' ■•■■■■■■"'■ ■ HI ■I Bsllssiigffi ■II §111 III Wmm m a sJwWSSrasSbcianScKa W* class T fHy jl Book -LBH— Copyjight^ /ff/^ COPYRIGHT DEPOSIT: LATERAL CURVATURE OF THE SPINE AND ROUND SHOULDERS LOVETT LATERAL CURVATURE OF THE SPINE AND ROUND SHOULDERS BY ROBERT W. LOVETT, M. D. BOSTON JOHN B. AND BUCKMINSTER BROWN PROFESSOR OF ORTHOPEDIC SURGERY, HARVARD MEDICAL SCHOOL; SURGEON TO THE CHILDREN'S HOSPITAL, BOSTON; SURGEON-IN-CHIEF TO THE MASSACHUSETTS HOSPITAL SCHOOL, CANTON; CONSULTING ORTHOPEDIC SURGEON TO THE BOSTON DISPENSARY; MEMBER OF THE AMERICAN ORTHOPEDIC ASSOCIATION; CORRESPONDING MEMBER OB THE ROYAL SOCIETY OF PHYSICIANS, BUDAPEST; KORRESPONDIERENDES MITGLIED DER DEUTSCHEN GESELLSCHAFT FUR ORTHOPADISCHE CHIRURGIE, SOCIO DELLA SOCIETA ITALIANA DI ORTOPEDIA THIRD EDITION, REVISED AND ENLARGED WITH 180 ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO 1012 WALNUT STREET in Copyright, 1916, by P. Blakiston's Son & Co. THE MAPLE PRESS XORK PA MAY I7I9I6 ©CI.A433028 TO ROBERT JONES LIVERPOOL A GREAT SURGEON AND AN OLD FRIEND PREFACE TO THE THIRD EDITION In the three years and a half since the second edition of this book was published there has been much discussion of the question of the treatment of scoliosis by forcible correction, and a greatly increased interest has been awakened in the matter. In 191 1 a modification of former methods of forcible correction w r as advocated, and for this modification was claimed a degree of effectiveness hitherto quite unknown and not in accord with our pathological knowledge. The method thus advocated was enthusiastically accepted and loudly acclaimed by many competent men. But in the last year or two a reaction has set in, and much unfavorable criticism of the method has been published. Under these circumstances I have fallen back on my own personal experience, and have published certain well-recorded cases showing what I have personally been able to accomplish by forcible correction. In addition to this I have stated what I believe to be the status of the matter at present, a status still unsettled. Apparently the time has come when a serious analysis of the results by means of roentgenograms will be required to place the matter on a convincing basis. Assertions and opinions have too long prevailed in scoliosis, and tangible facts are now re- quired. I have rewritten a large part of the section on treatment, and I have revised extensively other parts of the book, condensing where I could and expanding where it seemed necessary. A chapter on the history of scoliosis has been added, because there seemed to be nothing in English on the subject. I have endeavored to reclassify and rearrange certain parts of the book in order to present with greater clearness certain phases of this complicated affection, because consideration of the matter has in the past tended toward complexity, and it has seemed to me that a clear statement of essential points was desirable in a book intended largely for use as a text-book. Robert W. Lovett. PREFACE TO FIRST EDITION The successful treatment of lateral curvature of the spine cannot in the past be counted as one of the achievements of orthopedic surgery. The affection is not only intrinsically resistant to treatment, but the therapeutic measures employed have been on the whole largely empirical and have not been sufficiently correlated to its pathology and to the mechanism by which it is caused. In the last ten years, however, a good deal of progress has been made along new and prom- ising lines, by means of experimental and clinical work, the records of which lie scattered through later medical literature. In the follow- ing pages I have attempted to bring together this literature and to add my own personal views and experience, in the hope of presenting the subject in English in a modern light and to call attention to the prospect offered of obtaining better results. That such a book is needed I have been led to infer from many inquiries in connection with this subject by physicians, medical students, and teachers of physical training. If I have devoted too large a part of the book to the question of treatment it is because of the scant attention paid to that part of the subject in most books dealing with deformities. The anatomical part of the work is from the Anatomical Depart- ment of Harvard University, and much of the clinical work is from the Scoliosis Clinic of the Children's Hospital, Boston. It is impossible to acknowledge my indebtedness individually to those of my colleagues and others who have helped me by contribut- ing material and other assistance. I should, however, express my obligation to Professor Thomas D wight for his advice given in con- nection with the anatomical part of my work, for the liberal supply of anatomical material with which he has provided me, and for criticising my chapter on Anatomy. To Miss Amy Morris Homans, Director of the Boston Normal School of Gymnastics, I wish to ex- press my indebtedness for assistance given in many ways; and to my assistants, Fraulein Helene Seltmann and Miss W. G. Wright, for great help in preparing the list of exercises. I have used freely the chapters on Pathology and Occurrence in the admirable article on Scoliosis by Schulthess of Zurich, recently pub- lished in JoachimsthaFs "Handbuch der Orthopadischen Chirurgie." Robert W. Lovett. Boston. TABLE OF CONTENTS Chapter Page I. History of Scoliosis i II V The Anatomy of the Vertebral Column and the Thorax 8 III. The Movements of the Spine 29 IV. The Mechanism of Scoliosis 43 V. Description and Symptoms 51 VI. Examination and Record of Scoliosis 71 VII. Pathology 83 VIII. Etiology 97 IX. Occurrence in X. Relation of Scoliosis to School Life 117 XL Diagnosis 124 XII. Prognosis 127 XIII. Treatment 129 XIV. Faulty Attitude 191 Index 211 XI LATERAL CURVATURE OF THE SPINE AND ROUND SHOULDERS CHAPTER I THE HISTORY OF SCOLIOSIS 1 To write the history of scoliosis one must start with the begin- nings of medicine and follow down through some 2500 years the course of an affection for many centuries classed with other cur- vatures of the spine, and considered, as they were considered, due to dislocation of the vertebrae. One finds in this, as in most affections long recognized, that time brings about its identification as an entity, after which it gradually becomes separated from similar affections and is discussed by itself. The term "scoliosis" dates much farther back than the recogni- tion of the affection itself. c/coXtoco, from which scoliosis is derived, is a Homeric word meaning to bend or twist, and the term o-koXi'cosis was first used by Hippocrates, who lived four centuries before the beginning of the Christian era. His use of the word apparently was to designate a lateral form of the spinal curve supposed to be due to dislocation, the forward curve being called lordosis and the back- ward curve kyphosis. There were two other words in use at this time which have dropped out, and which are of no significance. Although the name scoliosis was given by Hippocrates, a very short extract from his works will show that he had little or no idea of what the condition was. After a description of posterior curvature of the spine, which is fairly accurate in a very rough way, he goes on: — "In some cases the curvature of the spine is lateral, that is to say, either to the one side or to the other, and most of such cases are connected with tubercles (abscesses?) within the spine, and in some the position in which they had been accustomed to lie cooperates with the disease but these will be treated of among the common affections of the lungs." 1 u Geschicte und Behandlung der seitlichen Ruckgratsverkriimmung," Strassburg, 1885. Chlumsky: " Prispezky k Dejinam Skoliosy," Prag, 1910 2 THE HISTORY OF SCOLIOSIS " Lateral curvatures also occur, the approximate cause of which is the attitudes in which these people lie. These cases have the prognostics accordingly." Yet Hippocrates gave a very clear description of club-foot, which was well recognized by him, and although the splints advised seem rather inefficient, the treatment by moulding and retention was advocated. Patients with spinal curves, however, were tied by the legs to a ladder, and the ladder raised and then dropped to the ground, striking on one end, thus tending to straighten the spine, or such patients were put into an apparatus to make extension and pressure on the prominence. He adds as a further refinement of his treatment: — "It is also safe for a person to sit upon the hump while extension is being made, and raising himself to let himself fall down again upon the patient." He also suggests putting one foot on the hump or using a long wooden lever, but one finds no mention of any attempt at retention, and the reason for this is that all the treat- ment was based on the supposition that the affection was due to a dislocation, which demanded reduction only. For about 2000 years after Hippocrates, scoliosis attracted little attention and no advance was made. Paul of Aegina, 650 A. D., suggested bandaging to wooden strips in cases of curvature of all varieties, and Albukasis 500 years later announced that "no one could cure curvature to the side." And so one comes down through the centuries with no new light to the time of Ambroise Pare, born in 15 10, and we find him where we left Hippocrates 2000 years before. I quote from his writings: " A dislocated vertebra standing forth and making a bunch is termed in Greek kyphosis, but when it is depressed it is called lordosis, but when the same is luxated to the right or left side it maketh a scoliosis, which, wresting the spine, draws it into the similitude of the letter S Fluid and soft bodies, such as children, are very subject to generate this internal cause of denuxion. Thus nurses, while they too straitly lace the breasts and sides of girls so to make them slender, cause the breast-bone to cast itself in forward or back, or else the one shoulder to be bigger or fuller, the other more spare or lean. The same error is committed if they lay children frequently and long upon their sides, then upon their backs, or if in taking them up when they walk they take them only by the feet or legs and never put their other hand in their backs, never so much as thinking that children grow most toward their heads." Then follows a fair ac- count of the deformity, and the reduction of the dislocation is on the HISTOKN 3 same lines as advocated by Hippocrates, by extension and pressure by the hand or by lever. He suggested, however, the use of a padded iron corset, the illustrations of which are familiar, but still it was always a dislocation that was considered. It was to be treated by levers and great force, and the after-treatment played only a very small part. Among the various authors of the next hundred years one finds silence on the subject in most, such as Fabricius, Hieronymus and Vesalius, but here and there are flashes of light, mostly fantastic speculations as to etiology, but the affection was frequent, for Riolan, in 1641, stated that in France the girls carried as a rule the left shoulder higher than the right, and that one could hardly find a case where the shoulders were rightly constructed. His speculations as to etiology were much the same as those of the nineteenth century, namely, the use of the right arm and the wearing of stiffened corsets. The first autopsy of a scoliotic case was reported in 1646 by Fabricius Hildanus, without apparently clearing up the matter. Glisson, writing of rickets, which he named rachitis, in 1660, described the spinal curves due to it, and suggested for this indiscriminate treat- ment gymnastics or suspension, but Glisson's suspension was from axillae, head and hands, by which the children were slung and allowed to play in the air, which he adds "they did with great enjoyment." The head sling proper dates from Nuckius in 1696, and was devised for the treatment of wry neck. From this time until the time of Andre in 1741, one cannot see that any author contributed much to progress, although it is evident that whalebone corsets were coming into use as a method of treat- ment, originating with Jungken in 1691, and the mention of scoliosis is more frequent than in the preceding century, but never apparently differentiated clearly from other curvatures. Andre was a man of originality, the inventor of the term "ortho- pedic," and he wrote more fully of spinal curves than his predecessors. He condemned high heels and blamed them and bad sitting positions for much of the faulty attitude. Among causes for spinal curves he mentioned hemorrhoids, which were so painful that the child could not sit squarely, and he called attention to the important fact that as a child grew the clothes must be made larger. He suggested gymnastics and apparatus as a means of treatment. Taking it altogether the middle of the eighteenth century, that is to say, the time of the beginning of the American Revolution, was a time of considerable activity and some little progress in the history 4 THE HISTORY OF SCOLIOSIS of scoliosis. Andre was the first to group deformities together and to give a name to the specialty. His directions about treatment were vague, but he recognized in bow legs at least that the same means must be taken to straighten them as were adopted to straighten the crooked stem of a young tree. He advocated friction of the de- formed parts and their gradual restoration by manual extension, pressure and localized movement. A very distinct step at about this time was made by the classical work of Percival Pott, who published in 1779, his essay on "The Palsy of the Lower Limbs in Consequence of a Curvature of the Spine." In this work he took out of the un- classified group of affections known as curvatures of the spine, those posterior curves caused by spinal tuberculosis. He stated with regard to the paralysis "that none of those strange twists and de- viations which the majority of European women get in their shapes from the very absurd custom of dressing them in stays during their infancy, and which put them into all directions but the right, ever caused anything of this kind, however great the deformity might be." His description of spinal tuberculosis was so accurate that it immediately identified posterior curvature as a carious or scrofulous disease of bone and not as a dislocation, and thus cleared the field for the recognition of scoliosis as an entity. About this time scoliosis was becoming more clearly defined. Autopsies were being performed, and it was being recognized that it was not to be classed and treated with the posterior curvatures. This came not only from the work of Pott, but was gradually coming in from all sides, and apparatus of various kinds began to be devised. The iron cross of Heister, invented in 1700, began to be displaced by apparatus more of the modern type, and the corset of Maguy, de- vised in 1762, would find a sale to-day in the instrument shops; but the greatest impetus was given by the apparatus of Levacher in 1768, which consisted of a whalebone corset to which was affixed jury mast and a head sling. Although, the period at the middle of the eighteenth century, as has been said, was one of considerable activity and progress in the development of scoliosis, at about this time there began and lasted for over a hundred years, the dreariest and most confusing period in the history of the affection. The theorist and the apparatus in- ventor went mad, and every form of device appeared. Braces and corsets infinitely complicated, worse than useless, appeared by the dozen. Beds especially constructed, chairs, slings, swathes, belts, levers and the like, all found their advocates, and theories as to the HISTORY 5 causation also ran riot, but on the whole the invention and elbaora- tion of apparatus held the center of the stage, and one heard but little oi gymnastics. It is difficult to trace the origin of the gymnastic treatment of scoliosis, for it had existed from an early time. Even as early as Glisson a system of gymnastics was clearly formulated, and appar- ent ly gymnastic treatment was not at that time by any means new. Sydenham, 1624-1689, wrote "If anyone knew of the values of friction and exercise and could keep his knowledge secret he might easily make a fortune/' and "Fuller's Medicina Gymnastica," published in 1704, was followed by a similar work by Tissot in 1781, and by Jahn and others, who worked with energy to spread German gymnastics. A very decided impetus came from Sweden from Henry Ling, who died in 1839, and who founded a system of gymnastics known as the Ling system or Swedish movement treatment. An institute under the supervision of the Swedish government was established in Stockholm, and Ling was its first president. A paper advocating gymnastic treatment was published by Langgard in 1868, and books and monographs followed in rapid succession. Thus toward the middle of the nineteenth century, at the close of the hundred-year period which has been spoken of as dreary and demoralizing, gymnastic treatment began to crowd apparatus treat- ment and to absorb some of the attention previously given wholly to mechanical treatment. From this point gymnastic treatment has increased in prominence until it is fair to say that to-day it constitutes the bulk of the scoliosis treatment in America. Shortly after the middle of the nineteenth century there began what seems to be the first real progress that had been made in the treatment of structural scoliosis. To one who reads the history of the past the impression is left that up to this time the etiology had been the subject of a great deal of loose and irrational theory, that the recognition and identification of the affection had been delayed for centuries, and that all treatment up to this time had been, as we see it to-day, ineffectual and comparatively useless. In 1878, Lewis A. Sayre published a book on "Spinal Disease and Spinal Curvature," in which he advocated their treatment by self-suspension and a plaster-of-Paris jacket. Self-suspension he credited to Dr. Benjamin Lee of Philadelphia and Prof. Mitchell of Philadelphia. He advocated the application of a plaster-of- Paris jacket in suspension, with the heels lifted from the ground, and he claimed for them nothing more than support in an improved posi- THE HISTORY OF SCOLIOSIS tion. The jackets were removable, and exercises were done daily. The treatment was too mild to be effective, but it contained appar- ently the germ of the modern progress in the treatment of the affec- tion. The use of plaster-of-Paris jackets thus became more or less common in cases of Pott's disease as well as of scoliosis, and the work of Calot in 1896, who advocated at that time the use of forcible cor- rection in the treatment of Pott's disease, suggested the use of more force than had been previously used in the correction of lateral curvature. Schanz published, in 1900, an account of an efficient technic for the application of jackets in suspension, and reported results in 1902. In 1901, the author reported results and described a technic where the patient lay on the face during the application, and there were other papers written at about this time, but the great impetus to the treatment by forcible correction came from Wullstein, who read a paper at the International Congress in Paris in 1900, and who published his experiments, methods and results in 1902. He showed experimentally that bony scoliosis could be produced in young dogs who were kept for some months in a bandage, inducing a lateral curve of the spine, and by the use of plaster-of- Paris jackets applied to the scoliotic patient in an improved position, induced by the use of great traction and lateral pressure, he secured results that were better than any previously reported. The work attracted much attention, and markedly modified the whole point of view with regard to forcible correction, which .began to gather a body of adherents whose number has steadily increased. The method of Wullstein has been extensively modified. Jackets have been applied with the patient on the face, on the side, on the back, with the spine flexed, with the spine hyperextended, on simple hammocks, and in complicated apparatus, but the principle demon- strated as effective by Wullstein and carefully elaborated by him has not been modified, namely, crowding the spine into an im- proved position and holding it there during as long a period as seems practicable, and for this purpose using plaster-of-Paris. There have been from time to time pieces of work elaborated which have modified our point of view with regard to the etiology of scoliosis, and have to a certain extent influenced our treatment. The work of Bohm in 1906, called our attention to the frequency of .congenital malformations as a cause of scoliosis, and immediately transferred many cases from the class of acquired to the class of congenital scoliosis. Subsequent work by Bohm and by others has laid stress on the fact that the occurrence of severe scoliosis is prob- HISTORY 7 ably due to congenital conditions or to abnormalities of bone, and that too much importance must not be allowed to the former ideas that severe scoliosis was caused by assumed bad posture, carrying burdens, bad school positions, etc. The discussion in the German Orthopedic Congress in 1910, with regard to school life as a cause of severe scoliosis was most illuminating, and the majority of the writers who participated were of the opinion that although the school might cause a postural scoliosis it was very doubtful if it could be accepted as a routine cause of severe scoliosis. The monumental work of Schultess in the Joachimsthal Hand- buch fur Orthopadische Chirurgie formulated, clarified and illustrated our knowledge of scoliosis. What the prevailing treatment of scoliosis is to-day cannot be stated in a few sentences. Some men advocate one method, some another. To those of us who believe that forcible correction has ac- complished more than any other treatment and will accomplish more in the future, the development of the real treatment of scoliosis dates from 1875. To those who believe that the gymnastic treat- ment of scoliosis is the best, and that forcible correction is wrong, the progress in the matter of scoliosis starts with Hippocrates and comes down in a wavering and discouraging line from that date until the present, with a better knowledge of the affection on the whole, with probably some more effective gymnastic technic, but without any very great advance within the last hundred years in the line of efficiency. CHAPTER II ANATOMY OF THE VERTEBRAL COLUMN AND THE THORAX The spine is a flexible weight-bearing column made up of a series of vertebrae separated from each other by twenty-three intervertebral discs and connected with each other by ligaments and muscles. In early life the vertebras are thirty-three in number. The upper twenty-four, remaining separate throughout life, are distinguished as true, movable, or presacral vertebras. In the adult the lower nine are fused into two masses to form the sacrum and the coccyx, and are called the false, fixed, or immovable vertebrae. The spine forms the central axis of the skeleton, situated in the median plane of the body and posterior part of the trunk. By the term "the spine" is generally understood the part of the column above the sacrum. In shape the spinal column is roughly pyramidal, the column of vertebral bodies tapering from below upward, and after early in- fancy it shows four curves, two anterior and two posterior, in the sagittal or median anteroposterior plane. These are called the physiological curves, which will be discussed later in the chapter. The spine encloses and protects the spinal cord, and provides, with the sacrum, thirty-one pairs of intervertebral foramina through which the spinal nerves emerge. It serves by its intervertebral discs to diminish the jar of walking. The total length of the spine is given as follows by different authors: Cunningham, 70 to 73 cm.; Morris, 70 cm.; and Krause, 72 to 75 cm. (along the curves), which is 45 per cent, of the body-length. The relative length of the separate regions is shown in the following table: Dwight 3 Cunningham 1 Morris 2 Beaunois -, , „ , 6 Males Females Cervical region 13-140111. 12.5 cm. 10.8 cm. 13.3 cm. 12.1cm. Dorsal region 27-29 cm. 27.5 cm. 27.0 cm. 28.7 cm. 26.5 cm. Lumbar region 12-15 cm. 17.5 cm. 16.8 cm. 19.9 cm. 18.7 cm. It is frequently stated that the length of the spine in different in- dividuals is pretty constant, but Dwight's figures show rather a wide 1 Cunningham: "Text-book of Anatomy," Macmillan, 1902. 2 Morris: "Human Anatomy," Blakiston, 1903. 3 Dwight: "Medical Record," Sept. 8, 1894. AX ATOMY 9 variation. In fifty-six male spines the longest was 69.8 cm. and the shortest 56.4 cm. In a straight line, the column measures in men from 66 to 70 cm., and in women from 66 to 69 cm., with an average of 67 cm. (Krause). This height is approximately 40 P er cent - of the total height of the Fig. 1. — The Spixe Seex from the Side, Showing the Physiological Curves. — (Warren Museum.) Fig. 2. — The Spixe Seex from the Froxt. — (Warren Museum.) individual. In the fetus and young child the column forms a greater proportion of the body-length. At puberty the more rapid growth of the rest of the body overtakes that of the spine, which completes its growth between the ages of twenty- three and thirty-one years. The percentage of total length of the individual occupied by the IO ANATOMY OF VERTEBRAL COLUMN AND THORAX spine without the sacrum is given for different ages by Moser as follows : Age Body-length Vert f e b -J h Column ^ brllfolurnlTo"' iengttl body-length o 50 192 38.4 3 86 31.7 36.8 5 112 35 30 11 138 41 29.7 14 152 44 28.9 15K 162 45 28.1 . Adult 167 57 34.1 The spine is divided into three regions corresponding to the parts of the trunk with which it is connected: (1) The cervical region; (2) the thoracic or dorsal region; (3) the lumbar region. The cervical region comprises, the upper seven vertebrae, including the atlas and axis; the thoracic, twelve vertebrae; and the lumbar, five vertebrae. The lower part of the spine may be spoken of as the posterior end, while the upper part may be called the anterior end of the column. The middle of the spine is placed at the eleventh dorsal vertebra. INTERVERTEBRAL DISCS The bodies of the vertebrae, from the second cervical to the sacrum, are firmly held together by the intervertebral discs lying between them, twenty-three in number. The discs correspond in size and shape to the horizontal surfaces of the bodies of the vertebrae be- tween which they are found, but they project slightly beyond the edges of the vertebrae. The sum of the heights of all the discs is greatest through the middle portion, next largest through the anterior borders, and least through the posterior borders. Singly the discs vary in height in the different regions of the spine. They are higher anteriorly in the cervical and lumbar regions and posteriorly in the dorsal region. The ratio of the height of the discs to the height of the bodies varies according to different authors. Weber gives the ratio of the average height of all the discs to the average height of all the vertebrae, not including the sacrum, as 1 :$. According to the same author the ratio of the height of all the discs through the centers to the height of the vertebral column, represented by a perpendicular from the highest point of the atlas to the sacrum, is as 1:4. The influence of the discs in the formation of the physiological curves of the spine is shown by the two curves in Fig. 4. Curve (^4) PHYSIOLOGICAL CURVES II vmh is formed by the bodies and the discs together, and curve (B) is the result obtained by placing the bodies one upon the other, forming a long curve with convexity backward, greatest in the lower dorsal region. The convexity of the thoracic spine is flattened in the upper part, and the lumbar and cervical physiological curves almost completely disappear when the discs are removed. The discs become smaller and harder with age, shrinking to a greater extent where they are thickest than in the region where they are thin. For this reason the curve of the spine in old age approaches the long convexity back- Fig. 3. — Lines Rep- resenting the Sum of the Thickness of the Intervertebral Discs. — (Fick.) v, At the front bor- der; m, in the middle of the disc; h, at the posterior border. A B Fig. 4. — Curves of the Vertebral Column. — {Fick.) A, With intervertebral discs; B, without intervertebral discs. ward represented by curve (B), and the bowed back of old age is substituted for the upright at- titude with a lumbar forward curve which is largely due to the influence of intervertebral discs. The discs are very firmly attached to the bodies of the vertebrae, and are also attached to the anterior and posterior common ligaments of the spine. The intervertebral discs thus furnish a connecting structure of great strength between each two vertebrae, and at the same 12 ANATOMY OF VERTEBRAL COLUMN AND THORAX time furnish each what amounts to a ball-and-socket joint on ac- count of the incompressible fluid pulp in the center of each disc between each two vertebral bodies, except of course the first two cervical. LIGAMENTS OF THE SPINE In addition to the connection of the bodies by means of the inter- vertebral discs the vertebrae are bound together by ligaments which serve to limit movement between them and contribute stability and strength to the column. Ligaments are composed of white fibrous Fig. 5. — Median Section of a Portion of the Adult Lumbar Vertebral Column, The Right Half Seen from the Left. — (Fick.) ( tissue, the strongest tissue in the body, highly elastic, but non- extensible. Two of the spinal ligaments, the ligamentum nuchas and the subflava, form exceptions to this statement, being made up almost entirely of yellow fibrous tissue. SACRO-ILIAC ARTICULATION The strong joint between the sacrum and the ilium through which the whole body-weight is transmitted is a synchondrosis. These transmit the weight of the spine to the pelvis and thence to the legs. SACRO-ILIAC JOIN [ 13 They arc car-shaped articular surfaces of irregular contour, in genera] vertical in direction, containing some synovia] membrane and heavy ligamentous bands. That they permit some motion is well estab- lished, but this amount of motion is small. Klein 1 found that 25 kg. of force applied to the symphysis with the sacrum fixed produced a rotation of the ilia on the sacrum, which on the average, measured by the excursion of the symphysis, was 3.9 mm. in man and 5.8 mm. in woman. Measured at the sacro-iliac joint this excursion was about one-sixth of this amount; that is, in man the average amount of motion in the sacro-iliac joint, measured at the pos- terior part of the joint, was about 0.6 mm. These joints are protected against much motion by intra- and extra- articular ligaments of the heaviest variety. In front of them lie the lumbosacral cord and sacral plexus. THORAX The thorax is a bony cage containing the principal organs of circulation and respiration. It is formed by the thoracic vertebrae, the ribs, the costal cartilages, and the sternum. The ribs, twelve on each side, form a double series of narrow, curved, flattened bones attached posteriorly to the thoracic vertebrae. They extend at first out- ward, and then forward, inward, and downward toward the me- dian line anteriorly. The seven upper ribs, called the true, sternal, or vertebrosternal ribs, are attached directly to the sternum by the costal cartilages anteriorly. The lower five ribs are called 1 Klein: Ztschr. f. Geburt. u. Gynak., 1891, xxi. Walcher: "Verhandl. d. deutsch. Gesellsch. f. Gynak.", Bonn, 1891. Strasser: "Lehrbuch der Muskel und Gelenk Mechanik, Berlin," 1913. Dieulafe and St. Martin, C. R.: "Assn. d. Anat.", 14 Reunion Revues, 191 2. Fig. 6. — Model of the Spine Showing the Anatomical Relations, Especially the Dis- position of the Soft Parts in the Lumbar Region. — (Warren Museum.) 14 ANATOMY OF VERTEBRAL COLUMN AND THORAX - false or asternal ribs; the eighth, ninth, and tenth are distinguished as vertebrochondral, as they are anteriorly indirectly united to the sternum by the cartilage of the rib or ribs above; the eleventh and twelfth are called floating ribs, as their anterior extremities are loose in the abdominal wall. The ribs increase in length from the first to the seventh or eighth, decreasing from the eighth to the twelfth. They are approximately parallel with the exception of the eleventh and twelfth, which slant somewhat more downward. It must be remembered that ribs are lower at their front ends than at their vertebral connection, so that if it is desired to rotate a vertebra by pressure on a rib, the rib horizontally opposite the vertebra is not to be chosen. It has been shown 1 in the cadaver (i) that rotation of Fig. 7. — Horizontal Section of Thorax at Seventh Dorsal Vertebra Showing the Position of the Vertebral Bodies. — (From Braun's Atlas-Corning.) vertebrae may be produced, when the extremities of the spine are fixed, by pressure upon any of the intermediate ribs; (2) that the vertebrae attached to the ribs on which pressure is made are the most affected; (3) that the rotation never equals the rib excursion; (4) that the most effective points for pressure or counterpressure are as far as possible from the midline anteriorly and posteriorly except on the lowest four ribs. STERNUM The sternum or breast-bone is situated in the median line of the trunk, completing the thoracic cage anteriorly. The sternum is a flat bone, and as a whole, it lies directed obliquely forward and 1 Keene: "Amer. Jour, of Orth. Sur.," July, 1906, page 69. SHAPE AND BOUNDARIES OF THE THORAX 15 downward. It consists of three parts — the manubrium sterni, the gladiolus, and the ensiform cartilage or xiphoid process. SHAPE AND BOUNDARIES OF THE THORAX In shape the thorax is somewhat conical, larger behind than in front and compressed antero-posteriorly. The posterior wall is formed by the thoracic vertebrae, and by the ribs, from their heads to their angles, and is convex vertically and horizontally. Laterally the cage is formed by the shafts of the ribs; it is somewhat convex vertically and sharply convex from before backward. The anterior Fibrous ring of in- tervertebral fibro- cartilage Anterior radi- ate or stellate ligament Costo-central synovial sac Pulpy nucleus of intervertebral fibro- cartilage Costo-transverse synovial sac Posterior costo-transverse ligament Fig 8 —Horizontal Section through an Intervertebral Fibro-cartilage and the Corresponding Ribs. — {Morris's "Anatomy. ) surface, slightly convex and directed forward and downward, is formed by the sternum and the costal cartilages. The plane of the superior opening or inlet of the thorax is inclined forward and downward, showing a greater obliquity in women than in men. The inferior border of the thoracic cage is formed by the twelfth thoracic vertebra, the lower -borders of the twelfth rib, and by two curved lines, extending from the anterior extremities of the last rib to the inferior angles of the gladiolus, touching the anterior extremi- ties of the eleventh rib and the costal cartilages of the tenth, ninth, and eighth ribs. The angle formed by these lines is known as the subcostal angle. The inferior surface of the thorax is directed forward and downward. i6 ANATOMY OF VERTEBRAL COLUMN AND THORAX MUSCLES OF THE SPINE AND THORAX The general grouping and arrangement of the muscles in their relation to the spine has an important practical bearing on scoliosis. The spine lies toward the back of a more or less cylindrical muscular Fig. o. — G. Herman Meyer. The Two Oblique Muscle Pulls. — (Feiss.) On the left the descending oblique, a, External intercostals; b, descending ob- lique or externus abdominis. On the right the ascending oblique muscle pull, c, Descending oblique or internus abdominis; d, internal intercostals; e, scalenus colli;/, cremaster. Fig. 10. — G. Herman Meyer. The Scheme of the Torso Musculature In- dicating the Direction of the Various Muscle Pulls. — (Feiss.) a. Posterior longitudinal muscle pull (sacrospinalis) ; b, anterior longitudinal muscle pull; c, oblique descending muscle pull; d, oblique ascending muscle pull; e, transverse muscle pull. tube of which the adbominal muscles form the front. Of muscles directly attached to the spine there are two varieties: (1) muscles running from one part of the spine to another part and to the head; (2) muscles running from the spine to the pelvis or shoulder-girdle. The abdominal muscles by their attachment to the thorax, which is comparatively rigid, have an action on the spine. By the combined MUSCLES 17 action of these three the erect position is maintained, or any variation from it is accomplished. In making a side flexion of the spine from the erect position, for example, no one muscle or group of muscles is alone active, but it implies a concerted and coordinated action of all the groups men- Frc 11. — G. Herman" Meyer. The System of the Sacrospinalis. — (Feiss.) a, Spinalis; b, longissimus dorsi; c, trans- versalis cervicis; d, trachelomastoideus; e, ileocostalis ; /, ascendens cervices; g, ileolumbalis (hinder portion of m. quad- ratic lumborum Auct.); h, obliquus capi- tis inferior; i, obliquus capitis superior; k, rectus capitis posterior major; /, rectus capitis posterior minor. Fig. 12. — G. Herman Meyer. An- terior Longitudinal Muscles of the Trunk. — (Feiss.) a, Sternocleido-mastoideus; b, rectus abdominis; c, pyramidalis. tioned, as well as of the muscles of the lower extremities, to keep the balance and perform the bending. The maintenance of the spine in the upright position by the muscles has been compared to the way in which a flagstaff: is held upright by stays reaching from the top of the staff to the ground. Although there is no one muscle running 1 8 ANATOMY OF VERTEBRAL COLUMN AND THORAX from the head to the pelvis, there is a continuous set of muscles supplementing each other's action. For example, in the anterior line the sternomastoid runs from the skull to the front of the top of the thorax, the sternum connects the upper and lower ribs and forms a rigid piece, and the lower thorax is connected with the pelvis by the rectus abdominis muscle. In the back the continuity of muscular action is shown by the fact that before the top insertion of the longis- simus dorsi has been reached, the complexus and transversalis cervicis have begun. The whole conception of muscular action in its relation to gymnastics is simplified by remembering the continuity of the muscular tube from the head to the pelvis. The thorax represents a comparatively fixed cage inserted in a structure quite movable above and below it; muscles attached to the thorax are therefore indirectly attached to the spine. The compara- tive rigidity of the thoracic part of the spine is due to the fact that the majority of the ribs are attached posteriorly between two vertebrae, that they pass forward to be also attached to the sternum, and that the whole structure is one well calculated to prevent physiological side bending or extensive forward or backward motion in that region; the cage must therefore largely move as a whole. It has been pointed out that the dorsolumbar junction is a dividing point for important muscular origins and insertions above and below it, e.g., the psoas muscles originate largely below it and the trapezius above it, and that it forms a weak and movable part of the spine for this reason. More important than this is the fact that muscles connecting the thorax and pelvis will move the spine where the rigid dorsal region changes to the movable lumbar region and that a large number of muscles will therefore express their contraction by motion at the dorsolumbar junction. A similar weak and movable part of the spine is said to exist at the cervicodorsal junction, where important muscles (splenius and rhomboids) have a dividing point. NERVE-SUPPLY The spinal nerves emerge from the spinal canal through the inter- vertebral foramina and are distributed to the integument and muscles all over the body. Eight are cervical nerves (the first passing over the atlas), twelve dorsal, five lumbar, five sacral, and one coccygeal. Each nerve is formed by the union of two nerve roots, which occurs outside of the spinal cord and just inside of or at the intervertebral foramen. The anterior, motor, or efferent fibers come from the I Sterno-mastoid Trapezius > Diaphragm J \ Serratus J Shoulder Arm Hand (ulnar lowest) NER\"E-SUPPLY MOTOR SENSORY 19 REFLEX Neck and scalp Neck and shoulder Shoulder muse. Arm Hand Scapular Front of thorax [ Xiphoid area } Epigastric Extensors, knee 1 Adductors 1 hip y Abductors Extensors(?) Flexors, knee(?) Muscles of leg moving foot Perinaeal and anal muscles Abdomen (Umbilicus 10th) Buttock, upper part Groin and scrotum (front) outer side Abdominal Thigh front [ inner side Leg ; inner side Buttock, lower part Back of thigh I 1 except in- foo d t I ■«»■* Perinaeum and anus Skin from coccyx to anus y Cremasteric j \ Knee-joint Gluteal Foot-clonus Plantar Fig. 13. — Diagram and Table showing the Approximate Relation to the Spinal Nerves of the Various Motor, Sensory, and Reflex Functions of the Spinal Cord. (Arranged by Dr. Gowers from anatomical and pathological data). — (Morris's "Anatomy.") 20 ANATOMY OF VERTEBRAL COLUMN AND THORAX cells of the anterior horn of the cord; the posterior, sensory, or afferent fibers emerge from the cells of the posterior horn on the same side of the cord. The nerve formed by these two roots on leaving the intervertebral foramen divides into an anterior and posterior branch, each with motor and sensory fibers. The posterior divisions are small and supply the skin and muscles of the back. The anterior divisions are distributed to the neck, the front and sides of the trunk, and to the extremities. Each anterior division is connected with a plexus, ganglion, or nerve of the sympathetic system. EVOLUTION OF THE SPINE The history of the spine in its evolution is of interest. In the Clyclostomata the vertebral column consists of a non-segmented, homogeneous, cartilaginous rod. Articular processes first appear in the Rays and Teleostei. The backbone of the lower fishes con- sists of a series of bony discs bound together by elastic intervertebral discs. It would seem from the history of the spine as if articular processes developed concomitantly with the elaboration of struc- ture, and as if they were incidental to its use rather than factors determining of themselves its types of motion. As will be mentioned in a later section, the human spine, from an evolutionary point of view, is practically the quadruped spine set on end, a matter which has a distinct bearing on its weaknesses as an upright supporting column. OSSIFICATION The ossification of a vertebra occurs from three primary centers, one for the body and one for each lateral mass. These appear in the sixth week, and in the cervical region the lateral centers are the first to appear, while in the dorsal region the one for the body is the first seen. The center for the body is often double in appearance if not in reality. The centers for the lateral masses are found near the bases of the articular processes and from them form the pedicles, laminae, articular processes, and a large part of the transverse and spinous processes, the bodies of the vertebrae forming from the other center. The vertebral epiphyses serve to assist in the formation of joints, to provide for the attachment of ligaments and tendons, and to increase the development in length of the bone of which they form a part. At about puberty appear five other secondary or comple- PHYSIOLOGICAL CURVES 21 mentary centers, one at the tip of the spinous process, one at the tip of each transverse process, and one at the upper and one at the lower surface of each body, occurring as a flat meniscus at about the seven- teenth year and uniting to the vertebral body a few years later (twentieth year). Inasmuch as vertebral growth occurs at each of these epiphyses, this complicated method of ossification is important because the injury or disease of one of these epiphyseal lines might lead to serious bony deformity of the vertebra (Figs. 14 and 15). ELASTICITY OF SPINE The spinal column is capable of some movement in all directions. The elasticity of the intervertebral discs is such that the ball-and- socket joint between each two vertebrae allows motion between them in any plane or direction until limited by bony contact and ligamen- tous or muscular tension. It also allows rotation to occur between two separate vertebrae in an approximately horizontal plane. Bone is slightly compressible, but this is not a factor of importance in con- tributing to vertebral flexibility. In childhood the vertebrae are largely cartilaginous, and the in- creasing proportion of bone, along with the diminishing proportion of cartilage, causes a decrease of flexibility from youth to adult age, aside from the fact that the flexibility of all joints is greater in youth. With old age the capability of movement of the spine is greatly less- ened on account of the atrophy of the intervertebral discs. PLANES OF THE BODY The planes of the body will be frequently spoken of and should be defined. The frontal plane is a vertical and transverse one. The sagittal or antero-posterior plane runs in the antero-posterior axis. The term horizontal plane is self-explanatory. PHYSIOLOGICAL CURVES (ANTERO-POSTERIOR) The physiological curves, so called, are antero-posterior curves and are important. They are three in number. The dorsal (backward) curve is the first to become evident, and was found present in 86 per cent, of normal children under one year old when lying on the face and in 99 per cent, of children over one year old. In children under six months this backward convexity 22 ANATOMY OF VERTEBRAL COLUMN AND THORAX included the lumbar region, but after this age it did not as a rule, 1 the lumbar curve then occurring at the expense, of the dorsal curve. The lumbar (forward) curve in lying showed frequently after the age of one year and in a very large majority of cases after the age of three years. The lumbar curve when it formed took the place of part of the original backward dorsal curve and was more marked Epiphyseal plate or disc Mammillary tubercle Transverse process Spinous process Epiphyseal plate or disc Fig. 14. — Lumbar Vertebra at the Eighteenth Year with Secondary Centers.- (Morris's "Anatomy") in standing than in lying. In standing it was present after the age of two years in a very large majority of cases, the exceptions being usually in children under three who had not walked. The lumbar curve in childhood is obliterated in the sitting position, only four chil- dren of those examined between the ages of nine and thirteen showing such a curve in the sitting position. Lamina Neuro-central suture Centrum Fig. 15. — 'Ossification of the Fifth Lumbar Vertebra. — (Morris's "Anatomy.") The cervical (forward) curve could not be accurately determined in either standing or lying in the youngest children, but after the age of fourteen months this curve was observed in standing. In the adult, the part played by the bodies of the vertebrae and the discs in producing the physiological curves is shown by the following table: ^ovett, Davis, and Montgomery: "Arch, di Ortopedia," iqo6,^v and vi, page 372. PHYSIOLOGICAL C\ RV] S 23 Difference between the Sums of the Anterior and Posterior Borders Vertebrae Discs Cervical region 1.3 mm. 7 . 8 mm. Dorsal region 13.3 mm. 9 . 2 mm. Lumbar region 6.7 mm. 21 . 1 mm. The cervical curve is formed principally by the intervertebral discs. It is a fairly mobile curve, and may be straightened by suspension. The dorsal curve is formed chiefly by the bodies of the vertebrae; it is a rigid curve and cannot be obliterated. The lumbar physiological curve is produced mainly by the greater anterior height of the intervertebral discs and is there- fore mobile. A slight physiological lateral curve convex to the right has long been recog- nized in the spine. It has been attri- buted to the pressure of the aorta on the vertebral bodies, to excessive use of the right side of the body in certain occu- pations, and to right-handedness. The almost constant occurrence of the curve indicates a common cause, which is most probably aortic pressure. The asymmetry extends from the fifth dor- sal to the second or third lumbar ver- tebra. The body of the fifth dorsal ver- tebra is flattened on the left side, and the discs above and below are similarly affected. There is a groove from ij^ to 2 cm. broad passing downward in a spiral direction, following the course of the aorta, to the anterior surface of the second or third lumbar vertebra. The discs between these vertebrae are usually less projecting than the others, and if the cutting away of the vertebra cannot be seen the flattening of the disc is always apparent. 1 PELVIC INCLINATION The position of the pelvis in relation to the horizontal plane would be of importance in relation to scoliosis and faulty attitude if it could be accurately measured in the living subject. ^ere: "Les courb. lat. norm du Rachis humaine," These de Toulouse, 1900. Fig. 16. — Section- of the Spine of a New-born Infant. 24 ANATOMY OF VERTEBRAL COLUMN AND THORAX If the front part of the pelvis is lowered and the back part cor- respondingly tilted up it is spoken of as "increased inclination" of the pelvis. If the front part is raised and the back part lowered it- is spoken of as "diminished inclination." With the former is asso- ciated an increase of the lumbar physiological curve, and with the latter a flattening of it. Changes in inclination of the pelvis must GIRL I '/a YRS Sitting Front Standing .7™C GIRL llYRS. .4™L -4™F? 4 TH L Fig. 17. — Tracings of Physiological Curves of Normal Children: on the Left of a Girl of One and a Half Years, on the Right of a Girl of Eleven. form an important element in the faulty attitude to be spoken of as round shoulders. The internal or true conjugate diameter (conjugata vera) of the pelvis is a line from the sacrolumbar junction to the top of the sym- physis pubis and is generally accepted as the line by which pelvic inclination is to be determined. The angle which this line makes with the horizon when the patient stands erect is spoken of as the PELVIC INCLINATION 25 "angle of pelvic inclination," and the observers do not wholly agree in their results. It is probable that no measurements of pelvic inclination in the living subject are sufficiently accurate to be of value. In men the variation in the average of collected results is from 44 degrees to 60 degrees, and in women from 41 degrees to 65 degrees. The results of Prochovnik were obtained by the most accurate method of any and the research was conducted entirely on living subjects. The variation in men, according to his figures, was from 26 degrees to 76 degrees, and in women from 40.5 degrees to 71 degrees. A research by Reynolds and Lovett 1 was undertaken as to the mechanics of the antero-posterior position in the upright living indi- vidual, in which research a determination of pelvic inclination and its variations under varying static conditions would have been of pre- sumable value, but after months of experimentation with various methods the investigators came to the conclusion that it was impos- sible to measure the variations in the inclination of the pelvis in a living individual with sufficient accuracy to be of any practical value. The following figures are therefore quoted in the belief that they can only be approximate and that they must be taken only in the most general way. They are partly obtained from the living, but in many instances are from the cadaver. Average in Average in men women Year 1 745, ATiiller 45 degrees Year 1825, Nagele 2 60 " Year 1836, Weber Brothers 3 65 degrees Year 184 1, Krause 4 60 " 60 " Year 1873, Meyer* 55 " 50 " Year 1882, Prochovnik 6 .. 54-17" S 1 -! 2 " Year 1898, Henggeler 7 44 " 41 . 1 " In 1 910 Engelhard 8 published some observations on pelvic inclina- tion in living children from six to fourteen. The extremes of inclina- tion were from 21 degrees to 46 degrees to the horizontal with an average inclination of 32 degrees. 1 .E Reynolds and R. W. Lovett: "Journ. Am. Med. Assn.," Mar. 26, 1910. 2 "Das Weibl Becken," etc., Carlsruhe, 1825. 3 "Mech. d. Menschl. Gehwerkzeuge," Gottingen, 1836. 4 "Hdbch. d. Mensch. Anat. Hauft.," 1, 1, 324, Hanover, 1841. 5 "Muller's Archiv," 1873, 9- 6 "Archiv f. Gyn.," 1882, xix, 1. 7 "Zeitsch. f. orth. Chir.," xii, 4, 613. 8 "Zeitsch. f. orth. Chir.," xxvii, page 1, 1910. 26 ANATOMY OF VERTEBRAL COLUMN AND THORAX Seventy-six males and eighty females, all apparently normal, over the age of fifteen were investigated and tabulated by Prochovnik as follows: Least inclination Greatest Average Males 26 degrees 76 degrees 51.72 degrees Females 40.5 " 71 " 54. 17 " The grouping of the results suggests that a normal pelvis shows an inclination of from 50 to 60 degrees, that there is a subnormal zone from 45 to 50 degrees, a supra- normal of 60 to 65 degrees, but that an inclination above 65 de- grees or below 45 degrees is to be regarded as pathological. The figures given refer to the external conjugate and are a little higher when the internal conjugate is taken as determining the angle of inclination. The whole subject of pelvic in- clination and its variations, the influences of such changes of in- clination on static conditions, and the difference of inclination be- tween children and adults must therefore be left in an unsatisfactory and unsettled condition. Fig. 18. — Female Pelvis, Median Section. — (Spalteholz.) The solid line running up and back from the symphysis indicates the "external con- jugate diameter." SURFACE ANATOMY OF THE BACK The position of the spine in the median line of the body is indicated on the normal back by a longitudinal furrow (median furrow) extend- ing from the occipital bone to the sacrum. The lower end of the furrow corresponds to the interval between the fifth lumbar vertebra and the sacrum. In the cervical region this furrow lies between the trapezii and complexi, and in the dorsal and lumbar regions it lies between the erector spinae muscles. It is usually most marked in the upper lumbar and lower dorsal regions. Identification of Vertebra. — In this median furrow the spinous proc- esses of the lower cervical vertebras can be felt easily, but the spine of the second cervical vertebra can be reached by. deep pressure in a relaxed neck; in a poorly developed individual they can be seen in the erect position, and in one well developed in forward bending. SURFACE ANATOMY OF THE BACK 27 The spinous process of the seventh cervical vertebra is usually quite prominent, though that of the first thoracic may be still more so. In proceeding downward the root of the spine of the scapula should be found opposite the. spinous process of the third dorsal vertebra, and the inferior angle of the scapula opposite that of the seventh dorsal vertebra. The spine of the fourth lumbar vertebra is on a level with the highest points of the iliac crests. The spinous process of the fifth lumbar vertebra is very short, and usually forms a slight de- pression instead of a prominence. The third sacral vertebra is on the line drawn between the posterior superior spines of the ilium, and this line lies over the sacro-iliac joints. The twelfth dorsal vertebra is found by counting down from the seventh dorsal and up from the fourth lumbar vertebra, and any vertebra may be found in this way. Of the methods of identification this is the most reliable. In the dorsal region the obliquity of the spinous processes causes the tip of each to be opposite the body of the vertebra next below it. So the spine of the second dorsal vertebra corresponds to the head of the third rib, but the eleventh and twelfth dorsal spines are opposite the heads of the eleventh and twelfth ribs. The spinous processes of the lumbar vertebras are opposite the lower parts of the correspond- ing bodies and the discs below them. In the adult the spinal cord ends at the lower border of the first lumbar vertebra; in children the cord terminates at the lower border of the third lumbar vertebra. Muscles. — The outline of the neck posteriorly is formed by the trapezii and underlying muscles. The surface of the shoulder is shaped by the deltoid and the muscles underlying the trapezius. The posterior border of the axilla is formed by the latissimus dorsi, which also takes part in forming the contour of the lower part of the back. In action the anterior edge of the latissimus dorsi may be seen as a fold extending from the crest of the ilium to the axilla. The erector spinae muscles form a rounded prominence longitudinally on either side of the spine in the lumbar region. The following table from Gray's "Anatomy" gives the relation of the spines of the vertebrae to important organs: 28 ANATOMY OF VERTEBRAL COLUMN AND THORAX Tabular Plan of Parts Opposite the Spines of the Vertebra (Gray) Cervical. Dorsal. 5th. Cricoid cartilage. Esophagus begins. 7th. Apex of lung: higher in the female than in the male. 3d. Aorta reaches spine. Apex of lower lobe of lung. Angle of bifurcation of trachea. 4th. Aortic arch ends. Upper level of heart. 8th. Lower level of heart. Central tendon of diaphragm. 9th. Esophagus and vena cava through diaphragm. Upper edge of spleen. 10th. Lower edge of lung. Liver comes to surface posteriorly. Cardiac orifice of stomach, nth. Lower border of spleen. Renal capsule. 12th. Lowest part of pleura. Aorta through diaphragm. Py- lorus. 1 st. Renal arteries. Pelvis of kidney. 2d. Termination of spinal cord. Pancreas. Duodenum just Lumbar.... \ below. Receptaculum chyli. 3d. Umbilicus. Lower border of kidney. 4th. Division of aorta. Highest part of ilium. Points for Lateral Corrective Pressure. — The points at which cor- rective side pressure may be applied to the spine are determined by anatomical conditions. The important structures lying on both sides of the spine in the cervical and lumbar regions make it impos- sible to use effective side pressure upon a curved spine in these re- gions. In the dorsal region side pressure on the ribs is effective on the vertebrae, but it cannot be exerted on the upper vertebras higher, of course, than the axilla. The anterior border of the axilla is formed by the pectoralis major muscle and is in the line of the fifth rib. This rib articulates with both the fourth and fifth dorsal vertebrae. Although with the arm nearly at the side the third rib may be reached by the exploring hand, side pressure on the thorax cannot be exerted efficiently above the fourth or fifth rib. CHAPTER III THE MOVEMENTS OF THE SPINE 1 The movements of the human spine are three in number: (i) Flexion, (2) extension, and (3) a compound movement — side bending-rotation. The statement that there are four movements (flexion, extension, rotation and side bending) is wholly incorrect, as neither side bending nor rotation exists in a pure form as may be demonstrated on any normal child. The statement that such movements exist as pure movements necessarily leads to a false basis for gymnastic exercises and obscures the whole mechanism of scoliosis. As long ago as 1844 Henry J. Bigelow wrote: "The principle of torsion is illustrated by bending a flat blade of grass or a flat, flexible stick in the direction of its width. The center immediately rotates upon its longitudinal axis to bend flatwise in the direction of its thick- ness. In the same way the spine, laterally flexed, turns upon its vertical axis to yield in its shortest or antero-posterior diameter." Occasional references are found to the association of torsion with lateral flexion, but no general recognition of the relation between the two has existed. The human spine is not an extremely flexible structure taken by itself; much of its apparent flexibility is due to accessory movements between the spine and the pelvis and the head. An extreme forward flexion, e.g., in the living model or the intact cadaver, with the flexed head, the drooping shoulders, and the rotated pelvis, implies a greater curve than the spine itself possesses. It is surprising to see in the cadaver how comparatively little actual mobility is possessed by the three regions of the spine considered separately, or by the whole spine. The application of this is obvious without extended comment. If active or passive exercises are given which are intended to take effect upon the spine alone and to be effective there, the pelvis must be fixed. If this is not done, part of the muscular force is used in displacing the pelvis to the opposite side to balance the body, and the movement becomes a general and not a spinal one. 1 R. W. Lovett: "Bos. Med. and Surg. Jour.," June 4, 1900, Oct. 31, 1901, Mar. 17, 1904, Sept. 28, 1905; c: Amer. Jour, of Anat.," ii, 4, 457. 29 30 THE MOVEMENTS OF THE SPINE I. FLEXION (FORWARD BENDING) Is a pure antero-posterior movement without perceptible rotation. It is the most evenly distributed of the spinal movements, and in extreme flexion the out- line of the tips of the spinous processes forms a curve approaching the arc of a circle. Most of the movement is accomplished in the lumbar region, which in extreme flexion loses most of its forward convexity, but in adult observations was not observed to become convex backward. Fig. 19. — Flexion of the Spine in the Model. The dorsal region in extreme flexion becomes decidedly more convex than in the upright position. The twelfth dorsal vertebra takes part in flexion more as a- lumbar than as a dorsal vertebra, and free movement occurs below it and fairly free movement between the eleventh and twelfth vertebrae . The cervical region cannot be accurately observed or measured in the model. In the cadaver it dries so rapidly that no conclusions can be drawn beyond the statement that its forward convexity may be obliterated by forcible flexion with the hands. FLEXION 31 The most marked flexion of the spine may be obtained by having the model sit CTOSS-legged and bend forward with the chest between the knees. Extreme passive flexion with the model lying on the side is not so great as that obtained by flexion in the cross-legged position. In flexion the distance of the seventh cervical vertebra from the sacrum when measured along the spinous processes is increased over the same measurement taken in standing or lying. Fig. 20. — Hyperextension in the Model. The head is supported to secure steadiness. There seems to be no constant difference in the amount of flexion obtained in the standing and sitting positions, the resultant curve being practically the same. The chief difference between flexion in model and cadaver seems to consist in a greater relative participation of the dorsal region in flexion in the model. Measurements and tracings of the spine in the model and in children show the relaxed sitting position to be one of slight flexion. Forward flexion of the spine in scoliosis tends to straighten the curved line formed by the spinous processes. 32 THE MOVEMENTS OF THE SPINE II. HYPEREXTENSION (BACKWARD BENDING) Hyperextension is a pure antero-posterior movement of the spine without perceptible rotation. It is not an evenly distributed movement, but occurs almost wholly in the lumbar and lower two dorsal vertebrae. A tracing taken over the spinous processes in extreme hyperextension in outline resembles a hockey stick. The dorsal region is but little affected, being slightly straightened by hyperextension. The bending reaches to about the tenth dorsal, the upper dorsal region showing but little diminution in the physiological curve, the twelfth dorsal vertebra, and, to a certain extent, the eleventh, behaving as do the lumbar vertebras in hyperextension. The character of the curve obtained in marked hyperextension is practically the same, whether it is obtained by active or passive means, and whether the model lies on the face or on the side, or stands, or sits. The column of vertebral bodies alone shows the same char- acter and distribution of the move- ment as does the intact spine of the cadaver. The illustration (Fig. 21) shows the characteristic rigidity of the dorsal region to hyperextension. In hyperextension, the distance from the seventh cervical vertebra to the sacrum, measured over the spinous processes, is decreased from the same measurement taken in the erect position. Ilia. LATERAL FLEXION (SIDE BENDING) Lateral flexion of the spine does not exist as a pure movement, but is to be considered as one part of a compound movement, of which twist- ing or rotation forms the other part. In describing this side bending it must be stated that the character and distri- bution of the movement vary widely according to the degree of flexion or exten- sion of the spine when the side bending is made. In other words, there is no one type of spinal side bending, as there are types of flexion and extension, but the character and distribution of the movements are wholly dependent upon whether the spine is flexed, erect, or hyperextended when the side bending is performed. Side bending will first be considered alone without regard to the rotation caused by it, and then the rotation accompanying each kind of side bending will be described. The extent and distribution of forward and backward bending have been investigated in children from six to fourteen years old by Engelhard, 1 and Fig. 21. — Hyperextension in the Cadaver. 1 "Zeitsch. fur orth. chir.," 1910, xxvii, p. 1. sim: BKMHNC 33 Fig, 31 shows the amount and distribution of these movements as formulated by him in an average individual. Side bending in lying on the face shows a more evenly distributed lateral curve than does that in the erect position. The character of the curve does not change essentially when the shoulders and pelvis are held and the middle of the trunk pushed to one side. The curve in this position of the spine is greater in the Fig. 22. — Side Bending to the Right in the Flexed Position of the Spine in the Model. A lateral curve convex to the left is formed and the vertebral bodies have turned to the left, as shown by the elevation of the left side of the back. upper lumbar vertebras and in the two lower dorsal than in the upper part of the spine. Rotation Accompanying Side Bending Lying on the Face. — With the cadaver lying flat on the face on the table no rotation in side bending was found by v. Meyer and in some experiments by Schluthess; it was, however, found by Benno Schmidt. With the cadaver lying prone on a table the conditions, of course, are against rotation, the thorax and shoulders being to a certain extent held against it by the surface of the table. No perceptible rotation is noted in slight side bend- ing under these conditions, but the vertebral bodies turn to the concave side in 3 34 THE MOVEMENTS OF THE SPINE marked side bending. In the model lying flat on a table one side of the chest is felt to press on the table harder than the other in moderate side bending. The point is not of great importance, as the practical problem is that of the behavior of the weight-bearing spine. Side bending in the flexed position of the spine is a more evenly distributed movement in which the dorsal region participates more and the lumbar region less than in the erect position. The greatest deviation from a line connecting the two ends of the spine occurs at about the eighth dorsal vertebra in both cadaver Fig. 23. — Side Bending in the Upright Position of the Model. The movement is chiefly located at the dorsolumbar junction. and model. In short, side bending occurs higher in the spine in flexion than in any other position, the lumbar region being comparatively locked against side bending by the flexed position. The more marked the flexed position, the higher in the spine is the side bending localized. Rotation Accompanying Side Bending in Flexion. — In the flexed position of the spine, side bending is accompanied by rotation of the vertebral bodies toward the convexity of the lateral curve. This rotation occurs chiefly in the dorsal region. SIDE BENDING 35 Side Bending in the Erect Position. — In the cadaver side bending is most marked below the tenth dorsal vertebra, and the dorsal region shares but slightly. The lumbar region is most affected in its upper part, but shares to some extent throughout. Side bending in the erect position is, therefore, largely a movement occurring in the neighborhood of and below the lumbar dorsal junction. It shows the same characteristics in the cadaver, the model, and the child, except that in the two last named the dorsal region takes a greater relative part than in the cadaver. Rotation Accompanying Side Bending in the Erect Position. — In this position side bending causes the rotation of the bodies of the vertebrae to the concave side of the lateral curve. This, however, occurs lower down in the spine than in the flexed position. The dorsal region participates less and the lumbar region more in the movement. Fig. 24. — Side Bending in the Upright Position of the Cadaver, showing the Same Characteristics as in the Model. Side Bending in the Hyperextended Position of the Spine. — With the spine of the cadaver, model, or child hyperextended, the side bending becomes a sharply limited movement, localized low down in the spine and occurring almost wholly below the eleventh dorsal vertebra, becoming therefore, essentially a lum- bar movement. The dorsal region bends as a whole upon the lumbar and rocks over to the side practically unchanged, being locked against side bending by the hyperextended position. Side bending, therefore, is situated highest in the flexed position, lower down in the erect position, and lowest in hyperextension in the model cadaver, and child. Rotation Accompanying Side Bending in the Hyperextended Position. — This is a sharply limited movement occurring in the lumbar region, including the 36 THE MOVEMENTS OF THE SPINE twelfth dorsal as functionally a lumbar vertebra. The thorax rocks over to the side unchanged, and the rotation of the bodies is to the concave side of the lateral curve. Rotation accompanying side bending is, therefore, of a different type in the flexed position of the spine from what it is in the erect or hyperextended position. Illb. ROTATION Rotation or twisting of the spine is to be considered as part of a compound movement of which side bending forms the other part. For purposes of simplicity Fig. 25. — Side Bexdixg to the Right ix the Hyperextexded Positiox of the Spixe ix the Model. The head is supported to secure steadiness. the rotation element of the movement will be considered by itself. Under or- dinary conditions it is essentially a movement of the dorsal and cervical regions in which the lumbar vertebrae take but little part except in hyperextension and with the use of traction. The lumbar vertebral region possesses some power of rotation, as has been generally observed. ROTATION 37 Rotation in the Erect Position. — Rotation is freest in the erect position and is situated in the cervical and dorsal regions, reaching its maximum at the top of the cervical column and extending down the spine to the lower dorsal region, where it disappears. With very forcible rotation applied to the top of the column in the cadaver, the first and even the second lumbar vertebra may be rotated. The rotation in this position is accompanied by a side bend of the rotated region away from the side to which the bodies of the vertebrae turn. If the rotation is to the right, it is accompanied by a lateral bend convex to the left and vice versa. In the model an active rotation to the right is accompanied by a displacement of the trunk to the left side and vice versa. If traction is applied to the head of the erect cadaver, forcible twisting of the head results in rotation of the lumbar vertebras, including the fourth. Fig. 26. — Side Bending to the Right in Hyperextension in the Column of Ver- tebral Bodies. The same characteristics are shown as in the previous figure. Fig. 27. — Side Bending to the Right in the Hyperextended Position of the Spine in the Cadaver. The movement occurs chiefly at and be- low the dorsolumbar junction, and the bodies of the vertebrae turn to the right, as shown by the pins. The lateral curve is convex to the left. Rotation in the Flexed Position. — Rotation in the flexed position of the spine occurs chiefly in the cervical and upper dorsal spine, the lower dorsal and lumbar region seeming locked against rotating forces by the flexed position. The more extreme the flexion the more markedly in cadaver, model, and child is the rotation restricted to the cervical and upper dorsal spine. Rotation in the Hyperextended Position.— In hyperextended positions rotation with moderate manual force occurs as a twisting of the whole thorax on an axis in the dorsolumbar region, the upper and middorsal regions apparently being locked against rotation by hyperextension. The site of rotating movement 38 THE MOVEMENTS OF THE SPINE in this position is, therefore, in the one or two vertebrae above and the one or two vertebrae below the dorsolumbar junction. Rotation, therefore, is located high in flexed positions, lower in erect positions, and is situated lowest and is more sharply localized, in hyperextended positions. Side Bends Accompanying Rotation. — A lateral deviation of the spine accom- panies all rotations. It is situated at the site of the rotation and is convex to the right when the rotation is to the left and vice versa. In the erect position rotation causes a marked side curve in the dorsal region. Fig. 28. — Rotation of the Model, Face to the Right, Causing a Dorsal Lateral Curve Convex to the Left and a Displacement of the Trunk to the Left. Reasons for Torsion. — It is obvious from these experiments that there must be some fundamental reason for the constant occurrence of one type of torsion for side bendings in flexion and the occurrence of another type in extension, as well as for the constant association of torsion with side bending. The vertebral column is a flexible rod capable of bearing great weight. It is not equally flexible in all directions, but it is, of course, capable of some movement in all planes, and, as such, should come under the control of the laws governing flexible rods in general. The extent of any of the movements of the spine is, of course, greatly TORSION 39 influenced by the shape of the vertebral bodies, the curves of the spine, the character of the articular processes, the resistance of the ligaments, and the relative strength of the muscles. From the mechanical point of view, torsion results from any motion of a straight flexible rod in which all the particles do not move in parallel planes. Consequently, if such a rod is bent in two planes at the same time, torsion must inevitably occur. The vertebral column is not a straight flexible rod, but one bent in physiological curves in the antero-posterior plane; side bending must therefore inevitably lead to torsion, because it means bending in two planes. Nor does the fact that the intervertebral discs permit motion in all directions affect the question, because from a mechanical point of view the vertebral column behaves in general as it would if it were a homogeneous, flexible rod. Fig. 29. — Rotation of the Spine of the Cadaver, Face to the Right, in the Flexed Position of the Spine. The movement is seen to be located in the upper part of the column by the deviation of the pins. u Fig. 30. — -Rotation of the Spine of the Cadaver, Face to the Right, in the Hy- perextended Position. The movement is seen to occur in the lower part of the spine by the rotation of the pins. A strip of sponge rubber, half an inch in diameter and 14 inches long, rotates in the same way that the vertebral column does in the same position. A lateral curvature, in what corresponds to the flexed position of the spine, may be pro- duced in the rubber strip following the same rule of rotation seen in life; that is, the front of the rod turns toward the convexity of the lateral curve. An artificial lateral curvature in the rubber strip, made in what corresponds to the extended position of the spine, results in a reverse rotation to that from the rotation of the flexed position. A piece of rattan, a piece of rubber tubing, a strip of sponge rubber, round or square, the backbone of a fish, or the backbone of a cat, behave all in the same way, and rotate in the same direction as does the human spine. 4Q THE MOVEMENTS OF THE SPINE Articular Processes. — Although it is easy to understand that the column of vertebral bodies by itself might easily behave as a flexible rod, yet the articular processes cannot be left out of account. They must be an important factor in determining torsion, and they must do one of two things. Either they must fall in with the behavior of the flexible column of bodies and serve to carry out the rotation which would occur without them, or the> T must obstruct or reverse the rotation which would occur in the column of vertebral bodies alone. ■ Experiments seem to show that the articular processes merely serve to accentuate the same rotation that would be present if the column of vertebral bodies were by itself. THE CERVICAL REGION Flexion. — It is possible to straighten the anterior physiological curve. Much of the apparent for- ward flexion in the cervical region in life is evidently due to the motion be- tween the occiput and the atlas. Hyperextension. — The physiolog- ical curve can be increased to a cer- tain extent. Side Bending. — Side bending is uniformly distributed throughout the cervical region and is accompanied by rotation of the. bodies of the ver- tebra to the concavity of the lateral curve, as in the lumbar region. Rotation. — Rotation is extremely free between the first and second cervical vertebra, but for the rest of the region it is limited. Rotation is accompanied by a side bend convex to the side opposite to which the bodies of the vertebrae turn; that is, in a right rotation the curve is con- vex to the left. Fig. 31. — Diagram of the Spinal Move- ments in a Living Child. — {Engelhard.) The solid line shows the normal position, the dotted line the forward bend and the line of dots and dashes the hyperextended position. DORSAL REGION The dorsal region is the least mobile part of the spine as a whole. The twelfth dorsal vertebra from the point of view of function must be regarded as a lumbar vertebra and not as part of the dorsal region. Flexion. — The dorsal spine already convex backward can be made somewhat more convex by forward bending, but the extent of the movement is not great and by no means comparable to the same movement in the lumbar region. Hyperextension. — Hyperextension is a motion of very slight extent in the dorsal region. It consists of a diminution of the backward convexity and is most noticeable in the lower half of the region. CONCLUSIONS AS TO MOVEMENTS . 4 1 Side Bending. — Side bending of the dorsal region is a fairly evenly distributed movement of slight extent, presenting an even curve which is greatest in the mid- dorsal region. It is freest in the erect position or lying on the face. It occurs less markedly in flexed positions and least in hyperextension. Side bending in this region is always accompanied by rotation of the bodies of the vertebrae to the convex side of the lateral curve. Rotation is the most marked of dorsal movements. It reaches its greatest extent in the upper dorsal vertebras and diminishes toward the lower end of the region. In a rotation of moderate force in the upright position it extends to and includes the seventh or eighth dorsal vertebra. Rotation of the dorsal region is less easily accomplished in flexion than in the erect position and in hyperextension it is much limited, while in extreme hyperextension in the cadaver the dorsal rotation movement seems to be obliterated. Rotation is accompanied always by side bending, the lateral curve being convex to the side away from which the bodies of the vertebrae turn. In a rotation of the top of the column to the left the lateral curve is to the right and vice versa. The practical points to be borne in mind in the study of the dorsal region are the facts that rotation is freer than side bending, that hyperextension is extremely limited, and that the region on the whole is comparatively immobile. LUMBAR REGION Flexion in the lumbar region is a movement of much freedom, but the physio- logical curve in the adult cadaver has not been obliterated in any case observed by the writer. Hyperextension as a general spinal movement is essentially a lumbar motion and in that region is an evenly distributed end. Side bending is a free movement in the lumbar region and forms in the erect position a very evenly distributed curve; it is greatest in the erect position and least in extreme flexion. The rotation accompanying side bending in the lumbar spine is always with the bodies turning to the concavity of the lateral curve, which is to be contrasted with the opposite rotation occurring in side bending in the dorsal region. Rotation in the lumbar region is extremely limited and is diminished by extreme hyperextension and is least or absent in extreme flexion. The lumbar region possesses marked mobility in flexion, hyperextension, and side bending, and but little in rotation. Side bending is more free than rotation in contradistinction to the relation of these two movements in the dorsal region. CERTAIN CONCLUSIONS AS TO THE MOVEMENTS OF THE THREE REGIONS OF THE SPINE 1. In the lumbar region flexion diminishes mobility in the direction of side bending and rotation, and extreme flexion seems to lock the lumbar spine against these movements. 2. In the dorsal region hyperextension diminishes mobility in the direction of side bending and rotation. Extreme hyperextension seems to lock the dorsal spine against these movements. 3. In flexion of the whole spine side bending is accompanied by rotation of 42 THE MOVEMENTS OF THE SPINE the vertebral bodies to the convexity of the lateral curve, the characteristic of the dorsal region. 4. In the erect position and in hyperextension of the whole spine side bending is accompanied by rotation of the vertebral bodies to the concavity of the lateral curve, the characteristic of the lumbar region. 5. The dorsal region rotates more easily than it bends to the side, whereas the lumbar region bends to the side more easily than it rotates. 6. Rotation in the dorsal region is accompanied by a lateral curve, the con- vexity of which is opposite to the side to which the bodies of the vertebrae rotate. These conclusions are true of the normal spine, but they do not necessarily apply to a deformed scoliotic spine. The nearer a scoliotic spine approaches the normal, the more likely are they to apply without modification. CHAPTER IV MECHANISM OF SCOLIOSIS The Mechanics of the Upright Position (Balance). — The spine is a curved, segmented, weight-bearing rod resting in unstable equilibrium on the sacrum, which forms part of a bony ring balanced on the hip-joints. Its upright position is due to a sense of balance possessed by the living individual, for if the cadaver is placed in the upright position- it falls on account of the absence of muscular ac- tion. This sense of balance expresses itself in a muscular contrac- tion by which the living individual keeps his center of gravity over the center of support. It is reflex and instinctive, and the individual has no knowledge of it as such, any more than he has of the mechan- ism of breathing or swallowing. The living individual, therefore, keeps his spine erect, ? first, because he has a sense of balance, and second, because he has a muscular system which responds to his instinctive nervous impulses and carries out of itself the necessary muscular adjustment which is too complicated to describe or formulate. This instinctive sense of balance and equilibrium must be regarded as an attribute of the erect living individual, and must be given a place in the study of scoliosis. It is effective in two directions: i. The erect person instinctively strives to keep the head approxi- mately over the middle of the pelvis, that is, in the sagittal or antero- posterior median plane of the body. 2. The erect person instinctively strives to keep the face to the front and the shoulder-girdle approximately in the same plane as the pelvis, i.e., in the frontal or lateral plane of the body. This adjustment, especially the element which seeks to keep the shoulder-girdle in the same plane as the pelvis while disturbances twisting the column below are taking place, is an important factor in explaining the phenomena of scoliosis, as will be seen later. The body is, however, not a firm mass, but consists of segments joined together, one segment resting upon the other, and firmly connected by a tube made up of muscles, fasciae, and integument. 1 Since to maintain the erect attitude the line of gravity must pass 1 Feiss: "Amer. Jour. Orth. Surg.," iv, i, 37. 43 44 MECHANISM OF SCOLIOSIS through the base of support, so in all positions in which balance is maintained there is a constant equilibration by means of shifting segments. It is necessary at this place to introduce certain elementary points in mechanics which are familiar to every one. These points are the following: i. The base of support of the upright human figure consists of a trapezoid formed by the outer borders of the feet and lines connect- ing the back of the heels and 1 I the front of the toes. fjj . . •■£ 2. The center of support lies V ■y'ofrtoi^ perpendicularly under the cen- ter of gravity and in the erect position must always lie within this trapezoid. "*= p 3. For the purpose of study- ^^H \ ing the mechanism by which any weight is borne by a solid body in unstable equilibrium, the entire weight may be re- garded as concentrated in the center of gravity, and the de- termination of the relation be- tween the center of gravity and the bearing points determines the lines of stress. The Defects of the Upright Position. — An important mat- ter in the mechanics of the spine and its appendages is that it is evolved with comparatively slight modifications from the quadruped spine, and, in fact, is hardly more than the quadruped spine set upright. In the quadruped the spine is a horizontal sustaining structure arched upward, supported at one end by two anterior limbs and at the other by two posterior limbs; the viscera hang directly down from this, being supported by ligaments and attachments at right angles to the supporting structure. On account of the angle of the ribs the thoracic cavity is helped in inspiration by gravity as the ribs fall into the position of thoracic expansion, but they must be pulled up to contract the thorax; and, finally, equilibrium is much more easily maintained than in the biped, because the supporting Fig. 32. — The Right Side of the Pelvis of the Cadaver is Raised and the Upper Part of the Spixe Falls to the Left, Making a Lateral Curve Convex to the Right. MKCHANISM OF SCOLIOSIS 45 base is broad and the weight of the mass to be supported is compara- tively small. When this structure with only comparatively slight modifications is set on end and made to fulfil the functions of a weight-bearing column in a plane at right angles to that for which it is best adapted, certain unfavorable factors are introduced which serve as distinct Fig. 33. — The Right Side of the Pelvis of the Model is Raised and the Upper Part of the Spine is Carried to the Right, Making a Lateral Curve Convex to the Left. (Cf. Fig. 44.) limitations. The column constructed to bear weight and sustain strain at right angles to its long axis must now bear weight and sus- tain strain in its long axis. The tw r o anterior limbs, which formerly served as props, now hang as dead weights to be supported by the column. To maintain equilibrium much greater muscular effort is necessary to maintain functional balance in the man than in the quadruped. The viscera hang no longer at right angles to the sup- 46 MECHANISM OF SCOLIOSIS porting structure, but in the line of its long axis. The thorax to expand has to raise all the ribs and work against gravity. But what is most important in the present connection is the fact that the upright position is decidedly hard to maintain, because the base of support is so small and the height of structure to be supported is relatively so great. This structure from a mechanical point of view consists of two vertical legs attached to a horizontal pelvis in the middle of which is set an upright column expanding into a bony cage carrying the weight of arms, head, and thoracic contents. All the weight comes down through a single column, the lumbar region of the spine, which column rests upon the middle of the pelvis. Such a structure is one necessarily susceptible. to disturbances of balance, and it will yield to such disturbances by assuming abnormal curves either lateral or antero-posterior. Relation of Balance to Curves.— -If the pelvis of a cadaver is raised on the right side and the upright spine is left free to move, the top of the column falls to the left and the spine is curved convex to the right. This is the position induced by gravity. If, on the other hand, the right side of the pelvis of a living model is raised v and the upright spine is left free to move, the top of the column remains upright and the spine is curved in the opposite direction, convex to the left. This is the position of balance overcoming the position induced by gravity. The sense of equilibrium has worked against the force of gravity and has reversed the position natural to the cadaver. Anything which causes any part of the body to be held in an asymmetrical position will cause a lateral deviation of some part of the spine, because a straight erect spine in the sagittal plane is possible only when the person stands on both feet or sits erect with the arms in similar positions and the head pointing straight ahead. Every step, every raising of the arm, every tilting of the head is accompanied by a deviation of the spine from the median plane of the body: in other words, by a temporary lateral curve which disappears as the symmetrical attitude is resumed. If there is a visual error that causes the head to be held obliquely; if there is a short leg causing the pelvis to be no longer horizontal but slanted; if the muscles of one side of the back are paralyzed; there must be a constant compensation or curve which will still enable the center of gravity to be held over the center of support. When such a curved position becomes habitual for any of the reasons given or PLASTICITY OF HONE 47 for other reasons, there exists in the adaptive character of bone a reason why this constantly assumed malposition should make a change in the shape oi the bones in a growing child and that these changes should become fixed. Plasticity of Bone. — The adaptability of bone to pressure has been recognized in general, and has been formulated and forms one aspect of what is often spoken of as Wolff's 1 law, which may be expressed briefly as follows: "Every change in the formation and function of the bones, or of their function alone, is followed by certain definite changes in their internal architecture and equally definite sec- ondary alterations of their external confor- mation in accordance with mathematical laws." The phenomena of lateral curvature have become somewhat more comprehensible since we have understood that bone is a plastic and adaptable structure, adapting itself to the demands on it, following in its growth the lines of least resistance, and in children sus- ceptible to great changes in shape from abnor- Fig. 34.— Experimental Scoliosis in a Rabbit Produced by Cutting the Erector Spin/e Muscles. —(Arndt.) Fig. 35. — Fifth Lumbar Vertebra from Experimental Scoliosis in Rabbit. — {Arndt.) mal conditions. As an instance of this may be mentioned the great distortion of the shape of the bones in the Chinese lady's foot produced by bandaging. It is not necessary to multiply them, for we have direct experimental proof of the case in question in the experiments of Wullstein and Arndt. 1 Wolff: "Das Gesetz der Transformation der Knochen," Berlin, 1892; Freiberg: ''Am. Jour. Med. Sci.," Dec., 1902; "Animal Mechanics," by Sir Charles Bell and J. Wyman, Cambridge, 1902. 48 MECHANISM OF SCOLIOSIS Wullstein 1 showed, by bandaging young dogs for months in posi- tions with the spine bent laterally in some and in others bent back- ward, that a permanent bony deformity occurred which could not be removed by traction in the length of the spine after death. A sec- tion of these columns showed wedge-shaped deformity of the verte- brae with a " lipping" or overgrowth of the borders of the vertebrae on the concave side of the curve, the trabeculae being thickened on the side of the bodies toward the concavity. The changes were more marked at the articular ends of the bones than in the middle of them. Arndt 2 produced similar permanent curves, characterized by bony deformity and marked rotation, in rabbits by extirpation of the erec- tor trunci muscles on one side. They showed, as in Wullstein's ex- periments, that the changes are greatest at the articular ends of the bodies, and the epiphyseal plates in the most deformed vertebrae clearly overlap the sides of the body. The point to be remembered is, that the erect position is a singu- larly unstable one and temporary lateral deviation of the spine occurs in almost every movement of the body. If such deviation becomes permanent for any reason, it must further be remembered that grow- ing bone is a plastic structure and that the spine will tend to conform its bony shape to the abnormal position. Here then, exists the mechanism for the acquiring of bony lateral curvature if sufficiently long continued. There are, of course, many other causes of lateral curvature which will be mentioned. TYPES OF LATERAL CURVATURE There are two types of malposition commonly described as lateral curvature or scoliosis. This is unfortunate and leads to misunder- standing and confusion. In one, the position is that which any normal spine may assume; in the second, the position is one that the normal spine cannot assume, a position which implies a change in the shape of the bones. It would add much to a better understanding of the subject if the former were called faulty attitude or some similar name, and the term scoliosis were reserved for the latter form. The first is due to the adjustment necessary to keep the balance of the spine in the presence of one of the disturbing causes mentioned. If this becomes habitual, it results in a typical attitude to be de- scribed as total or postural lateral curvature in the chapter on Descrip- i "Zeitsch. f. orth. Chir.," x, 2. 2 "Archiv f. orth. Chir.," i, 1, 2. BONY ROTATION 49 tion ami Symptoms. This attitude may persist as such or change to the second form to be described next. The second type of lateral curva- ture is accompanied by a change in the shape of the bones and soft parts. It cannot be reproduced experiment- ally in the model, cadaver, or child, and is not within the physiological limits of the spine. It must, there- fore, be classed as structural or organic lateral curvature. The characteristic feature is a local backward prominence of the ribs or lumbar transverse proc- esses in the curved region, which is called "bony rotation." Bony Rotation. — The reason that bony rotation or twisting of the verte- bral bodies always accompanies or- ganic lateral curvature has been widely discussed from every point of view, and the question has been much compli- cated by the abstruse reasoning applied to its solution. The facts seem to be these: the vertebral column is a flexible weight-bearing rod curved in the an- tero-posterior plane by the physiolog- ical curves: in a column affected by lateral curvature it is now beginning to be curved to one side in some part of its length. Growing bone, it has been stated, is a plastic structure and will yield to unequal conditions of weight or strain. This curved part of the column being subject to unequal con- ditions of weight on the two sides tends to yield to the side and to change its structure in accordance with these unequal conditions of weight. But a plastic weight-bearing column already curved in one plane cannot yield in another plane (i.e., to the side) without twisting, and in this twist the vertebrae can turn in only one way, namely, away Fig. 36. — Experimental Scoli- osis in a Young Dog Produced by Bandaging in a One-sided Posi- tion. — (Wullstein.) 50 MECHANISM OF SCOLIOSIS from the greatest weight and pressure, which is, of course, on the concave side of the lateral curve. If they were to turn toward the middle line instead of away from it they would encounter the greater instead of the less resistance and have to raise the whole weight of the parts above them. In so far as they are plastic they will be com- pressed where the weight is greatest or on the concave side. The deformity of the vertebrae is therefore due to their plasticity yielding to conditions of unequal strain, and turning where they must turn to escape. Double Curves. — The explanation of a double curve is more dim- cult. It has been observed that frequently a double organic curve grows out of a single functional one, the reason for which will be explained in the chapter on Description and Symptoms. It cannot be said that every case of organic double curve has first been a single postural one, for congenital, early rachitic, and other cases make that unlikely, but the mechanism is present for forming double curves from single ones under the influence of existing conditions. The occurrence of bony change in some cases and the persistence of func- tional curves in others can only be explained by assuming a plasticity of the bones in certain individuals which does not exist in the bones of others. The chain of events in the cases where a single curve changes to a double one is then, first, a disturbance of the symmetry of the body and the appearance of a functional curve; second, the persistence of this curve from the same causes that started it, the phenomena being still within the normal mechanism of the spine; third, the yielding of plastic vertebrae in the line of least resistance and the appearance of rotation on the convex side of the lateral curve; fourth, the formation of double curves from single ones by the normal mechanism of the spine originating in the sense of balance and adjustment. It seems that in many cases, perhaps the majority, these steps cannot be traced, but coincide in time. CHAPTER V DESCRIPTION AND SYMPTOMS SYNONYMS English: Scoliosis, lateral curvature of the spine, rotary lateral curvature of the spine. German: Skoliose, seitliche Riickgratsverkrummung, Kypho- skoliose. French: Scoliose, deviation laterale de la taille. Italian: Scoliose. Scoliosis, or lateral curvature of the spine, is the name applied to a condition in which any series of vertebral spinous processes shows a constant deviation from the median line of the body, a deviation always accompanied by an element of twisting. In certain rare cases the twisting may be the predominant appearance. Deviation of a single vertebra from the median line does not constitute scoliosis. Although scoliosis is generally studied and classified as a deformity of the spine, the laws of equilibrium of the body are such that any deviation of the vertebral column must disturb the whole balance of the body, and scoliosis is, therefore, accompanied by compensating lateral displacement of the pelvis and legs. In this wider sense scoliosis is to be regarded as a deformity of the whole body, espe- cially manifest in the spine. Lateral curvature of the spine is necessarily accompanied by a distortion of the symmetry of the body for which the patient or her parents seek advice. It is not generally recognized by the laity as a spinal distortion, but the patient is brought for surgical advice because of "a high shoulder," "a prominent hip," or "a projecting shoulder-blade." Very often the dressmaker is the first to recog- nize it because she finds that she must make the skirt longer on one side than on the other, or because the distance from the armhole to the waistband is longer on one side than on the other. The condition is essentially a distortion, and symptoms other than the deformity are rather unusual in average cases. Occasionally the patient complains of feeling " one-sided," but this is rare. Pain is generally not complained of, but in neurasthenic young women, 5i $2 DESCRIPTION AND SYMPTOMS especially with functional curves, backache may be felt more or less on standing. Pain in the severer cases is caused by the descent of the ribs to the level of the crest of the ilium against which the lower ribs may rub, and severe local pain may be felt. In other severe cases, nerve-root pressure may result from the distortion and be referred to the peripheral ends of the spinal nerves. The shortening of the trunk and the diminished capacity and im- mobility of the thorax may lead to impairment of the function of thoracic and abdominal organs, especially in severe cases, and short- ness of breath is common in such cases on account of diminished respiratory capacity. Displacement of the heart and phthisis fre- quently occur in severe cases during adult life. Disturbances of digestion are also frequent irom displacement of the stomach and liver. Impairment of vigor and of the general health generally result in severe cases in adult life, although children with severe curves, as a rule, suffer less deterioration of the general condition. It is not uncommon for patients to go through life with curves of moderate degree which have given rise to little or no trouble; but at or after middle life, when atrophy of the intervertebral discs has occurred, such curves may increase and give rise to a sense of asym- metry or to pain in the back or at nerve terminations. It can gen- erally be predicted that a curve of moderate severity may be more troublesome in later adult life. TERMINOLOGY The terms used in describing lateral curvature must be defined. Curves are named right or left according to their convexities, curves convex to the right being called right curves, and vice versa. In addi- tion to the terms right or left, the curves are named also according to the anatomical region involved in the curves. If a deviation involves the whole spine, it is called a total curve; all other curves are called cervical, dorsal, or lumbar, according to the region involved, with the qualifying adjective right or left preceding the anatomical name. If a curve involves more than one region, it is classed as cervicodorsal or dorsolumbar. If two curves exist, the upper curve is spoken of first and the lower follows, e.g., right cervicodorsal, left dorsolumbar; or right dorsal, left lumbar. It is important that the anatomical region affected by the curve be designated accurately and not loosely. For this purpose the seventh cervical and last lumbar vertebral spines are marked on the skin and FUNCTIONAL SCOLIOSIS 53 connected by a string representing the long axis of the spine. Parts of the spine lying to the right of this line are to be classified as right curves, parts to the left as left curves. Such curves must be assumed to begin and end where they pass under this string. For example, if the spine from the seventh cervical to the twelfth dorsal is to the right of the line and below it is to the left, it is a right-dorsal, left-lumbar curve. If the spine from the fourth dorsal to the third lumbar is to the right of the line, it is a right dorsolumbar curve. This, therefore, provides for a simple rule for the naming of every curve, insisting on the fact that the location of the upper end of the column has nothing to do with the naming of the curve. The upper end of the spine may be in the median plane or at either side of it, without affecting in any way the recognition and description of the spinal curves. The classification of curves into primary and secondary, or com- pensatory, is not of great importance, nor is it sound, as one cannot always say which curve was really primary. Often it is obvious that one curve is predominant and evidently the one to be attacked in treatment. In other cases this cannot be done, as the curves are of equal degree and importance so far as can be seen. It is, however, of importance to recognize the predominant curve where possible. For example, in a marked and predominant right dorsal curve it matters but little, practically, whether a slight lumbar curve exists or not; for purposes of treatment the case is a dorsal curve. In general, rational treatment must eliminate unimportant factors and deal with the salient ones. The former division of lateral curvature into stages has no rational basis. It is a progressive affection passing over only one sharp line, the transition from postural or functional curves to structural or organic ones. ' This classification of functional and structural will, therefore, be adopted here with slight emphasis on a certain puzzling type of cases evidently in the transitional stage from the functional to the structural type. FUNCTIONAL SCOLIOSIS (TOTAL, POSTURAL, OR FALSE SCOLIOSIS) The term " total scoliosis " is applied to cases where the spine forms one gradual curve to one side without compensatory curves. In 90 per cent, of such cases the curve is to the left. According to the figures of Scholder and at the Children's Hospital clinic, right total 54 DESCRIPTION AND SYMPTOMS scoliosis is very rarely seen, while the left curve is very common. The greatest point of deviation, i.e., the apex of the curve, is generally found at the ninth or tenth dorsal vertebra, but it may be found in any part of the lower half of the dorsal or upper half of the lumbar region. In frequency of occurrence total scoliosis stands in the fourth place in the records of the institute of Liining and Schulthess, where patients came for treatment, forming but 15.39 P er cent - °f the entire number of lateral curvatures. As to sex, the per- centage shown in these cases is 24 for males and 17 for females (Figs. 37 and 38). In boys the number of total scolioses in- creases steadily with age, but in girls a decrease is noted after Fig. 37. — Left Total Curve. Fig. 38. — Left Total Curve Bent For- ward, Showing Prominence of Back on the Right. the twelfth year, coinciding with an increase in the number of left lumbar curves. Total scoliosis is found between the ages of five and eighteen years, as a rule. The deviation at the greatest curve is not often over an inch and a half from the median line of the body. There is no obvious compen- satory curve, and the untrained eye is likely to find slight cases normal. There is, however, a perceptible displacement of the trunk to the left, especially as seen from the front, and a plumb-line sus- pended in the median line of the body as defined by the vertical fold FUNCTIONAL SCOLIOSIS 55 between the buttocks, will detect a decided deviation of the marked spines from the median plane. The typical characteristics of a left total scoliosis are as follows: (i) A general curve convex to the left; (2) the left shoulder is elevated; (3) the right side of the shoulder --girdle is carried back and the left side forward; (4) when the patient bends forward the right side of the back may be slightly higher than the left. Any case which simulates a left total curve and in which these signs are not all present should be subjected to the closest examination and will probably be found to be transitional in character. Functional curves disappear on suspension or recumbency, and side flexibility is but little limited, bending to the left being often somewhat re- stricted. In cases of right curves the description is reversed. Fig. 39. — Left Total Curve. The Patient from which Radiogram was Taken. The changed relation of the shoulders to the pelvis is more evi- dent in children with marked lumbar physiological curves than in cases with round backs. 1 The position in a typical functional total curve is merely the physio- logical one necessitated in every normal spine for any reason made convex to the left, and can be produced experimentally by putting a book under the right foot, which raises the right side of the pelvis and necessitates for balance a left convex curve of the spine. A spine making any bend convex to the left in the erect position will turn at its upper end to the right, as explained in the movements of the spine. The thorax and shoulders will be twisted backward on the right, and 1 Schulthess: "Zeitsch. f. orth. Chir.," vi, 399-566, 1902. 56 DESCRIPTION AND SYMPTOMS when the patient bends forward, this twisted position of the shoulders may be carried over into the position of forward bending, if the case has been of long standing, and the right side of the back will be higher Fig. 40. — Radiogram of Total Curve in Patient Shown in Fig. 39- in this position. This "reverse rotation," "concave torsion," "retrotorsion," as it has been called, has been much discussed 1 and is 1 Schulthess: "Zeitsch. f. orth. Chir.," x, page 489. TRANSITIONAL CURVES 57 an accompaniment of total scoliosis, but it is a physiological matter easily understood by studying the mechanics of the normal spine. It has been claimed that total scoliosis is really a triple-compound curve, 1 and that the torsion to the concave side is really due to a slight right dorsal curve; x-rays of such cases taken in the standing position show, however, in many cases, a grad- ual curve to the left without compensating curves (Fig. 40) ; in other cases apparently total curves in x-rays taken in this way seem to be transitional cases. Fig. 41. — Case of "Paradoxical Dor- solumbar Scoliosis" Figured by Wilbou- chewitch. (Compare Figs. 37~39-) Fig. 42. — Same Case as in Fig. 47 Bent Forward Showing Prominence of Ribs on Right Side with Left Curve. — (Wilbouchewitch.) TRANSITIONAL CURVES In many cases which on first inspection appear to be postural more careful examination will show that the curve is obviously changing from the postural to the structural type, i.e., is beginning to show changes in structure. In such transitional cases the upper part of the spine is less curved than the lower, and one or more of the characteristic signs of postural curves are most often wanting. For example, the right shoulder may be elevated in a left curve, or the left side of the back may be promi- nent upward in forward bending, or the left shoulder may be carried forward. Such cases must, of course, be recognized as early struc- tural cases, but are so nearly postural that they may be wrongly 1 Reiner and Werndorfl: "Verhandl. Deut. Gesel. f. orth. Chir.," 1906, page 232. 58 DESCRIPTION AND SYMPTOMS classed unless identified. It is not exceptional to notice that in a curve that has been clearly a typical left postural one a few months later the dorsal spine is straightening and even becoming slightly curved to the right, while the twist of the shoulder-girdle has dis- appeared or become reversed. The mechanism of this is as follows: Fig. 43. — Boy with Left Scoliosis Photographed from Overhead, Showing the Carrying Back of the Shoulder-girdle on the Right. The front edge of the board on the floor marks the lateral plane of the pelvis. Mechanism of Transitional Curves. — If total scoliosis tends to increase, it must do so by an increase of the existing side bend and of the existing twist, since both are correlated, not necessarily of both in exact proportion, but to some extent both factors must share in it. The shoulder-girdle will, therefore, be more twisted as the lateral curve increases. One, however, does not see the condition clinically of extreme left total curve and extreme right backward rotation of the shoulder- girdle except, possibly, in cicatricial, hysterical, or paralytic cases. An adjust- ment apparently takes place when the tendency of the total curve to increase passes beyond a certain point. For the explanation of this, one naturally looks to the instinctive tendency to equilibrium and balance spoken of as an in- trinsic property of the upright living spine. There must be going on at all times this effort to square the shoulder-girdle with the pelvis and to keep the head and upper spine as nearly as possible in the median line of the body. This adjust- ment will naturally occur where the spine offers the least resistance to it, and as individual vertebral columns vary, the compensatory adjustment will take various forms. Assume that a child stands and sits with a left total curve. He will, after a TRANSITIONAL CURVES 59 certain point in the deformity is reached, be continually striving instinctively and unconsciously to twist the upper part of his spine and his shoulder-girdle forward on the right and to bend the upper part of his spine convex to the right to restore his balance. We have seen that the dorsal spine twists more easily than it bends to the side. He is, therefore, more likely to twist his dorsal spine than to bend it to the side. He will, for this reason, twist the upper dorsal spine to the left, which twist, as we have seen, necessarily carries with it a dorsal lateral curve convex to the right. The tendency to correct the twist of the shoulder and upper end of the spine is sufficient to explain the transition of a left total curve to a right dorsal, left lumbar curve. Such a double curve can be reproduced experimentally in the Fig. 44. — The Upper End of the Spine of the Cadaver is Held by the Hand over the Middle of the Pelvis, while the Right Side of the Pelvis is Raised, and a Position Like that of the Living Model is Produced with a Lateral Curve Convex to the Left. (Cf. Fig. 33.) Fig. 45. — Experimental Double Curve (Right Dorsal, Left Lumbar) Produced in the Cadaver by Elevating the Right Side of the Pelvis and Twisting the Upper End of the Spine, Face to the Left. cadaver, the model, and the child by inducing a left total curve and adding a twist, active or passive, of the shoulder-girdle forward on the right. A right dorsal, left lumbar lateral curve then exists. Support is given to this idea by the fact that in structural right dorsal, left lumbar curves with bony rotation, one is likely to find in looking down upon the standing patient that the left side of the shoulder-girdle is seen to be carried backward in its relation to the pelvis and the right side forward, which, of course, is the reversed position to that seen in the left total curve. The same relation of the shoulder-girdle is to be noticed in single curves to the left which are ac- companied by bony rotation, the position again being the reverse of that seen in left total scoliosis. 6o DESCRIPTION AND SYMPTOMS The disappearance of concave-sided torsion which has once existed in any part of the spine may indicate that the compensatory change has already begun and that the so-called total scoliosis has begun on its transition to a compound curve. We should, therefore, regard with suspicion any case of apparent total scoliosis that shows any departure from the clinical type described (see page 55), such cases probably having entered on the stage of transition. Fig. 46. — •Experimental Double Curve (Right Dorsal, Left Lumbar) Produced in the Model by Elevating the Right Side of the Pelvis and Having the Model Actively twist the Upper Spine, Face to the Left. That left total curves most frequently change to right dorsal, left lumbar compound curves than to any other form is shown by the figures of Hess and by a statement of Schulthess. 1 But we cannot expect the same final curve always to result from the same initial curve. Various forms of curves may occur from the same simple curve. For example, the dorsal region may not react as described, 1 Liining and Schulthess: " Orth. Chir.," 1901, page 248. STRUCTURAL SCOLIOSIS 6 1 and the dorsal and lumbar region may yield, as a whole, to the left, later showing bony rotation on the left side. The spine has yielded backward and to the left as a whole, and other types of compound curves may obviously result from the same initial curve. In his investigations concerning the persistence of total scoliosis Hess records the observations of 86 cases between the ages of five and twenty-one years during periods varying from tw r o weeks to eight years and a half. Of these 86 cases, 6o persisted as total sco- lioses, and the remaining 26 underwent various changes, as showm by the list given below. (a) Left total scoliosis in — 7 cases changed to right dorsal, left dorsolumbar scoliosis. 4 cases changed to left lumbar curves, with two right dorsal. 3 cases changed to left dorsal curves. 2 cases changed to left dorsal, right dorsolumbar curves. 2 cases changed to right dorsal curves. 1 case changed to left dorsal, right dorsolumbar. 1 case changed to slight left cervicodorsal curve. 1 case showed slight compensating curves. (b) Right total scoliosis in — 1 case became right dorsal, left dorsolumbar. 1 case became left dorsal, right dorsolumbar. 1 case becsme left dorsal. 1 case became right dorsal. 1 case became left dorsal, right lumbar. 5 cases. STRUCTURAL SCOLIOSIS (ORGANIC, HABITUAL OR TRUE SCOLIOSIS) This term is applied to those cases in which there is reason to believe that a structural change has occurred in the vertebrae, which is discussed in the chapter on Pathology. Structural curves are simple or compound — simple, when the de- viation is accompanied by no compensating curves, e.g., left lumbar scoliosis. The scoliosis is compound when more than one curve is present, e.g., right dorsal, left lumbar scoliosis. The simple curves have sometimes been spoken of as C curves and the double as S curves. Triple curves at times exist. When compound curves are present, they alternate to the right and left, two left curves, e.g., not separated by a right curve, never being seen. 62 DESCRIPTION AND SYMPTOMS No attempt has been made to discriminate between the words " torsion" and ''rotation," and they have been used interchangeably in the text. The German writers distinguish between the two terms in a highly technical way, a distinction which it does not seem desirable to transfer to English. VARIETIES OF STRUCTURAL SCOLIOSIS (LUMBAR CURVES) Lumbar scoliosis exists as a simple curve, but more often is only one component of a compound curve, the dorsal curve being, of course, in the opposite direction. In the Schulthess figures the simple lumbar curve formed 11.7 per cent, of all cases treated, and right and left curves were of practically the same fre- quency. It occurs later than the total scoliosis, as shown by the ages of the patients observed. It occurs more fre- quently in females than in males (Scholder: 13.8 per cent, boys, 27.7 per cent. girls. Schulthess: . 6.3 per cent, males, 12.7 per cent, females). The greatest deviation from the straight line is most often found at about the second lumbar vertebra, and as the lum- bar region is short, the curve must be in general a sharp one. The trunk is displaced to the side of the convexity of the curve and the line of the waist flattened on that side, while the waist on the con- cave side of the curve is sunken in, and folds may form in the skin of the flank on this side. This is expressed by an apparent prominence and greater size of the hip on the concave side, and it is popularly said that one hip has ''grown out" or one hip is ''higher" than the other, meaning in anatomical terms that the crest of one ilium is Fig. 47. — Left Lumbar Scoliosis not Return- ing to the Median Line. The lines indicate the median plane and the flexibility to each side. DORSAL CURVES 63 more prominent than the other. This inequality of the hips and waist-line is the most striking feature of lumbar curves, and unless corrected, forms an unsightly deformity in women with prominent hips, and makes it necessary to make the skirt longer on one side than on the other. The relative height of the shoulders is not noticeably affected by lumbar curves. As the patient stands, a fullness of the back is noticed in marked cases on the convex side of the curve caused by the rotation of the vertebrae, which carry the heavy transverse processes around and make prominent the overlying structures. In the position of ex- Fig. 48. — Left Lumbar Curve with Slight Right Dorsal Curve. Fig. 49. — Left Dorsal Scoliosis. treme forward bending the side of the back which is on the convexity of the lateral curve is prominent upward, but lumbar rotation is always less prominent than dorsal, and to the untrained eye even in the severer cases seems slight (Fig. 56). In side bending, mobility is greater toward the side which makes the curve worse than to the side which improves it (Fig. 61). DORSAL CURVES A single dorsal curve is more frequent than the single lumbar type, but is much less frequent than dorsal curves in combination with other 6 4 DESCRIPTION AND SYMPTOMS forms; that is to say, dorsal curves are more often than not accom- panied by reverse or compensating curves above or below. In the Schulthess figures there were 19 per cent, of single dorsal curves and 30 per cent, where dorsal curves existed with others. The curves are as frequently to the right as to the left when they exist alone. The point of greatest curve is from the sixth to the eighth dorsal ver- tebra in the majority of cases. In a marked right dorsal curve, as seen from behind, the thorax is displaced to the right, and the right arm hangs farther from the side than the left; the right shoulder is raised and the waist-line on the right is less concave and much flattened in the severer cases, the ribs coming close to the crest of the ilium and obliterating the natural waist indentation. The rotation is made evident by a prominence, in the back, of the right side of the thorax, which may be seen as the pa- tient stands erect (Fig. 50). Unlike the rotation in lumbar cases, the rotation element in dorsal cases is a very marked feature of the deformity, and a sharp prominence extends down the right side of the thorax, composed of the angles of the ribs, which pushes the scapula backward and to the right. The left side of the thorax as seen from behind is flat or concave, the left scapula sunken and ro- tated with the glenoid cavity downward and the inferior angle in- ward. A fold in the skin frequently runs inward and upward from the waist-line. When the patient bends forward until the trunk is horizontal, the rotated ribs are very prominent upward on the right, and a long arch of rib angles is seen which is much more marked than in the standing position. On the left side the ribs are sunken and fall away, making a flat and even depressed surface to contrast with the striking prominence of the right side. In a right dorsal curve the right shoulder will inevitably be higher Fig. 50. — Advanced Right Dorsal Scoliosis in an Adult. DORSOLUMBAR CURVES 65 than the other unless a left compensating cervicodorsal curve exists above it. The absence of a high shoulder on the convex side there- fore should always lead to an examination for a compensating curve above. As seen from the front, the deformity is even more evident, the thorax is displaced to the right, the right shoulder is higher than the left, and the left side of the thorax more prominent in front than the right. In severe cases the lower end of the sternum is generally dis- placed toward the convexity of the curve — in this case to the right. The contour of the chest is changed, and the longest thoracic diameter is the oblique antero-posterior line from the point rotated backward on the right to the point rotated forward on the left — in this case from the right scap- ula to the left nipple. This descrip- tion is, of course, to be reversed for left dorsal curves. The dorsal physiological curve is most often increased, making the rounded and distorted back spoken of as kyphoscoliosis (Fig. 51). It may, however, be flattened, and even slightly concave forward in the dorsal region. Loss of height and shortening of the trunk are evident in the severer cases. The aspect is wholly different from that seen in lumbar cases, where, as has been said, the chief noticeable dis- tortion is in the hips and waist-line; in dorsal cases the distortion is. most noticeable in the thorax and shoulders. Fig. si. — Kyphoscoliosis. DORSOLUMBAR CURVES Dorsolumbar scoliosis is a form seen as a simple curve with con- siderable frequency (20 per cent.), being, therefore, much more com- mon than simple lumbar, but about as frequent as simple dorsal scoliosis. It naturally partakes of the character of the two forms 66 DESCRIPTION AND SYMPTOMS just described and affects nine females to one male. The seat of greatest curve is generally at the dorsolumbar junction. It is four times as frequently convex to the left as to the right. The trunk and lower thorax are displaced toward the side of the convexity of the curve and overhanging the pelvis, and the waist-line on that side is flattened or obliterated, while on the concave side the outline cuts in sharply above the pelvis, fre- quently forming folds in the skin. The attitude is more like that of an exaggerated total scoliosis than like either the dorsal or lumbar form. It is not so prone to be associ- ated with compensatory curves as are the other forms. CERVICODORSAL CURVES Cervicodorsal scoliosis is a comparatively rare form of the deformity, occurring in only 3.6 per cent, of all cases. It is convex to the left more often than to the right in the relation of 3 to 2, and the greatest curve is most fre- quently located at the third or fourth dorsal vertebra. The head is carried forward and tipped to the concave side of the curve. The neck is obvi- ously shortened, and the outline from the base of the skull to the shoulder is fuller and less crescentic in outline on the convex side of the curve than on the other. The shoulder on the convex side of the curve is raised and the other lowered, and the scapula of the raised side is conspicuously higher. The arm of the convex side hangs farther from the side than the other. The rotation appear- ances are marked, and the sharp angles of the upper ribs are promi- nent in the lower part of the curve, while above the rotation is less evident because there are only the transverse processes of the cervical vertebrae to make a projection. The trunk is displaced to the side of the convexity of the lateral curve. Fig. 52. — Left Dorsolumbar Scoliosis. COMPOUND STRUCTURAL CURVES 6 7 COMPOUND STRUCTURAL CURVES The pictures of compound curves cannot, of course, be as simple or uniform as those of the simple types. A right dorsal left lumbar curve, for example, will present a combination of the appearances described in both dorsal and lumbar curves; a right cervicodorsal left dorsolumbar, the sum of the pictures of the two factors. If the dorsal Fig. S3- — Cervicodorsal Curve due to Defective Ribs and Malforma- tion of Vertebrae. Fig. 54. — Right Dorsal Left Lumbar Scoliosis. element predominates, the appearances will be more dorsal than lum- bar, as is usually the case, and every grade of variation is to be seen, the predominant curve setting its stamp on the clinical appearance. The right dorsal left lumbar curve is the one most frequently seen. Dorsal scoliosis with compensating curves formed 30 per cent, of all cases in the Schulthess tables, and of these the dorsal curve was to the right in 80 per cent, of the cases. The greatest point of curve in these 68 DESCRIPTION AND SYMPTOMS was from the sixth to the eighth dorsal vertebra, and the most fre- quent reverse curve associated was in the lumbar region. It is a type of curve most frequently seen in older children, the bulk of the cases being from ten to sixteen years old, but it may be seen in very young children. The increased susceptibility to compound curves with in- creasing years is shown by Scholder's statistics of school children: 8 years old 0.4 per cent. 9 years old " 1 . 1 per cent. 10 years old ..1.2 per cent. 11 years old 2.4 per cent. 12 years old 2.1 per cent. 13 years old 3.3 per cent. 14 years old : 3.3 per cent. Women are more frequently affected than men, the proportion being 7 to 1. Fig. 55- — Dorsal Rotation Shown by Fig. 56. — Lumbar Rotation Shown by Prominence of Right Side in Bending Prominence of Left Side in Bending Forward. Forward. The appearances shown in the illustration (Fig. 54) will serve to demonstrate how the appearances of two types of simple scoliosis are brought together in the same patient. In a right dorsal left lumbar curve, the appearances of the thorax are those described for a simple dorsal curve, but the overhang of the thorax is modified by the dis- placement of the lower trunk in the opposite direction incident to the left lumbar curve. The resultant position may be, as in the simple curves, either accompanied by an increase or diminution of the physiological curves. That scoliosis may change from one clinical picture to another in COMPOUND STRUCTURAL CURVES 69 the same patient in the course of years is well established. Not only does the total curve frequently change to a compound type as men- tioned, but the structural curves change the body outline most fre- Fig. 57. — Severe Dorsal Rotation on Right Side in Forward Bending. Fig. 58. — Schulthess' Tracing of a Girl Six Years Old. — (Schulthess.) Fig 59. — Tracing of the Same Case Eight Years Later.- — (Schulthess.) quently by the addition of compensatory curves, e.g., the illustration shows the change of a left dorsal right lumbar curve to a curve of the same type causing, however, a different distortion. In general, how- ever, the later distortion is an exaggeration of the earlier. 70 DESCRIPTION AND SYMPTOMS The relative frequency of the common types as tabulated in 1137 cases coming for treatment by Schulthess was as follows: Total scoliosis 15 . 39 per cent. Lumbar 11. 7 per cent. Dorsal 19.0 per cent. Dorsolumbar 20.0 per cent. Cervicodorsal 3.6 per cent. Compound , 30.0 per cent. CHAPTER VI EXAMINATION AND RECORD OF SCOLIOSIS In undertaking the examination of a case of scoliosis it is important to obtain a fairly complete history of the child's early life, as throwing light on the cause of the deformity, and secondly, as giving informa- tion as to the child's condition at the time of beginning treatment, as indicating the probable resistance to fatigue, the existence of factors likely to complicate treatment, etc. ; and, also, it is important to ob- tain as accurate a record as possible of the curve at the beginning of treatment and at subsequent stages. These two matters will be dealt with in the order named. History. Family History. — The occurrence of scoliosis in other members of the family is of interest as possibly indicating a heredi- tary origin, i£ tuberculous family history would make one particu- larly careful about the child's hygiene. Personal History. — -The character of the labor if difficult may point to the possibility of some injury occurring at birth. The health of the child as a baby, whether it was bottle fed or nursed, and the date of the first teeth are important in their bearing on rickets, as are the existence of bowlegs or other signs indicating rickets. The his- tory of acute illnesses in childhood are significant in showing whether the child has been sickly or not, and any mysterious feverish attack may have been infantile paralysis. The age at which the curve was noticed and its subsequent progress are proper subjects of inquiry, but the information obtained is rarely reliable. It is important to note the child's mental make-up, whether nerv- ous and apprehensive or easy going and careless, as it has a bearing on the formulation of treatment. Evidences of overwork at home or at school are factors of importance. The height and weight should be taken, first to show whether there is a reasonable period of growth ahead of the individual child, and sec- ond, to show whether the child is backward in growth or decidedly oversize. Great excess of height or weight, or of both, is important because decidedly overgrown children as a rule show diminished resist- ance to physical exercise and seem particularly liable to defects of posture. The height and weight should be taken and compared to the average given in the table. 7i 72 EXAMINATION AND RECORD OF SCOLIOSIS Average Heights and Weights. — {T. M. Rotch) Boys Girls Age Height Weight Weight Height Inches Pounds Pounds Inches 19-75 7-i5 Birth 6-93 19.25 24.75 14.30 5 mos. 13-86 23-25 29.53 20.98 1 year 19.80 29.67 33-82 30-36 2 years 29. 28 32.94 37.06 34-98 3 years 33-15 36.31 39-31 37-99 4 years 36.36 38.80 41-57 41.00 5 years 39-57 41.29 43-75 45-07 6 years 43.18 43-35 45-74 48.97 7 years 47 • 30 45-52 47.76 53-8i 8 years 51-56 47.58 49-69 59.00 9 years 57.00 62. 23 49-37 51.68 65.16 10 years 51-34 53-33 70.04 11 years 68.70 53-42 55-n 76.75 12 years 78.16 55-88 57-21 84.67 13 years 88,46 58.16 59-88 94.49 14 years 98.23 59-94 The weights at birth, and in the first, second, and third years, were without clothing. The ordinary school clothes were worn in the weighing from five to fourteen years. As the tables were made up from children in the public schools, children in private practice will as a rule somewhat overrun these figures. EXAMINATION GENERAL CONDITION In the examination it is important to note the nutrition and devel- opment, that is, whether the child is fat or thin, flabby or firm, pale and anemic or of good color and apparently robust. The nervous condition of the patient may be estimated by the presence or absence of apprehension, crying, twitching, or tremor, but restlessness in young children means nothing. The condition of the heart should always be examined because otherwise, harmful exercise might be prescribed for a child with organic heart disease. The following points should also form part of a routine examination. Condition of lungs and chest expansion. Comparative length of legs. The existence of flat-foot or "weak ankles." Whether or not EXAMINATION OF SPINE 73 spectacles are worn. General gait and carriage. Manner of support- ing the underclothes and stockings, whether objectionable or not. EXAMINATION OF SPINE A patient with suspected lateral curvature should always be ex- amined with the back wholly bare. The clothes should be firmly pinned or fastened by a strap around the hips at a level low enough to show the top of the cleft between the buttocks and to show the out- line of the pelvis. In children the patients should be stripped to this level; in adolescent and adult young Women the chest should be cov- ered by an apron hanging over the front of the thorax, the strings of which are fastened around the neck. The patient should stand, back to the surgeon, squarely on both feet with the arms hanging at the sides. It is desirable to allow the patient to stand quietly for a minute or two before beginning the examination in order to secure the fatigued or relaxed position which is the characteristic one. The patient should not be handled or touched during the first inspection, as the contact of the hand fre- quently stimulates the muscles and negatives for the time being the relaxed position. Inspection of the natural standing position forms the first step in the examination. The surgeon notices first: i. The body outline, whether symmetrical or not, comparing on both sides the outline from the axilla to the crest of the ilium, whether one is flatter or more curved than the other. The trained eye estimates this asymmetry as a lateral displacement of the thorax or trunk with regard to the pelvis, and it is the safest guide. The appreciation of symmetry or the absence of it is essential in giving corrective gymnastics, and the most useful method to one trained is to erect an imaginary perpendicular from the cleft between the buttocks (anal fold), and estimate whether it cuts the trunk in the middle or whether more of the trunk lies to the left or right of it. It is obvious that if any part of the spine is laterally curved, it must carry with it a segment of the body to the right or left. This displacement will be accompanied by a change of body outline, and a difference in body outline on the two sides is presumptive evidence of a lateral curve. The outline of the body and displacement of the trunk to one side may always be seen more plainly from the front than the back, as the outline is sharper. In children this method should follow the one described. 2. The surgeon next notices the level of the shoulders, whether 74 EXAMINATION AND RECORD OF SCOLIOSIS one is higher than the other, and whether this is a constant position. The elevation of one shoulder is generally a sign of lateral curvature, but may exist rarely with no perceptible curve. 3. The position of the scapulae should then be noted and the two sides compared. It is not of primary importance, but it is desirable to note their relative distance from the spine, whether one or both of the scapulae are displaced forward, and whether any rotation of the bone has taken place. 4. The habitual position of the head should be noted, whether tipped to one side or held constantly rotated. 5. The antero-posterior physiological curves should be investi- gated and any increase or diminution of the dorsal or lumbar curves noted. Estimation of the Spinal Curve. — Over the middle of each spinous process a mark is then made on the skin by a flesh pencil or by ink while the patient still stands as described. The skin must not be drawn to one side or the other in making these marks, or distortion may be caused by the movements of the skin over the bony points. This line of marks is accepted as representing the spinal curve, al- though it does not accurately represent the position of the bodies of the vertebrae (see Pathology). If a curve is present, the line of marks will be evident as a curved instead of a straight line, for a normal spine shows a line of marks forming a straight line which lies in the median plane of the body. There are now two questions to be answered: (1) Is lateral curva- ture present? (2) If present, what sort of a curve is it? The median plane of the body is readily determined by holding a plumb-line behind the patient, the lower part of which passes through the cleft between the buttocks. In the normal spine each mark will lie under this plumb-line. The deviation of any number of spinous processes from this line represents a lateral curve. This method of erecting a perpendicular from below is preferable to the method of dropping a plumb-line from the top of the column (the Beely-Kirchoff method). If a curve exists, as shown by the plumb-line, the second question arises as to what sort of a curve it is, whether functional or structural. Functional curves have four definite attributes which should be looked for (see p. 55), and in the absence of any one of them the diagnosis of a functional curve cannot be made; under these con- ditions the case is, therefore by exclusion, structural. The curve is then described (p. 61). EXAMINATION OF ROTATION 75 Cervical curves must be roughly estimated by the eye, for on account of the inaccessibility of the cervical spinous processes and the instability of the head, they cannot be definitely measured. Estimation of Rotation or Twist. — The surgeon, having thus recognized any bodily asymmetry and having identified and defined the curve, is in a position to investigate the element of rotation or twist which is essential in every case. The surgeon, standing close behind the patient, looks down on her shoulder-girdle from above to estimate whether it is in the same lateral plane as the pelvis or whether twist- ed forward on one side and back on the other. This is of use chiefly in postural cases, and in structural cases is of less value. By sighting the scapulae and back of the thorax on the buttocks it is easily seen whether any twist of the thorax has occurred in relation to the pelvis. Evidence of ro- tation of the ribs or lumbar transverse processes backward on the convex side of the lateral curve, which accompanies structural cases, will in severe cases be evident in the stand- ing position, but it is generally examined for and estimated in a position of forward flexion of the trunk, sometimes spoken of as Adam's position. The patient bends forward until the trunk is horizontal with the arms hanging down and the knees not flexed. In this position the patient remains while the sur- geon glances along the back from behind or in front, with his head on a level with the spine, and looks to see whether either side of the trunk is more prominent upward in the lumbar, dorsal, or cervical region. Any such upward prominence represents rotation or twist Fig. 60. — The Plumb-line in the Cleft of the Buttocks to Determine the Me- dian Plane of the Body. 76 EXAMINATION AND RECORD OF SCOLIOSIS and is a most important matter. If it occurs on the concave side of the lateral curve and involves the curved region, it will be slight and evenly distributed through the spine and designates a functional or postural curve. That is, in a left total postural curve the right side of the back will probably be more prominent upward in the forward bent position. If it occurs as a well-defined local upward prominence occupying the curved region, it designates a structural curve at that location, the curve being convex to the side on which the prominence occurs and occupying the same anatomical area. That is, a right dorso- lumbar upward prominence designates a right dorsolumbar struc- tural curve. This must be clearly understood, for at times a curve which is obscure or confusing in the upright position is cleared up by a recognition of its rotation as seen in the forward bending position. Estimation of Spinal Flexibility. — The patient should now lie on the face and the position of the spinous processes be noted. The marks on the skin will represent the curve of the spine in the erect position, and any straightening of the spine in recumbency will be shown by finding that the spinous processes form a less curved line than that marked on the skin. In postural curves the spine will be- come straight in recumbency, while structural curves will be per- ceptibly straighter than when the patient is erect. The patient should now be suspended by a Sayre head sling, enough to take the weight off of the spine, and the straightening of the spine noted. This modification of the asymmetry of the trunk by suspension is important and should be carefully studied as to whether the asym- metry is practically unchanged, whether the overhang of the thorax is corrected, and whether the patient becomes wholly symmetrical. The position of the patient in suspension represents the maximum that may be expected from treatment in that individual case until further flexibility is restored by treatment directed to that end. The restoration of complete or almost complete symmetry by sus- pension points to an early case and one amenable to treatment, for one of the early changes in structural curves is a stiffening of the curved region of the spine which causes the persistence of the curve under suspension. So far as possible it should be noted whether the improvement in symmetry is produced by a straightening of the curve or curves or whether the modification in asymmetry is pro- duced by the other parts of the spine. For example, in a dorsal curve is the relation of the curved region changed or is the curved X-RAY 77 part simply pulled away from the pelvis by a stretching out of the lumbar region? The patient should then bend forward to determine normal flexi- bility forward. The average child can touch the floor with the fin- gers while the knees are straight, while in adult life less flexibility is obtained. The flexibility of an individual spine is a matter determined by age, habit, and individual peculiarity. To know in a general way what the normal flexibility at a given age should be, is important in children, but in adults it is so much a matter of individual habit that it is of less importance. One man of fifty, for example, who has taken exercise may be able to touch the floor with his hands in for- ward bending, while another man of the same age of sedentary life cannot get his finger-tips within a foot of the floor in the same posi- tion, yet both spines are to be classed as normal. How rapid the change in flexibility may be owing to exercise is shown by the case of a healthy boy of fifteen wS- — Boston School Desk and Chair —{Boston Schoolhouse Commission.) t of slanted handwriting for much of the bad attitude and the teaching of vertical writing was substituted, the patient sitting squarely in front of the desk and writing vertically, with a view of avoiding the distorted position incidental to slanted handwriting. Statistics have been reported in favor of the vertical system. These are: Percentage of Scoliotics In Slanted Writing In Vertical Writing Nuremburg 24 15 Zurich 32 12 Munich 24 15 Fiirth 65 31 Wurzburg 28 8 The question is by no means settled, Gould, of Philadelphia, having called attention to certain factors previously overlooked. 120 SCHOOL LIFE AND SCOLIOSIS " With 1 the head and body erect, the paper straight before the me- dian line of the body, and the penholder held as commanded, no per- son can or will write, for the simple reason that the writing and the writing field about the pen-point are hidden by the writing hand and the penholder. Immediately the pupil skews the paper, tilts the head to the left, and grasps the holder differently — all in order to bring the writing field and letters being made into clear view, and especially of the right or dominant eye. Fig. 86. — The Hand in the Writing Posture as Usually Ordered, but not Prac- tised, Because to the Writer the Writing Field is Hidden by the Thumb, Finger, and Holder. — -(Gould.) A view of the hand, as seen by the writer, with the head displaced in photographing. " The slanted handwriting is due merely to the fact that less torsion or rotation of the head to the right is rendered necessary, and a slight easing is secured by slanting the letters to the right. It may be assumed as reasonable (i) that bad air, fatigue and school life under poor general conditions, (2) improper school furni- ture, and (3) twisted writing positions favor bad attitude, and that the more constantly they are in operation the more effective will be their result in producing bad attitude. In the same way unfavorable 1 G. M. Gould: "American Medicine," ix, 14, 562, 1905. INCREASES DURING SCHOOL 121 home conditions in the way of bad food, overwork, and unsanitary surroundings depreciate muscular strength and favor bad attitudes. It is therefore likely on general principles that unfavorable school conditions are a competent cause of faulty attitude (false scoliosis) and of slight grades of true scoliosis, but that they are the cause of moderate and severe scoliosis is not, in the writer's opinion, likely. The reasons for this view have been expressed at the beginning of the chapter on Occurrence. This view is in accord with that of the best modern authorities, 1 but not in accord with former views. 2 It is therefore necessary to investigate existing data with regard to the occurrence of scoliosis in school life to see what evidence is to be found in them. There are practically no figures dealing with the question in America and it must be remembered that figures from foreign sources, although probably applying to our conditions, cannot be unreserv- edly accepted. It has already been shown that there may be a great variation in the percentage of scoliosis in the school children of two neighboring cities and between children of different schools in the same city (see Occurrence, page 113). Increase of Scoliosis during School Life. — When careful statistics are taken among school children they show most often, but not uni- formly, a larger proportion of children affected with scoliosis in the later than in the earlier years of school. Haglund's studies 3 were especially careful and show an increase with school age as follows: Year 6 7 8 9 10 11 12 13 14 15 1599 cases. Per cent, scoliosis. 11 13 18 16 18 24 22 22 .. 283 scolioses. Gronberg, from a careful study of 8350 school children in Finland, concluded that "the frequency of scoliosis increases as age increases and as the classes become higher. Constancy of progression is not, however, always to be found." His tables were as follows: Year, 11 12 13 14 15 Grammar schools. . . 12.2 15-6 12.5 n-3 16. 1 Higher schools / 9-4 \ 26.1 7-3 32.7 8.8 26.9 9.9 44-4 12.4 40.3 Boys. 1 ''Verhdlungen d. Deutsch. Ges. f. orth Chir.," 1910, pages 443-514. Schult- hess, Schanz, Mayer, Spitzy, Bohm, Muskat, Lubinus and others. 2 Smith: "Lat. Curv. of the Spine and Flat-foot," New York, 191 1, page 28. 3 "Zeitsch. f. orth. Chir.," xxvi, 649. 122 SCHOOL LIFE AND SCOLIOSIS Year, ii 12 13 14 IS 16 Grammar schools. . 21.2 18. 1 19. 1 23-3 26.5 21 .9 Higher schools f 16.9 ' I 48.1 18.9 49.0 21-5 49.6 20.9 59-8 22.3 63.2 24.7 56.8 Girls. The figures as to the increase of scoliosis during school life from 2314 cases examined at Lausanne are as follows: 1 Age Boys Girls 8 years 7.8 per cent. 9 . 7 per cent. 9 " 16.7 " 20. 1 10 " 18.3 " 21.8 11 " 24.2 " 30.8 12 " 27. 1 " 30. 2 13 " 26.3 " 37.7 On the other hand, certain observers have found the contrary. Spitzy 2 for ten years has examined about too girls from eight to six- teen years old each year in a large private school for girls in Graz and finds a constant percentage each year of about 20 per cent, of marked defects of position, and this percentage is not greater in children who have previously been to school than in those educated at home. Hippius 3 has demonstrated that severe scoliosis is frequent in children who have never been to school. Kirsch 4 in 1000 school children from the lower classes and 1000 from the more advanced classes investigated since 1906 found that "the greatest number of all fixed scolioses, which we find in school, are rachitic scolioses from early childhood." In 3234 girls, Silfwerskiold found percentages as follows: First class, 10. o per cent. Second class, 12. 1 " Third class, 12.5 " Fourth class, 17.0 " Fifth class, 9.9 " Forms of Scoliosis in School Children. — "So far as the forms of scoliosis which are most frequent in children, they are in a certain way peculiar and vary from the forms most frequently coming to specialists for treatment." 5 Of these curves only 24 per cent, were compound in Gronberg's series and the remainder were simple, 41.9 per cent, being left total 1 Combe, Scholder and Weith: "Jahrb. der Schu. Gesel. f. Schulgesundheits pflege," ii, Jahrg., 1901, i, Teil, 38. 2 ''Verhdl. d. Deutsch. Ges. f. orth. Chir.," 1910, page 462. 3 "Der kinderarzt als Erzieher," Berk, Munchen. 4 "Verhdl. d. Deutsch. Ges. f. orth. Chir.," 19 10, 94. 5 Gronberg: "Zeitsch f. orth. Chir.," xviii. 156. CONCLUSION 123 curves. In the Lausanne series 48.1 per cent, were left total curves and only 8 per cent, of the whole were compound scoliosis. The conclusion from which, is that apparently if one takes into account all grades of scoliosis, functional and structural (false and true), there is a tendency to increase during school years, but there apparently is no good evidence that moderate and severe structural scolioses increase during school life or are directly caused by it. CHAPTER XI DIAGNOSIS Scoliosis is an affection in most cases appearing before the tenth year; it is not a disease of the spine, but the result of mechanical forces acting upon a spine which in other than slight cases must be assumed for some reason to be abnormally formed or to possess less than normal resistance. It is not, as a rule, accompanied by any degree of pain. Stiffness, if it is present, is an accompaniment of late cases and the result of long-continued structural changes. In the diagnosis of scoliosis the first question that arises is whether or not scoliosis is present. A plumb-line is held in the line separat- ing the buttocks, and if all the spinous processes lie under that line scoliosis is not present. If any number of spinous processes do not lie under the plumb-line scoliosis is present. If scoliosis is present the question is, is it functional or structural, and what is the curve? The diagnostic signs of functional and struc- tural curves have been described (pages 55, 61, and by aid of these the curve is classed as one or the other or as transitional (page 57). The ends of the spine are connected by a string and the parts lying to the right are called right curves and those to the left are called left curves. If the curve is Junctional, it is desirable if possible to identify its cause in a short leg, unequal vision, etc. If the curve is structural it is important, if possible, to assign it to its proper etiological division. Scoliosis of Congenital Origin. — Such curves occur early, are gen- erally severe, and are best identified by the x-ray. When accom- panied by gross defects in the thorax or elsewhere they are easily recognized. Rachitic Scoliosis. — This form occurs early, is generally severe and characterized by a sharp curve, and most often found in the lower half of the spine. To establish the diagnosis, other signs of rickets should be found. These are the high square head, the rosary, curved bones, enlarged epiphyses and usually somewhat retarded general growth. A history of a late first dentition suggests the 124 DIAGNOSIS 125 existence of rickets. Osteomalacia is uncommon and characterized by severe general curvature of the bones. Infantile Paralysis. — This is a motor paralysis beginning with a feverish attack, generally in summer, followed by loss of power in one or more limbs. The affected limbs are in the severer cases cold and wasted and reflexes are lost. In the severer cases of scoliosis of this type the deformity becomes extreme. There are occasional cases of infantile paralysis where the attack is slight and the loss of motion is apparently recovered from, but where a lateral curve of more or less severity develops later as a result of the paralysis of some spinal mus- cles. The investigation into the history in doubtful cases becomes of much importance and the back should be examined in every case of infantile paralysis in any part of the body. Empyema and pleurisy are recognized as the causes of a severe form of scoliosis, especially when a resection of the rib has been per- formed in empyema. The curve is always convex toward the unaf- fected side of the chest and is dorsal or dorsolumbar. It is identified by the scar on the chest or the auscultation signs in the thorax and the history of the case. Any other scar of sufficient size is competent to produce the same result. Other evident causes of structural scoliosis are sufficiently indi- cated in the table given in the chapter on Etiology. Finally, in many cases no evident cause can be found and one is obliged to assume that the bones of the individual possess less than normal resistance to weight bearing. Pathological Conditions Accompanied by Lateral Curvature as a Symptom. — Cases of lateral curvature accompanied by pain, espe- cially if this is exaggerated by motion, should not be given exercises, but kept under careful observation until a perfectly definite diagnosis has been made. The same applies to slight curves accompanied by stiffness of the spine. Doubtful cases may often be cleared up by the use of the x-ray. These painful conditions accompanied by scoliosis must be care- fully separated from true scoliosis. The chief one of these is Potfs disease, or tuberculosis of the spine. The symptoms of this affection are stiffness of gait and loss of mobility in the spine, pain on motion or jar, and spontaneous pain in the chest and abdomen, elevation of temperature, and impairment of the general condition. As the disease progresses, a sharp prominence backward of the spinous proc- esses occurs at some part of the spine. Lateral deviation of the spine occurs in the acute stage of practically all cases, but it is a 126 DIAGNOSIS leaning of the body to one side rather than a true gradual curve; there is no rotation of note, and the lateral deviation is an index of the severity of the disease, disappearing after a period of recumbency in bed and being controlled by efficient treatment. The danger of mistaking Pott's disease for scoliosis lies in the early cases before the knuckle, or backward deformity, has occurred. A form of lateral deviation accompanies arthritis deformans of the spine, which is also known under the names of osteoarthritis of the spine, spondylitis deformans, ankylosis of the spine, spondylose rhizomelique, Bechterew's disease, Steifigkeit der Wirbelsaule, etc. This is essentially an affection of adult life, but not unknown in children. The spine is stiff and painful, the lumbar convexity is diminished or lost, and the carve a gradual one with slight or no rotation. The lateral curves accompanying tumors of the spine, dislocation of the vertebrae, etc., would hardly be mistaken for real scoliosis, the usual signs of those affections being present. CHAPTER XII PROGNOSIS WITHOUT TREATMENT Total curves may remain as such through life, probably increasing somewhat; they may change to structural curves; or they may be cured by proper treatment, but they are not likely to disappear spontaneously. So long as they remain purely functional curves, as defined above, they will probably not influence the general health unfavorably or produce any unpleasant result further than slight asymmetry. In neurasthenic women they are frequently accom- panied by backache. Structural curves, whether simple or compound, in young children should be regarded as serious, as almost sure to increase, and perhaps to increase rapidly. They will surely lead to some deformity, and perhaps to grave deformity. They are likely to affect the general health and to shorten life by inducing phthisis and ill health. Adults with severe scoliosis are, as a rule, less vigorous than normal. Slight or moderate structural curves in older children and adoles- cents which have not progressed rapidly through childhood are after puberty likely to increase but slowly, if at all, until late middle life, when the atrophy of the intervertebral discs is likely to make them more evident and troublesome. Severe structural scoliosis at any period of life is to be regarded as likely to shorten the patient's life and to induce ill health. The rapid increase of a postural or struc- tural curve is a threatening symptom demanding attention. WITH TREATMENT Total scoliosis should be entirely and permanently cured by adequate treatment. Structural scoliosis in young children when of moderate degree should be practically cured by adequate and long-continued treatment but only by that. If severe, it should be much improved by the same means, the prognosis in both classes being better in children with a long period of growth ahead than in adolescents. 127 128 PROGNOSIS Structural curves in older children and adolescents when of moder- ate degree should be greatly improved by adequate and long-continued treatment, but as a rule cannot be wholly cured. Severe structural scoliosis under these conditions can be markedly improved. When growth has been reached, only improvement and not com- plete cure is to be hoped for from treatment in true scoliosis of any but the mildest grade. In adults with severe scoliosis the general condition of the patient may be greatly improved by an improved position of the spine. In late adult life support of the spine in the best obtainable position is the only outlook from treatment, again often attended by improvement of the general health. Scoliosis due to severe congenital defects of the vertebrae, scapulae, or thorax, to infantile paralysis, or to empyema cannot be cured if a curve of moderate or severe grade has occurred, but can be improved. Rickets contributes a class of cases on the whole resistant to treat- ment, and in severe cases, even in young children, a complete cure is probably not obtainable. The existence of organic heart disease or phthisis makes the prospect of obtaining much improvement from treatment unfavorable. CHAPTER XIII TREATMENT The treatment of scoliosis can be most clearly considered if one separates for purposes of discussion the two types of cases already de- scribed (pages 55-61) — (1) the postural or functional, and (2) the organic or structural. That such a distinction is not always sharply to be made, that transition cases are to be seen, and that many therapeutic measures are common to both classes of cases, applies here as in most other departments of medicine and surgery where functional and organic conditions are separated. To call both of these varieties by one name, scoliosis, leads to confusion and contradiction, to widely differing statements as to etiology, and to marked divergence of views with regard to treat- ment and its results. If we grouped together all sprains and joint fractures under the term of "fractures" without regard to the presence or absence of bone injury, our classification and our treat- ment of these injuries would become confused, contradictory, and unsatisfactory. It is clearer to designate as "false" scoliosis the postural variety, and as "true" scoliosis the structural variety, so that in the con- sideration of etiology and treatment we may not be grouping under one name two conditions essentially different. True scoliosis constitutes our real problem, of course, but in order to make that part of the subject perfectly clear, we must first dis- cuss and remove from our field the less important question of false scoliosis. THE TREATMENT OF POSTURAL SCOLIOSIS (FUNC- TIONAL SCOLIOSIS, FALSE SCOLIOSIS) Regarding the condition as an habitual inability to stand correctly, as a postural malposition without marked structural change, it is evident that the treatment should consist in the substitution of a correct attitude for the faulty one. This is obviously to be preceded by eliminating conditions unfavorable to the maintenance of a correct 9 129 130 TREATMENT upright position. The conditions requiring investigation and pos- sible correction in every case as a preliminary to beginning treat- ment are — (1) seats and desks at school; (2) the manner of clothing the child; (3) the condition of the eyes and ears; (4) the existence of a short leg; (5) overwork or too long hours, leading to persistent fatigue; (6) excessive recent growth with consequent impairment of resistance. These matters are also of importance in structural lateral curvature. Having placed the patient under the most favorable conditions obtainable and having corrected so far as possible the defects above mentioned, the patient should work on the exercises to be described for from half an hour to two hours a day for a period of some weeks, which exercises should not be pushed beyond the limit of fatigue. After a period of vigorous daily work under the direct supervision of the surgeon, which should generally be continued for two or three weeks, home work under the direction of the parents may be sub- stituted for it, with occasional supervision by the surgeon at longer and longer intervals. But it is desirable that such patients should be under observation for at least a year. The length of treatment, the period of the exercises, and the extent to which they can be pushed will depend on the vigor of the child, as half-way measures are not likely to be successful and exercises done at home under the supervision of careless parents are less effi- cient than those given by persons trained in the art of gymnastics. The treatment lies within the range of any good teacher of gymnastics who will carry out the instructions of the surgeon. The causes of failure are to be found in the fact that such children are generally in poor muscular condition and are often overworked at school or under unfavorable conditions at home, or that the exercises are given too seldom and are not sufficiently vigorous. If flexibility to one side is limited, i.e., if the child can bend further to the right than to the left in a left total curve, the flexibility of the spine must be made equal, preferably by means of passive lateral stretch- ing in the apparatus, described on page 156, or by means of gymnas- tic exercises. Having restored the flexibility of the spine by this means or if flexibility to the two sides is alike, a treatment differing but little from the " setting-up drill" of the army recruit is to be instituted. Exercises suitable for the treatment of postural cases will be described in connection with the gymnastic treatment of structural scoliosis. TREATMENT 131 TREATMENT OF STRUCTURAL SCOLIOSIS (ORGANIC SCOLIOSIS, HABITUAL SCOLIOSIS, FIXED SCOLIOSIS, TRUE SCOLIOSIS) The problem to be met in the treatment of lateral curvature with fixed bony changes is a perfectly definite one. A clear understanding of the obstacles to be met and of the means at our disposal for meet- ing them is essential to successful treatment. The spinal column having curved to one side has, in the course of time, become fixed in the deformed position. In addition to the side curve, a rotation or twist in the length of the column has occurred at the seat of the main and compensatory lateral curves, particularly evident in the thorax. As the result of the maintenance of the vicious position over a long time, covering part of the period of growth, changes in bones, muscles, ligaments, and intervertebral discs have occurred. The individual vertebrae have become com- pressed on one side and twisted by the rotation. The ligaments and muscles have become adaptively shortened on one side and stretched on the other, and the intervertebral discs to a greater or less extent have become compressed on the con-cave side of the curve. The region of the vertebral column involved by the curve has lost its normal mobility and is partly or wholly stiff. There are secondary changes in the thorax and abdomen and in the contained organs. It is obvious that in the upright position gravity works to increase the deformity by exerting pressure upon the concavity of the curves already atrophied by an abnormal weight bearing. Of the twenty- four hours in each day only some ten or twelve at most are spent in recumbency. During the remaining twelve or fourteen hours the vertical position is assumed and gravity is at work. The treatment of structural lateral curvature presents, therefore, a much more serious and much less encouraging problem than the treatment of postural cases, and measures must be vigorous, ade quate and surgically sound to produce a permanently satisfactory result. The causes of failure of efficient treatment lie in the unwillingness of the parents or the patient to submit to sufficiently long-continued and effective treatment to remedy a condition which, on the slightest consideration, can be seen to be one which is necessarily difficult and resistant. It is evident, where the pathological changes have reached a moderate degree, that considerable and continuous force would on 132 TREATMENT general principles be necessary to force the column into a position approximately normal and also that on the forcing into and holding in such a position depends our sole hope of any considerable degree of favorable progress, progress necessarily due to the adaptive nature of growing bone — and to the fact that in its growth it will follow the lines of least resistance. The practical question is: how far may we depend on gymnastic treatment alone to accomplish this? Because gymnastic treatment is the traditional one for scoliosis, and is being pursued in this country to-day in the great bulk of all cases which are treated at all. GYMNASTICS Gymnastics have a two-fold object — first, to loosen up the curved portion of the spine to make an improved position possible, and, sec- ond, to aid in retaining the improved position by strengthening certain groups of muscles. Most exercises tend in a measure to accomplish both of these, so that a sharp division into mobilizing and. retentive exercises is not possible, and one can only point out that a certain exercise is especially valuable for one or the other purpose. It is essential to define and limit what place gymnastics should occupy in the treatment of structural scoliosis. It is obviously un- reasonable to expect free standing gymnastic exercises alone to straighten marked or severe curves or to change the shape of dis- torted bones. But after the greatest possible improvement has been secured in such curves by more efficient measures one must look to gymnastics to develop the muscles which will hold the improved position and make the gain permanent after the corrective jacket has been gradually discontinued. In marked and severe structural scoliosis, therefore, gymnastic treatment finds its use as supplemen- tary to forcible correction. The purely gymnastic treatment of severe structural scoliosis is to-day being largely pursued by two classes of persons. First, by irresponsible masseurs and medical gymnasts who hold as a tradition that gymnastic exercises are curative or at least helpful in scoliosis, and second, by surgeons who do not believe in corsets or supports. 1 The former class serves only to bring the legitimate use of gymnastics for scoliosis into disrepute; the latter class use the gymnastics more or less effectively, and take a pessimistic view of the results to be iTeschner: "N. Y. Med. Rec," Dec. 6, 1903; Erich: "N. Y. Med. Jour.," Oct. 7, 1899. GYMNASTICS 133 obtained in severe scoliosis. Structural scoliosis is a bone problem; a glance at the deformed column indicates that, but it has been too largely considered and treated as a muscle problem. Until recently the treatment has been an indirect, intermittent, and long-continued effort to remedy a bony deformity by muscular meang. A surgeon would be thought very much behind the times who to-day endeav- ored to correct bony knock-knee or congenital club-foot by muscular exercise, yet many an up-to-date surgeon does not hesitate to advo- cate gymnastic exercise as the sole treatment of a bony deformity equally severe. The excuse for Fig. 87. — Patient with Left Dor- sal Curve in 1900. Fig. 88. — Same Patient in 1905 after Five Years of Gymnastic Treatment. the use of gymnastic treatment under these conditions would be the fact that the results obtained by it were so very satisfactory that the practical outcome justified us in disregarding sound theory. But proof is wanting that this is the case. Gymnastic treatment in apparatus is, however, advocated as the sole treatment for all cases by such an eminent authority as Schul- thess, 1 and treatment by gymnastics and braces by an authority of 1 JoachimthaFs Handbuch d. orth. Chir., Bd. iii, iv und v, page 1035. 134 TREATMENT such great weight as Lange, 1 but neither of these men has published, nor apparently has claimed, such results as claimed and published by Wullstein, 2 Schanz, 3 Sever, 4 Abbott, 5 Lovett 6 and others. Nor can the author find the publication elsewhere of results from gym- nastic treatm«ut which are convincing as to the efficiency of the treatment in moderate and severe cases. Still, one must not pass too lightly over the opinions of such weighty authorities as Schulthess and Lange, and must allow due weight to them. If one makes no distinction between false and true scoliosis, and classes every lateral deviation of the spine as scoliosis, if he thus groups false and true scoliosis together and treats all cases by effect- ive gymnastics, the proportion of successful results will be large because of the predominance of the milder cases in almost any group. But if one uses the gymnastic treatment in a group composed wholly of moderate and severe cases of structural scoliosis, the results will be widely different from those of the first group. In this failure to separate the two varieties much of the contradictory evidence with regard to the results of treatment has arisen. Many well informed surgeons are deterred from the use of corrective jackets by the fear of inducing muscular atrophy of the back. But muscular atrophy of the back is quickly recovered from and the deformity is a grave one demanding measures which strike at the salient feature — the bony deformity. The history of the treatment of moderate and severe structural scoliosis as a muscle problem is a history largely of failure or of extravagant and unwarranted claims. Not only may gymnastics in moderate and severe structural scoliosis fail to do good, but they frequently do serious harm for the following reason : scoliosis of this grade soon results in a stiffening of the affected region of the spine. If efficient gymnastics are given, the spine is speedily rendered more flexible and if it is so rendered and not supported at once, it will sink into a worse position than before and the curve will be increased. The assumption made by the advo- cates of gymnastics is that the back muscles will be so developed by the exercises that they will immediately hold the spine in an im- proved position, but this does not happen,. and the flexibility in- 1 Lange and Spitzy: "Handbuch f. Khde., Leipzig," 1910, Bd. v, page 140. 2 Wullstein: "Zeitsch. f. orth. Chir.," 1902, Bd. x, Teil ii. 3 Schanz: "Zeitsch. f. orth. Chir.," 1908, Bd. xxii, page 57. 4 Sever: "Surgery, Gynecology and Obstetrics," September, 191 2. 5 Abbott: "New York Med. Jour.," June 24, 1911, and April 27, 1912, 6 Lovett: "Boston Med. and Surg. Jour.," October 31, 1901, March 17, 1904; "Jour. A. M. A.," June 23, 1906; Lovett and Sever: "Jour. A. M. A.," September 2, 1911. GYMNASTICS 135 creases much faster than does the holding power of the muscles. Much harm would be avoided in the gymnastic treatment of these cases if this practical fact were recognized. 1 Place of Pure Gymnastic Treatment. — In mild structural scoliosis efficient gymnastics should constitute the sole treatment, and may be continued as the sole treatment so long as the improvement from one exercise period persists until the next one. If such improvement is not held between exercises it must be assumed — (1) that the \ Mm SMmmgmm ^W^ m J <^LV? ■0 ' ;,. ''^^Bf \ ^BST 1 \ ? r-f ' W M m W L " ' MM mm BH| t t 3^1 Ik Fig. 89. — Trunk Bending Ap- paratus. — (Schulthess.) Fig. 90. — Shoulder Pushing Apparatus. — {Schulthess.) exercises are not good ones; (2) that they are not properly carried out; (3) that the amount of treatment is insufficient, or (4) that the case is too severe for purely gymnastic treatment. Progressive improvement must be assumed as the criterion of efficient gymnastic treatment. It is impossible to draw a general line either theoretically, or in practice at the outset between cases of structural scoliosis which are likely to be cured by gymnastics alone and those which are not. ^hlumsky: "Verhdlg. d. Deutsch. Ges. f. orth. Chir.," 1908, 317. 136 TREATMENT The line comes somewhere between the mild and the moderate cases and doubtful cases should be tried on the purely gymnastic treat- ment and kept on it only so long as they progressively improve. In other words mild cases are generally suitable for gymnastic treat- ment. Cases of moderate grade with slight rotation and not much lateral curve are also to be started on gymnastic treatment for trial, cases of moderate grade with marked rotation and curve are not suitable for gymnastic treatment alone and all cases of severe scoliosis are unsuited to gymnastic treatment. Fig. 91'. — Hip-pendulum and Shoulder- raising Apparatus. — (Schulihess.) Scheme of Treatment. — (1) Gymnastics may be given alone as a treatment, or (2) in cases where the patient becomes rapidly flexible or seems to require support between exercises, such treatment may be supplemented by the use of supporting jackets, braces or corsets. (3) In connection with gymnastic treatment intermittent passive stretching may be useful in restoring flexibility or (4) both corsets and stretching may find their use in connection with gymnastics. (5) Finally forcible correction should constitute the treatment of most moderate and all severe cases. GYMNASTICS IN APPARATUS 137 The use of braces and corsets alone cannot be considered a treat- ment for scoliosis. To make this matter plain the following scheme presents the above statements in the form of a table: W Gymnastics alone { $ JSffi^aratus. (2) Gymnastics and corsets. (3) Gymnastics and stretching. (4) Gymnastics and corsets and stretching. (5) Forcible correction. i (a). Gymnastics Given in Apparatus. — By means of apparatus gymnastic exercises can be very much more correctly localized, and the work of loosening the spine and of strengthening the desired muscles can go hand in hand. This method, which is in general use in Europe, has never found a foothold in this country on account of the complicated and expensive apparatus. The system of apparatus devised by Schulthess and its modifica- tions, the apparatus of Zander, and the simpler apparatus of Lange, are the best examples of the kind. The precision of the apparatus, its adaptation to anatomical needs, and the principle of securing correction and the development of desired muscles at the same time make the system sound and efficient. i(b). Gymnastic Exercises Given Without Apparatus. — This method of treatment is the one in most general use in America. It is open to the objection that the force exerted is not sufficiently localized, but is distributed over the spine. Fixation of Pelvis. — It is essential that the pelvis should be fixed during such exercises, as otherwise the pelvis is displaced and the movement becomes a general and not a local one. A simple wooden apparatus may be constructed which holds the pelvis and does away with the necessity of holding the hips of the patient between the knees, which must otherwise be done. This saves labor on the part of the person giving the exercises, and permits a closer supervision of the back than is possible w r hen part of the attention must be fixed on holding the patient firmly. The apparatus, which was suggested by that of Bade, 1 consists of a wooden clamp made by two flat boards set at right angles to a hori- zontal board on which they slide to hold the sides of a pelvis of any width. The whole apparatus moves up and down on an upright fastened to a large round floor platform and may be inclined at any angle to the horizontal plane. The patient is secured in place by sliding in and fastening the lateral clamps at the sides of the pelvis, 1 "Zeitsch. f. orth. Chir.," xii, 4, 799. i38 TREATMENT and by securing the front of the pelvis by a broad leather strap pass- ing from one arm to the other. The floor platform is so large that the apparatus cannot upset (Fig. 94). General Routine and Precautions.- — It is desirable that the back should be exposed during the exercises in order to note the effect of Fig. 92.— Composite Photograph (Two Exposures on the Same Plate) Show- ing the Model Standing Erect and Bending to the Right without Fixa- tion of the Pelvis. The Movement is a General One. Fig. 93. — Composite Photograph of the Model Standing Erect and Bend- ing to the Right with the Pelvis Fixed. The Movement is Limited to the Spine. each one. For this purpose the patient should wear during exercises a loose cotton dressing jacket, fastened around the neck and opening in the back. This protects the front of the body but permits inspec- tion of the spine. Such exercises should be simple and corrective in the strict sense; that is to say, an exercise which is of use should be seen to straighten GENERAL POSTURE AND PRECAUTIONS 139 the spine visibly. Complicated exercises are dangerous and unsur- gical. Work to yield results must be given by a competent gymnast for a period of from one to three hours a day, according to the vigor of the patient, and must be continued under personal supervision for a period of some weeks or months to obtain satisfactory results. Af ter this, exercises at home can be substituted for part of the per- sonal work. As a preliminary to gymnastic work the heart of the patient should have been, of course, examined. Afterward the weight should be taken each week as persistent loss of weight is an indication for Fig. 94. — Apparatus for Fixing the Pelvis During Gymnastic Exercises. moderating or discontinuing temporarily the exercises, providing that the patient is not being overworked at school, in which case the school conditions should first be remedied. During menstruation, gymnastic exercises should be suspended. Persistent fatigue, anemia, loss of appetite, nervousness, and frequent or profuse menstruation should cause a careful investigation of the patient's environment, as they may arise from that or from excess of gymnastic work. The following list of gymnastic exercises, selected from a large number, may be regarded as representative of the kind of gymnastics likely to be of use within the limits mentioned above. They will first 140 TREATMENT be described individually and then analyzed, and their application to different conditions will be indicated. The selection of exercises must depend on the requirements of each case. Simple develop- mental exercises have not been included here, as a description of them can be found in books on gymnastics. In the explanations to be given in connection with each exercise the general mechanical features will be discussed, but it must be remembered that conditions observed in the normal do not neces- sarily hold true in the deformed spine of scoliosis, although they form the best basis for analysis. The more nearly a spine approaches the normal, the more likely is such analysis to be correct. SYMMETRICAL EXERCISES Exercises in the Standing Position In all exercises given in this position the pelvis should be fixed unless otherwise stated. It must be remembered that exercises in this position call into play in varying relations all muscles concerned in maintaining the upright position, and therefore cannot be as highly specialized as can exercises given in the lying posi- tion. It must also be remembered that the superincumbent weight rests on the laterally curved spine, and that the curves are therefore not in as favorable a condition in such exercises as in the lying position. On the other hand, they are useful because any improvement of scoliosis must be interpreted as meaning improvement in the upright position, and all muscles concerned in that are therefore of importance. Fundamental Standing Position. — The patient stands with the knees extended, the hands on the hips, the back straight, the head erect, and the scapulae brought close to each other. The patient should not exaggerate the lumbar curve, and should press down w r ith both hands on the hips. I. Trunk Stretching. — (i) From the fundamental standing position the patient stretches the whole spine upward. The surgeon holds his hand slightly above the patient's head and urges her to stretch until she can touch his hand with her head, keeping both heels on the ground. The position of the hand is made higher as necessary. (2) From the upward stretched position the patient relaxes to the fundamental standing position. In count (1) the patient breathes in and in count (2) breathes out (Fig. 95). This is a general exercise calling upon the muscles which maintain the proper erect position, notably the spinal extensors. The elevation of the shoulders elevates and fixes the shoulder-girdle, giving a fixed point for the pull of the in- spiratory muscles, thus tending to increase chest capacity, and a general stretch- ing of the spine is also made easier by the fixed shoulder-girdle. The exercise is applicable to any case of scoliosis, especially to postural curves, as a general mobilizing and corrective one. II. Trunk Bending Forward with Trunk Stretched. — (1) The shoulders are raised as in Exercise I (1). (2) The patient bends her trunk forward to the hori- zontal position, the spine being held straight and the shoulders raised, movement occurring only in the hip-joints. (3) The patient raises the trunk to the upright SYMMETRICAL EXERCISES 141 position with the shoulders still raised and the spine straight. (4) The patient relaxes to the fundamental standing position(Fig. 96). This combines the essentials of Exercise I with the weight of the trunk thrown on the extensor muscles of the back and on the glutei, which must be held con- tracted to maintain the forward bent position and which must contract to bring the trunk again into the upright position. It has the corrective effect of Exer- cise I, in addition to which it is a fairly strong extensor spinal exercise with the lumbar curve flattened. It is a general mobilizing and corrective exercise which may be safely used in cases with a tendency to exaggeration of the lumbar curve. The patient inspires in (1), holds the breath during (2) and (3), and breathes out in count (4). The above exercises may be modified and made slightly harder by having the patient place both hands behind the neck with the elbows square back as far as possible. This raises the center of gravity of the trunk and therefore in- creases the leverage against the muscles. Fig. 95. Fig. 97. III. Trunk Twisting. — Position: Without pelvic fixation, the feet parallel and touching, the hands on the neck, the head and spine erect. (1) From this position the patient twists her whole body as far as possible to the right or left, the head being turned as far as possible in the same direction. (2) The original standing position is resumed (Fig. 97). Trunk rotation to the right causes a left dorsal curve and vice versa; in addition to this the exercise is intended to be mobilizing to the whole body, especially the hip-joints, and greater trunk excursion is possible with the feet parallel than with the legs rotated outward. The exercise is suitable for general spinal mobili- zation, and when given only to one side is a mild corrective exercise for lateral deviation. The effect of rotation upon the spine, especially in causing a lateral curve, may be located higher in the spine by giving the rotation in the forward bent position, and located lower by giving it in the hyperextended position. Exercises Given in the Horizontal Position In this group of exercises one set of muscles may be more readily picked out for exercise than in the erect position. The spine when prone is less curved than 142 TREATMENT in the upright position, and is slacker and more easily capable of side displace- ment. The fact that symmetrical hyperextensions are so much used for their corrective effect is explained by their empirical value and by anatomical reasons (page 32). J Fig. 98. Lying on the Face. — IV. Trunk Raising. — Position: The patient lies face downward on a table with the spine straight, the hands on the hips, the scapulae approximated to each other, and the legs secured to the table by a strap passing around the table and legs just above the ankles, or the legs may be held by the hands of an assistant. (1) The patient inspires and raises the trunk from the table, hyperextending the spine as far as possible, keeping the head^back and the face up, with the elbows still held well back. (2) The patient breathes out and sinks to the original position (Fig. 98). A Fig. 99. This is an extension of the spine from its normal position to extreme hyper- extension in which the spinal motion occurs largely below the tenth dorsal vertebra, where hyperextension anatomically takes place. The weight of the trunk is raised by action of the back extensor muscles which are very generally called into play. It is a general strengthening exercise for these muscles, but in cases with marked increase of the lumbar curve it must not be used to increase this, in such cases Exercise II being available. The latter is probably a weaker exercise, because in it the extensor muscles do not contract to their fullest ex- SYMMETRICAL EXERCISES J 43 Fig. ioo. Fig. ioi. Fig. 102. 144 TREATMENT tent. The exercise may be made harder by placing the hands behind the neck and squaring the elbows back or by extending the arms beside the head, which raises the center of gravity (Fig. 99). The above may be modified in the following manner: The patient clasps his hands behind his back above the level of the waist-line, with elbows flexed and Fig. 103. Fig.. 104. hand closed against the back, and, as he hyperextends his trunk, stretches his arms backward forcibly, extending the elbows, and keeping the hands clasped. By this modification the scapulae and shoulder- joints are carried back and the hyper extension done with an improved position of the shoulders. This is par- ticularly suited to round shoulders. Fig. 105. This exercise may be made stronger by the use of dumb-bells or a staff as indi- cated in Figs. 100, 101, 102. Exercises Lying on the Face, the Trunk Projecting over the End of the Table.— The legs rest on the table, the surgeon making the ankles secure by means of a strap or by holding them. The body above the hip-joints hangs over the table end, head downward. The hands are placed behind the neck with the elbows squared back. >\MMETRICAL EXERCISES 145 V, Trunk Raising from Head Downward Position. — (1) The patient inspires, and raises the trunk as far as possible by hyperextending the hip-joints and the spine. (2) During the expiration she sinks to the primary position. The spine should be kept in the mid-plane and the head not allowed to flex (Fig. 103). i This is a spinal extension movement mostly without superincumbent weight, beginning at forward flexion and ending in marked hyperextension, calling the extensor muscles into activity from a stretched to a completely contracted condi- tion. It thus combines the range of motion in Exercise II with that of Exercise IV. It is a heavier exercise than either. From the start of the exercise till the horizontal position is reached the spinal extensors and glutei are the muscles chiefly active, as the maintenance of balance does not require the contraction of other trunk muscles. The exercise may be made easier by placing the hands on the hips. It is of use as a general strengthening exercise for the back muscles in any .case where the patient is strong enough to take it. Exercises Lying on the Back. — The patient lies on a table or on the floor with the head, trunk, and legs straight, and the feet secured either by a strap or by being held. The arms are folded on the chest. i ) \ \ * Fig. 106. ^J VI. Trunk Raising to Sitting Position. — (1) The patient rises slowly to the sitting'position with the spine stiff and not allowed to flex. (2) The patient sinks to the' primary position with the spine still stiff, the head touching the table before the back (Fig. 106). The exercise is made easier by placing the hands on the hips, and harder by placing the hands behind the neck with the elbows squared back. The upright position is brought about by the contraction of the abdominal muscles, which aid in maintaining the upright position, and require exercise in cases of prominent abdomen and of increase of the lumbar physiological curve accompanying scoliosis and round shoulders. Miscellaneous Symmetrical Exercises VII. Weight Carrying on the Head. — A bag filled loosely with sand, weighing from 3 to 15 pounds, is placed on the top of the patient's head, and she walks slowly to and fro with the arms preferably clasped behind the neck and the elbows squared back. The exercise may be made more difficult by having the patient walk on tiptoe. The attitude assumed should be as erect as possible and the weight as heavy as can be carried steadily. 146 TREATMENT It is a matter of common information that the habitual carrying of baskets and loads upon the head induces an erect carriage and a straight spine. The presence of weight upon the head necessitates holding the spine as straight as possible under the weight, as it is thus most economically carried, and this in- stinctive adjustment to superincumbent weight is depended on for its corrective effect. The exercise is suited to mild cases with noticeable bad carriage and poor balance. VIII. Mirror Self -corrective Exercise. — The patient, bared to the hips, faces a mirror in front of which hangs a plumb-line. The patient then stands in such a position that the plumb-line cuts the middle of the pelvis, and by a muscular effort brings the middle of the thorax and the vertical line of the face as nearly as possible under the plumb-line, bringing three important landmarks into the median line of the body, thus securing an improved position. This is held for a few seconds and then the relaxed position resumed. The exercise is repeated several times, the improved position being held longer each time. The exercise is a muscle training and is not in any way a mobilizing exercise, but enables the patient to associate a certain position with a certain muscular effort, and is of great value in enabling patients to identify by muscular sense the corrected position. The exercise requires but little effort and may be done at home without assistance. It may be modified in various ways by adding free-arm, staff, or dumb-bell exercises, which change the center of gravity, strengthen muscles approximating the scapulae, and prolong the corrected attitude. ASYMMETRICAL EXERCISES IX. Hip Sinking (Hoffa). — Position: From the fundamental standing position the patient advances the foot, on the side opposite to the convexity of the lateral curve, forward and outward about two foot-lengths. (1) The patient bends the forward knee, sinking the hip on that side. (2) The patient resumes the primary- position (Fig. 107). Fig. 107. Fig. 108. Fig. 109. A passive side correction of the lumbar curve, due to a lowering of the pelvis on the side of the advanced leg when the knee is bent. Suitable for lumbar curves. X. Self -correction (Lorenz). — The patient assumes the fundamental standing position and places the hand of the side to which the dorsal spine is convex upon SYMMK IR1CAL EXERCISES 147 the side of the thorax opposite to the greatest dorsal curve; the other hand is then placed on the ilium. (1) By a side thrust of the hand on the thorax the patient corrects the dorsal curve as much as possible, maintaining the correction tor a few seconds. (2) The patient relaxes to the primary position. The exercise may be modified by placing the hand on the side to which the dorsal spine is con- cave on the top of the head, as it thus tends to raise a low shoulder. The rest of the exercise is performed as described (Fig. 108). A side thrust of the dorsal spine with pressure applied to the convexity of the dorsal curve against resistance furnished by the other hand on the ilium or the head. Suitable for dorsal scoliosis, but not powerful, and useful as a means of stretching; chiefly good because it can be done by the patient unaided at frequent intervals. Exercises IX and X may be combined for a double curve with one element dorsal and the other lumbar. XI. Hip Sinking from Stool. — Position: The patient stands erect on a stool on one foot (the foot on the side of the convexity of the curve). (1) The patient lets the free leg sink as much as possible, thus lowering the pelvis and hip on that side. The knee of the supporting leg must be kept straight. (2) The patient resumes the original position (Fig. 109). A passive side stretching of the lumbar curve suitable for lumbar scoliosis* The leg and pelvis drag down on the side of the concavity of the lateral cuver, tending to stretch contracted structures and straighten the curve. XII. Trunk Hyper extension with Side Bending — Lying on the Face. — The patient lies face downward on a table or on the floor as described in Exercise VII. (1) The trunk is raised from the table as far as possible by hyperextending the spine. (2) From this position the trunk is bent to the side toward which the lumbar curve is convex. (3) Position 1 is resumed. (4) The prone lying position is resumed (Fig. no). This exercise is an active lateral flexion of the spine in the position of hyper- extension. As hyperextension locks the dorsal region against side flexion, the movement is almost wholly confined to the lumbar region. If there is a right dorsal curve in connection with a left lumbar curve, bending to the left, while it corrects the lumbar curve, does not at the same time greatly increase the dorsal curve, as that part of the spine is locked against side bending. The exercise is, therefore, suited not only to lumbar curves, but especially to compound curves in both dorsal and lumbar regions. XIII. Drawing tip the Hip — Lying on the Face. — Position: The patient lies prone on a table, holding the end with both hands, the arms extended and the spine and legs in a straight line. (1) The surgeon grasps the ankle on the side of the lumbar convexity and resists while the patient draws the hip up as far as she is able, knee the being kept straight. (2) Position 1 is resumed (Fig. in). 148 TREATMENT The approximation of the side of the pelvis and the thorax on the side to which the lumbar curve is convex is brought about by an active contraction of the muscles on the convex side of the lumbar curve which it is desirable to develop. The amount of work thrown on these is determined by the amount of traction made on the ankle. The exercise is suited to cases of lumbar curves or to the lumbar element of compound dorsal and lumbar curves.. Fig. 112. XIV. — Side Flexion of the Trunk from the Side-lying Position. — Position: The patient lies on a table with the concavity of the lateral curve downward and the trunk projecting over the edge of the table above the pelvis, the patient being supported in this position, and the ankles secured by means of a strap. The spine is held in medium extension, the upper hand on the hip and the lower hand on the back of the neck, (i) The trunk is bent laterally and upward as far as possible. (2) The original supported position is resumed (Fig. 112). Fig. 113. Fig. 114. In this exercise the weight of the trunk is thrown on the muscles of the convex side of the lateral curve. The raising of the trunk tends both to diminish a curve existing near the dorsolumbar junction and to exercise strongly the muscles which aid in its correction. It is suited to total, lower dorsal and dorsolumbar curves. \S\M METRICAL EXERCISES 149 X\". Trunk Holding to Both Sides with Hand Pressure (Mikulicz). — Position: In the case oi a light dorsal left lumbar curve the patient places the right hand on the prominence of the ribs just under the shoulder-blade, and the left above the ilium on the lumbar curvature. (1) She then bends the body slowly to the right side, while the right hand and thumb press against the dorsal prominence. : ' The upright position is resumed. (3) The patient bends to the left and backward, pressing with the left hand against the lumbar curve. (4) The up- right position is resumed (Fig. 113). This is a combined mild active and passive correction for a double curve. Opposing forces are applied to the convexities of the curves, thus tending to straighten the spine, which is at the same time bent by means of muscular action, first to the side of the convexity of the dorsal curve and then to the side of the convexity of the lumbar curve. XVI. Passive Head Side Bending. — Position: The patient stands with the hand on the side of the concavity of the lateral curve against the side of the head above the ear. (1) The head is pushed as far as possible to the side that corrects the curve. (2) The original position is resumed (Fig. 114). A passive correction of the cervical lateral curve by a side bend of the upper part of the cervical region which tends to diminish the curve. Of use in cervical and cervicodorsal curves, either alone or existing in combination with others. Fig. 115. Fig. 116. XVII. Trunk Raising with Asymmetrical Position of Staff— from Prone Lying Position. — Position: The one described for exercises with the patient lying on the face (Exercise VII) with a staff grasped in both hands, the arms being extended beside the head. (1) The trunk is raised from the table and the staff brought over behind the head obliquely, the hand on the side of the convexity of the curve being carried down toward the feet, and the other carried up over the head until the staff is brought as nearly as possible into the long axis of the body and pressed against the back. (2) By a reversal of the movement the original position is resumed (Fig. 115). The scapula on one side is raised, and the position of the staff tends to correct an existing curve in the dorsal region. The exercise amounts to a spinal hyper- extension in a corrected position of the dorsal spine. The exercise is suited to total curves, to simple dorsal curves, and to compound dorsal and lumbar curves. i^o TREATMENT XVIII. Partial Suspension by One Arm with Other Arm and Leg Locked. — Position: The patient standing by a ladder or under a bar that can be reached without rising on the toes, grasps one rung of the ladder or the bar with the hand of the side to which the spine is concave. On the opposite side, the convex, the arm passes under the knee, the thigh being flexed at the hip, and the shoulder and pelvis are thus approximated, (i) The patient thus standing on one leg flexes that knee and allows the body-weight to come upon the arm. (2) The original position is resumed (Fig. 116). When the arm is placed under the knee the pelvis and shoulder are approxi- mated on that side and the spine made convex to the other side as far as it will go. The structures on the concave side are thus put on the stretch and, by allowing the body-weight to come on the arm holding to the ladder, a further stretching force is exerted on the structures on the concave side. The exercise is suited to total and dorsal curves. Creeping Exercises (Klapp). — In these exercises the patient supports the trunk in a horizontal position with the hands and knees or feet on the floor. The hands, knees, and toes should be protected by leather pads which are strapped on. Fig. 117. Fig. 118. XIX. Symmetrical Creeping. — The hand and knee of the right side are placed close together with the hand to the outer side of the knee, the head is twisted with the face to the right, and the trunk is rotated with the left shoulder upward. The left arm is extended beyond the head and the hand placed on the floor, palm down and fingers forward, as far forward as possible and directly in front of the right knee. The left knee is placed as far back and as near the median line as possible; the spine is strongly bent to the right. The creeping consists of forward locomotion by a series of reversals and regainings of the position described. The mechanism of the first reversal is as follows : the left knee is drawn forward to the inner side of the left hand in its original place and position, the right arm is extended above the head, and the hand placed as far in front of the left knee as possible with the palm down and fingers front. At the same time the spine is rotated to bring the right shoulder high, the face is twisted to the left, and the spine flexed to the left. The restoration to the first position is secured by again moving the back knee (right) and the back hand (left) (Fig. 117). This is a general muscle strengthening and spine-mobilizing exercise. It is comparatively mild and may be continued for long periods of from twenty to forty minutes. Symmetrical creeping is properly that which is done rapidly, and is of most value in restoration of flexibility. A modification is made by creeping slowly, holding each position and putting force into the stretching, usually holding the position longest which stretches the concavity of the most marked curve (Fig. 118). Another modification is creep- ing in place, which differs from the above in that the patient does not attempt locomotion. The position is somewhat as above except that the fingers of both hands are placed on the floor opposite to the side to which the face looks. The trunk is rotated till the side with the forward arm is uppermost, and the arm is carried directly over the head, while the under arm is flexed at the elbow which .1 AC 'RETS AND BRACES 151 points to the side toward which the face is turned; the posterior knee is straight- ened, and the foot only of that limb touches the floor. The patient then endeav- ors to look upward beneath the forward reaching arm. This is best employed as an asymmetrical exercise to correct the dorsal convexity and stretch the side of the concavity (Fig. 119). XX. Creeping Sidewise. — There is a third asymmetrical variation in "creeping sidewise" toward the side showdng the concavity of the curve to be corrected, for example, in a left total curve. The patient creeps sidewise to the right. The left hand and knee are placed under the trunk, and as far as possible to the right of the right hand and knee. The right hand and knee are then advanced to the right and the above is repeated. The face should look to the left (Fig. 120). This is a corrective exercise similar to other forms of creeping, and may also be used for dorsal curves as well as for those of the total type. Fig. 119. Fig. 120. XXI. Creeping with Arm Flinging Upward. — Another kind of creeping in which the upper part of the spine is especially concerned is the creeping with arm flinging upward. The starting position is the same as for ordinary creeping — hands and knees on floor, hand and knee of one side touching, hand and knee of opposite side stretched far apart. The patient brings up the backward knee until it touches the forward hand, then raises the opposite hand from the floor, and with elbow r straight swings the whole arm upward so that the impetus of the swing twists the dorsal spine and causes the whole trunk to turn. At the same time the patient turns her head and looks up at the hand that is raised. This stretched position is held for a second, then the arm is swung downward again and the hand placed as far forward on the floor as possible. (2) JACKETS, BRACES AND CORSETS Braces and corsets of themselves have no place in the corrective treatment of lateral curvature, and are only to be regarded as a means of retaining the gain secured by other methods. They must be regarded as having in themselves little corrective value, for such apparatus applied to the spine not previously loosened up by treat- ment is not able to secure any considerable correction by pressure on the spine because the base for the leverage to be obtained from the pelvis must consist in a pressure obtained from the space be- tween the crest of the ilium and the top of the trochanter. Direct pressure on the crest of the ilium is not tolerated, and pressure on the trochanter interferes with walking and sitting. It is manifestly 152 TREATMENT impracticable from this small space to obtain a hold which will exercise a sufficient side thrust on the thorax to be corrective. The current practice of the instrument-makers of fitting corsets and Fig. 121. — On the Left is a Plaster Torso Made from a Corrective Jacket. On the Right is the Same Torso Made More Symmetrical for the Application of a Re- movable Jacket. braces to such patients and allowing the parents to hope for any considerable benefit is therefore to be condemned. The complicated braces in former use have been largely displaced by Fig. 122. — Brace for Scoliosis, Back. — (£. H. Bradford.) Fig. 123. — Brace for Scoliosis, Front. — (E. H. Bradford.) ■ the jacket or corset. They maybe found described in the references. 1 The corset used in Germany is shown in the illustration (Fig. 126). 1 Hoffa: "Lehrb. d. orth. Chir.," fourth ed., 1905, page 429; Redard: "Chir- urgie Orthopedique, 5 ' Paris, 1892, page 382; Bradford andLovett: "Orth. Surg.," first ed., 1890, page 168. JACKETS, BRACES AND CORSETS 153 Fig. 124.— Brace for Scoliosis, Fig. 125.— Brace for Scoliosis Back.— (Z. B. Adams.) Front.— (Z. B. Adams.) Fig. 126.— Corset for Scoliosis Strength- Fig. 127.— Brace for a Case of Right Dorsal ened by Steel.— (Dolega.) Scoliosis, Applied.— (C. W. Keene. 154 TREATMENT The braces of Bradford, Adams, and Keene are representative of the best types of modern retention braces, but in the writer's ex- perience better correction is maintained by removable jackets than by braces. Under the conditions specified the choice between a removable jacket, a corset, or a brace, will be determined by the facility of the surgeon with each. (3) PASSIVE STRETCHING OF THE SPINE It is at times desirable to increase flexibility of the spine more rapidly than can be done by free standing gymnastics alone and stretching of the contracted structures is in all cases of structural scoliosis except the mildest more easily to be obtained by intermit- tent passive stretching in apparatus than by gymnastics alone. The following considerations bear on the use of stretching force as applied to the spine whether in intermittent stretching or in forcible correction. The least economical use of force in straightening, for example, a bent stick is to pull the two ends away from each other, i.e., to straighten it by a pull in its length. The most economical use of force is to take it by the two ends and press the point of greatest convexity against some resisting point which shall push it straight. Again, if one wishes to secure the greatest side displacement in a flexible rod, such displacement is more easily secured when the rod is not stretched in its length. If a rubber tube, for example, is fastened to a table by two pins, one at each end and is not put on the stretch, the middle of it can easily be pulled an inch to one side by the fore- finger. If, however, it is pinned to the table by two pins separated enough to hold it on the stretch, it will require much more force to displace it one inch to the side. The same is true of a strip of sponge rubber or a piece of rattan. To be sure that this theoretical consideration applied to the human spine the following experiment was made at the Harvard Medical School by the courtesy of the late Prof. Thomas D wight. . Head suspension is a passive stretching of the spine, corrective through its entire length, tending to improve both rotation and side deviation at the curves, but exercising still more force upon the more nearly normal parts of the spine because the latter are more movable. Suspension by the arms is less efficient, ' and does not affect the cervical vertebrae as does head suspension. A young male cadaver was laid on the face, and straps passed around the body at the level of the right shoulder and the right hip. These straps were then fastened to the left side of the table, holding the shoulder and hip against pres- STRETCHING OF THE SPINE 155 sure from the left. A strap was then passed around the left side of the thorax and by means of a spring balance pulled to the right. The side deviation of the spine was then measured at four levels, the measurements being taken from a base-line connecting the cervical spine and the sacrum. The measurements were all made from pins driven into the spinous processes. Three experiments were made with a side pull of 25 pounds and the results were recorded. A Sayre head-sling was then put around the head of the cadaver still lying on the face, and a traction force of 75 pounds was made in the length of the spine, the feet of the cadaver being fastened to the table. While the traction on the head was thus in force the same side pull of 25 pounds was made as before and the results noted. Two experiments of this sort were made. It was found that the spine without traction was displaced to the side nearly twice as far by a definite side pull as by the same amount of side pull when traction was being made. A confirmatory experiment was made on a healthy boy of fifteen, using 75 pounds of head traction and 15 pounds of side pull. The result was the same. The conclusion is that extension of the spine by an upward pull on the head is a corrective force in the nor- mal spine, but that much more force is required to accomplish a certain amount of side correction than is the case if the force is applied from the side. The other conclusion is that to secure the maximum of side dis- placement from a given amount of side pressure the spine must be slack and not stretched in its length. p IG . 12 8.— Head Traction. (4) PASSIVE STRETCHING BY SUSPENSION The patient stands or sits erect, and the head is pulled vertically upward by means of a Sayre head-sling, which embraces the chin and occiput. Traction should be made by a compound pulley, and the patient or the surgeon may hold the rope. Suspension is mildest — (1) when the feet are not made to leave the floor; next in grade comes (2) the position of tiptoe induced by the traction, and (3) a greater pull is secured by lifting the whole body until the feet swing free. i56 TREATMENT In this case the traction force equals the body-weight. The maximum traction can be secured (4) by strapping the thighs down to a seat on which the patient sits. An upward pull greater than the body-weight can now be exerted on the head (Fig. 128). Apparatus for the purpose has been devised, and is known as the Weigel-Hoffa frame, in which the patient is suspended by the head, Fig. 129. — Stretching Board with Loops, Ready for Application. — ("Jour. Am. Med. Assn. 1 ') Fig. 130. — Stretching Board with Loops Applied Tq a Patient. Reverse of Fig. 129, — ("Jour. Am. Med. Assn.") while pads are run in from the sides of the frame, making lateral pres- sure on the trunk in various directions. Correction of the lateral curve of the spine is, however, to be obtained more economically by having the patient lie prone, and the FORCIBLE CORRECTION 1 57 corrective force should be divided into two elements, the force to correct the rotation and the force to correct the side deviation. A simple apparatus for this is as follows (Fig. 129) : The patient lies face downward, with the knees flexed, on a board three feet wide by four feet long. Assuming the case to be of a right dorsal curve, a broad canvas strap is passed around the left thorax, over and under the patient, and fastened to a cleat on the right side of the board. This furnishes a point of pressure to the left against the upper thorax at the level of the axilla. A broad canvas strap is then passed around the pelvis of the patient above and below, and is fastened to a cleat at the right side of the board. This furnishes a point of pressure to the left at the level of the pelvis. A broad canvas strap is then passed around the thorax at the level of the greatest point of curve; it passes above and below the thorax and its upper end is fastened to a cleat at the left side of the board (Fig. 130). Its lower end is fastened by means of a string into a compound pulley attached to a cleat at the left side of the board. By means of this pulley any reasonable degree of force may be exerted against the right side of the thorax, pulling it to the left, and at the same time that it pulls, it tends to reduce the rotation from the fact that its upper end is fastened and its lower end moving toward the pulley. (5) FORCIBLE CORRECTIOX In marked moderate and in severe structural lateral curvature no means of treatment is in the opinion of the author so efficient as con- tinuous stretching by means of plaster jackets applied under force. This method is spoken of as "forcible correction." Such jackets are applied with the purpose of stretching the contracted structures and of inducing an improvement in the curve. From the time of the elder Sayre, who advocated for scoliosis the application of plaster jackets applied in mild suspension, in several papers between 1875 and 1885, there had been sporadic attempts at the use of continuous mild corrective force in the treatment of scolio- sis. Dating from the work in 1896 of Calot 1 who advocated at that time the use of forcible correction in' the treatment of Pott's disease, the attempts became more forcible. Schanz 2 published in 1900 an account of an efficient technic in suspension, and reported results in 1902. In 1 901 the author reported results and described a technic where the patient lay on the face during the application, 3 and there were other papers written at about this time, but the great impetus to the treatment by forcible correction came from Wullstein, 4 who read 1 Calot: "France Med.," 1896, 52; 12th Int. Med. Congress, Moscow, 1897. 2 Schanz: ''Munch, med. Woch.," 1900, Bd. xlvi. 3 Lovett: "Trans. Amer. Orth. Asso.," 1901, vol. xiv; "Boston Med. and Surg. Jour.," October 31, 1901. 4 "Zeitsch. f. orth. Chir.," 1902, Bd. x. 158 TREATMENT a paper at the International Medical Congress in Paris in 1900, and who published his experiments, method, and results in 1902. He showed experimentally that bony scoliosis could be produced in young dogs and by the use of plaster-of-Paris jackets applied to sco- liotic patients in an improved position, induced by the use of traction and lateral pressure, both of high degree, he secured results that were better than any previously reported. The work attracted much attention, and markedly modified the whole point of view with regard to "forcible correction," which began to gather a body of adherents whose number has steadily increased. The object of the corrective jacket being to force the spine into the best obtainable position, and in that position to apply a retentive plaster jacket, it becomes pertinent to inquire in what position and by what technic the best corrected position may be obtained. Five positions are to be considered; these are with the patient suspended and lying on the face, side or back, and in the rotated position advocated by Forbes. 1 Application in Suspension. — Sayre's jackets were applied with the patient suspended by the head with the heels lifted from the ground, and ke claimed for them nothing more than support in an improved position. The jackets were removable, and exercises were done daily. The treatment was too mild to be effective, and although extensively used was not followed by very successful results. Wullstein's method was also a suspension method, but he used 250 pounds of traction, and to secure this, the patient was strapped by the thighs to a revolving and tilting stool and lateral pressure was secured by pads running in from an upright frame on horizontal rods. These pads were incorporated in the jacket. Much greater force was used than ever before, and although unpleasant symptoms from pres- sure arose at times, the results were so good that the method was extensively used, and is still in vogue on the continent of Europe. The method of Schanz is simpler and in connection with the after- treatment highly efficient if one may judge by the admirable results obtained, but at the same time an amount of traction is used which is objectionable if the same results can be obtained by other means. The patient stands and the ankles are fastened by anklets to rings bolted to the floor. By means of a Sayre head sling extension is pro- duced by means of a windlass to the point of the patient's tolerance. A plaster jacket including the shoulders is then applied and as it is hardening the surgeon passes his arms around the pelvis of the patient »"N. Y. Med. Journ.," July 6, 1912. FORCIBLE CORRECTION 159 and with his shoulder protected by a pad, presses against the rotated and curved portion of the spine. The after-treatment followed by Schanz consists in prolonging recumbency in a corrected posterior plaster-of-Paris shell with head traction. The patient is turned once a day onto the face to have the back massaged, but no exercises are Fig. 131. — Patient with Plaster Jacket Applied in Wullstein's Apparatus. — (Wullstein.) given at this period. After months of recumbency a corset and headpiece are applied and the patient allowed gradually to sit up. At a later period exercises are begun. Advantages and Disadvantages of Suspension Positions. — The use of strong traction in the length of the spine tends to straighten the lateral curves and to diminish the rotation, but without added lateral i6o TREATMENT pressure sufficient correction is not obtained. Moreover, traction in the length of the spine makes it resistant to side displacement from lateral pressure, as a stretched spine is less easily displaced to. the side than a slack spine. Wullstein found that he must diminish the traction on the head to get the best results from side pressure. But the upright position is the one in which the patient will wear the jacket; the technic of application is in this position the simplest, access to the shoulders and neck is easy, and the lower part of the Fig. 132. — Appliance for Lateral Suspension and the Application of Retentive Casts. — {Rich, "Jour. Amer. Med. Assoc," Dec, 1911.) jacket can be accurately fitted to the pelvis. Under these conditions a close-fitting and presentable jacket can be most easily applied by this method. Application of Corrective Jackets Lying on the Side. — A method has been devised by Rich 1 in which the patient lies on the side and is suspended by a sling passing around the convexity of the lateral curve, other slings hold the head and pelvis, and rotation is con- trolled by an oblique pull. The jacket is applied as a figure eight 1 "Jour. Am. Med. Assn.," Dec. 30, 191 1. FoRnr.i.i: cokrectiox 161 bandage, with the upper turn embracing the root of the neck, the lower turn the pelvis, and the crossing coming over the convexity of the spinal curve. Advantages and Disadvantages of the Side Lying Position. — The chief advantages of this posi- tion consist in the fact that the patient is suspended, and thus all parts are easily accessible. The figure-of- eight bandage fulfils admir- ably the mechanical require- Fig. 133. — Anterior View of Pa- tient Showing Freedom of Chest over Areas of Concavity. — (Rich, " Jour. Amer. Med. Assoc, Dec, ion.) Fig. 134. — Patient Thirteen Years Old. Curvature Due to Rickets; Never Treated. ments, and the body weight is utilized to straighten the spinal curves. The method is not applicable, except to children. Application of Corrective Jacket in the Prone Position. — When corrective jackets are applied to the patients prone, it is desirable to flex the legs, as this diminishes the physiological curves of the spine and simplifies the problem. With a patient thus lying prone, the spine is open to inspection and relaxed. In this improved position the jacket is applied. l62 TREATMENT A simple application of this method is to be found by having the patient lie prone in a rectangular gas-pipe frame on two straps of webbing running from end to end, cross straps supporting the pelvis and shoulders. By means of web- bing straps attached to the side of the frame, in a right dorsal curve, one going around the left side of the pelvis and another around the left upper thorax, while a third pulls on the right side of the thorax against these as points of resistance, great force may be exerted on the spine, much more force than can be safely used. With the patient lying prone on the webbing strips which are padded, the pelvic and axillary straps are adjusted to the proper tension and tied around the side of the frame. A heavy pad of felt is then applied over the rotated and curved Fig. 135. — Patient Lying in Correc- tive Frame, Showing the Improvement Gained by the Horizontal Position. Photograph taken from above. Patient same as in Fig. 134. Fig. 136. — Patient in Corrective Frame with Side Pressure Applied by Strap. Showing additional correction to that in Fig. 135. portion and a webbing strap attached to the side of the frame and tied at one end. This strap is then passed over the rotation, under the patient and back to the frame. By pulling on this end of the strap (the upper end of which has already been tied) the curved portion of the spine is pulled to the side and the rotation acted on by the twisting action of the strap. When sufficient tension has been obtained the end of the strap is fastened to the frame. The jacket is then applied with the side webbing straps in place, the bandages being worked around the straps. When the plaster is sufficiently hard these side straps are cut off where they emerge from the jacket and a finishing bandage applied. The patient then stands up; the longitudinal straps are pulled out, the jacket is cut out under the arms and by plaster bandages the jacket should be P] \>IKR JACKETS 163 extended to include the shoulders, tolerated. which is always desirable, but not always / Mechanics and Technic of Application of Jackets in Prone Position. — When it comes to the application of corrective force it must be remembered that there are two elements in the deformity, namely, side deviation and rotation. A single correcting force would therefore have to be oblique, e.g., in a right dorsal curve for- ward and to the left. But for practical purposes it is desirable to use two forces, one forward and one laterally toward the spine, thus dealing separately with the two elements of the deformity. To attempt to correct the side curve by lateral pressure without attacking the rotation is likely to result in increase of the rotation by pressure on the already flat- tened shafts of the ribs. That this is not new may be appreciated by a quotation from Schreger 1 in 1810: "Der seitliche Druck auf die Rippen biege diese an den ohnehin schon mehr spitzen Wikeln noch mehr spitzig zu." That plaster jackets may cause increase of the rib angles is demonstrated by Hiissey. 2 The same point, that plaster jackets may increase the bony rotation apparent in the back, has been alluded to by Schulthess and Vulpius. 3 It may, therefore, be stated that attempts to diminish the lateral curve, by pure lateral pressure, not carefully antagonized, will result, in fixed curves, in an increase of the rotation. The solution lies in dealing separately with the rotation and with the lateral deviation. Having corrected the lateral deviation first, this correction is held, as will be described, while the rotation is corrected or vice versa. In this way one element is not improved at the expense of the other. 1 Fischer, quoted by Hiissey. 2 Hiissey: "Zeitsch. f. orth. Chir.," viii, 2, 235. Vulpius: ' : Yolkmann's Samml. klin. Vort.," 276. Fig. 137.— On the Left is a Diagram Showing a Right Dorsal Left Lumbar Curve. In the middle diagram the curve is shown straightened; on the right the curve has been pushed over to the left unchanged. 164 TREATMENT Technic of Application. — The patient should preferably be stretched once or twice daily for two or three days preliminary to the correction, but this is not essential. Anesthesia is never necessary, as all endurable correction may be obtained without much pain. A seamless undervest is put on and the iliac crests padded with heavy felt; a pad should also be placed over the sacrum. Under the side straps heavy felt or cotton pads are required. The correction is pushed to the point of causing mild discomfort, and difhculty in breathing is a sign of too much correction. The amount to be obtained in any case is better decided by the patient's sensations than by any theoretical stand- Fig. 138. — Patient of Whom Radiograms were Taken before Treatment. (January, 1906.) — ("Am. Jour. Med. Assn.") ard. The danger lies on the side of obtaining too much rather than too little correction, for the jacket will be much more uncomfortable when the erect posi- tion is assumed. After correction the patient should remain in a hospital under close obser- vation for at least twenty-four hours. Some shock is not infrequently experi- enced and in a case of the writer's very serious collapse and cyanosis followed the correction of a severe curve due to infantile paralysis in a child of six. Wull- stein has recorded the occurrence of somewhat serious symptoms following correction. Advantages and Disadvantages of the Prone Position. — The spine in this position is slack and easily displaced to the side and twisted, APPLICATION OF JACKETS 165 and the back is in view of the surgeon during the application, enab- ling him to see just what correction is being accomplished. But jackets applied by this method are clumsy, as it is difficult to fit the pelvis accurately, especially if the thighs are flexed, access to the chest and shoulders is not easy, and the front of the jacket is con- cealed from the surgeon's view. Application of Jackets in the Rotated Position {Forbes Method). 1 — The method assumes that it is probable that the deformity arises in some cases from the rotation of the vertebral bodies and that an artificial scoliosis in the other direction should be induced to counter- act it. But such an assumption does not seem to be borne out by what we know of the occurrence of scoliosis. Nor does untwisting one part of the rotation seem likely to be of much use when such a complicated set of rotations exist as one finds in compound structural scoliosis. The justification of such a method would have to be found in the fact that it produced correction. In this matter one may rely on the verdict of the Scoliosis Committee of the American Orthopedic Association who examined six cases to be treated by this method in October, 19 14, and again in April, 191 5, after six months of treatment. Their report is as follows: 2 "They were all in fairly good condition but in two cases collapse seemed imminent after the jacket had been removed and the patients kept standing for inspection. Not only had overcorrection not been secured in any case, but in none was there marked diminution in any elements of the deformity. . . . The treatment of all the cases in this group seemed to have been carried out with great care and perseverance, but the Committee feel justified in considering the results as distinctly discouraging/' In view of what has been said the treatment is not in the writer's opinion to be recommended until further evidence of its practical value is brought forward. Application of Jackets Lying on the Back with the Spine Flexed (Abbott's MeJiod). 3 — The patient lies on the back w r ith the legs flexed on the trunk, the back rests on a hammock about a yard long and fifteen inches wide cut obliquely across one end. This hammock is 1 Forbes: "N. Y. Med. Journ.," July 6, 191 2; Maidermot: "American Journ. of Orth. Surg., Feb., 1913; Forbes: "Surgery, Gyn. and Obst.," April, 1914; Adams: "American Journ. of Orth. Surg.," July, 1914. - '•American Journ. of Orth. Surg.," July, 1915, page 6. 3 Abbott: "Simple, Rapid and Complete Reduction of Deformity in Fixed Lateral Curvature of the Spine," "X. Y. Med. Journ.," June 24, 1911. 'Forcible Correc- tion of Lateral Curvature of the Spine, a Simple and Rapid Method of Obtaining Complete Correction," "N. Y. Med. Journ.," Apr. 27, 191 2. 1 66 TREATMENT fastened at each end to a steel rod by which it is loosened or tightened. It is held in place by being slung between the ends of a gas-pipe frame about five and one-half feet long and two feet wide. This frame rests on four gas-pipe legs and has a bar running lengthwise in the middle, about two feet above the main level of the frame to which the legs are slung, and nearer the ground are side bars to which straps may be attached. The patient is padded with thick felt and laid on the back on the frame and the legs are flexed and fastened to the upper rod, the shorter side of the hammock resting against the bulging ribs, a crosspiece of webbing supports the neck. Cross straps are now ap- plied around the body to pull in the desired direction, one in the axilla of the low shoulder carried obliquely across the frame to the upper corner, another around the pelvis pulling across to the same side of the frame as the axillary strap, another strap is passed over the most convex part of the dorsal lateral curve to the opposite side of the frame to pull on the dorsal curve and a fourth strap, wider than the others, may be used to pass from the side of the frame running over the anterior protruding ribs and hanging down. To this weights may be attached to influence the rotation. A large oval felt pad is placed over the back of the thorax on the side where the ribs are depressed. The straps are tightened and the jacket applied. In trimming the jacket it is left long behind at the bottom to main- tain flexion of the spine; at the top it is left high under the arm which has been elevated, but is cut away on that side in front; beneath the other arm it is trimmed low but left high in front to hold that shoulder back. A large window is cut in the back over the concave side, reaching well around to the side so that the spine may swing not only back but to the side, on the opposite, side in front a window is cut to allow the depressed ribs on that side to bulge anteriorly. After the jacket has been worn for a short time pads of felt are in- serted in front to push the ribs back through the window cut behind and sometimes pads are also to be used over the convexity at the back. Choice of Method. — In choosing between these methods it is prob- able that most of them are efficient and that the especial technic employed is probably less important than the skill of the surgeon and his experience with the particular method employed, the amount of force used and the efficiency of the after-treatment. But one fact must be borne in mind, there are two kinds of correction, one a real correction of the spine of which the .T-ray is the only criterion, and second, an apparent correction in which the thorax is rotated on the DISCUSSION OF METHODS 1 67 spine with great improvement and perhaps even overcorrection of the body outlines but in which an :v-ray shows the lateral curve to be largely or wholly unchanged. In other words it is easier to rotate the thorax on the spine than to change the curve of the spine itself and herein lies the weakness of the method advocated by Abbott in which the thorax is most easily to be rotated on the spine — apparent correction, that is, correction of body outline, has figured in many reported cases in which the .r-ray has not been shown and where progress has been judged only by photographs. An instance of this is given in the figures (Figs. 155 and 156). The prone lying and suspension methods do not render the thorax so easily movable on the spine and it is probable that force expended in correction is more nearly spent on the spine itself. But the whole question as to choice of methods is sub judice. As to the overcorrection of the curve in marked or severe struc- tural scoliosis, such a claim must be substantiated by very weighty evidence for such an overcorrection would be contrary to all that we know of bone pathology, and a claim of such overcorrection is not lightly to be accepted. A committee of the American Orthopedic Association appointed in 1913, in June, 191 5, reported as follows: They had sent out a questionnaire to fifty members of the association in which the following two questions were asked: "1. Have you personally had cases of undoubted structural scoliosis in which unquestionable overcorrection was obtained? "2. Have you succeeded in bringing about a definite cure of undoubted structural scoliosis? "But one man in fifty has claimed without qualification to have brought about a definite cure of undoubted structural scoliosis. Although he was immediately requested to furnish the evidence and although he had volunteered to do so, the committee has not received it. The committee therefore concludes that of the fifty men who have replied to the postal card questionnaire, none are in possession of material evidence with which to give an affirmative answer to questions 1 and 2 "Note. — Since the completion of the report the one definite and unqualified claim of cure in undoubtedly structural scoliosis has been retracted by letter to the committee." 1 The two most careful studies of the Abbott method, apart from Abbott's own articles, are by Lance of Paris and Kleinberg of New York. The conclusions of Lance 2 were as follows: 1( 'Am. Journ of Orth. Surg.," July, 1915, page 18. 2 Lance: Le Traitement des Scoliosis graves par la Methode d' Abbott. Paris, 1914. 1 68 TREATMENT "In the cases where there is no marked bony lesion one can always accomplish correction and hypercorrection of the lateral deviation. In the cases where there are bony lesions in a single curve without compensatory curves, or with a compensatory curve not presenting deformed vertebrae, one observes this — that the principal curvature diminishes in all the vertebrae which are not deformed, and there remains a little curve of two, three or four vertebrae in height, composed of cuneiform and rhomboid vertebrae, and above and below at rather a brusque angle are formed very extensive compensatory curves. We have never been able to obtain more. Abbott says that he has obtained complete redressment and hypercorrection of scoliosis with vertebral deformity, but he has never pro- duced radiographs demonstrative of the fact In the very severe cases, where the vertebral deformities exist not only in the upper curve but on one or two of the compensatory curves the action is very limited, and one will only obtain a result very slightly marked, and which will have very slight chance of being maintained." Kleinberg, 1 from an analysis of 60 cases, reaches the following conclusions : "As might have been expected, it was found that the deformity even in its mildest form, did not yield rapidly to the Abbott treatment, and that it took months to effect any real change. Of the 60 cases, 18. . .gave up treatment, 8 were not improved at all, and 34 were definitely made better in external appearance, with or without a corresponding change in the spine itself. Of this latter number 6 cases relapsed. This method, therefore, is applicable to the milder degrees of rigid scoliosis, most of which the writer has seen improved, though he has not yet seen any case, no matter how mild, cured, that is, trans- formed into one with a prefectly symmetrical back." Taking all this evidence which is wholly in accord with the writer's own experience one must fairly conclude that the situation is much what it was before. The method of Abbott is no cure all, and his claims have apparently not been substantiated by others. One has only to realize what Abbott's claim was to recognize its character. It was as follows: 2 "In a previous article on this subject 3 the state- ment was made that fixed lateral curvature of the spine yielded to treatment as easily as bowlegs or club-feet. Further experience has led me to believe that this deformity yields more readily than either of the others." The method of Abbott may be a little more or a little less effective than the suspended or prone lying positions, the scoliosis Committee of the American Orthopedic Association in their admirable report said: "It seems probable that greater degrees of correction may be 1 "American Journ. of Orth. Surg.," June, 1914. 2 "N. Y. Med. Journ.," Apr. 27, 1912. 3 "N. Y. Med. Journ.," June 24, 1911. DISCUSSION OF METHODS 169 obtained with the flexed position of the spine than with the extended position of the spine." Personally the author would regard the fully flexed position as the one in which it was easiest to secure an improvement in body outline for the spine thus seems to be more flexible to manipulation and it may also be the position in which the greatest real correction of the spine is to be obtained. But although one hesitates to generalize from a single instance, certain doubt was thrown on the latter point Fig. 139. — Patient Shown in Fig. 138 after Wearing Corrective Jacket for over a Year. (March, 1907.) by an observation of the author's in which #-rays were taken of a boy with scoliosis in the Abbott position and in the prone lying posi- tion with the same amount of lateral pull. The prone position showed slightly more spinal correction but such an observation would have to be confirmed to be convincing. For the present we need accurate data in the way of x-rays, photographs as explained are misleading and impressions of little value; meanwhile the ques- tion must remain subjndice. The choice therefore must be left to the individual surgeon, the 170 TREATMENT method by rotation (Forbes) has not apparently yielded results as good as have the other methods, the method of side lying (Rich) has not been generally adopted, and the surgeon must choose accord- ing to his preference between head suspension, prone lying and the flexed position lying on the back. Treatment Subsequent to Application of Jacket. — Starting from the application of the corrective jacket two methods of treatment are Fig. 140. — Radiogram of a Patient Seventeen Years Old (Fig. 138) Lying on the Back, before the Application of Jacket. (January, 1906). — {"Jour. Am. Med. Assn.") available; (i) the original jacket may be left on or (2) after one or more corrective jackets have been applied a removable jacket or corset or brace may be used. (1) Permanent Corrective Jackets. — When the jacket is hardened, it is left solid over the parts that are made prominent by the rotation IT. KM. WE NT CORRECTIVE JACKETS 171 behind and in front, that is, in a right dorsal curve the right back and left front are not touched, but large windows are cut over the depressed side of the chest behind and the corresponding portion diagonallv opposite in front, so that in a right dorsal curve the left side would be cut out behind and the right side in front. This makes it possible for the depressed parts of the chest to be expanded by respiration, while the prominent parts are compressed. Pads of felt Fig. 141. — Radiogram of Same Patient as Shown in Fig. 138, Taken after the Application of a Plaster Jacket through Windows Cut in Front and Back of Jacket. (January, 1906.) — {"Jour. Amer. Med. Assn.") are now inserted between the prominent part of the chest behind and the jacket, and in the corresponding region in the front, thus making the jacket more corrective, and thicker pads are substituted each week without changing the jacket, these being drawn through with- out difficulty by means of a bandage. In this way, a continual diagonal side-pressure is kept up on the curved portion of the spine and is steadily increased. When these pads have become so thick 172 TREATMENT that the jacket is pushed away from the patient and no longer fits it will be found that it is advisable to apply a new jacket, to cut it out in the same way and to begin on the progressive padding. The use of such a permanent jacket may be continued as long as it seems possible to gain further correction, being changed at intervals, and at the end of this time a removable jacket is substituted for the permanent one and gymnastic treatment is begun. The removable Fig. 142. — Fenestrated Jacket for Making Side Pressure by Strap. —(Ansel G. Cook.) jacket is then gradually discontinued while the patient's muscular condition is being improved by gymnastic exercises. (2) Removable Jackets. — The treatment, by removable jackets, is best started by the application of a forcible jacket either in recum- bency or suspension. This may be followed by a second forcible jacket at an interval of a week or so, if it seems advisable. For the construction of the removable jacket, the patient is suspended and a plaster jacket is applied which is immediately cut off to serve as a mold, and a forcible jacket is best applied to be worn while the removable apparatus is being made. The jacket which is to serve as CORRECTION OF TORSO 173 a mold is then hound together and filled with plaster of Paris and water, a torso thus being obtained. This torso is then remodeled by cutting off on the prominent side and building up on the other side, until it has become decidedly more symmetrical than the patient. It is also sawed in halves at the waist and set apart about an inch in order to secure continued extension of the trunk. On this corrected torso a plaster jacket is applied which is to be the removable jacket worn by the patient. This re- movable jacket should be supplied with shoulder pads, to hold the shoulders back in position, and should open down the front, being supplied with buckles and straps or lacings. It is generally advis- able to slash such jackets over the iliac crests in order to prevent chafing. The addition of 5 per cent. Portland cement to the plaster with which the jacket is made gives greater strength and dura- bility. This jacket is to be worn by the patient night and day and to be removed only for the exercise period, w r hich should consist of one hour or more daily, the exercises being of the type mentioned above. When the jacket is applied, it is sprung open and slipped on the patient, who then lies on the back, and the arms and legs are pulled on to extend the spine. It is then buckled tightly in place before the patient stands up. Such jackets may be made more effective by padding in- side of the jacket over the convexity of the curve with a large w r indow T cut on the side of the concavity. The Cook Strap. — The use of a broad webbing strap passing around the convexity of the spine and coming out of a large window on the opposite side of the jacket has been advocated by Cook 1 and possesses certain advantages over padding in removable jackets '"Am. Journ. of Orth. Surg./' July, 1913. Fig. 143. — Fenestrated Jack- et Applied to Patient with Lower Dorsal Curve Strap in Place. — {Ansel G. Cook.) 174 TREATMENT and even in permanent forcible jackets. It is easily adjustable, gives a well-distributed pressure and can be varied by the position of the strap to attack either the rotation or side deviation. In con- nection with a large window on the concave side of the curve it furnishes a powerful means of constant correction. Cook applies the strap to a jacket with large windows on both sides but the writer has found the best use of the strap as a substitute for padding in jackets not in any way modified from the usual pattern. Fig. 144. -Radiogram of Patient Shown in Fig. 138 after Wearing Corrective Jacket for over one Year. (March, 1907.) Jackets of either kind should be tested for efficiency by measuring the height of the patient with and without the jacket. Without the jacket the patient places the hands on the hips and pushes up, mak- ing himself as tall as possible, and his height is taken in this posi- tion. . The jacket is then applied and the patient's height is again taken. If the jacket does not hold him in as good a position as esti- mated by the greatest height the patient can possibly assume with MECHANICAL OBJECTIONS 175 the hands on the hips, it is discarded and a more corrective one is made. If such a jacket is worn by a patient who is making good progress, in a few weeks from the beginning of treatment it will be found to be inefficient and not to be holding him on account of his improvement. Under these conditions the torso must be again remodeled, more cut away from the prominent side and greater pressure exerted. In the W&t Fig. 145. — Permanent Corrective Jacket Applied. course of a year, probably two or three such remodelings would be re- quired. These jackets may be made of leather or celluloid if preferred rather than plaster, but the plaster is perfectly efficient, although heavier. Mechanical Objections to All Corrective Jackets. — In applying force to correct the lateral curve and rotation of the scoliotic spine we cannot apply such force directly to the spine, but we must apply the corrective pressure to the ribs. The ribs are loosely attached to the spine, and are, moreover, rather easily distorted themselves by pres- 176 TREATMENT sure. We, therefore, must do without that direct application of force to the affected structure which we possess in the treatment of most deformities. Secondly, to exert effective side pressure one must be able to press laterally not only against the apex of the lateral curve, but to exert counterpressure in the other direction at the top and bottom of the curve, 1 and this we cannot do by pressure against the thorax in high dorsal curves because we cannot reach as high as the top of the curve. To attempt to secure a higher level of side counter- Fig. 146. Fig. 147. Fig. 146. — Remodeled Torso Ready for Application of Jacket. In a case of right dorsal left lumbar scoliosis which has been cut in two at the waist and set apart one inch, so as to increase the upward pressure on the ribs. The dark areas on left of the torso show where plaster has been added on the concave side to allow for correction of displacement and deviation. — ("J. Am. Med. Assoc") Fig. 147. — Front of Jacket, made over Torso Shown in Fig. 146. Note Shoulder Pad. — ("/. Am. Med. Assoc") pressure against the root of the neck is to pull against soft structures overlying a nerve plexus, where strong pressure is not tolerated, nor can side pressure be exerted on the lumbar spine, consequently cor- rective jackets are not satisfactory in lumbar curves or in curves whose apex is as high as the upper dorsal region In lower dorsal and dorsolumbar curves they find their best application. Thirdly, forcible jackets, by fixation and pressure, cause atrophy of the muscles of the trunk and spine, and this fact has been much insisted on by the opponents of the method. But when the time has come to begin the after-treatment, such atrophy is quickly X F. Lange: " Zentrlblt. fur chir. and mech. orth.," Bd. v, Hft. 12. FORCIBLE JACKETS 177 recovered from by the use of gymnastics and massage, and by the gradual rather than the sudden discontinuance of the support when the proper time comes. That such jackets will prove detrimental to the general health is a fear which is not supported by facts, for the improved posture Fig. 148. — Patient in Removable Jacket. Note Window on Concave Side. Jacket Reinforced by Steel Strips. and the restoration of the viscera to a more normal position are more than enough to counterbalance the discomfort and the handi- cap of the jacket, in the great majority of cases. A gain in flesh 12 i 7 8 TREATMENT and improvement in the general condition may, as a rule, be pre- dicted from the application of a proper jacket. Finally, the danger to life from the application of jackets may practically be disregarded. Alarming symptoms have arisen and in a few instances deaths have occurred as a result, but in these cases the use of force has been too great. With the use of judgment Fig. 149. — Radiogram of Case I before Treatment by Jackets was Begun. and moderate force no real danger can be incurred in normal individuals. Curves due to congenital defects, infantile paralysis, rickets, and empyema are available for forcible correction, those from infantile paralysis being often among the most satisfactory in their results of all classes of moderate and severe scoliosis. RESULTS 179 Results. — The author's point of view with regard to results to be obtained has been stated under prognosis (page 127) but to make the matter more definite the personal experience of the author in a group of test cases is here given with a view of placing on record the x-rays of a set of cases carefully observed and personally treated. Six cases were selected from the Scoliosis Clinic of the Children's Hospital for treatment in the fall of 1914 and the photographs and Fig. 150. — Radiogram of Case I after Treatment by Jackets as Described :v-rays of these cases w T ere made under the supervision of the Scoliosis Committee of the American Orthopedic Association in October. In April these same cases were again presented to this Committee and their records again taken by them. These cases were under the personal treatment of the writer by whom all jackets were applied. i8o TREATMENT When it seemed advisable they were kept in the hospital for longer or shorter periods. Three of these cases are here presented. Case i. — Boy, five years old. Colored. Rachitic scoliosis, pre- viously treated by exercises. Right dorsal left lumbar curvature. Treatment was begun Nov. 23, 19 14, and ended in April. Four Fig. 151. — Radiogram of Case II before Treatment by Permanent Plaster Jackets. permanent jackets were applied. The patient is still under treatment by a removable jacket and exercises (Figs. 149, 150). Case 2. — Girl, eight years old, scoliosis due to infantile paralysis. Deformity noted in 19 10. Curve, left cervicodorsal, right dorsal, left dorsolumbar. First jacket Oct. 29, 19 14. Five permanent plaster jackets (Figs. 151, 152). Case 3. — Boy, eight years old, etiology not determined. Curve RESULTS 181 Four permanent left dorsolumbar. First jacket Nov. 9, 1914. plaster jackets (Figs. 153, 154). As the study concerned itself wholly with changes in the spine and not with changes in body outline only x-rays are presented, the photographs being omitted, which show on the whole much more Fig. 152. — Radiogram of Case II after Treatment by Permanent Plaster Jackets. correction than is indicated by the ac-rays. The x-rays were taken by the method of Bucholz and Osgood. 1 A further case is given showing both x-rays and photographs to make clear the point that great change in body outline may be secured without much alternation in the spinal curve as shown in the x-rays (Figs. 155, 156, 157, 158). i:< Am. Journ. of Orth. Surgery," 1914, xii, 77. I»2 TREATMENT Case 4. — Girl, six years old, curve due to rickets, deformity noticed when two years old. Left dorsolumbar curve treated by jackets since May, 191 1. First photograph Oct., 191 1, second, April, 191 5. Contemporaneous arrays showing that while the photograph shows much improvement, the spine itself has been nearly stationary. (Figs. 155, 156, 157, 158). Fig. 153. — Radiogram of Case III before Treatment by Permanent Plaster Jackets. Permanence of Results. — Successful permanent results can be ob- tained in hospital practice only in selected cases, the average patient being unable to appreciate the importance of following out the treat- ment sufficiently long. The criticism that such correction is not likely to be permanent at once presents itself. The grounds that lead one to suppose that retention of the growing spine in a corrected position over a sufficient period will lead to a change in the shape of RESULTS 183 the bones of the vertebral column and to a permanently improved position are as follows: (1) Club-foot may be cured by a similar proceeding. (2) The bones of the feet of Chinese women of rank are seriously misshapen by retention in an unnatural position. 1 Fig. 154. — Radiogram of Case III after Treatment by Permanent Plaster Jackets. (3) Wullstein produced bony changes in dogs by a few months of abnormal position. (4) Arbuthnot Lane has 2 demonstrated that the carrying of heavy loads by laborers will produce changes in the bony skeleton, and that the changes vary according to the habitual position of the load, the 1 P. Brown: "Jour. Med. Research," Dec, 1903. 2 Guy's Hosp. Rep., xxviii. 1 84 TREATMENT bones subject to the greatest pressure undergoing changes in shape. (5) The fact that bone under pressure changes shape after growth has been reached is shown in the fact that scar tissue pressing on bone will cause a change in shape, 1 e.g., on the chin. (6) Pressure of tumors or aneurysm will cause absorption of bone. These facts all point to the conclusion that bone alters its shape under changed conditions of pressure, and that although this would Fig. 155. — Case IV before Treatment by Plaster Jackets. Fig. 156. — Case IV after Treatment by Plaster Jackets. be more marked during growth, the phenomenon is not unknown in adult life. It seems reasonable to hope that the maintenance of improved position may be expected in time to produce a change in the shape of the vertebrae. It is obvious that such a corrected position must be maintained over a period of many months to secure permanent results. Schanz 2 has provided clinical evidence that his results have been permanent in the time during which they were observed. 1 Ziegler: Pathology, English ed., 1896, ii, 146. 2 "Verhdlg. d. Deutsch. Ges. f. orth. Chir.," 1908, page 57. GYMNASTICS l85 Choice of Methods. — The choice between the use of fixed or re- movable corrective jackets must be determined by the circum- stances of the patient, the temperament of the child, and similar considerations. Careless hospital patients will do better in a fixed jacket for a year or two, while nervous girls in private practice will do better in split jackets. Fig. 157. — Radiogram of Case IV before Treatment by Permaxext Plaster Jackets. Gymnastics Following Forcible Correction. — So soon as the final corrective jacket has been removed and replaced by a removable one, gymnastic treatment should be begun. The exercises to be used have been described in the section on Gymnastics. Such treatment to accomplish results must be given from one to four hours a day for a period of at least six months from the removal of the final corrective i86 TREATMENT jacket, after which less frequent and vigorous exercises may be suffi- cient. Exercises must be continued until the corrected position is maintained without apparatus from month to month, and the supporting apparatus discontinued at first for short periods, gradu- ally increasing in length. The length of time that active treat- ment must be continued will depend on the age of the child, the Fig. 158. — Radiogram of Case IV after Treatment by Permanent Plaster Jackets. severity of the case, the efficiency of the treatment, and similar factors, but any case of scoliosis severe enough to require forcible correction will not, as a rule, occupy less than two years, and often a longer period. The present discredit of gymnastic retentive treatment is due to its use in too small dosage and to a failure to appreciate that a problem OPERATIVE TREATMENT 187 so grave as the permanent maintenance of the corrected position in a spine, which has suffered some degree of bony distortion, is only to be obtained by a long continuance of accurate and mechan- ically sound treatment. Operation. — The question of the operative relief of scoliosis has been for the present abandoned. An operation was proposed by Fig. 159. — Boy Aged 12, before Treatment. — ("J. Am. Med. Assoc") Fig. 160. — Boy'Aged 14, after Two Years' Treatment by Means of Per- manent Jackets (see Fig. 159). Volkmann 1 in 1889, consisting of resection of the ribs on the convex side of the curve, and this operation was also performed by Casse 2 and Hoffa 3 with fair results. A similar operation was thought out by N. M. Shaffer, of New York, about fifteen years ago, and spoken of to the writer at that time but never put on record, as the general surgeons to whom it was referred refused to sanction it. 4 A good operative correction has been obtained by Hoke, 5 of Atlanta, Ga., who resected the ribs on the convex side of a girl of 1 Volkmann: "Berl. klin. Wochens.," 1889, 50. 2 Casse: "Bull, de l'Acad. Royal de Med. de Belgique," Dec. 30, 1893; «Jan. 27, 1894. 3 Hoffa: "Zeitsch. f. orth. Chir.," 1896, 401. 4 Shaffer: "Amer. Surg. Bulletin," Jan. 1, 1894. 5 Hoke: "Amer. Jour, of Orth. Surg.," i, 2. i88 TREATMENT nineteen and lengthened those of the concave side in a severe dorsal curve. By the application of a corrective jacket great improvement was obtained. Jaboulay 1 divided the cartilage of a single rib with a view of im- Fig. 161. — Girl Aged 16, before Treatment. — ("J. Am. Med. Assn.") proving the shape of the thorax. Bade 2 has reported a case where he resected the ribs, but cautions against the use of narcosis in severe scoliosis. 1 Jaboulay: "Prog. Med..'" Nov., 1S93. 2 Bade: "Klin. Mittheil." in Centralbl. f. Chir./' 1903, 38, 1045. TREATMENT 189 Fig. [62. — Girl Aged 18 after Two and a Half Years' Treatment by a Series of Permanent Corrective Jackets. See Fig. 161. — ("/. Am. Med. Assn.") 190 TREATMENT Fig. 166. Fig. 167. Figs. 163-167. — History of a Case of Scoliosis from 1903-1910. Increase under gymnastics and imperfect jacket treatment. Figs. 163, 164. — 1903-5. Figs. 164, 165. — -1905-7. Figs. 165, 166. — 1907-9. jacket. Figs. 166, 167.— 1909-10 only a mild brace was possible with no gymnastics Treatment by jackets (one forcible) and gymnastics. Left clinic and had gymnastics twice a week outside with no Returned to clinic but heart displacement was so great that CHAPTER XIV FAULTY ATTITUDE NORMAL ATTITUDE In addition to curves to the side in the spinal column, which have been described as scoliosis, there are modifications of the normal forward and backward spinal curves which demand consideration. Although it is comparatively easy to say whether or not a patient is normally symmetrical when seen from the back it is not so easy to say whether or not a given attitude as seen from the side is normal because there is no generally accepted normal attitude in the standing human figure as seen from the side. It is necessary first to consider those facts which are known with regard to the normal attitude before passing on to analyze its abnormalities. Normals have been de- scribed by Weber, Meyer, Langer, Parow, Henke, Staffel and others, which differ much among themselves as would have been expected, from the lack of a uniform or satisfactory system of measurement and also because the standing position is influenced by sex, age, race and occupation. As the problem is one of balance from the feet up, it is evident that any reliable method of analysis must take into account the base of support and the line of gravity in order correctly to represent the normal standing position as seen from the side. Merely to draw a spinal outline and construct an ideal figure without regard to the relation of such spinal curve to the legs or base of support is mis- leading. One has only to read the appended literature to realize that we have no reliable normal of the standing position as seen from the side. 1 1 Borellius, J. A.: "De Motu Animalium, Lugduni Batavorum," 1679. Braune, W., and Fischer: "Ueber den Schwerpunkt des menschlichen Korpers, Abhandl. d. k. Sachs.," "Akad. d. YVissensch., Math.-physik Klasse," Leipsic, 1889, xv, 7. Dickinson, R. L. : "The Corset; Questions of Pressure and Displacement," "New York Med. Jour.," Nov. 5, 1887. Duchenne: "Etude physiologique sur la courbure lombo-sacree et de l'inclina- tion du bassin pendant la station verticale," "Arch. gen. de med.," series 6, viii, 534- Goldthwaite, J. E.: "The Influence of Pelvic Joints on Posture," "Physical Education Rev.," June, 1909. 191 192 FAULTY ATTITUDE A new method of record which promises to enable one to analyze the normal standing position and its abnormalities is that of Reynolds and Lovett, 1 but until a very large number of normal studies have been made, no reliable statement of what the normal really is, can be made, and no very accurate information can yet be given of variations from the normal in this plane. This method gives a side elevation of the erect standing position of the individual, with at the same time, the position of the line of gravity in its relation to the body and to the base of support. On the platform of a dial scale registering up to 100 pounds is placed a sharp edge which supports one end of a flat board (B), the other end of which is sup- ported by a similar sharp edge placed on a rigid block (C). The distance be- tween the edge is 508 mm. (20 inches). A short distance behind the rigid block is placed an upright post (E) with a horizontal sliding arm (D, shown in section only), which furnishes a plane of reference from which the antero-posterior position of each of the important landmarks of the body can be determined by measuring their horizontal distance from this sliding arm (Fig. 168). The determination of the antero-posterior position of the center of gravity in the standing subject is made as follows: Goldthwaite : "The Relation of Posture to Human Efficiency," Borton: "Med. and Surg. Journal," Dec. 9, 1909. Gerdy: "Determination des levriers que forment la colonne vertebrale, les femurs et les tibias dans l'attitude verticale," "Rev. med.," 1834, 323. Horner, F. : "Ueber die Krummung der Wirbelsaiile im aufrechten Stehen," "Inaug. Diss. Zurich," 1854. Kellogg, J. H. : "Experimental Researches: Relation of Dress to Pelvic Dis- eases of Women," "Tr. Mich. State Med. Soc," 1888. Kellogg, J. H. : "The Relation of Static Disturbances of the Abdominal Viscera to Displacements of the Pelvic Organs," "Proc. Internat. Periodical Cong. Gynec. and Obstet.," 1892. Kohlrausch, E.: "Physik des Turnens Hof.," 1887, page 17. Lane, W. Arbuthnot: "Lancet," London, Nov. 13, 1909. Meyer, G. H. : ' 'Die Statik und Mechanik des menschlichen Knochengeriistes," Leipsic, 1873. Mosher, Eliza M.: "The Influence of Habitual Posture on the Symmetry and Health of the Body," "Brooklyn Med. Jour.," July, 1892. Mosso: "Application de la balance a l'etude de la circulation chez l'homme," "Arch. ital. de biol.," 1884, v. 131. Parrow, W. : "Studien iiber die physikalischen Bedingungen der aufrechten Stellung und der normalen Krummungen der Wirbelsaiile," "Virchows Arch. f. path. Anat," 1864, xxxi, 74. Schmidt: "Unsere Korper," 1903, page 63. Staffel, F. M.: "Die menschlichen Haltungstypen und ihre Beziehung zu den Ruckengratsverkriimmungen," Wiesbaden, 1889. Taylor, C. Fayette: "Spinal Irritation, or the Causes of Backache among American Women," New York, William Wood and Co., 1870; "Tr. Med. Soc, New York," 1864. Weber, M. and E.: "Mechanik der menschlichen Gewerkzeuge," Gottingen, 1836. 1 Reynolds, E., and Lovett, R. W.: "Method of Determining the Position of the Center of Gravity in Its Relation to Certain Bony Landmarks in the Erect Position," "Am. Jour. Physiol.," May 1, 1909; "Jour. Am. Med. Assn.," Mar. 26, 1910. ANALYSIS OF IPIUOltT POSITION 193 The subject is weighed on an ordinary set of scales. He is then placed on the balance plane (B) at a known point facing the scales. (The exact point is un- important, but after experimentation there was selected as most convenient that in which the heels are situated at one-fourth the length of the plane from the posterior sharp edge.) A removable ledge (F) against which the heels are placed is provided here. Since the balance plane on which the subject stands acts as a lever, in which the weight is borne between the fulcrum (the posterior sharp edge) and the sup- porting force (the spring which governs the scales), it is evident that the weight recorded on the dial (the balanced weight) will bear to the total weight the same proportion as that which obtains between the total length of the balance plane and the distance between the perpendicular dropped from the patient's center of gravity and the posterior end of the plane. That is: As the total weight is to ^ IS D Fig. 168. — Diagram of the Apparatus for Estimating the Center of Gravity. A, scale; B, balance plane on which patient stands facing A; C, block supporting triangular edge; D, movable horizontal arm on upright for obtaining horizontal distances; E, vertical upright for standard plane; F, ledge against which heels are placed. — (''American Journal of Physiology.") the balanced weight, so is the total length of the board to the horizontal distance of the center of gravity of the patient from the posterior sharp edge (the ful- crum), or, to illustrate by a specific instance: The subject's total weight is 140 pounds; when placed on the balance plane his weight is 50 pounds, and the total length of the board is 20 inches. The formula reads then: 140 _ 20 50 ~ x This is then worked out as follows: 140)1000(7.1 980 200 The center of gravity of the subject then lies perpendicularly above a point 7.1 inches forward from the posterior sharp edge. 13 194 FAULTY ATTITUDE After the determination of the position of the center of gravity, which should occupy on an average one or two minutes, the position of the following points which have been marked on the skin are measured and recorded. Fig. 169. — Apparatus in Use. The Lines Drawn Represent the Lines Shown in the Record Tracings. The Long Line Running Vertically is the Perpendicular of the Center of Gravity. — ("J. Am. Med. Assn.") 1. The position of the back edge of the malleolus. 1 1 In this and the following determinations the horizontal difference is obtained by a footrule, one end of which is placed against the marked point, while the body of the rule is held by the thumb against the upper surface of the sliding arm. Since this surface (and therefore necessarily the rule) is horizontal, the height of the point observed may be read at the same time, from a graduated scale which is marked on the upright post. NORMAL ATTITUDE 195 The position of the back of the head of the fibula. 3. The position of the middle of the trochanter. 4. The position of the posterior part of the spine of the fifth lumbar vertebra. 5. The position of the posterior part of the spine of the seventh cervical vertebra. All these points are taken under the usual conventions of somatologic measure- ments on the living. The measurements having been recorded, are then easily translated into graphic form by the reproduction of the observed measurements on a sheet of paper, of which the bottom represents the balance plane and the edge of the paper the posterior plane of measurement. These five comprise all the exact measurements which are taken, but since the value of their graphic represen- tation is considerably enhanced by its combination with some sort of representation of the body profile of the in- dividual, we have completed the examination by the use of a device which obtains this with fair accuracy and which is illustrated in Fig. 169. A series of horizontal metal arms, tipped with cellu- loid, slide easily through holes in the vertical wooden arm. These metal arms are shaken out to their full length, and their ends pushed rapidly and lightly against the subject's back in the median line, the point of the uppermost horizontal arm being applied to the seventh cervical vertebra. In the ' construction of the graphic record (Fig. 170), the position of this profile is known by its relation to the seventh cervical and fifth lumbar vertebrae; that is, these points are marked on the paper from the measurements taken, and the end of the upper- most arm of the profile instrument is laid against the mark which represents the seventh cervical, while a lower point is in contact with the mark representing the fifth lumbar vertebra. The curve is then traced on the paper containing the other measurements from the ends of the pins throughout its length. The body curve of the ventral surface is obtained in the same way. The uppermost arm of the profile in- strument is applied to the anterior surface of the neck at the level of the seventh cervical vertebra. The position of this curve on the chart is ascertained by using as points of reference the horizontal distances between the posterior parts of the seventh cervical and fifth lumbar vertebrae and the points horizontally opposite on the ventral surface, measured on the subject by a pelvimeter or other calipers. It would be very desirable that this graphic record should be completed in every instance by a representation of the inclination of the brim of the pelvis, which would, of course, include its relation to the trochanter, but after much experimentation we have been unable to measure with accuracy the inclination of the pelvic brim in the living subject. Fig. 170. — Record of the Normal Posi- tion AND THAT IN- DUCED by High-heeled Shoes, the Normal in Solid Line, the In- duced Position in Dotted Line. — ("J. Am. Med. Assn.") 196 FAULTY ATTITUDE The use of the profile curves in the graphic representation involves the dis- advantage that the chart must be drawn life-size, but it can be reduced later by a pantograph to any desired size. The sources of error incident to the method are swaying of the subject, errors in measurement from the vertical plane, distortion of attitude during observation, inaccuracy in locating on the skin the bony landmarks selected, varying position of the feet, horizontal rotation of the pelvis and psychical influences. These errors and their prevention are dealt with at some length in the original descrip- tion of the method. So far as the observations by this method have gone they show that in the erect position the center of gravity of the body lies in front of the ankle-joints, which are held from dorsal flexion in this position by the gastrocnemius muscles. The center of gravity lies also in front of the knees, which are similarly held in position by the ham- string and quadriceps extensor muscles. The center of gravity lies also anterior to the sacro-iliac joints and most of the vertebral joints. The position of the acetabula cannot be determined in the erect position in the living individual because we have no means of locating them from any available landmarks. If we were able to determine the position of the acetabula in the antero-posterior plane it would be possible to state definitely, from the relation of the center of gravity to them, whether the trunk in the erect position would tend to fall forward or backward at their level. But from the impossibility of obtaining definite data on this point we are obliged to resort to another line of observations to determine this matter. It has been shown by many experiments that when the cadaver is stood erect and the legs and ankles are fixed (to prevent the cadaver from collapsing on the ground), the trunk falls forward from the hips. In the erect position then, the trunk is held extended on the legs by the combined and continued action of the posterior musculature, the chief factors here being the hamstrings, the glutei and the erector spinae muscles. After a consideration of this theoretical side of the subject which will in time enable us to obtain exact information as to abnormalities of the standing position it becomes necessary to formulate our present knowledge with regard to these abnormalities. When the antero-posterior and lateral variations coexist, as frequently happens, the lateral variation is in general considered the more important one, and the case is classed as scoliosis. ROUND SHOULDERS ROUND SHOULDERS 197 Stoop or slant shoulders, round back, round hollow back, stoop- ing, faulty attitude, kyphosis, bowed back. German — Schlechte Haltung, runde Riicken, Kyphose, hohlrunde Rucken, kypholordose, habituelle Kyphose. French— Dos Voute, Cyphose. Italian — Schiene rotonde. Fig. 171. — Round Back with Flat Chest and . Prominent Abdomen. Grouped under this name are various types of faulty attitude. Variations from the normal antero-posterior attitude are in general grouped under the name of round shoulders. These shade into each other and are characterized by a disposition to economize muscular force in maintaining the erect position. These deviations have in ICjo FAULTY ATTITUDE general been grouped as round shoulders because an increased con- vexity of the dorsal spine is the most common characteristic. In general the attitude is familiar, the head is carried forward and is somewhat flexed, the physiological curve in the dorsal region is increased and the dorsal region unduly prominent behind, in which backward curve the lumbar region may share, or there may be also an increased lumbar curve forward. The shoulders are drooping and the chest narrow and flat, while the scapulae behind are promi- nent on their posterior borders and the inferior angles may stick out markedly (scapulae alatae). The abdomen is prominent, es- pecially in its lower part. Flat-foot or pronated foot frequently coexists. Children with round shoulders are, as a rule, below the average in muscular development and lack vigor; they are clumsy in their move- ments and walk heavily. In some cases the deformity can be re- moved by a muscular effort on the part of the patient or by gentle pressure with the hands, but in most cases of even average severity the deformity cannot be wholly corrected by gentle passive force, as the maintenance of the malposition has led to adaptive shortening of the soft parts concerned. The cases may, therefore, be considered as flexible or resistant, an important distinction in treatment. Great injustice is done to children with resistant round shoulders by the continual commands to "sit straight," a position which it is im- possible for them to assume. If such a child is laid face downward on a table with the arms at right angles to the body the arms may by passive force be carried back of the middle line of the body. If in this position the arms are carried up beside the head and then lifted back they cannot as a rule be carried so far as the median plane of the body. If such a child is told to put the arms up in the air in the standing position, it is done by making the back hollow in the lower part and protruding the abdomen, because the soft parts between the chest and arms have become contracted and do not permit a free movement. 1 Lateral curvature of the spine frequently coexists. The affection is not wholly one of the spine, but implies a disturb- ance of relations from the feet upward because an increase in the backward curve of the spine implies a forward curve or forward dis- placement somewhere else to balance it. The dorsal spine in other words cannot become more convex without a compensating lumbar 1 E. H. Bradford: " Round Shoulders," "Orth. Trans.," vol. x, page 162. ROUND BACK IQ9 curve forward, or a forward displacement of the pelvis and legs if the lumbar spine is involved in the backward dorsal curve. Round shoulders, therefore, is not to be considered or treated as an affair wholly concerning the dorsal spine and shoulders. On closer analysis these cases will be found to fall into four not very well- defined groups. Transition cases of all grades are seen, and the division is mentioned simply to aid in the study of the cases and their treatment. The groups are as follows: Fig. 172. — Round Back. i . Round Back. — The dorsal and lumbar spine form one convexity backward, which is physiologically a persistence of the infantile position (page 21). A lordosis is apparently of ten present, but on identifying the landmarks this will be found to be merely the up- ward and forward slope of the sacrum and that the lumbar spine does not share in it. 2. Round Hollow Back. — The dorsal spine is bowed backward, but the lumbar spine is bowed forward. The appearance of round shoulders is present, but the general attitude is modified because the 200 FAULTY ATTITUDE pelvis apparently has a greater inclination than in round back, the abdomen is prominent, and the gross appearance is the same as in round back (Fig. 173). 3. Round Upper Back.— In certain cases the dorsal backward curve occurs in the upper part of the spine and gives an especially noticeable forward thrust to the head and a prominence between the scapula?. These cases are Fig. 173. — Round Hollow Back. lA Fig. 174. — Round Upper Back. J rather likely to be rigid and respiratory capacity is poor. The lumbar physiological curve is not necessarily abnormal (Fig. 174). 4. Flat Back. — In certain cases the vertebral column is flat and has apparently nearly lost its dorsal and lumbar physiological curves. The pelvic inclination is obviously diminished and a frequent associa- tion with this attitude is a forward resistant position of the shoulders. l This forward position of the shoulder girdle may, however, ac- x Hasebrook: "Zeitsch. f. orth. Chir.," xii, 4, 613. ETIOLOGY 20I company other forms of antero-posterior deviation, such as round back. In certain cases as noted by Haglund 1 the back is rounded from side to side without especial kyphosis. It must be recognized how very superficial and unsatisfactory this classification is and it must be evident that we are a long way from recognizing the essentials which cause this condition. For purposes of discussion these four divisions will still be spoken of as round shoulders in spite of the fact that this is merely one expression of faulty antero-posterior attitude which involves the whole body from the base of support to the head. ETIOLOGY The shape of the figure is as characteristic of the individual as the form of the features and some children inherit straighter spines than others. A certain amount of importance must therefore be attached to the type of spine with which the child starts. Further evidence of a congenital origin of round shoulders than this (except in gross congenital lesions of the spine), is on the whole wanting. In general the causes of round shoulders are to be sought in — (a) conditions causing muscular weakness; (b) conditions causing a flexed position of the spine for long periods, and in (c) overweighting of the shoulders by improperly arranged clothing; (d) rickets. Some German writers incline toward the view that a weakness of the will is a more important cause than weakness of the muscles. a. Conditions causing muscular weakness are found in rapid growth, overwork and bad air at school, improper school furniture, acute illness, bad hygiene at home, and similar conditions. b. Prolonged flexion of the spine is induced by school furniture which fails to support the back, by errors in vision which necessitate stooping over the books in reading, and in careless attitudes of reading and sitting permitted at home. The child with normal eyes should not have to hold the book nearer than twelve to fourteen inches. c. The customary method of supporting a child's clothes in this community consists in the use of a waist, loose around the abdomen, to which drawers and skirts or trousers are buttoned. 2 To this waist are also attached side elastic stocking supporters which are kept tight to prevent the stockings from wrinkling. This waist is supported 1 Haglund: "Zeitsch. f. orth. Chir.," xxv, 649. 2 Bradford: "Orth. Trans.," vol. x, 162; Goldthwait: "Amer. Jour, of Orth. Surg.," vol. i, 64. 202 FAULTY ATTITUDE above by two shoulder-straps passing over the shoulders near their tips. The whole weight of the clothes and the added pull of stout elastics is thus transferred to the child's movable shoulders, of all parts of the body the least suited to hold against a steady downward pull. This pull is transferred in a measure to the spine by the muscles, clavicles, and thorax, and tends to produce flexion. The remedy of this condition consists in supporting as much as possible the clothing from a belt, ! using round garters, or in cases Fig. 175. — Flat Back; Forward Posi- tion of the Shoulder-girdle. Fig. 176. — Waist with Garters Pull- ing Shoulders Down and Forward. with markedly prominent abdomens the use of the corset waist to be described. OCCURRENCE In examinations of school children the observers find antero- posterior curves less frequent than lateral, but as before explained it is often impossible to say what is an antero-posterior curve and what is a normal. At Stockholm, Haglund found, in 1599 children, 280 scolioses and 170 antero-posterior curves "(90 boys and 80 girls). PROGNOSIS 203 The Lausanne series of 2314 children showed 571 scolioses (24.6 per cent.) and 135 antero-posterior curves (5.8 per cent.), with 47 combined cases included in the above. Gronberg found 715 antero-posterior curves in 8250 Finnish children. They were divided as follows according to his classification : Kyphosis (round back), 478 (66.9 per cent.). Kypho-lordosis (round hollow back), 149 (20.8 per cent.). Lordosis (hollow back), 88 (12.3 per cent.). The age of occurrence of round shoulders Covers the period of childhood from shortly after the time that walking begins to adoles- cence; most cases are seen by the surgeon in middle childhood and about puberty, when in girls especial attention is paid to the figure and carriage. PATHOLOGY AND MECHANISM The pathological changes in round shoulders must be determined rather by inference and interpretation of clinical symptoms than by postmortem examination. Permanent kyphosis in a healthy growing dog was produced ex- perimentally by Wullstein, who approximated the pelvis . and shoulders by straps, causing a flexed position of the spine. In children who continue to grow with the spine in flexion, analogous adaptive changes must occur in the spine and its surrounding struc- tures to those found in scoliosis. Hasebrook 1 considered the cause of resistant forward displace- ment of the shoulders to lie partly in the costoclavicular and coraco- clavicular ligaments and partly in the pectoralis and serratus muscles. He divided the cases into two groups — first, those due to contrac- tion of the muscles holding the shoulders forward, and, second, to weakness of the muscles holding them back. In certain cases, however, it is due to malformation of the upper part of the scapula? which prevents their approximation to the middle line behind. PROGNOSIS The attitude of round shoulders is not to be regarded as one which will be spontaneously outgrown. On the other hand, it requires treatment, and with adequate treatment and proper hygiene the prognosis for recovery is good in young children. In older children and adolescents improvement and perhaps cure are to be ob- l " Zeitsch. f. orth. Chir.," xii, 4, 613. 204 FAULTY ATTITUDE tained. Even in young adults an improved position of the shoulders and a better expansion of the chest are to be secured by adequate treatment. If the attitude of round shoulders is allowed to persist into adult life there are certain respects in which it may affect unfavorably the health of the individual. The flat chest and diminished chest capacity mean impaired respiratory capacity, and diminished room for the heart, and the large abdomen favors ptosis of the abdominal viscera, both factors leading to impaired efficiency. 1 Moreover, the bowed spine is generally a weak spine and such patients are liable to static backache, 2 that is, a backache due to strain of the posterior muscles described under the names of " hysterical spine," " irritable spine," etc. DIAGNOSIS The diagnosis of round shoulders, when it is present in any marked degree, as a rule, presents no difficulty, but at times it is not easily distinguished from more serious affections, causing a backward bow- ing of the spine. The means of distinguishing between the different varieties of round shoulders have been sufficiently indicated in the description of them. The important point is to distinguish a static bowing of the spine from one caused by disease. In the former there is no marked stiffness of the spine, pain is absent, the bowing is gradual, and x-ray appearances are normal. Differential Diagnosis. — Pott's disease (tuberculosis of the spine, angular curvature of the spine) was discussed in speaking of the diag- nosis of scoliosis. At certain stages of dorsal Pott's disease the attitude may resemble round shoulders. Arthritis deformans of the spine was discussed under the diagnosis of scoliosis. No gymnastic treatment for a case of round shoulders should be undertaken in a patient where pain or stiffness of the back is present without a very careful preliminary period of observation and a careful elimination of the first two conditions mentioned above. TREATMENT The treatment of round shoulders is different in flexible or non- resistant cases and in resistant cases. Non-resistant Round Shoulders (Flexible Round Shoulders). — The treatment does not differ radically from that of postural sco- 1 Goldthwait & Brown: "Am. Journ. of Orth. Surgery," Nov., ion. 2 Reynolds and Lovett: Loc. cit. "Journ. Med. Assoc," Mar. 26, 1910. TREATMENT 205 liosis in that both are of the type of the " setting-up drill" of the army recruit. In both, one tries to substitute a correct attitude for the incorrect or faulty one. What has been said with regard to the treatment of postural or functional scoliosis applies to the treatment of flexible round shoulders, the routine and exercises being described in that place (140) for both conditions, and certain exercises being being designated as especially adapted to round shoulders. Resistant Round Shoulders. — The treatment of these cases is similar in plan to that of structural scoliosis where first mobilizing Fig. 177. — Apparatus for Stretching Round Shoulders and for the Application of Forcible Jackets. and then retentive measures must be separately recognized, even if both are carried out simultaneously. Mobilization. — When the shoulders are held forward by contrac- tion of the soft parts and cannot easily be replaced in the normal position, simple gymnastics are likely to prove unsatisfactory and some stretching of the contracted parts is necessary in order to save time and make gymnastics more effective. To stretch these soft parts by gymnastic exercises is slow and often unsatisfactory, and 206 FAULTY ATTITUDE when it is done must be accomplished by passive stretching, induced by pulling back the shoulders either with the arms at the sides or on a level with the shoulders, whichever position offers the greatest resistance. Passive stretching, however, by means of an apparatus is more efficient and quicker. The means to be described offers a simple method. The apparatus consists of an oblong gas-pipe frame of the ordinary pattern. Fastened to this near the middle, and hinged so as to be raised to any degree, is another section of gas-pipe lying on the frame proper and of the same shape and size as the upper half of the frame. To this movable section is fastened, at right angles to it, and movable on it, a gas-pipe bridge rising about eighteen inches from the movable section (Fig. 177). When prepared for use two strips of webbing, lying one over the other, run from each of the buckles at the bottom of the frame. The lower two strips are tightly drawn, and run to the buckles at the end of the movable section. The upper two are loosely fastened to the bridge over the movable section. The cross- pieces are tightened and the patient laid face downward on the webbing strips, which may, if desired, have laid over them, a folded piece of sheet wadding. The strips, however, even in adults, are not uncomfortable. The thighs are flexed and the feet rest on the floor, so that the lumbar spine is flattened. Two pieces of webbing are passed over the mid-dorsal region from side to side, tied to the lower non-movable frame on each side. These furnish the resistance for the straightening of the spine when the upper end of the frame is lifted, carrying with it the head and upper chest. The upper part of the frame is lifted after the patient is in place and as much force as seems advisable is exerted. This should never be pushed beyond the point of mild discomfort. Several stretchings are first made of a few seconds each, and the movable part of the frame again let down to rest the patient. Forcible Correction. — In average cases intermittent stretching is sufficient to loosen up the contraction and to make an improved position possible. In the severer c^6es, however, a plaster jacket should be applied in the improved position. The patient's spine is hyperextended as described, by raising the movable part of the frame, which is then fastened in this position and a plaster-of-Paris jacket applied, including the shoulders, which must be well padded by felt on their anterior surface. This jacket holds the dorsal spine somewhat extended 1 and the shoulders back, by firm pressure, and the pressure can be increased from day to day by in- serting more felt between the jacket and the shoulders. Such jackets should be worn from two to four weeks, and on their removal efficient gymnastic work begun, supplemented by braces, if necessary, to hold the improved position between treatments. 1 R. W. Lovett: "Amer. Jour, of Orth. Sur.," ii, 2, 200. TREATMENT 207 The use of corrective or retentive braces in round shoulders is often unsatisfactory because they are, as a rule, constructed only to pull the scapulae and arms backward, without making efficient forward pres- sure on the curved dorsal spine or making any marked improve- ment in the general attitude. The " shoulder braces " sold in the instrument shops are notably unsatisfactory in most cases. Fig. 178. — Corset- waist for the Treatment of Round Shoulders. In flexible cases of moderate grade or in rigid cases of the same degree which have been made flexible, a properly constructed corset- waist to support the abdomen has, in the experience of the writer, in many cases proved more satisfactory than a brace in inducing an im- proved attitude. The abdominal element in these cases has been too much overlooked and the relaxed and stretched abdominal wall is a very important feature of the symptom- complex roughly called "round shoulders." 208 FAULTY ATTITUDE Efficient abdominal support by means of a corset-waist not only 'enables the stretched abdominal muscles to shorten and recover tone, but by supporting the abdominal contents enables the patient to assume a better general position. A better position of the thorax at once becomes easier and the whole attitude is improved. Fig. 179. — Round Shoulders before Forcible Correction. Fig. 180. — Round Shoulders after Treatment Following Forcible Cor- rection. See Fig. 153. Such corset- waists should fit tightest around the bottom just above the trochanters and should diminish in pressure from below upward, the upper part of the abdomen being free from constriction. They should button in front but be laced in the back, and from them may be hung skirts and stockings. There is no objection to their use in young children and the fear of the parents that they will " weaken" the abdominal wall will be dis- pelled as soon as the improved abdominal outline is seen after a short TREATMENT 209 use of them. They should be used, of course, only in connection with and accessory to gymnastic treatment (Fig. 178). Corsets and Braces. — The use of supports to maintain the spine in a correct position is indicated — (1) in the case of children with lax muscles who are unable to hold an erect position between gymnastic tieatments; (2) after forcible correction to retain what has been gained; and, (3) in resistant cases which are being stretched; but which cannot maintain between stretchings the improvement se- cured by each one. In all of these the brace is to be regarded as a temporary measure, supplementary to the other treatment, whether gymnastic or mobilizing, and to be given up as soon as it can be dis- pensed with. As the sole treatment of resistant round shoulders the use of a brace, which by its corrective effect is to cure the malposition, is not to be advised. The brace which, on the whole, is the most generally effective is the tempered steel upright support. It is made as follows: This form of apparatus consists of (a) a horizontal pelvic band, (6) two up- rights, and (c) a cross-bar. a. The horizontal pelvic band encircles the posterior part of the pelvis from a point one inch posterior to the anterior superior spine on one side to a similar point on the other side. It is curved to fit the contour of the pelvis and should lie close against it. It is made of No. 15 gauge sheet steel, one and one-eighth inches wide. The uprights run from the posterior pelvic band along the sides of the spine to a point about on a level with the acromion process. At this point they are curved outward on the flat, on an angular turn, at an angle of forty-five degrees or more, and run upward and outward to a point just behind the anterior border of the trapezius. In this upper part they are curved to fit the contour of the shoulders and should lie flat against the skin when the axillary straps are tightened. b. The uprights at their lower part are farther from each other than they are at the top. At the bottom their outer edges should be separated by a distance somewhat less than the distance between the two posterior superior spines. At the top they should lie over the transverse processes. They are made of No. 16 gauge sheet steel, five-eighths of an inch wide, and should follow the outline of the back in general, but whatever correction is desired in the standing position is to be made by bending the uprights to fit the curve of the back in a corrected position rather than in the faulty position. c. The cross-bar consists of a piece of steel, which in length should be one inch less on each side than the breadth of the body at the level where it is placed. It is riveted transversely to the uprights at a point just below the posterior fold of the axilla. The projecting ends beyond the bars should not rest on the scapulae, but, if necessary, should be set backward by an angular curve to clear the scapulae. These are made of the same material as the uprights. Buckles are placed on the ends of the pelvic band, and the cross-bar and axillary straps are riveted to the upper ends of the uprights, one on each side. 14 210 FAULTY ATTITUDE The brace is finished by being covered with leather, or by being nickel-plated, with leather covering to the front of the brace. The brace is attached to the body at the top by means of axillary straps and below by means of a broad belt of sheep-skin or cloth, which fits the abdomen and supports the lower part of it. Such a brace is worn continuously between exercise periods but not during the night. Summary of the Treatment of Round Shoulders. — Flexible cases are treated by gymnastics like postural scoliosis; a corset- waist or brace may be necessary to maintain a correct position between treatments. Resistant cases must first be made flexible — (a) by gymnastics; (b) by manual stretching; (c) by stretching in apparatus; (d) by forcible correction, after which the problem is to maintain the improved posi- tion, just as in cases originally flexible. INDEX Acquired scoliosis, 102 Age, 114 Anatomy, 8, 26 Arthritis deformans, 105-126 Articular processes, 40 Attitude, faulty, 191 normal, 191 Asymmetrical exercises, 146 Average heights and weights, table, 72 Back, surface anatomy of, 26 Bone, plasticity of, 47 Bony rotation, 49 Braces, 151 Cervicodorsal scoliosis, 66 Cicatricial scoliosis, 109 Compound scoliosis, 67 Congenital scoliosis, 99, 124 Corrective jackets, 151-157 Corsets, 151 Creeping exercises, 150 Curves, physiological, 11 Diagnosis of round shoulders, 204 of scoliosis, 124 Diseases of the extremities, 106 Dorsal scoliosis, 63 Dorsolumbar scoliosis, 65 Double curves, 50 Elasticity of the spine, 21 Empyema, 108, 125 Etiology of round shoulders, 201 of scoliosis, 97 Evolution of the spine, 20 Examination for scoliosis, 71 Exercises, asymmetrical, 146 creeping, 150 symmetrical, 140 Flexion of the spine, 30 Forcible correction, 157 Frequency of scoliosis, 70, 112, 115 Functional scoliosis, 53 Gymnastics, 130, 132 Habit scoliosis, 109 Habitual scoliosis, 61 Heart disease, 109 History of scoliosis, 1 Hyperextension of the spine, ^2 Hysterical scoliosis, 108 Identification of vertebrae, 26 Inclination of pelvis, 23 Infantile paralysis, 106, 125 Intervertebral discs, 10, 88 Ischias Scoliotica, 108 Jackets, removable, 172 Kyphoscoliosis, 65 Lateral corrective pressure, points for, 28 Lateral flexion of spine, 32 Ligaments of the spine, 12, 88 . Lumbar scoliosis, 62 Mechanism of scoliosis, 43, 58 Movements of the spine, 29 conclusions of, 41 Muscles of the spine and thorax, 16, 27, 89 Nerve supply, 18 Nervous diseases, 107 Normal attitude, 191 examination of, 73 False scoliosis, 53 Faulty attitude, 191 Flat back, 200 Occupation scoliosis, 109 Occurrence of round shoulders, 202 of scoliosis, in 212 INDEX Operative treatment, 187 Organs, internal, pathology of, 94 Organic scoliosis, 61 Ossification of the spine, 20 Osteomalacia, 105 Pain, 51 Paralytic scoliosis, 124 Pathology of round shoulders, 203 of scoliosis, 83 Pelvic inclination, 23 Pelvis, asymmetry of, 92, 102 obliquity of, 102 Photography in scoliosis, 79 Physiological curves, 11, 21 Phthisis, 109 Planes of the body, 21 Plaster jackets, corrective, 157 Plasticity of bone, 47 Points for lateral corrective pressure, 28 Postural scoliosis, 53 Prognosis of round shoulders, 203 of scoliosis, 127 Quadruped scoliosis, in Rachitic scoliosis, 104, 124 Record of scoliosis, 79 Relation to school life, 117 Removable jackets, 172 Retrotorsion, 56 Reverse rotation, 56 Rickets, 104-124 Rotation, bony, 49 of the spine, 36 Round back, 197-199 hollow back, 197-199 shoulders, 197 diagnosis, 204 etiology, 201 occurrence, 202 pathology, 203 prognosis, 203 treatment, 204 upper back, 200 Sacro-iliac articulation, 1 2 Scoliosis, acquired, 102 cervicodorsal, 66 Scoliosis, compound, 67 congenital, 99, 124 description, 51 dorsal, 63 dorsolumbar, 65 examination for, 71 false, 53 from asymmetries, 102 from cicatrices, 109 from empyema, 108, 125 from heart disease, 109 from malformations of vertebral column, 99 from malformations of scapula and thorax, 101 functional, 53 habit, 109 habitual, 61 history of, 1 hysterical, 108 in quadrupeds, in lumbar, 62 mechanism of, 43, 58 occupation, 109 organic, 61 paralytic, 106 pathology of, 83 postural, 53 prognosis, 127 rachitic, 104, 124 record of, 79 structural, 61-127 symptoms, 51 terminology, 52 total, 53 transitional, 57 types of, 48 School fatigue, 117 furniture, 118 life, 117 Schulthess' measuring apparatus, 82 Sex, 113 Short leg, 102 Shoulder girdle, pathology, 92 Side bending of the spine, 32 Spastic paralysis, 107 Spinal ligaments, 1 2 movements, 29 muscles, 16, 27 INDEX 213 Sternum, 14, 02 Stretching of spine, passive, 154 Structural scoliosis. 51-127 Surface anatomy of back, 26 Symmetrical exercises, 140 Symptoms of scoliosis, 51 Terminology, 5: Thorax, 13, 90 anatomy of, 8 muscles of, 16 shape and boundaries of, 15 Torsion, reasons for, 38 Torticollis, 102 Total scoliosis, 53-127 Tracings in scoliosis, 81 Transitional scoliosis, 57 Treatment of postural scoliosis, 129 of round shoulders, 204 of structural scoliosis, 1 27-131 Treatment, operative, 187 True scoliosis, 61 Tuberculosis of spine, 105-126 Types of scoliosis, 48 Unequal hearing, 103 vision, 104 Upright position, defects of, 44 mechanics of, 43 Varieties of structural scoliosis, 62 Vertebrae, changes in, 85 identification of, 26 pathological affection of, 104 Vertebral column, anatomy of, 8 Wolf's law, 47 Writing position, 119 X-ray in scoliosis, 77 LIBRARY OF CONGRESS 111