POTT’S PARAPLEGIA AS AFFECTED BY THE CORRECTION 
OF THE SPINAL DEFORMITY. 
A REPORT OF 
BY 
JOEL E. GOLDTHWAIT, M.D., 
BOSTON. 
From the Transactions of the 
American Orthopedic Association. 
1899. POTT’S PARAPLEGIA AS AFFECTED BY THE COR- 
RECTION OF THE SPINAL DEFORMITY. 
A Report of Cases. 
By JOEL E. GOLDTHWAIT, M.D., 
BOSTON. 
Until the past two or three years the commonly accepted treat- 
ment of Pott’s paraplegia consisted of rest in bed, with as thorough 
fixation of the spine as possible, together with the less common 
but frequent use of traction and counter-traction. 
The duration of the paralysis varied wuth the location of the 
disease and age of the patient. Rarely did it disappear before six 
months, and that in children, while in adults few recovered in less 
than eighteen months or two years. In a certain number of cases, 
even after a longer period of time and under the most careful treat- 
ment, the power failed to return. This has formerly been consid- 
ered to be due to degeneration of the cord, and, consequently, it 
was supposed that the condition was hopeless. 
Various theories have been offered in explanation of the paral- 
ysis, such as abscess; direct pressure of the softened vertebra upon 
the cord ; pressure due to a tuberculosis of the meninges, the tuber- 
cular process extending into the cord itself, involving the intersti- 
tial tissue surrounding the nerve fibres; an oedema of the cord, 
due to imperfect circulation at the seat of the disease; and prob- 
ably others which have escaped my notice or memory. 
As the result of the work which has been done during the past 
three or four years, in connection with the correction of the spinal 
deformities, the course of the paralysis has been changed in so 
striking a degree that it becomes necessary for us to reconsider 
some of our former views, and it may be possible, by studying a 
group of such cases, to speculate more definitely upon the exact 
etiology of the symptoms. 
The most striking fact ill treating these cases is that, whatever 
the etiological factor may be, the correction of the spinal defor- 2 
JOEL E. GOLDTHWAIT, 
mity, or only a partial correction of the deformity, has been fol- 
lowed by a very rapid and at times an instant relief from the paral- 
ysis. This result has been so universal in my own experience, and 
so common in the hands of others who have pursued the same 
method, that while at first the disappearance of the paralysis was 
supposed to be only a coincidence, coming in connection with the 
correction of the deformity, at present the correction of the defor- 
mity has come to be of secondary importance to relief of the paral- 
ysis which is to be accomplished in this way. 
In my own experience of the eleven cases which have been treated 
in this way all have shown a marked improvement in the motor 
control of the Jegs within a few days of the time of treatment. 
In some of the cases, either because of the location of the disease 
and the inability to hold the spine in the corrected position, or 
because of inability to control the after-treatment, it has not been 
possible to make the improvement permanent, and relapse has 
occurred. The fact, however, that the paralysis has been relieved 
by the change in the position of the spine has been demonstrated 
and the demonstration repeated several times in one of the cases. 
Of the eleven cases, five were reported at the last meeting of this 
Association, in the paper entitled “ Forcible Straightening of Spi- 
nal Deformities Resulting from Pott’s Disease,” and they are again 
mentioned because the subsequent history of the cases is of fully as 
much interest as the immediate result. 
Of the eleven cases three were children; of these, one with dis- 
ease in the upper lumbar region was entirely and almost immedi- 
ately relieved by hyperextending the spine. Ether was not used, 
and after one year, during which the position of the hyperextension 
has been maintained, there has been no return of the paralysis. In 
another child, with disease of the first and second dorsal vertebrae, 
the weight of the head alone was not enough to correct the defor- 
mity, so that ether was used for this purpose. This was followed by 
marked improvement in the control of the legs, but the improve- 
ment lasted a few days only. The treatment was repeated once or 
twice with the same result. Each time the paralysis was relieved, 
but the improvement lasted only a few days, the relapse being due 
undoubtedly to the inability to maintain the corrected position be- 
cause of the location of the disease. The child is none the worse pott’s paraplegia. 
3 
for the treatment, and is now being treated as formerly—in bed, 
with immobilization of the spine. The third child, with a large 
deformity in the mid-dorsal region and with complete paraplegia, 
was considerably benefited by the improved position of the spine, 
but the improvement has not been permanent. 
Of the eight adult cases five were men. The oldest patient was 
a man, forty-three years of age. In only one of the cases was 
ether used, and this was before the apparatus which is now in use 
had been perfected. At the present time I feel sure that even in 
this case ether would not have been necessary. 
Of this group of adult cases, one of the most suggestive and 
interesting, from a physiological as well as a pathological point of 
view, is the case of the man, forty-three years of age. In this case 
the disease of the spine had been present for about six years. 
During the first part of the time he was under my care at the Car- 
ney Hospital, but paralysis developing, and having no home, he 
was sent to the Almshouse Hospital at Long Island, and there he 
had lain for four years previous to the commencement of the pres- 
ent treatment. While at Long Island he was under the care of 
Dr. E. W. Taylor, and it was through his kindness that it was 
possible for me to see him. The knuckle was in the mid-dorsal 
region, and there was, with the exception of a slight tremor in three 
middle toes of the right foot, absolute paralysis of everything 
below the waist, together with a partial paralysis of the bowel. 
The knees and ankles were stiff, while the feet were not only stiff 
but were fully extended, so as to be in a straight line with the legs 
instead of at a right angle to them. 
The patient was transferred to the Carney Hospital in July of 
last year and a plaster-of-Paris jacket applied, with the spine in 
the hyperextended position. In a few days he could move the toes 
of both feet, but because of the long disuse the cerebration was 
uncertain for some time; for instance, when asked to move the 
right foot the left one was perhaps the one moved, and vice versa. 
This gradually improved, however, so that later the cerebration 
was in no respect peculiar. 
Since July jackets have been applied about every six weeks, so 
that the spine has been kept constantly hyperextended. Ether has 
been used but once, and that not for the spine, but to free the con- 4 
JOEL E. GOLDTH WAIT, 
tractions and adhesions about the knees and at the ankles. There 
has been a gradual improvement in the voluntary control of the 
muscles of the legs, so that at the present time there is a response 
in practically all. The improvement has naturally been slow, as 
after four years of absolute disuse the muscles had undergone the 
most extreme atrophy. The rectus feraoris, for example, was at 
first represented under contraction by a small baud not wider 
than one finger and not as thick, while at present, even though it 
is still very small, it has developed sufficiently so that when the 
knee is raised, flexing the joint thirty or forty degrees, the patient is 
able voluntarily to lift the leg from the bed and straighten the knee. 
At the present time the patient is able to stand with the aid of 
crutches, and by being steadied can swing himself along the length 
of the ward. 
The case is of interest, even though there be no further improve- 
ment, which is possible, as he has recently developed tuberculosis 
of the genito-urinary tract, as it demonstrates that the function of 
the spinal cord can be wholly arrested for at least four years, and 
still retain a portion at least of its power of transmitting impulses. 
Of the other cases, one of especial interest is Case IV., a young 
woman, twenty-one years of age. Paralysis had been present for 
about eighteen months and the disease for four years. The patient 
was first treated in January, 1898, with almost instant relief from 
the paralysis, so that in one month she was walking about. She 
then became and has since remained an out-patient, reporting about 
once in six weeks to have the jacket reapplied. The point of spe- 
cial interest is that during the extreme heat of last summer her 
request to have a removable jacket was granted, the understanding 
being that the jacket was to be opened only when lying down. 
One week from that day the patient was brought to the hospital 
with paraplegia. She was sent to the ward and a jacket applied 
the following morning. As soon as she was put in position on the 
frame—no force being used other than her own weight—she 
remarked ; “ Now my legs are all right.” The jacket was applied, 
and that afternoon she left the hospital, walking as well as ever. 
There has been no trouble since except once, when the jacket had 
softened considerably—the legs are said to feel weak and unsteady. 
The new jacket entirely relieved this sensation. pott’s paraplegia. 
5 
In two of the other cases there has been a temporary return of 
the paralysis, due to the softening of the jacket, and in both cases 
the condition has been relieved at once by the correction of the 
position of the spine in applying a new jacket. 
The following case (Case XL) is mentioned rather more in de- 
tail, as it represents a somewhat different condition, and the marked 
improvement which followed the treatment was more unexpected 
than in the other cases. With this one exception the cases which 
are here reported had developed the paralysis in connection with 
the acute or active stage of the disease. In this case, however, the 
active disease in the spine had occurred many years before, the 
spine having become aukylosed in the position of extreme defor- 
mity. In such a condition naturally very little was expected as 
the result of any attempt to correct the position of the back, the 
paralysis presumably being due to a late suppurative process devel- 
oping in the rigid canal, and thus causing piessure. The actual 
result, however, in this case was equally as striking as that obtained 
in the others. The paraplegia was much lessened by the applica- 
tion of the first jacket, and after the last one, which represented 
the third jacket, she was able to be up and move about. In this 
case the sensory paralysis which was present was likewise relieved. 
The cases in detail are as follows : 
Case I. M. A., a boy, eight years of age, with disease of the 
upper lumbar spine of two years’ duration. Paraplegia developed 
one year ago, and was entirely relieved by hyperextending the 
spine, without ether. Plaster-of-Paris jackets have been worn 
since then, the same position of the spine being continued. There 
has been no return of the paralysis as far as the motor control is 
concerned, but the knee reflexes are more lively than normal. 
There is no ankle clonus or noticeable weakness of the legs. 
Case 11. J. P.,a boy, six years of age, with high dorsal caries 
of one year’s duration; during that time he had been under 
treatment with the usual braces. A few months ago paraplegia 
developed, which was complete at the time of ray examination. 
Ether was used and the spine straightened, with marked relief, 
so that the child was able to move the legs about quite freely. In 
a few days, however, the paralysis returned, owing probably to 
the location of the disease and the inability to hold the spine hyper- 6 
JOEL E. GOLDTHWAIT, 
extended. The same manipulation was attempted two or three 
other times, and each time there was the same improvement, but 
also the same relapse in a few days. The child is none the worse 
for the treatment, and at present is being treated by recumbency 
with as thorough fixation as is possible. 
Case 111. R. L., a girl, aged eight years, with Pott’s disease 
of three years’ standing, and quite a marked knuckle. She was 
treated at the Good Samaritan Hospital. Several attempts were 
made without ether to hyperextend the spine by both Dr. Thorn- 
dike and myself, and while two of the attempts at least were fol- 
lowed by improvement, it was of but short duration. At present 
the paralysis is the same as before the treatment was begun. 
ADULTS. 
Case IV. K. St. J., a young woman, aged twenty-one years, 
with Pott’s disease of four or five years’ duration. There was a 
marked deformity, and paraplegia had been present for nearly two 
years previous to the time of the correction of the position of the 
spiue. Ether was used, and after the correction a plaster-of-Paris 
jacket was applied. The paralysis was relieved at once, and there 
has been no return, except once when the jacket was partially 
removed at home, and once or twice when the jacket had softened. 
At each time the correction of the position and a new jacket have 
relieved the trouble. The knee-jerks have remained much exag- 
gerated. There is no ankle clonus, and the voluntary motor control 
is normal. 
Case V. T. D., a man, aged twenty-one years, with disease in 
the mid-dorsal region of two years’ duration. Paraplegia, in which 
the bowel also was involved, developed twelve months ago. The 
position of the spine was corrected without ether with instant relief 
of the paralysis. An abscess has developed since the treatment 
was commenced, but there has been no further trouble from paral- 
ysis, either of the legs or bowel, except once, when there was a 
slight temporary return, due to the softened jacket. A new jacket 
entirely relieved the difficulty. The knee reflexes are still exag- 
gerated. 
Case VI. H. G., a man, twenty-six years of age, with disease pott’s paraplegia. 
7 
in the lower dorsal region of two and one-half years’ duration. 
Paralysis has been present, with the bowel also involved, for six 
months prior to the treatment. The correction of the position 
relieved the paralysis at once, aud there has been no trouble during 
the past year, except slight temporary trouble when the jackets have 
softened. 
Case VII. A man, thirty-six years of age, with mid-dorsal 
Pott’s disease of comparatively short duration previous to the time 
of the first examination, in April, 1898. At that time there was 
also disease of one knee-joint. The treatment for the spine was 
imperfectly carried out, owing to the fact that the patient lived at 
a distance from the city; but with the one jacket, with an impro- 
vised apparatus, there was a marked control in the motor control 
of the legs. The treatment was discontinued and the paralysis 
returned. 
Case VIII. T. M., a man, aged twenty-nine years, with dis- 
ease of the mid-dorsal spine of five years’ duration. At the time 
of the first visit to the Carney Hospital, in January, 1899, there 
was well-marked paraplegia. This was entirely relieved by the 
application of a jacket in the hyperextended position, and there has 
been no trouble but once, when the jacket had softened. 
Case IX. T. D., a woman, aged thirty-two years, with disease 
in the upper lumbar region of two years’ duration. Paralysis had 
been present for about three months previous to her admission to 
the Carney Hospital four weeks ago. A jacket was applied in the 
hyperextended position, and there has been a steady improvement, 
so that the patient is now able to walk about. 
Case X. P. M., a man, aged forty-three years, with disease 
in the mid-dorsal region of six years’ duration. For four years 
previous to beginning the present treatment he had lain on his back 
in the Almshouse Hospital, at Long Island (Boston), with absolute 
paralysis of both legs from the waist down, together with paralysis 
of the bowel. It was through the kindness of Hr. E. W. Taylor 
that I was able to see the patient. Nine months ago he was trans- 
ferred to the Carney Hospital. At that time there was absolutely 
no voluntary muscular movement below the waist, except a slight 
tremor in the three middle toes on the right foot, and this was so 
slight as to escape notice unless carefully looked for. Both feet 8 
pott’s paraplegia. 
were fully extended at the ankle, and were rigid, partly due to joint 
adhesions and partly to muscular stiffness. The knees or hips also 
could not be bent. The legs were oedematous, and the circulation, 
as shown by the condition of the skin, was very poor. Without 
ether the spine was hyperextended and a jacket applied. Within 
a week there were distinct voluntary movements in both legs. A 
few weeks later, under ether, the tendon-Achilles were cut and the 
joints of the legs manipulated. Until four months ago the patient 
made a steady gain, so that there was a voluntary response in prac- 
tically all of the muscles of the legs. At that time a tubercular 
process developed in oue testicle, necessitating surgical interference 
and a temporary discontinuance of the treatment for the back. 
For the past three months the spinal treatment has been continued, 
together with the manipulation of the legs, and even though there 
are some signs of a tubercular process higher up in the genito- 
urinary tract, the improvement has gone on so that there is enough 
strength in the anterior thigh muscles to raise the foot from the bed 
and straighten the leg when the kuee had first beeu flexed and sup- 
ported. With the aid of crutches and an assistant to steady him 
he is able to walk the length of the ward. The improvement has 
been so steady that were it not for the manifestation of the disease 
in the other organs I feel very sure that he would be able ultimately 
to go about independently. 
Case XI. Miss E., a woman, forty years of age, with a large, 
rounded kyphosis invading the mid-dorsal region, which had devel- 
oped over twenty years before. In 1892 there was an attack of 
paraplegia lasting for three months. In September of last year 
the paraplegia again developed, with sensory disturbances. The 
reflexes were extremely exaggerated and the voluntary motor con- 
trol entirely lost. The patient was seen in consultation with Drs. S. 
A. Lord and C. F. Painter. A jacket was applied with the spine 
hyperextended as much as possible, and since then three or four 
other jackets have beeu used. With each the paralysis has lessened, 
so that at present the patient is able to walk about freely. 
The apparatus which was used to obtain the desired position of 
the spine was described and pictured in a paper read by me before 
this Association at the meeting held last year, and afterward pub- 
lished in the Boston Medical and Surgical Journal, July 28, 1898.