For the after-treatment we recommend a steel brace similar to Dollinger's, constructed in two parts which are joined into one solid apparatus by four thumbscrews, thus making it impossible for the parents to loosen it and thereby to defeat its purpose by the loosening of straps or laces, etc. The anterior part leaves the chest and abdomen free and maintains the lordosis by bracing the upper part of the frame against the upper part of the sternum, which moves the least with the respirations, and by bracing the lower part against the hips where it fits snugly (Figs. 13Sa, 13Sb, 13Se).
In policlinic practice we have found Taylor's back brace, an Ameri can apparatus, very serviceable for the after-treatment. It is easily made, gives sufficient fixation for this late stage, and its cheapness permits its free use in this class of cases (Bradford and Lovett) (Fig. 139).
In ancient times attempts were made to remove the.kyphosis, and we read about this in the works of Hippocrates. Of late years Calot has brought once more the redresse ment force into short-lived revival.
Only at the very first did he press "avee toute sa force" upon the kyphosis of the patient in narcosis while the spine was extended from both ends. But as soon as accidents and bad complications arose more and more he dared to press only "tres doucement." Wullstein has shown that the dangers and accidents in this pro cedure do not differ in the least from those of any other brisement force, and that it is vain to hope that the defects in the bones and the cavities which arc caused by sudden tearing apart of the bodies of the vertebrre would he remedied; usually the opposite happens—that the process flares up anew. Steady pressure (Fink) by carefully graded bandages, which are applied in ex tension without. narcosis, may be able to correct the deformity, according to the advice of Wullstein.
The dressings include the head and the extension apparatus described by Wullstein allows every necessary position, so that we can give exactly the reclination which we are able to maintain while apply ing the dressing. Later on the casts are exchanged for braces and corsets which retain the reclination and redressement, and which thus keep up our results.
In spite of the splendid results of W'ullstein, we prefer Fink's treat ment, because we consider that it is easier to carry out and better adapted to the nature of the affection and less torturing. It is best, however, to combine this method with occasional periods of extension bandages, and here as well as in other branches of our work we will succeed best if we individualize and show due regard for individual and social conditions.
The operative treatment does not offer any remarkable results. Abscesses are treated according to the above mentioned conservative rules, otherwise the only indication for operative interference is formed by persistent paralyses which do not, yield to conservative treatment (lamincetorny). These must be considered a vital indication, because they will surely lead to death from vesical paralysis if allowed to exist for any length of time. We first try rest and extension, to which paraly sis from deviation will yield. These are most likely the cases in which Calot's redressement has cured the paralysis. Wullstein recommends, therefore, the redressement brusque in t hese cases, but it is essential that we should first acquaint the parents or guardians of these patients of the possible dangers of such a proeedtm..
A Russian author (\Cassiliew) has quite recently advised to ap proach the anterior surface of the bodies of the vertebra by the retro pleural route. Opening and drainage of congestion abscesses in that region through the back has in some cases cured paralysis. Laminectomy is the last resort, as is also chiseling open the vertebral arches. We remove the diseased tissues and the exuberant granulations and thus give the cord once more sufficient room (Bardenhetter). We cut down upon the spinous processes and the arches, resect them and remove as far as we can all diseased tissues, taking especial care not to touch the cord which is lying free in the dural sack (avoiding injuring the same through splinters of bone, also bleeding) (Trendelen burg, Bastianelli).
Massage and electricity are of use only in retarding the total atrophy which otherwise accompanies the interruption of the nerve current.