SPINAL ABSCESSES.

BY H F. BIGGAR, M.D.

Abscesses occurring as a symptom or in the course of spinal disease, are comparatively among the rarest of affections which the surgeon is called upon to treat, and not the least embarrassing, inasmuch as they very often terminate fatally.

They occur in about the same proportion among young people of both sexes having a systemic cachexia, tubercular or strumous in character, which may possibly be affected by climatic conditions.

The immediate or exciting cause is often referred to an accident, as a fall or a blow occurring some time previous, or in old people to sexual excesses. Yet as often the disease is found occurring spontaneously.

No part of the spine is exempt from paying tribute to the disease, and two or more different portions of it may be affected at the same time. This disease, which is a suppurative process or caries, always originates in the spinal column, confining itself to the anterior segments of the vertebræ as a rule, that is to the bodies of the vertebræ, the fibro-cartilage and the ligaments. The caries rapidly passes from one vertebræ to another without affecting the posterior arch, in which a reparative process is set up directly antagonistic to the destruction which is going on in front. The pus which is thrown out lies at first upon the carious vertebræ, the curvature of the spine favoring its accumulation in that position and the connecting tissue retains it there. Soon a pyogenic membrane is thrown about this accumulation and an abscess is formed within the parietes, of which two entirely opposite processes are going on; a formative or reparative at the deeper portions and an erosive or absorptive in the superficial. The course of the abscess now is either to terminate by resolution through the formative process overcoming the absorptive, its walls gradually thickening and obliterating the cavity, or the caries progressively advances. If it follows the latter course it must necessarily enlarge as the pus

accumulates. This it generally does by extending downwards along the sides of the bodies of the vertebræ. Yet an abscess produced by disease of the cervical vertebræ may locate itself behind the pharynx, at the sides of the neck, or even in the thorax or axilla.

Spinal abscesses are generally psoas, and to this division I shall limit my remarks-the description and course of which is given in Holmes' Surgery, page 487, as follows :

"The disease in the spinal column which gives rise to it is often seated above the origin of the psoas muscle, the pus traveling 'down the front of the column in the posterior mediastinum till it makes its way beneath the ligamentum arctuatum internum, and so gains the sheath of the psoas-sometimes on both sides. It then travels down the loins, forming a fullness which can often be distinctly recognized at the side of the lumbar spine, and sometimes irritating the muscle so as to produce flexion of the thigh and pain on attempting to extend it. It then fills the iliac fossa, passes beneath pouparts ligament on the outer side of the vessels, crosses beneath the femoral sheath to the inside of the thigh, where it usually stops, presenting and bursting just below the groin; but in rarer cases it may travel a long distance down the thigh before it bursts."

Sometimes the pus follows the course of the sartorius muscle down the thigh under the fascia, showing itself at the popliteal space, or occasionally not pointing until it reaches the calf or ankle. At other times the collection of pus in passing down points above pouparts ligament, or it may work its way into the pelvis and out through the sacrosciatic foramen, collecting itself in the gluteal region. Sir B. C. Brodie mentions a case where the abscess passed from the iliac region into the spermatic canal, presenting at the external abdominal ring. Other cases open into the intestines and bladder.

Symptoms. Weakness of the back, accompanied with a dull pain which is increased by exercise or pressure, are among the earliest symptoms complained of by the patient.

This pain manifests a tendency to exacerbations and remissions, but its persistency and long duration are of value in discriminating

the disease. On examination a deformity of the spine is generally observed. Also there is preternatural rigidity in the diseased portion as compared with the flexibility of the other portions of the spine. Sometimes the testicle of the affected side is drawn up with pain along the spermatic cord. Later, as the disease progresses, the limbs become atrophied, numb and cold. And there may be anorexia, uneasiness in the epigastrium, together with the symptoms of profuse suppuration, such as rigors, fever and fullness in the iliac fossa.

Differentiation. The differential diagnosis is of the highest importance, as it is liable to be confounded with femoral hernia, iliac abscess, abscess in the areolar tissue about the vertebral column without disease of the vertebræ, aneurism, morbus coxarius, pericæcal abscess and cancer. The diagnostic differences between psoas abscess and femoral hernia are about as follows: anatomically the abscess is diagnosed by lying outside the femoral vessels, while the hernia is upon the inside. Clinically the abscess is fluctuant if superficial, while the hernia never is. Frequently both have distinct impulses imparted to them on coughing, and both may be reduced by pressure, but the disappearance of the hernia is attended with a gurgle, which is untrue of the disappearance of the abscess.

Iliac abscess generally occurs after middle life, is diffuse, and points above pouparts ligament. Psoas abscess usually occurs before middle life, is circumscribed, and points below pouparts ligament. Abscesses situated in the areolar tissue about the vertebral column without disease of the vertebræ, are unassociated with deformity of the spine, dorsal pain and tenderness. Psoas abscesses are generally associated with a distinct history of spinal disease.

The differentiation from diffuse aneurism is sometimes very difficult, yet auscultation with a stethescope will usually give a bruit, which with the history of the case and the suddenness of its appearance, will generally enable the surgeon to recognize it. In morbus coxarius the limb is changed in length on the affected side, the fold of the nates is altered in position, pain is as a rule first felt in the knee. Also the joint is sometimes anchylosed and acute pain is produced by pressure over the trochanter. In psoas abscess these symptoms are absent.

Terminations. The prognosis is very unfavorable under the most auspicious circumstances. Sometimes the disease terminates fatally by the abscess bursting into the cord; more frequently, however, death results from exhaustion. In those cases which terminate favorably under good treatment, the diseased bones become consolidated and the patient recovers with a more or less incurable deformity. When recovery takes place the seat of the former inflammation is followed often by a residual abscess. Sir James Paget says: "Some of the most striking instances of residual abscesses may be found in connection with diseases of the spine."

Treatment. It is necessary, under all circumstances, to give the spine rest by every available means. This I do with the windowed plaster of paris jacket or the lace support made from it. Whether to allow the abscesses to burst of themselves or open. them, is a much mooted question. Holmes, Piriogoff, Bilroth, Erichsen, &c., all advise no interference unless the abscess is very large or painful, but when it seems proper to open it through the pus coming near the surface, how shall we proceed? Shall we make the subcutaneous puncture according to Abernethy? or tap with an aspirator or trocar with a tube passing into a basin of water so as to avoid the entrance of air? or make the valvular incision? Of late I have employed, to my great satisfaction, the method in vogue at St. Bartholomew's Hospital, London, of evacuating the abscess with a trocar, carefully avoiding the entrance of air by means of its tube passing under water. Into the opening thus made I put a drainage tube, and inject through it daily either a solution of Carbolic acid or Calendula, according as they may seem to be indicated. Where granulation is excessive, I employ the Carbolic acid and Calendula in alternation, finding the result much more satisfactory than from the use of either remedy alone.

Diet. A good and careful diet is highly essential and should not be neglected. It should include the cereals, as wheat, oat meal, &c.; also, meats, fish, milk and maltine are generally suitable. In some cases stimulants and tonics are absolutely necessary.

Hygiene. The patients should sleep alone in large, well ventilated rooms. They should daily employ sponge baths, either of sea salt and water or the acidulated water or ammonia and water,

following it immediately by vigorous friction to promote a reaction.

Therapeutics. I have found benefit in the use of only four remedies:

Asafoetida. The abscess discharges a thin, fetid pus, with stitching pains in the lumbar regions, which are very painful to contact, and when there is numbness of the affected parts. Especially in nervous, hysterical, scrofulous patients.

Calcarea phosphoricum. When there is great emaciation, with hard, bloated abdomen, and when there is profuse suppuration, with a tendency of the abscess to heal.

Mezereum. When the periosteum of the vertebræ is affected, and when there is excessive prostration, accompanied with violent nightly pains.

Phosphoric acid should be administered when there is great debility, profuse night sweats and symptoms of slow hectic fever, together with violent pains in the lumbar region, which are smarting or burning in character.