mm 
 
 ' 
 
 
 mm 
 
 ^™s-&sas£.rto. 
 
 LIBRARY OF CONGRESS. 
 
 UNITED STATES OF AMEEIOA. 
 
 981 
 
 . ■ 
 
2y 
 
POTT'S DISEASE 
 
 ITS 
 
 TATHOLCGY AND MECHANICAL TREATMENT 
 
 WITH REMARKS ON 
 
 ROTARY LATERAL CURVATURE 
 
 BY 
 
 NEWTON M? SHAFFER, M. D. 
 
 SURGEON IN CHARGE OF THE NEW YORK ORTHOPEDIC DISPENSARY; 
 
 ORTHOPEDIC SURGEON TO ST. LUKE'S HOSPITAL, 
 
 NEW YORK 
 
 
 \c y 18?9. <*y 
 
 NEW YORK 
 
 G. P. PUTNAM'S SON 3 
 
 1S72 
 
CorVRIGHT BY 
 
 G. P. TUT NAM'S SONS. 
 1S79. 
 
 > 
 
PREFACE, 
 
 The substance of the following pages was read before 
 the Medical Society of the County of New York, on June 
 24th, 1878. It was my intention to revise the essay pre- 
 sented on that occasion, for publication in The Hospital 
 Gazette, early in the Autumn. Various matters inter- 
 fered with this design, and it was not until February of 
 the present year that the subject seriously engaged my 
 attention. 
 
 About March 1st, Chapter I was placed in the hands 
 of the Editors of the Gazette. It alone nearly equalled 
 the original essay in volume. Chapter II was finished 
 before the first had been put in type, and it was then 
 thought by a few kindly critics, that the paper, as revised, 
 was worthy of publication in its present form. The Edi- 
 tors kindly released me from my engagement, and the 
 essay is now submitted to the profession. 
 
 That portion beginning with the third paragraph on page 
 38, and ending on page 48, is printed, with the exception 
 of the foot-notes, as read before the Society. I am in- 
 
IV PREFACE. 
 
 flucnced to call attention to this fact, and to leave this 
 part of the paper unchanged, (though recent experience 
 would permit me to speak more forcibly upon some im- 
 portant points there considered), because, I am convinced, 
 I was the first to call attention to the fallacies of the " plas- 
 ter jacket treatment " of Pott's disease; and still further, 
 because some of the same- poi:>ts were mentioned by Dr. 
 J. A. Wyeth in his paper on The Treatment of Pott's 
 Disease by Continuous Extension, read before the Medi 
 cal Society of the County of New York, on January 27th, 
 1879, anc ' published in The Hospital Gazette in its 
 next issue thereafter. Dr. F. H. Hamilton also, in dis- 
 cussing Dr. Wyeth's paper, incidentally demonstrated 
 some facts to which I had especially called attention 
 last June. 1 may also mention that some of these points 
 have been recently discussed abroad ; all of which tends 
 to prove that my remarks before the Society were in no 
 way premature. 
 
 An imp:rfect report of my paper, including an incom- 
 plete synopsis of my remarks on the defects of the 
 41 jacket " may be found in The Medical Record of Aug. 
 31st, 1878. 
 
 New York, April, 1879. 
 
POTTS DISEASE: ITS PATHOLOGY AND 
 MECHANICAL TREATMENT. 
 
 WITH REMARKS ON 
 
 ROTARY LATERAL CURVATURE. 
 
 CHAPTER I. 
 
 PATHOLOGY. 
 
 THE opportunities for making post-mortem examinations, 
 with a view to ascertain the pathological condition of 
 the vertebral column in the earliest stage of Pott's disease — that 
 is, before deformity occurs — are certainly very rare. If the 
 lesion presented at this period, an acute stage, during which the 
 patient might die, our pathological opportunities would be in- 
 creased, and many points still in dispute regarding its etiology 
 would be definitely settled. But I have never seen, nor obtained 
 the history of, an idiopathic, acute spondylitis. That which has 
 ordinarily been described to me as such, I am convinced, has 
 been nothing more than an exacerbation of an insidiously pro- 
 gressive, but semi-latent chronic state. And many of the so- 
 called acute and sub-acute attacks which ultimate in a com- 
 pletely disintegrated joint, are generally found as part of 
 the history of every progressive, chronic, osseous lesion of the 
 
2 POTT'S DISEASE. 
 
 articulations. On the other hand, the frequent occurrence of an 
 idiopathic, acute inflammation of some of the structures entering 
 into the formation of the larger articulations, and especially the 
 synovial membrane and fibrous capsule, has suggested to many 
 surgeons that this acute condition may pass by gradual stages 
 into a chronic one. But no one has, so far as I am aware, 
 attempted to trace a chronic spondylitis to a definite, acute, 
 non-traumatic origin. In every sense this disease may be con- 
 sidered a typically chronic one, from its very inception to its 
 ultimate result. Indeed, the disease is so typically chronic, 
 that it is always a difficult matter to decide in each case, as it 
 presents for examination, at just what time the lesion began : 
 nor is it always clear, especially in the latter stages of the 
 chronic lesions of the spine, hip or knee, as to just what tissue 
 was originally attacked. 
 
 If we question intelligent and observing persons who have 
 carefully watched the patient, regarding the early development 
 of the symptoms in a case of Pott's disease, we find, in many 
 instances, that the child has shown an indifference to his ordi- 
 nary amusements for an indefinite time, which preceded, how- 
 ever, the appearance of pain or deformity. This condition re- 
 sembles the incipient stage of chronic osteitis affecting the 
 larger articulations, and it points both in chronic epiphysitis of 
 the larger bones of the extremities, and in chronic spondylitis, 
 to a peculiar condition of the system, which, whether hereditary 
 or acquired, places the patient in a state where a slight injury 
 may act as an exciting cause. This peculiar tendency to de- 
 velop chronic osteitis, either in the vertebral column or the 
 larger epiphyses, upon slight provocation, accounts in great 
 
POTT'S DISEASE. 3 
 
 measure, for the readiness with which parents and nurses assign 
 a traumatic origin to the disease.* 
 
 I have never had an opportunity to examine, post-mortem, 
 the pathological condition of a vertebral column in the stage 
 alluded to in the first paragraph of this paper, viz., before the 
 appearance of deformity. Even if such examinations were on 
 record, it would require accurate microscopic descriptions of 
 many cases to establish facts regarding the changes which 
 primarily occur, and their most frequent seat. 
 
 We have Barwell's conclusions f as to the condition of the 
 joint ends in strumous children, which are, I believe, generally 
 accepted as correct. In the absence, among the authors I have 
 consulted, of other important facts bearing upon this point, and 
 based upon actual and very early pathological exploration, I 
 propose, with the aid I have derived from them and from my 
 own experience, both pathological and clinical, to consider the 
 lesion from these standpoints. 
 
 Pott's disease, or chronic spondylitis, as I have preferred to 
 call it, may be divided into four stages. 
 
 The first (the one before alluded to) may be very ill-defined, 
 and easily escape the notice of the careless observer. I saw a 
 case recently, for example, where the mother was certain that 
 the first symptom she noticed was " a pain in the back.'' 
 This was " a few days ago." The appearance of the child 
 
 * Guersant [Surgical Diseases of Children, Dunglison's Translation, 
 1873, page 107,) says, "An important observation we may make is, that 
 traumatic arthritis, properly treated, rarely passes into a chronic condition, 
 a fact which we have had many opportunities to verify, although often fear- 
 ing to the contrary. The cure is assured if the patients are not predisposed 
 to a scrofulous constitution." 
 
 \ Barwell on Diseases of the Joints, American edition, page 227. 
 
4 POTT'S DISEASE. 
 
 and the deformity did not indicate a disease of long duration, 
 but closer questioning elicited the fact that a few months before 
 the appearance of the pain in the back, he had had " malarial 
 fever." An examination developed an abscess in the sheath of 
 the psoas muscle, which, undoubtedly, was formed during the 
 " malarial fever." A careful examination — without intimating 
 its object to the person most familiar with the history of the 
 patient — will very frequently develop early symptoms which 
 are as insidious, as is the development, in many cases, of the 
 more apparent signs of the disease. This stage may continue 
 for many months, or it may exist for a few days only, and in 
 some cases it is, apparently, absent. Its existence was first 
 brought to my attention by voluntary statements on the part of 
 those having charge of patients, and it may be stated as the 
 result of my own experience in the matter that, in chronic 
 spondylitis, the first symptoms noticed by intelligent people, in 
 the majority of cases, are those which can only be described as 
 occurring in the prodromal stage. I have found that this con- 
 dition exists with great frequency, and is sufficiently well 
 marked to warrant its introduction as one of the stages of the 
 disease. 
 
 The second stage is that of pain. But this stage, like the 
 first, is sometimes absent, for as Billroth remarks of chronic 
 inflammation of the joints, so clinical experience demonstrates 
 we may say of chronic spondylitis : — " there are cases where 
 the bone is extensively destroyed without any pain."* I have 
 frequently seen cases where the kyphotic curve was the only 
 evidence of a progressive, fungous, non-suppurative osteitis of 
 
 * Hackley's Billroth, page 482. 
 
POTT'S DISEASE. 5 
 
 the vertebral bodies. Chronic osteitis of the hip joint also 
 may go on to an actual shortening of the femur, with an entire 
 absence of pain, so far as its oral expression is concerned. 
 Pain, however, is present in the great majority of cases of 
 chronic spondylitis, and it is generally accompanied, and not 
 infrequently preceded, by a marked reflex spasm of some of 
 the spinal muscles. This pain, which, in the earlier stages of 
 the disease, is most frequently experienced at the periphery of 
 the spinal nerves, probably arises from an irritation of these 
 nerves as they pass through their foramina ; but in many cases 
 the inflammatory focus does not involve those parts which are 
 immediately contiguous to the foramina, and are we prepared 
 to say that in all cases the " gastralgia," so-called, arises from 
 this cause and no other ? 
 
 The reflex spasm of the muscles does not form the subject 
 of any voluntary complaint on the part of the patient. As I 
 first pointed out,* this reflex muscular spasm in joint inflamma- 
 tion is due to an irritation, peculiar in its character, of the 
 peripheral nerves which actually supply the diseased or in- 
 flamed structure. It is accompanied, however, by an appre- 
 hensive feeling which is very difficult to define, but which is 
 certainly very distressing to the patient. This sensation, often- 
 times merging into violent paroxysms of pain, is not limited to 
 any particular region, and on account of the intimate relation 
 existing between the minute nerve filaments terminating in 
 the vertebrae, and the great nerve centres, evinces itself in 
 many ways, involuntarily. This spasm, which in many cases 
 
 * Reflex Muscular Contraction and Atrophy in Chronic Joint Disease. 
 Archives of Clinical Suigery, June 15th, 1877. 
 
6 POTT'S DISEASE. 
 
 might be called tetanoid, is present night and day, and after 
 many experiments in diseases of the larger joints, I have found 
 that it will yield to profound anaesthesia only. Certain it is, 
 that the causes which produce this reflex, tetanoid spasm leave 
 upon the patient, after a comparatively short space of time, 
 evidences of severe suffering — evidences which do not follow 
 chronic lesions of the synovial membrane or cartilage. 
 
 The third stage is that of deformity, and is due to some loss 
 of substance in one or more of the bodies of the vertebrae. Some- 
 times suppuration ensues rapidly, in others it ocqurs later, while, 
 not rarely, a morbid process, which has been aptly termed caries 
 sicca by German pathologists, occurs, which ultimates in a very 
 pronounced deformity without any evidences whatever of 
 pyogenetic action. When abscess occurs it forms the fourth 
 stage. Much might be written regarding this stage of the dis- 
 ease, but the limits of this paper will not permit any extended 
 remarks. I will merely say that the absence of suppuration or 
 any of its symptoms, together with an apparently arrested de- 
 formity, not unfrequently serves as a mask to the inherent 
 chronicity of the lesion. Nor does this apparently favorable 
 condition by any means insure the arrest of the destructive 
 inflammation, nor the really progressive kyphosis. There are 
 indications by which the permanent arrest of the morbid action 
 may be demonstrated. But they need not detain us here. 
 The clinical fact to which I wish to invite attention, especially, 
 is that if the symptoms one would naturally expect to find as- 
 sociated with this disease are not present, it does not afford 
 positive evidence upon which to make a favorable prognosis. 
 On the contrary, the absence of suppuration after the disease 
 
POTT'S DISEASE. 7 
 
 has existed for many months, points, in many cases, and 
 especially in the fungous caries, to an unfavorable prognosis in 
 point of time. The nearer a chronic spondylitis approaches 
 an acute disease in character the more favorable, and of course, 
 the more quickly obtained, is the result. Again quoting Bill- 
 roth, we may say of spinal caries, as of any other chronic joint 
 lesion, — " a good nutritive condition is the most important 
 point for a favorable prognosis, which would not be very 
 greatly affected by an early and extensive suppuration." An 
 early suppuration, even if it be extensive, has, in my own ex- 
 perience, been indicative of a timely and favorable result. 
 (See Case V.) In Pott's disease the formation of pus is, as a 
 rule, marked by exacerbations of pain, by an evening rise of 
 temperature, by a peculiar nocturnal cry, which I have named 
 the osteitic, and sometimes — though it is very difficult to obtain 
 this part of the history in children — by slight chilly sensations 
 in the early stage. The rise in temperature, like that which 
 occurs in the suppurative stage of chronic osteitis of the hip or 
 other joints, does not usually exceed io2°-io3° in the evening, 
 (I have seen it as high as 105 ) and in the morning the mercury 
 drops back to 99°-ioo°. If the disease occur in that region of 
 the spine which affords attachment for the psoas magmis, this 
 muscle, as well as the iliaats interims, may become the seat of 
 reflex spasm. Whenever, in chronic spondylitis, the psoas re- 
 sists when placed upon the stretch, it is well to explore, by 
 palpation, the pelvic fossae and the course of the contracted 
 muscle. There are some patients who will, involuntarily, 
 make the abdominal muscles tense when this examination is 
 attempted. Under these circumstances, I administer ether, 
 
8 POTT'S DISEASE. 
 
 after the plan of Dr. Packard,* of Philadelphia, and, during 
 the primary stage of anaesthesia, which in several of my cases has 
 been brought about in less than sixty seconds, I have been 
 enabled to examine for thirty or forty seconds, without meeting 
 any muscular resistance, the abdomen and pelvic fossae. In 
 this way I have been enabled to recognize the existence of an 
 abscess at my first examination, and before any external signs 
 whatever of it existed. As it is always important to know 
 whether pus exists or not in these cases, I can confidently 
 recommend this plan, which I first tested in St. Luke's Hos- 
 pital, with Dr. Andrew H. Smith, in a case where considerable 
 difficulty in making the pelvic and abdominal examinations led 
 to the adoption of this simple, useful procedure. 
 
 I have attempted to make an intelligent pathological division 
 of the various phenomena of Pott's disease. I cannot avoid 
 recognizing that it is impossible in the present state of our 
 pathological knowledge to do much more than make an 
 arbitrary classification of the disease into different stages. 
 
 In a typical case, we find the stages I have attempted to de- 
 scribe clearly marked. In many cases we find them all present 
 at the first examination : viz., malaise, pain, deformity and sup- 
 puration, with no intelligent history as to their sequence. Again, 
 I have seen several cases where profuse suppuration preceded 
 the appearance of deformity, others where paraplegia occurred 
 before the curvature, and many cases where pain, or rather the 
 oral expression of pain, was wholly absent, though the kyphosis 
 was marked. I was tempted to make a fifth, or exceptional stage, 
 namely, paraplegia ; but this condition is so clearly symptomatic, 
 
 * Am. Jour. Med. Sciences, July, 1S77. 
 
POTT'S DISEASE. 9 
 
 and, in reality, occurs so rarely under intelligent treatment, that I 
 have classed it among the symptoms of any of the stages. The 
 irregularity, however, with which the various prominent phen- 
 omena appear, has also been accompanied by other peculiari- 
 ties which have added much to the clinical and probable patho- 
 logical aspects of the subject. They have, in the main, served 
 to strengthen, rather than weaken the division I have made. 
 
 As before stated, chronic spondylitis may be divided into 
 two classes, viz., that in which suppuration is a comparatively 
 early symptom, and the non-suppurative, or that in which caries 
 sicca occurs. As Billroth forcibly expresses it, " The fungous 
 articular inflammations are often accompanied by caries sicca ; 
 the affection may go on for years without the formation of ab- 
 scess, especially in adults otherwise healthy ; there may be exten- 
 sive destruction in the cartilage and bones, with the consecutive 
 dislocations already mentioned under caries, without a drop of 
 pus." * This extremely interesting condition I have seen very 
 often, clinically, both in the spine and larger joints, and on sev- 
 occasions after amputation and excision of the larger joints. 
 For reasons which I shall state hereafter, I think it very rare 
 that this condition of caries sicca is seen in the vertebral column 
 after death. Billroth's description of the pathological appear- 
 ances of this fungous caries is brief and practical. I will con- 
 dense and quote it here : " If you examine the granulations in 
 the joint and bone, you will find them firmer than usual, and 
 occasionally of cartilaginous consistence, like granulations about 
 to atrophy or cicatrize. Indeed, they do partly atrophy, but 
 the proliferation goes on again, and the bone is destroyed : the 
 
 * Op. cit., p. 478. 
 
IO POTT'S DISEASE. 
 
 process is analagous to cirrhosis ; the more luxurious the pro- 
 liferation of the granulations, the more extensive the destruc- 
 tion." * 
 
 In the vertebral column, the initial lesion may be, among 
 other conditions, an osteitis i?iterna fungosa seu granulosa ; an 
 osteitis interna caseosa ; a caries super ficialis, following a perios- 
 titis, or a caries interna necrotica. These descriptive titles, taken 
 from different pathologists, express some of the conditions 
 that may be met with clinically, and pathological investigations 
 prove that the original lesion may be termed, in all but the ex- 
 ceptional cases, a chronic osteitis, to which we may add the vari- 
 ous qualifying terms to express the exact pathological condition. 
 The German authors use many names to describe the several 
 conditions found in chronic articular lesions, and while sub- 
 divisions of the two general classes — fungoid and suppurative, 
 (the latter frequently taking the atonic form) may be made with 
 advantage pathologically, the terms caries and chronic osteitis 
 are used synonymously by many modern writers, the former 
 signification of caries, " ulceration accompanied by suppura- 
 tion, open ulcers of the bone," being, to a great extent, 
 ignored. It is thus that we speak of a fungous osteitis, 
 where the inflammatory neoplasia proliferate and then contract 
 and cicatrize, but which may degenerate under certain circum- 
 stances into an ichorous, flocculent discharge, which marks 
 the atonic form of caries. A very practical remark of Billroth 
 will bear repeating here : " Pathological anatomists who see 
 caries in the dissecting room only, seldom know the ganulo- 
 fungous variety well, or regard it the less frequent one. But 
 
 * Op. Cit., page 476. 
 
PO TT'S DISEA SE. I I 
 
 any one who has frequent opportunities of examining pieces of 
 carious bone during life, especially the resected joints of chil- 
 dren, where the process is in a state of active development, will 
 form a very different opinion/' \ The general failure of the 
 vital force which precedes death, produces an effect upon these 
 fungous granulations which results in a rapid breaking down of 
 the neoplastic proliferations of the dry caries — the. result is 
 the formation of a degenerate pus, which is discovered at the 
 autopsy. Hence it is that some observers have concluded 
 that "all spinal caries is suppurative." 
 
 In a former paragraph I used the phrase, " comparatively 
 early suppuration." I mean by this, when speaking of chronic 
 spondylitis, a suppuration which progresses rapidly enough to 
 appear as a " cold abscess " within, we will say, a year from the 
 first, specific expression of the disease. As a rule, and depend- 
 ing on the site of the initial lesion, the suppurative form of the 
 disease is characterized by the early appearance of pain at the 
 periphery of the irritated spinal nerve, and an abrupt curvature 
 which is apt to result from the rapid loss of bone and fibro- 
 cartilage. Reflex muscular spasm is not so marked in the 
 suppurative as it is in the fungous form — and suppuration, in 
 spinal osteitis as in caries of the larger joints, seems to exert a 
 modifying influence upon the reflex spasm. The peculiar de- 
 formity which results, in many cases, from the suppurative 
 form of the lesion, has been for a long time known under the 
 solecism, "Angular Curvature." In the majority of cases, in 
 my own experience, but few vertebrae are involved in this 
 active, suppurative process, though as the disease progresses 
 
 % Billroth's Surg. Path., Sydenham Ed., Vol. II., page 15S. 
 
12 POTT'S DISEASE. 
 
 and involves other vertebrae, the abruptness of the projection 
 may be lost. The caries sicca, on the other hand, more 
 frequently involves a considerable number of the vertebrae 
 primarily, and the resulting deformity partakes more of the 
 character of a true curvature, sometimes, especially in the 
 adult, like the excurvated spine of the old writers. 
 
 In the early history of the dry caries the pain partakes of an 
 apprehensive character, which, however, may become acute 
 under slight traumatic influence, and as in the granular caries 
 of the large articulations, the intense muscular, spasm shows 
 the profound impression which the fungous proliferations make 
 upon the nerve filaments distributed to the spongy and vascular 
 osseous tissue. Another fact which I have noticed in connec- 
 tion with these two important conditions — the dry and humid 
 forms of the disease — is that while no portion of the spinal 
 column is exempt from either, the non-suppurative variety 
 occurs more frequently in the dorsal region — more frequently 
 indeed than in the cervical and lumbar regions combined. 
 
 The atonic variety of suppurative spondylitis occurs very fre- 
 quently among strumous children, and is usually described as the 
 typical, strumous Pott's disease. It is, as a rule, accompanied 
 by several of the commonly accepted evidences of scrofula, 
 while on the other hand, I have frequently remarked that the 
 dry caries may exist to a very considerable extent, and progress 
 to marked deformity and loss of osseous tissue, without any 
 marked evidence of dyscrasia in the patient. I have a 
 patient now in my ward at St. Luke's Hospital, whose health is 
 apparently good. There are no evidences whatever of struma, 
 unless we except the joint disease and a slightly tinged sclerotic, 
 
POTT'S DISEASE. 1 3 
 
 and yet he has had a fungoid osteitis of the hip joint for two 
 years. The thigh muscles are atrophied, the limb is shortened 
 an inch, and the joint is practically immobilized by the most 
 intense and persistent reflex muscular spasm. The analogue 
 of this condition in the spine, I have seen very frequently, 
 where all evidences of suppuration were wanting, and the excel- 
 lent general condition of the patient gave delusive hopes that 
 the kyphos was permanently arrested. This non-suppurative 
 variety of spondylitis, however, is found more frequently, in 
 proportion to the whole number of cases, among adults. It 
 may, however, and following a failure of the general health, it 
 frequently does, assume a suppurative phase. The transforma- 
 tion of the fungoid into the atonic form of the disease is 
 ordinarily attended with urgent symptoms, and in the adult is 
 followed, as a rule, by death. Septicaemia and amyloid de- 
 generation are the most frequent causes of death in the 
 suppurative variety, while tubercular meningitis has only too 
 frequently, in my own experience, followed upon the dry caries, 
 both in public and private practice. 
 
 Brodie first called attention to the fact that adults sometimes 
 experience a non-suppurative form of spinal disease. The 
 granular caries was apparently, not known as such to him, and 
 as in many cases, he found a rheumatic history, this eminent 
 writer considered the condition to be of rheumatic origin. In 
 whatever light, however, we view the dry, granulo-fungoid 
 osteitis of the vertebral bodies, clinical experience demonstrates 
 that it is the most tedious disease, either in children or adults, 
 that can affect the articulations : that it is the most difficult 
 to control, and the typical rotary scoliosis alone excepted, the 
 most insidiously progressive. 
 
H POTT'S DISEASE. 
 
 I have already referred to the reflex muscular spasm, which 
 is not only an early symptom of chronic spondylitis, but also of 
 chronic epiphysitis. This muscular spasm is a prominent 
 symptom of the dry form of spondylitis and when once fairly de- 
 veloped, it is a pretty sure indication that the best efforts in the 
 way of treatment, both constitutional and mechanical, will not 
 suffice to prevent some increase in the spinal curvature. On 
 the other hand, in the more favorable forms of suppurative 
 spondylitis, where the pus approaches the laudable in character, 
 this spasm is not so marked, as I have before stated, and the 
 result, other things being favorable, should be good. Of the 
 atonic variety I need only say that the ichorous, flocculent dis- 
 charge tells its own story, and that too much should not be ex- 
 pected of an already overburdened constitution. 
 
 There are some forms of spinal deformity or curvature, the 
 etiology of which, in the absence of pathological exploration, is 
 quite obscure. I cannot stop here to mention all these condi- 
 tions, or to attempt to classify them. I may simply say that they 
 seem to have one symptom in common at some stage of their 
 development, viz., a painless contraction or spasm of some of 
 the spinal muscles. In rotary lateral curvature, for example, 
 there is, seemingly, no direct evidence of muscular contraction 
 in the ec^-liest stage of the lesion, though I have found resistance 
 to lateral flexion quite marked in many cases. If the inter- 
 vertebral articulations were the perfect analogues of the larger 
 joints, such conditions might correspond, in their incipient 
 stage, to the chronic synovial inflammations of the latter, 
 which, as I first pointed out,* are not accompanied to any 
 
 * Loc. cit. and Seguin's American Clinical Lectures, Vol. Ill, No. VI. 
 
POTT'S DISEASE. I 5 
 
 great extent by a reflex muscular spasm, and which are also, for 
 a physiological reason, practically painless. I have seen many 
 cases of varied and great deformity of the spine, where the chief 
 agency or factor in the production of the deformity was a pain- 
 less, but very persistent muscular contraction, and where the ap- 
 parent condition was, from an ultimate cause yet to be ascertain- 
 ed, an absolute motor paresis of some of the spinal muscles, fol- 
 lowed by a shortening of the unbalanced antagonists. In many of 
 these cases also, there are neural symptoms, or even the history 
 of a severe lesion of one of the nerve centres. Such, for ex- 
 ample, was the case of H. M., a boy of 14 years. This case 
 was referred to me by Dr. T. M. Markoe, and was seen in con- 
 sultation with Dr. B. F. Dexter, in November, 1877. In the 
 fall of 1876, the patient, after severe mental exertion at school, 
 had an attack of spinal meningitis, which greatly imperilled his 
 life. He recovered, however, and became, instead of the strong, 
 boy he was formerly, a very delicate and effeminate lad. Soon 
 a slight lordosis of the spinal column was noticed. This be- 
 came slowly progressive, until at the time of the consultation,, 
 the anterior curvature of the spinal column was very marked, — 
 resembling indeed the position of the spine in extreme opistho- 
 tonos. There was little or no muscular rigidity of the spinal 
 muscles in the erect position. The abdominal muscles were 
 tense ; by supporting the abdomen in front, the spine could be 
 gradually straightened, but this the patient could not accomplish 
 unaided. There was no pain whatever after forcible tests. 
 The lordosis disappeared almost completely when the patient 
 assumed a prone position. The malposition was quite easily 
 corrected with apparatus, but as the anterior curve disappeared 
 
1 6 POTT'S DISEASE. 
 
 under treatment, a typical lateral curvature appeared, accom- 
 panied by rotation of the bodies and rigidity, to a considerable 
 extent, in lateral flexion. This is the boy's condition at pres- 
 ent, though the scoliosis is under control. There are other 
 cases where, after an insidious prodromal stage, the symp- 
 toms partake more of an apparently sub-acute character. 
 The latter stage is generally short, pain being more or less 
 marked. This is followed by a painless, reflex spasm of 
 the muscles. The condition described occurs most fre- 
 quently in the cervical region ; or, at least, it is the best 
 studied in the neck, and the muscular phenomena present some 
 very curious and anomalous conditions : for example, a mark- 
 ed contraction of the right sterno-mastoid existing with 
 rotation of the chin to the same side ; an apparent anatomical 
 contradiction. This was the condition in a patient, a girl 
 of 12, whom I saw in consultation with Dr. Henry B. Sands 
 in January, 1878, and where we subsequently 'February, 1879, 
 one and one-half years after the first symptoms appeared), de- 
 monstrated that the muscular contraction was reflex, all mus- 
 cular resistance disappearing under ether. The lesion in this 
 case was a spondylitis sicca in the upper cervical region, and 
 yet there has been no pain present for over a year, and the 
 patient possesses an apparently normal degree of muscular 
 power in flexing, extending or circumducting the head within 
 the limits of the contraction, just as patients with rotary scoli- 
 osis possess, in many instances, a considerable degree of 
 strength in the spinal muscles, the exercise of which does not 
 produce pain. It certainly is a remarkable fact which I have 
 seen demonstrated many times, that a prolonged reflex spasm 
 
PO TT'S DISEA SE. 1 7 
 
 of certain muscles either of the spine or limbs (yielding wholly 
 under ether) may exist without any history of pain. Another 
 fact, that I have seen too often illustrated to regard as a coin- 
 cidence, is that in all, or nearly all these cases, the muscular 
 atrophy and spasm could be traced to an osseous lesion, and 
 particularly to the bodies of the vertebrae or the epiphyses. 
 
 That muscular contractions occur in the typical, rotary 
 scoliosis is very apparent, and that these contractions are 
 reflex, or due to some specific cause, is equally evident 
 when their nature is studied. These cases form, however, 
 a distinct group, yet the ultimate muscular condition . re- 
 minds me of that which exists in the lower extremities after 
 infantile paralysis. There are other cases where there is a 
 distinct and readily traced paralysis of some of the spinal 
 muscles. The case of H. D. P. will illustrate this condition. 
 The patient was six years old and was placed under my care 
 by Drs. W. H. Draper and E. C. Seguin. The original lesion 
 was a poliomyelitis. Dr. Seguin has furnished me with a 
 memorandum of the muscles primarily affected. Those par- 
 tially paralyzed (which recovered wholly under Dr. Seguin's 
 treatment) were the muscles of the neck, arm and thigh (left 
 side). Those wholly paralyzed — and which did not recover — 
 were the left s&rratus magnus, the left transversalis and obliquus 
 externus, and the supra and infra spinati of the same side. The 
 vertebral column presented an inflexible dorsal curvature toward 
 the paralyzed side, with the usual compensatory (?) curve in the 
 lumbar region. The most marked rotation that I have ever seen 
 occurred in this case, though, as above stated, the boy was only 
 six years old. There was marked contraction of the unparalyzed 
 
I 8 POTT'S DISEASE. 
 
 antagonists on the right side. I have seen several of this class, 
 also, and one patient, a girl of thirteen, is now under observa- 
 tion at the Orthopaedic Hospital. I mention these cases and 
 describe their condition, because I am convinced, after studying 
 over three hundfed cases of the typical, rotary lateral curva- 
 ture — and especially the development of the muscular resist- 
 ance — that no analagous muscular contraction exists, in any 
 condition, without some central or marked reflex cause. At 
 any rate, I am prepared to state that rotary lateral curvature 
 has a specific, pathological cause — not merely a mechanical 
 etiology. The absolute demonstration of this statement and 
 the location of the lesion, of course, lie in post-mortem explo- 
 ration. On another occasion I shall dwell more particularly 
 upon this interesting and important subject. 
 
 I have at least demonstrated from a clinical standpoint that 
 a simple, non-specific loss of muscular equilibrium cannot 
 explain the phenomena of a typical, rotary lateral curvature. 
 In other words, the typical, progressive scoliosis does not devel- 
 op from a simple alteration of the pelvic plane — where an 
 unequal length of the lower extremities causes, in locomotion, 
 a primary lateral curvature in the lumbar region as a matter of 
 compensation. I have carefully noted the conyparative length 
 of the lower extremities in over one hundred cases of the 
 typical, progressive, rotary lateral curvature, and I have found 
 only three where the difference in the length of the limbs 
 amounted to three-eighths of an inch, or more. In view of 
 recent statistics regarding the comparative length of the lower 
 extremities,* this, certainly, is a small percentage, as the patients 
 
 * Dr. Cox, Am. Joicr. Med. Sciences, April, 1875 ; Dr. Wight, Arch. 
 
POTT'S DISEASE. 1 9 
 
 were all either adults or adolescent girls who had nearly attained 
 their growth. On the contrary, where the actual difference 
 between the length of the lower extremities has been great from 
 disease or arrest of development (hip joint disease, infantile paral- 
 ysis) amounting to from one to three inches, I have found after 
 examining a large number, only two where the typical scoliosis 
 existed, and, from the histories presented by these cases, I doubt, 
 very much, the etiological value of the altered pelvic plane. In 
 these cases a strictly compensatory curvature results, — but it is 
 readily removed by artificially supplying the necessary length 
 to the shortened member, or by placing the patient in the prone 
 position. In closing this digression, I will merely say that the 
 widest difference exists, clinically, between the purely compen- 
 satory curvatures, and the other two classes of lateral curva- 
 ture to which I have referred. The former are strictly mechan- 
 ical in their origin, and although, after many years, the interver- 
 tebral fibro-cartilages may become modified by the unequal 
 pressure, the curvature is, as a rule, easily remedied in the 
 manner pointed out ; while the latter, commencing without any 
 apparent, primary, mechanical cause, progresses very insidi- 
 ously, and, if the progressive deformity be not arrested, it 
 ultimates in a condition which is, of all the abnormal positions 
 which the orthopaedic surgeon is called upon to treat, the most 
 difficult to relieve. 
 
 To revert again to the subject more directly under consider- 
 ation, we may say that in whatever portion of the vertebral 
 column the inflammation most frequently has its origin, it has, 
 
 Clin. Surgery, February, 1877 ; Dr. Hunt, Am. Jour. Med. Sciences, 
 January, 1879. 
 
20 POTT'S DISEASE. 
 
 as before remarked, many features in common with the chronic 
 forms of disease attacking the larger articulations. The min- 
 ute structure of the vertebrae need not detain us here, nor is it 
 necessary to enter upon a detailed account of the structure, 
 functions or normal motions of the vertebral column as a 
 whole. The tissues most liable to inflammation are those which 
 interest us most, and we may say that the one most liable to 
 attack is the same in the spine as in the larger articulations. 
 The great joint factors are bone, synovial membrane, cartilage 
 and ligaments. We exclude the fibrous capsule, for while it is 
 frequently the seat, especially in the knee, of acute inflam- 
 mation, it rarely, in my opinion, becomes the seat of primary, 
 chronic imflammation, — and for another reason — the fibrous 
 capsule is not very extensive in the vertebral column, and is 
 situated at points where the disease rarely has its origin. 
 
 We find, if we examine the vertebral bones, that the osseous 
 tissue entering into their structure is of two kinds ; the soft, 
 spongy bone existing in the bodies, and the hard, compact 
 tissue being found in the laminae, pedicles and processes. 
 Synovial membrane exists to a limited extent only, and is not 
 found at points where pathological exploration has demon- 
 strated the lesion most frequently begins. A mass of ligaments 
 bind the bones together, and a series of fibro-cartilages, making, 
 in the aggregate, nearly one-fourth of the entire vertebral 
 column, are interposed between the bodies. Each vertebra, 
 therefore, rests upon a triangular base, the intervertebral disc 
 forming the medium of support anteriorly and the two articular 
 processes posteriorly. 
 
 Histologists tell us that the bodies of the vertebrae are very 
 
POTT'S DISEASE. 21 
 
 vascular, and Kolliker remarks, " Of the short bones I have 
 found the vertebrae to be the most abundantly supplied with 
 nerves, and especially the bodies." * The synovial mem- 
 brane, while possessing considerable vascularity, has a much 
 less abundant supply of neural tissue, and Kolliker again 
 states, " In the knee I have seen nerves, even in the true 
 synovial membrane, although in general they are rare." f 
 Nicolodini J also demonstrates by the chloride of gold 
 test the existence of nerves in the " intima " of the synovial 
 membrane. But all histologists that I have, as yet, consulted, 
 agree in stating that the bodies of the vertebrae and the 
 vascular epiphysis have a very abundant supply of nerves, 
 while the true synovial membrane has, comparatively, a very 
 limited supply. The epiphyses are local nutritive centres — the 
 synovial membranes are simple serous membranes. Morris, in 
 his recent work on the " Anatomy of the Joints," remarks that 
 the synovial membranes " are supplied with nerves and ab- 
 sorbents," — and in speaking of the ligaments he further says : 
 " Often, however, and especially in the larger joints, it is easy 
 enough to follow nerve branches through the ligamentous fibres 
 of the articulation." The " tendon reflex " would seem to 
 sustain this assertion, though Dr. Gowers, after his recent 
 experiments {Lancet, Feb. ist, 1879), was not assured that the 
 seat of the " tendon reflex" was not in the muscles. It is a 
 well known fact, which scarcely needs repetition here, that 
 articular cartilage, in a normal state, is destitute of both blood- 
 vessels and nerves. 
 
 * Manual of Human Histology, Syd. Ed., Vol. I, page 336. 
 
 t ■• - " » •• 338. 
 
 % Strieker 's Jahrbueher, 1873. 
 
22 POTT'S DISEASE. 
 
 The intervetebral discs, according, to Kolliker and others, 
 consist, i st, of exterior concentric layers of fibro-cartilage and 
 whitish connective tissue ; 2ndly, of a central, principally, fibro- 
 cartilaginous substance ; and 3dly, of two cartilaginous layers 
 applied immediately to the bones. The soft, central substance 
 does not differ materially in its elements from cartilage, for the 
 microscope shows the preponderance of fibro-cartilage cells. 
 These discs contain, like the true articular cartilage, neither 
 vessels nor nerves, in a normal state, but vessels may, under 
 certain morbid conditions, develop in them (Rokitansky, 
 Kolliker). They may also undergo two species of degenera- 
 tion, viz., atrophy and ossification. The former occurs from 
 very obscure causes, and is accompanied by no marked symp- 
 toms. These two conditions are found principally in senile 
 spinal curvatures, though Rokitansky states, " true ossification 
 of fibro-cartilage is, in every case, highly problematical." * 
 The same authority states, " Inflammation though rarely met 
 with in the fibro-cartilage, does unquestionably occur in them. 
 It is remarkable for its acute course, and for the rapid ulcera- 
 tive destruction of the fibro-cartilage to which it leads. An 
 inflammation is sometimes met with in the intervertebral carti- 
 lages, which terminates sooner or later in suppuration, and 
 is generally combined in the end with inflammation and caries 
 of the bodies of the vertebrae." f 
 
 My own experience leads me to believe that an acitte inflamma- 
 tion of either the intervertebral discs, or of the ligaments, would 
 find expression in considerable pain. We know, for instance, 
 
 * Rokitansky s Path. Anat. Syd. Ed. Vol. III. Page 281. 
 f " " " '« " 279. 
 
POTT'S DISEASE. 23 
 
 that an acute synovitis of the knee-joint is exquisitely painful, 
 while a chronic synovitis may exist for years without any ex- 
 pression of pain at all. Acute inflammation of any of the 
 appendages of the vertebral bones (excluding those due to direct 
 traumatism) are quite rare, and I have seen only a few cases 
 which could be thus classified. Two of them, I am inclined to 
 believe, were lesions of the intervertebral cartilages, with suppura- 
 tion. Markedly acute symptoms, high temperature, the rapid 
 formation of pus, and complete recovery in a few weeks with slight 
 deformity and rigidity of the spine, limited to two or three 
 vertebrae, summarize their histories. Primary inflammation of 
 the ligaments, as a factor of chronic spondylitis, I do not think, 
 occurs. Their structure would not predispose them to a 
 chronic form of inflammation. For evident reasons the spinal 
 synovial membrane should not give rise to much trouble, and 
 Brodie, after many post-mortem examinations, says, " Although 
 it is not to be supposed that the synovial membrane belonging 
 to the joints between the articulating processes of the vertebrae 
 are altogether exempt from the liability to inflammation, there 
 is no doubt that inflammation in them is of rare occurrence, 
 and no case has fallen under my own observation in which the 
 existence of such disease was proved by the examination of 
 the dead body." * 
 
 I have analyzed thus briefly the histology and pathology of 
 the important joint factors, so far as the authorities I have re- 
 ferred to throw direct light upon the subject. I might cite 
 others also, were such a course necessary, in confirmation. I 
 have also summarized their pathology in the light of a very 
 
 * Diseases of the Joints, 5th Ed., page 300. 
 
24 POTT'S DISEASE. 
 
 considerable experience, based upon a service of over fifteen 
 years in public institutions especially devoted to the treatment 
 of deformities, and notably those of the spine and hip. It is, 
 however, to be regretted, that there exist almost insuperable 
 difficulties in the way of obtaining autopsies in dispensary and 
 hospital practice, especially among children. I not only find 
 that many mothers object to leaving their children in any hos- 
 pital ward, but that the bare suggestion of an autopsy is suffi- 
 cient to incur the lasting displeasure of the friends of the 
 patient. In dispensary practice patients that are seized with an 
 acute, intercurrent trouble, usually find their way to some gen- 
 eral dispensary for treatment, and if death ensues, we are made 
 aware of the fact only when they are beyond the reach of post 
 mortem examination.* Even if these facts were otherwise, the 
 post mortem appearances of advanced Pott's disease are not al- 
 ways satisfactory, for reasons already stated. I have therefore 
 found my greatest pathological aids from examinations of the 
 diseased tissues in the larger joints after resection and amputa- 
 tion. We cannot observe the spinal column under these favor- 
 able conditions. As Dr. Heitzman expresses it in his lectures 
 on the " Development of Bone/' when referring to the compara- 
 tive value of microscopic examinations of recent and dried 
 specimens of osseous tissue, " * * * it is the difference between 
 examining a mummy, and the recently deceased body." In 
 stating the matter in this way, I have no wish to underrate the 
 
 * Of 299 cases of Pott's disease treated at the Orthopaedic Dispensary in 
 1877, 10 died. One from Bright's disease, 2 tubercular meningitis, 1 whoop- 
 ing cough, 3 pneumonia, 1 diphtheria, and 2 unknown. During 1878, 267 
 patients were treated for Pott's disease in the same institution. The deaths 
 were 13 ; 2 Bright's disease, T tubercular meningitis, 1 bronchitis, 2 scarli- 
 tina, 2 myelitis, 2 phthisis, I exhaustion, and 2 unknown. 
 
POTT'S DISEASE. 25 
 
 contributions of others, or to expose myself to the criticism of 
 discarding the evidence obtained at autopsies made in advanced 
 Pott's disease. Compared with these latter evidences, however, I 
 regard the fresh specimens examined immediately after resec- 
 tion or amputation, as being far more valuable than those ob- 
 tained after the changes have occurred which precede and fol- 
 low death. 
 
 Viewed in the light of the symptoms presented, the pathology 
 of chronic spondylitis becomes more interesting, and many im- 
 portant conclusions may be drawn by applying the known histo- 
 logical and pathological facts, to the indices of this insidiously 
 progressive lesion. The most important symptom upon which 
 we are obliged to rely for the early diagnosis of certain forms, 
 (the osteitic) of articular disease and before an actual loss of 
 substance occasions deformity, are those which come to us 
 through the medium of the nervous system. It is a remarkable 
 clinical fact to which, so far as I am aware, I was the first to call 
 attention, that a chronic disease may exist in any given articular 
 tissue which is sparsely supplied with nerves, or which is de- 
 void of neural elements, without presenting any subjective symp- 
 toms which are of sufficient importance to attract the attention 
 of the patient. Instances of this may be found in the chronic 
 lesions of the synovial membrane, and the cartilages of the 
 larger articulations. Atrophy and almost complete disappear- 
 ance of the cartilage may occur without any symptom during 
 life, as before stated, and among the many instances of chronic 
 synovial inflammations which I might cite, I will briefly state 
 the case of a young lady of 22 years, who recently consulted me 
 regarding a diseased knee. The history of the case covered 
 
26 POTT'S DISEASE. 
 
 ten years, and the first symptom noticed was a simple, painless 
 swelling of the joint. Local rise of temperature occurred later 
 and has been present most of the time, but the important fact 
 that I wish to call attention to is, that during the past year only, 
 has there been any pain. Since the bone has become involved 
 in the diseased process which originated years ago in the 
 synovial membrane, there has been limping, (there was none be- 
 fore, except after very long and fatiguing walks), nocturnal pain, 
 " starting of the limb," contraction of the joint, and a more 
 rapid atrophy of the muscles. When the bone becomes in- 
 volved, the neural response is unmistakable. The marked re- 
 flex spasm of the muscles occurs quite early in all inflam- 
 mations involving the epiphysis or bodies of the vertebrae, and is 
 almost uniformly absent, oris developed only to a slight extent, in 
 all true, chronic synovial inflammations. It has become an inter- 
 esting matter in this connection to study the origin of the nerves 
 which supply the vertebral bodies. It has been demonstrated 
 by Kolliker, Luschka and Kobelt, that the nerves which ter- 
 minate in the vertebral bodies can be traced not only to the 
 cerebral and spinal nerves, but also to the great sympathetic. 
 In this way does the irritation of the peripheral nerves supplying 
 not only the vertebral bodies, but also the larger epiphyses (for 
 the same thing has been demonstrated in connection with them) 
 give expression to such a variety of neural manifestations, viz., 
 pain, (which mayor may not find expression orally); a peculiar, 
 persistent and involuntary muscular spasm ; a pronounced and 
 direct atrophy of the muscles thus affected ; an agonizing and 
 piercing nocturnal cry, (which, however, may be present only 
 for a limited time), and a general, particularly a facial, express- 
 
POTT'S DISEASE. 2J 
 
 ion of suffering not always seen in the more especially fatal 
 chronic diseases of other tissues. In the same way may be ex- 
 plained the absence of these symptoms where a tissue with a 
 sparse neural basis * is attacked with the same chronic inflam- 
 mation. In other words these simple facts explain many im- 
 portant differences which exist between chronic osteitis and 
 chronic synovitis, and they form valuable aids in the differential 
 diagnosis of these two conditions, as I have pointed out in the 
 Clinical Lecture before mentioned. 
 
 The primary lesion in Pott's Disease gives marked evidence, 
 in all but exceptional cases, of these early and marked neural 
 symptoms. In chronic disease of the knee-joint, for instance, 
 we look for our first symptoms to the bone or synovial mem- 
 brane. The latter present only, at first, objective signs — with- 
 out any important subjective symptoms. In the spine we must 
 look to the bone for our first symptoms, for the intervertebral 
 discs, like the synovial membrane in the hip-joint, may, I 
 believe, continue in a state of degeneration for a long time 
 without giving any important evidence of the fact. The carti- 
 lage becomes primarily affected, in exceptional cases only. 
 Those cases in which I have been able to diagnose an acute, 
 fibro-chondritis, with suppuration, the patients have recovered 
 without any deformity other than a slight irregularity, with 
 rigidity, limited to two or three vertebrae, as before stated. I 
 can imagine, however, that the intervertebral fibro-cartilage 
 
 * It is probable that the great difference existing between the symptoms 
 of chronic osteitis and chronic synovitis which are here pointed out, arises 
 not only from the inequality of the neural distribution to these two impor- 
 tant joint factors, but also from the fact that the synovial membrane being 
 a simple tissue, like other serous membranes, and not a local nutritive centre, 
 like the epiphyses, does not possess such profound and intimate relations with 
 the great nerve centres. 
 
28 POTT'S DISEASE. 
 
 may become diseased without involving the bone. Brodie 
 states * that he has observed ulceration of the intervertebral 
 cartilage where the bones were " in a perfectly healthy state." 
 I can understand how a central osteitis may occur in a verte- 
 bral body without producing disintegration of the disc. But, 
 other things being equal, and the nbro-cartilage depending 
 for its nourishment upon the bone, it is very exceptional that 
 the initial lesion of either Pott's disease, or chronic osteitis 
 of the knee-joint, for instance, occurs in the cartilage. In any 
 event, in chronic joint affections, until the bone is involved, the 
 marked neural symptoms do not occur, and I may repeat here 
 the conclusion I reached in my study of the " Etiology and 
 Pathology of Chronic Joint Disease," viz. : that " reflex muscu- 
 lar spasm in chronic joint disease always indicates osteitis." 
 That this muscular spasm is always present, to a greater or less 
 extent in chronic osteitis affecting either the articular ends, or 
 the bodies of the vertebrae, I am assured. Its presence is due 
 to a direct pathological cause and is not " conservative " — a 
 fact which I have taught for the last two or three years at the 
 Orthopaedic Dispensary — and was, I believe, the first to point 
 out. This pathological, yet local, muscular spasm is easily 
 explained, and its purely reflex character may be demonstrated 
 by the administration of an anaesthetic — when, if the muscle 
 has not undergone structural change, the spasm will wholly 
 disappear, and the " fibrous anchylosis " gives way to a per- 
 fectly movable joint. In the early history of the spasm, the 
 patient can voluntarily exercise the affected muscles within 
 certain limits, as is illustrated in the case of spondylitis sicca 
 * Op. cit. 5th Ed., p. 301. 
 
POTT'S DISEASE. 2Q 
 
 seen with Dr. Sands ; but in the latter stages, the muscular 
 spasm does not permit the patient either to flex or extend the 
 joint. The muscles become, in the first stage, temporarily con- 
 tracted under the stimulus of extreme motion or pressure, and 
 in the last stage, this spasm may so fix the joint that no motion 
 can be detected by the most delicate examination, and this long 
 before the muscles become structurally shortened. 
 
 After all, viewed in the light of their symptoms there are 
 but few important differences between a chronic spondylitis, 
 and a chronic epiphysitis of one of the larger articulations. 
 The pain at the periphery of the spinal nerves — first noticed 
 by Brodie — has its analogue in the pain at the knee in hip-joint 
 disease. The reflex muscular spasm which renders the verte- 
 bral column, at the point of disease, very rigid, also finds 
 expression in the same localized, muscular spasm which occurs 
 in coxo-femoral osteitis. The hip joint is not only held rigid 
 by the muscular spasm, but the various positions assunied by 
 the thigh, producing the deformities in joint disease, are due to 
 the same cause. In some other respects the two conditions 
 resemble each other, but enough has been said regarding the 
 similarity of these two pathological states. That the symp- 
 toms are so nearly allied is, at least, corroborative evidence 
 that, in chronic disease of the articulations of the lower ex- 
 tremities, the lesion most frequently to be diagnosed is a chronic 
 osteitis, and not a chronic syitovitis. 
 
 Several practical deductions based upon many experiments 
 and observations of the phenomena of chronic diseases of the 
 hip and knee, may be of value here as bearing upon the 
 mechanical treatment, which I shall soon consider, of Pott's 
 
30 POTT'S DISEASE. 
 
 disease, ist. A severe examination of a diseased joint by mak- 
 ing forcible and extensive movements of the articulation, under 
 ether, is almost always followed by a decided aggravation of 
 the symptoms ; 2ndly ; If ether be administered with a view to 
 perform tenotomy of the contracted muscles, and the contrac- 
 tion disappears after the anaesthesia becomes profound, the 
 mere division of the tendons will accomplish but little, for the 
 spasm will recur as soon as the reflex power is recovered, and 
 the complete reunion of the tendon is a question of a few days 
 only ; 3dly ; So long as the joint movements are impeded by this 
 localized, reflex muscular spasm, during consciousness, and all 
 muscular resistance disappears under ether, an osteitis of, or 
 near, the articulation exists ; 4thly ; As in chronic epiphysitis, 
 so in chronic spondylitis, the reflex, tetanoid spasm yields to 
 ether, but not to such agents as morphine and chloral, if admin- 
 istered in the customary doses. 
 
 While suspension is employed now-a-days " to reduce the 
 deformity " of Pott's disease, it cannot, for reasons to be assigned 
 hereafter, do more than modify the compensatory curves, unless, 
 ether be administered after the plan of the German surgeons. If 
 this be done — and it cannot, in my opinion, be other than dan- 
 gerous, or at best, useless — it will be found that the pathological 
 curvature is more readily reduced, inasmuch as the reflex 
 spasm yields when an anaesthetic is administered. It is due to 
 the presence of this muscular spasm, during the process of sus- 
 pension without an anaesthetic, that more harm is not done by 
 the rejuvenated custom of using " the gallows " in the treat- 
 ment of Pott's disease. 
 
POTT'S DISEASE. 3 I 
 
 CHAPTER II. 
 
 TREATMENT. 
 
 It would be a very difficult matter to name the many writers 
 upon Spinal Deformities. From the earliest times the subject 
 has received the attention of the medical profession. The 
 searching analysis which many works upon deformities have 
 received in the columns of the Medico-Chirurgical Review con- 
 veys many wholesome lessons that might well be heeded by the 
 writers of the present day. The frequency with which these 
 essays appeared is illustrated by quoting from some of the 
 reviews in the periodical above referred to. In 1825, the 
 review of Bampfield commences with these words : " Of late 
 years works on the Spine have presented themselves in as 
 regular succession as the ghosts of Banquo." — In 1831, Beale 
 is reminded that " works on this subject have been surprisingly 
 numerous of late years." — And in 1852, a carefully prepared 
 analytical review of Bishop, Tamplin, Verral, and Godfrey has 
 this initial sentence : " Each successive year produces its crop of 
 books on Deformities just as regularly as the strawberries ap- 
 pear in June." The reviewer then states : "The burden of the 
 whole of them is nearly the same ; there may be an exception 
 here and there, but the vast majority of them speak as follows :. 
 * * * The author has met with unexampled success in 
 this department of his profession, and * * * has invented 
 
32 POTT'S DISEASE, 
 
 (some of them call it discovered^) an instrument which he can 
 guarantee will screw the most crocked back straight again. 
 Many other persons profess to do this, and perhaps honestly 
 think they can do it ; and far be it from the author of this 
 veracious treatise to insinuate that they are quacks. He owes 
 a duty, however, to the public ; and he regrets to say that a 
 short time ago he saw a deplorable instance of the mischief 
 which had been produced by the machine of Mr. A. of 
 B Square, and that he was recently consulted by a lady whose 
 daughter had been under the care of Messrs. C. D. E., and 
 also the aforesaid A., but who had derived no benefit from 
 their prolonged and expensive attendance. It was his better 
 fortune, however, owing to the more scientific principles upon 
 which he went to work, to achieve a more favorable result ; in 
 this instance, one of the worst he had ever witnessed, the 
 patient has been restored to her sorrowing friends and is now 
 the life of her social circle, the most active among the active, 
 and the sweet dispenser of the best form of charity — in the 
 shape of advertisements and recommendations to the author 
 and his establishment." * 
 
 It would seem that the practice of attempting to enhance 
 one's reputation by publicly commenting on the alleged ill 
 success of others — a proceeding which many of our profession 
 witnessed in this city not long ago — does not possess even 
 the merit of originality. 
 
 I have been fortunate enough to obtain a very consid- 
 erable number of works upon spinal deformities. A careful 
 perusal of them leads me to express surprise that so little at- 
 
 * British & Foreign Medico-Chirurgical Review . Vol. X, T852, page 164. 
 
POTT'S DISEASE. 33 
 
 tention has been paid by the vast majority of their authors to 
 the actual pathology of the diseases which produced the 
 deformities. Had the pathology of the different lesions been 
 studied more carefully before the treatment was devised, there 
 would have been far fewer " machines " and much less suffer- 
 ing would have been inflicted by the various, crude appliances 
 that are pictured in the works of many writers, even of recent 
 date. It has been the habit of many of these authors to ignore 
 the pathology, and to then " devise " a mechanical treatment. 
 They have apparently looked upon the distorted spine as a 
 mechanic would contemplate a curved, metallic bar, which needed 
 only a certain degree of force to straighten it. But, as the 
 spines are bent in obedience to a mechanical law — of course — 
 but not from a primary mechanical cause, the curvatures, in 
 many instances, went on progressively just as if they had not 
 been treated from an empirical standpoint. And herein, in my 
 opinion, lies not only the error of the past, so far as the scientific 
 treatment of spinal curvatures is concerned, but also the danger 
 of the future. It is a proposition which, I think, can be easily 
 demonstrated, that errors of form which do not involve vital 
 parts, and which are due to, strictly speaking, mechanical causes 
 alone, need, as a rule, mechanical treatment only. But the 
 deformities of the spine having their origin in the lesion which 
 produces Pott's disease, and in the primary change which 
 ultimates in the typical and progressive rotary lateral curvature, 
 have many elements which cannot, I am convinced, be ex- 
 plained upon any mechanical or traumatic basis. We are apt 
 in Orthopaedy, as in other departments of Medicine to confound 
 cause and effect \ and thus a series of etiological errors have 
 
34 POTT'S DISEASE. 
 
 arisen, based upon mechanics and traumatism, which cannot 
 be too soon removed. Years of study and exploration will 
 probably pass before many of these errors can be removed. 
 In the meantime various opinions will be held ; — the human 
 body will be looked upon, by some, as a simple series of 
 mechanical actions, and " machines " will be made with the 
 object of accomplishing the impossible. Mechanical " demon- 
 strations " of the etiology of lateral curvature, for instance, 
 illustrated in the dried and mounted vertebral column, and 
 arranged with obedient springs and checks, cannot represent 
 the curving spine with its multiplicity of functions and levers, 
 and the vital force controlling and operating them ; — nor can 
 the progressive deformity of Pott's disease be explained upon 
 the basis of traumatism and gravity. The agencies at work in 
 the production of spinal curvatures — whether lateral or pos- 
 terior — would operate, I am convinced, in many cases, were 
 both these elements removed ; and while they both become very 
 important factors after the lesion is established, we must look 
 further and deeper for our primary cause. 
 
 In entering directly upon the treatment of Pott's disease, 
 I shall avail myself, as I did in studying its pathology, 
 of my experience in treating analogous inflammations of 
 the larger articulations. There are so many points in com- 
 mon, as relating to the etiology, pathology and symptoms 
 of these two conditions of chronic spondylitis and chronic 
 epiphysitis in children, that it would be difficult to consider the 
 one condition, in the present state of our knowledge of these 
 diseases, without drawing conclusions based upon our observa- 
 tions, both clinical and pathological, of the other. 
 
POTT'S DISEASE. 35 
 
 The difficulties in the way of successfully treating Pott's dis- 
 ease mechanically are, sometimes, very great. If we were deal- 
 ing with a simple traumatism as a cause, and gravity as a second 
 factor, the mechanical treatment of Pott's disease would present 
 scarcely greater difficulties than the mechanical treatment of frac- 
 ture, for instance. Unfortunately, as I have pointed out when 
 considering the pathology of this lesion, we have to deal with a 
 very insidiously progressive disease, where very important fac- 
 tors in the production of the increasing deformity have been either 
 ignored or overlooked by those who claim that the lesion has a 
 traumatic etiology. And I may also say that many of those who 
 have regarded the disease from a constitutional standpoint have 
 also disregarded certain pathological conditions which contri- 
 bute to the progressive character of the disease. A progressive 
 inflammation, involving a gradual loss of substance — whether by 
 a process of " regressive metamorphosis," which ultimates in a 
 flocculent discharge, or a fungous proliferation unaccompanied 
 by suppuration, and occurring in such a tissue as we have found 
 the vertebral bodies and the epiphyses to be, — must, it seems 
 to me, be accompanied by peculiar manifestations. I have 
 tried to point out what some of these manifestations are, and 
 to trace their relation to the lesion. It is the pathological value 
 of these symptoms to which I wish to call attention among 
 other matters, in pointing out the mechanical difficulties which 
 present in the treatment of chronic spondylitis. 
 
 And first let me ask, is there any mechanical treatment which 
 can wholly cover the pathological condition met with in a typi- 
 cal case of Pott's disease ? Can we expect any mechanical 
 treatment to always, or even as a rule, cure a progressive lesion 
 
36 POTT'S DISEASE. 
 
 of such magnitude as that we have attempted to describe ? Are 
 we justified in claiming that we can accomplish any more, by 
 an artificial mechanical appliance, in an osseous disease where 
 motion acts as a great factor in aggravating the symptoms, 
 and where the lesion exists in a tissue especially endowed with 
 vessels and nerves, than we can in a somewhat analogous patho- 
 logical condition in the shaft of a long bone when the mechani- 
 cal treatment is supplied by nature herself ? There are those 
 who claim that we can. I differ from the gentlemen who 
 make the assertion that Pott's disease is traumatic in its 
 origin, and hence quite easily cured, and I do not deem an 
 apology necessary in this connection for the statement that my 
 conclusions are founded upon an experience which is based 
 upon an aggregate of many thousand cases of joint and spinal 
 disease, the histories of over four thousand of which were 
 either recorded by myself, or taken under my personal instruc- 
 tion. 
 
 . What then should be the indications for the mechanical treat- 
 ment, for all will admit, in any event, that the elements of loco- 
 motive traumatism and gravity, after the lesion is established, 
 make mechanical treatment of some kind absolutely necessary ? 
 Perhaps I can better answer this question, after experiments 
 directly bearing upon this point, by stating what they should not 
 be. 1 st. Mechanical treatment, either in the spine or larger 
 joints should not be used with the idea of overcoming the mus- 
 cular resistance. We may succeed in antagonizing the muscular 
 spasm to a certain extent, but it cannot be annulled by any 
 mechanical therapeutics we may devise. As I have previously 
 stated, neither morphine nor chloral, even in quite large doses, 
 
POTT'S DISEASE. 37 
 
 perceptibly modifies this tetanoid spasm in a well developed case. 
 2ndly. The traumatism of suspension, like the traumatism of 
 forcible examination in articular osteitis of the hip, has in my 
 own experience, in some cases, aggravated the lesion, increased 
 the subsequent muscular resistance and intensified the pain. I 
 have seen irreparable damage inflicted by an unnecessarily severe 
 examination of a suspected hip joint under ether, and I have 
 known more than one case where the error was made of eliminat- 
 ing any joint lesion because " stiffness of the joint " relaxed un- 
 der an anaesthetic. Even more — I have had cases under my 
 care, where the surgeon previously in charge of the case had 
 diagnosed an " hysterical joint," a sciatica or a rheuma- 
 tism — for the same reason. It is a fact which cannot be 
 mentioned too often, that the reflex spasm of the muscles 
 in chronic osteitis of the larger articulations will yield to 
 ancesthetics only, and that the ancesthesia produced by ether or 
 chloroform suspends all the really important symptoms upon which 
 we should rely for our diagnosis, especially in the early stages of 
 the lesion. Hence, as a rule, ether should not be administered 
 in joint disease for diagnostic purposes, except to eliminate 
 doubtful points, and for the purpose of ascertaining the condi- 
 tion of a joint with reference to exsection. Some German sur- 
 geons have recently administered anaesthetics in cases of Pott's 
 disease, prior to the application of the plaster jacket. Under 
 these circumstances it is found to be a comparatively easy 
 matter to reduce the pathological curvature. We see here, 
 again, the effect of anaesthesia upon the muscular spasm, for, 
 without ether, I have never seen the true pathological curve re- 
 duced by suspension. This procedure, which I have often 
 
38 POTT'S DISEASE. 
 
 wished to test but never cared, for obvious reasons, to attempt, 
 has determined a question which would still remain unset- 
 tled without some such demonstration. It proves that the - 
 weight of the body, acting as a counter extending force 
 during suspension, is not sufficient to modify the curvature due 
 to the lesion itself, while if, under the same circumstances, ether 
 be administered, the projection is more easily reduced. If, in 
 the first instance, the kyphosis remained unchanged from ad- 
 hesions which had taken place, it would have remained so 
 under ether, other conditions, of course, being equal, and the 
 modification of the true curvature under anaesthesia demon- 
 strates, to my mind, with a multitude of similar experiences 
 in the hip and knee, that the reflex muscular spasm is as 
 important a symptom in chronic spondylitis as it is in chronic 
 epiphysitis, and that it bears the same relation to the lesion. 
 
 With these preliminary remarks, I will proceed to detail the 
 results of my experience in the mechanical treatment of Pott's 
 disease, and to consider the two most prominent methods now 
 before the profession. 
 
 The mechanical treatment of the two conditions most frequent- 
 ly mentioned in this essay, viz., Pott's disease and hip-joint dis- 
 ease, varies with the widely different functions performed by the 
 structures involved. In hip disease, for instance, we have a 
 lesion involving only one articulation, and as, anatomically, 
 there are excellent opportunities to make both extension and 
 counter-extension, we can so apply our force against the 
 tuber ischii as to produce that kind of fixation which relieves 
 much of the pain, antagonizes, to a greater or less extent, the 
 muscular spasm, and places the joint under the best local con- 
 
POTT'S DISEASE. 39 
 
 dition for repair. But the spine does not offer any anatomical 
 facilities to apply such a method of treatment, and it is 
 absolutely impossible to apply a continuous extension and 
 counter-extension which can be maintained with any degree of 
 success.* It would be an especially difficult task to so direct 
 the extension that the ultimate force would be expended upon 
 the diseased bones alone. Let us suppose, for instance, that 
 six or eight bones are diseased, the intervertebral discs 
 disintegrated and the ligaments badly implicated, as is not 
 unfrequently the case, how could we be assured that the exten- 
 sion reaches all the diseased tract ? When extension by means 
 of suspension is applied, as it frequently is now-a-days, to the 
 whole vertebral column from the first cervical vertebra down, 
 in cases of spinal disease and the curvatures resulting there- 
 from, how much of the apparent change that takes place in the 
 projection is due to the effect produced upon the projection it- 
 self? It is a well-known fact that our height is increased in the 
 morning after a few hours' rest in the recumbent position. Ex- 
 tension made through the healthy intervertebral fibro-cartilages 
 and the other structures binding the vertebral bones together, for 
 a few moments only, is capable of lengthening the vertebral col- 
 umn to a very considerable extent. How much one-half hour's 
 extension or suspension would stretch these healthy tissues I do 
 not know. But when the extension is applied to the healthy 
 spine the normal curves are also obliterated and the spinal 
 column becomes straight, as it is in early infancy. When the 
 same force is applied where a portion of the vertebral column 
 
 * I have had no occasion to change my opinion regarding this statement, 
 even after reading Dr. Wyeth's paper on " The treatment of Spinal Curva- 
 ture by Continuous Extension." — See The Hospital Gazette, Jan. 30th, 
 1879. 
 
40 POTT'S DISEASE. 
 
 is diseased, the compensatory curves which result from the 
 changed centre of gravity are also greatly modified, and the 
 deformity is thus placed under far different relations to the 
 healthy parts of the spine, and without, in my own experience, 
 affecting, to any appreciable extent, the true, pathological 
 curvature. In other words, the change is apparent rather than 
 real, and the great increase in height noticed after a suspension 
 of this kind, is due to the extensibility of the unaffected 
 structures, and the obliteration or modification of the compen- 
 satory curves. There can be no actual lengthening of the 
 vertebral column except that which comes from the elastic 
 nature of the ligaments and fibro-cartilage. If, after applying 
 suspension, the projection should decrease it is due to the 
 separation of the diseased osseous surfaces at the expense of 
 pressure upon the articular processes — making a lever of them, 
 in other words, the weight of the body below forming the 
 resistance, and the cervical region being the seat of the applica- 
 tion of the suspending power. If suspension separates the 
 bones, it does so at the risk of breaking up any reparative 
 process that may have begun, and I am inclined to think that 
 , it may accomplish more, in this respect, than is advisable in ad- 
 vanced cases, and if this same force be used, the tetanoid spasm 
 of the muscles prevents, in a great measure, separation of the 
 diseased surfaces in the more recent cases.* 
 
 * If we place a patient with hip disease upon a soft mattress in the supine 
 position, and after flexing the thigh and grasping the pelvis, attempt rotation 
 of the hip joint, we find, in many instances, that little or no motion can 
 be developed in this direction. If the case be one of caries sicca, I find it 
 happens very frequently that, after having made this test, the limb be al- 
 lowed to lie quietly upon the mattress for a few moments, quite a degree 
 of rotation can then be developed, if the entire limb be allowed to rest upon 
 the bed, and only a gentle force be applied at the knee. 
 
POTT'S DISEASE. 41 
 
 Recumbency, in the prone position for a few moments, will 
 produce all the " separation " necessary ; indeed, all the " sep- 
 aration " required is that which produces an adequate modifica- 
 tion of the injurious pressure or contact. This gained, we have 
 accomplished just as much, as a matter of treatment, as if we 
 had actually drawn the bones asunder, and the gap thus 
 created by, what must necessarily be, forcible means, cannot, I 
 am convinced, be filled by osteophytic action. 
 
 I have seen cases where the projection apparently decreased 
 
 under the extension produced by suspension.* I confess that 
 
 in these cases I have proceeded very carefully with the plastic 
 
 envelope. But these patients have done no better than others. 
 
 My experiments have proved to me that the weight of the body 
 
 below the point of disease could not overcome the reflex muscular 
 
 spasm which resists our mechanical efforts to overcome it. It is, 
 
 probably, very fortunate that this is so, for even if the spine could 
 
 be straightened it would lead to false hopes of a speedy cure ; and 
 
 what right have we, even if continuous extension and counter 
 
 extension could be accurately maintained, as in cases of hip and 
 
 knee-joint disease, to expect that we could cure spinal caries any 
 
 more rapidly than either of these former conditions, which, even 
 
 under favorable circumstances, may take years to accomplish ? 
 
 Another fact I have noticed is, that when patients return for a 
 
 second application of the plaster jacket, I have found, before 
 
 * I am convinced that this apparent decrease arose from the fact that the 
 compensatory curves were so great, producing such a marked effect when 
 suspension was used, as to leave the impression that the pathological curva- 
 ture had been actually reduced. If only two vertebrae are diseased, for in- 
 stance, the resulting posterior curvature may seem to involve the three or 
 four contiguous bones above and below. It is especially under these circum- 
 stances that I have found such marked changes without affecting, in reality, 
 the real projection. 
 
4 2 POTT'S DISEASE. 
 
 the old apparatus was removed and suspension again applied, 
 that the spine had fallen back, to its old position, or nearly so. 
 It is certain that a comprehensive mechanical extension in a typi- 
 cal case of dry osteitis of the hip or knee joint does no more than 
 to slightly modify the reflex muscular spasm,* Suspension or 
 extension, even if they could be made continuous, can do no 
 more in Pott's disease. Some years ago it was the custom to 
 treat hip joint disease by applying a plaster of Paris splint, 
 after extending the limb. This plan was thoroughly tried, 
 found useless and abandoned. It would be as scientific, in the 
 present state of our knowledge of the pathology of hip joint 
 disease, to suspend the patient by the leg while we put a plaster 
 jacket on his hip, as to expect, by simply suspending the patient 
 by the upper vertebrae, making him (we will say), one or two inches 
 taller at the expense of healthy tissues and the modification of 
 the compensatory curves, and then permitting the spine to 
 gradually sink back into its old position, we could cure spinal 
 caries more rapidly than by a more reasonable and a more 
 scientific method. f 
 
 To those who have had a considerable experience in the 
 treatment of chronic articular diseases, and more especially 
 Pott's disease, I am, I know, expressing a very common expe- 
 
 * That "extension with motion " is a fallacy in the mechanical treatment 
 of chronic osteitis of the hip or knee, is very easily demonstrated. 
 
 \ A case now in my service at St. Luke's Hospital will illustrate some of 
 these points. The patient, a boy of 6 years, has Pott's disease in the dorso- 
 lumbar region, involving four vertebrae. In the course of five months I ap- 
 plied three plaster jackets, carefully and snugly, after suspension. When the 
 first jacket was removed, the projection was evidently larger, and this was 
 the case after each of the others had been taken off, until, when the last one 
 was removed, the deformity had increased nearly f of an inch. The patient 
 was carefully watched, and I personally inspected the jacket several times a 
 week during the treatment. 
 
POTT'S DISEASE. 43 
 
 rience when I say that the application of almost any support 
 which acts upon correct principles, affords almost instantaneous 
 relief. In some cases the primary effects are almost magical, 
 and are apt to mislead those to whom the scientific, mechanical 
 treatment of articular diseases is a novelty. In dispensary 
 and hospital experience — as well as in private practice — I 
 have frequently had occasion to remark this fact. But reliev- 
 ing the symptoms and curing the disease are two very different 
 matters. Treatment by the gypsum bandage forms no excep- 
 tion to the rule which applies to the other forms of apparatus — 
 or, indeed, which applies to any local measures adapted 
 to the treatment of a constitutional disease. The same 
 may be said of the actual cautery in Pott's disease — 
 it affords temporary relief in many cases — but it cannot be 
 called curative any more than any other form of efficient 
 counter irritation. It has been my experience, for instance, to 
 apply a plaster jacket to a patient — a little boy (not the one re- 
 ferred to in the last foot note) in my service at St. Luke's Hos- 
 pital. It was, apparently, a favorable case, and one where a good 
 result might be anticipated. The disease was in the lower dorsal. 
 His breathing became better after the jacket was applied, pain 
 was relieved, the patient walked with a firmer tread, and, to the 
 uninitiated, the result promised brilliantly. I had seen too 
 many other cases, however, of similar character treated by 
 various methods, which progressed in the same satisfactory 
 manner for awhile, to expect too much of any local treatment. 
 The patient died in a few months from amyloid degeneration. 
 I have seen many cases of Pott's disease, promising cases too, 
 improve at first very markedly under Taylor's antero-posterior 
 
44 POTT'S DISEASE. 
 
 support,* only to find in a few weeks that the psoas magnus 
 was contracting as a premonitory symptom of abscess, or 
 some other complication presented which would cause those 
 who might formulate a brilliant prognosis in the early history 
 of the mechanical treatment, to very materially modify their 
 opinion. This much may be stated as the result of my 
 clinical experience, — suspension, with the application of the 
 plaster jacket is not so likely to cure caries of the vertebrae 
 as would the same methods applied to caries of the larger joints. 
 The fact is that, after a chronic disease has been once set up in a 
 vertebral body or an epiphysis, there is nothing that aggravates 
 the morbid process, or produces pain and suffering, more, than 
 the traumatism which results from the movement and pressure 
 which is imparted by locomotion. It not unfrequently happens 
 that about all that any apparatus accomplishes is to prevent this 
 traumatism, and in this way to modify, or greatly mitigate, the 
 symptoms. So in Pott's disease, apparatus rightly constructed, 
 be it of steel, or plaster, prevents motion at the point of dis- 
 ease. But the disease still exists, and although the apparatus 
 places it under conditions favorable to recovery, the result, not 
 unfrequently, is beyond our control. If Pott's disease were 
 traumatic in its origin, as many seem inclined to believe, no 
 doubt a speedy cure would result under any comprehensive 
 local treatment embodying correct principles. 
 
 * To avoid repetition and ambiguity, I will here state that when the 
 phrase " antero-posterior support " is used in the subsequent pages, that form 
 of apparatus which embodies the principles of the " Taylor's spinal 
 assistant," or the "Davis spinal brace" is indicated, unless other- 
 wise specified. In like manner, " plaster jacket " refers to the method and 
 apparatus which were first used by Dr. Bryan in the treatment of Pott's 
 disease, and subsequently introduced to the profession by Dr. Sayre. 
 
POTT'S DISEASE. 45 
 
 I would say a few words more regarding the great relief that 
 follows the use of a properly adjusted apparatus in Pott's dis- 
 ease. It is so marked in many cases, that the friends of the 
 patient look forward to a rapid cure. Sometimes, — not rarely, 
 I am sorry to say, — the surgeon lacking experience, or, it may be, 
 being too enthusiastic regarding a favorite method, finding all 
 subjective symptoms removed and an apparently arrested de- 
 formity, proceeds to remove the support, and to discharge the 
 patient as cured. Following some slight indiscretion, perhaps, 
 — but this is not always necessary — a relapse undeceives 
 both patient and surgeon. These are very unpleasant facts 
 but clinically they need no demonstration. A very considera- 
 ble experience with the plaster jacket and other methods of sup- 
 port, warrants me in saying that I do not believe any apparatus 
 is capable of accomplishing such uniformly good results as 
 those claimed for the jacket. I have seen many excellent 
 results follow the use of the antero-posterior support long 
 before the introduction of the plaster jacket. A conscien- 
 tious use of the latter shows inferior results, and the ap- 
 paratus is open to objections which will be mentioned later. 
 
 It is attempted, in using the gypsum bandage in the treatment 
 of Pott's disease, to maintain that position of the spine which is 
 acquired by suspension, by means of the plastic material em- 
 ployed. For the reason that the bandage encircles the thorax 
 and abdomen, it cannot, as a bandage, pass above the axillae. 
 It becomes obvious, that, as a support, the plaster jacket,/*?/- 
 se, ceases to be operative above the seventh dorsal vertebra. 
 (Of 666 cases of Pott's disease treated at the Orthopaedic Dis- 
 pensary prior to 1876, 516 were either cervical or dorsal^. How- 
 
46 POTT'S DISEASE. 
 
 ever, in order to make the gypsum base operative for disease 
 in the upper dorsal, and cervical regions, a curved iron bar is 
 imbedded, by Dr. Sayre, in the plaster and passed over the 
 head,* with which the attempt is made to extend the spine, or 
 to support the head by a submaxillary and an occipital strap. 
 That this method must prove inoperative as an effective means 
 of extension is obvious, for what child could, or would, 
 tolerate an absolute extension force to the head for a 
 length of time sufficient to cure a spinal caries, at, for instance, 
 the second to sixth dorsal, the region most difficult to control 
 in the whole vertebral column ? This ungainly and defective 
 apparatus, as a means of support, cannot be compared to the 
 light and comfortable chin piece devised by Dr. Taylor, which 
 makes the treatment of cervical caries one of the pleasures 
 of the orthopaedic surgeon. In any event we would discard 
 the plaster above the seventh dorsal, which limits its use to only 
 ten of the vertebrae, and these ten, the five lower dorsal and the 
 five lumbar, are the most easily controlled and supported by 
 any apparatus. As shown by the statistics quoted above, these 
 ten vertebrae are not so likely to be affected as are the other 
 fourteen. 
 
 I may state, further, my views in general upon the compara- 
 tive merits of the antero-posterior support and the plaster jacket. 
 The former acts scientifically upon the principle of a lever with 
 the fulcrum at the point of disease. The points of pressure 
 are the pelvis, which forms the basis of support ; the transverse 
 processes of the diseased vertebrae and those immediately con- 
 
 * This " jury-mast" is pictured in Shaw on 44 Distortion of the Spine," 
 Supplement, 1825, page too. 
 
POTT'S DISEASE. 47 
 
 tiguous to them, (the fulcrum}, and the anterior, superior wall of 
 the thorax and the axillae, (the resistance). A sufficient power 
 is thus maintained, through the medium of the two uprights of 
 the apparatus, to support the spine in the position acquired 
 by recumbency. In my own hands (though it is not per- 
 fect), it has accomplished many excellent results in the treat- 
 ment of Pott's disease, without any of the objections which 
 pertain to the plaster jacket. It can be easily applied and it 
 requires no more training or ability to adjust it intelligently and 
 effectively, than it does to apply a gypsum bandage. A coun- 
 try practitioner, with a village blacksmith (though this is not 
 necessan could treat any case successfully with a few practical 
 hints, which would be materially strengthened, of course, by a 
 clinical demonstration. The many advantages which the 
 antero-posterior support possesses (especially the modification 
 I have used), will, I hope, induce many to use it who have per- 
 haps, been led to infer from the exaggerated statements of 
 the foremost partisans of the plaster treatment, that the gypsum 
 bandage forms the basis of the only scientific mechanical 
 treatment. 
 
 The principal advantages of the antero-posterior support are, 
 i st. The ease with which it can be adjusted, and the great 
 comfort experienced by the patients who wear it. 2ndly. It can 
 be removed with safety at any time by placing the patient in the 
 prone position, when such modifications can be made as are 
 necessary to the comfort of the patient, or the treatment of the 
 case. 3rdly. The concentration of the requisite pressure at 
 suitable and convenient points without interfering with 
 transpiration or respiration, and finally, the cleanliness and 
 
4§ POTT'S DISEASE. 
 
 lightness of the whole apparatus ; matters which certainly ought 
 to be consulted in a long and necessarily tedious treatment. 
 
 On the other hand, the objections to the plaster jacket are, 
 i st. Its great weight and the necessary occlusion of so large an 
 area of skin. 2ndly. The great danger of excoriations which 
 may develop any time and remain hidden for many days or 
 weeks. 3rdly. The absolute necessity of suspension each time 
 the curvature is inspected or the patient cleansed. 4thly. Its great 
 filth, and lastly, its failure to accomplish, in the great majority 
 of cases, for reasons I have assigned, the objects for which it 
 applied. Among those who are able to purchase a steel support, 
 there is certainly no necessity for the adjustment of a plaster 
 jacket, for the simple reason that all that the plaster apparatus ac- 
 complishes and more beside, can be accomplished by a suitably 
 adjusted and accurately fitting antero-posterior support ; while 
 among the New York City poor, where so many are huddled 
 together in tenement houses, and absolute cleanliness is 
 very difficult of attainment, a plaster jacket soon becomes a 
 nest for all sorts of vermin. Several dispensary patients 
 have begged me to remove the jacket on this account, 
 and more than one, after repeated trials, has declined to 
 have the plaster splint readjusted, because the projection 
 steadily increased under its use. 
 
 I have earnestly endeavored to weigh the merits of the 
 plaster jacket as a mechanical aid in the treatment of Pott's 
 disease. I regret that I can find so little to commend, and so 
 much to condemn, regarding its use. I can safely say that 
 with less trouble, though at a little greater expense, much more 
 satisfactory results can be obtained by the intelligent use of 
 
POTT'S DISEASE. 4'J 
 
 the antero-posterior support. I do not mean to say that the 
 gypsum splint should be wholly discarded in the treatment of 
 Pott's disease. It may be made very useful — where the 
 pecuniary condition of the patient will not permit the expendi- 
 ture of the small amount necessary to purchase a suitable 
 antero-posterior support — in the comparatively limited number 
 of easily controlled cases occurring below the seventh dorsal. 
 In this region, if applied by the surgeon himself, it affords a much 
 better support than any other form of apparatus, adjusted by an 
 instrument maker at the request of the physician, who, through 
 inexperience or indifference, delegates this essential part of the 
 treatment to the uneducated mechanic. It is not the fault, 
 either of the medical profession at large, or the students who 
 are now attending lectures, that they have not been, and are 
 not taught, comprehensively, the subject of mechanical thera- 
 peutics as applied to the treatment of chronic and progressive 
 deformities. Dr. Sayre,*for instance, places himself on record 
 as saying that he employs the plaster jacket " to the exclusion 
 of all other methods of local treatment " * in Pott's disease. 
 Among the other teachers of general or orthopaedic surgery in 
 our colleges I have not succeeded in finding one who gives a 
 systematic course of instruction upon the various and complex 
 mechanical indications to be met in the treatment of this 
 insidiously progressive lesion. Instrument makers, who make 
 no pretensions to special training or anatomical knowledge ; 
 mechanics who know nothing whatever of the pathology of the 
 disease, are the source to which many practitioners look for 
 
 * Spinal Disease and Spinal Curvature. By L. A. Sayre, M.D. Smith, 
 Elder & Co. 1878. Page I. 
 
50 P07'T y S DISEASE. 
 
 assistance or advice, after leaving college, in treating a case of 
 joint disease. And some of these mechanics, being under no 
 obligation whatever to follow the ideas of the surgeon who first 
 devised a given splint for any purpose, are very prone to intro- 
 duce so-called" improvements," which, in many instances, render 
 the apparatus practically inoperative. And hence it sometimes 
 occurs that a general practitioner, even if he wishes to use a 
 given form of apparatus, is not certain to obtain the appliance 
 he seeks. 
 
 I have no doubt that much of the ill repute that attaches to 
 many forms of apparatus, and many of the failures that have 
 resulted from their use, have arisen from one or both of these 
 causes. And this state of things will continue, and many valu- 
 able aids will be lost to the profession, until the student is 
 taught with system and detail, in the various medical colleges, 
 to do with all forms of apparatus, which have proved of value 
 in the treatment of deformities, as he* has been taught to do 
 w T ith the plaster jacket, viz., to first understand the principle of 
 the application of the apparatus, and then to perform his own 
 work untrammelled by untrained mechanicians. Upon this 
 basis the surgeon will find that the treatment of any case of 
 Pott's disease, with an efficient form of antero-posterior support 
 will prove far more satisfactory to himself, and far more com- 
 fortable to his patient, than the gypsum apparatus, which 
 not only necessitates injurious procedures in its application, 
 but which fails, for reasons already pointed out, except in a 
 limited number of cases, to accomplish satisfactorily the object 
 for which it was devised. 
 
 Clinical experience has taught me to divide the vertebral 
 
POTT'S DISEASE. 5 I 
 
 column into three regions, so far as the mechanical treatment 
 of spinal caries is concerned. The first region includes the 
 lumbar and the last five dorsal ; the second comprises the first to 
 the seventh dorsal, — both inclusive ; and the third includes all 
 the vertebrae above the first dorsal. The mechanical treatment 
 of chronic spondylitis in these three regions presents either pecu- 
 liarities or difficulties which modify not only the treatment 
 but also the prognosis. I feel warranted, therefore, in calling 
 especial attention to them. 
 
 When the disease occurs in the first region (the dorso-lum- 
 bar) the mechanical problem is very simple. It is compara- 
 tively easy to adapt any of the various antero-posterior sup- 
 ports in use with the effect of preventing any considerable 
 increase of deformity. With a tolerably firm pelvic base, the 
 axillae and the antero-superior wall of the thorax (being situ- 
 ated higher up than the diseased point) may be made the 
 means of maintaining the requisite degree of fixation and sup- 
 port. As a rule also, Pott's disease, occurring in this region 
 requires the minimum amount of watching, and the greater 
 number of cases reported, by many writers, as cured, are selected 
 from this region. 
 
 In cases involving the middle region (the superior dorsal) we 
 find many difficulties presenting in the way of securing an ade- 
 quate degree of fixation. The indications are to support a 
 rigid projection in the middle of an, otherwise, flexible column. 
 In addition to this, we have to contend with the constant trau- 
 matism which results from the respiratory movements of the 
 ribs. In this region it is very difficult to adapt any apparatus 
 which will satisfactorily meet all the indications. The antero- 
 
52 
 
 POTTS DISEASE. 
 
 posterior support, starting with the pelvic base, sends a long 
 arm to the projection, and its efficient leverage is affected by 
 the fact that the upper arm, held by the superior thoracic and 
 axillary straps, is too short to exert an adequate counter-pres- 
 sure. If we surmount the antero-posterior uprights with any 
 
 Fig. i. 
 
POTT'S DISEA SE. 
 
 53 
 
 conceivable head-rest, we cannot, even then, secure the verte- 
 bral column satisfactorily. The plaster jacket, in this region, 
 as I have already pointed out, is inoperative, and the ungainly 
 "jury mast," — which I saw used in the Hospital for the Rup- 
 tured and Crippled, as long ago as 1863 — exerts no competent 
 
 Fig. 2. 
 
54 POTT'S DISEASE. 
 
 force. Taylor's chin piece, acting as a long, superior arm of 
 the lever, affords the best medium, in my own experience, of 
 securing efficient support ; — not by extending the spine, as some 
 have thought ; nor yet by acting as a, strictly speaking, antero- 
 posterior support, as has been advanced by others. Recession 
 of the inferior maxillary occurs if it be used continuously on 
 the latter principle. It has answered best, in my hands, as a 
 simple, but firm and unirritating head rest, limiting the anterior 
 flexion of the head and spine, and removing the greater part 
 of the weight from the vertebral column. 
 
 In the third region (the cervical) the mechanical elements 
 again become much easier of adaptation, and some of the 
 best results I have ever witnessed in Pott's disease have been 
 obtained in this region by the use of the chin piece surmount- 
 ing the two lateral uprights of the antero-posterior support. The 
 objection to the use of a plaster base, simply for the purpose of 
 mounting a "jury mast " upon it, must be evident to any one, 
 when some simple support laced to the body, such as Knight's 
 apparatus, would answer the same purpose and allow also of 
 frequent ablutions. But as it has proved inoperative in my 
 own hands, and as it is not only ugly in appearance, but 
 inflicts unnecessary pain and humiliation upon the patient, I 
 have discarded it. 
 
 In the treatment^ of Pott's disease in the first region, I have 
 found a modification of Taylor's antero-posterior support, 
 secured with a plaster zone, to answer an excellent purpose. 
 This apparatus is pictured in figs. Nos. i and 2. 
 
 It consists (Fig. 1) of the pelvic band, A, to which are 
 riveted two perfectly plain uprights, B B, of annealed bar 
 
POTT'S DISEASE. 55 
 
 steel, which uprights extend to the shoulder pieces, D D, and 
 are steadied at a point opposite the scapulas by the cross pieces, 
 E E. There are no " pad plates," " hinges " or " screws " about 
 this apparatus at all, and the pads at C C, are simple rolls of can- 
 ton flannel stitched to the uprights by transverse threads, shown 
 in the engraving. jP, represents the location of the deformity, 
 and E E E E, shows the plaster zone securing the uprights in firm 
 contact with the tissues lying over the transverse processes. 
 
 Fig. 2 illustrates the anterior appearance of the apparatus. 
 E JF\ are the shoulder straps passing from the ends of the 
 shoulder pieces, D D (Fig. i), to the buckles, H H, in Fig. i. 
 y, is a piece of padded webbing crossing the anterior and 
 superior wall of the thorax. It is secured at G G, in Fig. i. 
 Z, is also a piece of padded webbing, which completes the 
 circumference of the pelvis by fastening at the buckles attached 
 to the pelvic band A. (Fig. i). K represents the anterior 
 appearance of the plaster zone. 
 
 At D D, (Fig. i) and at ^ S y (Fig. 2) are the shoulder pieces 
 which an eminent Professor of Orthopaedic Surgery has spent 
 so many hours in condemning. It is claimed, by him, that they 
 exert a pressure downward upon the tissues underlying them, 
 and thus increase, rather than diminish, the pressure upon the 
 diseased vertebral surfaces. The object to be accomplished 
 by these shoulder pieces, as used by myself, is directly the 
 reverse of that so frequently stated by Dr. Sayre. Properly 
 used, they prevent pressure, and serve as points of attach- 
 ment for the axillary straps, so that these axillary straps, in 
 passing over the shoulders, shall not exert undue downward 
 pressure. In short, they so modify the pressure of these straps, 
 
56 POTT'S DISEASE. 
 
 that it is exerted antero-posteriorly rather than perpendicularly. 
 Being annealed, these shoulder pieces may be bent in any direc- 
 tion desired ; and they should be curved so that a very little 
 space exists between them and the subjacent parts. The 
 pelvic base is sufficient upon which " to hang the apparatus," 
 and it becomes quite frequently necessary to apply perineal 
 pads to prevent the moving upward of the apparatus, rather 
 than to adjust shoulder pieces to keep the appliance from slip- 
 ping down. 
 
 With Figs, i and 2 before us, I will attempt to describe the 
 method of applying the plaster zone apparatus to a case of 
 Pott's disease involving the first region. 
 
 1 st. Take two light bars of annealed steel, of a length which 
 corresponds to the distance between the commencement of the 
 anal commissure and the spinous process of the second dorsal 
 vertebrae. These form. the uprights. 2ndly. A piece of sheet 
 steel, about one inch wide and long enough to *each from the 
 top of one trochanter major to the other ; bend it to corre- 
 spond with the transverse sacro-iliac region, and cover with 
 chamois or other soft material. This forms the hip band. 
 3dly. Two cross pieces, four or five inches long, which are 
 riveted to the uprights at points which correspond to the lower 
 border of the axilla, and the inferior angle of the scapula. 
 4thly. Two small pieces of light bar- steel about two and a half 
 inches long, which are covered and riveted to the upper end of 
 the uprights at an angle of about 45 °, and bent as shown in 
 the engraving. Buckles are now attached to the ends of the 
 shoulder pieces, the cross pieces and the pelvic band. The 
 distance between the uprights should be about one inch and 
 
POTT'S DISEASE $7 
 
 a quarter, or sufficient to avoid any pressure upon the spinous 
 processes. These component parts being riveted together, two 
 rolls of canton flannel about three-eighths of an inch thick and 
 a little wider than the upright bar are now prepared. They 
 should reach from about one inch above the pelvic band to the 
 lower cross-piece. Two broad webbing bands as shown at J 
 and Z, in Fig. 2, are then made ready.* 
 
 We are now prepared to apply the apparatus. To do this 
 we proceed as follows : The patient is placed upon two tables 
 of equal height, and the tables are then separated so that the 
 parts selected for the zone may be freely accessible from all 
 sides. One assistant now grasps the patient under the axillae, 
 the other makes steady, but easy, traction at the thighs. 
 While the patient is in this position, the operator fits the up- 
 rights to the line of the transverse processes ; in other words, 
 adjusts the apparatus to the deformity. A pair of "monkey 
 wrenches " may be easily used as a pair of levers with which to 
 bend the annealed steel uprights into any position. It takes 
 but a few moments to adapt the uprights to the deformity. In 
 the meantime the patient is quiet. He does not struggle nor 
 cry. The traction is affording relief, and is not producing any 
 injury. While he lies quietly, and the canton flannel pads are 
 sewed on, we pass a piece of canton flannel, or merino gauze, 
 around the body over the projection. Then, the plaster band- 
 
 * Messrs Tiemann & Co., No, 67 Chatham Street, New York, will furnish 
 this " plaster zone apparatus " at a cost of from $5.00 to $7.00, according 
 to size. It would also be well, in sending the measurements to enclose an 
 outline of the spinal column, from the spinous process of the second dorsal 
 down. This may be done by placing a strip of lead along the spinous pro- 
 cesses, and moulding it accurately to the outline presented. By transferring 
 this lead carefully to a sheet of paper, an accurate profile of the spine 
 may be obtained with a lead pencil tracing. 
 
58 POTT'S DISEASE. 
 
 ages and everything being in readiness, the apparatus is laid on 
 the back accurately, traction is steadily maintained, the thoracic 
 and pelvic straps are fastened, and the plaster zone is snugly 
 applied. We leave the axillary straps until the plaster is hard- 
 ened, and the patient is ready to sit up. When the operation 
 is complete, the patient is firmly secured in an apparatus, which 
 affords a support that can be maintained by the thoracic, 
 axillary and pelvic straps, and the uprights are held, without 
 undue pressure, in their position by the plaster zone. 
 
 The many advantages of this plan are obvious. The appa- 
 ratus, as such, is wholly under control of the surgeon, and 
 there are no mysterious " pad-plates," no "cork" or "hard 
 rubber" pads, no screws or " hinges," no " aprons," with many 
 webbing tails, to confuse the uninitiated. It is very simple in 
 its application, and requires no special education to adjust it. 
 There are no opportunities for the deformity to increase, if 
 mechanical means will suffice to control it, for the thoracic, 
 pelvic and axillary straps furnish us with a means of regulating, 
 from time to time, the relation of the superior (thoracic) and 
 inferior (pelvic) portions of the apparatus to the spinal column. 
 If the zone becomes loose, as it almost always does, it may- 
 be taken off and an inch, or more, removed from the front. 
 Eyelets may then be inserted, and the zone may be tightly 
 laced, as Sayre does with the jacket. It is a matter of very 
 little trouble to apply a new zone, and patients have no dread 
 whatever of the operation. 
 
 On the other hand, the zone allows us to insert the finger 
 under the bridge formed between the two uprights, and explore 
 in the region of the deformity ; only a small portion of the 
 
POTT'S DISEASE. 59 
 
 body is occluded, and respiration is not interfered with. There 
 are no " dinner pads," and suspension is wholly avoided. 
 Cleanliness is possible, and the unsteady " apron " of Taylor's 
 apparatus is supplanted by a firm anterior support. The appa- 
 ratus answers an admirable purpose in cases of spinal caries, 
 accompanied by lordosis. We may sum the matter up in a 
 few words : Manual extension gives the acquired position ; 
 the uprights secured by the plaster zone give unvarying sup- 
 port, which can be maintained by the pelvic, thoracic and 
 axillary straps. No excoriations have occurred in the cases 
 thus treated. 
 
 37his method is especially applicable to chronic spondylitis in 
 the first region (the dorso-lumbar). I have not, as yet, tried it 
 in the superior dorsal. If certain difficulties can be overcome, 
 the plaster zone promises well in this region. As a means of 
 arresting the motion of the ribs, it will also prove of great ser- 
 vice, as Sayre points out. Thus far the form of apparatus 
 which has proved most useful in the superior dorsal region, in 
 my hands, has been the antero-posterior support, with the chin 
 piece, and a ball and socket pivot, which I have devised. I 
 will now proceed to describe both the pivot and its application. 
 
 Dr. Taylor's chin piece is made to surmount the uprights of 
 his apparatus through the medium of a pivot which slides into 
 a u keeper." This " keeper" is simply riveted transversely to 
 the upper extremities of the uprights. The pivot, acting as a 
 centre upon which the head is supported, requires a very ac- 
 curate adjustment in order to meet the indications, and when 
 after many trials, the apparatus is apparently nicely fitted, it is 
 found that the position of the head in the chin piece is not 
 
6o 
 
 POTT'S DISEASE. 
 
 wholly satisfactory, it becomes a matter of great difficulty to 
 change Dr. Taylor's pivot, which simply slides up and down in 
 its keeper, and is made of one piece of steel. This pivot itself 
 cannot be bent nor twisted, except at great risk of breaking it, 
 and to the general practitioner who is not supplied with a large 
 number of duplicates of different angles, a progressive adjust- 
 ment of the head-piece cannot be made, and this is always 
 necessary in the treatment of cervical or superior dorsal disease. 
 To overcome this difficulty, I devised, for a case which I saw 
 in consultation with Dr. Henry B. Sands, a ball and socket 
 pivot, which is shown in the accompanmg engravings, and 
 which, with the upper keeper (C, Fig. 4), represents, as nearly as 
 may be, the atlanto-axoidean articulation. 
 
 Fig. 3 shows this ball and socket 
 pivot, the long shaft with holes re- 
 presents the part which fits into the 
 "keeper." P, is the pivot which is 
 inserted in the ;i keeper " C, of the 
 chin piece, 'see Fig. 4). The dotted 
 lines in Fig. 3 represent the range of 
 lateral action of the pivot, P. The 
 same amount of antero-posterior 
 
 movement is permitted — indeed, the pivot JP, may be placed at 
 any desirable acute angle with the base. A clamp holds the 
 ball of the pivot, a hinge at £, and a screw at X, being the means 
 of securing it. The key D, (Fig. 4), operates the screw both at 
 X and X, which latter will be explained in the description of 
 Fig. 4 
 
POTT'S DISEASE 
 
 61 
 
 Fig. 4 represents Taylor's chin piece with occipital uprights 
 E £, and the form of " chin cup " H y I have found the most 
 useful. I have introduced a screw at K, by which the head- 
 piece may be secured at any point as it swings laterally on the 
 pivot at C. We thus, with the ball and socket pivot, and the 
 screw at A", possess the means of securing the head in any posi- 
 tion desired, and of changing it at will without removing the 
 apparatus from the patient. In Pott's disease or torticollis, 
 where a head support is necessary, the apparatus here described, 
 if surmounted on a proper pedestal, answers every indication 
 in a mechanical sense. 
 
 In Figs 4 and 5, F represents the hinge upon which the 
 anterior half of the chin-piece opens, and G is a slide which 
 locks the apparatus after it is applied. 
 
 Fig, 5> 
 
 Fig. 5 gives a lateral view 
 of the chin-piece, with the 
 occipital uprights, the ball 
 and socket pivot in position, 
 and the key applied through 
 which the various changes 
 are made. 
 
 In chronic spondylitis of the cervical region, the plaster 
 base, as I have before stated, is as unnecessary as it is uncom- 
 fortable. Still, if it should be deemed best or expedient 
 to use it as a pedestal upon which to surmount a head rest, 
 Dr. Putnam's combination of the plaster jacket with Taylor's 
 
62 POTT'S DISEASE. 
 
 chin-piece * presents many advantages over the " jury mast." 
 Except that it is cheaper, however, it has no advantages what- 
 ever over other and more appropriate pedestals. By running 
 the pad-plates of Taylor's apparatus well up on the uprights 
 and using the shoulder pieces as a basis of support (for here 
 the disease is above the shoulders), I have accomplished many 
 excellent results. The adjustment of the chin-piece is some- 
 times difficult to the uninitiated, but when once the apparatus 
 is properly fitted there is no other which I have used, that is 
 applicable to this region, which is so complete in its action, or 
 so comfortable to the patient, as Taylor's chin-piece with the 
 ball and socket pivot. 
 
 I have deemed it proper, in closing my remarks, to select 
 from my case-books a few illustrations of the results that have 
 been obtained by the use of the antero-posterior support 
 During the year 1877, out of 299 cases of Pott's disease treated 
 in my service at the N. Y. Orthopaedic Dispensary, sixteen 
 were discharged as cured. Each case was under observation 
 for several months, without apparatus, before it was so dis- 
 charged. So far as I know, none of these patients have had 
 any return of symptoms and there has been no increase of 
 deformity. With a few exceptions, every case has been seen 
 during the present year. Forty-four of these 299 were dis- 
 charged as relieved — which means that, while all of them have 
 been very greatly benefited, many of them, I doubt not, cured y 
 I cannot speak with sufficient positiveness regarding their con- 
 dition to call them, as I have the others, absolutely cured j 
 
 * Taylor's Apparatus for Pott's Disease in the Cervical and upper Dorsal 
 Regions, mounted on the Plaster of Paris Jacket. By Charles P. Putnam, 
 M.D., of Boston. Archives of Clinical Surgery, June 15th, 1 8 77. 
 
POTT'S DISEASE. 63 
 
 fourteen were discharged for neglect — i. e., they would not give 
 sufficient attention to our instructions to warrant the expendi- 
 ture of either the time or the material necessary to treat them ; 
 two were incurable ; ten died ;* 213 were continued to 1878. 
 Of 267 treated in 1878, eighteen were discharged cured, each 
 case again having been watched for many months after the 
 removal of apparatus. With one exception, no symptoms have 
 appeared indicative of any return of the lesion. This one 
 case, suffering a relapse, was a young man with caries sicca in 
 the middle dorsal region. He had worn apparatus three years. 
 A year after its removal, while engaged in a down town dry 
 goods house, he lifted a heavy case of goods. A return of 
 symptoms occurred. He still maintains his position, however, 
 with his apparatus adjusted. — Forty-four, of these 267, were 
 discharged relieved after a careful analysis of the cases based 
 upon visitations and examinations, where they could be ob- 
 tained ; six were discharged for neglect ; and twelve died. 
 From these cases, and others occurring in my private practice, 
 I have selected a limited number from those that had not pre- 
 viously been treated by any other method, (except Case IV, 
 treated by recumbency) and which will illustrate the difficulties 
 of treatment, and present average results. 
 
 I have selected them with a further view of presenting one 
 or more cases representing the three regions I have described, 
 viz., the dorso-lia?ibar, the superior dorsal, and the cervical : 
 Case I. represents disease of the second and third cervical; 
 Case II., sixth and seventh cervical and first dorsal ; 
 Case III., fourth and fifth dorsal ; Case IV., fifth to ninth 
 
 * The causes of death are recorded on page 24. 
 
64 POTT'S DISEA SE. 
 
 dorsal; Case V., eleventh dorsal; Case VI., twelfth dorsal; 
 Case VII., the first lumbar ; Case VIII., second and third 
 lumbar. As nearly as may be, therefore, the whole vertebral 
 column is represented in these eight cases. To further dupli- 
 cate them would be unnecessary, and neither time nor space 
 would permit more on this occasion. All of these cases were 
 treated by the antero-posterior support. The plaster zone has 
 not been in use a sufficient length of time to contribute any 
 permanent results. 
 
 Case I. Miss A. C, aged 8 years. Residence Yonkers, 
 N. Y. Chronic spondylitis (sicca) involving second and third 
 cervical vertebrae. First examined April 29th, 1876. 
 
 Hereditary history good. Neither phthisis nor joint disease 
 known in family. Has brothers and sisters all of whom are 
 healthy. 
 
 The early history of patient develops the fact that during 
 the first three years of her life she had no serious illness. 
 Since that age has had measles, whooping cough, scarlet fever, 
 and diphtheria — the two latter being of recent date. The 
 attack of diphtheria (which was very slight) preceded the 
 development of the neck symptoms, by a few weeks only. 
 
 On February 22nd, 1876, patient "seemed to have taken 
 cold." There was no marked onset of the symptoms due to 
 the spondylitis. They came on about this time, commencing 
 "like a cold." They progressed insidiously ; the patient being 
 better some days, and worse — much worse — other days. The 
 neck u became troublesome and very stiff sometimes," and 
 very painful, especially upon sudden motion. Occipital neural- 
 gia developed, then ear-ache, accompanied by deafness. Dur- 
 
POTT'S DISEASE. 65 
 
 ing the latter part of March the symptoms became much worse, 
 and the patient consulted Dr. E. C. Seguin, who made a diag- 
 nosis of cervical spondylitis and referred the patient to me for 
 an opinion as to her condition. I wholly concurred in the 
 diagnosis of Dr. Seguin, who kindly placed the patient under 
 my care. Upon examination, I found the local symptoms of 
 chronic spondylitis (sicca) very marked. The reflex symptoms 
 were very prominent — muscular spasm and pain were ex- 
 cited upon any considerable motion of the head. The nor- 
 mal movements of the head were limited in every direction, 
 especially in rotation, the left sterno-mastoid showing consider- 
 able resistance, though the chin was rotated to the same side. 
 The nocturnal, osteitic cry had been present and was still a 
 frequent symptom. There was an appreciable thickening in 
 the region of the second and third cervical vertebrae and deep 
 pressure here produced pain. 
 
 On May 10th, 1876, the antero-posterior support with chin- 
 piece was applied with relief to the more important subjective 
 symptoms. I have kept very comprehensive notes of this case, 
 which are very interesting. To summarise them I may say that 
 the patient improved steadily — pain upon motion gradually 
 disappearing, the muscular spasm being the last to yield. The 
 patient wore the apparatus without any discomfort and could 
 run and play like other girls of her age, during the whole of 
 the treatment. The entire apparatus, including the chin-piece, 
 with occipital uprights, was also worn at night without any 
 complaint after the first week. Patient improved markedly in 
 every way physically while wearing the apparatus, and the relief 
 from pain was great. 
 
66 POTT'S DISEASE. 
 
 Patient was discharged as cured November 17th, 1877. Her 
 general condition then was excellent. The local condition was 
 as follows : There was slight limitation of motion in extreme 
 rotation of head to the right, which limitation was not preceptible 
 unless the shoulders were firmly held, and the movement com- 
 pared with the opposite one. The resistance was not due to any- 
 muscular spasm or contraction, but to changes which had taken 
 place in the vertebras. The thickening in the upper cervical 
 region was still present, but could be detected upon digital ex- 
 amination only. I have seen the patient several times since 
 apparatus was removed, and Dr. Seguin examined her at my 
 request one month after the apparatus was removed. At that 
 time Dr. Seguin made the following note, which he has permit- 
 ted me to copy from his case-book : — " December 17th, 1877. 
 Apparatus removed a few w r eeks ago. Cure perfect ; patient 
 can bear any motion and flexes the spine well in all directions ; 
 is rosy and fat." 
 
 I do not submit outlines of the vertebral column. No change- 
 whatever is perceptible at the point of lesion between the one 
 which was taken when the patient was first examined, and the 
 one which illustrates this result. The patient grew an inch 
 and a half during treatment. 
 
 Summary. Apparent duration of disease prior to treatment, 
 about two months; length of treatment, eighteen months ; time 
 elapsed since removal of apparatus, sixteen months. 
 
 Case II. — Christina S , aged 6 years. Admitted to N. Y. 
 
 Orthopaedic Dispensary, August 7th, 187 t. Pott's disease ; 
 6th and 7th cervical and 1st dorsal. 
 
 As is the case with many dispensary patients, it was found im- 
 
POTT'S DISEASE. 6j 
 
 possible to obtain a reliable family history. There seems to be 
 no record of phthisis, or joint disease, in the immediate family. 
 Other than this nothing could be obtained bearing upon 
 heredity. 
 
 Patients early history unfavorable. Had a great deal of 
 " sickness" prior to her third year, though the nature of this 
 illness could not be ascertained. 
 
 The mother states that the cause of the disease was " many 
 falls out of bed." Six weeks before the patient appeared for 
 treatment, it was noticed that she "walked to one side and 
 stooped forward." This was accompanied by " a pain between 
 the shoulders upon sneezing or any sudden jar." The general 
 condition of the patient is described as unfavorable in the notes, 
 and " there is a prominence at the first dorsal, lateral inclination 
 of head to right side, rigidity of the spinal column at the point of 
 disease, and motion of head limited laterally." Much pain was 
 produced by attempts at motion, especially when the effort was 
 made to carry the head beyond the points at which muscular 
 resistance began. 
 
 The antero-posterior support, with chin-piece, was adjusted 
 August 13th, 187 1. Excellent support was obtained, and the 
 case progressed favorably and, apparently, very rapidly. A 
 speedy result was anticipated by both the parents and myself. 
 In July, 1872, however, a very severe attack of dysentery oc- 
 curred, which ultimated in great emaciation, and a return of all 
 the unfavorable symptoms. The recovery of lost ground was 
 extremely slow, and we find entries running through the history, 
 which demonstrate that while the support was excellent, the 
 general condition did not improve. Abscess formed, accom- 
 
68 POTT'S DISEASE. 
 
 panied by much pain, hectic and great debility. The gums 
 became spongy, and bled very easily. Thorough constitu- 
 tional treatment, and the faithful use of the apparatus, 
 finally conquered, and the patient was discharged cured 
 January 26th, 1877. On February 5th, 1879, Dr. S. A. y 
 Foster, senior Assistant Surgeon to the Dispensary, visited 
 the case, and obtained an accurate outline of the spine, 
 over two years after the removal of apparatus. The 
 result is shown in Fig. 6. The site of disease is shown 
 at x ; the dark line showing the outline as taken by 
 myself when the case first presented for treatment ; the 
 dotted line, the result as taken by Dr Foster. ' 
 
 Summary. — Apparent duration of disease prior to treat- lj 
 ment, indefinite ; many months. Length of treatment, // 
 about five and a-half years. Time elapsed since removal 
 of apparatus, over two years. 
 
 Case III. — R. R., aged 6 years, resides in Morrisania, 
 
 . Fig. 6. 
 
 N. Y. Examined Jan. 5th, 1870. Pott's disease, 4th 
 
 and 5th dorsal. 
 
 Hereditary history, good. Has healthy parents. No phthisis 
 or articular disease known among ancestry, which can be 
 traced back through two generations. 
 
 The early history of patient develops the fact that he had 
 " a very severe inflammation of the bowels " during infancy ; 
 and that an attack of diphtheria, also very severe in character 
 occurred shortly before the development of the first symptoms 
 traceable to the vertebral lesion. Has two brothers and two 
 sisters — all in apparent good health. Patient never had any 
 fall or injury other than those which ordinarily occur to boys 
 of his age. 
 
POTT'S DISEASE. 69 
 
 Examination. Patient a fairly nourished lad, broad-shoul- 
 dered and of good frame. Has a peculiar brownish tint to 
 skin, which is not localized, nor hereditary. An evident pro- 
 jection in the middle, dorsal region. The mother assigns no 
 cause for the disease. The first symptom noticed was " a 
 peculiarly sharp cry at night, occurring during sleep." The 
 cause of this cry was inexplicable to the parents and several 
 consultations with physicians did not throw any light upon the 
 subject. At length, many weeks after the nocturnal cry, <; a 
 lump was seen in the back." Pain could be easily produced 
 by any sudden jar — even if it were slight. Attitude and facial 
 expression alike expressed suspense and profound distress. 
 Nocturnal cry still present. 
 
 The antero-posterior support was applied a day or two after 
 the examination. The lesion was situated in that region of 
 the spine, where great difficulties present in the way of giving 
 adequate support. The anterior and superior wall of the 
 thorax, and the axillae, not affording sufficient counter-pressure, 
 the chin-piece was added. The relief was marked. 
 
 This case — a typical one, in some respects, of caries sicca 
 vertebralis, — I had the opportunity of following very closely, and 
 the mother made an excellent and attentive nurse. At the end 
 of six months all the subjective symptoms were absent, and, as I 
 remarked at the time, many surgeons might have considered the 
 case cured. Some four months subsequently, however, a slight 
 injury a^ain developed the latent symptoms. To be brief, the 
 support was worn until January, 1877 — just seven years. Dur- 
 ing the last two years of treatment, however, the chin-piece was 
 removed, and the apparatus was worn as a matter of pre- 
 caution only. 
 
yo POTT'S DISEASE. 
 
 The result is shown in Fig. 7. The dark line illustrates 
 the outline of the spine in January 1870 — before appara- 
 tus was applied, — the dotted line shows the deformity as 
 it appeared on February 9th, 1879. Both outlines were 
 taken by myself. 
 
 Summary. Apparent duration of disease before treat- 
 ment, — several months — a year or longer. Length of 
 treatment, seven years. Time elapsed since removal of 
 apparatus, twenty-seven months. 
 
 Case IV. Anna H , aged 20 years. Residence 
 
 Brooklyn. Admitted to New York Orthopaedic Dis- 
 pensary, July 26th, 1872. Diagnosis ; Pott's disease, — / 
 5th to 9th dorsal. Fig. 7. 
 
 Hereditary history. Father died when patient was 10 years 
 old ; cause not known. Mother living in Ireland. Patient 
 has had four brothers and four sisters ; two of these brothers 
 are living and are in good health ; one died in infancy, the 
 other recently of " hasty consumption." Two of the sisters 
 also are dead ; one in infancy, the other from puerperal fever. 
 The others are well. 
 
 The early history of patient shows nothing noteworthy, as 
 related by herself. Had measles when a baby. Several attacks 
 of "fever and ague" and "rheumatism" occurred shortly 
 before the disease of the spine manifested itself. 
 
 The history of the development of the spinal lesion is very 
 indefinite as to the early symptoms. The first symptom 
 which the patient herself noticed was a pain in the right 
 side — which pain was especially aggravated in stooping, 
 lifting heavy articles, or sweeping. This was " some time 
 
POTT'S DISEASE. 71 
 
 in 1S70." No projection had been discovered by the patient 
 or her friends, at that time. About seven or eight months 
 after the pain appeared the patient began to limp. Then 
 it was that the projection was noticed. The limp proved 
 to be a premonitory symptom of a progressive paraplegia — 
 which became complete at the end of about twelve months. 
 The left lower extremity became paralyzed first, the right three 
 or four months later. Among the symptoms noticed, which 
 either came before the limp above referred to, or were co- 
 incident with it, was a " numbness and a pricking sensation " 
 and an inability to walk with the eyes closed. The patient could 
 not tell at this time " where her legs were, when she was lying 
 down in the dark." In the meantime the projection became 
 larger, and when the paralysis had become complete the de- 
 formity was " about as large as a chestnut." Partial paralysis 
 of the bladder and rectum also occurred. In 1871 (May nth) 
 patient entered a Brooklyn hospital, completely paralyzed. 
 She was treated by the recumbent position for thirteen months, 
 the spinal curvature increasing very much in the meantime. 
 Slight bed sores developed over the spinous processes and 
 sacrum — which yielded to careful treatment. Patient left the 
 hospital on June 19th, 1872, utterly unable to move her lower 
 extremities. A week after the patient had left the hospital I 
 saw her in Brooklyn. I found a very marked deformity. 
 There was at that time complete paralysis of the lower extremi- 
 ties ; the rectum and bladder also were partially paralyzed ; 
 marked anaesthesia, especially of the left leg. Slight titillation 
 of the soles of the feet produced marked and prolonged " reflex 
 trembling." The adductors of the thigh were very tensely 
 
72 POTT'S DISEASE. 
 
 contracted, the knees were extended, and the entire lower ex- 
 tremity on either side was stiff and unyielding, except upon the 
 application of great force. The knees were held closely in 
 contact, and incipient sloughs were appearing as the result of 
 the pressure. Patient's general health good. 
 
 In September, 1872, the patient was, at my suggestion 
 removed to this city and placed in a private boarding-house — 
 the late Mr. Theodore Roosevelt kindly agreeing to meet 
 all necessary expenses incurred in pursuing this plan. 
 Her symptoms then were much the same as above de- 
 scribed, aggravated, if anything, by undue attempts to sit 
 up, and the journey from Brooklyn. An antero-posterior sup- 
 port was applied, the patient, of course, keeping the recumbent 
 position. By these means, recumbency and the use of ap- 
 paratus, the vertebral column was practically immobilized. 
 In two weeks after the application of the splint sensation 
 began to return to the lower extremities. In six weeks she 
 was able to stand alone, and in nine months the paraplegia had 
 entirely disappeared. The patient continued under my care 
 for several years, and wore the apparatus (without the chin- 
 piece) as a matter of precaution until May 1st, 1877, when she 
 was discharged, cured. Since that time she has been engaged 
 as nurse, and has done much heavy lifting without any incon- 
 venience or return of symptoms. 
 
 The original outline of the deformity is shown in Fig. 8. 
 It was taken by myself in 1872, before treatment was com- 
 menced. When I last saw the patient, for some unexplained 
 cause, she objected to having an outline taken of the result. 
 The original " pattern" placed over the projection, however, 
 
POTT'S DISEASE, 
 
 n 
 
 showed a slight increase of the deformity. There 
 was an increased incurvation — a lordosis — of the 
 spinal column at the point o. Otherwise the projec- 
 tion was practically the same as shown in the figure. 
 
 Summary. — Apparent duration of disease before 
 treatment, not definitely stated ; several months. 
 Length of treatment, nearly five years. Time 
 elapsed since removal of apparatus, twenty-two 
 months. 
 
 I have seen too many cases in the condition above 
 described improve under similar circumstances, after 
 an accurately fitting support was adjusted, to regard 
 the improvement in this case as simply co-incidental 
 with the application of apparatus. Among many 
 others, I may mention the case of an adult male 
 in the surgical ward of Roosevelt Hospital, who 
 was similarly affected. At the request of Drs. H. B. 
 Sands and R. F. Weir, I applied a comprehensive 
 antero-posterior support to the patient. The improvement 
 was very rapid and permanent. I have another case now 
 under observation in my service at St. Luke's Hospital, (Jane 
 McG., aged 47,) whose case in many important particulars re- 
 sembles that of Anna H. The recovery from the paraplegia 
 has been very slow, however, and the patient altogether has 
 passed three years in bed, wearing an antero-posterior support. 
 She is now well, but still wears an apparatus. The case of Mr. 
 M., aged 45, who remained for several years in the Orthopaedic 
 Hospital, will also illustrate the advantages of the combined 
 recumbent position and the antero-posterior support. This 
 
74 POTT'S DISEASE. 
 
 case, one of the most severe and protracted I have ever seen 
 (the lesion at one time threatened the life of the patient) was 
 seen several times in consultation by Dr. E. C. Seguin. The 
 paraplegia was complete. The condition of this patient when 
 he left the hospital was such that, in the recumbent position, he 
 could voluntarily execute any movement with his lower ex- 
 tremities. It was a question of a few weeks only as to how 
 soon he would be permitted to stand alone. He passed into 
 the hands of a prominent surgeon after leaving the Orthopaedic 
 Hospital, and was soon " cured " by the plaster jacket. I could 
 refer to several others, some of which are as interesting as those 
 I have already referred to. I have mentioned only adults. I 
 could report very many cases occurring among children, where 
 the paraplegia of Pott's disease was very speedily relieved by 
 the antero-posterior support, after simple recumbency had 
 failed. 
 
 Case V. — F. J. R., aged 5 years ; resides in New York City. 
 Admitted to N. Y. Orthopaedic Dispensary May 16th, 1877. 
 Diagnosis, Pott's disease, nth dorsal. 
 
 Hereditary history very unfavorable. Mother died of phthisis. 
 Four other children, brothers or sisters of patient, have died at 
 an early age, and one now living is " very delicate." " Heredi- 
 tary lung trouble on mother's side," several members of the 
 family dying shortly after puberty of " hasty consumption." 
 
 The patient was " apparently healthy" as a baby ; dentition 
 easy ; no serious illness. About March 1st, 1877 (or two 
 months before he was brought to the Dispensary) he was " no- 
 ticed to walk sideways." He also " bent forward, and sup- 
 ported himself by placing his hands on his knees." Was 
 
POTT'S DISEASE. 75 
 
 treated for hip disease, with weight and pully, by a Brooklyn 
 physician. 
 
 At the time he applied for treatment, the patient seemed fairly 
 nourished, though he was very pale and apprehensive. Slight 
 movements of the spine produced pain. There was flexion of 
 the thigh on the left side due, probably, to the presence of pus, 
 though no other sign of suppuration could be detected. The 
 deformity was very slight, though the posterior curvature was 
 greatly exaggerated by a general excurvation of the whole verte- 
 bral column. (See Fig. 9). No cause was assigned, by the 
 father, for the disease. There had been a fall two years before 
 the first manifestations of the spinal lesion, but no connection 
 could be traced between it and the development of the symp- 
 toms. Has had " whooping cough, bronchitis and chicken-pox." 
 
 On May 24th, the antero-posterior support was applied, fol- 
 lowed by the usual marked relief. On June nth, "a large 
 abscess has formed and is pointing just below the posterior, supe- 
 rior spinous process of the ilium, left side." June 25th, " abscess 
 has opened spontaneously and is discharging a thin pus." The 
 abscess continued to discharge very profusely for several weeks, 
 when the discharge diminished and it became thicker and more 
 like laudable pus. On April 4th, 1878, the abscess had wholly 
 closed. It has remained so ever since. There has been a very 
 slight increase of the deformity due to the lesion, while the great, 
 posterior curvature has been wholly overcome. This is a 
 case where an apparent reduction of the deformity occurred. 
 But a glance at the two outlines will demonstrate that it is not 
 real. The excurvation of the spine has been overcome, but the 
 actual curvature due to the disease has really increased. The 
 
76 POTT'S DISEASE. 
 
 antero-posterior support accomplished in this case, what sus- 
 pension does, viz., it modified the apparent curvature without 
 affecting that due to the lesion. 
 
 This boy is perfectly well, and has been in a condition to 
 have the apparatus removed, for many months. The father 
 of the patient, however, has preferred to keep it applied, though 
 I directed its removal in November, 1878. It was finally taken 
 off about February 15th, 1879. 
 
 The dark line in Fig. 9 represents the profile of the 
 vertebral column when patient was first examined. The 
 dotted line shows the result. 
 
 Summary. — Apparent duration of disease before treat- 
 ment was commenced, about two months. Length of 
 treatment, about eighteen months. Time elapsed since 
 apparatus was removed, about two months. 
 
 Case VI. — M. S., aged 4 years. Residence Brooklyn. 
 Admitted to Orthopaedic Dispensary November 16th, 
 1876. Pott's disease, twelfth dorsal. 
 
 Patient's grandparents on both sides lived to be old ; 
 no phthisis or articular disease known in family history. 
 Both parents living and in good health, apparently. Has pj„ * 
 one brother living ; one sister died at sixteen months, cause 
 not stated, other than " general weakness." 
 
 When the patient was five months old she had a severe attack 
 of diarrhoea, which continued for eighteen months. Notwith- 
 standing this, she passed through her dentition easily. She 
 recovered from the immediate effects of the diarrhoea, for at 
 three years of age, the patient " was apparently as healthy as 
 any child of similar age." 
 
POTT'S DISEASE. 77 
 
 About one year before patient applied to the Dispensary, her 
 parents noticed that she had a peculiar gait ; she would fall 
 easily, and get up with great difficulty. Had great pain when- 
 ever she fell, or when suddenly lifted. No cause was assigned 
 for the disease by the parents. There was no history of any 
 fall or blow, "no injury of any kind/' The patient was in an 
 apparently good condition, when she applied for treatment. 
 An evident projection existed at the twelfth dorsal, pain could 
 be easily excited by sudden and unexpected movements of the 
 vertebral column, and the rigid spine, that gives the Pott's 
 disease patient his peculiar attitude, was very marked. 
 
 On November 21st, 1876, the spinal support was applied, 
 with the immediate effect of relieving the pain, improving the 
 .attitude, and modifying the apprehensive gait. The patient 
 improved rapidly in every way under the mechanical and con- 
 stitutional treatment. The patient came to the Dispensary 
 with a fair degree of regularity until May 6th, 1878, when we 
 find the record, " doing excellently well. The patient not re- 
 turning for many months, a letter was sent requesting attend- 
 ance on November 2nd, 1878. Two days later the patient 
 called when, after examination, she was discharged, cured. The 
 patient has been recently examined. No increase of deformity 
 since apparatus w r as removed. 
 
 The dark line in Fig. 10 shows the outline of the spine when 
 patient first applied for treatment, November 16th, 1876. The 
 dotted line shows the result as taken November 4th, 1878. It will 
 be observed that there is an evident decrease of the deformity, 
 and that the normal curves of the spine are obliterated. 
 From the seventh cervical to the sacrum the line is nearly a 
 
78 POTT'S DISEASE. 
 
 straight one. The vertebral column is rigid in the im- 
 mediate region of the deformity. 
 
 There is no doubt in my mind that had this patient re- 
 ported with regularity to the Dispensary, she would have 
 been discharged, cured, much sooner. 
 
 Summary. — Apparent duration of disease before treat- 
 ment was commenced, at least one year. Length of 
 treatment, two years. Time elapsed since apparatus was 
 removed, five months. 
 
 Case VII. — R. E., aged five years. Residence, New 
 York City. Dispensary. Diagnosis, Pott's disease. First 
 lumbar. Admitted March 7th, 1870. Fig. 10. 
 
 There is nothing of interest in the boy's hereditary history. 
 The parents are Germans, free from any appearance of disease 
 or debility. The remote history cannot be obtained. Patient 
 has four brothers and one sister. They are well. Relatives, 
 "all are healthy." The patient himself was "in seeming good 
 health " when he first applied for treatment. 
 
 Patient " fell from a girl's arms, as she was swinging him at 
 at arm's length" in October, 1869. Soon after "he was taken 
 to a doctor for a pain in the stomach." In January, 1870, 
 projection was first noticed. It progressed until it appeared, 
 on the occasion of our first examination, as shown in the dark 
 line of Fig. 11. 
 
 On March nth, 1870, the patient came to the Dispensary for 
 his apparatus, walking badly. Has suffered much pain night 
 and day. The antero-posterior support was applied, with 
 marked relief. Several entries in the history show that 
 the patient steadily improved until May 16th, 1870, when the 
 
POTT'S DISEASE. ?g 
 
 relief afforded by the apparatus gave the patient so much con- 
 fidence, that he became too active, running and jumping like 
 other lads. Ordinary exercises are always permitted with a 
 suitable support in Pott's disease ; but extraordinary or violent 
 exercises are not advisable, be the support what it may. Our 
 " caution regarding too violent exercises," (May 30th, 1870) 
 was not heeded. In addition to this he became negligent re- 
 garding his attendance, but " wore his brace constantly." He 
 came for observation very rarely during the summer of 1870. 
 
 On September 16th, there was made this entry : " Ascertained 
 that patient had a very bad fall two weeks ago." We feared 
 the return of pain ; but October 19th, there is recorded, "No 
 unfavorable symptoms." We finally lost sight of the patient 
 for two years or more ; but he wore his apparatus steadily, and 
 his mother kept it in repair. 
 
 On February 16th, 1876, this entry occurs : "Patient doing 
 well ; came for repairs to brace." Another long absence oc- 
 curs, after a few visits for repairs, when Ave found the following 
 record under date of June 1st, 1877: "Was to-day examined 
 and pronounced cured. Apparatus removed." 
 
 The history and progress of this case illustrate how much 
 may be accomplished under adverse circumstances, with appa- 
 ratus acting upon correct principles, and constantly worn. 
 Once accurately fitted to a deformity occurring in the dorso- 
 lumbar region, the antero-posterior splint does not need many 
 changes, and an intelligent mother, in a case like this one, may, 
 with occasional consultations, conduct the mechanical treat- 
 ment with success. The advantages of this method of pro- 
 
SO POTT'S DISEASE. 
 
 cedure in private practice over the constant renewals of plaster 
 jackets, must be obvious to those who have followed both 
 methods conscientiously. 
 
 In this case the apparatus was worn a long time. Had he 
 been attentive to our instructions, I do not doubt it would 
 have been shortened fully one-half. 
 
 I have seen the patient many times since the removal of 
 the apparatus. There has been no return of the symp- 
 toms. The boy is now over 14, and is engaged as a clerk 
 in a grocery store. 
 
 The dark line in Fig. n shows the outline of the spine 
 on March 7th, 1870 ; the dotted line the result. The 
 latter tracing was taken June 1st, 1877. The increase of 
 deformity is quite apparent. There has been no increase 
 since removal of apparatus. 
 
 Summary. — Apparent duration of disease before treat- 
 ment, about six months. Length of treatment, seven years. 
 Time elapsed since removal of apparatus, twenty months. 
 
 Case VIII. — T. F., aged to years. Residence, Brooklyn. '/ 
 Admitted to Orthopaedic Dispensary July, 1874. Diagnosis, Fig. 
 Pott's disease ; 2nd and 3d lumbar. Patient referred to the "• 
 Dispensary by Dr. Pilcher, of Brooklyn. 
 
 Hereditary history very unreliable. Very little ascertained 
 of father's family. No phthisis nor joint disease known in 
 mother's family. Patient has two brothers ; one " quite deli- 
 cate." Has had three sisters ; one is living, " in good health ;" 
 two have died ; cause not known. 
 
 Patient had whooping cougii and scarlet fever during infancy, 
 otherwise has been " healthy " since birth. 
 
P07*T"S*. -disease:, 8-1 " 
 
 '.The cause of disease was stated by the mother of patient to 
 be " a fall down stairs." We were, unable, however, to ascer- 
 tain just when the fall occurred", or how the patient traced the 
 connection between the disease and. the injury. 
 
 The first, sym-ptoni which really attracted the attention of the 
 parents was the deformity.. After this had been discovered, it 
 was remarked that the patient had been " pining away " for 
 some time, and had experienced some " pain in the back and 
 stomach " for several months. 
 
 In July, 1874, (the exact date is missing), the anteropos- 
 terior support was applied. Patient proved to be a very irregu- 
 lar attendant. He came with sufficient frequency however, to 
 have an adequate support maintained. Patients themselves 
 can easily tell when an apparatus fails to give sufficient pressure. 
 The apparatus was broken several times, and as many times J 
 repaired. 
 
 The patient last visited the Dispensary, wearing the 
 apparatus, in August, 1877. He was visited by one of 
 the Dispensary staff on December 22nd of the same 
 year, when the apparatus was removed and the patient 
 was discharged cured. At my request he visited the 
 Dispensary, November 4th, 1878. It was found that 
 there had been no increase in the deformity since his 
 discharge. There were no evidences whatever of dis- 
 ease about the boy, except the arrested deformity. 
 
 The dark line in Fig. 1 2, shows the profile of the spinal 
 column at the first examination of the patient in July, 
 1874. The improved outline is seen in the dotted line. 
 Still, I doubt, if the real projection has diminished any, Fig. ia 
 
82 PO TT'S DISh 4 SB.. 
 
 though others might so claim. The superior, compensatory 
 curvature has been modified. 
 
 Summary. — Apparent duration of disease before treatment 
 was commenced, indefinite — " several months." Length of 
 treatment, three years and five months. Time elapsed since 
 removal of apparatus, fifteen months. 
 
 THE END. 
 
m 
 
 IS?? 
 
 
 11111111