other material.
To these reclination beds (Lorenz) we can easily apply an extension apparatus for the head, if we should consider this necessary on account of the high location of the process or of the intensity of the pains (Sayre).
In children during their first few years and always during the florid stage we consider this method of treatment, which has been inaugurated by Lorenz and elaborated by Fink, the only sensible one and one which should be persisted in as long as feasible (Fig. 137).
Fink has shown that even a pronounced kyphosis may be redressed gradually and without causing any pains, through the weight of the child itself, by gluing tongues of felt to the skin around the kyphosis in the shape of a grating.
Only after all pain has disappeared do we permit the child to be placed in the upright position in the splint. Impatience on the part of the parents or a yielding on the part of the physician will usually cause trouble. Even the best-fitting corset with the most ingenious jury mast will not entirely relieve the weight of the body nor prevent the formation of a gibbus, unless we apply strong plaster casts which include the head, such as W'ullstein advises; but these require first-class technic and considerable orthopedic experience.
We keep our children lying down until they have absolutely no pain; then we give them a well moulded plaster corset (Sayre), which includes the head only when the disease is high up, or a well-fitting brace made of celluloid or leather. When the patient is accustomed to this, then we allow him out of bed, but we do not let him walk, but only creep at first, as this does not place any weight upon the spine and all side motion is prevented by the corset and still better by the patient's own muscles. This mode of locomotion is kept up for some months before the child is allowed to stand upon its legs.