THE SURGICAL TREATMENT 1 OF *• •Jr-?*'? . r-M. > POTT'S DISEASE. Read before the Orthopcedic Section of the College of Physicians of Philadelphia, October 20, 1893. BY W. W. KEEN, M.D., Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. REPRINTED FROM THE THERAPEUTIC GAZETTE, JANUARY ij, 1894. DETROIT, MICH. : GEORGE S. DAVIS, PUBLISHER. 1894. THE SURGICAL TREATMENT OF POTT'S DISEASE.* THE first laminectomy for Pott's disease seems to have been done by Jackson, of Sheffield (Brit. Med. Journ., 1883, i. p. 812); but the modern surgery of Pott's disease really dates from the operation of Macewen (Lancet, 1885, i. 881), when he operated on a case of paraplegia with incontinence of urine and faeces, due to a connective-tissue tumor at the seat of angular curvature of the spine. In this boy, nine years of age, between the theca and the bone was found a fibrous neoplasm one-eighth of an inch in thickness, firmly attached to the theca and covering two-thirds of its circum- ference. After this was dissected away, the cord was able to expand backward, and pulsa- tion, which had been absent, showed itself, es- pecially opposite the fifth dorsal vertebra. Twenty-four hours after the removal of the pressure the limbs had lost their livid color and were warm; the spastic rigidity was greatly lessened; the perception of tickling the soles had returned and that of touch was * The first part of this paper is part of a paper on the " Surgery of the Spine" in the supplementary volume of Buck's " Reference Hand-Book of the Medical Sciences." 2 improved. Movement was first observed eight days later, and soon after this he had perfect control over the sphincters. After six months he was able to go about without support. Five years afterwards he could walk three miles ; attended school regularly, joining in all the games, including even foot-ball. A second and more aggravated case (Brit. Med. Journ., 1888, ii. 308), operated on in 1884, showed a slight tumor with organic changes in the cord, which had shrunk to about half its normal dimensions. In ten hours after the operation the limbs had lost their lividity and felt warm. From the fourth day she obtained control over her bladder and rectum ; six weeks after the operation she could move her limbs freely; and two months after walked a quarter of a mile and was able to perform light duties in the house. Three other similar cases were operated on, one of which was successful, but the other two died. Besides these cases, he reported the evacuation of an abscess in the posterior medi- astinum, which was pressing on the heart and bronchi. This case was also completely suc- cessful. Another similar and striking illustrative case is reported by Southam (Brit. Med. Journ., 1892, i. 655), in a child three and a half years old, all four extremities being so par- alyzed that the patient lay helpless in bed, with incontinence of both urine and faeces. In this case, at two operations three months apart, he removed the laminae from the fourth cervical to the first dorsal vertebra inclusive, and removed a quantity of granulation tissue. But little improvement was noticed for nine 3 months after the second operation ; then-a most important point of encouragement-the child began to improve, and when the case was reported two years later could walk without assistance and had control over the sphincters. The source of the nervous symptoms seems not generally to be the mere curvature of the spine, nor the acute myelitis, but the pressure caused either by fungous masses of granulation tissue over the bodies of the vertebrae by in- flammatory swelling, but oftenest by a chronic pachymeningitis, or by the accumulation of pus. For instance, W. Arbuthnot Lane (Lancet, 1891, ii. 989) reports eleven cases of Pott's disease in which the compression in all but one was caused by an abscess. In none of these were there any fibrous neoplasms, such as are described by Macewen. In such cases death follows either as the result of pulmonary com- plications, or more frequently from cystitis and renal complications, bed-sores, pain, sleepless- ness, etc. In all of Lane's cases the large amount of disease would have precluded a cure by anchylosis. He urges, therefore, that '' every case of paraplegia due to spinal caries should be operated on with as little delay as possible." In view, however, of published clinical results, especially as shown by Lloyd (Annals of Sur- gery, October, 1892, 289), who has tabulated seventy-five cases of laminectomy for Pott's disease, this opinion seems too sweeping if taken without reservation. Thus, Meyers has reported recovery from paraplegia in fifty-five per cent, of two hundred and eighteen cases, Gibney fifty per cent, in fifty-eight cases, Tay- lor and Lovett ninety per cent, in nineteen cases, and Sayre ninety per cent, in thirty- eight cases. The views of Burrell and Bullard and Kraske seem to be the more reasonable. " So long as we have reasonable or even mod- erate chances of recovery without operation," say the former authors, "we do not believe it advisable or justifiable, in the present condition of spinal surgery, to perform so serious an op- eration as the resection of the laminae." Kraske's rule for interference is well expressed. "It is necessary before operating to have ex- hausted all other methods of treatment. I would say interfere when a paralysis of the bladder is established; this is the one symp- tom which is so serious as to justify every- thing" (Lloyd). To which Lloyd adds, that " the first sign of degeneration of the cord should indicate immediate operation." It will be especially observed that ordinary cases of mere curvature from Pott's disease are ex- cluded, and only those in which paraplegia with all its dire evils has resulted from the caries should be considered suitable for opera- tion, and then only with the limitations al- ready stated. If there are other tubercular complications it is contraindicated. It will be observed that the cases above re- ferred to fall into two categories: First, the cases of paraplegia from pressure, either by masses of granulation tissue which may arise from the vertebrae within the spinal canal or from thickening from pachymeningitis,-a thickening which, for instance, in Macewen's case, amounted practically to a tumor so far as pressure on the cord is concerned; secondly, cases of paraplegia as a result of pressure on the cord from abscesses resulting from the breaking down of the granulation tissue. 4 5 Cases of paraplegia from either of these lesions may be treated by laminectomy, with removal of the neoplasm, the granulation tissue, the pus, the carious bone, etc., by the usual means employed in such cases, provided they fulfil the conditions already mentioned. Besides these there are many cases of ab- scesses in Pott's disease in which modern sur- gery has of late achieved notable improve- ments in the way of preventing the later lesions of the cord, which may properly be briefly alluded to. Until within a few years surgical interference has been limited to evacu- ation and drainage of these abscesses at their lowest point,-e.g., at the thigh below Pou- part's ligament,-with or without curetting or injection of iodoform in ether or an emulsion of iodoform in olive oil. This left the source of the evil-the carious vertebrae-untouched and also very imperfectly treated the abscess. Mr. Treves, in June, 1884 {Med.-Chir. Trans., vol. Ixvii.), urged the evacuation of psoas ab- scess in the loin, combined with the removal of the carious and necrosed bone by the usual means employed elsewhere. This method he has perfected and extended, and at the present time carries it out as fol- lows, which I condense from his " Manual of Operative Surgery" (ii. 731): A vertical in- cision two and a half inches long is made in the loin, whether it be in lumbar or psoas ab- scess, in order to reach the spine itself rather than merely to drain the abscess at its lowest point. The centre of this incision is midway between the crest of the ilium and the last rib. It is about two and a half inches from the lum- bar spines. The lumbar aponeurosis and the attached muscular fibres of the latissimus dorsi are divided the entire length of the incision, thus exposing the erector spinae, which is drawn strongly towards the middle line, exposing the middle layer of the lumbar fascia. Through this can readily be felt the transverse process of the third lumbar vertebra. A vertical in- cision, as near the transverse processes as is convenient, exposes the quadratus lumborum, which here is very thin. The quadratus is di- vided close to the extremity of the transverse processes, and the incision cautiously enlarged until the muscle is divided to the full extent of the external wound. The abdominal branches of the lumbar arteries may easily be wounded, but care should be exercised to avoid them, as well as the main trunks of the lumbar vessels, by keeping close to the transverse processes and reaching the spine by following them. The inner edge of the quadratus is over- lapped by the psoas muscle, and on dividing the quadratus the psoas is therefore exposed. As the fibres of the two muscles run almost parallel, it is important to observe that the in- terval between them can be recognized by a thin but distinct layer of fascia, known as the anterior layer of the lumbar fascia. Next, the tendinous fibres of the psoas arising from the transverse processes having been divided, the finger is introduced beneath the muscle until it reaches the anterior aspect of the bodies of the vertebrae, when the incision can then be en- larged as far as is necessary. All risk of wounding the peritoneum will be avoided by making the incision in the quadratus as near the transverse processes as possible. When the abscess cavity is well opened, the 6 anterior surface of the spine is examined by the finger. An irrigator is then introduced into the abscess, and it is flushed by many gallons of sublimate solution (x to 5000). While this is being done, the position of the patient is re- peatedly changed, so as to fill and again empty the abscess cavity many times. During this washing out, the finger is introduced into every accessible portion of the abscess, diverticula are opened by it, collections of caseous matter scraped away with the finger-nail, and in gen- eral all the tubercular granulation tissue got rid of as far as possible. The sharp spoon can be used, but, should be used with caution, especially on the anterior wall, which is thin. Mr. Treves thinks a piece of fine Turkish sponge on a long sponge-holder is the best means of removing the granulation tissue, by wiping and scrubbing the inner wall with a ro- tary movement of the sponge in every part of the abscess and its diverticula. I have found the ordinary gauze sponges equally good ; but to accomplish the object in view much time, many sponges, and prolonged and thorough scrubbing, rubbing, and wiping of the interior of the ab- scess are necessary. When the sponge or gauze is drawn out practically unsoiled, then the cavity can be regarded as prepared for healing. During this process, or as a separate stagd, thor- ough flushing out is again accomplished. Fi- nally, the abscess is wiped dry and the wound closed by a series of silkworm-gut sutures, in- cluding the muscular and tendinous structures. Then the ordinary antiseptic dressing is placed over the wound, and I also prefer to place a large abdominal pad over the site of the ab- scess anteriorly, so as to assist in obliterating 7 8 the cavity by pressure. " The subsequent treat- ment," in the words of Mr. Treves, "consists in absolute rest in the recumbent position for a period of months,-a period which may easily be too short, but can hardly be too long." In adults it will probably be over a year ; in chil- dren somewhat less. If it can be spent in the best hygienic conditions, out of doors, at the sea-side, etc., so much the better. A second similar operation may be needed, but Mr. Treves states that on no occasion has he had to do a third operation. Sometimes Mr. Barker's hollow-handled flushing gouge or sharp spoon, which answers so well for bone, can be used also in these ab- scesses, but must be used with caution. Tn the cervical region retro-pharyngeal ab- scesses are usually accessible through the mouth, and the bone can also be treated by the same route. Burckhardt (Centralbl. f. Chir., 1888, No. 4) has advocated an external incision at the inner border of the sterno-cleido mastoid, reaching the abscess by the inner side of the sheath of the vessels. Chiene, as early as 1877, advocated a similar operation on the outer bor- der of the sterno-cleido mastoid, and Kramer (Centralbl. f. Chir., 1892, No. 12) has success- fully carried out Burckhardt's proposed opera- tion with ease. These operations have the ad- vantage, of course, of permitting more thorough antisepsis than the oral route, but the mortality of the latter has been very small. In abscesses in the cervical region, with difficulty accessible by the mouth, however, these methods of oper- ating will probably prove of greater value than that by the mouth. In the dorsal region, Shafer {Journal of the 9 American Medical Association, December 19, 1891, 943) proposed " to incise the soft tissues one inch from the spinous processes, uncover and remove the transverse process of the diseased bone or of the one just below it, and resect the head and neck of the corresponding rib. This permits a large finger to reach the postero- lateral angle of the diseased bone, and gives room for the introduction of the curette, sharp spoon, or forceps, and leaves a large space for a drainage-tube. Should it be desired to carry the drainage-tube through the column, the trans- verse process with the end of the rib of the op- posite side can also be removed, when it can readily be passed through." A somewhat similar method was published four months later by Vincent (Rev. de Chir., April,,1892, 273). In this somewhat elaborate paper he describes three different methods of side-to-Side drainage: (1) prevertebral drain- age,-that is, in front of the bodies of the ver- tebrae ; (2) premedullary drainage,-that is, in front of the spinal cord and its membranes, in case of the destruction of the bodies; and (3) vertebral trans-somatic drainage, or drainage through the bodies of the vertebrae. In all cases he selects the point of greatest curvature, makes an incision along the external border of the erector spinae eight to ten centimetres in length, with a transverse incision from the mid- dle of the first and at right angles to it, about five centimetres long. One or two ribs are re- sected, the intercostal muscles separated, the pleura and the tissues in the chest are detached by the finger or any blunt instrument, and, fol- lowing the track of the granulation tissue and the sinuses, we are able finally to pass the drain- 10 age-tube from side to side. The method is not essentially different, whether the tube is passed in front of the bodies of the vertebrae or behind them and just in front of the medulla and its membranes. In the latter case great care should be taken not to puncture or otherwise injure the membranes or the cord itself. Only wide- spread destruction of the bodies of the vertebrae would allow of premedullary drainage. In vertebral trans-somatic drainage, the earlier steps are precisely the same as before, with the addition that, by means of the curette or perforator or other such instrument, the body of the vertebra is perforated from each side and the drainage-tube carried through the canal so made. Shafer reports three cases, in one of which the sinuses, excepting one, all healed in two months and in six months after the operation the patient left the hospital, but a year after the operation she died of pulmonary tuberculosis. In the second case, in which the same procedure was used in the cervical region, there was very serious hemorrhage (checked by packing) in the cavity of the body of the fourth cervical, and the disturbance of the vertebral column was such that her neck felt as though it were broken. A jury-mast enabled her to walk about, and she was discharged from the hos- pital six weeks after the operation. About six months later (the time is indefinite) the jury- mast was laid aside, she could hold her head erect, was engaged about the house and feeling well. In the third case there was caries of the body of the sacrum, with secondary inflamma- tion of the trochanter major. The patient was somewhat more comfortable after the operation, although the prognosis as to his lungs was very bad. Vincent reports two cases,-one of trans- somato-vertebral drainage and the other of pre- vertebral drainage. The first made an excellent recovery; the second died. The conclusion that I should reach as to this somewhat heroic method is very much that of Vincent: "We cannot as yet come to a con- clusion in favor of such operative procedures in Pott's disease. All we can say actually is that they have been practised without accident" (?) -and with varying results. The procedure will only be occasionally useful, and great care must be taken to avoid wounding the pleura, the ganglia of the sympathetic, and the spinal nerves. The intercostal arteries are almost in- evitably injured, and it seems possible that even the vertebral was involved in one of Shafer's cases. 11 JANUARY 16, 1893. WHOLE BERIKS. VOL. XVtl. No. I. t THIBO SERIES. VOL. IX. 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