Suddenly the tumour disappeared, and the patient has been led to entertain hopes of a speedy recovery. But these have been soon disappointed, in consequence of the discovery of a large collection of matter in the posterior part of the limb, behind the little trochanter of the thigh. In a case of this kind, in which I had the opportunity of examining the morbid appearances after death, I found that the abscess had taken the course of the common tendon of the m. psoas magnus and iliacus internus, to their insertion into the little trochanter, afterwards extending further backward, over the inferior edges of the m. quadratus femoris." (pp. 260, 61.)

(3) “The pain,” says BRODIE, "at first trifling, but afterwards more severe, is aggravated by any sudden motion of the spine; by percussion, or by a jar communicated to it in any other way; as by stamping on the ground, striking the foot accidentally against a stone, sneezing or coughing. In the advanced stage of the disease the pain is sometimes so severe, and so easily induced that the patient cannot bear the slightest movement. Yet in other cases there is sometimes no pain whatever in the spine, from the first access of the disease to its termination;" of which he mentions one remarkable case, "in which, judging from the degree of distortion, I was," says he, "satisfied that the bodies of not fewer than four or five of the dorsal vertebræ must have been destroyed, and that the disease had been going on for several years; yet he had never been known to complain of pain; and the first circumstance which attracted the attention of the parents was the angular projection of the spinous processes. This patient ultimately died; and, on examing the body after death, a large abscess was discovered lying on the surface of the carious vertebra. In another case, in which the disease was supposed to have been cured, and the patient had not experienced pain for the two or three preceding years, on examining the appearances after death, I found the bodies of the vertebra still in a state of caries, and an abscess, containing not less than half-a-pint of matter, connected with them." (p. 250.)

(4) "When the spine is incurvated forwards," observes BRODIE, " in consequence of the destruction of the bodies of the dorsal vertebræ, the angular projection behind is more distinct than it ever is where the disease has attacked the vertebræ of the neck or loins. This is to be attributed to the greater length of the spinous processes in this part of the spine, and to the circumstance of their being, in the ordinary position of the parts, inelined more or less downwards. When the curvature is considerable the thorax becomes at the same time altered in figure. The diameter of the thorax, from above downwards, is rendered shorter, while the other diameters are increased; so that, while the figure of the chest is altered, there is but little difference in its actual capacity." (p. 257.)]

258. On examination after death, one or several of the bodies of the vertebræ are found destroyed by caries; the neighbouring vertebræ are eaten away and crushed together in front, so that the spinous processes project. A sac is formed of the apparatus ligamentorum anticus, cellular tissue, and so on, at the part where the vertebræ are destroyed, which contains a purulent cheesy mass, and from which openings lead into the external abscesses; in these sacs loose pieces of bone often lie. The bones are often converted into a spongy mass, which yields to the knife. Sometimes

the interarticular cartilages especially are attacked, loosened up, and destroyed. Circumscribed deep holes are often found in the bodies of the vertebræ, filled with cheesy matter, and which I hold, with DELPECH and others, to be tubercles (1). The area of the spinal canal is generally undiminished; sometimes, however, it is so, and there are traces of chronic inflammation, redness, thickening or softening of the spinal marrow, of its membranes, and of the nerves passing through them.

These examinations show that the disease occurs sometimes as a primary affection of the cartilages and ligaments, sometimes as a primary affection of the spongy substance of the bones themselves.

(1) NICHET (a) has endeavoured to prove this view of the disease by numerous examinations. On the other hand, JÆGER (b) believes that these supposed tubercles are merely the modification of pus in the bony cells and beneath the periosteum, or inflamed and suppurating lymphatic glands on the spinal column.

(a) Gazette Médicale, 1835, Nos. 34, 35.

(b) Handwörterbuch, vol. i. P. 572.

[The pathological history of caries of the spine is thus briefly recapitulated by BRODIE (a):-"In some instances it has its origin in that peculiar softened, and other wise altered condition of the bodies of the vertebrae, the appearance of which, in the bones belonging to other joints, and which seems to be connected with what is called a scrofulous state of constitution. In these cases ulceration may begin on any part of the surface, or even in the centre of the bone; but, in general, the first effects of it are perceptible when the intervertebral cartilage is connected with it, and in the intervertebral cartilage itself. In other cases, the vertebræ retain their natural texture and hardness, and the first indication of the disease is ulceration of one or more of the intervertebral cartilages, and of the surfaces of bone with which they are connected." (p. 243.) In reference to this point KEY (b) observes :-" In scrofulous ulceration, the intervertebral substance is not unfrequently the part in which the degeneration begins; large masses of the fibro-cartilaginous structure degenerate and disappear, cavities containing pus are found in its substance, and the broken down fibres surrounding the walls of the abscess sufficiently attest the nature and progress of the action." (p. 140.) On the other hand, according to LAWRENCE, "this disease attacks only the bodies of the vertebræ, that is, it attacks that part of the bony structure of the spinal column, which is its most frequent seat in other parts of the skeleton, the cancellous or spongy part. The processes of the vertebra, which are composed of firm or compact bony tissue, it does not attack." (p. 561.) "There is still another order of cases," says BRODIE; "but these are of more rare occurrence, in which the bodies of the vertebræ are affected with chronic inflammation, of which ulceration of the intervertebral cartilages is the consequence. In whichever of these ways the disease begins, if not checked in its progress, it proceeds to the destruction of the bodies of the vertebra and intervertebral cartilages, leaving the posterior parts of the vertebræ unaffected by it; the necessary consequence of which is an incurvation of the spine forwards, and a projection of the spinous processes posteriorly At this period of the disease, the membranes of the spinal cord sometimes become affected with a chronic inflammation, which may extend even to the spinal cord itself; and when there is much incurvation, the latter not only becomes incurvated with it, but actually compressed in such a manner as cannot fail to interfere with the due performance of its functions.

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Suppuration sometimes takes place at a very early period; at other times, not until the disease has made considerable progress. The soft parts in the neighbourhood of the abscess become thickened and consolidated, forming a thick capsule, in which the abscess is sometimes retained for several successive years, but from which it ultimately makes its way to the surface, presenting itself in one or another situation, according to circum

stances.

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In the advanced stage of the disease, new bone is often deposited in irregular masses on the surface of the bodies of the neighbouring vertebra; and when recovery takes place, the carious surface of the vertebra above coming in contact with that of the vertebra below, they become united with each other, at first by soft substance, afterwards by bony anchylosis. The disposition to anchylosis is not the same under all circumstances; it is much less where the bones are affected by scrofula, than where they retain their natural texture and hardness; and this explains wherefore, in the former class of cases, a cure is effected with more difficulty than in the latter.

"Occasionally portions of the ulcerated or carious bone lose their vitality, and, having become detached, are found lying loose in the cavity of the abscess. It is scarcely necessary to add, that the existence of such exfoliations is, of itself, almost sufficient to preclude all chance of the patient's recovery." (p. 243-45.)]

259. The causes of this disease are scrofula, masturbation, rheumatism, gout, external violence. Where the complaint arises more from scrofula, it seems to originate as a primary disease of the bone; if, on the contrary, from gout, external injury, and so on, the cartilages and ligaments rather are attacked.

260. The stealthy progress of the disease must render the medical attendant very cautious in his diagnosis. Every thing depends upon attacking the disease at the onset. If once displacement have happened, the most fortunate result is that the swelling of the parts should diminish, and the pressure on the nerves springing from the spinal marrow be removed. If (a) Third edition. (b) Med.-Chir. Trans., vol. xix.

abscesses have already taken place, the prognosis is always very unfavourable; if left alone, symptoms of hectic consumption come on, when they burst, and the patient quickly sinks; or they contract to fistulous openings, discharge but little serous or purulent fluid, and the patient lives a long time in a miserable condition. Very commonly no treatment can prevent this melancholy result. The practitioner must be exceedingly careful with little children who do not yet walk, because in them the most important diagnostic character is deficient.

To determine more precisely the seat of the disease, various distinguishing signs have been given. According to COPELAND, great sensibility of the diseased vertebræ on external pressure, and on rubbing down with a sponge dipped in hot water. According to WENZEL, the pain should be increased by pressure with both hands upon the shoulders acting on the parts beneath, or on the application of volatile irritants, especially caustic ammonia. According to STIEBEL, the situation of the disease is more distinctly shown in a warm bath with potash. But all these methods of proof give no decided result; and I have observed, on the contrary, many cases in which, as the result proved, no spondylarthrocace was present, although it had been indicated by these tests. (MELKER) (a). I consider especially important in the diagnosis of this disease, the peculiar carriage of the body which often precedes, but always accompanies, weakness of the lower limbs. The knees of the patient in standing are somewhat bent, and the head inclined backwards, so that the neck sinks between the shoulders; in walking, the arms are bent at the elbow-joint and hold to the trunk; the patient always seeks after a resting-place with his hands, places them upon the hips, and in stooping, upon the thighs; in bed he can turn only with difficulty, and very commonly sweats at night. This disease is clearly distinguished from the curvature depending on rickets or improper action of the muscles, though it may be connected with them. In adults the disease is more dangerous than in children.

In children whose head and the upper part of whose body are very heavy, there often appears, when they first begin to walk, a bending of the spine and a weakness of the legs, so that they draw them back at every attempt to place themselves erect. This condition, which depends on weakness of the muscles of the back and the weight of the head, may be, as I have frequently seen, mistaken for spondylarthrocace. Careful observation of the condition of the body, examination of the spine in the prone position, and the projecting curve which the spine forms in sitting and standing, easily determine the diagnosis.

[The distinction between curvature of the spine from caries, and that from rickets, is very well marked, and the two can rarely be mistaken. In caries, the spine is always bent forwards, and, having usually a sharp abrupt form, is called the angular curvature, or, from its direction, the anterior curvature; and there is rarely, if ever, more than one curvature of this kind. But in rickets, as LAWRENCE well observes, "you never find a single turn only in the vertebral column. If the vertebra were weakened in the loins, so that the column would bend towards the right side, that must necessarily be followed by a bending of the spine higher up towards the left side, in order to preserve the line of gravity of the body. If the vertebral column were to bend altogether towards the right side, the weight of the head and upper parts of the body could not be supported at all. Thus one curvature in the bones of the spine necessarily induces a deviation in another part. You sometimes find that you have two, three, or more of these curves; the effect of one compensates for the other; so that, however great the curvatures may be, the weight of the upper part of the body still falls upon the pelvis and lower extremities. The curvature, which takes place in consequence of this condition of the spinal column, is on one side, and is commonly called the lateral curvature of the spine, from the circumstance that the incurvations are all of them towards the side; so that sometimes the spine exhibits, under these circumstances, very much the form of the letter S,

(a) Diss. de Medulla Spinalis Erethismo. Francof., 1838.

instead of the natural upright appearance. This is an affection which takes place in young persons. It occurs during the period that the body is growing, and at the time of puberty; when the frame acquires its full strength and solidity, the bones become firm and strong, they lose their softened or rickety state; they, however, are not natural in their form, and consequently the figure remains permanently deformed." (pp. 533, 34.) In rare cases, however, curvature forwards of the spine also occurs from "a weak condition of the muscles, or a rickety affection of the bones," and upon such examples BRODIE observes:-"In general, in such cases the curvature occupies the whole spine, which assumes the form of the segment of a circle. At other times, however, it occupies only a portion of the spine, usually that which is formed by the superior and inferior dorsal vertebra; as I have ascertained, not only by examinations during life, but by dissection after death. Here the curvature is always gradual; never angular, and thus it may be distinguished from the curvature as arising from caries. Nevertheless, I am satisfied that these different kinds of curvature, arising from different causes, have frequently been confounded with each other; and that some of the cases which have been published as examples of caries of the spine, and in which it may, at first, be a matter of surprise that so complete and so speedy a cure has been effected, have in reality been cases of an entirely different malady" (p. 253.) BRODIE refers to some excellent observations of HENRY EARLE (a) on this subject.

BRODIE states that, "as the disease advances, the patient, in some instances, complains of pains, which are referred to one groin and hip, such as may lead to the suspicion that there is disease in the hip-joint; and, in fact, a very common error (and one into which even Surgeons of great experience are liable to fall) is to regard the symptoms of caries of the middle and inferior dorsal vertebræ as indicating incipient caries of the hip.” (p. 285.)]

In

261. The treatment must be conducted in reference to the previous rules. At the onset, according to the constitution of the patient, leeches, cupping, and internal remedies adapted to the general cause of the disease, must be employed. In traumatic inflammation of the spine, cold applications, with suitable antiphlogistic treatment, must be used from the beginning. When the inflammatory symptoms have been, in this way, diminished, rubbing in mercurial ointment and (in scrofulous persons) iodine ointment, are exceedingly serviceable; but the most important are continual derivations, most conveniently made by several issues of caustic placed on both sides of the diseased part of the spine (1), or by several suitable long streaks with the actual cautery. If improvement take place, and the weakness of the lower limbs cease, the issues must nevertheless be kept open for a long time. sluggishness of the bowels, attention must be paid to regulating the motions; in failing of the powers, they must be supported by bark and proper dietetic treatment; and, in retention of urine from weakness of the bladder, care must be taken to empty it with the catheter. An attempt to remove the deformity of the spine by machinery, and the like, shows an entire misunderstanding of the disease, but is necessary, both on account of resting the diseased part, as well as to prevent further sinking down of the spinal column, to preserve strictly the horizontal position on the back or belly during the whole treatment (2). When abscesses are formed, they must, if not very large, be left alone; if the caries of the vertebræ be brought to heal by the application of powerful derivatives, these abscesses often disperse of themselves by the pus in them being absorbed and their walls contracting to a cord; in rare cases, the pus contained in them may be changed into a mass like adipocere. (DUPUYTREN) (b). If these abscesses be very large and threaten to break, they must be opened by a single thrust of a lancet, emptied of the pus by equable pressure, without permitting the entrance of the air, and the opening carefully closed with sticking plaster. The edges of the opening soon unite, and the emptying of the swelling, if the (a) Edinburgh Medical Journal, Jan. 1815. (b) Leçons Orales de Clinique Chirurgicale, Paris, 1832, p. 138.

re-collection of the pus should make it necessary, is to be repeated in the same way (3).

Compare B. ST. HILAIRE (a) upon the symptomatic abscesses which accompany caries of the vertebra, and upon the possibility of being able to determine anatomically, from the external seat of these depositions of pus, the diseased vertebra.

[(1) In regard to the fact "some cases occur in which the caustic issues seem to be productive of little or no benefit," BRODIE observes, “probably it is with diseases of the vertebral as it is with those of the other joints, and issues may be of little or no efficacy where the ulceration of the cartilages is preceded by a scrofulous disease of the cancellous structure of the bones; and they may be productive of real benefit where it takes place under other circumstances. Nor, if my observations on the subject be well founded, is this to be regarded as a merely theoretical opinion. I have repeatedly known the greatest relief to follow the establishment of issues where the patient has suffered severe pain in the situation of the carious vertebræ, presenting, at the same time, no distinct indications of a scrofulous diathesis; while in young persons, with fair complexion and dilated pupils, in whom the disease has proceeded with little or no pain, they have appeared to be either inefficacious or actually injurious. It appears to me, also, that, in caries of the spine, as well as in that of other joints, issues are to be employed only in the early stages of the disease with a view to prevent suppuration, and that they are of no service after abscess has actually formed." (p. 268.) With great deference to so high authority as BRODIE, I cannot agree to the opinion last mentioned, as I am quite sure that I have several times seen issues extremely useful after suppuration has taken place, so that, under their employment, the irritation which has given rise to the abscess has subsided, and the disease cured.

(2) "The mode in which the disease becomes cured is," says ASTLEY COOPER, "by the upper portions of the vertebræ falling on the lower, and, in this way, anchylosing. This must be your object in the treatment of this disease. You should keep the spine of the child as much as possible at rest; with this view he should be constantly in the recumbent posture, so that the vertebra may be suffered to fall into contact, and, by coalescing, effect anchylosis. If you attempt to keep the spine straight, you will defeat the object of nature; do not keep the patient in a direct straight line, but rather assist nature in producing the union of the vertebræ. *** If the child cannot be kept at rest, if the parents are unable or refuse to observe these instructions, the next best treatment will be to apply one of CALLOW's backs, which is worn upon the spine, and fixed round the pelvis and shoulders. As to avoiding deformity, that is out of the question; in all these cases deformity is inevitable: whatever you do, this cannot be prevented." (p. 459.) "The incurvation forwards," says LAWRENCE, "is necessary to fill up the deficiency produced by the ulcerative absorption. The bodies of those vertebra which have been partially destroyed cannot be restored, for, as the spine bends forwards, the upper part comes in contact with the inferior, and an imperfect kind of anchylosis ensues; some additional bony matter is thrown out, which attaches the two ends of the chasm, consolidates them together, as we might say, gives a sufficient degree of solidity to the parts, and enables them to sustain the weight of the body above, and to admit of the ordinary motions of the spine. The curvature, therefore, here, is really only a necessary part of the curative process. The disease cannot be brought to an end with preservation of the straight figure of the spine where it has gone to a certain extent; nor when the curvature has once taken place, will any attempt to restore it succeed." (p. 562.)

From the first moment," says BRODIE," in which the nature of the case is clearly indicated, the patient should abandon his usual habits and be confined altogether to his bed or couch. In some instances in which severe pain in the vertebra is among the early symptoms of the disease, the patient will submit to the privations which are thus imposed upon him with sufficient willingness, while in others nothing but a candid exposition of the ill consequences which may otherwise arise will overcome his reluctance to do so. The invalid bedstead, contrived by Mr. EARLE, will, in ordinary cases, afford the most convenient means of conducting this part of the treatment. The use of it is attended with this great advantage, that the patient may be laid on his back, and the trunk and thighs may be, from time to time, and within moderate limits, elevated or depressed, so that their relative position may be varied without the smallest movement being communicated to the carious vertebra. Where, however, the disease has been going on for a long time, and there exists already a considerable angular curvature of the spine, it is desirable that the patient should recline on his side rather than on his back; or if he finds this in any way inconvenient or disagreeable, he should lie, not ou

(a) Journal Hebdomadaire, 1834, Décembre.