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LATERAL CURVATURE OF THE SPINE 
 
 AND 
 
 ROUND SHOULDERS. 
 
 LOVETT, 
 
V 
 
LATERAL CURVATURE OF 
 THE SPINE 
 
 AND 
 
 ROUND SHOULDERS 
 
 BY 
 
 ROBERT W. LOVETT, M.D. 
 
 BOSTON 
 
 ASSOCIATE SURGEON TO THE CHILDREN'S HOSPITAL, BOSTCiN ; SURGEON TO THE INFANTS* 
 
 HOSPITAL ; INSTRUCTOR IN ORTHOPEDIC SURGERY, HARVARP MEDICAL SCHOOL ; 
 
 MEMBER OF THE AMERICAN ORTHOPEDIC ASSOCIATION; KORRE- 
 
 SPONDIERENDE MITGLIEDER DER DEUTSCHEN (iESKLL- 
 
 SCHAFT FUR ORTHOPADISCHE CHIRURGIE 
 
 Mitb 154 1fllu0tration6 
 
 PHILADELPHIA 
 
 P. BLAKISTON'S SON & CO 
 
 IOI2 Walnut Street 
 1907 
 
TJ>^7/ 
 
 L^f 
 
 
 C0P\TJIGHT, 1907, BY P. BlAKISTON'S SOX & CO. 
 
 GfROF 
 TEACHERS COLLEee 
 
 PRESS OF 
 
 WM. F. FELL COMPANY 
 
 1220-24 Sansom Street 
 
 philadelphia, pa. 
 
TO 
 
 ALBERT HOFFA 
 
 BERLIN 
 AS A TOKEN OF FRIENDSHIP AND RESPECT 
 
PREFACE. 
 
 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 thera- 
 peutic measures employed have been on the whole largely empirical and 
 have not been sufficiently correlated to its pathology and to the mech- 
 anism by which it is caused. In the last ten years, however, a good 
 deal of progress has been made along new and promising lines, by means 
 of experimental and clinical work, the records of which lie scattered 
 through later medical literature. In the following pages I have at- 
 tempted 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 obtain- 
 ing 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 Department 
 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 contributing 
 material and other assistance. I should, however, express my obligation 
 to Professor Thomas Dwight for his advice given in connection 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 x\natomy. 
 To Miss Amy Morris Homans, Director of the Boston Normal School 
 of Gymnastics, I wish to express my indebtedness for assistance given 
 in many ways; and to my assistants, Fraiilein 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 Ziirich, recently pub- 
 lished in Joachimsthal's " Handbuch der Orthopadischen Chirurgie." 
 
 Robert W. Lo\ett. 
 BosTO.v, 1907. 
 
TABLE OF CONTENTS. 
 
 CHAPTER PAGE 
 
 j/*^- The Anatomy of the Vertebral Column and the Thorax i 
 
 • II. The Movements of the Spine 23 
 
 III. The Mechanism of Scoliosis 38 
 
 IV. Description and Symptoms 46 
 
 V. Examination and Record of Scoliosis 64 
 
 j>^I. Pathology 77 
 
 "- VII. Etiology — Influence of School Conditions. 91 
 
 VIII. Occurrence ' loS 
 
 /IX. Di.\GNOSis : ; 113 
 
 / /X. Prognosis 116 
 
 / XI. Treatment 118 
 
 II. Faulty- Attitude 167 
 
 ^' 
 
 *■ 
 
LATERAL CURVATURE OF THE SPINE AND 
 ROUND SHOULDERS. 
 
 Chapter I. 
 
 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 vertebrae are thirty-three in number. The upper twenty- 
 four, remaining separate throughout life, are distinguished as true, 
 movable, or presacral vertebrae. 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 verte- 
 bral bodies tapering from beloAv upward, and after early infancy it shows 
 four curves, two anterior and two posterior, in the sagittal or median 
 anteroposterior plane. These are called the physiological curves. 
 
 The column is supported in unstable equilibrium on the sacrum. 
 It receives the weight of the arms, the head, and the thorax, and their 
 contents, which it transmits through the sacro-iliac joints to the pelvis 
 and thence through the legs to the ground. 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: 
 
 Cunningham. 1 Morris.- Beaunois. Dwight.s 
 
 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 cm. 28.7 cm. 26.5 cm. 
 
 Lumbar region 12-15 cm. 17.5 cm. 16.8 cm. 19.9 cm. 1S.7 cm. 
 
 ^ Cunningham: "Text-book of Anatomy," Macmillan, 1902. 
 ^Morris: "Human Anatomy," Blakiston, 1903. 
 ^ Dwight: "Medical Record," Sept. S, 1S94. 
 
2 ANATOMY OF VERTEBRAL COLUMN AND THORAX. 
 
 It is frequently stated that the length of the spine in different individuals 
 is pretty constant, but Dwight's figures show rather a wide 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., 
 
 £.. ;»^ 
 
 Fig. I.— The Spine Seen from the 
 Side, Showing the Physiological 
 Curves. — ( IFarreji Museum.) 
 
 Fig. 2. 
 
 Thk Sf'iNi Si;en from the 
 Front. — ( Warren Museum.) 
 
 and in women from 66 to 69 cm., with an average of 67 cm. (Krause). 
 The height along the chord of this arc is forty per cent, of the total 
 height of the^ndividual. In the fetus and young child the column forms 1/ 
 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 
 
INTERVERTEBRAL DISCS. 3 
 
 completes its growth between the ages of twenty-three and thirty-one 
 years. 
 
 The percentage of total length of the individual occupied by the 
 spine without the sacrum is given for different ages by Moser as follows: 
 
 Per Gent, of Verte- 
 Vertebral Column bral Column to 
 Body-length. Length. Body-length. 
 
 o 50 19-2 38-4 
 
 3 86 31.7 36-8 
 
 5 112 35 30 
 
 II 138 41 29.7 
 
 14 152 44 28.9 
 
 15^ 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: (i) The cervical region; (2) 
 the thoracic or dorsal region; (3) the lumbar region. 
 
 The cervical region comprises the upper seven vertebras, 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. 
 
 The line of gravity in the upright position passes through the bodies 
 of the second and twelfth dorsal vertebras, and touches the lower ante- 
 rior border of the last lumbar 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 between which 
 they are found, but they project slightly beyond the edges of the verte- 
 brae. The sum of the heights of all the discs is greatest through the 
 middle portion, next largest through the "Snterior 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 vertebra?, not including the 
 sacrum, as i : 5. According to the same author the ratio of the height 
 of all the discs through the centers to the height of the vertebral column. 
 
4 ANATOMY OF VERTEBRAL COLUMN AND THORAX. 
 
 represented by a perpendicular from the highest point of the atlas to 
 the sacrum, is as i : 4. 
 
 The influence of the discs in the formation of the physiological curves 
 of the spine is shown by the two curves in Fig. 5. Curve (a) 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 con- 
 vexity of the thoracic spine is flattened in the upper part, and the lumbar 
 
 Fig. 3. — Median Section of a Portion of the Adult Lumbar Vertebral Column. 
 The Right Half Seen from the Left. — {Pick.) 
 
 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 backward represented by curve (h), and the bowed back 
 of old age is substituted for the upright attitude with a lumbar forv\-ard 
 curve which is largely due to the influence of intervertebral discs. 
 
 The discs are very firmly attached to the bodies of the vertebrae. 
 On the anterior surface of the column the free edge of the disc shows 
 
LIGAMENTS OF THE SPINE. 
 
 vmh 
 
 Fig. 4.— Lines Repre- 
 senting THE Sum 
 OK THE Thickness 
 
 OF THE InTERVER- 
 
 1 TEBRAL Discs. — 
 
 V, At the front border; 
 ni, in the middle of 
 the disc; h, at the 
 posterior border. 
 
 lamellc-e consisting of fibers passing obliquely from 
 one \ertebral body to the other. The fibers of 
 successive lamelLne are at right angles to each 
 other, and interlace, suggesting a closed lattice. 
 At the upper and under surfaces the fibers pass 
 into the thin plates of half-calcified hyaline cartil- 
 age covering the horizontal surfaces of the bodies. 
 The discs are also attached to the anterior and pos- 
 terior common ligaments of the spine. The inter-" 
 vertebral discs thus furnish a connecting structure 
 of great strength between each two vertebrae, and 
 
 Fig. 5. — Curves of the Vertebral Column.— (i^/t/t.) 
 A, With intervertebral discs; B, without intersertebral discs. 
 
 at the same time they furnish what amounts to a 
 ball-and-socket joint, on account of the incom- 
 pressible fluid pulp in the center of each disc, be- 
 tween 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 intervertebral discs the vertebrre are 
 bound together by ligaments which serve to limit 
 movement between them and contribute stabilitv 
 and strength to the column. Ligaments are com- 
 
ANATOMY OF VERIEBR.\L COLUMN AND THORAX. 
 
 posed of white fibrous tissue, the strongest tissue in the body, highly 
 elastic, but non-extensible. Two of .the spinal ligaments, the ligamentum 
 nuch^e 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 which permits 
 but little motion. \\Tiat motion occurs between the sacrum and the 
 ilia consists of a forward and backward tilting of the sacrum on the 
 ilia on a transverse axis passing through the second sacral vertebra. 
 If the top of the sacrum is tilted backward because of the obliquity 
 of the articular surfaces the ilia are separated.^ 
 
 The sacro-iliac joint is made safe and strong in part by the wedge 
 shape of the sacrum, but chiefly by the iliosacral ligaments. The corre- 
 sponding articular surfaces of the tv\-o bones are covered more or less 
 completely with hyaline articular cartilage and the ver}^ slight joint cav- 
 ity between them is crossed by fibrous bands. The capsule is formed 
 by the ligaments surrounding the joint. The anterior sacro-iliac liga- 
 ment is thin, and consists of short strong fibers passing between the 
 adjacent surfaces of the sacrum and the iliac fossae. The posterior 
 sacro-iliac ligament is very strong, and is responsible for holding the 
 weight of the trunk, head, and arms suspended upon the pelvis and 
 is usually regarded as consisting of t^'O portions. The short posterior 
 sacro-iliac ligament is formed by bundles of fibers passing from the 
 first and second transverse tubercles of the sacrum to the rough posterior 
 part of the inner surface of the ilium, above and behind the auricular 
 surface. The long or oblique sacro-iliac ligament is a superficial part 
 of the short ligament and is a band of fibers extending from the third 
 and fourth transverse tubercles of the sacrum to the posterior superior 
 spine of the ilium. 
 
 THOR-\X. 
 The thorax is a bony cage containing the principal organs of circu- 
 lation and respiration. It is formed by the thoracic vertebrae, the 
 ribs, the costal cartilages, and the sternum. The ribs, tn-elve on each 
 side, form a double series of narrow, curved, flattened bones attached 
 posteriorly to the thoracic vertebrae. They extend at first outward, 
 
 1 Goldthwait and Osgood: "Bos. Med. and Sur. Jour.," INIay 25 and June i, 
 1905, with literature. 
 
THE THORAX. 
 
 and then forward, inward, and downward toward the median hne 
 anteriorly. The seven upper ribs, called the true, sternal, or vertebro- 
 sternal ribs^are attached directly to the sternum by the costal cartilages 
 anteriorly. /i he five lower ribs are called 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 extremi- 
 ties 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 down- 
 ward. 
 
 \ It must be remembered that 
 
 1 ribs are lower at their front ends 
 
 \ than at their vertebral connec- 
 
 1 tion, so that if it is desired to 
 1 rotate a vertebra by pressure on 
 1 a rib, the rib horizontally oppo- 
 Isite the vertebra is not to be 
 Vchosen. It has been shown' in 
 me cadaver (i) that rotation of 
 vertebras may be produced, 
 when the extremities of the 
 spine are fixed, by pressure 
 upon any of the intermediate 
 ribs; (2) that the vertebrae at- 
 tached to the ribs on which pres- 
 sure is made are the most affected; (3) that the rotation never equals 
 the rib excursion; (4) that the most efi"ective points for pressure or 
 counterpressure are as far as possible from the midline anteriorly and 
 posteriorly except on the lowest four ribs. 
 
 Fig. 6.— Model of thk Spine Showing the 
 Anato.mical Relations, Especially the 
 Disposition of the Soft Parts in the 
 Lumbar Region. — (U'arien Miiscmii.) 
 
 ^ Keene: "Amer. Jour, of Orth. Sur.," July, 1906, page 69. 
 
8 ANATOMY OF \'ERTEBRAL COLUMN AXD THORAX. 
 
 STERNUM. 
 The sternum or breast-bone is situated in the median line of the 
 trunk, completing the thoracic cage anteriorly. As a whole, the ster- 
 num is a flat bone, and it lies directed obliquely fonvard and downward. 
 It consists of three parts — the manubrium sterni, the gladiolus, and the 
 ensiform cartilage or xiphoid process. 
 
 SHAPE AXD BOUNDARIES OF THE THORAX. 
 In shape the thorax is somewhat conical, larger behind than in 
 front and compressed anteroposteriorly. The posterior wall is formed 
 
 Anterior radi- 
 ate or stellate 
 ligament 
 
 ['Costo-centra 
 .. . sj'novial sac 
 
 Fibrous ring of inter- 
 vertebral fibro-car- 
 tilage 
 
 Pulpy nucleus of in- 
 tervertebral fibro- 
 cartilaare 
 
 Costo-transverse synovial sac 
 
 Posterior costo-transverse ligament 
 
 Fig. 7.' 
 
 -Horizontal Section through an Intervertebral Fibro-cartilage and the 
 Corresponding Ribs. — (Morris'' s "Anatomy.'") 
 
 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 surface, 
 slightly convex and directed fom-ard and downward, is formed by the 
 sternum and the costal cartilages. The plane of the superior opening 
 or inlet of the thorax is inclined fonvard and do\vnward, 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 gladio- 
 
MUSCLES OF THE SPINE AND THORAX. 
 
 lus, touching the anterior extremities of the elevfenth 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. 
 
 Fig. 8. — G. Herman Meyer. The Two 
 Oblique Mcscle Pulls.— (j^^m.) 
 
 On the left the descending oblique, a, 
 External intercostals ; b, descending- 
 oblique or externus abdominis. On 
 the right the ascending oblique muscle 
 pull. c, Descending oblique or in- 
 ternus abdominis ; d, internal inter- 
 costals ; e, scalenus colli ; f, cre- 
 master. 
 
 Fig. 9.— G. Herm.^n Meyer. The 
 Scheme of the Torso Muscula- 
 ture Indicating the Direction of 
 theVarious Muscle Pulls. — {Feiss.) 
 
 a, Posterior longitudinal muscle pull 
 (sacrospinalis) ; <J, anterior longitudinal 
 muscle pull ; c, oblique descending 
 muscle pull ; d, oblique ascending mus- 
 cle pull ; e, transverse muscle pull. 
 
 MUSCLES OF THE SPINE AND THOR.\X. 
 The general grouping and arrangement of the muscles in their rela- 
 tion to the spine has an important practical bearing on scoliosis. The 
 spine lies at the back of a more or less cylindrical muscular tube of 
 which the abdominal muscles form the front. Of muscles directly 
 
lO 
 
 ANATOMY OF \T.RTEBRAL COLUMN AND THORAX. 
 
 attached to the spine there are two varieties: (i) 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 
 
 a, 
 
 Fig. 10.— G. Herman Meyer. The Sys- 
 tem OF the Sacrospinalis. — (Feiss.) 
 Spinali.s; b, longissimus dorsi ; c, 
 transversalis cervicis ; d, trachelo- 
 mastoideus ; e, ileocostalis ; y, as- 
 cendens cervices; ^, ileolumbalis 
 (hinder portion of m. quadratus luni- 
 borum Auct.); A, obliquus capitis 
 inferior; /, obliquus capitis superior; 
 k, rectus capitis posterior major; /, 
 rectus capitis posterior minor. 
 
 Fig. II.— G.' Herman Meyer. Ante- 
 rior Longitudinal Muscles of the 
 Trunk. — {J^eiss. ) 
 
 a, Sternocleido-mastoideus ; b, rectus ab- 
 dominis ; c, pyramidalis. 
 
 rigid, have an action on the spine. By the combined action of these 
 three the erect position is maintained, or any variation from it is ac- 
 complished. 
 
 In making a side flexion of the spine from the erect position, for 
 
NERVE-SUPPLY. 1 1 
 
 example, no one muscle or group of muscles is alone active, but it implies 
 a concerted and coordinated action of all the groups mentioned 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 
 from the head to the pelvis there is a continuous set of muscles supple- 
 menting 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 vipper 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 longissimus dorsi has been reached 
 the complexus and transversalis cervicis have begun. The whole con- 
 ception 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 struc- 
 ture quite movable above and below it; muscles attached to the thorax 
 are therefore indirectly attached to the spine. The comparative rigid- 
 ity of the thoracic part of the spine is due to the fact that the majority 
 of the ribs are attached 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 side bending or extensive forward or back- 
 ward 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 (Ludloff), but more important than this is the fact that mus- 
 cles 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 Aveak 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 
 
ANATOMY OF VERTEBRAL COLUMN AND THORAX. 
 
 MOTOR 
 
 Sterno-:mastoid 
 Trapezius 
 
 SENSORY 
 
 Neck and scalp 
 I Neck and shoulder 
 
 Shoulder 
 
 Arm 
 
 Hand 
 
 REFLEX 
 
 Scapular 
 
 ■ Front of thorax 
 
 -Xiphoid area 
 
 Abdominal 
 muscles 
 
 Flexors, hip 
 
 Extensors, knee 
 
 I ^Adductors 
 J i 
 
 Epigastric 
 
 hip 
 
 j- Abductors 
 
 J Extensors(?) . 
 'i Flexors, knee (?) 
 
 Muscles of leg 
 moving foot 
 
 •Abdomen 
 (Umbilicus loth) 
 
 (.Buttock, upper 
 j part 
 
 Groin and scrotum 
 (front) 
 
 outer side 
 
 . Thigh 
 
 [ iimer side 
 Leg, inner side 
 f Buttock, lower 
 I part 
 
 i Back of thigh 
 
 Leg) 
 
 and -except in- 
 Ifoot) ner part 
 
 Abdominal 
 
 Cremasteric 
 I Knee-jomt 
 
 Gluteal 
 
 Foof-clonus 
 Plantar 
 
 I Perinseal and anal |- Perinceum and anus 
 
 muscles 
 
 '- Skin from coccyx 
 j to anus 
 
 Fig. I2.-DIAGRAM and Table showing the Approxi.mate 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.)-(7l/or7-Ji s 
 '■'Anatomy .") 
 
OSSIFICATION. 13 
 
 all over the body. Eight are cervical nerves (the first passing over the 
 atlas), twelve dorsal, five lumbar, five sacral, and one coccygeal. Each 
 is formed by the union of two nerve roots, which occurs outside the 
 spinal cord and just inside of or at the intervertebral foramen. The 
 anterior, motor, or efferent fibers come from the 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 ante- 
 rior division is connected with a plexus, ganglion, or nerve of the sym- 
 pathetic system. 
 
 EVOLUTION OF THE SPINE. 
 The history of the spine in its evolution is of interest. In the Cyclo- 
 stomata 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 consists 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 structure, as if they were incidental to its use 
 rather than factors determining of themselves its types of motion. 
 
 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 pro- 
 cesses, 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 devel- 
 opment in length of the bone of which they form a part. At about 
 puberty appear five other secondary or complementary 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, occur- 
 
14 
 
 ANATOMY OF VERTEBRAL COLUMN AND THORAX. 
 
 ring as a flat meniscus at about the seventeenth year and uniting to 
 the vertebral body a few years later (twenty years). The arrest of the 
 development of one-half of one of these latter may become a serious 
 matter. 
 
 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 anteroposterior plane runs in the anteroposterior axis. The 
 term horizontal plane is self-explanatory- 
 
 Epiphyseal plate or disc 
 
 Mammillary tubercle 
 Transverse process 
 
 — Spinous process 
 
 EpipliNseal plate or disc 
 
 Fig. 13.— Lumbar Vertebra at the Eighteenth Year with Secondary Centers.- 
 {Morris's "Anafotny.") 
 
 Pedicle 
 
 Neuro-central suture 
 Centrum 
 
 Fig. 14.— Ossification of the Fifth Lumbar Vertebra— (Morris' s "Aiiatonir.") 
 
 PHYSIOLOGICAL CURVES. 
 
 In examining the literature relating to the physiological curves such contradictory 
 and unsatisfactory information was found that the whole subject was taken up by 
 the writer for investigation, the results of which are presented here.^ 
 
 In this investigation the position of the spine in the human embryo was studied. 
 The spinal curves of the skeletons of mammalia were observed. Measurements 
 were made of the anterior and posterior borders of the bodies of the vertebras in 
 sagittal section of the spine of new-born children and of a child two years old, and 
 
 iprom a paper presented at the Italian Congress of Orth. Sur., "Arch, di 
 Ortop.," 1906, V and vi, page 372, Milan, Sept. 22, 1906. 
 
PHYSIOLOGICAL CURVES. 
 
 15 
 
 lead strip tracings were taken of the back of two hundred normal children between 
 the ages of four days and thirteen years in the positions of slack standing, natural 
 standing, and in prone lying. 
 
 Measurements of medial sections of detached spines showed in new-born 
 infants a slight bony curve in the lower dorsal region, convex backward. This 
 curve was visible on the anterior surface of the column and reappeared after cor- 
 rective manipulation of the spine. The curve of the spine of a child two years old 
 was more developed than in the new-born. Measurement of the anterior and pos- 
 terior borders of the vertebral bodies showed in the cervical region a difference 
 of 0.5 mm. in favor of the anterior borders, in 
 the dorsal region a difference of 16 mm. in favor 
 of the posterior borders, and in the lumbar spine 
 9.5 mm. in favor of the anterior borders. In 
 this spine therefore the three physiological curves 
 were present in the bodies of the vertebrae. 
 
 Tracings over the spinous processes were 
 taken by means of flexible lead strips and the 
 curves transferred to paper for study. The trac- 
 ings showed clearly the form and development 
 of the dorsal and lumbar curves in standing and 
 in lying prone. The natural sitting position as- 
 sumed by all the children was practically the 
 same, a convexity backward of the dorsal and 
 lumbar spines with a maximum at the dorso- 
 lumbar junction. In the younger children this 
 curve included the sacrum. Only four of the 
 children between the ages of nine and thirteen 
 showed a lumbar curve in sitting. " The char- 
 acter of the curves varied most in the youngest 
 children, and became more constant with age. 
 The variations from the accepted normal type 
 of tracing were most numerous in the youngest 
 children, and decreased in percentage and in 
 variety with age. 
 
 In lying the backward dorsal curve was found 
 in 86 per cent, of cases under one year, and in 
 all but two of the 178 children over one year 
 old. The curve was marked at fourteen months, 
 and increased with age. In children under six 
 
 months the curve included the lumbar and sacral regions; in those over six months 
 it did not. The lumbar 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 cervical 
 curve could not be observed to advantage in lying, or in standing, in the }'oungest 
 children, but over the age of fourteen months a cervical curve with anterior con- 
 vexity was observed in standing. The dorsal curve appeared in standing in the 
 earliest tracing in this position, that of a child ten months old, and persisted abso- 
 lutely. The curve was well marked at fourteen months and increased with age, 
 changing in character as it became limited to the dorsal spine, and the maximum 
 receded from the dorsolumbar junction to the middorsal region. The dorsal 
 
 Fig. 15.— Section of the Spine 
 OF A New-born Infant. 
 
i6 
 
 ANATOMY OF VERTEBRAL COLUMN AND THORAX. 
 
 curve was greater in standing than in lying. The lumbar curve in standing appeared 
 first in a child of seventeen months, and from the age of two years persisted in a 
 very large majority of cases, the exceptions being usually children under three 
 years who had not walked. The curve increased ai the expense of the dorsal 
 curve, and was usually greater in standing than in lying. 
 
 GIRL 
 
 1/2 YRS 
 
 Sitting Front 
 
 -7^"C 
 
 Standing 
 
 .7THC 
 
 .4^"L 
 
 4THL. 
 
 .4"^"R 
 
 Fig. 16. — 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. 
 
 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: 
 
 DiiTERENCE Between the Sums of the Anterior and Posterior Borders. 
 
 VERTEBR.3E. DiSCS. 
 
 Cervical region 1.3 mm. 7.8 mm. 
 
 Dorsal region 13.3 mm. 9.2 mm. 
 
 Lumbar region 6.7 mm. 21. i mm. 
 
PELVIC INCLINATION. 
 
 17 
 
 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 inter- 
 vertebral discs and is therefore mobile. 
 
 A slight physiological lateral curve convex to the right has long been 
 recognized in the spine. It has been attributed to the pressure of the 
 aorta on the vertebral bodies, to excessive use of the right side of the 
 body in certain occupations, and to extreme 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 dorsal to the second or third lumbar vertebra. The body 
 of the fifth dorsal vertebra is flattened on the left side, and the discs 
 above and below are similarly affected. There is a groove from one 
 and a half to two centimeters 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 verte- 
 bras 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 ap- 
 parent.^ 
 
 PELVIC INCLINATION. 
 The position of the pelvis in 
 relation to the horizontal plane is of 
 importance in relation to scoliosis 
 and faulty attitude because it must 
 vary from the normal with every 
 variation from the normal of the 
 body in the upright position. If 
 the front part of the pelvis is low- 
 ered a'ld the back part correspond- 
 ingly tilted up it is spoken of as 
 "increased inclination." If the 
 
 front part is raised and the back part lowered it is spoken of as 
 "diminished inclination." With the former is associated an increase 
 of the lumbar physiological curve and with the latter a flattening of it.« 
 
 ^ Pere: "Les courb. lat. norm du Rachis humaine," These de Toulouse, 
 1900. 
 
 Fig. 17. — Female Pelvis, Median Sec- 
 tion. — (Spalteholz.) 
 The solid line running up and back from 
 
 the symphysis indicates the " external 
 
 conjugate diameter." 
 
l8 ANATOMY or \'KRTEBRAL COLUMN AND THOR.\X. 
 
 Changes in inclination of the pelvis form an important element in the 
 faulty attitude to be spoken of as round shoulders, but have been to a 
 certain extent overlooked. 
 
 The internal or true conjugate diameter (conjugata vera) of the pelvis is a 
 line from the sacrolumbar junction to the top of the symphysis pubis and is gen- 
 erally 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 "angle of pelvic inclination," and the observers do not wholly agree in 
 their results, which are as follows: 
 
 Average in Men. Average in Women. 
 
 Year 1745, Mtiller 45 degrees 
 
 Year 1825, Nagele^ 60 " 
 
 Year 1836, Weber Brothers' 65- degrees 
 
 Year 1841, Krause^ 60 " 60 " 
 
 Year 1873, Meyer* 55 " 50 " 
 
 Year 1882, Prochovnik^ 54-i7 " 5i-72 " 
 
 Year 1898, Henggeler^ 44 " 41. i " 
 
 The question has been chiefly studied by gynecologists and obstetricians, and 
 from their point of view most of the work was done over twenty-five years ago. 
 Prochovnik's method of observation commends itself as reliable, and his conclusions 
 are therefore worthy of consideration. He observed living patients, whereas many 
 of the other observations were on cadavers. He measured the patient standing 
 and took in front the height from the ground of the top of the sjTiiphysis pubis and 
 the height of the fifth lumbar spinous process behind. The distance between these 
 two was then measured and the inclination thus determined of a line connecting 
 the fifth lumbar spinous process and the top of the os pubis, a line differing but 
 little from the true conjugate. This he called the external conjugate and used as 
 the basis of all his calculations. By adding from 8 to 12 degrees to his measure- 
 ments the true conjugate is to be found. 
 
 Seventy-six males and eighty females, all apparently normal, over the age of 
 fifteen were investigated and tabulated. 
 
 Le.\st 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 
 supranormal of 60 to 65 degrees, but that an inclination above 65 degrees 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 variation in the inclination of the pelvis in individ- 
 
 ^ "Das Weibl Becken," etc., Carlsruhe, 1825. 
 
 ^ "Mech. d. Menschl. Gehwerkzeuge.," Gottingen, 1836. 
 
 ^ "Hdbch. d. Mensch. Anat. Hauft.," i, i, 324, Hanover, 1841. 
 
 * "Miiller's Archiv," 1873, 9. 
 
 ^ "Archiv. f. Gyn.," 1882, xix, i. 
 
 " "Zeitsch. f. orth. Chir.," xii, 4, 613. 
 
NUMERICAL VARIATION. 1 9 
 
 uals is so wide that the average has but little meaning in any individual case. The 
 angle which the long axis of the leg makes with the horizon as seen from the side 
 in the upright position varies a good deal, being, on the whole, a larger angle for 
 men than for women (8o| degrees in men and 77 degrees in women); that is, the 
 leg axis in women is more oVjlique and less vertical than in men (Prochovnik). 
 
 In the normal, upright position the anterior superior spines of tlje ilium and 
 the tubercle of the os pubis are in the same vertical plane. This was found true 
 by Meyer and Prochovnik and is at least true for Germans. The fact is of impor- 
 tance in determining the normal inclination of the pelvis during life and in measure- 
 ments of cadavers. 
 
 The inclination of the pelvis is influenced by the position of the legs. In the 
 widest possible spread of legs (27J degrees in men and 22^ degrees in women) 
 the inclination of the pelvis is increased on the average by i8i degrees in men and 
 16^ degrees in women. The angle between the lumbar spine and external con- 
 jugate of the pelvis is not, however, greatly changed by this position, as the lumbar 
 spine changes also. The angle in the normal upright position with the legs together 
 being 148 degrees, with the legs spread it becomes 154 degrees in men and 146 
 degrees in women, a difference of only a few degrees. 
 
 As the method of Prochovnik is slow and tedious, Henggeler attempted to find 
 an available practical measure of the pelvic inclination in the obliquity of a line 
 connecting the anterior and posterior superior iliac spines, and made 661 measure- 
 ments for this purpose on children for the most part scoliotic or with other abnor- 
 mality. Knowing the obliquity of this line he attempted to translate it into terms 
 of obliquity of the conjugate diameter by means of anatomical measurements made 
 on the pelves of eight male and fifteen female adult cadavers. He estimated that 
 to obtain the inclination of the conjugate there should be added to the inclination of 
 the line connecting the two superior iliac spines a " constant" which in the measure- 
 ments varied from 24.5 degrees to 47 degrees, with an average for men of 32 degrees 
 and for women of 35.5 degrees. 
 
 Inasmuch as the results of these measurements differ so widely from those of 
 other observers, as the clinical material consisted largely of scoliotic children, and 
 as the "constant" was obtained from the study of adult pelves and applied to the 
 measurements of children's pelves, it is not possible to attach the same importance 
 to these figures as to those of Prochovnik, and this low pelvic inclination cannot 
 be accepted without more extended investigation. 
 
 With regard to pelvic inclination in children there are no figures upon which 
 we can rely to determine whether it is greater or less than in adults. 
 
 NUMERICAL VARIATION IN THE VERTEBRAL COLUMN. 
 
 The number of vertebrae in the different regions of the spine may vary, and 
 the subject has a distinct bearing on the etiology of scoliosis.' Numerical variation 
 in the human spine is estimated by Bardeen as .occurring in 15 or 16 per cent, of 
 people. The following classification of the abnormal spines in the Dwight collec- 
 tion in the Warren Anatomical Museum will show the more usual forms.^ 
 
 I. The number of presacral vertebrae is normal, but there is an irregularity at 
 the junction of the dorsal and lumbar or dorsal and cervical regions. 
 
 ' Fischel: " Untersuchungen liber die Wirbelsaiile und dem Brustkorb, des 
 Menschen," Wiesbaden, 1906. 
 
 ^Thomas Dwight: "Mem. Bos. Soc. of Nat. Hist.," v, 7, 1901.. 
 
20 ANATOMY OF \^RTEBKAL COLUMN AND THORAX. 
 
 2. In some specimens the twenty-sixth presacral vertebra is the one forming 
 the largest part of the auricular surface in contact with the ilium {vertebra fulcralis), 
 but in which the twenty-fifth is not quite separated from it. 
 
 3. There may be more than twenty-four perfectly free presacral vertebras, 
 
 (a) the extra one being thoracic, (b) or lumbar, (c) or both thoracic and lumbar, 
 the latter being sacralized on one side and the twenty-seventh the vertebra fulcralis. 
 
 4. One or more presacral vertebrae may be imperfectly developed — (a) one or 
 more being fused, (6) the atlas and occiput being fused, (c and d) the twenty-fourth 
 being more or less sacralized, 
 
 5. There may be lacking one presacral vertebra — (a) in the lumbar region, 
 
 (b) in the thoracic region, (c) there being twelve pairs of ribs, the first pair being 
 cervical and perfect on one side. The twenty-fourth is the vertebra fulcralis in 
 all groups of this division. 
 
 The two sides of the column may vary independently, a point of much impor- 
 tance. Clinically these variations are described as cervical ribs, Ivmibar ribs, 
 extra lumbar vertebrae, sacralized vertebrae, deficient vertebras, etc. 
 
 When present these variations are usually at the regional boundaries and are 
 found more frequently toward the posterior end of the spine than anteriorly. 
 
 The numerical anomalies which occur may be called a variation around a 
 mean. The error in development having once occurred, there is evident an effort 
 on the part of the organism to correct it as much as possible. If there are but eleven 
 thoracic vertebrae the bodies very often are longer than usual. If the last rib be 
 rudimentary the penultimate is unusually long; if there be an irregularity in the 
 lumbar vertebrae an effort is apparent to imitate the usual aspect of the region 
 as nearly as may be in the spread of the transverse processes. In cases where 
 the last rib is like a transverse process and there are only four lumbar vertebrae, 
 the appearance is often very striking. 
 
 The thorax may be segmentally reduced or extended at either end, extended 
 at both ends, or extended at one end and reduced at the other; a simultaneous 
 reduction at both ends has not been reported. 
 
 According to Bardeen,' the original position of the ilium is opposite the anterior 
 part of the lumbar region, and in development it travels downward. When once 
 it has joined a vertebra it never leaves it. The junction of the spine and the ilium 
 occurs about the end of the fifth week. No chondrification has yet occurred, but 
 there is no subsequent change in segmentation. Even at this early period the 
 thoracic vertebrae are differentiated from the others. Consequently an increase 
 or decrease in the number of thoracic vertebrae is not necessarily determined by 
 the point at which the ilium stops in its migration taUward, but presumably depends 
 on an error of segmentation (D wight, Fischel), 
 
 Speaking broadly, these variations may be regarded as being variations (a) in 
 a cranial direction, {b) in a caudal direction; in the former all the regional bounda- 
 ries are placed higher, there being only six cervical vertebrae; in the latter the regional 
 boundaries are lower than normal. The vertebrae at the regional boundaries are 
 called "transitional vertebrae" and have the features of both regions. 
 
 The present condition as to the meaning of these variations is expressed by 
 Dwight as follows: "The cause of the original error is as yet undetermined, but 
 
 ^"Numerical Variation in the Human Adult and Embryo. " "Anat. Anz., " 
 Bd. XXV, 1904. 
 
SURFACE ANATOMY. 21 
 
 there is no reason to suppose that it is either hereditary or a step toward the 
 future." ' 
 
 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) extending 
 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 erec- 
 tor spinse muscles. It is usually most marked in the upper lumbar and 
 lower dorsal regions. 
 
 Identification of Vertebrce. — In this median furrow the spinous pro- 
 cesses of the lower cervical vertebrae can be felt; in a poorly developed 
 individual they can be seen in the erect position, and in one well de- 
 veloped in forward bending. The upper cervical vertebrae lie too deeply 
 to be either seen or felt. The spinous process of the seventh cervical 
 vertebra is usually quite prominent, though that of the first thoracic is 
 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 depression instead of a 
 prominence. The third sacral vertebra is on the line drawn between the 
 posterior superior spines of the ilium. 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 these 
 methods the latter is the more reliable. In the dorsal region the ob- 
 liquity 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 vertebrae are opposite the 
 lower parts of the corresponding 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 
 'Rosenberg: '^Morph. Jahrb.," xxvii, S. 1-18S. 
 
22 ANATOMY OF VERTEBRAL COLUMN AND THORAX. 
 
 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 spinse 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 : 
 
 Tabular Plan of Parts opposite the Spines of the Vertebra (Gray). 
 
 P / Sth. Cricoid cartilage. Esophagus begins. 
 
 \ 7th. Apex of lung : higher in the female than in the male. 
 
 f 3d. Aorta reaches spine. Apex of lower lobe of lung. Angle 
 
 I of bifurcation of trachea. 
 
 I 4th. Aortic arch ends. Upper level of heart. 
 
 I Sth. Lower level of heart. Central tendon of diaphragm. 
 
 I 9th. Esophagus and vena cava through diaphragm. Upper 
 
 Dorsal -i edge of spleen. 
 
 loth. 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. 
 
 f I St. Renal arteries. Pelvis of kidney. 
 I 2d. Termination of spinal cord. Pancreas. Duodenum just 
 
 Lumbar -j below. Receptaculum chyli. 
 
 I 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 structures lying on both sides of the spine 
 w in the cervical and lumbar regions prevent the use of lateral corrective 
 i force in these regions. In the dorsal region side pressure on the ribs 
 is effective on the vertebrae, but it cannot be exerted on the upper ver- 
 tebrae 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 II. 
 THE MOVEMENTS OF THE SPINE. ^ 
 
 The movements of the spine are generally accepted as being four 
 in number: 
 
 (i) Flexion (forward bending); (2) hyperextension (backward bend- 
 ing); (3) lateral bending (side bending); (4) torsion or rotation. 
 
 Although this classification is usually found in the books, it has been 
 often recognized that torsion is in some way associated with lateral 
 bending. That lateral flexion probably does not exist as a pure move- 
 ment has for some time been recognized by some if not all anatomists, 
 and has been taught for some years by Professor Thomas Dwight. 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 thickness. In 
 the same way the spine, laterally flexed, turns upon its vertical axis to 
 yield in its shortest or anteroposterior 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 move- 
 ments of the spine should therefore be considered as three in number: 
 (i) Flexion; (2) extension; (3) side bending, rotation. 
 
 The human spine is not an extremely flexible body 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 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. 
 
 * R. W. Lovett: "Bos. Med. and Surg. Jour.," June 4, 1900, Oct. 31, 1901, 
 March 17, 1904, Sept. 28, 1905; "Amer. Jour, of .Anat.," ii, 4, 457. 
 
24 
 
 THE MOVEMENTS OF THE SPINE. 
 
 FLEXION (FORWARD BENDING) 
 Is a pure anteroposterior movement without perceptible rotation. It is the most 
 evenly distributed of the spinal movements, and in extreme flexion the outline 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 the observations made was not 
 observed to become convex backward. 
 
 Fig. i8.— 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 vertebras. 
 
 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. 
 
 25 
 
 The most marked flexion of the spine may be obtained by having the model 
 sit cross-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 
 
 Fig. Tg. — Hyperextension in the Model. 
 The head is supported to secure steadiness. 
 
 measured along the spinous processes is increased over the same measurement 
 taken in standing or lying. 
 
 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 the model and cadaver seems to consist 
 in a greater relative participation of the dorsal region in flexion in the model. 
 
 Measurements and '.racings of the spine in the model and in children show 
 the relaxed sitting position to be one of slight flexion. 
 
26 
 
 THE MO\^EMENTS OF THE SPINE. 
 
 HYPEREXTENSION (BACKWARD BENDING). 
 Hyperextension is a pure anteroposterior 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 vertebra. 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 vertebrae 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 bodies 
 alone shows the same character and 
 - : :,, - , distribution of the movement as does 
 the intact spine of the cadaver. The 
 illustration in this case 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 spin- 
 ous processes, is decreased from the 
 same measurement taken in the erect 
 position. 
 
 LATERAL FLEXION (SIDE 
 BENDING). 
 Lateral flexion of the spine ap- 
 parently does not exist as a pure 
 movement, but is to be considered 
 as one part ' of a compound move- 
 ment, of which twisting or rotation 
 forms the other part. 
 
 In describing this side bending it 
 must be stated that the character and distribution of the movement vary widely ac- 
 cording to the degree of flexion or extension of the spine when the side bending is 
 made. It is also affected if the spine is twisted before it is bent to the side. 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 de- 
 pendent upon the anteroposterior position of the spine. 
 
 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 de- 
 scribed. 
 
 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 
 
 Fig. 20. — Hypere.xtension in thk Cadaver. 
 
SIDE BENDING. 
 
 27 
 
 of the trunk pushed to one side. The curve in this position of the spine is greater 
 in the upper lumbar vertebrae 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 Schulthcss; it was, however, found by Benno Schmidt. 
 
 Fig. 21.— 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. 
 
 With the cadaver lying prone on a table the conditions, of course, are against rota- 
 tion, 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 bending under these 
 conditions, but the vertebral bodies turn to the concave side in 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 impor- 
 tance, as the practical problem is that of the behavior of the weight-bearing spine. 
 
28 
 
 THE MOVEMENTS OF THE 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 
 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 
 
 Fig. 22. — Side Bending in the Upright Position of the Model. 
 The movement is chiefly located at the dorsolumbar junction. 
 
 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 bodies to the convexity 
 of the lateral curve. This rotation occurs chiefly in the dorsal region. Each 
 vertebra twists upon the one below it in the long axis of the spine;- the body turning 
 in one direction and the spinous process in the other. 
 
 In side bending of the model in the flexed position the active movement is 
 accompanied by a much greater degree of rotation than is the passive movement, 
 
SIDE BENDING. 29 
 
 the addition of muscular force in this movement seeming to accentuate the element 
 of twisting. 
 
 Side Bending in the Erect Position. — In the cadaver the 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. The whole dorsal region takes some part in the movement, 
 but the dorsal region, except its lower part, compared to the lumbar, is resistant 
 to side bending. 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 
 
 Fig. 23. — Side Bending in the Upright Position of the Cadaver, showing the Same 
 Characteristics as in the Model. 
 
 The column of vertebral bodies alone behaves in side bending in all positions in 
 the same way as do the intact cadaver, the model, and the child. 
 
 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. It occurs lower dowTi in the spine than in the flexed position. 
 The dorsal region participates less and the lumbar region more in the movement. 
 
 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 
 whoUy below the eleventh dorsal vertebra, becoming, therefore, essentially a lumbar 
 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 hyper- 
 extended position. Side bending, therefore, is situated highest in the flexed position, 
 
30 THE MOVEMENTS OF THE SPIXE. 
 
 lower down in the erect position, and lowest in hyperextcnsion in the model, cadaver, 
 and child. In side bending in all positions the twelfth dorsal vertebra behaves 
 as a lumbar, not as a dorsal, vertebra. 
 
 Rotation Accompanying Side Bending in the Hyperextended Position. — This 
 is a sharply limited movement occurring in the lumbar region including the twelfth 
 dorsal as functionally a lumbar vertebra. The thoxax rocks over to the side un- 
 changed, and the rotation of the bodies is to the concave side of the lateral curve. 
 
 Fig. 24. — Side Bending to the Right in the Hyperextended Position of the 
 
 Spine in the Model. 
 The head is supported to secure steadiness. 
 
 The rotation accompanying this type of side bending is essentially a different kind 
 •of motion from that occurring in side bending in flexion, as it is less distributed 
 through the spine and is of a more decided character. The column of bodies alone 
 rotates in essentially the same way as does the intact spine in side bending in the 
 erect and hyperextended position. 
 
 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. 
 
ROTATION. 
 
 31 
 
 In the flexed position the lumbar region is locked against side bending, and the 
 side bend and rotation occur chiefly in the dorsal region and conform to the dorsal 
 type, i. e., the bodies turn to the convexity of the lateral curve. In side bending 
 occurring in the erect or hyperextended position, however, the lumbar region and 
 
 Fig. 25.— Side Bending to the Right in 
 hvperextension in the colu.mn of 
 Vertebral Bodies. 
 
 The same characteristics are shown as in 
 the previous figure. 
 
 Fig. 26. — 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. 
 
 lower dorsal region is the chief seat of the movement, and -as in all side bends 
 in the lumbar region the bodies of the vertebrae turn to the concavity of the lateral 
 curve. 
 
 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 
 the rotation element of the movement will be considered by itself. Under ordinary 
 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 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. 
 
32 THE MO\TEMENTS OF THE SPINE. 
 
 where it disappears. With very forcible rotation appHed 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 bend convex to the left and vice versi. In the 
 model an active rotation to the right is accompanied by a displacement of the trimk 
 to the left side and vice versa. If traction is applied to the head of the erect 
 
 Fig. 27.— 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. 
 
 cadaver, forcible twisting of the head results in rotation of the lumbar vertebrae 
 including the fourth. 
 
 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. 
 
 33 
 
 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 
 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 of a different type, being more sharply localized, in 
 hyperextended positions. In the column of bodies alone rotation possesses the 
 same characters as does the intact column. 
 
 Fig. 28.— 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 devi- 
 ation of the pins. 
 
 Fig. 29. — Rot.ation of the Spine of the 
 Cadaver, Face to the Right, in 
 the Hyperextended Position. 
 
 The movement is seen to occur in the lower 
 part of the spine by the rotation of the 
 pins. 
 
 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. 
 
 Reasons for Torsion. — It is obvious from these experiments that there 
 must be some fundamental reason for the constant occurrence of one type of tor- 
 sion 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 gen- 
 3 
 
34 THE TiIOVEMENTS OF THE SPINE. 
 
 eral. The extent of any of the movements of the spine is, of course, greatly influ- 
 enced 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 the anteropos- 
 terior plane by a series of gentle curves; 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, and one does not have to wait for torsion to 
 occur until the intervertebral discs are compressed and the edges of the vertebrse 
 come into contact, for, from a mechanical point of view, the torsion begins with 
 the beginning of the side bending. It therefore seems very unlikely that pure 
 lateral flexion of the spine ever exists. 
 
 A strip of sponge rubber, half an inch in diameter and fourteen 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 
 produced 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. 
 
 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 they 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. 
 
 Two vertebral columns, which had been previously used and which had con- 
 formed to the usual rule, were prepared for experiment by removing the column of 
 bodies by cutting through the pedicles. The columns experimented upon then 
 consisted of laminae and articular processes with their ligaments. The ribs were 
 not removed from these columns. These could no longer be regarded as flexible 
 rods, and were only anatomical preparations to demonstrate just what part in 
 rotation the articular processes would play if left to themselves. 
 
 Each of these spines was then placed in a vise and pulled to the side. When 
 the spine was hyperextended and pulled to the left, rotation occurred of the same 
 type as in the intact column in the similar position, a rotation of the ribs backward 
 on the side of the concavity. That is, the articular processes alone do the same 
 thing in side bending in the extended position that the intact column does. 
 
 In side bending from the flexed position, however, the spine without bodies 
 
MOVEMENTS BY REGIONS. 35 
 
 rotates in just the reverse direction from that of the intact spine in the same position, 
 the rotation of the ribs being backward on the side of the concavity. This, of 
 course, suggests that in side bending in the extended position the articular processes 
 are active, but that in flexed positions they are not. 
 
 To see if this state of affairs really existed, a spine which had been used and 
 which had followed the rule was sawed longitudinally in such a way as to divide 
 each articular process in the long axis of the spine. The portion on the outer side 
 of this cleft was removed, giving a view of. each articulation. The spine was then 
 flexed, and it was found that as moderate flexion began the articular joint surfaces 
 in the dorsal region, which was the particular field observed, began to separate, and 
 in extreme flexion were separated by an interval of perhaps one thirty-second of an 
 inch. As the spine was extended they seemed to come into close contact at about 
 the point where the flexion rotation changes to the extension rotation. In marked 
 extension they were firmly in contact. 
 
 The conclusion from this is that the column of vertebral bodies alone, without 
 articular processes, rotates in just the same way in side bending, in flexion, and 
 extension that the column does with articular processes present; that in flexion 
 they are not sufficiently in contact to determine the rotation, but that in extension 
 they are in contact, and are the active factors in determining the rotation which 
 occurs in extension. That rotation is, however, in the same direction that it would 
 be if the column consisted of vertebral bodies alone. They apparently serve to 
 accentuate and carry out the behavior of a flexible rod in general, although they 
 undoubtedly aid in preventing pure lateral flexion of the spine. 
 
 :he cervical regioi 
 
 Flexion. — It is possible to straighten the anterior physiological curve. Much 
 of the apparent forward flexion in the cervical region in life is evidently due to the 
 motion between the occiput and the atlas. 
 
 Hyperextension. — The physiological curve can be increased to a certain extent. 
 
 Side Bending. — Side bending is uniformly distributed throughout the cer- 
 vical region and is accompanied by rotation of the bodies of the vertebrae to the 
 concavity of the lateral curve, as in the lumbar region. Rotation and side bending 
 seem always associated. 
 
 Rotation. — Rotation is extremely free between the first and second cervical 
 vertebras, 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 vertebra turn; 
 that is, in a right rotation the curve is convex to the left. 
 
 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. 
 
36 THE MOVEMENTS OF THE SPINE. 
 
 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 here 
 is always accompanied by rotation of the bodies of the vertebrae to the convex side 
 of the lateral curve. With the upper end of the column free the rotation occurring 
 in flexion is very marked in cadavers from which the sternum has been removed. 
 
 Rotation is the most marked of dorsal movements. It reaches its greatest 
 extent in the upper dorsal vertebrae 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 this region is less in 
 flexion than in the erect position and does not extend so far down. In hyperexten- 
 sion it is much limited and 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 rotation of the vertebrae in side bending in the dorsal region is 
 always toward the convexity of the lateral curve. 
 
 LUMBAR REGION. 
 
 Flexion in the lumbar region is a movement of much freedom, but the physi- 
 ological 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 bend. 
 
 Side bending is a free movement in the lumbar region and forms in the 
 erect position a very evenly distributed curve. It varies markedly in the flexed, 
 erect, and hyperextended positions. 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; in a bend convex to the left 
 the vertebral bodies turn to the right. This is to be contrasted with the opposite 
 rotation occurring in side bending in the dorsal region. "•*. 
 
 Rotation in the lumbar region is extremely limited. It is diminished by 
 extreme hyperextension and is least or absent in extreme flexion. Under natural 
 conditions the rotation is greatest in the erect position, but by the addition of trac- 
 tion in that position it is decidedly increased. 
 
 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. 
 The rotation whiqh accompanies side bending is also the opposite of that occurring in 
 the dorsal region. In the lumbar region the bodies turn toward the concavity of 
 the lateral curve, i. e., in a bend convex to the left the bodies tuin to the right. 
 The lumbar region must be considered in function as including the twelfth dorsal 
 vertebra. 
 
CONCLUSIONS AS TO MOVEMENTS. 37 
 
 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 vs^hole spine side bending is accompanied by rotation of 
 the vertebral bodies to the convexitjf 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. 
 
 7. The column of vertebral bodies obeys in flexion, hyperextension, side 
 bending, and rotation, and in the combinations of them the same rules which 
 govern the intact spine, a fact of much significance in connection with the rotation 
 theories of v. Meyer and Albert. 
 
Chapter III. 
 
 MECHANISM OF SCOLIOSIS. 
 
 Elasticity of Vertebrae and Intervertebral Discs. — 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 direc- 
 tion until limited by bony contact and ligamentous or muscular tension. 
 It also allows rotation to occur between two separate vertebrae in an ap- 
 proximately horizontal plane. Bone is slightly compressible, but this is 
 not a factor of importance in contributing to vertebral flexibility. 
 
 Lange^ has experimented with vertebrse at different ages, and has found that 
 their resiliency when released from pressure is greater in adult life than in childhood, 
 but in the former very much less compression is possible. He has further shown 
 that cohesiveness of a vertebra is greatest in children, less in adults, and still less 
 with advancing age. In other words, a child's vertebra may be more easily com- 
 pressed but less easily torn apart than that of an adult. 
 
 Fessler gives the elasticity of intervertebral discs as perfect, inasmuch as they 
 resume their original form after compression and they are exceedingly tough and 
 strong. Fracture of the vertebral column through a disc will occur only \mder 
 a pull exerted in the long axis of the spine. Under such conditions the separation 
 in the cervical and lumbar regions will occur through the discs, starting at the 
 posterior part and overcoming last the resistance in the anterior common ligament. 
 In the dorsal region, on account of the natural kyphosis of that part of the spine, 
 the anterior ligament wUl be the first to give way. 
 
 In childhood the vertebrae are largely cartilaginous, and the increas- 
 ing proportion of bone, along with the diminishing proportion of car- 
 tilage, 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 lessened on 
 account of the atrophy of the intervertebral discs. 
 
 Loss of Height During the Day. — It has been noticed that 
 measurement of the height of the same individual taken in the morn- 
 ing and in the evening shows a decrease in the total height of the body 
 of from I to 2 cm. during the day. 
 
 ^ "Zeitsch. f. orth. Chir.," x, 1902, 47. 
 
UPRIGHT POSITION. 39 
 
 Story found an average loss in height of 1.452 cm. during the day; 
 1.342 cm. of this loss occurred in the spine, the rest below the trunk. 
 This point is of practical importance when exact measurement of the 
 height is to be taken, as in individual cases the loss is much more than 
 the average mentioned.^ 
 
 This has been variously attributed to an increase of the normal 
 physiological curves of the spine through fatigue, and to compression 
 of the intervertebral discs due to the continuous weight supported by 
 the spinal column in the upright position, and also to a general settling 
 down of the whole body. Some observations not yet published, made 
 by students of the Boston Normal School of Gymnastics, show no 
 increase of physiological curves. 
 
 Upright Position. — The spine, it has been seen, is a curved, seg- 
 mented, weight-bearing rod resting in unstable equilibrium on the sac- 
 rum, 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 in- 
 dividual,, for in the cadaver in the upright position no such erect attitude 
 obtains on account of the absence of muscular action. This sense of 
 balance expresses itself in a muscular contraction 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 mechanism 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 sys- 
 tem 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 equilib- 
 rium 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: 
 
 1. 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 eyes straight 
 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 
 
 ' T. A. Story: "Amer. Jour, of Orth. Sur.," i, 2, page 234. 
 
40 
 
 MECHANISM OF SCOLIOSIS. 
 
 %4., 
 
 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 con- 
 nected by a tube made up of muscles, fasciae, and integument.^ Since 
 to maintain the erect attitude the line of gravity must pass through 
 the base of support, so in all positions in which balance is maintained 
 there is a constant equilibration by means of shifting segments. 
 
 If the pelvi§ 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 con- 
 vex 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 and the upright 
 spine is left free to move, the 
 top of the column remains up- 
 right and the spine is curved in 
 the opposite direction, convex 
 to the left. This is the position 
 of balance overcoming the posi- 
 tion induced by gravity. The 
 sense of equilibrium has worked 
 against the force of gravity and 
 has reversed the position nat- 
 ural to the cadaver. Anything 
 which causes any part of the 
 body to be held in an asym- 
 metrical position will cause a 
 lateral deviation of some part 
 of the spine, because a straight, erect spine in the sagittal plane is pos- 
 sible 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. 
 
 Fig. 30. — The Right Side of the Pelvis 
 OF THE Cadaver is Raised and the 
 Upper Part of the Spine Falls to 
 the Left, Making a Lateral Curve 
 Convex to the Right. 
 
 ^Feiss: "Amer. Jour, of Orth. Sur.," iv, i, 37. 
 
PLASTICITY OF BONE. 
 
 41 
 
 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. Wlien such a 
 curved position becomes habitual for any of the reasons given or for 
 
 Fig. 31. — 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. 41.) 
 
 Other reasons, there exists in the adaptive character of bone a reason 
 why this constantly assumed malposition should make a change in the 
 shape of the bones in a growing child and that these changes should 
 become fixed. 
 
 Plasticity of Bone. — The adaptability of bone to pressure has been 
 
42 
 
 MECHANISM OF SCOLIOSIS. 
 
 recognized in general and has been formulated and forms one aspect of 
 what is often spoken of as Wolff's^ 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 secon- 
 dary alterations of their external conformation 
 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 de- 
 mands on it, following in its growth the lines 
 of least resistance, and in children susceptible 
 to great changes in shape from abnormal con- 
 ditions. As an instance of this may be men- 
 tioned the great distortion of the shape of the 
 bones in the Chinese lady's foot produced by 
 iDandaging. It is not necessar}'- to multiply 
 them, for we have direct experimental proof 
 of the case in question in the experiments of 
 WuUstein and Arnd. 
 
 Fig. 32. — Experimen- 
 tal Scoliosis in a 
 Rabbit Produced 
 BY Cutting the 
 Erector Spin^e 
 Muscles. — {Arnd.) 
 
 Fig. 33.— Fifth Lu.mbar Vertebra fro.m Experi.mental 
 Scoliosis in Rabbit. — (Arnd.) 
 
 Wullstein' showed, by bandaging young dogs for months in posi- 
 tions with the spine bent laterally in some and in others bent backward, 
 
 '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. 
 
 ^"Zeitsch. f. orth. Chir.," x, 2. 
 
TYPES OF LATERAL CURVATURE. 
 
 43 
 
 not be 
 section 
 
 removed 
 of these 
 
 that a permanent bony deformity occurred which could 
 by traction in the length of the spine after death. A 
 columns showed wedge-shaped de- 
 formity of the vertebras with a "lip- 
 ping" of the borders of the vertebrae 
 on the concave side of the curve, the 
 trabeculas 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^ produced similar permanent 
 curves characterized by bony deformity 
 and marked rotation in rabbits by ex- 
 tirpation of the erector trunci muscles. 
 They showed, as in WuUstein's experi- 
 ments, that the changes are greatest at 
 the articular ends of the bodies, and 
 the epiphyseal plates in the most de- 
 formed vertebrae clearly overlap the 
 sides of the body. There are of course 
 many other causes of lateral curvature 
 which will be mentioned, such as in- 
 equalities of structure on the two sides, 
 congenital malformation, and the like. 
 
 TYPES OF LATERAL CURVATURE. 
 
 There are two types of malposition 
 in lateral curvature: in one, the posi- 
 tion is that which any normal spine may 
 assume; in the second, the position is 
 one that the normal spine cannot as- 
 sume, a position which implies a change 
 in the shape of the bones. 
 
 The first is due to the adjustment 
 necessary to keep the balance of the 
 spine in the presence of one of the dis- 
 turbing causes mentioned. If this be- 
 comes habitual, it results in a typical 
 attitude to be described as total or postural lateral curvature in the 
 
 ' "Archiv f. orth. Chir.," i, i, 2. 
 
 Fig. 34. — E.XPERI.MENTAL SCOLIOSIS 
 
 IN A Young Dog Produced by 
 Bandaging in a One-sided 
 Position.— ( Wullsteiu.) 
 
44 MECHANISM OF SCOLIOSIS. 
 
 chapter on Description and Symptoms. This attitude may persist as 
 such or change to the second form to be described next. 
 
 The second type of lateral curvature implies a change in the shape 
 of the bones. It cannot be reproduced experimentally in the model, 
 cadaver, or child, and is not within the physiological limits of the spine. 
 It must, therefore, be classed as structural or organic lateral curvature. 
 The characteristic feature is a local backward prominence of the ribs 
 or lumbar transverse processes opposite the lateral curv^e, and this 
 backward prominence or bony rotation is always backward on the 
 side of the convexity of the lateral curve, i. e., left in left curves. 
 
 Bony Rotation. — The reason for this seems to be fairly plain. 
 A permanent curve is forming, we will say, convex to the left; the verte- 
 bral bodies in their growth will follow the line of least resistance, and 
 if they are plastic, they will expand where the pressure is least and 
 become compressed where it is greatest. They will turn away from 
 the line of weight, which is obviously nearer the concave than the con- 
 vex border, and their avenue of escape is toward the convex border 
 or away from the middle line of the body. If they were to turn toward 
 the middle line instead of away from it they would encounter the greater 
 resistance and have to raise the whole weight of the parts above them. 
 In so far as they are plastic they will be compressed where the weight 
 is greatest or on the concave side. The deformity of the vertebrje 
 is therefore due to their plasticity yielding to conditions of unequal 
 strain, and turning where they must to escape. 
 
 Double Curves. — The explanation of a double curve is more difficult. 
 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 functional 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. 
 
 But lateral curvature is not wholly an affair of the upright position — 
 its occurrence in quadrupeds shows that ; again it is seen as a congenital 
 condition, and in empyema and paralysis it would probably occur if 
 recumbency were substituted for the upright position. Yet in quad- 
 rupeds the phenomena are the same as in cases which are the result 
 of superincumbent weight, the spines of the animals showing a rotation 
 
DOUBLE CURVES. 45 
 
 of vertebral bodies backward on the convex side of the lateral curve, 
 in spite of the fact that superincumbent weight is absent as a deforming 
 factor. 
 
 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. 
 
 IX 
 
Chapter IV. 
 DESCRIPTION AND SYMPTOMS. 
 
 SYNONYMS. 
 
 English: Scoliosis, lateral curvature of the spine, rotary lateral 
 curvature of the spine. 
 
 German: Skoliose, seitliche Ruckgratsverkriimmung, Kypho-sko- 
 liose. 
 
 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 n||dian line of the body, a deviation always 
 accompanied by, an element'^f twisting. In certain rare cases the 
 twisting may be the predominant appearance. Deviation of a single 
 vertebra from the sagittal plane 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 
 displacement of the pelvis and legs. In this wider sense scoliosis is 
 to be regarded as a deformity of the whole body, especially manifest 
 in the spine. 
 
 Lateral curvature of the spine has for its chief clinical characteristic 
 a distortion of the symmetry of the body for which the patient or her 
 parents seek advice. It is rarely 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 recognize 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 of the waist to the waistband 
 is longer on one side than on the other. 
 
 The condition is throughout 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 gener^ 
 ally not complained of, but in neurasthenic young women, especially 
 
 46 
 
TERMINOLOGY. h 
 
 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 pres- 
 sure 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, and in severe cases this must result to some 
 extent. Shortness of breath is common in such cases on account 
 of diminished respiratory capacity and displacement of the heart. 
 Phthisis frequently occurs in severe cases during adult life. Disturb- 
 ances of digestion are also frequent from displacement of the stomach 
 and liver. Impairment of vigor is the rule in adults with scoliosis of 
 the severer grades, and impairment of the general health generally results 
 in severe cases in adult life, although children with severe curves as 
 a rule suffer but little deterioration of the general condition. 
 
 It is not uncommon for patients to sp through life with curves of 
 moderate degree which have given rise to little or no trouble; but after 
 the age of fifty or sixty, when atrophy of the intervertebral discs has 
 become marked, such curves may increase and give rise to a sense of 
 asymmetry or to pain in the back or at nerve terminations. It can 
 generally 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 dorsoiumbar. If two curves exist, the upper curve is spoken of 
 first a'ld the lower follows, e. g., right cervicodorsal, left dorsoiumbar; 
 or right dorsal, left lumbar. 
 
 • It is important that the anatomical region affected by the curve be 
 chisignated accurately and not loosely. For this purpose the seventJi. 
 cervical and last lumbar vertebral spines are connected by a string repre- 
 
48 DESCRIPTION AND SYMPTOMS. 
 
 senting 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 vi'here 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 cun-e. 
 
 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 col- 
 umn 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 devia- 
 tion. 
 
 The classification of curves into primary and secondar}', or com- 
 pensatory, is not of great importance. 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 cur\-es are of equal degree 
 and importance so far as can be seen. It is, however, of importance 
 to recognize the predominant cun-e where possible. For example, 
 in a marked and predominant right dorsal curve it matters but little, 
 practically, whether a slight lumbar cun-e exists or not; for purposes 
 of treatment the case is a dorsal curve. If a marked lumbar curve 
 exists with a dorsal curve, however, the situation is wholly different. 
 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 SCOLIOSIS; POSTURAL 
 
 SCOLIOSIS). 
 
 The term "total scoliosis" is applied to cases where the spine iorms 
 
 01- e gradual curve to one side without marked rotation or compel sa- 
 
 tory curves. In 90 per cent, of the cases the curve is to the left. Acconl- 
 
 ing to the figures of Scholder and at the Children's Hospital clinic, 
 
FUNCTIONAL SCOLIOSIS. 
 
 49 
 
 right total 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^^ cent, of the entire 
 number of lateral curvatures. 
 As to sex, the percentage shown 
 in these cases is 24 for males 
 and 17 for females. In boys 
 the number of total scolioses 
 increases steadily with age, but 
 in girls a decrease is noted 
 after the twelfth year, coincid- 
 ing with an increase in the 
 number of left lumbar curves. 
 
 Fig. 35.— Left Total Curve. 
 
 Fk;. 36. — Left Total Curve Bent For- 
 ward, Showing Prominence of Back 
 ON THE Right (Same Patient as Fig. 
 
 35)- 
 
 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 the plumb-line will detect a decided 
 4 
 
50 DESCRIPTION' AND SYMPTOMS. 
 
 deviation of the marked spines from the median plane. The character- 
 istics of the type in 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 0} 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 
 
 Fig. 37. — Radiogram of Total Curve in Patient Shown in Fig. 35. 
 
 slightly higher than the left. Any case 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. Even in apparently 
 typical cases an a--ray taken in the standing position will sometimes 
 show a slight tendency to curve to the right in the dorsal region, which 
 
FUNCTIONAL SCOLIOSIS. 
 
 SI 
 
 may be due to the physiological curve to the right there or to a beginning 
 structural change. Functional curves disappear on suspension or 
 recumbency, and side flexibility is but little limited, bending to the 
 left being perhaps somewhat restricted. In cases of right cur\es 
 the description is reversed. 
 
 The changed relation of the shoulders to the pelvis is more evident 
 in children with a lumbar curve than in cases with round backs. ^ 
 
 The position in a typical functional total curve is merely the physio- 
 logical one necessitated in every 
 normal spine 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 ex- 
 plained in the movements of the 
 
 Fig. 3S. — Case of " Paradoxical Dorso- 
 LUMBAR Scoliosis" Figured by Wil- 
 EOUCHEWITCH. (Compare Figs. 35-37.) 
 
 Fig. 39 — Same Case as in Fig. 38 Bent 
 Forward Showing Prominence of 
 Ribs on Right Side with Left 
 Curve. — {Wilboucheivitch.) 
 
 spine. The thorax and shoulders will be twisted backward on 
 the right, and when the patient bends forward, this twisted posi- 
 tion 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 in this position. This "reverse 
 rotation," "concave torsion," "retrotorsion," as it has been called, 
 has been much discussed- and is an accompaniment of total scoli- 
 
 ^ Srhulthess: "Zeitsch. f. orth. Chir.," vi, 399-566, 1902. 
 ^ Schulthess: "Zeitsch. f. orth. Chir.," x, page 489. 
 
52 
 
 DESCRIPTION AND SYMPTOMS. 
 
 osis, 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/ 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 
 gradual curve to the left without compensating curves (Fig. 37); in 
 
 Fig. 40. — Boy with Left Total 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. 
 
 other cases apparently total curves in .T-rays taken in this way seem 
 to be transitional cases. 
 
 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 
 of structure. The mechanism of this is as follows: 
 
 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- 
 
 * Reiner and Werndorff : "Verhandl. Deut. Gesel. f. orth. Chir., " 1906, page 232. 
 
TRANSITIONAL CURVES. 
 
 53 
 
 girdle will, therefore, be more twisted as the lateral curve increases. One, however, 
 does not see the condition clinically of e.xtreme left total curve and extreme right 
 backward rotation of the shoulder-girdle except, possibly, in cicatricial, hysterical, or 
 paralytic cases. An adjustment 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 intrinsic 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 ad- 
 
 .^, 
 
 Fig. 41. — 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 Posi- 
 tion Like that of the Living 
 Model is Produced with a Lat- 
 eral CiiRVE Convex to the 
 Left. (Cf. Fig. 31.) 
 
 Fig. 42. — E.xpkrimental Double 
 Curve (Right Dorsal, Left Lum- 
 bar) Prodl'ced in the Cadaver 
 BY Elevating the Right Side of 
 the Pelvis and Twisting the 
 Upper End of the Spine, Face to 
 THE Left. 
 
 justment 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 
 certain point in the deformity is reached, be continually striving 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, 
 
54 DESCRIPTION AND SYMPTOilS. 
 
 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 cadaver, 
 the model, and the child by inducing a left total curve and adding a twist, active 
 
 Fig. 43.— 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. 
 
 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. This, of course, is the reversed 
 position to that seen in the left total curve. The same relation of the shoulder- 
 
TRANSITIONAL CURVES. 55 
 
 girdle is to be noticed in single curves to the left which are accompanied by bony 
 rotation, the position again being the reverse of that seen in left total scoliosis. 
 
 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 50). Such 
 cases must be regarded as probably having entered on the stage of transition. 
 
 That left total curves most frequently change to right dorsal, left lumbar com- 
 pound curves than to any other form is shown by the figures of Hess and by a 
 statement of Schulthess.^ But we cannot expect the same final curves 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 de- 
 scribed, 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 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 prominent 
 upward in forward bending, or the left shoulder may be carried forward. 
 Such cases must, of course, be recognized as early structural cases, but 
 are so nearly postural that they may be wrongly classed unless identi- 
 fied. 
 
 It is not exceptional to notice that in a curve that has been clearly 
 a typical postural one, a few months later the dorsal spine is straight- 
 ening and even becoming slightly curved to the right, while the twist 
 of the shoulder-girdle has disappeared or become reversed. 
 
 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 two weeks to eight years 
 and a half. Of these 86 cases, 60 persisted as total scolioses, and the 
 remaining 26 underwent various changes, as shown by the list given 
 below. 
 
 (a) Left convex 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. 
 
 I case changed to right dorsolumbar, left dorsal. 
 
 I case changed to slight left cervicodorsal curve. 
 
 I case showed slight compensating curves. 
 
 21 cases. 
 
 1 T.iinr iT nnrl 9IrViiiltVif><;<;" "Orfh PViir " Tnnr n_ -> \R. 
 
56 DESCRIPTION AND SYMPTOMS. 
 
 (b) Right convex total scoliosis in — 
 
 I case became right dorsal, left dorsolumbar. 
 
 I case became left dorsal, right dorsolumbar. 
 
 I case became left dorsal. 
 
 I case became right dorsal. 
 
 I case became left dorsal, right lumbar. 
 
 5 cases. 
 
 STRUCTURAL SCOLIOSIS (ORGANIC OR HABITUAL 
 SCOLIOSIS). 
 
 This term is applied to those cases in which there is reason to believe 
 that a structural change has occurred in the vertebrae. What this 
 structural change is, is discussed in the chapter on Pathology, but the 
 phenomena are no longer to be explained in physiological terms, for the 
 spine has assumed a position which implies organic change. 
 
 Structural curves are simple or compound-^simplewhen the deviation 
 is accompanied by no compensating curves, e^. §., left lumbar scoliosis. 
 The scoliosis is compound when more than one curve is present, e. g., 
 right dorsal, left lumbar scoliosis. The simple curves are sometimes 
 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 not separated by a right curve never 
 being seen. 
 
 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. By rotation they designate the turning of the 
 vertebral column as a whole at the distorted region; by torsion, the 
 distortion of the individual vertebra. 
 
 LUMBAR SCOLIOSIS. 
 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 frequency. It occurs later than the total 
 scoliosis, as shown by the ages of the patients observed. It occurs more 
 frequently 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 
 
STRUCTURAL SCOLIOSIS. 
 
 57 
 
 found at about the second lumbar vertebra, and as the lumbar 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 is sunken in, and folds may form in the skin of the flank on 
 the concave side. This is ex- 
 pressed by an apparent promi- 
 nence 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. 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 height of the shoul- 
 ders is not noticeably affected 
 by lumbar curves. 
 
 As the patient stands, a full-' 
 ness of the back is noticed in 
 marked cases on the convex side 
 of the curve caused by the ro- 
 tation of the vertebrae, which 
 carry the heavy transverse pro- 
 cesses around and make promi- 
 nent the overlying structures. 
 In the position of extreme for- 
 ward 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. 51). 
 In side bending mobility is greater toward the side which makes the 
 curve worse than to the side which improves it (Fig. 55). 
 
 Fig. 44. — Left Lumbar Scoliosis not Re- 
 turning TO the Median Line. 
 The lines indicate the median plane and the 
 flexibility to each side. 
 
58 
 
 DESCRIPTION AND SYMPTOMS. 
 
 DORSAL SCOLIOSIS. 
 A single dorsal curve is more frequent than the single lumbar type, 
 but is much less frequent than dorsal curves in combination with other 
 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 dor- 
 sal vertebra 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 further 
 from the side than the left; the 
 right shoulder is raised and the 
 waist-line on the right is less con- 
 cave and much flattened in the 
 severer cases, the ribs coming 
 close to the crest of the ilium 
 and obliterating the natural 
 waist indentation. The rota- 
 tion is made evident by a promi- 
 nence, in the back, of the right 
 side of the thorax, which may 
 be seen as the patient stands 
 erect (Fig. 49). 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 rotated with the glenoid cavity downward and 
 the inferior angle inward. 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 
 
 Fig. 45.— Advanced Right Dorsal Scoli 
 osis in an Adult. 
 
DORSOLIIMBAR SCOLIOSIS. 
 
 59 
 
 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 fiat and even depressed surface to 
 contrast with the striking prominence of the right side. 
 
 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 displaced 
 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 from the 
 point rotated backward on the 
 right to the point rotated for- 
 ward on the left — in this case 
 from the right scapula to the 
 left nipple. This description 
 is, of course, to be reversed for 
 left dorsal curves. 
 
 The dorsal physiological 
 curve is most often increased, 
 making the rounded and dis- 
 torted back spoken of as kypho- 
 scoliosis (Fig. 46). It may, 
 however, be flattened, and 
 even slightly concave forward 
 in the dorsal region. The 
 loss of height and shortening 
 of the trunk are evident in the 
 severer cases. The picture is 
 wholly different from that seen 
 in lumbar cases, where, as has 
 been said, the chief noticeable 
 distortion is in the hips and 
 waist-line; in dorsal cases the distortion is most noticeable in the 
 thorax and shoulders. 
 
 DORSOLUMBAR SCOLIOSIS. 
 Dorsolumbar scoliosis is a form seen as a simple curve with con- 
 siderable frequency (20 per cent.), being, therefore, much more common 
 than simple lumbar, but about as frequent as simple dorsal scoliosis. 
 It naturally partakes of the character of the two forms just described 
 and aft'ects nine females to one male. The seat of greatest curve is 
 
 Fig. 46,— K^■PHOscoLIosIS. 
 
6o 
 
 DESCRIPTION AND SYMPTOMS. 
 
 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 cun-e and overhang 
 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, 
 frequently forming folds in the skin. The attitude is more like that 
 of an exaggerated total scoliosis than like either the dorsal or lumbar 
 form. The severest cases are characterized by a kyphosis of 
 
 the spine (kyphoscoliosis). It 
 is not so prone to be associated 
 with compensatory curves as 
 are the other forms. 
 
 CERVICODORSAL 
 SCOLIOSIS. 
 
 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 great- 
 est curve is most frequently 
 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 obviously short- 
 ened, and the outline from the 
 base of the skull to the shoul- 
 der 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 further from the side than the 
 other. JThe rotation appearances are marked, and the sharp angles 
 of the upper ribs are prominent 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. 47. — Left Dorsolumbar Scoliosis, 
 
COMPOUND STRUCTURAL CURVES. 
 
 6l 
 
 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 element predominates, the 
 appearances will be more dorsal 
 than lumbar, as is usually the case, 
 and every grade of variation is to 
 
 Fig. 48.— Cervicodorsal Curve due 
 TO Defective Ribs and Malfor- 
 mation OF VERTEBR/E. 
 
 Fig. 49.— Right Dorsal Left Lum- 
 bar Scoliosis. 
 
 be seen, the predominant curve setting its type on the clinical appear- 
 ance. 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 was from the sixth to the eighth dorsal vertebra, and 
 
62 
 
 DESCRIPTION AND SYMPTOMS. 
 
 the most frequent 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 increasing vears is shown bv Scholder's statistics of school children: 
 
 years old 0.4 per cent. 
 
 13 
 14 
 
 .1.1 
 
 .1.2 
 .2.4 
 .2.1 
 
 ■3-'3 
 ■3-3 
 
 Women are more frequently affected than men, the proportion 
 
 being 7 to i. 
 
 The appearances shown in the 
 ilkistration (Fig. 49) will serve to 
 demonstrate how the appearances 
 
 Fig. 50.— Dorsal Rotation Shown ev 
 Prominenck of Right Side in Bend- 
 ing Forward. (See Fig. 49.) 
 
 Fig. 51. — Lumbar Rotation Shown by 
 Prominence of Left Side in Bend- 
 ing Forward. (See Fig. 49.) 
 
 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 displacement 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 in type from one clinical picture to another 
 in the same patient in the course of years is well established. Not 
 only does the total curve frequently change to a compound type as 
 mentioned, but the structural curves change most frequently by the 
 
COMPOUND STRUCTURAL CURN'ES. 
 
 63 
 
 addition of compensatory curves, e. g., the illustration shows the change 
 of a right dorsal to a right dorsal left lumbar curve (Figs. 52 and 53). 
 The frequency of this is not yet known, and can only be determined 
 when a sufficient numl)er of exact records reaching over a series of 
 years has been accumulated. 
 
 Fig. 52. — ScHULTHESs' Tracing of a Girl Fig. 53. — Tracing of the Same Case Eight 
 Six Years Old. — (Schulthess.) Years l^xvKK.—iSchidthess.) 
 
 The frequency of the common types as tabulated in 1137 cases 
 by Schulthess was as follows : 
 
 Total scoliosis. ; 15-39 P^r cent. 
 
 Lumbar 11. 7 
 
 Dorsal 19 
 
 Dorsolumbar 20 
 
 Cervicodorsal 3.6 
 
 Compound 30 
 
Chapter V. 
 
 EXAMINATION AND RECORD OF SCOLIOSIS. 
 
 It is a matter of practical importance that an accurate examination 
 and reliable record be made of cases of scoliosis, for not only is it essen- 
 tial for accurate treatment that the curves be clearly formulated at the 
 outset, but progress under treatment is only to be estimated by a com- 
 parison of such records. 
 
 The following points are of importance: 
 
 Family History. — The occurrence of scoliosis in the family and the his- 
 tory of any hereditary deformity. The existence of a tuberculous history. 
 
 Personal History. — The character of the labor. The health of 
 the child as a baby. Whether nursed or bottle-fed. The history of 
 infectious and other sicknesses. The age at which dentition began, 
 the date of walking, and the existence of bowlegs or any signs suggest- 
 ing rickets. The age at which the curve was noted and its progress 
 since observation. The child's mental make-up, progress at school, 
 resistance to fatigue, and liability to slight illnesses. The character 
 of growth, whether recent or not, whether rapid or slow. The relative 
 height and weight of the child are of importance and should be taken 
 and compared to the average given in the table, as in formulating the 
 prognosis it is important to know if the child is of average development 
 and if it may reasonably be expected to have in prospect a considerable 
 period of growth. 
 
 Average Heights and Weights. — {T. M. Rotch.) 
 
 BOYS. 
 
 Age. 
 
 GIRLS. 
 
 Height. 
 
 Weight. 
 
 
 Weight. 
 
 Height. 
 
 Inches. 
 
 Pounds. 
 
 
 Pounds. 
 
 Inches. 
 
 19-75 
 
 7-15 
 
 Birth. 
 
 6-93 
 
 19-25 
 
 24-75 
 
 14.30 
 
 5 mos. 
 
 13.86 
 
 23-25 
 
 29-53 
 
 20.98 
 
 I year. 
 
 19.80 
 
 29.67 
 
 ii-^^ 
 
 30.36 
 
 2 years. 
 
 29.28 
 
 32-94 
 
 37.06 
 
 34.98 
 
 3 " 
 
 33-15 
 
 36.31 
 
 39-31 
 
 37-99 
 
 4 " 
 
 36.36 
 
 38.80 
 
 41-57 
 
 41.00 
 
 5 " 
 
 39-57 
 
 41.29 
 
 43-75 
 
 45-07 
 
 6 " 
 
 43.18 
 
 43.35 
 
 45-74 
 
 4S.97 
 
 7 " 
 
 47.30 
 
 45-52 
 
 47.76 
 
 53.81 
 
 8 " 
 
 51-56 
 
 47-58 
 
 49.69 
 
 59.00 
 
 9 " 
 
 57.00 
 
 49-37 
 
 51.68 
 
 65.16 
 
 10 " 
 
 62.23 
 
 51-34 
 
 53-33 
 
 70.04 
 
 II " 
 
 68.70 
 
 53.42 
 
 55-11 
 
 76.75 
 
 12 " 
 
 78.16 
 
 55-88 
 
 57-21 
 
 84.67 
 
 13 " 
 
 88.46 
 
 58.16 
 
 59.88 
 
 94-49 
 
 14 " 
 
 98.23 
 
 59-94 
 
 64 
 
EXAMINATION FOR SCOLIOSIS. 65 
 
 The weights at birth, and in the first, second, and third years, were 
 without clothing. The ordinary school clothes were worn in the weigh- 
 ing from five to fourteen years. 
 
 EXAMINATION. 
 
 GENERAL CONDITION. 
 Nutrition and development. Color. Nervous condition. Con- 
 dition of muscles. Condition of heart and lungs. Chest expansion. 
 Comparative length of legs. Flat-foot. Whether or not spectacles 
 are worn. General attitude and carriage. Manner of wearing cloth- 
 ing, 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 outline of 
 the hips. In children the patients should be stripped to this level; in 
 adolescent and adult young women the chest should be covered 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 lo 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 character- 
 istic one. The patient should not be handled or touched during in- 
 spection, as the contact of the hand frequently 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, whether one arm hangs further from the side than the 
 other. The apparent prominence of one hip is noted. 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 appre- 
 ciation of symmetry is essential in giving corrective gymnastics, and 
 the most useful method to one trained is to erect an imaginary perpen- 
 dicular from the cleft between the buttocks (anal fold) and estimate 
 whether it cuts the trunk in the middle or whether more of the trunk 
 
66 EXAMINATION AND RECORD OF SCOLIOSIS. 
 
 lies to the left or right of it. It is obvious that if any part of the spine 
 is laterally curved, it must carry v\'ith it a segment of the body to the 
 right or left. This displacement will be seen by a change of body 
 outline, and a change 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 plainh' 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 
 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 Avith 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 scapula; 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 anteroposterior physiological curves should be investigated 
 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 movement of the skin over the bony points. 
 This line of marks is accepted as representing the spinal curve, although 
 it does not accurately represent the position of the bodies of the verte- 
 brae (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. 
 
 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 dcA-iation of any number of spinous 
 processes from this line represents a lateral cur\-e which is anah'zed 
 as described in Terminology (p. 47). 
 
 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-Kirckhoff method), which introduces a confusing element 
 
EXAMINATION FOR SCOLIOSIS. 
 
 67 
 
 and does away with the consideration of the deviation as a problem 
 of support, making it a problem of the overhang of the top of the column 
 with regard to its base. 
 
 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 defin- 
 itely measured. 
 
 The surgeon, having thus 
 recognized and described any 
 bodily asymmetry, and having 
 identified and described the 
 curve, is in a position to in- 
 vestigate the element of rota- 
 tion or twist which is essential 
 in every case. 
 
 Estimation of Rotation 
 or Twist. — The surgeon, stand- 
 ing 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 
 twisted 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 scapulas 
 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 rotation 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 standing position, but it is generalh- 
 examined for and estimated in a position of forward tlexion of the 
 trunk sometimes spoken of as Adams' position. The patient bends 
 forward until the trunk is horizontal with the arms hanging down and 
 the knees not flexed. In tliis position the patient remains while the 
 surgeon glances along the back from beliiiKl or in fn)nl, with his head 
 
 Fig. 54.— Thk Pli'mk-line ix thk Cleft ok 
 THE Buttocks to Determine the 
 Median Plane of the Body. 
 
68 EXAMIXATIOX AND RECORD OF SCOLIOSIS. 
 
 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 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 dis- 
 tributed through the spine and designates a afunctional or postural 
 cun^e. That is, in a left total postural ciu^ve the right side of the back 
 will probably be more prominent upward in the fon\'ard 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 dorsolumbar 
 upward prominence designates a right dorsolumbar structural curve. 
 This must be clearly understood, for often a cvirve 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. For example, 
 a patient standing erect shows a right dorsal axrxt, and the inference 
 from the general attitude is that a left lumbar curve probably also 
 exists. It is in any event slight and cannot be clearly defined. If 
 the patient bends fonvard, lumbar rotation will be present or absent, 
 and on this showing lumbar lateral deviation may be excluded or ac- 
 cepted. A slight difference in the levels of the back at the sides of the 
 lumbar region in the forward bent position is sufficient to establish 
 lumbar rotation. 
 
 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 posi- 
 tion, and any straightening of the spine in recumbency will be shown by 
 finding that the spinous processes form a less curved line in recumbency. 
 In postural curves the spine will become straight in recumbency, struc- 
 tural cun-es will be perceptibly straighter than when the patient is erect. 
 The patient should now be suspended by the arms, or preferably . by 
 a Sayre head-sling, enough to take the weight off of the spine, and the 
 straightening of the spine noted. The modification of the asymmetry 
 of the trunk by suspension is most important and should be carefully 
 studied, whether the asymmetry 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 repre- 
 sents the maximum that may be expected from treatment in that indi- 
 vidual case unless further flexibility is restored by treatment directed 
 to that end. The restoration of complete or almost complete symmetry 
 
EXAMINATIOX FOR SCOLIOSIS. 69 
 
 by suspension 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 \yhether the 
 improvement in symmetry is produced by a straightening of the cur\e 
 or curves or whether the modification in asymmetry is produced 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 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 fingers 
 while the knees are straight, while in adult life less flexibility obtains. 
 
 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 forward bend- 
 ing, while another man of the same age of sedentary life cannot get 
 his finger-tips within a foot of the floor in the same position, yet both 
 spines are normal. How rapid the change in flexibility may be owing 
 to habit is shown by the case of a healthy boy of fifteen who could not 
 touch the floor with his finger-tips in forward bending. He injured 
 his knee and was obliged to wear a ham splint. The exertion necessary 
 to dress himself with his leg stiff so increased his forward flexibilitv 
 that in ten days he could place the palms of his hands on the floor 
 without exertion in forward bending. 
 
 The patient then stands with the elbows out and the hands clasped 
 behind the neck, and bends to one side and to the other. The character- 
 istics of side bending have been fully described, and modifications and 
 restrictions of this are to be studied. Patients with curves can, as a 
 rule, bend better to the side that makes the curve worse than to the 
 side that improves it. 
 
 General Condition. — The examination should conclude with an ex- 
 amination of the chest and heart. 
 
 The examination has been dealt with thus at length because rational 
 treatment cannot be undertaken without a clear formulation of the 
 character of the deformity, and experience shows that in the loose 
 use of terms and in slipshod examinations some of the failures to obtain 
 proper results from treatment have their origin. 
 
 X-ray. — The .v-ray is of use in showing the existence of bonv defects, 
 
70 
 
 EXAMINATION AND RECORD OF SCOLIOSIS. 
 
 numerical variation, or other anomalies, and the presence of deformity 
 in the bones. It is of great value in showing the character of the curve 
 in doubtful cases, and its results do not always agree with the clinical 
 
 Fig. 55.— Patient with a Right Dorsal Left Lumbar Structural Curve Bending to 
 THE Left and Right, showing the Comparative Rigidity of the Lumbar Region 
 TO Left Bending and of the Dorsal Region to Right Bending. 
 
 appearances, certain cases judged to be apparently slight by clinical 
 examination showing in the x-ray marked bony deformity. The amount 
 of rotation is indicated in the :x;-ray by the position of the shadow of the 
 spinous processes in relation to the shadows of the bodies; normally the 
 
RECORD OF SCOLIOSIS. 7 1 
 
 spinous process appearing in the middle of the body. But the element 
 of distortion must be remembered. A patient is likely to be twisted by 
 lying on the back if rotation is present, and any deviation of the tube 
 from the middle line of the body is expressed as distortion of the verte- 
 bras. The rr-ray does not as yet provide a method of accurate record 
 on account of the ease with which distortion is produced in shadows. 
 rr-Rays taken in the standing position obviously represent the condition 
 to be treated more correctly than do those taken in recumbency. 
 
 RECORD. 
 
 What is required for record is some accurate method within the 
 reach of the average practitioner or specialist on the subject. 
 
 MEASUREMENTS OF THE LATERAL CURVE. 
 
 Photography, although open to many objections, is probably the 
 most generally available means of record at our disposal. 
 
 The advantages are that no more than average amateur skill in 
 photography is required to get with practice a good picture, that the 
 record can be made in the physician's office, that the results are fairly 
 accurate if taken wdth great care, and that good photographs may 
 be translated into graphic curves by means of a device to be mentioned. 
 
 The objections are that practice is required to obtain proper results, 
 that lights must be studied, that unsteadiness of the patient blurs the 
 picture, that distortion is easily produced by any carelessness, and that 
 the picture at best takes no cognizance of rotation. 
 
 The following rules must be observed : 
 
 1. The patient must stand at ease with the legs straight and the 
 arms hanging at the sides in the relaxed position, which comes on at the 
 end of about one minute. 
 
 2. The heels of the patient must be on a line parallel to the lens, 
 otherwise distortion is inevitable. This relation must be measured 
 and not left to guesswork. The simplest solution is to. have a stand for 
 the patient which is provided with two leathers for the heels. This 
 stand is always placed in a definite location, the relation of which to 
 the camera is formulated. 
 
 3. The patient must stand at a fixed distance from the camera in 
 all cases if pictures are to be used as accurate records. 
 
 4. The light must be oblique from behind, preferably diffused, 
 and not the direct light of the sky if possible, which gives too violent 
 contrasts between light and shadow. A light from overhead throws 
 
72 
 
 EXAMINATION AND RECORD OF SCOLIOSIS. 
 
 the shadow of the shoulders onto the back and obscures the spinal 
 furrow. A light directly from behind gives a flat white picture without 
 contours. A light directly from the side throws the shaded part of the 
 body into such blackness that the body outline of that side is lost. A 
 crossed light obliterates contour and gives a flat and confusing picture. 
 
 5. The shadows must be diminished by a white reflector on the side 
 of the patient away from the light. This is easily obtained by the use 
 of a common clothes-horse, one surface of which is covered with sage 
 green, which serves as a background, while the other wing is covered 
 with white to serve as a reflector. The patient faces the green surface 
 while the white surface is placed at the desired angle to throw the 
 light onto the shaded side. By this arrangement contour may be secured 
 in the picture. 
 
 6. The unsteadiness and swaying of the patient may be obviated 
 
 \Ji.ant.siif.Spne ^ 
 
 Fig. 56. — Tracing Taken by the Feiss Apparatus.— (/V/jj-.) 
 
 in a measure by placing an ordinary photographer's rest against the 
 chest. ^ 
 
 Measurement of Photographs. — If it is desired to measure and study 
 the curve from the finished photograph, the method devised by Fitz 
 is of value. ^ A fixed distance is decided on at which to take the pictures. 
 A large sheet of paper is then divided into carefully measured squares 
 of any desired size. This sheet of paper is then photographed with 
 the camera at the fixed distance to be adopted. The negative will 
 reproduce the diagram on the paper, each square on the negative repre- 
 senting in measurement the square upon the paper. This diagram 
 on the negative may then be transferred to a thin sheet of clear celluloid 
 
 ' G. W. Fitz: "Bos. Med. and Surg. Jour.," Nov. 16, 1905. 
 
RECORD OF SCOLIOSIS. 
 
 73 
 
 (_2 o_ Qf a^n inch in thickness) by scratching with a needle-point the 
 Hnes appearing in the negative. By laying this transparent scale upon 
 any print taken at this fLxed distance 
 a scale of measurement is provided. 
 
 Tracing. — A simple and approxi- 
 mately accurate record may be made 
 by marking the spinous processes and 
 laying on the back, while the patient 
 stands erect, a strip of crinoline gauze, 
 through which the spinal marks may 
 be seen. They are thus easily marked 
 on the gauze, which may be kept as a 
 record. The error lies in the possible 
 slipping of the gauze and the necessity 
 of placing the hands on the patient. 
 
 Any one interested in the sub- 
 ject may find a number of methods 
 described, together with the liter- 
 ature of the subject, in the reference.^ 
 
 Record of the Rotation. — The 
 method of Feiss ^ is fairly accurate and 
 represents the simplest available means 
 of securing a record of rotation in the 
 upright position. The apparatus con- 
 sists of a square upright on a heavy 
 base; on this upright slides a horizon- 
 tal arm carrying two arms at right 
 angles with it, all pierced with holes 
 two inches apart, the size of a lead 
 pencil. The patient stands in the ap- 
 paratus, and by means of a skin pencil 
 pushed through a hole on each side 
 and a hole at the back of the sliding 
 arm three marks are made on the skin 
 in the same horizontal plane. These 
 marks are first made at the level of the 
 
 anterior superior spines, and then the sliding arm pushed up to the level 
 of the deformity, and through the same holes three similar pencil marks 
 are then made on the skin at that level and at other levels if desired. 
 
 ^ "Ueber die Messmethoden des Riickens," Hovorka, Wien, 1904. 
 ^ "Bos. Med. and Surg. Jour.," July 13, 1905. 
 
 Fig. 57. — Apparatus for Recording 
 Rotation' in Scoliosis. — {Fci'ss.) 
 
74 
 
 EXAMINATION AND RECORD OF SCOLIOSIS. 
 
 The patient now steps out of the apparatus, and, by means of a 
 rubber flexible rule or a lead strip, front and back tracings are made 
 
 Fig. 5S.— Leveling App.'^ratus (Nivellier Trapez) for the Measurement. of Rota- 
 tion IN THE Forward Bent PosiTiot^.—lScku/Zhess.) 
 
 Fig. 59.— Schulthess' Measuring Apparatus. 
 
 at each level and the three points""are marked on the tracings. These 
 tracings are then drawn on a paper, the corresponding marks on each 
 
RECORD OF SCOLIOSIS. 
 
 75 
 
 outline being superimposed, so that as each series of pencil marks 
 is in one vertical plane, the outlines represent a series of superimposed 
 contours in their proper relation to each other. 
 
 Rotation may be estimated in degrees with accuracy in the forward 
 bent position by means of the Schulthess level square (Nivelli'er trapez) , 
 which consists of two arms sliding on a rod to which they are at right 
 angles. These arms are placed on corresponding levels of the back 
 
 -Tracing of a Left Dorsal Right Lumbar Curve Made bv the Schulthess 
 Measuring Apparatus. — {Children's Hospital.) 
 
 at equal distances from the spine, and the rod is provided with a pro- 
 tractor and swinging weight to show the inclination of_^the rod to the 
 horizontal plane in degrees (Fig. 58). 
 
 Methods which wculd estimate the rotation while the patientpies 
 prone on the face are inaccurate because the pressure of the table on 
 the prominent side of the front of the thorax tends to rotate the chest 
 and cause distortion. 
 
76 EXAMINATION AND RECORD OF SCOLIOSIS. 
 
 The Schulthess Apparatus for the Record of Scoliosis. — The 
 
 Schulthess apparatus, which is generally accepted as being the most 
 accurate means of record at our disposal, consists of an upright 
 frame in which the patient stands, the pelvis being fixed by clamps 
 and the sternum steadied by an adjustable rod. Behind the patient 
 there is a sliding bridge with counterweights which move up and 
 down on the uprights. Attached to this bridge is a pointer which 
 moves forward and backward and sideways. The movements of 
 this pointer by an arrangement of weights and pulleys are recorded 
 upon two glass panels parallel to the sagittal and frontal plane of the 
 body by means of pencils moving on paper attached to the glass panels. 
 By tracing from below upward the marked lines of spinous processes 
 on one panel the anteroposterior curve of the spine is recorded, while 
 on the other the lateral curve is simultaneously marked. 
 
 By a longer pointer the lateral body outline is then traced in the 
 frontal plane after the position of the scapulae has been recorded. The 
 two pencils in use are then thrown out of action, and by means of a 
 third pencil working upon a glass plate on the sliding bridge horizontal 
 contours are recorded at three levels. By means of an additional 
 sliding bridge working in front of the apparatus a late modification 
 of it provides for anterior as well as posterior contours which may be 
 joined to give a complete contour of the body at different levels (Figs. 
 59 and 60). 
 
Chapter VI. 
 PATHOLOGY. 
 
 The pathological changes found in scoliosis are not the result of 
 disease of the bones, but are modifications in shape and structure result- 
 ing from abnormal pressure and strain in a growing spinal column. 
 
 The pathological changes occurring in scoliosis may vary from mod- 
 erate asymmetry to extreme distortion. In general the spine is curved 
 to one side in some part of its length, or it is curved in one direction 
 in one part and in the opposite direction above or below or both above 
 and below. This curve is formed by the deviation of the vertebrae 
 from the median sagittal plane of the body and is more marked in the 
 column of bodies than in the column of arches. The lateral curve 
 may be a general sweep to one side, or it may be sharp and in the severer 
 cases angular. In the severer cases it exists not alone in the presacral 
 vertebrae, but may also involve the sacrum and coccyx. 
 
 In addition to the lateral deviation, the curved region is rotated 
 or twisted on a vertical axis, the bodies of the vertebrae always turning 
 toward the convex side of the lateral curve. This rotation is the me- 
 chanical accompaniment of the lateral curve, and one cannot exist 
 without the other, although in some cases the rotation is out of propor- 
 tion to the lateral deviation, and in other cases the lateral curve pre- 
 dominates over the rotation. Pure forms of wedge-shaped and lozenge- 
 shaped vertebrae (to be described below) are rare, and both processes 
 are common in the same vertebra. 
 
 In connection with the lateral curve, alteration in the normal antero- 
 posterior physiological curves may occur, consisting chiefly of an in- 
 creased or diminished dorsal convexity. W'Tiile shghtly developed 
 scoliosis leaves the physiological curves almost unchanged, with scoliosis 
 of middle degree there is often found a marked flattening of the dorsal 
 spine, and in severe scoliosis there may be an exaggerated kyphosis in 
 the segment affected by the lateral deviation. In extreme cases there 
 may even be a complete reversal of lumbar and dorsal anteroposterior 
 curves, for, as the lateral deviation is not limited to any one segment, 
 
 77 
 
Fig. 6!.— Scoliotic Spink from the Dwight Collection of Abnormal Spines in the 
 
 Warren Museum. 
 Sacralization of the twenty-sixth vertebra on the right. Thirteen dorsal and six lumbar 
 vertebrse. Fusion of several vertebra and of first three ribs on the left. The changes in 
 the vertebral bodies are characteristic of severe scoliosis. 
 
 78 
 
CHANGES IN THE \'ERTEBR^. 
 
 79 
 
 neither is the flattening nor the formation of a backward prominence 
 Hmited to the points of physiological kyphosis or lordosis. The relation 
 of these changes to the lateral curve is but little understood. 
 
 Such being the gross pathological changes occurring in the spine as a 
 whole, it will add to clearness in considering this most complex matter 
 to take up individually the alterations in the separate elements. 
 
 CHANGES IN THE VERTEBR.^. 
 
 Vertebral Bodies. — The scoliotic vertebrse are to be divided into 
 two classes, according to their pathological changes, those in the angle 
 of the curve being called wedge vertebrae, while those between the apices 
 of the curves or between the apices and the normal portion are called 
 lozenge-shaped or oblique vertebrae. 
 
 A certain amount of rotation and also a transverse displacement 
 of one vertebra upon another is 
 normally possible up to a certain 
 degree by means of the elasticitv 
 
 Fig. 62. — A "Wedge" Vertebra. — 
 
 {Schulthess.) 
 
 Second lumbar seen from in front ; left 
 
 lumbar curve. 
 
 Fig. 63. — An "Oblique" Vertebra. — 
 
 (Schultliess.) 
 
 Fourth lumbar seen from the front ; from 
 
 a left lumbar curve. 
 
 of the intervertebral discs and the flexibility of the ligaments, but 
 usually the pathological process is not satisfied with the normal ex- 
 cursions, but rotates the vertebra in its structure. This rotation is 
 expressed in the relation of the upper and under surfaces of the verte- 
 bral body and in a twist between the body and arch. 
 
 Wedge Vertehrcv. — The vertebrae at the apex of the lateral curve 
 and just above and below it, from one to five in number, are called 
 the wedge or apex vertebra; (Keil- or Scheitelwirbel), and are com- 
 pressed on one side and consequently wedge-shaped. The obliquity 
 may aft'ect chiefly the upper surface when the vertebrae are below the 
 apex of the curve, and the lower surface chiefly when they are above it, 
 but it may aft'ect both upper and lower surfaces nearly equally, as in 
 
8o PATHOLOGY. 
 
 the vertebra at the point of the curve, and some modification of both 
 surfaces is generally to be noted. The thinnest part of a wedge vertebra 
 is found on the side of the concavity of the lateral curve and generally 
 toward the posterior aspect of the body. The side of the body toward 
 the concavity is broadened and lipped in severe cases, and synostosis 
 between two vertebral bodies may occur in this location. As a whole, 
 the apex vertebrae are rotated toward the convexity of the lateral 
 curve. 
 
 Lozenge-shaped Vertebrce (torsion vertebrae, oblique vertebrae, Inter- 
 ferenz- or Schragwirbel). — The vertebrae between the apex vertebrae 
 of the two curves or between the apex vertebrae and normal vertebrae 
 are deformed in a somewhat different manner. The upper surface 
 of the vertebra is displaced on the lower in such a way that the outline 
 of the vertebra is lozenge-shaped, the longest diagonal axis being toward 
 the apex of the lateral curve, the top of the vertebra being shoved side- 
 ways on the bottom. Such vertebrae may show oblique ridges on the 
 front of the body. The upper part of the body, moreover, twists on 
 the bottom part, below a right dorsal curve, the upper part of the verte- 
 bra twisting in the same direction as would the hands of a watch, while 
 above the apex of the curve the twist occurs in the opposite direction. 
 This is called longitudinal torsion. 
 
 The vertebral foramen in the dorsal region, instead of being round 
 as in the normal, in severe scoliosis becomes pointed at the end toward 
 the concavity. In the lumbar region the normal triangular shape is 
 distorted by being irregularly blunted at the angle on the side of the 
 concavity. 
 
 Arches of the Vertebrae. — Pedicles. — In the wedge vertebra the 
 original elevation of the pedicles may be retained. As a rule, they are 
 lowered on the concave side of the ciurve and tend to be more oblique 
 on the convex side, but in the vertebra at the point of the ciurve they 
 may be alike on the two sides. The pedicle on the convex side is 
 directed straight backward and the other backward and outward. 
 In the dorsal vertebrae the pedicle of the concave side may be narrowed, 
 but in the lumbar region it is more generally broadened and the transverse 
 process becomes smaller. In the lozenge vertebrae below the apex the 
 pedicles are likely to be depressed and above it elevated, according to the 
 intensity of the curve. In severe scoliosis the shortening of the trunk 
 is so great that the vertebrae are pressed together, and, as the bodies 
 offer less resistance to compression than the arches, the displace- 
 ment of the pedicles on the bodies is brought about. 
 
 Articular Processes. — The articular processes being connected with 
 
CHANGES IN THE VERTEBR.E. ,,/ 8 1 
 
 the pedicles share in any change that they undergo. Owing to the fact 
 that the joint planes afe so different in the dorsal and in the lumbar 
 regions the pathological appearances differ widely in the articular facets 
 of the dorsal and lumbar vertebrae. The crowding together of the 
 articular processes on the concavity of the lateral curve results in an 
 enlargement, deepening, and broadening of the joint surfaces, while 
 on the convex side the facets are smaller and higher. In the lumbar 
 region the superior articular facets on the concave side are hollowed 
 out, while the inferior ones are correspondingly prominent and rounded, 
 and the cartilage is thickened on the concave side. The involvement 
 of these joints is a matter of some practical importance, and the changes 
 suggest an adaptation to greater demands on the joints on the concave 
 side of the column. Synostosis may occur in these joints, and the 
 ligaments may share in the ossification. 
 
 Transverse Processes. — The transverse processes tend to remain 
 more horizontal than the body of the affected vertebra, and as the verte- 
 bra becomes inclined to the horizontal plane by the changes described, 
 the transverse processes strive to remain as nearly horizontal as possible. 
 As a result of this the transverse processes on the convex side above 
 the apex are elevated and below it depressed, on the concave side above 
 the apex they are depressed and below it elevated. In the vertebra 
 at the apex of the curve the level is approximately horizontal. In the 
 lumbar region this change is seen in its most marked form, so that in 
 cases of severe curvature here the transverse processes may point almost 
 straight up and down. Not infrequently the transverse processes are 
 shorter and thicker than normal on the convex side above and below 
 the apex of the curve. 
 
 Spinous Processes. — The spinous processes are directed toward 
 the convexity of the lateral curve in the dorsal region. This, it seems, 
 may be explained as being the physiological position when the spine is 
 laterally curved and is retained in structural scoliosis imder the effect 
 of muscular pull, while the bodies of the vertebrae, being influenced 
 largely by weight bearing, an individual plasticity of bone, and certain 
 unformulated conditions, are forced, as has been said, from the con- 
 cavity to the convexity Of the curve. 
 
 In the lumbar region in severe cases the spinous processes are 
 diverted toward the concavity. This deviation, it would seem, is the 
 result of a shoving to the side of the root of the spinous process from 
 extreme rotation, as the tips of the processes show the endeavor to 
 conform to the physiological position by being in some degree approxi- 
 mated to the convexity of the curve. In the dorsal region the spinous 
 6 
 
82 
 
 PATHOLOGY. 
 
 processes are also displaced downward, and the direction of each spinous 
 process is therefore influenced by its contact with the one below it. 
 
 The angle between the lower border of the spinous process in this 
 region and the arch becomes on the convex side smaller and on the con- 
 cave side larger than normal, and the appearance of displacement to 
 the convex side is thus increased. If the arch is displaced horizontally 
 upon the vertebral body, as described above, by the lowering of one 
 pedicle and the elevation of the other the spinous process undergoes 
 
 a rotation around its own longi- 
 tudinal axis. The irregularity 
 of these appearances may be ex- 
 plained by the pull of the mus- 
 cles, a matter which is at present 
 imperfectly formulated. 
 
 Joints between Vertebrae 
 and Ribs. — These of course are 
 of two kinds: first, the joints 
 between the heads of the ribs 
 and the sides of the vertebra; 
 second, the joints between the 
 tubercles of the ribs and the 
 transverse processes. These are 
 both similarly afi"ected in severe 
 scoliosis, being deepened on the 
 side of the convexity and faintly 
 indicated on the side of the con- 
 cavity, especially above the apex 
 of the cun-e. The articular facets on the side of the vertebral body are 
 moved forward on the concave side and backv.-ard on the convex side. 
 
 Fig. 64. — Distorted Anteroposterior 
 Plane of a Scoliotic \'ertebra.— 
 {Riedinger.) 
 
 INTERVERTEBRAL DISCS. 
 These show the earliest changes, and at the points of greatest curve 
 are compressed and project beyond the edges of the vertebral bodies 
 as if the bodies had grown into them. On the convex side they are 
 thicker than on the other. 
 
 LIGAMENTS. 
 
 On the side of the concavity the anterior common ligament is dense 
 
 and thick, while on the convex side of the curve it is thinned and shows 
 
 no definite lateral border. In the lozenge-shaped vertebra3 the fibers 
 
 run obliquely in a direction corresponding to the ridges on the anterior 
 
CHANGES IN THE MUSCLES. 83 
 
 surface of the vertebral bodies. The posterior common ligament near 
 the apex is found more to the convex side than normal because its in- 
 sertions into the intervertebral discs do not share in the broadening out 
 of the concave side of the vertebral bodies, and the vertebra thus grows 
 to the concave side while the ligament remains more nearly in the middle. 
 The ligaments connecting the heads of the ribs and the spine are long 
 and atrophied on the convex side and short and tense on the concave 
 side. 
 
 MUSCLES. 
 
 ^^^lere muscles are thrown out of use they atrophy and may undergo 
 fatty or fibrous degeneration. When increased demands are made 
 upon them they hypertrophy. When under changed conditions they 
 pass over a surface of bone they may become tendinous where the con- 
 tact occurs. Nutritive or adaptive shortening occurs when the ends 
 of muscles are approximated. All these changes are to be found in 
 cases of severe scoliosis, but the muscular changes in slight scoliosis 
 have not been formulated.^ 
 
 The change which muscles undergo in lateral curvature is first of 
 all a change of direction of pull caused by the displacement of the thorax 
 in relation to the pelvis toward the right or left. For example, if the 
 trunk is displaced toward the left, the muscles taking origin from the 
 crest of the ilium are directed toward the left at their insertion in the 
 spine. Under normal conditions the contractility of the muscles would 
 be sufficient to bring them back to their normal positions, but in a strong 
 lateral inclination of the lumbar segment above the sacrum the psoas 
 muscle, for example, acquires a broad insertion and becomes fan- 
 shaped, thereby assuming a different function. Under normal condi- 
 tions the insertion of this muscle is more linear and placed at an acute 
 angle to its direction of pull. 
 
 Following the loss of function of the muscles on the concave side 
 of the lateral curve in severe cases fatty degeneration is observed. On 
 the convex side the muscles are wasted and thin, and sometimes, in 
 exceptional cases, fatty degeneration is found here also. On the 
 convex side more often a fibrous degeneration is found; that is, atrophy 
 of the muscular tissue and the formation of larger tendons. 
 
 The diaphragm assumes an oblique position and is lower on the side 
 of the convexity of the dorsal curve. If the apex of the dorsal cur\e 
 is situated high up and associated with kyphosis, the top of the diaphragm 
 may be much elevated — even as high as the level of the third rib. 
 
 ' Phelps: "Trans. .-Vmer. Orth. Assn.," vol. xiv. 
 
84 
 
 PATHOLOGY. 
 
 THORAX. 
 
 In lumbar scoliosis the changes in the thorax are slight, but some 
 rotation of the structure as a whole is noted in relation to the frontal 
 plane of the pelvis. 
 
 In dorsal scoliosis the thorax is not only displaced as a whole toward 
 
 Fig. 65. — Radiogram of Left Scoliosis, Resulting from Empyema of the Right 
 Side with Resection of the Ribs. 
 
 the convexity of the curve, but its structure is distorted. The thorax 
 as a whole tends to retain its normal position with regard to the frontal 
 plane of the body more closely than does the spine, which, as it were, 
 rotates in the thorax. It thus undergoes a twist in the opposite direction 
 from that of the spine. This results in a change in its diagonal diameters, 
 by which the one from the side of the convexity behind to the concavity 
 in front is lengthened, and the corresponding one on the other side is 
 
CHANGES IN THE THORAX. 
 
 85 
 
 shortened. For example, in right dorsal scoHosis the thorax is dis- 
 placed to the right and becomes prominent on the right side behind 
 and the left side in front, and the diagonal diameter from the right side 
 behind to the left side in front is lengthened. As a result of this the 
 internal surfaces of the shafts of the right ribs are brought nearer to the 
 front of the vertebral bodies, and the right side of the thorax is seriously 
 diminished in capacity. 
 
 Ribs. — The ribs on the convex side of the lateral curve show a back- 
 ward increase of their angularity, forming on the side of the back of the 
 thorax a more or less sharp and prominent ridge, spoken of technically 
 
 c' 'd 'i 
 
 Fig. 66. — Thoracic Ring in a Right Dorsal Scoliosis, seen from Abovk. — (Loretiz.) 
 
 as "the rotation" (Rippenbuckel). In compound curves of the dorsal 
 region these phenomena accompany each curve. 
 
 From the angle forward to the sternum the ribs of the convex side 
 show a loss of their normal curve. The ribs on the side of the con- 
 cavity of the lateral curve show a straightening of their angles and an 
 increased outward bowing of their shafts. The costal cartilages of the 
 concave side in front show an increased curvature forward and form 
 on the front of the chest a prominence at the side of the sternum (vor- 
 dere Rippenbuckel). 
 
 The ribs of the side of the convexity are spread apart and have 
 a more oblique direction; on the side of the concavity they are closer 
 
00 PATHOLOGY. 
 
 together and tend to a more horizontal course. These phenomena 
 are dependent upon the degree of inclination of the part of the spine 
 to which the ribs are attached. 
 
 Sternum. — The sternum as a rule deviates but little from its normal 
 position and direction except in very sen-ere scoliosis. The variations in 
 position consist — (i) In a lateral displacement; (2) in an obliquity of the 
 lower end, which turns either to the convexity or concavity of the lateral 
 curve; (3) in a rotation around its longitudinal axis, making one lateral 
 border, commonly the one toward the concavity of the lateral curve, 
 more prominent. A detailed study of the variations of the sternum 
 may be found in the reference.^ 
 
 SHOULDER-GIRDLE. 
 
 The marked deformity of the thorax cannot be without influence 
 on the form of the clavicles and scapulae. The scapula undergoes, 
 because of the deformity, various changes of position and eventually 
 of form. It always acquires that position to which it is forced by the 
 form of the thorax, the weight of the shoulder and arm, and the tension 
 of its muscles. On account of the backward prominence of the thorax, 
 the scapula is moved away from the vertebral column on the convex 
 side, and if the scoliosis is located high up in the dorsal region, the scapula 
 moves upward also. If the thorax is strongly compressed from the 
 side, the scapula may lie sidewise, so that its dorsal surface has a lateral 
 and not a backward direction, or it may swing backward so that its 
 inferior angle crosses the line of spinous processes to the other side. 
 It may furthermore acquire a strong curve on itself if it lies on a thorax 
 sharply deformed, and become convex backward. 
 
 The clavicle, whose first function is to keep the scapula at a certain 
 distance from the sternum, also changes according to the situation of 
 the spinal curve, and may be found more sharply curved in scoliosis. 
 
 PELVIS. 
 Sacrum. — In low curves (generally convex to the left in the lumbar 
 region) the sacrolumbar junction becomes practically the apex point, 
 and here one looks for rotation, and pressure changes may continue 
 the curvatures of the presacral vertebrae. The sacrum is affected in 
 such low lateral curves in a way analogous to that of the other vertebrae, 
 but modified in extent by the fixed position of the sacrum. In a right 
 dorsolumbar curve the following changes in the sacrum were found 
 and may be taken as exemplifying them (Schulthess) : 
 
 ^ Fauconnet: "Zeitsch. f. orth. Chir.," xvii, page 201. 
 
CHANGES IN THE PELMS. 
 
 87 
 
 1. A decrease in the height of the first sacral vertebra on the concave 
 side {cj. wedge vertebra). 
 
 2. A broadening of the base of the sacrum on its concave side {cj. 
 broadening of concave side of vertebral body). 
 
 3. Forward displacement of the left or concave half with its cor- 
 responding ala and backward displacement of the right or convex half 
 {cj. rotation of vertebral bodies). 
 
 4. Broadening of the part of the sacrum corresponding to the pedicle 
 on the concave side. 
 
 5. Lowering of the arch on the concave side. 
 
 In addition to this there is to be seen at times a slight indication 
 of a lateral curve of the sacrum, 
 reaching its apex at or below the 
 middle of the bone. In this 
 the coccyx may share, empha- 
 sizing the curve, but the sac- 
 ral curve is most easily seen by 
 sighting along the anterior sur- 
 face of the sacrum or looking 
 down the vertebral canal. This 
 curve shows slight indications 
 of the same changes noted in 
 the presacral vertebrae. 
 
 The pelvis is somewhat 
 changed in diameter and shape 
 in severe low lumbar curves in 
 which the sacrum shows dis- 
 tortion. In a left lumbar curve 
 the diagonal diameter from the 
 left side behind to the right side 
 in front is greater than the op- 
 posite diagonal; thus in an individual case of right dorsal left lumbar 
 curve the thorax and pelvis would be twisted in opposite directions. 
 
 Fig. 67.— Oblique Pelvis Accompanying 
 Scoliosis. — ( IVaireii Museum, cast from 
 a specimen in Musei DupuytreUy Paris.) 
 
 SKULL. 
 In long-continued scoliosis, especially of the upper part of the column, 
 asymmetry of the face and skull has been claimed (Hoffa) ; on the other 
 hand it has been disputed except in connection with congenital tor- 
 ticollis, asymmetry of congenital origin, and in rickets (Schulthess). 
 
Ob PATHOLOGY. 
 
 INTERNAL ORGANS. 
 
 In scoliosis, especially in middle and severe forms, a shortening 
 of the trunk is apparent which prevents the normal development and 
 function of the internal organs. By the lateral displacement of the 
 trunk and rotation of the thorax the pleural and abdominal cavities 
 become distorted. The patients become anemic and show a certain 
 disposition to tuberculous pulmonary diseases. Bachmann,^ in 197 
 autopsies in scoliotic patients of moderate and severe type, has found 
 in 28.3 per cent, tuberculous disease of the lungs, while in milder degrees 
 of scoliosis there were 66 per cent, so affected. 
 
 The secondary changes in the internal organs are essentially depend- 
 ent upon the narrowing of the containing cavities. In a severe right 
 dorsal curve the right pleural cavity is very much narrowed — so much 
 so that in extreme cases the inner surfaces of the ribs are found lying 
 close to the vertebral column. The narrowing of the pleural cavity 
 on the left, that is, on the concavity, is not so important as that of the 
 right. It follows that the right lung must suffer from the distortion 
 more than the left. Mosse^ found apex infiltration in 60.2 per cent, 
 of 100 scoliotic children between five and sixteen years old. Kamine 
 V. Zade ^ found apex affections in 73 per cent, of scoliotic women, the 
 lung affection being predominantly of the lung on the convex side of 
 the curve. 
 
 Affections of the pleura, adhesive pleuritis, leading to total oblitera- 
 tion of the pleura and atelectasis, are found very frequently. Bach- 
 mann gives the following figures: 74.6 per cent, affections of pleura, 
 with 7 per cent, of total obliteration and 31 per cent, atelectasis of 
 lungs. The atelectasis depends either upon the failure of the respira- 
 tory muscles to bring about expansion of the lung in certain places, 
 or upon the fact that a real compression between bony walls, or between 
 a bony wall and the diaphragm, has taken place. This compression 
 is more readily possible if certain parts of the lungs are held back by 
 adhesion. Bachmann found such compression in 24.3 per cent, of 
 cases. He furthermore gives the percentage of pneumonia in cases of 
 severe scoliosis as 22.8 per cent. 
 
 Undoubtedly the lungs of scoliotic patients, especially in cases of 
 kyphoscoliosis, are predisposed toward a greater number of diseases 
 than the lungs of normal individuals. 
 
 ^Bachmann: "Bib. med.," Abt. 1, Heft 4, 1899. 
 ^ Mosse: "Zeitsch. f. klin. Med.," xli, pp. 1-4. 
 ^Kamine v. Zade: "Deut. Arzte. Zeit.," 1902, xx. 
 
CHANGES IN THE INTERNAL ORGANS. 69 
 
 Heart and Vessels. — The same narrowing of thoracic space afifects 
 the heart. It is frequently found pushed upward and pressed against 
 the anterior chest-wall, and it is at the same time, according to the 
 direction and the extent of the curvature, more or less displaced later- 
 ally. In right curves generally the heart is displaced tow^ard the left; 
 but this is not a constant condition. Hypertrophy and dilatation of 
 the cavities of the heart are very frequent, especially of the right heart 
 in severe scoliosis. Bachmann found it in 56.4 per cent, of cases, 
 while the left heart was similarly affected in 17.5 per cent. This phe- 
 nomenon was found in both right and left sides in 25.9 per cent. 
 
 The aorta in general follows the curvature of the spine, particu- 
 larly in right curves. In a left dorsal curve, however, the aorta does 
 not, as a rule, lie on the convex side of the curve, but runs straight like 
 the chord of an arc, more often in front or even a very little to the right 
 of the spine. The large veins show less typical changes. The vena 
 cava in the region of the liver, where it is relatively fixed, and occasion- 
 ally at the entrance of the renal veins, may show a change in its course 
 corresponding to the change of position of the organs. 
 
 The most reasonable explanation for the hypertrophy of the heart 
 is the insuf&cient depth of respiration of scoliotic patients. Even in 
 relatively slight distortion of the thorax, respiration is more shallow 
 than the normal, consequently the right side of the heart, in order to 
 push the necessary amount of blood through the lungs, must do an extra 
 amount of work. 
 
 If the scoliosis increases, the chest space is restricted still more, and 
 the expansion of the lungs, already damaged by adhesions and thicken- 
 ing, is impeded. The heart is also pressed against the front wall of 
 the chest, and the blood-pressure is changed on account of the bends in 
 the vessels, which conditions add greatly to the work of the heart. The 
 difficulty which the blood finds in passing through the lungs leads to a 
 great degree of venous dilatation if the condition continues long enough. 
 This is especially noticeable in the veins of the head, neck, and arms. 
 
 Esophagus. — In general the esophagus has a tendency to deviate 
 in the direction of the concavity of the curve, although frequently its 
 form and course are but little changed. The influence upon the course 
 of the esophagus is least when the radius of the curve is a large one 
 and the secondary curve lies below the diaphragm. In e\ery case the 
 esophagus follows a straighter course than the aorta, and it crosses 
 the aorta near the point at which it pierces the diaphragm.^ 
 
 Intestines. — The abdominal contents are, in consequence of re- 
 ' Hacker: "Wicn. mod. Woch.," 1887, page 46. 
 
90 PATHOLOGY. 
 
 stricted space, pressed downward and forward, and added to this is the 
 influence of the approximation of the chest to the pelvis and the side 
 displacement of the vertebral column. The downward pressure results 
 in crowding the intestines into the true pelvis. The lateral displace- 
 ment of the thorax affects chiefly the transverse colon, which may be- 
 come almost vertical. 
 
 Liver. — In right curves the liver is pushed toward the left, the left 
 half is better developed than the right half, and finally the organ on the 
 right side may be indented by the ribs. 
 
 Kidneys. — In right dorsal scoliosis the right kidney is often dis- 
 placed upward along the spine and the left one downward, and while 
 the right kidney suffers as a rule slight changes, the left is more likely 
 to be affected severely from rib pressure. Cystic degeneration and 
 floating kidney are common. Bachmann enumerates, among i8o ob- 
 servations, 14 cystic kidneys, 31 cases of granular atrophy, 18 cases of 
 simple atrophy, and 6 cases of hydronephrosis. 
 
 Spleen. — The spleen may be higher than normal. Perisplenitis, 
 atrophy, and cyanotic induration have been observed (Bachmann). 
 
 Stomach. — The position of this is influenced by that of the liver 
 and duodenum. The pylorus is depressed, while the cardiac end gener- 
 ally lies high. 
 
Chapter VII. 
 
 ETIOLOGY— INFLUENCE OF SCHOOL CONDITIONS. 
 
 It is difficult to present in a complete yet simple form the manifold 
 causes of scoliosis. The danger of confusion lies in too great subdi- 
 vision, to which the subject easily lends itself. It is obvious that cases 
 must be of either congenital or acquired origin — further than this the 
 following subdivisions suggest themselves : 
 
 A. Congenital scoliosis. 
 
 1. Malformation of the spine. 
 
 2. Malformation of the scapula. 
 
 3. Malformation of the thorax. 
 
 B. Acquired scoliosis. 
 
 1. Anatomical, physiological, or other asymmetries elsewhere than 
 
 in the spine. 
 
 a. Torticollis (wry-neck). 
 
 b. Pelvic asymmetry. 
 
 c. Pelvic obliquity. 
 
 d. Unequal vision. 
 
 e. Unequal hearing. 
 
 2. Pathological affections of the vertebrae. 
 
 a. Rickets. 
 
 b. Osteomalacia. 
 
 c. Pott's disease. 
 
 d. Dislocation. 
 
 e. Arthritis deformans. 
 /. Tumors, etc. 
 
 3. Pathological affections of the bones and joints of the ex- 
 
 tremities. 
 
 a. Diseases of bones and joints of the leg. 
 
 b. Diseases of bones and joints of the arm. 
 
 4. Distorting conditions due to disease of the soft parts. 
 
 a. Infantile paralysis. 
 
 b. Spastic paralysis. 
 
 c. Nervous diseases. 
 
 d. Empyema 
 
 e. Organic heart disease. 
 /. Scars. 
 
 g. Throat and pulmonary disease. 
 
 5. Habit or occupation (school scoliosis). 
 
 91 
 
92 
 
 ETIOLOGY INFLUENCE OF SCHOOL CONDITIONS. 
 
 A. SCOLIOSIS OF CONGENITAL ORIGIN. 
 
 Scoliosis due to congenital defects was formerly thought to be a 
 decidedly rare affection. In the last few years it has been recognized 
 that it is much more common than was supposed/ and a steadily increas- 
 ing number of cases are referred to a congenital origin,^ a change largely 
 
 due to the use of the x-ray and 
 ' '^ the more accurate study of the 
 
 spine thus made possible. 
 
 I. DUE TO MALFORMATIONS 
 OF THE VERTEBRAL COL- 
 UMN. 
 
 Scoliosis may occur as a con- 
 genital condition in connection 
 with severe malformations, such 
 as rachischisis and the like,^ 
 and in connection with "fetal 
 rickets" and paralysis.^ It oc- 
 curs also as the result of less 
 severe spinal defects, such as 
 cervical ribs,^ spina bifida, and 
 abnormal formation of the last 
 lumbar vertebra. 
 
 Congenital scoliosis may be 
 evident — (i) immediately after 
 birth, as in the case of the 
 severest malformations (Col- 
 ville^ in 1015 cases of new-born 
 children found only one case of 
 scoliosis) ; or (2) only when the 
 child begins to walk, in the case of malformations not severe enough 
 to cause a curve in the recumbent position. In these latter cases the 
 curvature appears as the result of the superincumbent weight coming 
 upon the defective spine or as the result of asymmetrical growth due to 
 
 ^ Liining and Schulthess: "Ajlas d. orth. Chir.," Miinchen, 1901. 
 ^ Atlianassow : "Archiv f. orth. Chirr," i, 3. 
 
 ^Schmidt: "Allg. Path, und path. Anat. d. Wirbelsaule," Liibersch's "Ergeb. 
 zur allg. Path.," 4. Jahrg., 1897. 
 
 ■' Schuhhess : " Joachimsthal's Hdbch. d. orth. Chir.," Jena, 1903, iii, 708. 
 ^ Breuss and Kolisco, quoted by Schuhhess. 
 sColville: "Rev. d. Orth.," 1896, 7. 
 
 Fig. 68. — Scoliosis due to Congenital 
 Defects in Spine and Thorax, the 
 Ribs Being Bifurcated and Defective. 
 
CONGENITAL SCOLIOSIS. 93 
 
 the malformation. Such cases as these are perhaps not strictly con- 
 genital, but might be better spoken of as scoliosis due to a congenital 
 cause. 
 
 The two most common locations of congenital defects are in the 
 cervicodorsal and lumbar regions. In the former, cervical ribs are a 
 frequent accompaniment (Halsrippenskoliose) . The formation of 
 a cervical rib is often associated with a splitting of the vertebral 
 bodies, as shown by the x-ray, and in some cases the cervical rib is ac- 
 companied by a rudimentary extra vertebral body.^ The shoulder on 
 the side of the cervical rib is elevated, and the curve is a sharp cervico- 
 dorsal one with a compensatory opposite curve below. 
 
 In the lumbar region the curve is frequently associated with spina 
 bifida, spina bifida occulta, or sacralization of one side of the last lumbar 
 vertebra. 
 
 Bohm^ has called attention to the, fact that numerical variation in 
 the vertebral column apparently plays a part in causing a scoliosis 
 really of congenital origin, but not necessarily appearing at birth. . In 
 the Dwight collection of abnormal spines in the Warren Anatomical 
 Museum there are three that show a scoliosis apparently resulting from 
 the numerical variation: (i) a sacrolumbar curve to the left, with cau- 
 dal variation (see chapter on Anatomy, page 19), and union of the 
 sacrum, one vertebra higher on one side; (2) dorsal scoliosis with cranial 
 variation and cervical ribs of unequal development; (3) dorsolumbar 
 scoliosis with cranial variation and fusion of the last three lumbar and 
 first sacral vertebrae, with asymmetry of the articular processes between 
 the eighteenth and nineteenth vertebree. All these scolioses are of 
 comparatively slight extent. 
 
 Clinically he found from :x;-ray examination in 16 out of 24 cases of 
 "habitual scoliosis," from which rickets and other acquired causes 
 could be excluded, types of variation at the primary seat of the deformity 
 present. From the fact that numerical variation is not infrequently 
 asymmetrical in the spine the conclusion is presented that such defects 
 may cause scoliosis, which does not appear until the beginning of the 
 second decade on account of the fact that at this time the articular 
 facets undergo a change in character. 
 
 Malformation of a part of a vertebra, such as one of the epiphyses, 
 a process, or a part of the arch, will lead to asymmetrical growth, which 
 
 ^Drehmann: "Verhdl. d. Deutsch. Gesell. f. orth. Chir.," 5th Congress, 1906, 
 page 12. 
 
 ^Bohm: "Bos. Med. and Surg. Jour.," Nov. 22, 1906. 
 
94 
 
 ETIOLOGY — INFLUENCE OF SCHOOL CONDITIONS. 
 
 may disturb mechanical conditions and lead to scoliosis. Abnormal 
 curves in the anteroposterior plane also occur. 
 
 2. MALFORMATIONS OF THE SCAPULA. 
 Congenital elevation of the scapula (Sprengel's deformity) will 
 cause a scoliosis which is usually a high cervicodorsal curve with com- 
 pensating dorsolumbar curve, 
 " ' One scapula is occasionally ab- 
 
 sent or malformed (Fig. 69). 
 
 3. MALFORMATION OF THE 
 THORAX. 
 
 Occasionally great irregu- 
 larity characterizes the ribs of 
 one or both sides. Some may 
 be bifurcated, while others are 
 deficient. Such irregularities 
 are a cause of scoliosis. 
 
 Heredity must also be con- 
 sidered, as it is known that 
 scoliosis is apparently inherited 
 in some families, Schulthess 
 estimating that from 10 to 15 
 per cent, of scolioses are heredi- 
 tary. Congenital defects of 
 form can be inherited, and 
 would reasonably lead to sim- 
 ilar forms of scoliosis, while an 
 inherited weak skeleton or a 
 disposition to rickets would not 
 necessarily lead to a reproduction of the form of scoliosis. There are 
 cases, however, in which the form also seems to be hereditary. 
 
 Fig. 
 
 9. — Congenital Elevation of the 
 Scapula Causing Scoliosis. 
 
 B. ACQUIRED SCOLIOSIS. 
 Scoliosis is to be classed as acquired when the deformity comes 
 on after birth from some cause not apparently congenital, and this 
 includes, so far as we know now, the greater number of cases. It may 
 be said in general that any anatomical or physiological condition which 
 causes the spine to be held habitually curved to one side during the 
 period of growth is a competent cause of scoliosis, and, although certain 
 
SCOLIOSIS CAUSED BY ASYMMETRY. 95 
 
 individuals under tiaese conditions will escape permanent bony defor- 
 mity, certain others will acquire a change in the shape of the spinal 
 structure. The experimental production of scoliosis in animals has 
 been demonstrated and is discussed elsewhere (page 42). The ac- 
 quired varieties of scoliosis may be considered as follows : 
 
 I. ANATOMICAL OR PHYSIOLOGICAL ASYMMETRIES ELSEWHERE 
 THAN IN THE SPINE. 
 
 (a) Torticollis, or wry-neck, a condition characterized by the con- 
 traction of one sternocleidomastoid muscle, causes a tilted and twisted 
 position of the head and necessitates a compensatory lateral curve of the 
 spine to preserve the balance and enable the head to assume an approx- 
 imately normal position. Unilateral torticollis, if sufficiently long con- 
 tinued, is always accompanied by scoliosis. 
 
 (b) Asymmetry of the Pelvis. — The spine is not always located 
 in the middle of the pelvis, but at times is found at one side of the 
 median sagittal plane of the body (amesiality of the pelvis) . The pelvis 
 may be in other respects asymmetrical. In these cases a compensating 
 lateral curve is necessary in order to allow the head to be held over the 
 center of the body^ (Fig. 70). 
 
 (c) Obliquity of the Pelvis. — Any condition which causes the 
 pelvis to be held higher on one side in the horizontal plane is a com- 
 petent cause of scoliosis, because such obliquity necessitates a lateral 
 curve of the spine to secure normal balance. A short leg must be 
 counted a frequent cause of scoliosis. But it must be remembered 
 that a difference in the length of the legs is very common in children,^ 
 and that the frequency of scoliosis is less than the frequency of short 
 legs. The association of short legs and scoliosis has been investigated, 
 with a wide variation in results. 
 
 Sklifowsowsky 21 cases of scoliosis — 17 right leg longer. 
 
 Staffel 230 cases of scoliosis — 62 left shorter. 
 
 H. L. Taylor 32 cases of scoliosis — 28 shorter on one side. 
 
 Lorenz 100 lumbar scolioses — i case of shortening. 
 
 Dolega 200 scolioses — 2 cases of shortening. 
 
 Schulthess estimates, without analyzing his cases, that from i to 
 5 per cent, show this association. From the figures quoted it may 
 be seen that there is no agreement in the matter, and that it must be 
 determined by the careful examination of large groups of cases. The 
 measurement taken with a tape-measure from the two' anterior superior 
 
 ^ Barwell: "Edin. Med. Jour.," Feb., 1901; "Brit. Med. Jour.," Feb. 4, 1899. 
 ' Bradford and Lovett: "Orth. Surgery," 3d ed., page 476. » 
 
96 
 
 ETIOLOGV — INFLUENCE OF SCHOOL CONDITIONS. 
 
 spines to the inner malleoli while the patient lies on the back is inexact 
 and of little value as determining the real position of the pelvis in stand- 
 ing, and too much importance must not be attached to it. The most 
 reliable method that we have of determining the horizontal plane of 
 
 the pelvis and the obliquity which 
 must exist when there is really a 
 
 Fig. 70. — Scoliosis due to Asym- 
 metry of the Pelvis, THE Right 
 Side Being Smaller. 
 
 Fig. 71. — Left Lumb.^r Scoliosis 
 from Inequality in the Length 
 OF THE Legs. 
 
 short leg is to place a level on the two anterior superior spines when 
 the patient stands erect. 
 
 As an example of the little value to be attached to the conventional 
 measurement, the left leg may be one-quarter of an inch shorter by the 
 ordinary measurement taken while lying on the back, yet there may 
 
CAUSES OF SCOLIOSIS. 97 
 
 exist a flat-foot on the right side which does not appear in the measure- 
 ment and when the patient stands may lower the pelvis a half inch on the 
 right, more than making up for the shortening shown by measurement. 
 It is not an uncommon experience to find that the spinal curve is in- 
 creased by putting a block under the foot on the side shown to be short 
 by measurement, but that the spinal curve is improved by making the 
 long leg longer by the same method. 
 
 To sum up the facts in regard to a short leg and scoliosis: The 
 mechanical aspect would lead us to believe it a likely cause in certain 
 cases. The observers differ widely, and the ordinary method of measure- 
 ment is inaccurate and often misleading. The determination of the 
 level of corresponding points on the pelvis when the patient stands is 
 the most reliable method of measurement at our command. 
 
 (d) Unequal hearing causes a tilting or tw^isting of the head which 
 may produce lateral cur\'ature in the cer\-ical and upper dorsal regions. 
 
 (e) Unequal vision, necessitating a tilting of the head to bring ver- 
 tical objects into clearer vision, may cause scoliosis. It has been claimed 
 that the bad postures assumed by children in writing are of ocular 
 origin, and the school observations at Lausanne are of interest here, 
 as a steady increase in the percentage of scoliotic and myopic children 
 was found from the lowest classes upward, as is shown by the table. 
 
 Class. 
 
 I 
 
 II 
 
 Ill 
 
 IV 
 
 V 
 
 VI 
 
 VII 
 
 Scoliotic. 
 
 Myopic. 
 
 8.7 per cent. 
 
 3.0 per cent 
 
 18.2 
 
 4-5 
 
 19.8 
 
 5-2 
 
 27.2 
 
 6.0 
 
 28.3 " 
 
 8.5 " 
 
 32-4 
 
 13-7 
 
 31.0 
 
 19.4 
 
 The relation between scoliosis and myopia has not yet been determined. 
 It is obvious that astigmatism may be a cause of head tilting and 
 consequently will predispose to scoliosis. The subject has been care- 
 fully worked out by Gould,^ whose conclusion is that in asymmetrical 
 astigmatism the axis of the dominant eye determines a tilting of the head 
 to the right or left, but that this does not occur in symmetrical astigma- 
 tism. 
 
 2. PATHOLOGICAL AFFECTIONS OF THE VERTEBRA. 
 
 (a) Rickets, a constitutional disease affecting young children, 
 
 causes a local or general disturbance in the normal process of ossification 
 
 ^ G. M. Gould: "Amer. Medicine," Mav 21, 1904; Mar. 26, 1904; April 8, 
 1005; "N. Y. Med. Record," .\pr. 22, 1895.' H. A. Wilson : "N. Y. Med. Jour- 
 nal," June, 1906. 
 
 7 
 
qS etiology — INFLUENCE OF SCHOOL CONDITIONS. 
 
 of the bones, whereby the epiphyses become enlarged and the affected 
 bones soft and plastic. Deformities in the spine occur chiefly in the 
 acute stage of the disease. The softening of the vertebra? causes the 
 column to collapse symmetrically, producing kyphosis, or asymmet- 
 rically, producing scoliosis. A large number of scolioses originate 
 directly or indirectly from rickets (Fig. 123). 
 
 The severest types of lateral curvature are of rachitic origin. They 
 are distinguished by a shortening of the trunk, so that the ribs may 
 meet the pelvis, and by a marked deformity of the thorax. 
 
 (b) Osteomalacia, a process like rickets in causing a softening of 
 the bones, but more frequently seen in adolescents and adults, is accom- 
 panied occasionally by lateral curvature. 
 
 (c) Tuberculous disease of the spine, or Pott's disease, is a 
 destructive pathological process attacking the bodies of the vertebrae. 
 Lateral deviation of the spine associated with stiffness and very slight 
 rotation often exists in connection with the backward "hump" or 
 kyphosis, which is the characteristic sign of the disease. 
 
 (d) Severe injuries of the spine, resulting in chronic sprain of the 
 vertebral column, dislocation of the vertebrae, and injury of the epi- 
 physeal cartilage, may be accompanied by lateral deviation of the spine 
 as a symptom. 
 
 (e) Arthritis deformans is characterized by a progressive stiffening 
 of the spine due to deposits of newly formed bone on the front and sides 
 of the column, binding the vertebrae together. The intervertebral 
 discs degenerate and the vertebrae become fused; bony deposit occurs 
 in the ligaments, and the articulations of the vertebra with the ribs 
 may lose some or all motion. Lateral deviation, accompanied by 
 general kyphosis, may result. 
 
 Other causes of this class are tumors of the spine and hereditary 
 syphilis. The scolioses of this class are symptomatic of a serious con- 
 dition, and except for that of rickets are not to be treated like ordinary 
 primary scolioses and would be much injured by such treatment. 
 
 3. AFFECTIONS OF THE BONES AND JOINTS OF THE EXTREMITIES. 
 
 (a) Diseases of the bones and joints of the lower extremity play 
 a larger part in the etiology of scoliosis than those of the arm and shoulder. 
 Lateral curvature may be caused by the shortening of one leg, due to 
 derangement of growth; to unilateral diseases of the hip-joint causing 
 shortening, dislocation, contraction, or ankylosis in a position of adduc- 
 tion, abduction, or flexion; to unilateral congenital or paralytic dis- 
 
PARALYTIC SCOLIOSIS. 
 
 99 
 
 location of the hip; to coxa vara, coxa valga, and fractures of the 
 lower extremity; to diseases and malformations of the diaphyses of the 
 leg or thigh bones ; to diseases of and operations on the knee-joint causing 
 shortening, contraction in the flexed position, or knock-knee on one 
 side; and to diseases and malpositions of the foot, especially flat-foot. 
 Scoliosis due to a shortening 
 of one lower extremity is fre- 
 quently spoken of as "static 
 scoliosis." 
 
 (b) Diseases of the shoul- 
 der-joint, causing partial or 
 complete ankylosis, may be ac- 
 companied by a curve of the 
 spine in the dorsal region. 
 
 4. DISTORTING CONDITIONS 
 DUE TO DISEASE OF THE 
 SOFT PARTS. 
 
 (a) Infantile spinal par- 
 alysis or anterior poliomye- 
 litis is a fairly common cause 
 of lateral curvature. It occurs 
 during the second dentition in 
 children, although adults show 
 the later changes. The lower 
 extremity is more often affected 
 than the upper. The deformi- 
 ties produced are due to shorten- 
 ing of bone or to muscular par- 
 alysis. Scoliosis results in one 
 of three ways: 
 
 1. From inequality in the 
 length of the legs, causing a tilt- 
 ing of the pelvis. 
 
 2. From unilateral paralysis of the muscles directly controlling 
 the vertebral column, which may cause a deviation of the spine either 
 to that side or to the other side. It does not follow, as shown by x^rnd 
 experimentally and as recognized clinically by others, that a paralysis 
 of the muscles of one side of the back is followed by a curve convex 
 toward the paralyzed muscles, as would naturally be expected. The 
 curve is the result of the effort of the patient to adjust his center of 
 
 F"iG. 72. — Right Doksal.Curve Due to Lv- 
 FANTiLE Paralysis. 
 
lOO 
 
 ETIOLOGY — INFLUENCE OF SCHOOL CONDITIONS. 
 
 gravity to the new conditions induced by unilateral paralysis. This 
 equilibration may result in a curve convex either to the right or left in a 
 right-sided paralysis. 
 
 3. From faulty spinal attitudes assumed in consequence of paraly- 
 sis elsew^here, as in paralysis of the arm. 
 
 (b) Spastic paralysis or Little's disease in general is the result of a 
 cerebral lesion and a descending degeneration of the lateral columns 
 
 Fig 73.— Hysterical Scoliosis. 
 
 Fig. 74. — Right Dorsal Curve dl'e 
 TO Left Empyema. 
 
 of the spinal cord. The growth of bones is often retarded, and mus- 
 cular irritability and stiffness are noted with contractions. Scoliosis 
 is an occasional accompaniment. 
 
 (c) Other nervous diseases, represented by a much smaller number 
 of cases of lateral curvature, are multiple neuritis, meningitis, cerebro- 
 spinal meningitis, syringomyelia, pseudomuscular hypertrophy, loco- 
 motor ataxia, Friedreich's ataxia, tumors of the spinal cord, and obstetrical 
 paralysis. Lumbar neuritis gives rise to a lateral curve which is rather 
 
HABIT SCOLIOSIS. lOI 
 
 an anomaly of position than a true scoliosis and is called ischias scolio- 
 tica} A similar malposition is observed in hysteria^ (Fig- 73)- An 
 analogous malposition is found in sacro-iliac disease in which the lateral 
 curve is induced by the instinctive effort to spare the affected joint. 
 
 ((/) Empyema is followed by lateral curvature in certain cases, 
 both without operation and after the operation for removal of a rib. 
 The scar contraction seems to be the cause of the deviation, which 
 is always to the right in left empyema and vice versa. 
 
 {e) Scars rarely cause scoliosis, although it sometimes is found after 
 extensive burns when the deviation of the spine is brought about by 
 contraction of the scar tissue. 
 
 (/) Phthisis and diseases of the pleura and obstructions in the 
 nasopharynx are to be mentioned among the diseases of the respiratory 
 organs sometimes followed by scoliosis. 
 
 C?) Organic heart disease, especially in children, is a competent 
 cause of lateral curvature. 
 
 S. HABIT OR OCCUPATION. 
 
 A large number of scolioses are observed which cannot be attributed 
 to congenital malformation nor to the direct or indirect results of the 
 pathological process of disease. Some apparently have their cause in 
 an habitual or frequent malposition necessitated by the occupation of 
 the individual, and these are to be classed as habit or occupation 
 scolioses. 
 
 In adults, habit or occupation scoliosis is attributed to the habitual 
 and compulsory maintenance of one position for long periods of time, 
 as is required in certain occupations. In these cases the form and 
 extent of the lateral deviation are determined by the form of faulty pos- 
 ture. On account of relative plasticity of bone and periods of rapid 
 growth, accompanied by lax muscular tone, children are especially 
 subject to deformities of attitude and are particularly liable to acquire 
 habit scolioses. Common causes of scoliosis in children are faulty 
 attitudes in sitting and in standing, the former favored by improper 
 school furniture, and the latter by an arrangement of the clothing 
 almost universally bad, which will be discussed elsewhere. Typical 
 instances are found in violin playing, riding horseback on a side saddle, 
 carrying heavy weights asymmetrically, as children on the arm, heavy 
 
 ' Bahr: "Zentralbl. f. Chir.," 1896, 14; Ehret: "jNIitt. aus d. Grcnzgcb. d. 
 Med. und Chir.," iv, 5. 
 
 'Binswanger: 'Hysterical Scoliosis," "Deutsch. mcd. Wochens.," \'ereinsbcil., 
 1902, 5. 
 
I02 ETIOLOGY — INFLUENCE OF SCHOOL CONDITIONS. 
 
 baskets, and heavy bundles of paper supported by a strap over one 
 shoulder. 
 
 It may be considered as possible that the bulk of all scolioses, tak- 
 ing mild and severe cases together, is an "occupation" scoliosis ac- 
 quired by faulty attitudes at school and elsewhere; but this does not 
 answer the question, because all children are subject to these conditions 
 and only a part develop scoliosis. As a rule, the children affected are 
 of less vigorous build and of slightly poorer physique than those who 
 are not affected. Severe scoliosis accompanied by marked rotation in 
 children is generally due to congenital malformation of the spine, 
 rickets, empyema, or infantile paralysis. Any account of the etiology of 
 scoliosis would be very incomplete which did not make it perfectly 
 clear that in many cases of the deformity the surgeon must be content 
 to leave the cause not satisfactorily accounted for. 
 
 School Fatigue.^ — -A correct attitude is dependent upon the tone 
 and strength of the muscles by which the upright posture is maintained, 
 so that any cause, such as fatigue, which lowers the muscular tone, has 
 a bearing in this connection. 
 
 Mental Fatigue. — Muscles become relaxed not alone by physical 
 but by mental exertion and mental fatigue.^ Mental work is at first 
 stimulating, but if continued for a long time, especially concentrated on 
 one topic, will produce both mental and bodily fatigue. 
 
 Continuous mental labor, though of only short duration, will produce a greater 
 degree of fatigue, and that more quickly, than the same amount of work interrupted 
 by brief intervals of rest. A change of work, particularly from a hard to an easy 
 subject, will afford the same relief as a short rest. Severe fatigue comes on -n-ith 
 great regularity in periods of the ancient languages and mathematics, while recu- 
 peration takes place during history, geography, and nature study. The modern 
 languages occupy a middle place; singing and drawing make rather great demands 
 on those who do well in these branches. After violent or prolonged exercise one 
 is less fit for study, but after moderate exercise intellectual work seems to become 
 easier. The proper relation between physical and intellectual work, in 'order to 
 obtain the greatest good from each, is a question which should receive the careful 
 consideration of educators. 
 
 Exhaustion in Children. — One of the first ways in which fatigue shows 
 itself is in the slight amount of force expended in a movement and frequently a 
 lessening in the number of movements. In extreme exhaustion the ordinary 
 movements are not excited by ordinary stimuli, and such as do occur are slow and 
 
 1 Schanz: "Schule und Skoliose," "Zeitsch. f. orth. Chir.," x^-ii, 170; Kron- 
 ecker: "Ueber die Ermiidung und Erholung der gest. Muskeln, " Leipzig, 1871; 
 Mosso: "Fatigue," "International Science Series." 
 
 ^Sikorsky: "Sur les effets de la Lassitude provoquee par les travaux intel- 
 lectuals chez les enfants de I'age scolaire"; Leo Burgerstein: "Die Arbeitskurve 
 einer Schulstunde" ; Hugo Laser: " Ueber geistige Ermiidung beim Schulunterrichte." 
 
SCHOOL FURNITURE. I03 
 
 labored. This may be accompanied by irritability and occasional jerky movements 
 not controlled by circumstances. The eyes may wander and not be distinctly 
 fixed by the sight of the objects around; the face becomes toneless and devoid of 
 expression; there may possibly be a fullness under either eye. Frequently there 
 is manifest an asymmetry of posture and movement. The head is held on one 
 side; the arms when extended are not horizontal — usually the left one is lower; the 
 hand balance is weak; that is, when hands and arms are held straight out in front, 
 the fingers and wrists are not extended, and the thumb is not on the same plane 
 as the fingers; this also is more marked in the left hand. Lack of muscular tone 
 shows itself in a "slumped" position either standing or sitting. The face may be 
 lengthened from relaxation of the muscles and falling of the jaw. Sighing and 
 yawning are common symptoms. Speech is slow, and the tone of the. voice altered, 
 and in general there are slowness and inaccuracy of mental response. 
 
 School Furniture. — It is obviously important to furnish school chil- 
 dren with seats and desks which do not favor improper attitudes in 
 sitting and writing. The figures show that scoliosis is a constantly 
 increasing affection during school life, and it is a matter of common 
 information that "school scoliosis" and round shoulders are frequent in 
 school children.^ In 1842 Barnard, of Hartford, published an article 
 on the subject, followed twenty years later by Fahrner,^ of Zurich, 
 Meyer,^ Cohn,* Schenk, Lorenz,'^ Schulthess,^ and Scholder." The 
 most practical study of the matter made in late years was undertaken 
 by the Boston Schoolhouse Commission,* and use will be made of their 
 report in this section. 
 
 The two things to be prevented in school furniture are — (a) the pro- 
 longed stretching of the back muscles by the continued maintenance 
 of flexion of the spine, and (b) the assumption of distorted and twisted 
 attitudes, children with tired muscles tending to rest them by assum- 
 ing a change of position. Furniture of bad design or improperly fitted 
 tends to favor both of these. ^ 
 
 A large number of desks and seats have been devised; it is said that 
 150 have been proposed, but at least over 30 have been tried. The 
 chair ^^ devised for the Boston Schoolhouse Commission in 1903, which 
 
 ^ Scudder: "Determination of the Muscular Strength in Growing Girls," 
 "Bos. Med. and Surg. Jour.," Nov. 6, 1890. 
 ^ "Das Kind u. d. Schultisch," 1865. 
 
 ^ "Die Mech. des Sitzeijs," "Virch. Arch. f. path. Anat.," x.xxv, 1S67. 
 ^"Beitr. zur Losung der Subsellenfrage, " Berlin, 1885. 
 ^ Lorenz: "Ueber die Skol.," Wien. 
 " Schulthess: "Zeitsch. f. orth. Chir.," 1892, i, i. 
 ' "Archiv fiir Orth.," i, 2. 
 
 ^ Boston Schoolhouse Commission Reports for 190 1-5. 
 'Feiss: "Cleveland Med. Jour.," Aug., 1905. 
 ^"Reports of Boston Schoolhouse Commission, 1903, 1904, 1905. 
 
I04 
 
 ETIOLOGY — INFLUENCE OF SCHOOL CONDITIONS. 
 
 was carefully worked out by Dr. F. J. Cotton in the Scoliosis Clinic 
 of the Children's Hospital, will be here considered as embodying the 
 theoretical requirements and as having worked well on rather a large 
 scale in some years of practical use, there being 22,000 such seats now 
 in use in Boston public schools. The theoretical requirements which 
 are by common consent accepted will be first discussed. 
 
 1. The height of the seat from the floor should be such that in sit- 
 ting the feet rest on the floor. Too high a seat produces pressure on 
 the back of the thighs; too low a seat induces flexion of the lumbar spine. 
 
 2. The slope of the seat should be backward and downward about 
 three-eighths of an inch. The depth of the seat should be about two- 
 thirds the length of the thisrhs. 
 The width of the seat should 
 be that of the buttocks. Some 
 concaving of the seat is com- 
 fortable, but not essential. 
 
 3. The hack of the seat 
 should have a slope backward 
 of one in twelve from the ver- 
 tical line (Saxon 'regulations). 
 The more modern expression 
 of this is found in two back 
 supports, one low down, ^ to i 
 inch in front of the back edge 
 of the seat, and a second higher 
 up, i|- inches behind the back 
 edge of the seat. In the experi- 
 mental . study of school seats 
 alluded to it Avas found that in 
 
 a nearly balanced sitting position a relatively low back support was 
 
 ample and the upper one not required. 
 
 4. The height of the desk should be such that the back edge allows 
 the forearm to rest on it naturally with the elbow at the side. The 
 height of this edge from the edge of the seat is known technically as the 
 "difference." 
 
 5. The slope of the desk has been advocated at all angles from o to 
 45 degrees. The theoretically best slope for reading is at least 30 
 degrees, but this is practically too steep and books slide off, and it is not 
 practicable for writing. From 10 to 15 degrees is the usually accepted 
 inclination. The proper distance of the eyes from the desk is from 12 
 
 Fig. 75. — Boston School Desk and Chair. — 
 {Boston Schoolhouse Commission.') 
 
SCHOOL FURNITURE. ■ I05 
 
 to 14 inches. The width of the desk is immaterial, 22 to 24 inches 
 being the usual size. 
 
 Two separate models for back rests, one for older and one for 
 younger children, were worked out independently by means of modelling 
 wax and wood, and the curves of the two were found to be practically 
 identical. A third model for adolescent girls was later found necessary 
 on account of the larger hips, and was slightly higher, with flattened 
 lower corners. The description of the back rest for the middle group 
 is given here.^ 
 
 " The model finally settled on consists of a curved support of wood, 
 nine and three-quarters inches wide and five inches high, with a con- 
 cavity of one inch in depth from side to side, with a convexity of one 
 inch in profile, the whole very slightly tilted backward. The maximum 
 convexity lies one-third of the way up, and when properly adjusted 
 comes about opposite, or a little above, the fourth lumbar vertebra. 
 This support is carried on a light casting, running in the groove of a 
 single cast-iron upright attached to the back of the seat. A set-screw 
 fixes the height after adjustment. 
 
 " Seats have been manufactured from these models in two sizes, and 
 are used with adjustable desk and seat castings that provide for height 
 and adjustment. As the matter stands, the new furniture provides a 
 seat adjustable for height, with the new back rest also adjustable for 
 height, and a desk likewise provided with a vertical adjustment. 
 
 "As to the distance from the seat to the desk, the vertical writing 
 system calls for such a space as shall let the hand come down nearly to 
 the edge of the desk without the elbow striking the back support, 
 namely, a distance from seat-back to desk-edge equal to the length 
 from wrist to elbow. This brings the desk-edge pretty close to the 
 body in comfortable writing position. 
 
 "This arrangement makes it possible to write freely and easily 
 with the body pretty evenly balanced, or even leaning backward 
 slightly. With the desk-edge so close the pupil is rather cramped and 
 in poor position for reading. The compromise usually made is to have 
 the desk a few inches further forward; this is well for reading, but for 
 writing this requires a forward sitting position which is undesirable, 
 because — (a) the back loses its support, (b) the supporting of weight on 
 the arm tends to rotated postures of the spine, (c) the posture tends 
 to round shoulders, and (i) the posture tends to bring the eyes too 
 close. 
 
 "For these reasons it is desirable to be able to have an adjustment 
 ' F. J. Cotton: "American Phys. Education Review," Dec, 1904. 
 
Io6 ETIOLOGY INFLUENCE OF SCHOOL CONDITIONS. 
 
 to give a writing and a reading distance to desk from chair to suit the 
 occasion.^ 
 
 "This adjustment should have a range of at least four or five inches. 
 In the avoidance of vicious attitudes this adjustment is of the utmost 
 importance, and a surprising amount has been written in regard to 
 positive, negative, and nil 'distance.'^ With the 'distance' ad- 
 justable we have plenty of room to move about and an easy supported 
 position for reading, and, for wTiting, a good position with a minimum 
 tendency to lean forward or twist, and with a support to the lower back 
 that works against distortion. With no single position can all these 
 things be attained."^ 
 
 Writing Position. — Of late years there has been a tendency to blame 
 the teaching of slanted handwriting for much of the scoliosis, 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 
 
 Miinich 24 15 
 
 Fiirth 65 31 
 
 Wurzburg 28 8 
 
 To these figures must be attached considerable importance, but the 
 question is by no means settled, Gould, of Philadelphia, having called 
 attention to certain factors previously overlooked. 
 
 "With^ the head and body erect, the paper straight before the me- 
 dian line of the body, and the penholder held as commanded, no person 
 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 pen- 
 holder. 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. 
 
 "The slanted hand^-riting is due merely to the fact that less torsion 
 
 ^ "School Seats," "Bos. Med. and Surg. Jour.," Oct. 5, 1899, page 338. 
 
 ^ Distance is the horizontal distanc2 from the desk-edge to the front edge of 
 the chair, positive when the chair is behind the vertical, negative when they overlap, 
 nil (Null-distanz) when the edges are one above the other. 
 
 ^ G. M. Gould: "American Medicine," ix, 14, 562, 1905. 
 
THE WRITING POSITION. 
 
 107 
 
 or rotation of the head to .the right is rendered necessary, and a shght 
 easing is secured by slanting the letters to the right. 
 
 "The cure of the false position and of slanted handwriting consists 
 in: (a) Placing the paper vertically, and opposite the right shoulder, 
 and upon a desk leaf pitched at an angle of 30 degrees, and 12 to 14 
 inches from the eye, the body normally erect and hygienically posed. 
 
 Fig. 76. — 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.— (Cow/rf.) 
 A view of the hand, as seen by the writer, with the head displaced in photographing. 
 
 (b) Or, by the use of angled penholders, leaving the paper straight in 
 front of the body, (c) The grasping the old straight holder between 
 the first and second fingers, or as the Japanese and Chinese do their 
 brushes, from two to three inches from the point, and the upper end 
 held vertically or somewhat slanted to the right. This would require 
 that our common steel pens should be made somewhat differently." 
 
Chapter VIII. 
 OCCURRENCE. 
 
 Scoliosis is not wholly a disease of the upright position, as it has 
 occasionally been found in mammals, fowls, and fishes. A case occur- 
 ring in a pig has been carefully studied by Schulthess.^ A case in a 
 goose has been reported by Schmidt,^ and it has been observed occur- 
 ring spontaneously in a goat. In such cases a true rotary lateral curva- 
 ture has been found with a turning of the vertebral bodies toward the 
 convexity of the lateral curve. Double curves have been observed. 
 Experimentally it has been produced in dogs, rabbits, and goats by 
 WuUstein, Arnd, and Ribbert. 
 
 In the human spine scoliosis is usually developed during the years 
 of growth. In its lighter forms it is very frequent. Lateral curvature 
 occurs in all classes of people, though certain forms are more commonly 
 found in certain classes than in others, e. g., in America the rachitic 
 forms more frequently occur in negroes and southern Europeans. 
 
 Statistics are lacking as to the percentage of scoliosis in the popu- 
 lation as a whole. It is only in hospitals and institutions that such 
 records are made, and these cannot be regarded as indicating the true 
 situation because the clienteles of various hospitals differ so widely. 
 As examples of the numbers furnished by orthopedic institutions may 
 be cited those of Fischer, Behrend, and Schanz. Fischer found 353 
 scolioses among 3000 patients; Behrend with the same number found 
 900 scolioses, and Schanz in 1000 patients found 295 cases of scoliosis. 
 The figures of Behrend and Schanz show approximately 2,3^ per cent, 
 of scoliosis. 
 
 Statistics made from the records of the examination of large num- 
 bers of school children are the only means of estimating the percentage 
 of scoliosis rationally, and they are especially valuable as showing the 
 frequency of scoliosis during the school years. The following table 
 shows that scoliosis is found in from 25 to 50 per cent, of the children 
 in city schools. In this, as in all the other tables given, it must be 
 
 ^"Zeitsch. f. orth. Chir.," 1901, ix, i, page 7. 
 ^ " Zeitsch. f. orth. Chir.," 1903, xi, 2, page 352, with literature. 
 
 108 
 
SEX. 109 
 
 remembered that the number of asymmetries recorded depended on the 
 standard of the individual observer, which varies of course with diiler- 
 ent investigators. A standard which notes the slightest asymmetries 
 of the trunk and the vertebral column will show a much larger percen- 
 tage of deformities than one which recognizes only the easily identified 
 typical curves. The figures of Scholder may be taken as representa- 
 tive, being recent statistics taken by competent observers. 
 
 Number 
 Investigator. Examined. Scolioses. Per Cent. 
 
 Peter Wisser 515 272 52.81 
 
 Krug 1418 357 25.17 
 
 Scholder 2314 571 24.7 
 
 Brunner, Klaussner, and Seydel ....4169 .. 46.4 
 
 Meyer 336 189 37 
 
 Guillaume 731 218 30 
 
 SEX. 
 
 In adults it is generally the opinion that women show a greater num- j 
 ber of scolioses than men, although published statistics confirming this 
 fact do not exist. Records of the relative frequency of scoliosis in 
 boys and in girls made in orthopedic institutions where patients apply 
 for treatment show a very much larger percentage of scolioses among 
 girls than in boys. That this is not the case in all classes of the com- 
 munity was proved recently by the examination of the school children, 
 which shows that young boys and girls are almost equally affected 
 with scoliosis and that in some instances the percentage of boys is even 
 greater than that of girls. To explain this difference we must either 
 assume that boys outgrow scoliosis, or that they do not come to the 
 institutions for treatment until the curves become severe or until com- 
 plications arise, while in girls the effects of scoliosis upon the figure are 
 perceptible much earlier, and treatment is sought to remedy curves 
 which in boys would pass unnoticed by the parents. According to 
 different authors, severe forms of scoliosis, usually rachitic, occur 
 quite as frequently among boys as in girls. 
 
 The two tables which follow are excellent examples of the difference 
 existing between the records of orthopedic institutions and the figures 
 resulting from the examination of school children. The first table, 
 from the records of institutions where patients apply for treatment, 
 shows 75 to 93 per cent, of scoliosis in girls, and 7 to 20 per cent, in 
 boys. The second table, from the examination of school children, 
 shows the approximately equal occurrence of scoliosis in both sexes. 
 
no OCCURRENCE. 
 
 Figures from Institutions where Patients are Treated. 
 
 Boys. Girls. Boys. Girls. 
 
 Per Cent. Per Cent. Per Cent. Per Cent. 
 
 Etilenburg 13 87 Adams 12.8 87 
 
 Ever 7 93 Scholder 14.8 85 
 
 Ketch 17 83 Schanz 25 74.8 
 
 KoUiker 20 So Rosenthal 22 78 
 
 Roth 8.5 91 Schulthess 14.2 85.5 
 
 Wedberger 15.9 84 Redard 15.6 83.3 
 
 Behrend 13.4 86 
 
 Figures from School Children. 
 
 Boys. Girls. 
 
 Total No. No. Scoliotic. Per Cent. Total No. No. Scoliotic. Per Cent. 
 
 Drachmann 16,789 141 0.8 11,386 227 2 
 
 Scholder and Combe. 1,290 297 23 1,024 ■ 274 26.7 
 
 Krug 695 181 26 723 163 22.5 
 
 Wisser 292 167 57-23 223 105 47.08 
 
 AGE. 
 
 Scoliosis is an affection of the years of growth in a large majority of 
 cases, but it is often extremely difficult 'to form an accurate idea of the 
 age at which the deformity begins in individual cases. Scoliosis in 
 very young children may occur from the first up to the fifth year, due 
 to rickets and congenital causes. In general, however, the inaccurate 
 observations of parents furnish no foundation upon which to base the- 
 ories or statistics concerning the time of the beginning of the scolioses 
 observed in older children. 
 
 For the school age, the investigations of Scholder at Lausanne show 
 a steady increase in the percentage of scoliosis, in both girls and boys, 
 from the eighth to the thirteenth year. This increase is especially 
 noticeable from the eighth to the eleventh year, and is probably con- 
 nected with the rapid growth of children during this period. 
 
 Age. 
 
 9 
 
 13 
 
 Boys. 
 
 Girls. 
 
 7.8 per cent. 
 
 9.7 per cent 
 
 6.7 " 
 
 20.1 " 
 
 8.3 " 
 
 21.8 
 
 4.2 
 
 30.8 
 
 7.1 
 
 30.2 " 
 
 6.3 " 
 
 37-7 
 
 In regard to the age at which scoliotic children are brought for 
 treatment, Eulenburg found over 50 per cent, of all cases between seven 
 and ten years old, and but 10 per cent, between the ages of ten and 
 fourteen years. 
 
 The clinical material collected by the Institute of Liining and 
 Schulthess at Zurich has been used by Sutter and Miiller in preparing 
 curves of the frequency of scoliosis at different ages. Miiller finds the 
 
FREQUENCY OF DIFFERENT FORMS. Ill 
 
 greater number of cases in the fourteenth year. The number increases 
 gradually from the eighth to the fourteenth year, and decreases rapidly 
 from the fourteenth to the seventeenth year. Sutter found that the 
 number of boys brought for treatment reached the maximum in the 
 ninth, thirteenth, and fourteenth years. The number of cases under 
 treatment at fourteen years of age is double that for nine years, and 
 shows not only an increase in frequency of scoliosis, but an increase of 
 deformity in curves already existing. 
 
 Reviewing the occurrence and frequency of scoliosis the following 
 statements can be made: (i) Scoliosis occurs in all classes of people. 
 (2) There are no statistics concerning the proportion of scoliosis among 
 adults. (3) Children of both sexes show from 25 to 50 per cent, of 
 scoliosis during the school years, with the best authenticated average 
 at about 26 per cent. (4) With regard to sex — (a) in adults women 
 are generally supposed to be affected with scoliosis more often than 
 men ; (b) of children at school, boys and girls are about equally affected ; 
 (c) of children coming for treatment, the girls very largely outnumber 
 the boys. (5) Scoliosis has been observed in children from the first year. 
 The age at which the greater number of cases are recorded for treatment 
 is given by Eulenburg as from seven to ten, and by Schulthess as 
 fourteen years. 
 
 RELATIVE FREQUENCY OF THE DIFFERENT FORMS OF SCOLIOSIS. 
 
 Statements concerning the frequency of the simple forms of scolio- 
 sis are of very recent origin. All statistics agree, howxver, in showing 
 that for all forms there aire more scolioses convex to the left than to the 
 right. There is less unanimity as to which of the single forms is the 
 most frequent. Lorenz states that left lumbar scoliosis is the most 
 numerous. KoUiker, from the examination of 721 cases, finds the sim- 
 ple dorsal scoliosis the most frequent. By considering the tables of 
 other investigators Schulthess found the compound right dorsal scolio- 
 sis the most frequent form, followed in order by the simple dorso- 
 lumbar curves, total scoliosis, and lumbar scoliosis. The cervicodorsal 
 form was the least frequent. 
 
 Among the 571 school children with lateral curvature out of 2134 
 children examined by Scholder at Lausanne, 401, or 60.3 per cent., 
 showed curves convex to the left, 121, or 21. i per cent., curves convex to 
 the right, and 49, or 8.6 per cent., compound curves. The table compiled 
 by Scholder shows the percentage of curves as to their form and con- 
 vexity. The total cvirve is the most frequent form in school children, 
 
112 OCCURRENCE. 
 
 and is followed by the left and right lumbar curves and by left dorsal 
 scoliosis. 
 
 Left Convex. Right Convex. Total. 
 
 Total scoliosis 48.1 per cent. 7.8 per cent. 56 per cent. 
 
 Dorsal scoliosis 8.4 " 4.3 " 12.7 " 
 
 Lumbar scoliosis 11.8 " 8.5 " 20.3 " 
 
 Combined scoliosis 8.5 per cent. 8.5' " 
 
 Almost the only records that have been studied and tabulated for 
 definite study are those of the Institute of Liining and Schulthess, and 
 it is from these investigations that much of the following material is 
 drawn. 
 
 Age. — At eight years the left scolioses form 64 per cent, and the 
 right scolioses 33 per cent, of the total number of curves. In the four- 
 teenth year the number of curves convex to the left and right is about 
 equal. The number of compensating curves increases from 27 per 
 cent, in the eighth year to 45 per cent, in the seventeenth year. 
 
 Position of Apex of Deviation. — To ascertain the location of the 
 point of deviation Durrer has constructed a set of curves which show 
 that for the .left convex scolioses the maximum deviation is at the dorso- 
 lumbar junction, and for the right convex curves the apices are found 
 in the region of the seventh dorsal vertebra, which showed a much 
 greater deviation than the adjacent vertebrae, while in the left convex 
 curves the deviation is more evenly distributed over the length of the 
 spine. 
 
 Schulthess finds four principal apices of deviation for single and com- 
 pound forms of scoliosis: (i) The upper dorsal region to the right; 
 (2) the dorsolumbar junction to the left; (3) the upper dorsal and lower 
 cervical regions to the left; (4) the lower lumbar region to the right. 
 
 In the eighth year the maximum deviation of the right dorsal curves 
 is in the region of the sixth to the eighth dorsal vertebrae, and is still 
 found there in the seventeenth year. The apex of the left convex 
 curves in the eighth, ninth, and tenth years is at the ninth or tenth dor- 
 sal vertebra; between the ages of eleven and thirteen it is found at the 
 twelfth dorsal vertebra, and descends to the first or second lumbar 
 vertebra between the ages of fifteen and eighteen years. 
 
Chapter IX. 
 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 for some reason is abnormally formed 
 or possesses less than normal resistance. It is not accompanied by any 
 degree of pain and none in its earlier stages. Stiffness, if it is present, 
 is an accompaniment of late cases and the result of long-continued struct- 
 ural changes. The curvature of the spine is self-evident if one hangs 
 a plumb-line in the middle of the back, and scoliosis can be said either 
 to be present or absent in any given case. Of course, absolute sym- 
 metry does not exist, but a perceptible variation of the line of spinous 
 processes from a straight line situated in the median anteroposterior 
 (sagittal) plane of the body constitutes scoliosis. 
 
 It is important, first, to recognize lateral curvature when it exists; 
 second, it is desirable to identify the cause of the affection if possible; 
 and, third, it is essential to discriminate from scoliosis other affections 
 resembling it, of which it is only a symptom. 
 
 First, the recognition of scoliosis has been sufficiently discussed in 
 speaking of the method of examination (see chapter on Examination 
 and Record). 
 
 Second, the differentiation of the varieties of scoliosis is to be made 
 by the recognition of special characteristics in each case (see chapter on 
 Description and Symptoms) . 
 
 Scoliosis of Congenital Origin. — The A;-ray is of importance in 
 making plain the character of the bony deformity. In the class of 
 cases where a comparatively slight congenital anomaly is present the 
 use of the .T-ray is essential to establish the congenital origin of the case. 
 Where due to defects in the thorax or scapula, the scoliosis is located 
 in the upper part of the column, is s'evere and exists in early life. 
 The defects in the chest or thorax are usually self-evident. 
 
 Acquired Scoliosis. — In acquired scoliosis the existence of torti- 
 collis, pelvic asymmetry, and impaired vision or hearing are competent 
 causes of the deformity and should have been identified in the examina- 
 tion. The existence of any one makes it likely that the scoliosis is due 
 8 113 
 
114 DIAGNOSIS. 
 
 to that as a cause. The discovery that one leg is shorter than the other 
 does not establish that as the necessary cause of the scoliosis for the 
 reasons mentioned, although it is a competent cause. 
 
 Rickets is one of the most frequent causes of severe scoliosis. It 
 occurs early and, as a rule, this is a severe and intractable form. ]Most 
 often the curve is lumbar or dorsolumbar, a compound curve with 
 marked deformity of the thorax, or cervicodorsal. Asymmetry of the 
 head is said by Schulthess to be a frequent accompaniment. The curves 
 are generally rather sharp, thoracic deformity is frequent, and rotation 
 appearances conspicuous. The existence of signs of former rickets is 
 presumptive evidence of this form of deformity; these are enlarged 
 epiphyses, a rosary or beading of the anterior ends of the ribs, a square 
 prow-shaped forehead, and the curvature of the long bones. 
 
 Osteomalacia as a cause of scoliosis is made evident by the existence 
 of the disease elsewhere. 
 
 Diseases of the joints, of the arms, or legs is easily distinguished and 
 mention need only be made that this is a competent cause of scoliosis. 
 
 Infantile paralysis is a motor paralysis of certain groups of muscles 
 or of a whole limb. It is manifested by loss of power in the affected 
 muscles, by loss or diminution of reflexes, by coldness and muscular 
 atrophy, and the reaction of degeneration in the muscles to electricity. 
 The resulting curves are most often low in the spine, are characterized 
 by great deformity and shortening of the trunk, and are not easily mis- 
 taken for other forms of scoliosis. The frequent association of scolio- 
 sis with infantile paralysis of one or both legs from some slight involve- 
 ment of the back muscles makes it imperative to examine the back in 
 every case of infantile paralysis. 
 
 Nervous disease of other forms may be accompanied by scoliosis, 
 but in these it is generally of secondary. importance and only of slight 
 or moderate degree as a rule. 
 
 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 unaffected 
 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. 
 
 Organic heart disease is in some cases accompanied by and is pre- 
 sumably the cause of a scoliosis. As the examination of the heart 
 should form a routine part of all examinations for scoliosis, this should 
 be easilv detected. 
 
SCOLIOSIS AS A SYMPTOM. II 5 
 
 Cases of scoliosis which do not fall into one of the above divisions 
 may be classed as Jiahit or school scolioses, which is an admission that 
 we are ignorant of the real cause in the individual case. 
 
 Pathological Conditions Accompanied by Lateral Curvature as a 
 Symptom. — Cases of lateral curvature accompanied by pain, especially 
 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. DouJotful cases may be cleared up by the use of the ,T-ray. 
 
 The^cmust be carefully separated from true scoliosis. The chief 
 one of tnese is Pott's disease, or tuberculosis of the spine. The symp- 
 toms 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 abdo- 
 men, elevation of temperature, and impairment of the general condi- 
 tion. As the disease progresses a sharp prominence backward of the 
 spinous processes occurs at some part of the spine. Abscesses in the 
 neck, the loin, and the iliac region occur in severe cases. Lateral devia- 
 tion of the spine occurs in the acute stage of practically all cases, but it 
 is a 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 of the spine accompanies arthritis defor- 
 mans, which is also known under the names of osteoarthritis of the 
 spine, spondylitis deformans, ankylosis of the spine, spondylose rhizo- 
 melique, Bechterew's disease, Steifigkeit der Wirbelsaiile, 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 curve a gradual one with slight or no rotation. The lat- 
 eral curve accompanying tumors of the spine, dislocation of the verte- 
 bra?, etc., would hardly be mistaken for real scoliosis, the usual signs 
 of those affections being present. 
 
Chapter X. 
 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 unfavorabl)^ or pro- 
 duce any unpleasant result further than slight asymmetry. In neuras- 
 thenic women they are frequently accompanied 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 per- 
 haps 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. 
 
 Structural curves in older children and adolescents which have not 
 progressed rapidly through childhood are after puberty likely to increase 
 but slowly 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 structural curve is a threatening symptom demanding 
 attention. 
 
 WITH TREATMENT. 
 
 Total scoliosis should be entirely and permanently cured by ad- 
 equate 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. 
 
 Structural curves in older children and adolescents when of moder- 
 ate degree should be greatly improved by adequate and long-continued 
 
 ii6 
 
PROGNOSIS WITH TREATMENT. II7 
 
 treatment, but cannot be wholly cured. Severe structural scoliosis 
 under these conditions can be markedly improved. 
 
 WTien growth has been reached, only improvement and not com- 
 plete cure is to be hoped for from treatment in scoliosis of any form. 
 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, but can 
 be improved. Rickets contributes a class of cases on the whole resis- 
 tant to treatment, and in severer cases, even in young children, a com- 
 plete cure is not obtainable. The existence of organic heart disease 
 or phthisis makes the prospect of obtaining much improvement from 
 treatment unfavorable. 
 
Chapter XI, 
 
 TREATMENT. 
 
 The treatment of scoliosis can be most clearly considered if one 
 separates for purposes of discussion the two types of cases already 
 described (page 49) — (i) 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 de- 
 partments of medicine and surgery where functional and organic con- 
 ditions are separated. 
 
 THE TREATMENT OF POSTURAL SCOLIOSIS (FUNC- 
 TIONAL SCOLIOSIS). 
 
 Regarding the condition as an habitual inability to stand correctly, 
 as a postural malposition without marked structural change, it is evi- 
 dent that the treatment should consist in the substitution of a correct 
 attitude for the faulty one. This is obviously to be preceded by elim- 
 inating conditions unfavorable to the maintenance of a correct up- 
 right position and by tonicity. The conditions requiring investigation 
 and possible correction are — (i) 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, lead- 
 ing to persistent fatigue. These matters are also of importance in 
 structural lateral curvature. Having placed the patient under the most 
 favorable conditions obtainable and having corrected 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. 
 The exercises should not be pushed beyond the limit of fatigue, and 
 after the active period has ceased the child should do home gymnas- 
 tics and be kept under supervision 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 mea- 
 sures are not likely to be successful and exercises clone at home under 
 the supervision of careless parents are less efficient than those given by 
 
 118 
 
STRUCTURAL SCOLIOSIS. IIQ 
 
 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 suffi- 
 ciently 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 146, or by means of gymnas- 
 tic exercises. Haxing 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. Ex- 
 ercises suitable for the treatment of postural cases will be described 
 in connection with the gymnastic treatment of structural scoliosis 
 (page 127). 
 
 TREATMENT OF STRUCTURAL SCOLIOSIS (ORGANIC 
 SCOLIOSIS, HABITUAL SCOLIOSIS, FIXED 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 
 years 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 vertebne have become compressed on one side or twisted 
 by the rotation. The ligaments and muscles have become adap- 
 tively shortened on one side and stretched on the other, and the inter- 
 vertebral discs to a greater or less extent have become compressed on 
 one side. 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 
 
I20 TREATMENT. 
 
 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 eight or ten at most are spent in recum- 
 bency. During the remaining fourteen or sixteen 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, adequate, 
 and surgically sound to produce a permanently satisfactory result. 
 
 The causes of failure lie in the unwillingness of the parents or the/ 
 patient to submit to sufi&ciently long-continued and effecti\-e treatment 
 to remedy a condition which, on the slightest consideration, can be 
 seen to be one which is necessarily difi&cult and resistant. 
 
 The surgical treatment of structural lateral curvature must obviously 
 consist of two divisions: First, to loosen up the stiffened parts of 
 the spine to make an improved position possible, and, second, to hold 
 the improved position when it has been rendered possible. These 
 two elements are not sufficiently separated as a rule in treatment; they 
 frequently go hand in hand and treatment must often be simultaneous 
 for both, but it adds very much in a clear formulation of treatment 
 to keep the two things perfectly separate. 
 
 The treatment of structural lateral curvature will be described 
 under the following headings: Gymnastics with Apparatus; Gymnastics 
 without Apparatus; Passive Stretching; Forcible Correction; Braces 
 and Corsets; Operative Treatment. 
 
 GYMNASTICS. 
 
 Gymnastics have a two-fold object — first, .to loosen up the curved 
 portion of the spine to make an improved position possible, and, second, 
 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 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 unrea- 
 sonable to expect free standing gymnastic exercises to straighten marked 
 or severe curves or to change the shape of distorted bones. But after 
 the greatest possible improvement has been secured in such curves by 
 more efiicient measures (passive stretching and forcible correction) 
 one must look to gymnastics to develop the muscles which will hold 
 
GYMNASTIC TREATMENT. 
 
 the improved position and make the gain permanent after the correc- 
 tive jacket has been gradually discontinued. In marked and severe 
 structural scoliosis, therefore, gymnastic treatment finds its best use 
 as supplementary 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 ex- 
 ercises are curative or at least 
 helpful in scoliosis, and, second, 
 
 liLiSU 
 
 Fig. 77. — Patient with Left Dor- 
 sal Curve in 1900. 
 
 Fig. 78. — Same Patient in 1905 af- 
 ter Five Years of Gy.mnastic 
 
 Treatment. 
 
 by competent surgeons who do not believe in corsets or supports.* 
 The former class serves only to bring the legitimate use of gym- 
 nastics for scoliosis into disrepute; the latter class use the gym- 
 nastics understandingly, and, on the whole, take a pessimistic view of 
 the results to be obtained in severe scoliosis. Moreover, it is a mistake 
 
 ' Teschner: "N. Y. Med. Rec," Dec. 6, 1903; Erich: "N. Y. Med. Jour.," 
 Oct. 7, 1S99. 
 
122 TREATMENT. 
 
 to make a spine more flexible unless one is prepared to hold the spine 
 in the improved position by a corset or brace or by muscular develop- 
 ment, because if flexibility is increased, the spine will sink further 
 into the bad position by virtue of its increased mobility unless some 
 means is provided to prevent this. In mild structural scoliosis 
 efiicient gymnastics may constitute the sole treatment, and may be 
 continued as the sole treatment so long as the improvement from one 
 
 
 Fig. 79. — Trunk Bending Appa- 
 ratus. — (Sc/iuUhess.) 
 
 Fig. So.— Shoulder Pushing Apparatus.- 
 (SchuUliess.') 
 
 e.xercise period persists until the next one. If such improvement is 
 not held between exercises it must be assumed — (i) that the 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, and it 
 must be recognized that, on the whole, gymnastic treatment by itself is 
 
GYMNASTICS IN APPARATUS. 
 
 123 
 
 not satisfactory in scoliosis -characterized by any marked degree of bony 
 deformity. 
 
 The treatment by gymnastics alone may be supplemented (a) by 
 the use of jackets, braces, or corsets, or (h) by the use of intermittent 
 passive stretching, or (c) by both. If the case is too severe for gym- 
 nastics, (d) forcible correction followed by gymnastics and corsets is 
 the proper treatment. The use (e) of braces and corsets alone is not 
 
 Fig. 81. — HiP-PENDULCM and Shoulder-raising Apparatus. — {Schulthess.) 
 
 to be considered a treatment for lateral curvature. Gymnastic treat- 
 ment may be given with or without apparatus. 
 
 Gymnastics Given in Apparatus. — By means of apparatus gym- 
 nastic 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 compli- 
 cated and expensive apparatus. 
 
 The system of apparatus devised by Schulthess and its modifica- 
 
124 TREATMENT. 
 
 tions and the apparatus of Zander are the best examples of the kind. 
 The aim of this method of treatment, as stated by Schulthess, is "to 
 correct, and in the corrected position to allow exercises to be done, or 
 through the movements carried out in the apparatus to shape o^•er the 
 body from the pathological to the corrected form." The various forms 
 of apparatus are as follows: (i) For side bending with the pelvis fixed; 
 (2) for side bending with the shoulders and pelvis fixed; (3) for 
 forward and backward bending; (4) for trunk rotation; (5) for 
 active transverse pushing of the shoulder-girdle; (6) for active rais- 
 ing of the shoulder ; (7) for active movement of the thorax with shoul- 
 ders and pelvis fixed. In some of these the pendulum principle is 
 used. 
 
 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. It is 
 described in detail in the reference,^ and is not dwelt on here as it is a 
 treatment not often available in America (Figs. 79, 80, 81). 
 
 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 oj Pelvis. — It is essential that the pelvis should be fixed 
 diiring such exercises, as otherwise the pelvis is displaced and the move- 
 ment becomes a general and not a local one. A simple wooden appa- 
 ratus 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 when part of the attention must be fixed on holding 
 the patient firmly. 
 
 The apparatus, which was suggested by that of Bade," 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, and by securing 
 the front of the pelvis by a broad leather strap passing from one arm 
 
 ^ Schulthess: Joachimsthal's "Hdbch. der orth. Chir.," Lief v, page 1104. 
 ^ "Zeitsch. f. orth. Chir.," xii, 4, 799. 
 
GYMNASTIC TREATMENT. 
 
 125 
 
 to the other. The floor platform is so large that the apparatus cannot 
 upset (Fig. 84). 
 
 General Routine and Precautions. — It is desirable that the back should 
 be exposed during the exercises in order to note the effect of each one. 
 For this purpose the patient should wear during exercises a loose cotton 
 
 Fig. 82.— Composite Photograph (Two 
 Exposures on the Same Plate) 
 Showing the Model Standing 
 Erect and Bending to the Right 
 without Fixation of the Pelvis. 
 The Movement is a General One. 
 
 Fig. S3.— Composite Photograph of 
 THE Model Standing Erect and 
 Bending to the Right with the 
 Pelvis Fixed. The Movement is 
 Limited to the Spine. 
 
 dressing jacket, fastened around the neck and opening in the back. 
 This protects the front of the body but permits inspection 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 
 the spine visibly. Complicated exercises are dangerous and unsur- 
 
126 
 
 TREATMENT. 
 
 gical. Work to obtain results must be given by a competent gym- 
 nast 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. 
 After this exercises at home can be substituted for part of the personal 
 work. 
 
 As a preliminary of gymnastic work the heart of the patient should 
 have been, of course, examined, and the weight should be taken each 
 week. Persistent loss of weight is an indication for moderating or 
 
 Fig. 84. — Apparatus for Fi.xing the Pelvis During Gymnastic Exercises. 
 
 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 care- 
 ful investigation of the patient's environment, as they may arise 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 
 likelv to be of use within the limits mentioned above. They will first 
 
SYMMETRICAL EXERCISES. 1 27 
 
 be described indi\idually and then analyzed, and their apfiHcation to 
 different conditions will be indicated. 
 
 The selection of exercises must depend on the requirements of each 
 case, and so far as possible the especial value of each exercise has been 
 indicated. Simple developmental 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 remem- 
 bered that conditions observed in the normal do not necessarily 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 position. 
 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 be- 
 cause any improvement of scoliosis must be interpreted as meaning improvement 
 in the upright position, and all muscles concerned in that are therefore of impor- 
 tance. 
 
 Fundamental Standing Position. — The patient stands with the knees 
 extended, the hands on the hips, the back straight, the head erect, and the scapulas 
 brought close to each other. The patient should not exaggerate the lumbar curve, 
 and should press down with both hands on the hips. 
 
 I. Shoulder Raising and Sinking. — (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 (i) the patient breathes 
 in and in count (2) breathes out (Fig. 85). 
 
 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 inspiratory 
 muscles, thus tending to increase chest capacity, and a general stretching 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 Shoulders Raised. — (i) The shoulders are 
 raised as in Exercise I u)- (2) The patient bends her trunk forward to the hor- 
 
128 
 
 TREATMENT. 
 
 izontal 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 
 position with the shoulders still raised and the spine straight. (4) The patient 
 relaxes to the fundamental standing position (Fig. 86). 
 
 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- 
 
 FlG. 85. 
 
 Fig. 87. 
 
 Fig. SS. 
 
 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 Exercise 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 (i), holds the breath during (2) and (3), and breathes out in 
 count (4). 
 
 The above exercises may be modified and made slightly harder by ha\ang 
 
SYMMETRICAL EXERCISES. 
 
 129 
 
 the patient iilace both hands behind tlie neck with the elbows square, back as far 
 as possible. This raises the center of gravity of the trunk and therefore increases 
 the leverage against the muscles. 
 
 III. Trunk Twisting. — Position: Without pelvic fi.xation, the feet parallel 
 and touching, the hands on the hips, the head and spine erect, (i) 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. 87). 
 
 Trunk rotation to the right causes a left dorsal curve and vice versa; in addition 
 to this the e.xercise 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 mobilization, 
 and w'hen given only to one side is a mild corrective exercise for lateral deviation; 
 in the latter case the pelvis should be fixed to localize the movement in the spine. 
 
 Fig. Sg. 
 
 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. These two variations 
 should be done with the pelvis fixed. 
 
 IV. Trunk Circling. — Position: Hands on the hips, the trunk flexed to the \ 
 horizontal, the spine straight. From this position the patient describes a circle i 
 with the trunk about a vertical axis passing between the feet. The horizontal ; 
 plane of the circle described is quite irregular, and the movement is divided into, 
 four counts: (i) From the position of forward bending the trunk passes to the 
 right or left through side bending with flexion and rotation to extreme side bending. 
 (2) From extreme side bending the circle is continued backward through side 
 bending with its accompanying rotation to extreme hyperextension of the median 
 plane. (3) The reverse of count (2). (4) The forward bent position is assumed. 
 The face is directed forward during the entire exercise (Fig. 88). 
 
 This is a general mobilizing and strengthening exercise. When a marked 
 lumbar curve is present, the exercise is preferably made unilateral to the side that 
 improves rather than increases the lumbar curve, e. g., in a left lumbar curve 
 9 
 
I30 
 
 TREATMENT. 
 
 half circling to the left is preferable to the complete circle so far as any corrective 
 aspect is concerned. 
 
 V. Swimming. — Position: The patient bends fonvard until the trunk is 
 horizontal, the arms are held at the sides, the elbows flexed, and the hands together 
 against the chest, (i) The arms are extended upward beside the head. (2) The 
 arms describe a half circle outward and are brought to the sides of the body. (3) 
 The arms return to position (Fig. 89). 
 
 In this exercise the pelvis is flexed on the hip-joints and the weight of the 
 trunk is thrown forward. The extensor muscles of the spine and the glutei are 
 called upon to maintain the position during the movements of the arms. All the 
 muscles of the shoulder-girdle, especially those concerned in drawing the scapulae 
 together, take part in the movement. This is a general strengthening exercise, 
 especially addressed to spinal extensors, and is also valuable in cases of flexible 
 round shoulders. 
 
 VI. Head Movements from the Fundamental Standing Position. — The head 
 and cervical spine, as far as possible, alone should participate in these exercises. 
 A. (i) Head flexion, (2) original position. B. (i) Head hyperextension, (2) original 
 position. C. (i) Side bending of the head to the right or left, (2) original position. 
 D. (i) Head twisting, right or left, (2) original position. E. Head circling with the 
 face to the front, a combination oi A, B, and C following one another. 
 
 General mobilizing exercises for the cervical region. For corrective effect 
 in a cervical curve they should be given only to the side that improves the curve. 
 
 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 cur\'ed than 
 in the upright position, and is slacker and more easily capable of side displace- 
 
 J 
 
 Fig. 90. 
 
 ment. The fact that symmetrical hyperextensions are so much used for their cor- 
 rective effect is explained by their empirical value and by anatomical reasons (page 
 35)- 
 
 Lying on the Face. — \TI. Trunk Raising. — Position: The patient lies 
 face downward on a table with the spine straight, the hands on the hips, the scap- 
 
SYMMETRICAL EXERCISES. 
 
 131 
 
 ulae approximated to each other, the toes brought over the end of the table, 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, (i) 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. 90). 
 
 This is an extension of the spine from its normal position to extreme 
 hyperextension in which the spinal motion occurs largely below the tenth dorsal 
 
 Fig. 91. 
 
 Fig. 92. 
 
 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 extent. 
 The exercise may be made harder by placing the hands behind the neck and squar- 
 ing the elbows back or by extending the arms beside the head, which raises the 
 center of gravity (Fig. 91). 
 
13^ 
 
 TREATMENT. 
 
 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 
 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 
 hyperexterision done with an improved position of the shoulders. This is par- 
 ticularly suited to round shoulders. 
 
 Fig. 93. 
 
 Fig. 94. 
 
 VIII. Trunk Raising with Dumb-bells and Staff. — These are merely varieties 
 of Exercise VII, in which the position of the shoulders is modified by means of 
 dumb-bells or wands held in the hands, or in which the center of gravity is changed 
 by the dumb-bells, making the exercise harder, (a) The patient grasping dumb- 
 bells, places them together against the back and as high up as possible, (b) The 
 patient grasping the dumb-bells with the arms extended above the head, circum- 
 ducts the arms during the two counts of the exercise, (c) A staff is grasped in 
 both hands by the patient, who lies with arms e.xtended above the head, hands 
 palms down and rather widely separated. This position of the arms is main- 
 tained during the exercise, {d) This exercise differs from the last (c) in that the 
 
SYMMETRICAL EXERCISES. 
 
 133 
 
 Staff is brought over the head and down behind the scapula; during "raising," 
 and the original position resumed during "sinking" (Figs. 92-94). 
 
 These exercises increase the muscular effort elicited by Exercise VII by chang- 
 ing the center of gravity; most of them call into action the muscles which approx- 
 imate the scapulae and tend to stretch contractions holding them in a forward 
 position. Probably in some an element of forced hyperextension of the dorsal 
 spine is present. They find their use, consequently, in addition to scoliosis, 
 in cases of both flexible and resistant round shoulders. The individual applica- 
 tion must be decided by the special characteristics of the case. ' 
 
 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. I 
 
 Fig. 95. 
 
 Fig. 96. 
 
 IX. Trunk Raising from- Head Downward Position. — (i) The patient in- 
 spires, and raises the trunk as far as possible by hyperextending the hip-joints 
 and the spine. (2) During expiration she sinks to the primary position. The 
 spine should be kept in the mid-plane and the head not allowed to flex (Fig. 95). 
 
 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 
 VII. 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 easief by placing the hands on the 
 hips. It is of use as a general strengthening e.xercise for the back muscles in any 
 case where the patient is strong enough to take. it. 
 
 X. Trunk Circling. — The position is the same as in Exercise IX. The exer- 
 cise is done in four counts, as described under Exercise IV (Fig. 96). 
 
 This is a heavier exercise than I\' because the weight of the trunk is a factor 
 
134 
 
 TREATMENT. 
 
 entering into each component of the movement. For corrective effect it shoiild 
 be given only to the side that improves the lateral curve. 
 
 XI. Sivimming. — This exercise is done in the same way as Exercise V, except 
 that the patient first raises his trunk as high as possible, and holds the position 
 while he goes through the movements of swimming (Fig. 97). 
 
 It differs from Exercise V because the spine is held in a position of hyperexten- 
 sion, and is not flexed on the pelvis. It thus exercises chiefly the spinal extensors 
 
 Fig. 97. 
 
 / ■> 
 
 in a position necessitating their maximum contraction. It is not suitable to cases 
 with increased lumbar curve. 
 
 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 XII. Trunk Raising to Sitting Position. — (i) The patient rises slowly to the 
 
 i 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. 98). 
 
SUSPENSION. 
 
 135 
 
 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 lum- 
 bar physiological curve accompanying 
 scoliosis and round shoulders. 
 
 Exercises in the Suspended Posi- 
 tion. 
 
 The patient stands erect, and the 
 head is pulled vertically upward by 
 means of a Sayre head-sling, which 
 embraces the chin and occiput. Trac- 
 tion should be made by a compound 
 pulley, and the patient or the surgeon 
 may hold the rope. Suspension is 
 mildest — (i) when the feet are not 
 made to leave the floor; next in grade 
 comes (2) the position of tiptoe in- 
 duced by the traction, and (3) a greater 
 pull is secured by lifting the whole 
 body until the feet swing free. 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. 99). 
 
 Head suspension is a passive 
 stretching of the spine, corrective 
 through its entire length, tending to 
 improve both rotation and side devi- 
 ation at the curves, but exercising 
 still more force upon the more nearly 
 normal parts of the spine because 
 the latter are more movable. Sus- 
 pension by the arms is less efificient, 
 and does not affect the cervical ver- 
 tebrae as does head suspension. Hanging is a generally useful and purely mobil- 
 izing procedure suitable to any case, slight or severe. 
 
 If it is desired to make hanging exercises more locally corrective in the dorsal 
 region, the patient should hang by the hands from a bar, the hand on the convex 
 side of the lateral curve grasping a loop on the bar which is at least two inches 
 below it. By this means the concave side will be subjected to a greater stretching. 
 
 XIII. Hanging — Body Circling.— In the original position the patient is not 
 suspended by the head-sling, but the sling is lax and the feet touch the floor. The 
 patient then swings forward until restrained by the suspension apparatus, and' 
 
 Fig. 99. — Head Traction. 
 
136 
 
 TREATMENT. 
 
 then circles to the right, backward and forward, and to the left, gaining a mo- 
 mentum with which to continue the circling. After the patient has circled to the 
 right the desired number of times she reverses the direction and circles a desired 
 number of times to the left. In this exercise the body is swung about the feet as a 
 pivot. The feet are kept in one place on the floor, the trunk describing a circle 
 which involves the entire range of side bending and forward and V:)ackward motion. 
 
 This is a general mobilizing exercise for the entire spine, and may be modified 
 by being given only to the side that improves the lateral curve to increase its correc- 
 tive effect. 
 
 XIV. Hanging — Pelvic Rotation. — The patient hangs by both hands from a 
 bar and rotates the pelvis and legs rapidly and forcibly first to the right and then 
 to the left, alternating the two rotations in succession. 
 
 The exercise is intended to mobilize the lower dorsal and upper lumbar region. 
 
 Miscellaneous Symmetrical Exercises. 
 
 XV. Heavy Weight Raising^ (Teschner). — The patient stands facing a table, 
 which touches the front of the thighs or pelvis, against which she rests. She then 
 
 raises slowly a heavy bar, weighing from 10 to 30 or 
 more pounds, over the head as high as the arms will 
 
 '■ •' : ■- ,• -'--".:"-"-:"-'-'.::;:::' reach, keeping the eyes fixed on the middle of the 
 
 ; i ; ; bar and keeping the bar horizontal. It is then low- 
 
 ered slowly, but should be held or rested at the level 
 of the shoulders and not allowed to drag on the 
 arms. The exercise is repeated as often as may be. 
 The patient should use as hea^y a bar as can be put 
 up steadily and which produces a corrective effect 
 on the curve when the point of upward stretch is 
 reached. The weight should be steadily increased 
 as the muscular capacity of the patient increases (Fig. 
 100). 
 
 The exercise tends to develop all the muscles of 
 the trunk, as its correct performance necessitates a 
 contraction of the muscles maintaining the erect 
 position. It is not particularly corrective to the 
 curve, but fills out the flanks, improves the body- 
 ^'^' '°°' outline, and tends to strengthen the muscles main- 
 
 taining a correct upright attitude, in this way tend- 
 ing to fix the improved position. It is a developmental exercise suited to any 
 curve,' of retentive rather than corrective value, and therefore best used as sup- 
 plementary to other and more corrective work. 
 
 XVI. 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. 
 
 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 getting the spine as straight as 
 
 'Teschner: "Ann. of Surgery," Aug., 1S95 : "Orth. Trans.," vol. ix. 
 
ASYMMETRICAL EXERCISES. I37 
 
 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. To carry a weight on the head with the spine not held in its best position 
 by muscular effort would be undesirable. The exercise is suited to mild cases 
 with noticeable bad carriage and poor balance. 
 
 XVII. 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 tlie middle of the thorax and the vertical line of the face as nearly as possible 
 under the plumb-line, bringing thus 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 cor- 
 rected 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. 
 
 XVIII. 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, (i) The patient bends 
 the forward knee, sinking the hip on that side. (2) The patient resumes the pri- 
 mary position (Fig. loi). 
 
 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. 
 
 XIX. Self-correction (Lorenz). — The patient assumes the fundamental stand- 
 ing position and places the hand of the side to which the dorsal spine is convex 
 upon the side of the thorax opposite to the greatest dorsal curve; the other hand is 
 then placed on the ilium, (i) By a side thrust of the hand on the thorax the 
 patient corrects or overcorrects the dorsal curve, maintaining the correction for 
 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. 102). 
 
 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 XVIII and XIX may be combined for a double curve with 
 one element dorsal and the other lumbar. 
 
 XX. Hip Sinking fr.^m Stool. — Position: The patient stands erect on a stool 
 on one foot (the foot on the side of the convexity of the curve), (i) 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. 103). 
 
138 
 
 TREATMENT. 
 
 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 curve, 
 tending to stretch contracted structures and straighten the curve. 
 
 XXI. Trunk Hyperextension with Side Bending — Lying on the Face. — -The 
 patient lies face downward on a table or on the floor as described in Exercise 
 VII. (i) 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 i is resumed. (4) The prone lying posi- 
 tion is resumed (Fig. 104). 
 
 This exercise is an active lateral flexion of the spine in the position of hyperex- 
 tension. As hyperextension locks the dorsal region against side flexion, the move- 
 ment 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, 
 
 Fig. ioi. 
 
 Fig. 102. 
 
 Fig. 103. 
 
 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. 
 
 XXII. Drawing up 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, (i) 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, 
 the knee being kept straight. (2) Position i is resumed (Fig. 105). 
 
 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 com- 
 pound dorsal and lumbar curves. 
 
 XXIII. 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 
 
ASYMMETRICAL EXERCISES. 
 
 139 
 
 Fig. 104. 
 
 Fig. 105. 
 
140 
 
 TREATMENT. 
 
 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. 106). 
 
 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. 
 
 XXIV. Self-correction with Arms Extended Behind Back (Mikulicz). — The 
 patient stands without pelvic fixation with the arms hanging behind the back, with 
 extended elbows, and the hands clasped loosely with the palms together, (i) The 
 patient bends forward, flexing the spine. (2) The patient then straightens the 
 
 Fig. 107. 
 
 arms with force, getting the shoulders as far back as possible and stretching the 
 hands down, and then describes a half circle to the right or left to the hyperextended 
 median position. The bend is to the right in right curves and vice versa (Fig. 107). 
 
 The exercise is a side flexion made in the direction that improves the lateral 
 curve, with the shoulders in a corrected position. The arm on the convex side 
 presses against the rotated thorax and has some corrective efi^ect. The exercise 
 is particularly useful in dorsal scoliosis with increase of the dorsal physiological 
 curve (kyphoscoliosis). 
 
 I XXV. Trunk Bending to Both Sides with Hand Pressure {Mikulicz). — Posi- 
 tion: In the case of a right 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, (i) She then bends the body slowly to the 
 right side, while the right hand and thumb press against the dorsal prominence. (2) 
 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 upright position is 
 resumed (Fig. 108). 
 
 This is a combined mild active and passive correction for a double cur\'e. Op- 
 posing forces are applied to the convexities of the curves, thus tending to straighten 
 
ASYMMETRICAL EXERCISES. 
 
 141 
 
 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. 
 
 XXVI. 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. (i) The head is pushed as far as possible to the side that corrects 
 the curve. (2) The original position is resumed (Fig. 109). 
 
 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. 
 
 XXVII. 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 VIII) with a staff grasped in both hands, the arms being extended 
 beside the head, (i) The trunk is raised from the table and the staff brought over 
 
 / 
 
 Fig. I 
 
 Fig. 109. 
 
 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. 1 10). 
 
 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. 
 
 XXVIII. 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 fle.xes that knee 
 and allows the body-weight to come upon the arm. (2) The original position is 
 resumed (Fig. iii). 
 
 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. 
 
142 
 
 TREATMENT. 
 
 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. 
 
 XXIX. 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 
 
 Fig. no. 
 
 Fig. III. 
 
 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. 112). 
 
 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. It is said to be of value to lengthen shortened muscles and ligaments on 
 / the concave side. 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 
 orce into the stretching, usually holding the position longest which stretches the con- 
 cavity of the most marked curve (Fig. 113). Another modification is creeping 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, pointing opposite to the side to which the face looks. The trunk is rotated 
 
CREEPING EXERCISES. 
 
 143 
 
 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 points to the side toward 
 which the face is turned; the posterior knee is straightened, and the foot only of 
 that limb touches the floor. The patient then endeavors to look upward beneath 
 
 Fig. 112. 
 
 Fig. 113. 
 
 Fig. 114. 
 
 the forward reaching arm (Fig. 114). This is best employed as an asymmetrical 
 exercise to correct the dorsal convexity and stretch the side of the concavity. 
 
 XXX. Creeping Sidewise. — There is a third asymmetrical variation in "creeping 
 sidewise" toward the side showing the concavity of the curve to be corrected, for 
 
144 
 
 TREATMENT. 
 
 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. 115). 
 
 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. 115. 
 
 PASSIVE STRETCHING OF THE SPINE. 
 
 Increased mobility of the stiffened parts of the spine and stretching 
 of the contracted structures is in all but the milder cases of structural 
 scoliosis more easily to be obtained by intermittent passive stretching 
 in apparatus than by active or passive gymnastic exercises without 
 apparatus. 
 
 The following considerations bear on the use of force for stretching 
 in both intermittent stretching and in forcible correction. 
 
 Such passive stretching of the spine is commonly secured by hang- 
 ing by the arms from a bar, but preferably by upward traction on the 
 head by means of a Sayre head-sling. A pull in the length of the ver- 
 tebral column is not, however, an econo mical use of for ce. 
 
 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. The 
 relative force exerted will be recognized if one is reminded how easy it is to break 
 a bent stick by striking it on the knee while one hand holds each end and how very 
 difficult it would be to break the same stick by a pull in its length. 
 
 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 forefinger. If, however, it is pinned to the table by two pins separated, 
 
PASSIVE STRETCHING. I45 
 
 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 fol- 
 lowing experiment was made at the Harvard Medical School by the courtesy of 
 Prof. Thomas Dwight. 
 
 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 pressure 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 mea- 
 sured 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 with- 
 out 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 normal 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 displace- 
 ment from a given amount of side pressure the spine must be slack 
 and not stretched in its length. 
 
 Apparatus for the purpose has been devised, and is known as the 
 Weigel-Hoffa frame, in which the patient is suspended by the head, 
 while pads are run in from the sides of the frame, making lateral pres- 
 sure in various directions. 
 
 Correction of the lateral curve of the spine is, however, to be ob- 
 tained most economically by pressure on the slack spine, which is most 
 easily secured by having the patient lie prone, and the 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. ii6): 
 
 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 upper thorax, over and under the patient, and 
 fastened to a cleat on the right side of the board. This furnishes a point of pressure 
 
146 
 
 TREATMENT. 
 
 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 cur\-e; it passes above and below the thorax and its 
 
 Fig. 116. — Stretching Board with Loops, Ready for Application. — {"Jour. Am. 
 
 Med. Assn.") 
 
 Fig. 117. — Stretching Board with Loops Applied to .a P.atient. — ("Jour. Am. Med. 
 
 Assn.") 
 
 upper end is fastened to a cleat at the left side of the board (Fig. 117). Its lower end 
 is fastened bv 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 piills, it tends to reduce the rotation from the fact that its upper end is 
 fastened and its lower end moving toward the pulley. 
 
PASSIVE STRETCHING. 
 
 147 
 
 A better and much more efficient appliance has been made by Dr. 
 Z. B. Adams, of Boston. 
 
 In this a patient lies prone, with the knees flexed, on a table which is split 
 transversely into five parts. The lower one, on which the pelvis rests, is furnished 
 with two sliding wooden horns, which hold the pelvis firm. The next three pieces 
 are provided with a pad sliding in from the side and a pad coming down from the 
 top. These three movable pieces slide from side to side, and also rotate on a gas- 
 pipe running the length of the table longitudinally. The patient is placed in the 
 
 Fig. 118. — Machine for Intermittent Correction Applied to a Patient.- 
 
 Am. Med. Assti.") 
 
 -{"Jour. 
 
 apparatus, the pads are adjusted to the side and back of the loin or thorax, or both, 
 and, by side pressure and a twisting of each arm, both rotation and lateral deviation 
 are corrected separately at each level. In this way it is possible to correct both lat- 
 eral deviation and rotation at one, two, or three levels for the purposes of stretching 
 the spine by directly applied pressure. The top part of the table farthest aw^ay from 
 the pelvis of the patient is fixed and on it rest the arms and head. 
 
 The patients are stretched daily in this apparatus and left in the corrected 
 position for as long a time as can be borne comfortably — generallv from fifteen 
 minutes to half an hour. 
 
148 TREATMENT. 
 
 CONTINUOUS STRETCHING BY MEANS OF PLASTER-OF-PARIS 
 JACKETS (FORCIBLE CORRECTION). 
 
 In severe cases of structural lateral curvature no means of treatment 
 is so efficient as continuous stretching by means of plaster jackets applied 
 under force. This method is spoken of as "forcible correction." Such 
 jackets are applied in the hope of stretching the contracted structures 
 and of inducing an improvement in the curve. By virtue of their be- 
 ing at work day and night they accomplish much better results than 
 are to be obtained in any other way. 
 
 The treatment of severe scoliosis by plaster jackets applied in a 
 corrected position is not new. But the force has generally been applied 
 to the spine during suspension. Bradford and Brackett^ described a 
 frame in which the jacket was applied as the patient lay prone, but even 
 here head traction was used. Nebel,^ Calot,^ Redard,"* and others have 
 used the horizontal position. 
 
 The whole question was given a new impetus by Calot's work on 
 the forcible correction of the deformity in Pott's disease published in 
 1896.'^ The later tendency has been toward the use of much greater 
 force than was previously employed. 
 
 The most noteworthy advance in the forcible corrective treatment of 
 scoliosis was made by WuUstein, who has applied the above-mentioned 
 principles with force and precision and who published photographs 
 showing marked improvement in patients (Fig. 119). His method is to 
 forcibly extend the head while the patient's pelvis is strapped to a seat 
 which can be tilted to make the pelvis oblique and which also can be 
 rotated to change the relation of the pelvis to the spine. Lateral pres- 
 sure is made by pads running in horizontally from the sides of the appa- 
 ratus. By a combined motion of the seat and adjustable pads any 
 degree of twist of the spine upon the pelvis may be produced. WuU- 
 stein uses a large amount of force in his traction, applying up to 250 
 pounds of pull, and he applies a plaster jacket while the patient is thus 
 stretched and pushed into a corrected position. This jacket embraces, 
 as must all such jackets to be wholly efficient, the chest, shoulders, and 
 head. The amount of force required, however, is excessive, as must 
 be the case where force is not economically applied. He is attempt- 
 
 ' "Bos. Med. and Surg. Jour.," May 11, 1893; Oct. 10, 1903. 
 
 ^ "Nebel: "Zeitsch. f. orth. Chir.," iv. 
 
 ^Calot: XII Internat. med. Kongress zu Moskau, 1897. 
 
 ^ Redard: "Trans. Amer. Orth. Assn.," xi, 447. 
 
 ^ Calot; "France Med.," 1896, 52; Schanz: "Berl. klin. Wochens.," 1902, 48 
 
FORCIBLE CORRECTION. 
 
 149 
 
 ing to straighten the bent stick by puUing the two ends apart, and when 
 a great amount of force has thus been expended in stretching the spine, 
 lateral pressure is applied, when it also must be pushed to an extreme 
 on account of the stretching of the spine in its length. 
 
 Fig. 119.— Patient with Plastfr Jacket Applied in Wl'i.i. stein's Apparatus.— 
 
 (irnllstrin.) 
 
 In some experiments' on the scoliotic spine of a cada\'er the following points 
 were evident: 
 
 There was in the spine a fixed region, bounded above and below by the most 
 movable parts of the spine — the lower cervical and the lower dorsal region. Man- 
 ipulations to correct either the rotation or the lateral curve were, therefore, more 
 likely to take effect above and below the curve than in the curve itself. Side pres- 
 
 * R. W. Lovett: " Bost. Med. and Surg. Jour.," Oct. 31, iqoi. 
 
^5° 
 
 TREATMENT. 
 
 sure pushed the whole dorsal region to the left, but made little impression on the 
 curve itself. 
 
 This contrast between the fixed and movable portions was notably to be seen 
 in attempts to correct the rotation. If oblique forward pressure were made upon 
 the angles of the ribs, as prominent on the right side of the back, the cage of the 
 thorax revolved horizontally, in one piece, upon the two movable parts above and 
 below it, and the lateral curve, as^seen from the back, was increased. This was 
 
 Fig. 120. — Patiknt with Right Dorsal Curve with Right Side of Thorax Carried 
 Forward and the Rotation Improved while the Lateral Curve is Made 
 More Evident. 
 
 because the curved part of the spine, convex to the right, was twisted and carried 
 further to the right, and the convexity of the lateral curve was apparently increased 
 by being carried into another plane, thus making the whole lateral curve appear 
 more marked, as seen from the back. 
 
 The reverse of this manipulation (that is, backward side pressure upon the 
 right side of the chest) increased the rotation, but diminished the lateral de%dation 
 of the spinous processes and made the spine straighter when \aewed from the back. 
 
FORCIBLE CORRECTION. 
 
 151 
 
 A similar experiment was made upon an adult woman patient, with a severe 
 fixed curve similar to that of the cadaver. It will be seen that, when the bony 
 rotation was diminished by forward pressure on the angles of the ribs on the right 
 side, the lateral deviation was increased, no side pressure being made. When 
 the rotation was increased by backward twisting of the right side, on the other 
 hand, the lateral deviation was diminished (Figs. 120 and 121). 
 
 This criticism applies not only to the use of much corrective apparatus, but 
 
 Fig. 121.— Same Patient with the Right Side of the Thorax Carried Backward 
 AND the Rotation Increased but the Lateral Curve Made Less Evident. 
 
 also to gymnastic work where attempts to correct the rotation in fLxed curves is 
 made by manual pressure upon the prominent ribs. 
 
 Forcible correction by pure side pressure may increase the rotation, but, so 
 far as it is effective, will diminish the lateral deviation. That this is not new may 
 be appreciated by a quotation from Schfeger^ in 1810: " Der seitliche Druck auf 
 die Rippen biege diese an den olmehin scho?; mehr spitzen Wivkein noch mehr 
 
 ' Fischer, quoted by Htissey. 
 
152 
 
 TREATMENT. 
 
 Spitzig zu." That plaster jackets ma_v cause increase of the rib angles is demon- 
 strated by Hiissey.^ The same point, that plaster jackets may increase the bony 
 rotation apparent in the back, has been alluded to by Schulthess and \'ulpius.^ 
 
 It may, therefore, be stated that attempts, in fixed curves, to dimin- 
 ish the rotation by force in any degree directed forward, not carefully 
 antagonized, will lead to an in- 
 crease of the lateral curve. 
 Conversely, attempts to dimin- 
 ish 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 
 
 Fig. 122. — On the Left is a Diagr.a.m 
 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 un- 
 changed. 
 
 Fig. 123.— Patient Thikti i;n \'ears Old. 
 Curv.xtlre Due to Rickets; Never 
 Treated. 
 
 separately with the rotation and with the lateral deviation. Having 
 corrected the lateral deviation first, this correction is held, as will be 
 
 ^ Hiissey: "Zeitsch. f. orth. Chir.," viii, 2, 235. 
 ^Vulpius: "Volkmann's Samml. klin. \'ort.," 276. 
 
FORCIBLE CORRECTION. 
 
 i53 
 In this wav one 
 
 described, while the rotation is corrected or vice versa. 
 element is not improved at the expense of the other. 
 
 Corrective jackets should be applied to the patients prone, and 
 preferably with the legs fie.xed, as this diminishes the physiological curves 
 of the spine and further simplifies the problem. With a patient thus 
 lying prone, the spine is in the most favorable condition for side cor- 
 rection, both as regards side deviation and rotation, and by an intelli- 
 
 FiG. 124.— Patient Lying in Correc- 
 tive Frame, Showing the Im- 
 provement Gained by the Hor- 
 izontal Position. 
 
 Photographed from above. Patient same 
 as in Fig. 123. 
 
 Fig. 125. — Patient in Corrective 
 Frame with Side Pressure Ap- 
 plied BY Strap. 
 
 Showing additional correction to that in 
 Fig. 124. 
 
 gent application of force to correct each of these elements separately 
 and independently. In this improved position the jacket is applied. 
 
 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 webbing 
 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 
 
154 
 
 TREATMENT. 
 
 improvement in the position may be obtained, which is secured by the application 
 of a plaster jacket, but the apparatus is deficient because it corrects chiefly the 
 side deviation and makes but little pro\dsion for the correction of rotation, which 
 must be largely done by the hands. 
 
 The problem of the appHcation of plaster jackets on this plan hav- 
 ing thus presented itself was worked out mechanically by Dr. Z. B. 
 Adams, of Boston. 
 
 The apparatus consists^of a heavy gas-pipe frame, three by four feet. The 
 patient lies face downward on two webbing strips running from end to end of the 
 
 Fig. 126. — App.\ratus for Forcible Correction bv Plaster Jackets. — {''Jour. 
 
 Med. Assn.'") 
 
 fi:ame with the legs flexed. Near the bottom of the frame is an adjustable cross- 
 bar bent to fit into the flexure between the thigh and the pelvis on which the patient 
 rests the lower part of the body. Sliding on this bar are two arms, which slide 
 in and clamp down on the buttocks, holding the pelvis steady on the cross-bar. 
 This bar is movable from side to side in order to induce or correct curvature in the 
 lumbar region when necessary. There are three vertical transverse rings, two 
 feet in diameter, fastened to pieces on the sides of the frame so that they can be 
 moved to any desired point along the frame. These rings are also movable from 
 side to side, and by an independent movement they can also be rotated through 
 a half circle. Any one of these movements can be checked at any point by turning 
 a screw. The shoulders are held by a pair of axillary straps fastened together by 
 a strap across the chest in front. These straps are suspended from the ring nearest 
 to the top of the frame, and can be made to hold the shoulders in any desired degree 
 of twist by a rotation of the ring. 
 
 Each ring is provided with two long rods at the two poles of the ring. These 
 rods are adjustable on the ring, and can be set at any desired angle to it. They 
 can be pushed up or down and are controlled by a ratchet. By rotating the ring 
 
FORCIBLE CORRECTION. 
 
 155 
 
 and adjusting the angle of the rods they can be made to press down or up on any 
 part of the back or chest. 
 
 For the application of the jacket the patient lies on the face on the two web- 
 bing strips, the lower part of the trunk resting on the cross-rod and the bars clamping 
 
 i) 
 
 the buttocks; the feet rest on the floor, and the arms are extended above the head. 
 The rings are then adjusted at the two levels where it is desired to make correction. 
 For side correction a bandage is fastened to one side of the ring, carried around 
 the patient's side over a heavy pad of felt, and back to the ring. The same is 
 done to the other ring at the other level where side correction is desired, while the 
 
156 
 
 TREATMENT. 
 
 top ring controls the shoulders by means of the pads and two loops of bandages 
 passing through each axilla and fastened to the top of the ring. The rings are 
 then pulled to one side, the bandages around the patient tighten, and any endurable 
 degree of side correction is thus obtained. 
 
 When the side correction is made, the ring is rotated till the rods are opposite 
 the points where it is desired to correct rotation. They are then pushed down 
 on to the patient, their points being protected by sheet-iron pads, two by three 
 inches, which are covered with heavy felt. These pads are incorporated in the 
 jacket. 
 
 A plaster jacket is applied to the patient held in this way. It is easy to see 
 
 -Patient of Whom Radiograms were taken, before Treatment. 
 .■^RY, 1906.) — {"■ Jo7ir. Am. Med. Assn.") 
 
 (JANU- 
 
 that the method is perfectly definite and that the amount of force at the operator's 
 disposal is very great. 
 
 Technic of Application. — The patient should preferably be stretched once 
 or twice daily for two or three days preliminary to the correction in the machine 
 in which the jacket is to be applied, 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 hea^'y felt; a pad 
 should also be placed over the sacrum. Under the side straps heavy felt pads 
 are required. 
 
 The correction is pushed to the point of causing mild discomfort, and difficulty 
 
FORCIBLE CORRECTION. 
 
 157 
 
 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 standard. 
 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 position is assumed. 
 After the patient has been removed from the apparatus the shoulders are incor- 
 porated in the jacket. 
 
 After correction the patient should remain in a hospital or under close obser- 
 vation for at least twenty-four hours. Some shock is not infrequently experienced 
 
 Fig. 129.— Patient Shown in Fig. 12S after Wearing Corrective Jack;et for over 
 A Year. (March, 1907.) 
 
 and in a case of the writer's very serious collapse and cyanosis followed the cor- 
 rection of a severe curve due to infantile paralysis in a child of six. Wullstein has 
 recorded the occurrence of somewhat serious symptoms following correction. 
 
 Successful permanent results can be obtained in hospital practice in 
 only selected cases, the average patient being unable to appreciate 
 the importance of following out the after-treatment. The most favora- 
 ble cases for forcible correction are curves affecting the lower dorsal 
 and dorsolumbar regions. Lumbar curves are not accessible to side 
 pressure, and high dorsal curves are resistant because one cannot ob- 
 tain a counterpoint higher than the axilla, which is not far above the 
 
158 
 
 TREATMENT. 
 
 center of the curve. Such cases are to be corrected, if at all, by jackets 
 applied in suspension by the head by a Sayre sling. Curves due to 
 infantile paralysis, rickets, and empyema are available for forcible 
 correction. 
 
 Permanence of Results. — The criticism that such correction is not 
 
 Fig. 130.— Radiogram of a Patient Seventeen Years Old (Fig. 128) Lying on the 
 Back, before the Application of Jacket. (January, 1906.) — {"Jotir. Atn. Med. 
 Assn.") 
 
 likely to be permanent at once presents itself. The grounds that lead 
 one to suppose that retention of the growing spine in a corrected posi- 
 tion over a sufficient period w'Al lead to a change in the shape of the 
 bones of the vertebral column and to a permanently improved position 
 are as follows : 
 
 (i) Club-foot may be cured by a similar proceeding. 
 
FORCIBLE CORRECTION. 1 59 
 
 (2) The bones of the feet of Chinese women of rank are seriously 
 misshapen by retention in an unnatural position.^ 
 
 (3) Wullstein produced bony changes in dogs by a few months of 
 abnormal position. 
 
 (4) W. Arbuthnot Lane" has demonstrated that the carrying of 
 
 Fig. 131.— Radiogram of Same Patient as shown in Fig. 128, Taken after the Ap- 
 plication OF a Plaster Jacket through Windows Cut in Front and Back of 
 Jacket. (January, igo6.) — {''Jour. Am. Med. Assn.") 
 
 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 bones subject to the greatest pressure undergoing changes in shape. 
 
 (5) The fact that bone under pressure changes shape after growth 
 
 ^ P. Brown: "Jour. Med. Research," Dec, 1903. 
 ^ Guy's Hosp. Rep., xxviii. 
 
i6o 
 
 TREATMENT. 
 
 has been reached is shown in the fact that scar tissue pressing on bone 
 
 will cause a change in shape/ 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. 132.- 
 
 -Radiogram of Patient Shown in Fig. 12S aftkr Wearisg Corrective 
 Jacket for over One Year. (March, 1907.) 
 
 be more marked during growth, the phenomenon is not unknown in 
 adult life. 
 
 That a practical gain in the curved part of the spine may be secured 
 by this method is demonstrated by the .v-rays shown in the illustra- 
 tions. The patient was a girl of seventeen, with a severe right 
 dorsal curve, which was extremely rigid and had never been treated. 
 The first x-ray was taken with the patient lying on the back. A correc- 
 tive jacket was applied in the Adams apparatus, the front and back of 
 
 ^Ziegler; Pathology, English ed., 1S96, ii, 146. 
 
FORCIBLE CORRECTION. 
 
 l6l 
 
 the jacket were cut away to permit another .r-ray, and the improvement 
 in position is evident. It seems reasonable to hope that the mainte- 
 nance of such an improved position may be expected in time to produce 
 a change in the shape of the vertebrae. It is obvious that such a cor- 
 rected position must be maintained over a period of many months to 
 secure permanent results. As a rule, the first corrective jacket does 
 not secure the maximum correction, and a second or even third correc- 
 tive jacket should be applied if there is reason to suppose that there is 
 
 133. — Patient Seventeen Years Old, Never Previously Treated, Before 
 Treatment. — {''Jour. Am. Med. Assti.") 
 
 further gain to be obtained. An interval of one or two weeks between 
 the jackets is sufficient (Figs. 130-132). 
 
 When this final jacket has been applied, there are two methods of 
 procedure, (i) The final jacket may be removed, and one holding 
 an equally good positicn may be applied after a month or more from the 
 forcible correction (see Braces and Corsets). This jacket is worn night 
 and day, and is to be removed only during the exercise periods, gym- 
 nastic treatment having been commenced when the final jacket is re- 
 
l62 
 
 TREATMENT. 
 
 moved, (2) In the second method of procedure the final corrective 
 jacket is worn for a year or more without being split, with a view to 
 conforming the child's figure to the shape of the jacket, just as a club- 
 foot is made to grow straight in a corrective plaster splint and as the 
 Chinese girl's foot is shaped by continuous bandaging (Figs. 128 and 129). 
 The choice between these methods must be determined by the 
 circumstances of the patient, the temperament of the child, and simi- 
 lar considerations. Careless hospital patients will do better in a fixed 
 
 Fig. 134. — Same Patient as in Fig. 133, after Two Jackets. Whole Interval, Three 
 Weeks. — {^^ Jour. Am. Med. Assti.") 
 
 jacket for a year or two, while nervous girls in private practice will do 
 better in split jackets. 
 
 Schanz has provided clinical evidence of the permanence of results 
 in a series of cases reported by photograph,^ and presents his conclu- 
 sion, which expresses thoroughly the views of the writer, as follows: 
 
 "That one by a careful selection of cases and correct carrying 
 through of the necessary measures can retain the results of forcible 
 
 * "Verhandl. d. Deutsch. Ges. f. orth. Chin," 4. Congress, page 61. 
 
BRACES AND CORSETS. 163 
 
 correction of scoliosis and permanently avoid the danger of relapse, 
 my experience of over eight years with the method has proved beyond 
 doubt." 
 
 It is undesirable to undertake forcible correction unless the patient 
 can be under control for a period of two years at least. 
 
 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 
 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 support- 
 ing apparatus discontinued at first for short periods, gradually increas- 
 ing in length. The length of time that active treatment must be con- 
 tinued will depend on the age of the child, the severity of the case, the 
 efficiency of the treatment, and similar factors, but any case of sco- 
 liosis 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 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 mechanically sound 
 treatment. 
 
 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 no corrective value, for such apparatus applied 
 to a spine not previously loosened up by treatment 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 pres- 
 sure obtained from the space between 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 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 
 
164 
 
 TREATMENT. 
 
 corsets and braces to such patients and allowing the parents to hope 
 for any considerable benefit is therefore to be condemned. 
 
 The most easily made and available corset is to be manufactured 
 by removing from the patient the last corrective jacket, filling it with 
 plaster-of-Paris and water, thus securing a torso of the patient. This 
 torso is then further corrected by cutting away the plaster on the convex 
 side and by building up on the concave side so as to secure a symmetrical 
 or over corrected model on which a jacket may be applied, or the pa- 
 tient may be suspended by a Sayre sling and a jacket applied and cut 
 off to serve as a model for a torso. The torso is then shellacked and 
 covered with a layer of stockinet or an undershirt, and a plaster jacket, 
 having been applied on the torso, is cut off, furnished with lacings. 
 
 Fig. 135. — On the Left is a Plaster Torso Made from a Corrective Jacket. 
 On the Right is the Same Torso Made More Symmetrical for the Applica- 
 tion OF A Removable Jacket. 
 
 and suppHed to the patient. All plaster jackets applied for forcible 
 correction and retention must embrace the shoulders, and even the 
 head should be included, but the disfigurement is so great that most 
 patients are unwilling to submit to it in America. On the torso obtained 
 as described may be constructed jackets of celluloid, leather, or other 
 material, or corsets made of cloth and reinforced by steel. 
 
 The writer has found a segmented jacket of more general use than 
 the ordinary one. A jacket is applied on a plaster torso in the usual 
 way, and then the upper section, corresponding to the thorax, is sepa- 
 rated from the rest of the jacket by a transverse cut. The lower sec- 
 tion, corresponding to the pelvis, is separated in a similar way, and the 
 two sections are then set in any desired relation to each other by means 
 
BRACES AND CORSETS. 
 
 165 
 
 of three steel strips, running vertically at the back and sides of the jacket, 
 connecting the two sections. The thorax may thus be lifted in relation 
 to the pelvis, displaced to either side, or rotated in relation to the pel- 
 vis, or any combination of these may be brought about. As treat- 
 ment progresses the gain may be secured by changed relations of tho- 
 racic and pelvic sections (Fig. 136). The shoulders are controlled by 
 pads pressing on the anterior aspect of the shoulder-joints. 
 
 Fig. 136.— Segmented Corrective Plaster J.acket. 
 
 The complicated braces in former use have been largely displaced 
 by the jacket or corset. They may be found described in the refer- 
 ences.^ The corset used in Germany is shown in the illustration (Fig. 
 137). The brace devised by C. W. Keene, of Boston, is efficient and 
 may be taken as an example of the type of modern brace (Fig. 138). 
 
 Operation. — The question of the operative relief of scoliosis is still 
 snhjudice. An operation was proposed by Volkmann- in 1889, consist- 
 
 ^Hoffa: "Lehrb. d. orth. Chir.," fourth ed., 1Q05, page42Q; Redard: "Chirurgie 
 Orthopedique," Paris, i8q2, page 382; Bradford and Lovett: "Orth. Surg.," 
 first ed., iSqo, page 16S. 
 
 ^Volkmann: "Bcrl. klin. Wochens.," 18S0, 50. 
 
i66 
 
 TREATMENT. 
 
 ing of resection of the ribs on the convex side of the curve, and this 
 operation was also performed by Casse^ and Hoffa^ 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.^ 
 
 A good operative correction has been obtained by Hoke,* of Atlanta, 
 Ga., who resected the ribs on the convex side of a girl of nineteen and 
 
 Fig. 137. — Corset for Scoliosis 
 Strengthened by Steel.— (Z^o- 
 
 FiG. 138. — Brace for a Case of Right 
 Dorsal Scoliosis, Applied. — {C. 
 IV. Keene.) 
 
 lengthened those of the concave side in a severe dorsal curve. By the 
 application of a corrective jacket great improvement was obtained. 
 
 Jaboulay^ divided the cartilage of a single rib with a view of im- 
 proving the shape of the thorax. Bade® has reported a case where he 
 resected the ribs, but cautions against the use of narcosis in severe sco- 
 liosis. 
 
 ^ Casse: "Bull, de I'Acad. Royal de Med. de Belgique," Dec. 30, 1893; Jan. 
 27, 1894. 
 
 ^Hoffa: "Zeitsch. f. orth. Chir.," 1896, 401. 
 
 ^ Shaffer: "Amer. Surg. Bulletin," Jan. i, 1894. 
 
 *Hoke: "Amer. Jour, of Orth. Surg.," i, 2. 
 
 ^Jaboulay: "Prog. Med.," Nov., 1893. 
 
 ' Bade: "Klin. Mittheil. in Centralbl. f. Chir.," 1903, 38, 1045. 
 
Chapter XII. 
 
 FAULTY ATTITUDE. 
 
 The investigation of the types of faulty attitude must be preceded by 
 a consideration of the normal attitude in the anteroposterior plane. 
 
 NORMAL ATTITUDE. 
 
 Normals have been described by Weber/ Meyer/ Danger/ Parou/ 
 Henke/ Staffel/ and others/ which differ much among themselves, as 
 would have been expected from the lack of a uniform system of measure- 
 ment and because the normal type of standing is affected by age, sex, 
 race, fashion, and occupation. A military cadet would not be expected 
 to present the same normal as a woman of the same age who had worn 
 tight clothes, heavy skirts, and pointed boots for some years. 
 
 One simple relation seems fairly constant above ten or twelve. A 
 plumb-line held against the back of the sacrum touches or comes near 
 the convexity of the dorsal spine. In young children it cuts this con- 
 vexity. Slack standing makes the dorsal spine more prominent back- 
 ward, and the dorsal curve lies in part back of this line under these con- 
 ditions. 
 
 In order to approach the subject of normal attitude and the varia- 
 tions from it with some hope of solution a method of analysis and mea- 
 surement was devised which has proved satisfactory. 
 
 Former observations have been concerned mostly with the spinal 
 curve alone, but to appreciate the affection properly the base of support 
 must also be considered. This method of record throws a certain 
 practical light upon the question of treatment. 
 
 The apparatus by which the measurements are taken consists of the 
 ordinary wooden upright with a sliding arm used for measuring the height. 
 
 * "Mechanik der mensch. Gehwerkzeuge." 
 '"Ueber den Mech. des mensch. Ganges," 1885. 
 
 '"• Langer and H. Meyer: "Anat. der ausseren Formen d. mensch. Korpers." 
 
 * Parou: "Virchow's Arch.," 1864, xxxi, 1-2. 
 
 ^ Henke: "Anat. u. Mech. der Gelenke," p. 213. 
 
 'Franz Staffel: "Die menschl. Haltungstypen," etc., Wiesbaden, 1889. 
 ^ Froriep: "Anat. f. Kiinstler," Leipzig, 18S0, p. 40. 
 
 167 
 
i68 
 
 FAULTY ATTITUDE. 
 
 On this sliding arm and at right angles to it is a horizontal arm eighteen 
 inches long, which is placed six inches from the back surface of the ujj- 
 right rod. This back surface of the upright rod is taken as the per])en- 
 
 
 
 
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 Fig. 139. — Apparatus for Measuring \'aria- 
 TioNS FROM Normal Attitude in the 
 Anteroposterior Plane. 
 
 Fig. 140.— Graphic Representation 
 OF Standing Position, with the 
 Patient Faced to TfiE Left. 
 
NORMAL ATTITUnE. 1 69 
 
 dicular plane from which distances are to be noted, and the measure- 
 ments are made from the shding horizontal arm, which is always six 
 inches distant from the back surface of the upright. Any point, therefore, 
 more than six inches from the sliding horizontal arm is in front of the 
 perpendicular plane agreed on, and any point less than six inches is 
 behind it (Fig. 139). 
 
 The middle of the external malleolus was taken as the lower end of 
 the perpendicvdar plane from which measurements were to be made. 
 The patient stands without boots, in a natural position, with the feet 
 forming an angle of 45 degrees, and with the middle of one malleolus 
 opposite the back surface of the upright, the back of the patient being 
 toward the sliding horizontal arm. 
 
 The measurements of the bony landmarks to be mentioned are then 
 taken from the sliding horizontal arm, and the height at which each 
 measurement is taken is recorded. This may be done, of course, either 
 in inches or centimeters. Having then the height of each point desired 
 as well as its distance from the ground, it is a simple matter to pro- 
 duce graphically the relation of these points by using ordinary coordi- 
 nate paper and allowing one inch or one centimeter to each space on the 
 paper. To secure uniformity of results, it may be assumed that the 
 patient is seen facing the left. 
 
 The landmarks taken for measurement were those which could be 
 easily identified by touch. They are as follows from above downward: 
 (i) The middle of the mastoid process; (2) the spine of the vertebra 
 prominens; (3) the spine of the seventh dorsal vertebra (on a level with 
 the inferior angle of the scapula) ; (4) the spine of the fourth lumbar 
 vertebra (on a level with the top of the iliac crest) ; (5) the middle of 
 the great trochanter; (6) the middle of the head of the fibula ; (7) the 
 middle of the external malleolus. 
 
 The measurement is taken by marking with a skin pencil the points 
 to be measured. The patient is then placed with the back to the slid- 
 ing arm and the outer malleoli opposite the back edge of the upright. 
 In order to get the measurements before the patient becomes fatigued 
 and sways, it is necessary to work quickly. The mastoid measure is 
 taken, and then the arm pushed rapidly down while the distances of 
 the points from it are measured with a rule at each level. Having 
 taken these down, it is necessary, if the curve is to be reproduced 
 graphicallv, to record the height from the ground of each bony land- 
 mark, and the sliding arm is again pushed up and the level of each 
 marked bonv landmark recorded. B\- this division of the two measures 
 
I 7© FAULTY ATTITUDE. 
 
 the first and important one should be finished before the patient be- 
 comes unsteady, and in the second set swaying is of no account. 
 A typical measurement would be as follows: 
 
 Case M. L. T\-pe a. 
 
 Distance from Upright. Height. 
 
 Mastoid yf inches. 49 inches. 
 
 Seventh cervical 5^ 
 
 Seventh dorsal 4^ 
 
 Fourth lumbar 5^ 
 
 Trochanter 7 J 
 
 Head of fibula 7! 
 
 Malleolus 6 
 
 46i 
 40 
 
 I4i 
 
 2i 
 
 The curve is plotted by marking the points on coordinate paper and 
 drawing lines between them. As below the level of the fourth lumbar 
 vertebra the line no longer follows the back outline of the body, but 
 changes to the axis of the leg; the fourth lumbar and trochanter marks 
 are not connected by a line. 
 
 The method has been repeatedly tested by taking two successive 
 independent measurements of the same patient and comparing them, 
 and by taking measurements on succeeding days and comparing them, 
 with the result of finding that the two conformed on the whole, the type 
 persisting and the chief difference being in slight swaying forward or 
 back which was at times evident. 
 
 The method is not intended to be mathematically accurate, but to 
 give a fairly accurate graphic representation of the patient's method of 
 standing. It has the advantage of being applicable in adults, where 
 record by full-length phocographs is not available, and the measure- 
 ments can obviously be taken without objectionable exposure in the case 
 of women. 
 
 The measurements of seventy-two normal boys between the ages of 
 fifteen and nineteen, taken by Dr. Greenwood, seem the material most 
 available to compare with the normals described. They were all healthy, 
 well-developed boys, averaging eighteen years of age, and the individual 
 tracings differed but little from each other. An average curve of the 
 tracings is, therefore, representative of the standing position of these 
 young men (Fig. 141). 
 
 Tracings of the curves of the normal attitudes as represented by 
 v. Meyer, Langer, and Stafi'elwere then taken by marking on then: figures 
 the places of the bony landmarks adopted, connecting them with lines 
 and considering them in their relation to a perpendicular erected through 
 the external malleolus in each case. The normal of v. ]\Ieyer repro- 
 duced in that way was unlike any curve found in normal persons, while 
 that of Langer is also unusual. The normal curve constructed from 
 
NORMAL ATTITUDE. 
 
 171 
 
 StaffePs figure is, however, practically identical with that of the 
 seventy-two boys. 
 
 With regard to the cur\es of six hundred college girls, taken by the 
 
 Fig. 141. — Composite Fig. 142.— Staf- Fig. 143.— Langer's Fig. 144.— v. Meyer's 
 
 Curve of Seventy- pel's Normal. Normal. Normal. 
 TWO Normal Boys. 
 — (Greenwood. ) 
 
 physical examiner of the college, the individual variations are much 
 greater than in the males, and there is a general tendency to carry the 
 
172 
 
 FAULTY ATTITUDE. 
 
 body further forward and to hyperextend the knees, the lumbar curve, 
 
 also, as one would expect, being greater 
 I than in the males (Fig. 148). 
 
 Types of Variation in Faulty Atti- 
 tude. — As no one classification of these 
 types has been universally adopted, and 
 as the classifications difi'er among them- 
 selves, it seemed best to start afresh 
 
 Fig. 145. — Type 
 A OF Round 
 Shoulders. 
 
 Fig. 146. — Type 
 B OF Round 
 Shoulders. 
 
 Fig. 147. —Type C 
 of Round Shoul- 
 ders. 
 
 Fig. 148.— Curve of 
 Young Adult 
 Fkm.'I.le of Good 
 Carri.age. 
 
VARIATIONS FROM NORMAL ATTITUDE. 1 73 
 
 and see if these measurements of patients (mostly children) offered any 
 basis of reasonable classification by which they might be divided into 
 groups for study, to see what constant types of variation the curves 
 showed, and to find out by photographs to what clinical types of faulty 
 attitude these variations corresponded. 
 
 It was difficult to decide what factor in the attitude should be the 
 basis for classification; whether it should be the relation of the trunk 
 to the legs, of the pelvis to the perpendicular, of the whole swing of the 
 body backward or forward, or of the relation of the points in the spine 
 itself. On examining the graphic representations of the tracings of 
 fauljy attitude in this connection the most constant grouping seemed to 
 be by the spinal curve. That is, the cases showed four types of spinal 
 curves, and, arranged according to these types, the other characteris- 
 tics of the curves seemed to be fairly constant in each group. 
 
 The four types of spinal curve were as follows: 
 
 Type A. — A general curve (an exaggeration of the normal lines), 
 where the spine from the mastoid to the fourth lumbar forms one gen- 
 eral curve backward. As a rule, there is little lordosis in these cases (as 
 shown by the relation of the fourth lumbar to the trochanter). The 
 pelvis is, as a rule, well in front of the perpendicular, and the body axis 
 lies generally in the perpendicular, but may be wholly in front of it, and 
 in one case only lay behind it. The legs, as a rule, incline forward, and 
 are rarely hyperextended at the knee. This is the most frequent type, 
 and consists, in a word, of rounded back with little forward lumbar 
 curve (Fig. 145). 
 
 Type B. — Backward projection greatest in the mid-dorsal region, 
 the seventh cervical and mastoid points forming a straight line above it. 
 There is generally lordosis, the pelvis is near the perpendicular, and the 
 body axis lies, as a rule, behind the perpendicular. The legs are rather 
 vertical, and if there is not marked lordosis, the knees are apt to be hy- 
 perextended. This type is second in frequency, and represents the 
 seventh dorsal point as the most prominent point backward, with some 
 lordosis in the lumbar region (Fig. 146). 
 
 Type C. — The lower part of the back is straight, and the head runs 
 forward from the seventh cervical. There is generally not much lor- 
 dosis, the pelvis is not pushed forward, but is near the perpendicular, 
 and the body axis lies back, as a rule. The knees may or may not be 
 hyperextended. In this case the head is thrust forward from the upper 
 part of the spine, and the body weight is thrown back (Fig. 147). 
 
 Type D. — The spinal points form a line nearly or cjuite straight. 
 
174 FAULTY ATTITUDE. 
 
 The back is nearly flat, lordosis is marked, the pelvis is generally back, 
 but it may be forward, and the knees generally somewhat flexed. 
 
 It is of interest to inquire what relation these types bear to the types 
 formulated by Staflel. Points were marked on his figures correspond- 
 ing to the bony landmarks selected, lines drawn, and a perpendicular 
 erected through the external malleolus. Group A in this classification 
 corresponds to his "round back"; Group B is his "round hollow 
 back " ; Group C is his " hollow back " ; and Group D is his " flat back. " 
 The difference between Groups C and D in his classification is not so 
 distinct as in these cases. 
 
 The flat hack is to be considered rather a peculiarity of conforma- 
 tion than a deformity requiring attention. It is significant largely from 
 the fact that such children are particularly likely to develop scoliosis. 
 
 The hollow back within moderate limits is in the same way to be re- 
 garded as a peculiarity of conformation. The hollow back or lordosis, 
 however, may reach a high degree in certain pathological conditions. 
 The least abnormal pathological deviation in lordosis is found in the 
 marked hollow back of backward contortionists. Lordosis occurs 
 pathologically in connection with pregnancy, in paralysis of abdominal 
 or back muscles, in tuberculous disease of the lumbar spine, in severe 
 rickets, in double congenital dislocation of the hip, in double coxa vara, 
 in ankylosis of the hip in a flexed position from tuberculous disease 
 or other cause, and in spondylolisthesis. 
 
 ROUND SHOULDERS. 
 
 Stoop or slant shoulders, round back, round hollow back, stooping, 
 faulty attitude, kyphosis, bowed back. 
 
 German — Schlechte Haltung, runde Riicken, Kyphose, hohhrunde 
 Rucken, Kypholordose, habituelle Kyphose. 
 
 French — Dos Voute, Cyphose, 
 
 Italian — Schiene rotonde. 
 
 Grouped under this name are various types of faulty attitude. Va- 
 riations from the normal attitude in the lateral plane of the body have 
 been discussed under scoliosis. Variations in the anteroposterior plane 
 will now be taken up. When the two variations coexist, as frequently 
 happens, the lateral variation is in general considered the important 
 one, and the case is classed as scoliosis. Variations from the normal 
 anteroposterior attitude are in general grouped under the name of 
 round shoulders, shading into each other and characterized by a dispo- 
 sition to economize muscular force in maintaining the erect position. 
 
ROUND SHOULDERS. 17,5 
 
 These deviations have been but imperfectly studied or formulated, and 
 have in general been grouped as round shoulders because an increased 
 convexity 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 fiat, while the scapulae behind are prominent on their pos- 
 terior borders and the inferior angles may stick out markedly (scapulas 
 alatse). The abdomen is prominent and the pelvic inclination varies. 
 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 movements 
 and walk heavily. In some cases the deformity can be removed 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 impor- 
 tant 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 impossible 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 do not permit a free movement.^ 
 Lateral curvature of the spine coexists in the majority of cases of this 
 sort. 
 
 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 
 curve forward, or a forward displacement of the pelvis and legs if the 
 lumbar spine is involved in the backward dorsal curve. 
 
 ' E. H. Bradford: "Round Shoulders," "Orth. Trans.," vol. x, page 162. 
 
176 
 
 FAULTY ATTITUDE. 
 
 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 three 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 : 
 
 I. ROUND BACK. 
 
 The dorsal and lumbar spine form, one convexity backward, which 
 
 is physiologically a persistence of the infantile position. A lordosis 
 
 is apparently often present, but on identifying the landmarks this will 
 
 be found to be merely the upward and forward slope of the sacrum 
 
 Fig. 149.— Round Back. 
 
 and that the lumbar spine does not share in it. A plumb-line dropped 
 through the mediotarsal joint passes behind the ear and the hip-joint, 
 but most of the dorsal curve is behind it. The pelvic inclination is 
 diminished. This corresponds to T^-pe A of the classification given 
 above and to the round back of Staft'el and Combe. 
 
ROUND SHOULDERS. 
 
 177 
 
 2. ROUND HOLLOW BACK. 
 The dorsal spine is bowed backward, but the himbar spine is bowed 
 forward. The appearance of round shoulders is present, bvit the general 
 attitude is modified because the pelvis has a greater inclination than 
 in round back and is not so far forward, the abdomen is prominent, 
 and the gross appearance is the" same as in round back — the essential 
 modification being produced by the greater pelvic inclination. This 
 
 corresponds to Type B of the 
 classification given above, to the 
 round hollow back of Staft'el, and 
 the kypholordosis of Combe. 
 
 Fig. 150.— Round Hollow Back. 
 
 Fig. 151.— Forward Position of the 
 Shoulder-girdle. 
 
 3. FORWARD DISPLACEMENT OF THE SHOULDERS. 
 A condition has been described by Hasebrook ^ in which a forward 
 displacement of scapulae and shoulders is the chief characteristic. 
 ' "Zeitsch. f. orth. Chir.," .xii, 4, 613. 
 
lyS FAULTY ATTITUDE. 
 
 This displacement may exist with a fiat back, in which case it is quite 
 unlike ordinary round shoulders, or it may exist in connection with 
 a rounded back, in which case it is not conspicuously different from 
 the types described. The displacement may be flexible or resistant 
 to correction by passive force. For purposes of clearness the name 
 round shoulders will be used to designate the three groups. 
 
 ETIOLOGY. 
 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 lumbar spine for long periods, and in (c) overweighting 
 of the shoulders by improperly arranged clothing. Hoffa inclines 
 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.^ To this waist 
 are also attached side elastic stocking supporters which are kept tight 
 to prevent the stockings from wrinkling. This waist is supported 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, in using round garters, and in having 
 a waist ,made in which the. pull comes at the root of the neck instead of 
 at the tips of the shoulders. 
 
 ^Bradford: "Orth. Trans.," vol. x, 162; Goldthwait: "Amer. Jour, of Orth. 
 Surg.," vol. i, 64. 
 
ROUND SHOULDEKS. 1 79 
 
 OCCURRENCE. 
 Scholder found 5.8 per cent, of round backs in the school children 
 of Lausanne, about equally divided between boys and girls, the per- 
 centage of scoliosis in these children being above 25. The age of occur- 
 rence of round shoulders covers the period of childhood from shortly 
 after the time that walking begins to adolescence; 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 WuUstein, 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 structures to those found 
 in scoliosis. Fitz, in a series of dissections on about one hundred 
 normal cadavers, supplemented by clinical observation on fifty-six 
 children with round shoulders, concluded that in resistant round shoul- 
 ders the obstacle to reposition was not to be found in the pectoral muscles, 
 but that the most common factor was tightness of the serratus muscle. 
 Occasionally associated with this was to be found shortness of the 
 coracoclavicular and acromioclavicular ligaments.^ 
 
 Hasebrook^ considered the cause of resistant forward displacement 
 of the shoulders to lie partly in the costoclavicular and coracoclavicular 
 ligaments and partly in the pectoralis and serratus muscles. He 
 divided the cases into two groups — first, those due to contraction of the 
 muscles holding the shoulders forward, and, second, to weakness of the 
 muscles holding them back. 
 
 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 prog- 
 nosis for recovery is good in young children. In older children and 
 adolescents improvement and perhaps cure are to be obtained. Even 
 
 ^ G. W. Fitz: "Bos. Med. and Surg. Jour.," Apr. 19, 1906. 
 ^"Zeitsch. f. orth. Chir.," xii, 4, 613. 
 
ISO FAULTY ATTITUDE. 
 
 in young adults an improved position of the shoulders and a better ex- 
 pansion of the chest are to be secured by adequate treatment. 
 
 DIAGNOSIS. 
 
 The diagnosis of round shoulders, as a rule, presents no difiB.culty, 
 but at times it is not easily distinguished from more serious affections, 
 causing a backward bowing of the spine. The means of distinguish- 
 ing between the different varieties of round shoulders have been sufl&- 
 ciently indicated in the description of them. The most 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. — PoWs disease (tuberculosis of the spine, 
 angular cur\'ature of the spine) is discussed in speaking of the diagnosis 
 of scoliosis. At certain stages of dorsal Pott's disease the attitude 
 may resemble round shoulders. 
 
 Arthritis deformans of the spine is discussed under the diagnosis 
 of scoliosis. 
 
 The neurasthenic spine (hysterical spine, irritable spine) exists 
 both by itself and as a complication of round shoulders in persons of a 
 nervous temperament. It affects generally female adults, but may 
 occasionally be seen in children, generally in girls approaching puberty. 
 The back is painful and perhaps somewhat stiff on motion, the skin 
 is sensitive, and symptoms of irritability are acute. The x-ray appear- 
 ances are normal. Such irritable spines may follow accidents, strains, 
 and overuse. 
 
 No gymnastic treatment for a case of round shoulders should be 
 undertaken in a patient where pain or stiffness /^f the back is present 
 v^ithout 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 scoliosis 
 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 equally to the treatment of flexible round 
 shoulders, the routine and exercises being described in that place (page 
 
TREATMENT OF ROUND SHOULDERS. l8l 
 
 124) for both conditions, and certain exercises 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 
 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 stretch- 
 ing 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 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. 152). 
 
 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 middorsal region from side to side, tied to the lower 
 non-movable frame on each side. These furnish the resistance for the straighten- 
 ing 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 
 suf&cient to loosen up the contraction and to make an improved po- 
 sition possible. In the severer cases, however, a plaster jacket should 
 be applied in the improved position. 
 
l82 
 
 FAULTY ATTITUDE. 
 
 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,^ and the shoulders back by firm 
 pressure, and the pressure can be increased from day to day by insert- 
 ing more felt between the jacket and the shoulders. 
 
 Fig. 152. — Apparatus for Stretching Round Shoulders and for the Application of 
 
 Forcible Jackets. 
 
 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 bet^-een treatments. 
 
 Braces. — ^The use of supports to maintain the spine in a correct 
 position is indicated — (i) in the case of children with lax muscles who 
 are unable to hold an erect position betv\'een gymnastic treatments; 
 (2) after forcible correction to retain what has been gained, and (3) 
 in resistant cases which are being stretched but which cannot maintain 
 
 ^ R. W. Lovett: " Amer. Jour, of Orth. Sur., " ii, 2, 200. 
 
TREATMENT OF ROUND SHOULDERS. 
 
 183 
 
 between stretchings the improvement secured by each one. In all 
 of these the brace is to be regarded as a temporary measure supple- 
 mentary to the other treatment, whether gymnastic or mobilizing, and to 
 be given up as soon as it can be dispensed with. As the sole treat- 
 ment of resistant round shoulders the use of a brace, which by its correc- 
 
 FiG. 153. — Round Shoulders befork 
 Forcible Correction. 
 
 Fig. 154. — Round Shoulders after 
 Treatment Following Forci- 
 ble Correction. 
 
 tive effect is to cure the malposition, is not to be advised. The use of 
 modified suspenders, known as "shoulder braces," as sold in the instru- 
 ment shops, is not satisfactory. 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, (b) two upr 
 rights, and (c) a cross-bar. 
 
184 FAULTY ATTITUDE. 
 
 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 their upper part they are curved to fit the contour of 
 the shoulders and should lie flat against the skin when the axillary straps are tight- 
 ened. 
 
 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 
 gage sheet steel, five-eighths of an inch wide, and should foUow 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 cmtwq of the back in a corrected posi- 
 tion 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. 
 
 Holes are drilled for buckles at each anterior end of the pelvic band, at the 
 top of the uprights, and at the ends of the cross-bar. 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. The brace is finished by being 
 covered with leather sewed down the back throughout, or by being nickel-plated 
 and having its anterior surface only covered with padded leather strips slightly 
 wider than the metal parts of the brace. These are attached to the brace by 
 loops running around the uprights, pelvic band, and the cross-bar. 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 surcingle cloth, which connects the anterior ends of 
 the pelvic band by passing over the lower part of the abdomen. In cases in which 
 there is much prominence of the abdomen, it is desirable to add an abdominal 
 band, from four to six inches wide, running from one upright around the abdomen 
 to the other upright. 
 
 Such a brace is worn continuously between exercise periods but not 
 during the night. 
 
 A brace used by the writer in cases where forward displacement 
 of the shoulders is a factor consists of two parts — (a) an anterior chest 
 piece ; {h) two triangular steel plates to be used posteriorly, one on each 
 side, (a) The chest piece consists of two slightly oval pads of sheet 
 steel about the size of a silver dollar, which fit over the anterior surfaces 
 
TREATMENT OF ROUND SHOULDERS. 185 
 
 of the shoulder-joints and are connected by a flat iron strip of the 
 proper length, curved so as not to touch the chest. Each pad is pro- 
 vided with a vertical piece of steel about three inches long, on the top 
 and bottom of which is a buckle, (b) Two triangular flat steel plates, 
 about half the size of the scapula of the child, are made of sheet steel 
 and provided each with three buckles. One of these lies over each 
 scapula. The front piece holds the shoulders back, and each end is 
 secured to the triangular plate on that side behind by one strap passing 
 over the shoulder and one through the axilla. The front piece being 
 fastened to each of the triangular plates, the latter are brought together 
 by a webbing strap connecting them until an efficient pull is secvu-ed. 
 A webbing support which is of use in the slighter cases has been described 
 by Goldthwait.^ 
 
 "Occasionally, when the stoop shoulder is marked, some additional support 
 may be necessary, and with many of the cases it has been possible to accomplish 
 the result by using a brace made of firm webbing one inch wide, carried as a loop 
 around each shoulder, the ends crossing in the back, and being attached to the belt 
 of an ordinary stocking supporter. The attachment of the shoulder strap to the belt 
 should be at the side, directly over the stocking straps, and the belt should be worn 
 about the hips, and not about the waist, as they are ordinarily used. The straps 
 should be sewed where they cross at the back, over the angles of the scapulas, but 
 should not be sewed where they cr6ss in the midline. This allows all the body 
 movements, both side and forward bendings, without straining upon the straps or 
 changing the position of the belt, the level of the belt not being changed in the 
 movement. 
 
 " It is at once apparent that with such a brace the pull occasioned by the stock- 
 ing supporters, which is a very appreciable force, tends constantly to draw the 
 shoulders backward; and, while so simple a brace cannot be expected to take 
 the place of the many forms of apparatus which are used to correct round shoulders, 
 it has, nevertheless, been of real value in many cases." 
 
 Summary of the Treatm.ent of Round Shoulders. — Flexible cases are 
 treated by gymnastics like postural scoliosis ; a brace may be necessary 
 to mairttain 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 position, 
 just as in cases originally flexible. 
 
 ' "Am. Jour. Orth. Surg.," i, 64. 
 
INDEX. 
 
 Acquired scoliosis, 94 
 Age in scoliosis, no 
 Asymmetrical exercises, 137 
 Asymmetry of the pelvis, 95 
 Attitude, 167 
 
 faulty, 167 
 
 normal, 167 
 
 B. 
 
 Balance of spine, 39 
 Braces and corsets, 163 
 
 C. 
 
 Cervico-dorsal scoliosis, 60 
 Compound curves, 61 
 Congenital scoliosis, 92 
 Creeping exercises, 142 
 
 D. 
 
 Diagnosis of scoliosis, 113 
 Dorsal scoliosis, 58 
 Dorso-lumbar scoliosis, 59 
 
 E. 
 
 Elasticity of spine, 38 
 Errors in vision, 97 
 Etiology, 91 
 
 Examination for scoliosis, 64 
 Exercises, asymmetrical, 137 
 
 creeping, 142 
 
 symmetrical, 127 
 
 F. 
 
 Faulty attitude, 167 
 
 Forcible correction, 148 
 
 Forvsrard displacement of the shoulders, 
 
 177 
 Frequency of different forms, in 
 Functional scoliosis, 48 
 
 H. 
 
 G)Tnnastics, 120 
 
 G. 
 
 Habit scoliosis, 10 1 
 
 Intervertebral discs, 3 
 
 J- 
 Joint disease as a cause of scoliosis. 
 
 Ligaments of the spine, 5 
 Lumbar scoliosis, 56 
 
 M. 
 
 Mechanism of scoliosis, 38 
 Movements of the spine, 23 
 Muscles of the spine, 9 
 
 N. 
 
 Normal attitude, 167 
 Numerical variation, 19 
 
 O. 
 
 Occupation scoliosis, loi 
 Occurrence of scoliosis, 108 
 Operative treatment, 165 
 
 Paralytic scoliosis, 99 
 Passive stretching of the spine, 144 
 Pathology of scoliosis, 77 
 Pelvic inclination, 17 
 Physiological curves, 14 
 Plaster-of -Paris jackets, 148 
 Plasticity of bone, 41 
 Postural scoliosis, 48 
 Prognosis of scoliosis, 116 
 
 R. 
 
 Rachitic scoliosis, 97 
 Rate of normal growth, 64 
 
 187 
 
INDEX. 
 
 Record of scoliosis, 71 
 Round back, 176 
 
 hollow back, 177 
 
 shoulders, 174 
 treatment of, 180 
 
 Sacro-iliac articulation, 6 
 
 School conditions, influence of, 91 
 
 fatigue, 102 
 
 furniture, 103 
 Scoliosis, acquired, 94 
 
 age in, no 
 
 cervico-dorsal, 60 
 
 congenital, 92 
 
 diagnosis of, 113 
 
 dorsal, 58 
 
 dorso-lumbar, 59 
 
 examination for, 64 
 
 functional, 48 
 
 habit, loi 
 
 joint disease as a cause of, 98 
 
 lumbar, 56 
 
 mechanism of, 38 
 
 occupation, loi 
 
 occurrence of, 108 
 
 paralytic, 99 
 
 pathology of, 77 
 
 postural, 48 
 
 prognosis of, 116 
 
 rachitic, 97 
 
 record of, 71 
 
 sex in, 109 
 
 structural, 56 
 
 Scoliosis, symptomatic, 115 
 
 terminology of, 47 
 
 transitional, 52 
 
 treatment of postural, 118 
 of structural, 119 
 Sex in scoliosis, 109 
 Short leg, 95 
 Spinal iierves, 11 
 Spine, balance of, 39 
 
 elasticity of, 38 
 
 ligaments of the, 5 
 
 movements of the, 23 
 
 muscles of the, 9 
 
 passive stretching of the, 144 
 Structural scoliosis, 56 
 Symmetrical exercises, 127 
 Symptomatic scoliosis, 115 
 Surface anatomy, 21 
 
 Terminolog}^ of scoliosis, 47 
 Thorax, 6 
 Torticollis, 95 
 Transitional scoliosis, 52 
 Treatment of postural scoliosis, 
 of structural scoliosis, 119 
 
 V. 
 
 Variations in height, 38 
 
 W. 
 Writing position, 106 
 
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