occasion for interference with these pus-collections. A number disap-
pear by resor])tion. A certain number open s]iontane<)usIv, and either
close witiiin a short time or continue to discharge through a sinus. I
nuist enter a protest against the
free incision of an al)seess in adult Tie- 29s.
cases of Pott's disease. My own
experience, su])plemented by a
pretty large observation, leads
me to believe that it is next to
impossit)le to avoid sepsis sooner
or later, even by the most skil-
ful operators.
The deformities of the hip
Fio. 297.
Thu Banning brace.
Nuck's tspinal brace.
and thigh which result from muscular contraction or contracture usually
right themselves after the case comes under good ])roteetive treatment.
There are very few cases of psoas contraction that, in my .judgment,
require any special treatment, yet where these contractions persist and
contracture has become fully established the deformity may be corrected
either by traction with weight and j)ulley or by subcutaneous or open
incision. A treatment tliat has attained an ej>hemeral degree of jxipu-
larity is the direct incision U])on the Iwme and removal of the tuber-
culous foci. AVhile this may be a step in the right direction, the mor-
tality which is already to the credit of this operation is rather against
its continuance. At least, it i.s against my own suggestion in an article
of this kind.
To recapitulate, then, the treatment should be —
(1) Protective, the ])rotcction absolute and extending through a period
of from twelve to eighteen months.
(2) At the expiration of the eighteen months, if no exacerbation has
LATERAL rVEVATrUK OF THE SPIXE.
2S7
occurrod witliiii tla- past six iiioiitlis, a corset-jacket may l)e substituted
for the solid jacket, and the protection need not be so complete.
(3) After a period of two or three years' treatment certain precau-
tions may be omitted, such as having the patient sleep in the support at'
Fifi
GUI fiirin itf spinal hrart'
night, or having iiim either suspended or lying ])rone wiien tiie apparatus
is removed.
(4) The support to be used l:)y the average ])ractitioner, whether he be
medical or surgical, is the plaster-of-Paris jacket or corset.
(5) The complications are to be treated expectantly, as a rule — the
compression-myelitis by rest and by the avoidance of electricity of any
kind. Internal medication may be employecl, my own preference being
])otas
iodide in large doses. The ['aquclin cautery is freijuentlv
useful, but simply as an adjunct.
(G) Abscesses should be let alone, unless they interfere with the appli-
cation of apparatus or become jjainful or distressing, and interfere by
their size with the function of imjtortant organs or other precautions.
(7) Aspiration is preferaljle to incision : incision should l)eemploved
when aspiration fails.
(8) Deformities resulting from muscular comractions require no
special treatment unless they become fixed by contracture.
(9) Good hygienic surroundings, nutrients in abundance, good climatic
influences whenever possible.
Lateral Ccibvature of the Spine.
The synonyms for lateral curvature (
curvature. Scoliosis, and Siiinal iMirvature
f the sjtine are Rotary lateral
It is not cnstomarv tointro-
288
on thoi'.tjdk • sur(ii-:r y.
(luce Pott's disease and latei-al curvature in such close connection, but
one can give a better idea of" the del'orniities tiiat belong to these two
ortiioptedic subjects by introducing them in this order.
Definition. — I.,ateral curvature of the sjiine is not a disease of the ver-
tebra', but is, more j)ro]icrly s|H'aUing, a lack of syninietry of the two
sides of the i)ody brought about bv a rotation of the vertebne on the
vertical a.xis, this rotation of itself inducing a lateral deviation of the
colunui. So that the term " lateral," as applied to the curvature, i.s a cor-
rect one, and is sufficiently significant to enable one to distinguish the
curve from the angular deformity of Pott's disease ; which deformity,
when it rarely assumes the shape of a curve, is an antero-jiosterior curve.
Etiology. — There is really no deformity of the human body which
presents more difficult problems etiologically than does scoliosis. The
various theories may be enumerated in the following order : Congenital
asymmetry of the articular facets of the lateral masses ; rhachitic changes
in these facets, inducing the asynunetry ; faidty positions long maintained
during the early ]icrioil of life; nuiscular asyninietry dependent upon
some obscure disturbances of the nerve-centres ; faulty attitudes at school,
either in stanclinu- or sittint;-. In tracina: the causes in individual cases I
have been impressed with the frequency with which lateral curvature
Fi<i. :W(1.
Lateral eurvature from myositis ossificans.
develops in very early life, and it has occurred to me that the greater
number might lie traced to rhachitic changes, such changes brought about
by carelessness in supporting the child while the bones were yet soft, and
the failure on the part of the mother or nurse to maintain correct atti-
LATERAL CURVATUEE OF THE SRIXE.
289
tudes. Tlir rluu'liitic tlicnrv is not ;i i;(Mi(l working theory, l)ccause
parents themselves are not aware nf the jiresenee of riekcts, the cliildren
are usually treated for disturl)anees of digestion and various minor ills,
while the jjliysieian himself dislikes to apply the term "rickets" to cases
occurring in <'hildren in the better walks of life. The parents, therefore,
become aware only after the deformity has developed that the child has
passed through the rhaehitie stage.
^\'llile predisposing causes are so uncertain, it behooves us to look for
exciting causes. Among these may be mentioned faulty attitudes at school
Fig. 301.
Fig. ;;02.
A common type of lateral curvature.
Lateral LurvaturL- from poliomyelitis.
long continued, 'faulty positions in standing, whether at home or in school.
Errors in refraction may lead to lateral curvature, becau.se the child must
needs bend forward in order to read or stuily with any dcgr(>e of com-
fort. The occurrence of lateral curvature ujion the right side so fre-
(juently is du(> largely, it seems to me, to the increased use of the right
side brought about by vocations in general.
A very rare cause of lateral curvature of the spine is mvositis ossifi-
cans. Fig. â– M)i) is a case that was for many years under mv observation,
and I had an opjxirtunity of ol)serving the ca.se tiirough its diH'ereut
Vol. II.— I'J
290 ORTIIOrJEDIC SURGERY.
stages. Poliomyelitis i.s a not inf'n'(|U('iit cause of lateral curvature. It
occurs not so much from ])aralysis of the mnselcs of the body as from
paralysis of tiie nmscles of tjie extremities. For instance: a (lelti)iil par-
alysis will give rise to a ciirvatnre on tiie (i))posite side. Crural asym-
metry of any kind will often produce a lumbar curve, while the extreme
loss of power that is associated with a dangle-leg often results in a mod-
erate grade of spinal curvature. Indeed, the case which is represented
in Fig. r)02 is of this type. And, last but not least, crural asymmetry
is the most fre(pient cause of luml)ar curve.
Pathology. — Tiie pathology is well iniderstood. It is a lack of sym-
metry between the two sides of the vertebrse, a rotatidii of the \('rtebra>
upon the vertical axis, a wcdge-sliaj)ed condition of the vertel)r», a bend-
ing of the ribs near the spinal articulations, besides nimierous changes in
the thoracic walls and cavity. The involvement of the spinal cord or
the meninges is exceedingly rare, yet there are on record cases showing
disturbances of muscular nutrition, various forms of neuralgia, and even
paraparesis, clearly dependent u})ou the pressure on the cord, and espe-
cially on the nerves at the foramina of exit. A true ostitis is rarely
present, and when it is present it is confined to the edges of the ver-
tebra or the lateral masses, and is secondary to, or dejiendent upon, the
pressiu'e of these parts one ujhui the otlier by reason of the distortion
and the shortening of muscular tissue. The text-books are so re-
plete with illustrations of the .scoliotic spine that I have refrained from
presenting tiie customary figures.
Clinical History. — The changes that lead u]) to a well-marked rotary
curvature of the spine are so insignificant and so very slight that one
seldom encounters a case in what is known as the very early stage. The
attention is generally first called to tlie di'formity by tlu' dressmaker or
by the mother herself when she is fitting garments, and attention is tlien
called either to what is known as the " angel-wing " or to the high hi]).
By " angel-wing " is understood the undue jirominence of one scapula.
The low'er angle is on a plane nuich ])osterior to the lower angle of tiie
other scapula. The body of the scapula is raised from the cheSt-walls
apparently, so that tlie vertical jilaneof the body itself is posterior to the
vertical plane of the body of the other scapula. By the higji iii])is umler-
stood tiie Jirominence of one iliac crest over that of the otlier. This is
due to olili(juity of the pelvis, and associated with the high hip is a deep
ilio-costal space. The prominent scapula is associated with the earliest
stages of a lateral curvature. It is true tliat to detect the prominence of
this bone an observant eye is often called into requisition ; but rotation
of the vertebra; cannot take place without a projection of the rii)s
on the convex side aii<l a depression of the ribs on the concave
side. This projection will, of necessity cause change in the ap-
pearance of the scapula. Long before any actual lateral deviation
occurs the rotarv element is present, and the lateral deviation appears as
the rotation becomes more pronounced. Next in order of fre(|Uiiicv we
have a lack of symmetry between the tips of the shoulders. One is a
little higher than the other. The acromion process is on a plane ante-
rior to the acromion process of the other side. Among other signs we
have a lack of svmmctry between tlie ilio-costal spaces — the one is rather
deep, the other long; the actual deviation, with a compensatory devia-
LATERAL CURVATURE OE THE SI'EXE. -JOl
tion on the opposite side, tiie mirve resfiiihling a letter S ; the reeession
of the ciiost-walls on tlie eoiieave side, witli a tihin<r of the hiwer angle
of tiie scapula toward the vertical line ; an unc(|ual mammary develo[)-
ment ; a narrowing of the chest-walls anteriorly ; and often an obliquity
of the ])elvis. The jjigeon-hreast or " bird's-nest " deformity is frequently
associated with lateral curvature, and their presence rather confirms the
rhachitic origin of the distortion. As the deformity inei'eases from month
to month, or son;etimes from year to year, the patient is shortened in
stature ; the angel-wing becomes more jirominent ; the ribs on that side,
in fact, form an enormous bosse known as hunchback ; the axilla on the
concave side approaches quite closely the iliac crest ; the free ribs are
unduly ])rominent ; and the patient has a very awkward gait. In Fig.
301 we have a lateral curvature, with the spinous ])rocesses dotted in
order to bring out in more prominent relief the actual lateral deviation
and the letter S curve. In order to represent an extreme degree of
lateral curvature I have introduced Fig. .302. This occurred in a child
•with poliomyelitis, and the extreme distortion here noted is largely de-
j)endent upon the paralysis which develo]K'd in earlv life.
Diagnosis. — In the (leturniity now under considc'ration earlv <liagno-
sis is (juitc as important as in any deformity within the range of ortlio-
p;edic surgery. Lateral curvature which is well advanced docs not
require any s|)ecial skill in diagnosis, and it is only necessary to note
the characteristics of a lateral curvature to differentiate this from the
deformity of Pott's disease, or from round shoulders, or rhachitic kypho-
sis, or irritable spine. An early diagnosis presupposes a knowledge of
the normal positions of the sca|)uhe, the synnnetry of the chest-walls,
the synnnetry of the iliac crests, and the normal anatomy of the spinal
column itself.
A routine examination is the first step in diagnosis, and the ])oints
for observation are the following : The relationship of the scapuhe one
to the other; observe whether they are symmetrical; observe the ilio-
costal spaces; note whetiier one is ileeper than the other or one hjuger
than the other ; note the position of the tijjs of the shoulders, the
acromion processes ; then have the patient bend forward at the hips,
knees perfectly straight, and note whether the cliest-walls on one side
are more prominent than those on the other; note the prominence or
recession of the transverse ])rocesses ; dot the spinous ])rocesses, and
let a plumb-line fall from the vertebra proniinens, and draw a line
with a dernKitiigra|)h or jien along the line — the slightest deviation can,
in this way, be detected ; learn the habitual attitude of the patient. In
making a differential diagnosis one must distinguish between a slight
rotary curvature and an irritable spine. In irntable spine we have
intercostal neuralgia, tenderness along the sjjinous processes, and espe-
cially on either side of the spinous processes. This condition is so
closely allied to hysterical spine that tenderness on jiressure may be
found at various bony points. From round shoulders the diagnosis can
i)e nnvde by the tests above given.
Treatment. — No hard-and-fast rules can be fornuilated for the treat-
ment of lateral curvature. The ideal treatment is pro])erly supervised
medical gymnastics. The use of apparatus is occasionally called for,
an out-of-door life with the tonic effects t)f a bracing atmosphere, regular
292 orthopjEdig surgery.
hcmrs for catiiii;; and sl('c]>iiiti- ; i" ntlu r words, a good hygiene enters
largely into the tlierapciitic tui'iiuilary i'or lateral ctirvatiire. It is diffi-
cult to detcnuine always just Ikjw inucli cxei'eise a eliild shall take or
liciw tlie exercise shall be taken. Suffice it to say that any exercises
which are ])rescribed ought to be not only taught, but insisted upon.
For convenience curvature may be divided into three classes : (1)
tlie incijiient curve, wiiich presents very tew changes and a scarcely
aj)precial)k' dct'orniity ; (2) the well-marked curve, associated with the
rotation of the vertebrae, prominent sca])ula, prominent ribs, and unsyra-
metrical ilio-costal sjiaees ; (•'>) the exaggerated curvature, with great
■deformity, an unyielding s])inal c(jlumn — what is known as a rigid col-
umn — associated usually with a low-grade of nuiscular development and
distortion of the thoracic walls and vertclira\
In the first class the rule is not to ap])ly any form of a]iparatus.
Even shoulder-braces should be discouraged. Light gymnastic exer-
cises, employed symmetrically, are amply sufficient. The muscles can
be very well developed in any gymnasiiun, provided the patient attend
the gymnasium M'ith any specific purjwse in view. It is quite essential
that the patient siioidd devote more time to athletic pursuits of all kinds
than is usually prescribed, and that the hours for study, both at school
and at the piano, should be shortened. So far as my own experience
goes, the family practitioner has, when these cases have been recognized,
been able to afford relief by attention to ordinary hygienic rules. It is
well to sul>niit the case to an occasional critical ol)servation, in order that
more heroic measures be emplf)yed should the deformity belong to the
acti\ely progressive kind.
In the second class gynmastic exercises are always desirable, and are
to be preferred to any form of apparatus. The exce])tions are — stupidity
on the part of the patient, and sluggishness and a failure on the part of
the parents to ap])reciate the ini]>ortance of close attention to details in
gymnastic practice. To bring tliis out in better relief: Given a child
who is either too young or too inattentive to learn well a series of exer-
cises, it is aseless to follow this course longer than one or two months:
we must supplement the exercises with an appliance of some kind ; and
for the average practitioner there is nothing quite so good as the plaster-
of-Paris corset, worn the greater part of the day, taken off toward
evening, and (lis])ensed with until the following morning. Again, some
children, although old enough to a}i|)reciate the advantages of this treat-
ment, seem to lack gray matter. They are stupid, dull ; they fail to
study at school — fail to apply themselves at anything which requires any
effort or a reasonable amount of intelligence. The combination of exer-
cises with apj)aratus is not generally regaixled as the best form of treat-
ment, yet there are some very good ortho])iedic surgeons who not only
combine aj)paratus with active exercises, but devote a good deal of per-
sonal attention to forcible movements, day by day, with the idea of
coi-recting the rotary element. They admit, as we all do, that apj)aratus
of itself, no matter how skilfully constructed and how accurately applied,
fails to untwist ; but in the skilled hands of the surgeon an impression
can certainly be made ujjon the rotary element.
It is difficult in a work of this kind to describe the various exercises.
My own plan is to follow, as nearly as possible, the list given l)y Mr.
LATERAL CURVATVEE OF THE SPINE.
293
Bernard Rotli of London, and to su]ij)lenu'nt these with forced move-
ments, adding from time to time other exercises as the ease seems to
demand. A good working list is the foHowing :
(1) Rrxpinttnrji. — Insist upon the patient standing erect. Then, with
a dumb-hell grasped in each hand, take a fnll inspiration with the month
closed, and hold the breath as long as possilde ; then ojicn the mouth
and gradually exhale. Let this inspiration and expiration be rej)eated
five or six times. With the arms and hands _
fully extended above the head, still grasping
the dumb-bells, repeat the procedure.
(2) Head R<,Mwi,.— \\\th the dumb-liells
grasped tightly, arms by tlu' side, and shoul-
ders well back, rotate the head from side to
side to the fullest extent, throwing into the
movement all the muscular force that is pos-
sible. Do this from fifteen to twenty times.
Let the patient count aloud every one of
these rotations of the heail.
(3) Lateral Flexion of the Head. — Same-
position as in 2, with the head rtilled vigor-
ously from side to side toward the shoulders,
counting as above.
(4) Circumdiietion of Arm.^. — With fore-
arms extended, dundvbclls well grasped,
make as complete circumduction as is jxis-
sible with the arms from the shoiddcrs.
From ten to twenty times will be sufiicient.
(5) Pugilistic. — This is a mere arbitrary
name for this exercise, which is done as fol-
lows : The patient standing erect, shoulders
well back, forearms extended on the arms,
extend both arms forward at a right angle
with the body, palm upward; clinch tlie bells
tightly, then flex the forearm vigorously on
arm, while the arm falls to the side and is
even forced backward, then extend ; flex the
forearm as before ; extend the arm from the
side with palm upward; bring the whole
arm, with forearm fully extended, down
forcibly against the side. This exercise may
be repeated from seven to ten times.
(0) Kei/-note. — With dumb-bells grasped
tightly extend the arm and forearm of the
concave side well above the head, and the
other arm and forearm extended laterally from the side at a right angle
with the body. Now let the patient, with arms in the position just
described, rotate back and forth to the fullest extent the upraised arm,
counting one for a complete revolution. Repeat this ten times. (See
Fig. 303.)
(7) Four Count. — With dumb-bells, l>ring the arm forward from the
side of the body to a right angle, forearms fully extended, jialms facing ;
oy-niitf iKisitii'u.
2!»4 oirnroi'.EDTC si^RaEnr.
tlimw tlic iirins well liaok, and then strike the ends (if the dunib-bells
briskly against each ntiier back of tiie hips. As they rehound strike the
seciind time. Rej)eat this niovenient from eight to ten times.
(8) Aiiril Stroke. — Starting in the same position as above, bi'ing the
arms back of the liody with forearms fully extended, and by a rotary
movement of tiie slioulders strike the dnmb-l)ells together, first one end,
then the other. This should be done from ten to twenty times.
Additional t'xereises may be added to those just given, and resistance
may be offered in a variety of ways. Heavy dumlj-bells may be lifted
from the floor and carried to the extreme point above the head. Exer-
cises may be given to the lower limbs with the patient lying both prone
and supine on a table. Indeed, the surgeon can devise a variety of
means whicii will tend to correct the curvature and at the same time
bring out in full development tlie muscles which seem to be weak. It
must be remembered that all exercises should be light and infrequent
at first, that heavier weights should be used as the muscles develop, and
that adecpiate periods of rest should be insisted upon, both while the
patient is drilling under the eye of the surgeon and under the eye of
the mother or luirse at home. I'^rom a Jialf iiour to an liour a day is
little enough to devote to these exercises. After they have been well
learned they should be continued every day for from one to two or
three years.
Self-suspension in the swing has not liad the reputation of effecting
much relief. A verv fair illustration of the improved position is shown
in Figs. .•]()4 and :V)b.
My aim in outlining a course of exercises has been to pi'csent such
as any surgeon or physician can cmjiloy in his own office and without
the aid of various appliances for forcible correction. The apparatus of
Hoffa, the bars of Lorenz, and the usual devices employed in a gymna-
sium have not been presented, because they are not only difficult to keep in
order, but because the results obtained from tiiese devices have not been
sufficiently gratifying to enal)le me to urge them upon the consideration
of the readers of this article. The management of a case of lateral
curvature in a well-to-do family is sufficiently easy, for the reason that
the time can be given for treatment — the families themselves are inter-
ested in the improvement noted ; but among the poor and the shiftless
the management of such cases is exceedingly difficult. Among this class
may be noted working-girls, whose time is taken u]) throughout the
entire day, and who are really too much worn out to drill or jiractise
in the evening. At the Hospital for the Ruptured and Crippled
attempts are being made from time to time to treat the school-girls
among the poorer classes, and, while much is being accomplished, it
is very difficult to carry out any form of treatment to a satisfactory
issue.
In estimating tiie amount of relief afforded, the scoliosometer, em-
ployed at long intervals, may be advised, but the ideal instrument is yet
to be devised ; and, after all, one relies more on his own observations
carefully made at stated intervals, and on the reports that come from
the mother, the teachers, or the dressmaker. Such reports as the follow-
ing are very suggestive. From the dressmaker, for instance: "Less
padding is required. It is easier to fit the dresses." From the mother
LATERAL crRVATrnLJ OF THE SPTXE.
295
or nuive : " TIk' girl hoKls hcivclt' in imicli liettcr position. It is no
longer nocessarv to insist upon \wv liokling IktscH' straight," etc. etc.
In tile treatment of the third class the plaster-of- Paris jacket and the
varit)us tbrnis of steel braces are really necessary to prevent a further
increase in the deformity. Illustrations of the various braces are omitted,
for the reason tiiat no one is universally recommended, and the claims
for any one in [)articular are tliat it
simply ])revents increase in deform- Fig. 305.
ity. The advocates of mechanical de-
vices usually supplement with gym-
nastic exercises and forced move-
ments. In my own hands the solid
FfG. 304.
Self-suspension in the swing.
plaster-of- Paris jacket applied at intervals of from two to three months,
and applied witii tlie patient .self-sus])eiided to the utmost limit and
under a great amount of lateral pressure, lias yielded the best results.