Treatment of

1
i
lilts
ERNARD ROTH,
SKCOND
EDI'
lill
BOSTON
MEDICAL LIBRARY
IN THE
Francis A.Countway
Library of Medicine
BOSTON
THE TREATMENT
OF
LATERAL CURVATURE OF THE
SPINE.
FRONTISPIECE.
Note. All
six photographs of Case
of the patient
of the
I.
were taken the same morning before com-
and 3 represent the "habitual" posture

and photographs 4, 5, and 6 represent the " best possible " posture
same patient after she had been so placed by the Author. This improved
mencing treatment.
Photographs
1,
2,
posture could only be maintained for the second or two required for taking the
photographs.
THE TREATMENT
fy*-r. ftt&
LATERAL CURVATURE
OF
THE SPINE
APPENDIX
GIVING
AN ANALYSIS OF 1000 CONSECUTIVE CASES TREATED BY

POSTURE AND EXERCISE" EXCLUSIVELY (WITHOUT
MECHANICAL SUPPORTS).
BY
BERNARD ROTH,
P.R.C.S.
ORTHOPEDIC SURGEON TO THE ROYAL ALEXANDRA. HOSPITAL FOR SICK CHILDREN, BRIGHTON
CORRESPONDING MEMBER OF THE AMERICAN ORTHOPEDIC ASSOCIATION.
SECOND EDITION
LONDON
H. K. LEWIS, 136,
GOWER
1899
STREET, W.O.
LONDON
H. K. Lewis,
136,
Gower
Street, W.C.
PREFACE
SECOND EDITION,
TO THE
My
of
Publishers having asked rue to issue a second edition
my
work on the Treatment
Lateral Curvature of
of
the Spine which was out of print, I thought
of
and re-arrange
re-write
entirely
more
practical use to medical
make
hoping to
it,
men
best to
it
desirous of carry-
ing out the rational treatment of this deformity.
embodied
in
this
the ten years

reference
is
analysis of
my
book was published.
Frequent
Curvature of the Spine treated by
upon
Association in
been more
given
osseous
which
Annual
Montreal
for
i.e.,
brae, will,
first
The number
time,
incurable
I hope,
the
of
than doubled, and

the
" Posture
gives
an
Lateral
of
and Exercise
to
of
Plates
of
Medical
illustrations
have
and
now
I.
illustrate
deformity
add to the
British
the
II.,
degrees of
the ribs and verte-
utility of the book.
BERNARD ROTH.
38,
Haeley Street,
Cavendish Square, London. W.
January 2nd,
1899.
"
read a short paper at the
Meeting
1897.
have
gained in
made to the Appendix, which

One Thousand Consecutive Cases
exclusively,
further experience
edition
since
it
PREFACE
TO THE
FIRST EDITION.
Although my views on
Lateral
Curvature
the prognosis and treatment of
have undergone con-
Spine
the
of
siderable modification during the fourteen
years
have
been engaged in orthopaedic practice, this monograph
mainly based on the
" Lateral
article
is
Curvature of the
Spine " which I contributed to Mr. C. Heath's " Dictionary

Surgery," 1886; on the papers published in
of Practical
the British Medical Journal, " The Treatment of Lateral
Curvature of the Spine,"

Consecutive Cases of
without
treated
1885
May
Lateral
Mechanical
and " Scoliosiometry,
Method
of
"
Curvature
Supports,"
or,
Recording Cases
13th, 1882
An
Two Hundred
of
Spine
the
October
31st,
Accurate and Practical
of Lateral
Curvature of the
Spine," October 27th, 1888; and on the paper read before
the
Clinical
Lateral
Society
Curvature
(April
of
ment without the Use
the
of
13th,
Spine,
1883),
"A
illustrating
Mechanical
Case
Treat-
its
Supports
of
"
(vol.
xvi. Clin. Soc. Trans., 1883).
BERNARD ROTH.
February. 1889.
TABLE OF CONTENTS.
Age
Causes
Sex
PAGE
............
Definition of Lateral Curvatu.be of the Spine (Scoliosis)
Position of
Classification
Stage
Q,
WritingCongenital Malformation
Postural Class or Stage
I.
Antero-posterior Curvatures
the Mangle" Types
AND
2, 3; S> >
" Gorilla
II.
"
and
.
3-8
Osseous Class or
Lateral Curvatures.
"
8-10
Passed through
.
10-11
Method of recording the Amount of Osseous Deformity when

present in a case of lateral curvature
scoliosiometer
Pain or Backache
Flat-foot associated with Lateral Curvature
(a)
21-23
Author's Method of Examination for Lateral Curvature
...........
......
........
........
pte-education of the patient's
muscular sense
as to
(d)
24-28
28-30
30
Improved Position to be maintained at all Times, while

SITTING OR STANDING
(c)
23
an
Erect or Improved Position

(b)
11-20
20-21
....
Relaxed or Over-extended Condition of the Elbow- joint
Treatment
Attention to Dress
36-37
Training of the Spinal and Other Muscles,
Systematic
including the development of the thorax
First Prescription of Medical Gymnastic Exercises
Second
30-36
37-43
38-39
40-43
......
Duration of the Treatment under the Personal Daily

Supervision of the Surgeon
43

TABLE OF CONTENTS.
Vlll
Attention to General Health
(e)
Treatment of Pain or Backache

(/) Subsequent
Home Treatment
......
......
PAGE
43-44
44
to prevent Eelapse in the
Improvement or Cure that has been obtained by the
Home
Surgeon
45-48
Prescription
45-48
.......
.........
The Treatment of Flat-foot
48-52
Duration of the Author's Treatment of Lateral Curvature by

" Posture and Exercise "
Statistics from the 1000 Cases
in
the Appendix
Result of the Author's Treatment of Lateral Curvature by

" Posture and Exercise "
.
Illustrative Cases,
I.
to VIII
Summary of Prognosis and Treatment

Appendix
Series
of
......
52-53
53-57
57-80
80-82
One Thousand Consecutive Cases of
Curvature of the Spine (Scoliosis) which were

the
under
author's treatment by " posture and exercise "
in Private Practice from July 27, 1885, to November 24,
Lateral
1892
83-141
i-l
Gi
E^
03
 E>
H M H
H
o
fa Ph
O
>H
J
^
3
pq
P3
22
tjl
E-i
of
<!
> <
t~
P
3
Cs
H
H g
E-<
fa"
Fig. 26.
Fig.
2it.
Fk;.
j
,o.
Fig. 31.
Fig. 32.
Fig. 33.
Fig. 34.
Fig. 35.
Fig. 36.
Fig. 37,
THE TREATMENT OE

Definition.
is
Lateral
a deformity which
Curvature of the Spine

is
SPINE.
(Scoliosis)
characterised by lateral deviation
and distortion or rotation of the spinal column, nearly

always accompanied by more or less exaggeration or
diminution of the normal antero-posterior curves.
An Appendix at the end of this book gives the particulars
of 1000 consecutive cases of Lateral Curvature which have
been under the writer's treatment in private practice, from
June 27th, 1885,

of
at
November
and are exclusive

a previous series of 200 cases, a paper on which was read
the annual meeting of the British Medical Association
to
24th, 1892,
in 1885.
Sex.
Out of the 1000 cases in the Appendix there are
122 males and 878 females. Messrs. Bradford & Lovett,
in their " Orthopaedic Surgery," 1890, have collected 2342
cases of Lateral Curvature, of which 363 were males and
1979 females that is, a percentage of 15 '5 males to 84*5
females, which is to be compared with my percentage of
122 males to 87*8 females. The much larger proportion
of girls than of boys afflicted, is due to the fact that girls
and women, in addition to being much handicapped by
their dress, do not have, as a rule, one-fourth of the amount
of physical exercise, such as cricket, football, hockey, etc.,
allowed to and enjoyed by boys and men.
The muscles
of girls either never develop as they ought, or become
weak
although they sit no worse than boys at their
lessons, they have not sufficient strength to hold themselves erect, and to restore the equilibrium of their curved
backs out of school hours.
At the onset of puberty
their development throws a greater strain on their health
THE TREATMENT OF
and strength than is the case with boys.
observe in young women lineae albicantes
I frequently
i.e.,
more or
on the outer
sometimes even
transverse similar fissures of the skin in the loins, caused
by the very rapid growth of the underlying tissues at
puberty, outstripping the growth of the skin, which gives
way and partially splits but I have never seen a similar
phenomenon in young men, and this I attribute to the fact
that boys do not develop so rapidly as girls do at the onset
Girls at that age usually put on such inof puberty.
less reel-coloured oblique fissures in the skin
aspects of the thighs and buttocks, and
creased weight, that, although, according to the tables of

the average weights of the two sexes, boys up to the age
of twelve years are heavier
than
girls at this age, girls in-
crease so rapidly that they are heavier than boys of similar

age, until about sixteen years, when boys again take the
lead until their greater weight and height are established.
Age. Where possible I have noted the age when the

deformity was sufficiently marked to have been noticed
by the friends, and this is best given in the form of
the following table, which has been extracted from the
pendix
:
Number of Cases
developed
Lateral Curvature.
Age.
....
1 year old
2 years ,,
Number of Cases
came under
the Writer's Treatment
....
10
10
11
12
13
14
15
16
17
18
24
34
55
46
50
89
94
107
117
103
84
69
25
19
19
20 to 29 years old
*
30 39
,.
40 49
,.
GO 76
,,
23
32
31
40
49
55
71
79
111
93
92
66
37
10
31
37
121
10
34
10

LATERAL CURVATURE OE THE SPINE.
The average age of the 1000 cases is 12 32 years for

the commeiiceraent of the deformity, and 15*65 years for
It will be
the age they came under my treatment.
seen that S97 cases (i.e., 89*7 per cent.) commenced to
develop Lateral Curvature between the ages of five and
seventeen years, and that more than one-half viz., 594
commenced between the ages of ten

Arranging
them in another way, there
and
were 50 cases under six years old, 274 cases between six
and ten years old, 505 cases between eleven and fifteen
years old, 136 cases between sixteen and twenty years old,
and 35 cases above twenty-one years old.
Lateral Curvature of the Spine is induced, in
Causes.
the large majority of cases, by weakness of the spinal
muscles, combined with long-continued sitting or standing
in stooping or relaxed positions, such as standing on one
leg, sitting, writing, and reading with the trunk leaning
or twisted to one side (see figs. 1 and 3), or with the
The position of writing, as generally
thighs crossed.
frequently than anything else, an
is,
more
practised,
initial cause of most cases of Lateral and other curvatures not due to diseased bone or Infantile Paralysis.
For many years past I have made it a rule, when
examining for Lateral Curvature, after having noted the
kind and degree of curvature present, to let the patient
sit down and write his or her name, and to observe the
posture then assumed nine times out of ten, the patient
will have placed himself or herself in a posture corresponding with the form of the curvature, except that
usually it is highly exaggerated.
In most early cases,
where, as we shall see later on, the whole spine is usually
convex to the left, this is found to be exactly the posture
of writing
in severer (i.e., more advanced) cases, where
the usual type is to have the dorsal (upper) curve with
(i.e., 59"tt
per cent.)
fifteen years.
convexity to the right, the patient in writing generally

raises the right shoulder, and this to a far greater degree
than in the ordinary posture of the Lateral Curvature.
This vicious posture during writing is due to the unfortunate custom of teaching a slanting handwriting from left
THE TREATMENT OE
upwards obliquely, whereas the natural direction
the handwriting ought to be really in the opposite
direction, as any one will recognise by sitting perfectly
to right
of
erect with his hands symmetrically placed on the desk,

and then attempting to write without screwing the right
Fig.
1.
WEITING.
an
Proper
Faulty position at
ordinary desk.
FIG.
position at
Glendenning's Patent
Adjustable Desk.
Fig.
3.
4.
BEADING.
Faulty position at an
ordinary desk.
Proper position at
Glendenning's Patent
Adjustable Desk.
hand round or twisting the body
I have therefore been

glad to see that, in the so-called " reformed " handwriting,
children are taught to make the letters vertical or even
sloping the other
In 231
of the
could be
way
from right to left upwards.

the Appendix no assignable cause
viz.,
1000 cases of
made
out, whilst the causes of the
cases are best given in the
form
remaining 769
of the following table
LATERAL CURVATURE OP THE SPINE.

CAUSES OF LATERAL CURVATURE OF THE SPINE.
.........
Hereditary
Rapid growth
Delicate
......
......
Always delicate
Delicate
Very delicate
General weakness
After acute fevers
297
203
108
43
19
6
176
18
Scarlet fever
Whooping cough
.14
Measles
Typhoid fever
Influenza
Diphtheria
Acute rheumatism
Severe fever
Low
fever
Dysentery
59
Lung
affections
Pneumonia
Asthma
Weak
20
8
lungs
Bronchitis
Pleurisy
Empyema
3
1
Phthisis
Hay
fever
41
Horn
in the Tropics
In India
In the West Indies
.
25
2
27
Nerve diseases:
Neurotic (hysteria)
Infantile paralysis
Other nerve diseases
Education
10
4
10
24
Violin-playing
Over-study
Piano (8 hours daily)
14
Premature birth
11
Eye
One
10
affections
of twins
Elderly parents
Miscellaneous
Very
tall
(above G feet)
Rickets
Congenital dislocation of hip
Rheumatoid
arthritis
Abscess, jaundice, and torticollis

11

THE TREATMENT OF
117 out of these 769 cases had apparently two causes

It will he observed that
predisposing to the deformity.
500 cases (50 per cent, of the whole 1000 cases) were
attributed to hereditary tendency (297 cases) and to
It is interesting to note that
rapid growth (203 cases).
211 cases were related to one another, either as brothers
and sisters, parents and children, or as first cousins. There
are two sets of four members of the same family, who
viz., cases Nos. 603, 620, 621, and 641
and one brother), and cases Nos. 287, 294,
If we add
296, and 310 (three sisters and a cousin).
together the 176 cases who were delicate, the 59 cases
debilitated by acute fevers, the 41 cases following lung
affections, and the 27 cases born in the Tropics, we total
up 303 cases (30' 3 per cent.), which were directly due
to a general weakness of the muscular system; and if to
these are added the 203 cases attributed to "rapid growth,"
which always presupposes a general ill-development of
the muscles, we find that upwards of 50 per cent, (exactly
506 cases) suffered from muscular weakness. Again, want
of development of the muscles is always associated with
a corresponding weakness or softness of the bones to which
they are attached. Mr. Ernest Payne, Honorary Skiagraphist to the Royal Alexandra Children's Hospital,
Brighton, has repeatedly taken X-ray photographs of
were
scoliotic
(three sisters
my
attending the Orthopaedic Departup till now he has never been

able to obtain a well-defined picture of the curvature
showing the rotation of the bodies of the vertebrae he
attributes this to the vertebrae being more transparent
to the X-rays in patients afflicted with Lateral Curvature,
whereas, in straight-backed individuals, he has no difficulty
This
in obtaining a good photograph of the vertebrae.
scoliotic
ment
patients
of that hospital, but
an interesting fact, and I should like to have it

confirmed by other X-ray photographers.
Rickets is
frequently a cause of Lateral Curvature in the very young
children of the poorest classes. The very small percentage
attributed to rickets in my 1000 cases, is due to the fact
that these patients belonged chiefly to the middle and
is
LATERAL CURVATURE OF THE SPINE.
wealthy classes and included no hospital cases. It will

be seen that Infantile Paralysis is credited with only 4
cases of Lateral Curvature this is not quite correct from
a statistical jioint of view, because I left out of the 1000
series, all severe cases of Infantile Paralysis with useless
or almost useless limbs these cases have such complicated
deformities, that it did not seem right to include them with
ordinary Lateral Curvature.
Inequality in the lengths of the lower extremities as
a cause of Lateral Curvature is conspicuous by its absence,
and I believe this cause of Scoliosis has been much exaggerated, although the great shortening that occurs in
;
long-standing hip-joint disease frequently induces Lateral

Curvature here again I did not include in my 1000 series
;
any cases
of Scoliosis complicating or following hip- joint
disease.
Playing the violin in the usual standing position has

no doubt contributed to bring on Lateral Curvature in
many cases, but only 8 cases were solely attributed to
Some anomalous cases of Lateral
that accomplishment.
Curvature may be directly due to congenital malformation
of the individual vertebra?, and although up to the present
time, such cases have not yet been diagnosed in the living
patient, it is quite possible they will be recognised in
future by means of further improvements in X-ray photography. Figure 5 is a drawing I made of a pathological
specimen of Lateral Curvature in the museum of the
General Hospital at Vienna. It has been described by
the celebrated anatomist, Rokitansky, who found it while
In this specimen
dissecting the body of a young man.
of
the vertebral column, the fifth and sixth dorsal
vertebrae are ankylosed together, and have only one
left transverse process between them (a), while there
is
an extra wedge-shaped half-vertebra interposed on
the left side between the eleventh and twelfth dorsal
vertebrae (b), and another similar half -vertebra on the
same side between the first and second lumbar vertebrae
It can be easily understood how extremely difficult
(c).
it would have been to have diagnosed the real cause of
THE TREATMENT OF
this case of
congenital Lateral Curvature in the living
patient.
Classification.
The
usual
given
history
is
that
the
mother has noticed one shoulder-blade

or one hip-bone (iliac crest) beginning
to
grow out in a
child,
the
of
girl
at
quently the
to
direct
very often a
puberty
fredressmaker is the first
onset
attention to the fact that
measurements are
different
on the two
sides of the trunk, or that a dress is

a misfit on one side, although it has
been made perfectly symmetrical. The
family medical man is called in
generally he does not strip the girl
to below the hip-bones (iliac crests),
and then tells her to bend the trunk
forwards or, as I have several times
been informed, the doctor examines
fiu"
^>*-r/i //,j the patient in bed without even having
the night-dress or chemise removed,
simply passing his hand down the
back outside the article of dress.
If
there is no decided or marked irregularity of the back when examined in
this haphazard way, the family doctor
too often assures the anxious mother
that the patient " will grow out of
it " and that nothing special need be
done, except perhaps lying down for
one or two hours daily (the very worst
advice he could have given) and the
use of dumb-bells, or so-called calisthenic exercises.
I am constantly
hearing this story and its numerous
Fig.
variations, when examining a case of
severe Lateral Spinal Curvature, which has developed
in the course of one or more years after the abovementioned verdict of the family doctor. It is, however,
;
*y
precisely at the time when there is no bony deformity

Before Lateral Curvature
that complete cure is possible.
it
osseous
deformity,
must gradually
with
occur
can
through
pass
the
patient
many
first
shows
that
to
Dr. Oscar Witzel, in Gerhardt's

der Kinder-Krankheiten, 1887," very ably
every pathological form that is, osseous
position of the
"Handbuch
stages, from the time

assume a temporary vicious
intermediate
began
trunk.
deformity of the spinal column is preceded by a pathological posture, in just the same way that the normal
osseous form of the spine in the adult is the result of
the habitual postures of the individual during the years
Most surgeons are now agreed

growth from infancy.
that, in Lateral Curvature of the Spine, " osseous " de"
formity is always preceded by so-called "postured
of
deformity
as soon as osseous deformity is present, not
only do the individual vertebrae become wedge-shaped and
misshapen with the attached ribs, but the actual bony
fibres or spiculse of the spongy tissue of the bodies of
the Aêrtebrse participate in the deformation, and show
in section, from above down, a whorl or twisting, corresponding to the rotation deformity of the whole adjacent
group of vertebras. Some surgeons still deny that Lateral
Curvature exists unless associated with osseous deformity
of the vertebrae and ribs, and they speak and write about
"weak spines" which "frequently pass into and become
cases of confirmed Lateral Curvature."
However, when
osseous deformity has set in, the case is now acknowledged
to be incurable to that extent by all or most surgeons.
Cases with osseous deformity differ from one another
according to the degree and the various forms of this
deformation.
I therefore divide all cases of Lateral
Curvature into two large classes, quite irrespective of
their causation and forms
(I.) Postural class or stage
viz., those without any osseous deformity of the ribs and
vertebrae; and (II.) Osseous class or stage viz., those with
osseous deformity which may be conveniently subdivided
for clinical purposes into slight, moderate, severe, and
extreme, according to the degree of osseous deformity
:
THE TREATMENT OE
10
present.
It will be readily understood that, in
any given
case of osseous Lateral Curvature, the ribs and dorsal vertebrae may exhibit slight osseous deformation with severe
osseous deformity of the lumbar vertebrae or vice versa.

There are six different well-marked forms of Lateral
Curvature, and I attach to each the number of each variety

in the 1000 consecutive cases given in the Appendix.
A. Curvatures with the whole convexity to the left

(ordinary letter C)> 523 cases viz., 523 per cent.
B. Curvatures with double curves, the dorsal (upper)
curve being convex to the right and the lumbar (loAver)
curve convex to the left (reversed letter 3) 329 cases
32 9 per cent.
C. Curvatures with the whole convexity to the right
(reversed letter Q), 72 cases viz., 7"2 per cent.
D. Curvatures with double curves, the dorsal (upper)
curve being convex to the left and the lumbar (lower)
curve convex to the right (ordinary letter S)> 45 cases
viz., 4*5 per cent.
with triple curves, the highest and
JE. Curvatures
lowest curves being convex to the left and the middle
curve convex to the right (ordinary Greek letter g), 28
viz., 2*8 per cent.
cases
F. Curvatures with triple curves, the highest and
lowest curves being convex to the right and the middle
curve convex to the left (reversed Greek letter ), 3 cases
viz., 0*3 per cent.
The normal anteroposterior curves of the Spine are
nearly always affected in Lateral Curvature, causing the
patient to stoop in many cases the whole spine is convex
posteriorly, with disappearance of the lumbar hollow,
which becomes convex instead of concave posteriorly
the result is that the head projects forwards, the anterior
chest, walls become flattened and the abdomen becomes unduly prominent. This typical stoop, which is so frequently
associated with Lateral Curvatures, has been described by
me for the last eight or nine years as the "gorilla" type
of the antero-posterior curves, on account of its similarity
to the normal shape of the ourang-outang and the gorilla.
viz.,
The "gorilla" type
11
sometimes so severe, that it tends to

conceal the presence of Lateral Curvature, and I have often
been unable on account of this to determine the form of
the Lateral Curvature on first inspecting a patient's back.
Another modification of the antero-posterior curves of
the spine, occurs, with or without obliteration of the
lumbar hollow, with such an approximation of the anterior
and posterior walls of the thorax, that the trunk appears
to have been flattened from before backwards, and this I
have for some years described as "passed through the
mangle " type. Patients, with the " passed through the
mangle " type of stoop, often look as if they were good
chested when observed in front, but the contraction of
the chest-cavity is perceived at once if they are inspected
sideways.
The above two types are sometimes associated in
the same individual, when the result is most distressing yet
even in such a case, placing the patient in the best possible
posture will often, not only remove the undue prominence
of the abdomen, but also enlarge and unflatten the thorax.
is
Method of recording the amount of osseous deformity

when present in a case of Lateral Curvature. I attach
greatest importance to recording the presence or

absence of osseous deformity in Lateral Curvature.
If
osseous deformity is present, to that extent the case is
incurable and as far as I know, no patient has ever been
shown at a recognised medical society, before treatment
with slight or severe osseous deformity, due to the scoliotic
torsion of the vertebrae, and exhibited again after treatment, with disappearance of this same bony deformation.
the
still
consider
in
27th,
1888,
time
the
amount
the
method
of
Scoliosiometry
first
British Medical Journal of October

the most satisfactory, and at the same
simplest and most rapid, for recording the
described
the
as
any given
a simple piece
of tin tape, which, when rolled up round an ordinary
yard
tape
measure, can easily be carried in the
waistcoat pocket.
The Scoliosiometer is made of pure
tin, twenty inches long,
five-eighths of an inch wide,
case.
of
osseous
deformity
The only apparatus
present
required,
is
in
THE TREATMENT OF
12
and about one-twentyfifth of an inch thick (fifty

centimetres long, 15 centimetres wide, and one millimetre thick), and can he obtained from the surgical
instrument makers, Mayer & Meltzer, of 71, Great
The scoliosiometric tracing
Portland Street, London, W.
The patient,
of the ribs posteriorly is taken as follows
with feet together and the knees extended, flexes the
trunk as far as possible, the arms being allowed to hang
The lower angle of the left shoulderdown loosely.
blade is felt, and, fixing one end of the metal tape with
the left hand at that point, the tape is carefully moulded
close to and over the left ribs, across the spine, over
the right ribs to the lower angle of the right shoulderWith
blade, which is likewise to be carefully felt for.
a copying pencil, the metal tape is marked opposite the
dorsal spine, and is then carefully removed, upper edge
downwards, on to a sheet of quarto-size paper, and a tracing
drawn inside the concavity of the curved tape, marking
on the paper the point where the tape touched the spine.
:
The pencil line is afterwards inked, and the tracing cut

out and folded down the middle (see figs. 24 and 27)
opposite the point marking the spine, and we have now
an accurate and permanent record of the present state
of deformity of the ribs posteriorly.
In some cases, the
most marked deformity of the ribs posteriorly, is one,
two, or more fingers' breadth, or even a hand's breadth
below the lower angle of the shoulder-blades, and if the
tracing has been taken at that level, this fact is noted
on the tracing. In cases of extreme osseous deformity
I have found
sometimes advisable to take the tracing

a higher level, that is, from the top of
the left axilla to the corresponding place on the right,
it
posteriorly at
including thus a portion of each shoulder-blade. When

is done, the metal tape should be
marked where
it touches the inner border of each shoulder-blade, and
this copied on the tracing, as taken in fig. 21, page 62.
Unless this modification is adopted that is, taking the
tracing from between the axillse, instead of from between
the lower angles of the shoulder-blades tracings of the
this

ribs
posteriorly, in
extreme cases
13
deformity, are un-
of
too little of the ribs posteriorly being given

the tracing simply extends from the lower angle
of one shoulder-blade to that of the other, from the more
or less increased immovability and displacement of the
satisfactory,
when
shoulder-blades, as can be seen in
fig.
where very
21,
little
would be shown, if the tracing

had stopped on reaching the right shoulder-blade.
of the right ribs posteriorly
Similarly a record should be taken of the loins, usually

midway on each side between the last ribs and the
that is, opposite the third lumbar vertebra
iliac crests
marking the tape as before, where it crosses the spine (see

A little more dexterity is required if the
figs. 22 and 28).
patient
is
stout, or the erectores spina?
much
muscles are bulky,
employed in moulding the

tape to the contour of the loins, the muscles and soft
tissues will cause the tape to spring up and alter its
shape when the pressure is removed, and this would vitiate
as,
if
too
pressure
is
the record. This outline of the erectores spina? muscles

is then transferred to the paper in the same way as that
of the ribs posteriorly, not omitting to
of the third
lumbar vertebra.
mark the
Although
this
position
method
of
recording the osseous deformity of the ribs posteriorly

(i.e., the amount of rotation of the dorsal vertebra?), and
of the
it
lumbar
vertebra?, has taken rather long to describe,
enables a surgeon to obtain a correct and reliable record
of a case of osseous Lateral Curvature, in less
than a minute,
Several writers on Lateral Curvature

of the Spine have employed a metal tape
but their records
are of little use, because the tracings were taken while the
patient was erect, when the real amount of osseous deformity
after a little practice.
is
more or
less
masked by the shoulder-blades,
as far as
the ribs posteriorly are concerned, and by the contraction

of the loin
When
muscles with reference to the lumbar vertebrae.

is marked osseous deformity of the ribs
there
anteriorly, especially in cases of pigeon-breast, a tracing
can be easily taken from one axilla to the other, either

on a level with the nipples, or, where the mammae are
developed, just below or above them, marking on the
THE TREATMENT OF
14
the nipples and the mid-sternuni.

the patient should be
made to extend the spine backwards as much as possible,
with the thorax well thrown forwards
and he should
endeavour to press against the tape whilst it is being
tape, the position
In taking
this
of
anterior tracing,
moulded to the anterior walls of the thorax. My friend,

Dr. R. Tait McKenzie, of McGill University, Montreal,
has invented an ingenious instrument for directly recording on paper, but one-fourth the real size, exactly
the same tracings as I have just described (see British
Medical Journal, Oct. 9th, 1897). I have employed this
method of recording cases of Lateral Curvature for upwards of fifteen years, and have found it indispensable.
By its means, I have been able to show gradually increasing osseous deformity in cases of Lateral Curvature
due to severe Infantile Paralysis of the spinal muscles,
than which there are no worse cases to treat, and also
in bad cases of Lateral Curvature after Empyema, which
go on from bad to worse, on account of the irresistible
force of the cicatricial
I
have
also,
by means
contractions of
of
the lung-cavity.
these tracings, demonstrated
further increase of the osseous deformity, where my advice

has not been followed, and the patient has returned to
an interval of months or years. I am convinced

that, if this method of recording cases of Lateral Curvature
was generally adopted, few surgeons would continue to
treat them by steel, poroplastic, or other supports, except
in those rare cases due to more or less complete paralysis
These tracings enable surgeons
of the spinal muscles.
to recognise how the osseous deformity of the ribs and
vertebrae gradually progresses from bad to worse, in spite
of the most complicated and expensive spinal supports.
They would prove that the only rational and really
successful treatment of Lateral Curvature, and one which
is far more rapid than any other yet offered to the prothat is, re-education
fession, is that which I advocate
of the muscular sense of the best possible position,
and methodical exercises of the muscles, to enable the
patient to maintain this improved position without effort
me
after

put
or, to
more
it
15
" treatment by posture and
shortly,
exercise."
amount
The
deformity
osseous
of
classified,
is
as
already stated, as extreme (<?), severe (s), moderate (m), a

trace {t), and if the ribs and erectores spinse are perfectly
symmetrical on the two sides when the patient's trunk

well flexed, absence of osseous deformity (o) is diagnosed,
provided the ribs anteriorly are also symmetrical when
the patient stands fully erect.
is
In Table I., I give the amount of osseous deformity of

Lateral Curvature in the
each of the 523 cases of
Appendix.
TABLE
I.
DEGREE OF OSSEOUS DEFORMITY OF THE

Left Ribs
OSTERIORLY.
523 CASES OF
SCOLIOSIS.
Left Erector
Muscle.
Spinas
117
76
71
VI
71
66
28
24
t
{
Ki glit ribs anteriorly

too prominent
15
12
6
s
VI
2
1
523 Cases.
Explanation.
The
first line of
cases of
ribs
C=
extreme.
trace.
Table
scoliosis
I.,
= severe.
= no osseous deformity.
"
o m 117,"
m =
moderate.
means that 117
had no osseous deformity of the

was moderate osseous
posteriorly, but that there
left
de-
undue prominence) of the left erector spinse

caused by the torsion of the lumbar vertebrae,
Avhich are convex to the left.
The second line, " t m
76," indicates that 76 cases had a trace of osseous deformity of the left ribs posteriorly, caused by the torsion
formity
muscle,
{i.e.,
THE TREATMENT OE
16
which are
convex to the left,

and moderate osseous deformity of the lumbar vertebrae.
The fifth line, " o o 66," means that, although the
whole spine was habitually convex to the left in 66
cases, there was no osseous deformity of the dorsal and
The sixth line, " m s 28," shows
lumbar vertebrae.
that 28 cases had moderate osseous deformity of the left
ribs posteriorly, and severe osseous deformity of the lumbar
The last line, " e e 1," shows that only one
vertebrae.
case of C lateral curvature had extreme osseous deformity, both of the left ribs posteriorly and of the
When I speak of slight, moderate,
lumbar vertebrae.
severe, or extreme osseous deformity of the left ribs
posteriorly, I also imply a corresponding osseous deof the dorsal vertebrae,
also
formity shown by a sinking or thrusting forwards of the

corresponding right ribs posteriorly.
TABLE
II.
329 CASES OF
SCOLIOSIS.
Right Ribs
Left Erector
Posteriorly.
Spinê Muscle.
VI
52
44
34
24
20
11
11
10
67
m
m
329 cases.
Explanation {;:
extreme.
trace.
=
=
severe.
no osseous deformity.
m = moderate,
17
was only one case out

curvatures without any osseous
It will be observed that there
these 329
lateral
deformity (" o o 1 ") whereas, in Table I., 66 out of
523 cases of
Lateral Curvatures presented no osseous
deformity
also that 197 cases of
Lateral Curvatures
had no osseous deformation of the ribs posteriorly, and
that in 313 of these same
Lateral Curvatures there is
proportionally more lumbar than dorsal (ribs posteriorly)
osseous deformity.
These facts constitute, in my opinion,
a strong argument for the view that most cases of
of
scoliosis
commence
as cases of
scoliosis,
and that those
who maintain
that the
develop in the large
majority of all classes of Lateral Curvature. This is also
scoliosis,
confirmed by the fact that, in 32 cases of
there is no osseous deformity of the right ribs posteriorly,
against only 9 cases of
scoliosis with no osseous deformity of the lumbar vertebras.
This is, besides what
would be expected a priori on anatomical grounds, because
the lumbar vertebras are far more mobile than the dorsal
orthopaedic surgeons
lumbar
curvature
are
is
correct
the
first
to
vertebras.
TABLE
III.

Right Ribs
Posteriorly.
72 CASES OF
SCOLIOSIS,
Right Erector
Sphsls.
14
12
6
4
'
3
2
2
1
1
1
Bight
ribs anteriorly
too prominent
/
I
_1
72 cases.
Explanation
fe
extreme.
trace.
=
=
severe.
m =
moderate.
THE TREATMENT OF
18
TABLE
IV.

Left Ribs
Right Erector
Posteriorly.
Spinê.
45 CASES OF
SCOLIOSIS.
10
2
2
VI
e
t
45 cases.
e
Explanation.
extreme.
=
=
moderate.
severe.
Here, again, it is interesting to note, that, although. 12

out of the 72 cases of
scoliosis have no osseous deformity, only 2 out of the 45 cases of
scoliosis have
scoliosis, 13 have
normal vertebrae and that of the
only osseous deformity of the lumbar vertebrae, against 2
with only osseous deformity of the left ribs posteriorly.
This also indicates the strong probability that
scolioses
scolioses, and that the
are often the early stages of
Lumbar Curvature is developed in most cases before the
dorsal one.
In the next two tables, V. and VI., of triple Lateral

Curvatures, although it is not indicated, most of the
uppermost curvatures included one or more of the cervical
vertebra?.
remarkable that not a single one of the above

31 cases of triple Lateral Curvature is without wellmarked osseous deformity, proving them to be all in a
later or more aggravated stage of development than the
double or single Lateral Curvatures. It will help the
reader to understand what I mean by the different degrees
It
is

TABLE
19
28 CASES OF
SCOLIOSIS.
Left Ribs
Right Ribs
Posteriorly.
Above Scapula.)
{Below Scapula.)
VI
Left Erector
Spin.e Muscle.
Posteriorly.
m
m
m
VI
28 cases
^.
Explanation.
=
s
m =
severe.
TABI ,E
moderate.
Right Ribs
Posteriorly.
Left Ribs
Posteriorly.
(Below Scapula.)
m
t
t
trace.
VI.
(Above Scapula.)
3 CASES
OF
SCOLIOSIS.
Right Erector
Spinas Muscle.
3 cases
Explanation-
m =
extreme
severe.
trace.
moderate,
by looking at the series of tracings

and of the erectores spinse muscles,
and II. In Plate I., figs. 6, 7, 8, and
of osseous deformity,
of the ribs posteriorly,
given in Plates I.
9 are all scoliosiometric tracings of the ribs posteriorly,
taken according to my method, and have been reproduced
the natural size, being facsimiles of those I took of
Nos. 911, 985, 224, and 10 of the 1000 cases in the
Appendix.
Eig. 6 exhibits,
at
first
any difference between the right and
inspection, scarcely
left ribs posteriorly
but on careful comparison, especially by

expedient of folding the paper along the
drawn through the place where the tracing
dorsal spine, it will be seen that the right ribs
the simple
dotted line
crossed the
posteriorly,
THE TREATMENT OF
20
are a trace
more prominent than the
left ribs posteriorly.
7, the moderate osseous deformity of the right

ribs posteriorly is very evident; in fig. 8, the severe, and
in fig. 9, the extreme deformity are only too self-evident.
In
fig.
Before the ribs posteriorly can be so extremely deformed

as in fig. 9, they must of necessity gradually pass through
all the intermediate stages, from the time they were
perfectly symmetrical, and began to show the earliest
Similarly,
stage of osseous deformity as seen in fig. 6.
and
are
II.,
figs.
13
scoliosiometric
in Plate
10, 11, 12,
tracings of the loins taken opposite the third lumbar
and exhibit respectively, what I describe as a

trace of, moderate, severe, and extreme osseous deformity
of the lumbar vertebrae.
vertebra,
JPain or Backache.
Pain
in the back, generally of the
under or in the neighbourhood
loins, or
blade, or between the shoulder-blades,
is
of one shoulder-
the
first
symptom
observed in a large number of cases. The following is a

of the backache experienced by the 1000 cases in
In 11 cases there was extreme pain, in 230
the Appendix.
cases severe pain, in 87 cases moderate pain, and in 148
cases slight pain ; so that in 476 cases (47'6 per cent.),
or in nearly one-half of the cases, there was more or
I would mention case No. 261 as an
less backache.
example of extreme pain, where the son, a medical man,
wrote to me that his mother " has suffered an incredible
summary
amount
pain from the deformity, which would seem

to be of a neuralgic character, coming and going suddenly."
The pain is in most cases, however, a dull aching, wearying,
at times it is very sharp and acute,
or bruised feeling
like ordinary neuralgia.
I have frequently examined
patients who complained of a pain like a red-hot iron
being pressed into the spine, or like a sharp knife being
plunged into the trunk. Most scoliotic pains are relieved
by exercise, and strangely enough in many cases by lying
down, in the same patients to whom movement gives relief.
The backache is generally brought on or aggravated by
sitting for any length of time at lessons, especially writing,
sewing, or playing the piano, etc., or by attending church,
of
LATERAL CURVATURE OP THE SPINE.
21
It will be observed that, in a bare

majority of the cases in the Appendix (52"4 per cent.),
theatre, or concert.
there never has been any backache whatsoever.

It may
be stated generally that the amount of pain complained
of, is seldom in proportion to the amount of deformity.
Cases of extreme Lateral Curvature are sometimes seen
where there is not, and never has been, any backache
felt by the patient, although the health may have been
affected in other ways, by indigestion, headache, shortness
of breath, etc.
On the other hand, life may have become
almost unbearable on account of constant backache and
the symptoms almost assume those of so-called " spinal
irritation," in cases where the curvature is but slight
It is, hoAvever, fortunate for the patient when pain in the
;
an early symptom, because attention is then drawn

and a commencing Lateral Curvature detected
which would otherwise have been overlooked, till the
development of osseous deformity had progressed to such
a degree that a non-professional eye would easily have
recognised it, even through the dress.
I was one of the first surgeons to point
Flat-foot.
out the extremely frequent association of flat-foot with
Lateral Curvature of the Spine (see my paper in the
British Medical Journal of May 13th, 1882).
Mat-foot
back
is
to the spine,
be defined as a falling down or giving way of the

of the foot, which may be so slight as
almost to escape notice, except from the discomfort it
causes, or be so severe that the whole tarsus presents
as great a convexity inward as it ought to present a
concavity, with the foot so everted that the internal
malleolus almost touches the ground, while the outer
border of the foot is raised, with the sole directed outward, as in some cases of infantile paralysis. Sir James
Paget speaks of " the constant pain and weariness of
the lower limbs associated with flat-foot.
The feet are
elongated, flat, low, without insteps
the heels are too
little prominent, the plantar arches sunken, the ankles
thick
the astragalus, navicular and inner cuneiform
bones, are below their right level.
The pains complained
may
normal arch
THE TREATMENT OE
22
are those of the muscles and tendons, which are

habitually overworked in the task of keeping the body
erect when its proper hearings on its supports are disI consider this description is generally true
turbed."
of
a severe case not due to infantile paralysis.

Pain
and much deformity are not always associated together;
growing boys and girls approaching puberty, are frequently
brought to me, complaining of severe pain in the instep,
whose feet exhibit scarcely any deformity. Again, the
severest cases of flat-foot, those due to infantile paralysis,
frequently have no pain or discomfort in the feet,
although sensation is perfectly normal. I find that all
of
on commencing to walk are normally flat-footed

without any tarsal arch; whereas after they have
stood and run about a few months, and the leg-muscles
I
have become developed, a perfect arch is formed.
have often been consulted by an anxious mother about
her baby's feet when the child begins to run alone, the
normal absence of a tarsal arch being often at first
exaggerated by a pad of fat opposite the plantar aspect
I have always been able to reassure her,
of the tarsus.
that the feet would become arched in
her
and to tell
and the
time and the adipose instep pad disappear
Mr. Le
result has proved my prognosis to be correct.
"In reviewing the action of the
Gros Clark wrote
various muscles around the foot, it is obvious that their
attachment is designed to preserve the plantar arch, and
that such healthy condition must depend in great measure
on the evenly balanced action of those muscles upon
their several attachments.
Thus the peronei and tibial
muscles antagonise each other, and the expanded insertion of two of them into the tarsal bones, is very
instrumental in preserving the transverse, as well as the
antero-posterior arch." Although the bones of the instep
are apparently so well supported by their ligaments and
the tendinous prolongation of the muscles inserted in
the sole, yet, as soon as these muscles shirk their work
from weakness, undue strain is thrown upon the tarsal
ligaments
and they gradually yield, accompanied by
infants
i.e.,

23
less aching and pain, or none at all, according

the idiosyncrasy of the sufferer, just as is the case
At first there is no osseous
with Lateral Curvature.
malformation, and so long as this is so, complete
restoration to the normal is possible
but in time the
more or
to
become altered in shape, the bones

and the ligaments so shortened and thickened
that, even with severe brisement force under anaesthetics,
only a partial improvement is brought about.
Plat-foot
therefore directly due to the weakness of the legis
muscles which are attached to the bones of the foot.
Out of the 1000 cases in the Appendix, there are 149
(14'9 per cent.) with severe flat-foot, 416 (41'6 per cent.)
with moderate flat-foot, and 256 (25" 6 per cent.) with a
articulating surfaces
distorted,
By
trace of flat-foot.
cases
severe flat-foot, I distinguish those
is a more or less permanent damage

the foot, so that the deformity does not
where there
to the arch of
disappear altogether
when
the patient
is
made
to stand
on the toes with the heels raised in moderate cases, and

those with only a trace, the normal arch of the foot is
;
restored
I
when
believe
the patient raises the heel
some
surgeons
would
not
off
the ground.
agree
with
my
diagnosis of a trace of flat-foot

but even after eliminating the latter, the 1000 cases in the Appendix show
some 565, or 56' 5 per cent., with well-marked flat-foot
cases which require special treatment of the foot deformity, if a satisfactory result is to be obtained.
Every
surgeon will admit the great importance of having good
legs and feet to enable a patient to have a firm basis on
which to develop a strong and straight spine.
Relaxed or over-extended condition of the elbow-joint.
A deformity, which, in my experience, is almost as often
;
associated with
Lateral Curvature as flat-foot,
is
a more
or less relaxed condition of the ligaments of the elbow-
causing an over-extension of that articulation and

known asa u double " joint. In extreme cases of
this deformation, the axis of the fore-arm is nearly 30
degrees beyond the prolonged longitudinal axis of the
upper arm, Avhen the patient fully extends the elbow.
joint,
jôpularly
THE TREATMENT OF
24
This deformity of the elbow- joint

weakness of its flexor muscles.
is
undoubtedly due to
Knock-knee is occasionally met with in Lateral Curvature

patients, and is usually associated with more or less severe
flat-foot.
Author
method of examination for Lateral Curvature
of the Spine.
After
obtaining a history of the patient's
and ascertaining any probable predisposing causes

the deformity and an account of any past treatment,
case,
of
questions should be put concerning the present

patient's general
the
health.
state
of
In the large majority of

this having been failing
a history of
and the friends explain that the
patient is generally tired and easily knocked up by
slight exertion, which he or she would have thought
nothing of a few months or years previously. Scoliotic
patients are very liable to catch cold on slight provocaMany suffer from want of appetite, and frequently
tion.
commence the day by taking scarcely any food for breaktime after time, I have found a scoliotic young
fast
lady's breakfast has consisted solely of a cup of tea and
half a slice of dry toast, and this after fasting all night.
These patients frequently suffer from indigestion, due to
the vegetative existence they have been accustomed to lead,
especially those who have been condemned by previous
medical advisers to lie down for several hours daily in
the hopes of straightening their weak and crooked backs.
As might be expected, the circulation is languid in most
a far larger proportion suffer from chilblains in
cases
the winter than would be the case in an equal number
of non-scoliotic individuals
the hands and feet are sometimes so cold and the circulation so stagnant, even in
warm weather, that it would be easy to mistake them on
there
cases,
is
some time
for
past,
first
inspection for cases of
and young women the

quired into
suffer
many
Raynaud's disease. In girls

menses should be in-
state of the
are irregular in their courses
others
from profuse monorrhagia, which, strangely enough,
often ceases as soon as methodical exercise
is
employed,
indicating that this condition Avas probably due to a form
25
of passive congestion of the uterus.
Next, questions about

absence
of
backache
or
should be put (see
presence
the
page 20) and about school life, whether suitable sloping
;
desks, or simply flat tables
ployed.
The patient
is
and benches, have been emrequested to undress, and
now
the sexes afflicted with Lateral

Curvature is more than seven females to one male, we
will suppose she is a young woman
the boots should
always be removed, and the petticoat or knickerbockers
fixed by a safety-pin round the pelvis, well below the
as
the
proportion
of
level of the iliac crests, so that the gluteal cleft
We
take
is
just
granted that the legs are

of equal lengths, or have been made so by a block placed
under the shorter limb. The patient is placed with her
back in front of the surgeon, with knees extended and
the feet together. Here I may say, that surgeons who
can draw ever so little, will find a rough outline sketch
of the patient's back and spine, while in the habitual
position, useful before proceeding further, and that the
curve of the spine is more readily recognised, if the
posterior spinous processes are marked from above, down,
with a soft copying-ink pencil (see figs. 20 and 23). Those
who cannot draw would probably find Dr. It. Tait
McKenzie's scoliosiometer, previously mentioned, of use.
After inspecting the patient laterally, noting whether
there is little or much exaggeration of the normal anteroposterior curves of the spines (slight, moderate, or severe
''gorilla " type), or even diminution of these same anteroposterior curves (slight, moderate, or severe "as if passed
through a mangle " type), and in front, noting any inequality of the mammae, etc., the trunk should be flexed
as far as possible, the knees being kept extended and the
arms allowed to hang down loosely, so that the scapular
muscles are thoroughly relaxed. Now, the level of the
ribs posteriorly, uncovered by the shoulder-blades, should
be carefully examined for any inequality. In the second
most common form of Lateral Curvature, with dorsal
visible.
will
it
for
scoliosis),
(upper) convexity to the right (reversed letter
if there be any osseous deformity present, the right ribs
THE TREATMENT OP
26
will be more or less unduly prominent, sometimes so slight

that a good light and a well-trained eye are necessary to
make out a difference on the two sides. Now a scoliosio-
metric tracing of the ribs posteriorly is taken, as has been

similarly, a record is taken
already described on page 12
of the loins, usually opposite the third lumbar vertebra.
After this careful examination, which has included a
record of any osseous deformity present, as well as
of the ribs anteriorly, before allowing the patient to
dress, it is essential to ascertain to what extent the
spine can be restored to its normal position by a voluntary
effort, with the help of the surgeon.
In cases of Class I. viz., " Postural, or non-osseous
:
stage "
where
there is no bony deformity of the ribs and

"
best possible position " will be perfectly
vertebrae, this
normal, with the shoulder-blades and hip-bones (iliac
symmetrical, the thorax well thrown out, the
crests)
abdomen withdrawn from undue prominence, and the head
erect (see Frontispiece Photographs, figs. 1 to 6, although
had some osseous deformity).

In cases of Glass II. viz., " Osseous stage," the improvement effected will depend on the amount of bony
deformity present. One arm directed and held upwards,
and the other arm outwards, is frequently useful in
helping to partially restore the symmetry of the trunk
(see photographs, fig. 7 and fig. 8, which represent a girl,
aged seven years, with severe Lateral Curvature, in the
"habitual " posture [photograph, fig. 7] and the " best possible" posture [photograph, fig. 8]).
Sometimes the best
result is obtained by both arms being raised vertically by
the side of the head, while avoiding undue elevation of
this case
the shoulder-blades, the elbows being either grasped above

the head, or well extended upwards at other times it
is found that the desired result is obtained by grasping
:
both arms being extended upwards by the

This best position of the patient's
the head.
trunk and arms, for improving the form of the spine, is
the " kevnote " of the exercises to be practised during
treatment.
one
sides
wrist,
of
27
committee on Lateral Curvature of the Spine,

appointed on March 11th, 1887, by the Clinical Society
of London, and before whom I demonstrated the same
patients both before and after treatment, reported that
" The amount of improvement which may be hoped for in
any given case may not unsafely be gauged by the improvement which the patient can voluntarily effect in his
or her position when first seen" (see "Clin. Soc. Trans.,"
This
not
quite
correct
the
committee should have qualified the sentence " which the
patient can voluntarily effect " by the words " directed
vol. xxi., 1888, p. 301).
is
The importance
or helped by the examining surgeon."
of placing the patient in the " best possible position " at
the
first
prognosis
consultation,
of
is
therefore
the curvature
is
evident,
if
a correct
The patient
desired.
is
only able to maintain this improved position

by a great muscular effort, for a few seconds, during
which she will feel as if she were more crooked than
before.
The muscular sense has become so perverted
that the habitual position appears to her to be far more
natural and straighter than the really erect or improved
posture.
A corroboration of this fact is given in cases
of wry-neck
(non-spasmodic torticollis)
after a few
days' methodical exercise, I divide the contracted sternomastoid tendons, Avhen at first the patient will continue
to hold the head in the habitual vicious oblique position
because that appears to him to be the erect position,
and it will only be after three or four weeks' daily
medical gymnastic treatment that he will be trained
really to hold the head symmetrically, having recovered
the normal muscular sense of such position. Even the
eyesight becomes affected in long-standing wry -neck.
I remember one young man on whom I operated, who
for several weeks after the operation declared that, when
he held his head vertically, everything he looked at
seemed on the oblique and crooked a remarkable example
of the force of habit.
It is always advisable before concluding the examination to ascertain whether the dress
is too tight across the anterior thorax.
This is best done
generally
THE TREATMENT OF
28
by trying on the underclothing,
dress,
stays,
bodice,
and
outdoor jacket one after the other, while the patient

is in the best possible posture, which is often most easily
obtained by letting her stand with her back against the
door, heels, sacrum, dorsum, and back of head touching
it, and with the shoulders well thrown back.
While in
this position, her mother or friend should be requested
to try to fasten her stays and clothes in front.
In most
cases, these will not meet for one or more inches, such
great alteration and enlargement of the thorax anteriorly
being temporarily effected by this simple device. This
applies equally to male patients, the shirt-collar band,
waistcoat, coat, and overcoat frequently not meeting for
an inch or more, when the patient is placed thus with
his back against the door.
Finally, the stockings being
removed, notice should be taken whether the patient is
flat-footed or not (see page 21).
After dressing, let the
patient write her name in her usual sitting position, as
described on page 3.
This is a good opportunity for
testing the eyesight, and to find out whether she can
read at the normal distance.
TREATMENT.
in
the
Difference
sense
suggests
that
practical
lengths
of
lengths
the
lower
by wearing a thicker
the
of
inequality
in
legs.
the
Common
potential
extremities
is
to
or
be
on the shorter leg,

appear to be indicated.
Practically I find that a difference of a half -inch or less
may be ignored, and a rough and easy test for measuring
corrected
whatever
other treatment
sole
may
the lengths of the legs, if inequality is suspected, is to

let the patient lie supine on the floor, with the hips and
knees flexed and the soles close together on the ground
:
if
the bared knees appear perfectly symmetrical in position,
may rest assured that, if there be any difference in the lengths of the lower extremities, it is less
than half an inch, and may be ignored.
If, however,
one knee is markedly higher or more forward than the
the surgeon
29
then measurements should be taken in the usual
other,
way from the
superior iliac spinous
anterior
if there
the internal malleolus
inch difference, obliquity of the
;
is
process to
more than half an
pelvis
will
be notice-
standing position, and by pressing the

the soft tissues above the iliac crests
on either side of the patient, this will be made easily
apparent.
Of late years the implicit faith formerly placed in the
treatment of Lateral Curvature of the Spine by steel and
other spinal supports, or stays, has been gradually undermined and even those who still adhere to the mechanical
able
in
the
fore-fingers
into
treatment of spinal deformities not due to diseased

bone, attach more and more importance to its association
with suitably prescribed gymnastics. Lateral and other
Curvatures due to paralysis of the spinal muscles, when
the patient is unable by a voluntary effort to maintain
himself in an improved position for even a few seconds,
are the only cases in which spinal supports may be of
In these paralysed backs, attempts should
some use.
be made, although, more often than not, they fail, to
prevent further increase of the osseous deformity; and
in some few cases this is possible by the application of
a well-made posterior spinal support, which is fixed by
means of a strong leather pelvic band and shoulder-straps.
This support will, however, have to be worn most probably
for the remainder of the patient's life, because more or
less disappearance of the spinal muscles is presupposed.
It is to be understood that the support is worn with
the sole idea that it may possibly prevent further increase
of deformity and without any hope of its being curative,
and it should be left off at night in bed. Lying on the
back, or on the prone couch, for several hours daily, still
almost universally prescribed by orthopaedic and other
surgeons, is perfectly useless as far as cure of the Lateral
Curvature is concerned. If a limb with weak and flabby
muscles were put into stiff splints and kept at rest for
several hours daily, the muscles would naturally become
weaker and this is equally true of the spinal muscles.
;

THE TEEATMENT OF
30
The patient may
lie on the back or prone for a few

minutes at a time for the relief of pain, or when fatigued
by exercise but lying for longer periods does far more
harm than good.
The treatment is based upon principles which may be
taken under the following heads
(a) Eie-education of the patient's muscular sense as to
an erect or improved position.
(b) Improved position to be maintained at all times,
while sitting or standing.
;
Attention to dress.
Systematic training of the spinal and other muscles,
including the development of the thorax.
(e) Attention to general health.
(f) Subsequent home treatment to prevent relapse in
the improvement or cure that has been obtained by the
surgeon.
{a) He-education of the patient's muscular sense as to an
(c)
(d)
improved position.
with
confirmed
Lateral Spinal Curvature, is so habituated to the crooked
position, that considerable patience and perseverance are
frequently required to convince him or her, that an erect
or improved posture is really such and not an exaggeration
The best way of commencing this reof the deformity.
education is for the patient to lie on the back in the
best possible position, and while thus to practise slow
breathing, the shoulders being kept well pressed back
voluntarily.
All the simple movements of the head
(neck), arms, and legs can be practised in this position.
hand looking-glass as well as an ordinary wall mirror
are useful, so that the patient may see and be convinced of
the improved position. This re-education of the muscular
sense for the improved or normal posture is to be kept in
mind throughout the whole treatment.
(b) Improved position to be maintained at all times,
while sitting or standing. This best possible posture is
always to be maintained while sitting, whatever the
at meals, at the
occupation of the moment may be
It is most
piano, while reading, writing, drawing, etc.
erect
or
patient,

by
31
with the sacrum, loins, dorsum,

and shoulders well supported against the back of the
chair, which should be moulded to the normal shape of
the spine, with a slight prominence to fill the hollow of
Almost any ordinary chair can be made to
the loins.
Of
answer the purpose, if a suitable cushion is used.
named
after
chair,
a
well-known
recent years a school
eye-surgeon who unfortunately knew little about Lateral
Curvature, has been much lauded, of Avhich the back only
this is injurious,
extends to below the shoulder-blades
because, even for any one with a strong, healthy back, it
is difficult to sit for any length of time in such a lowbacked chair how much more difficult for a weak-spined
readily obtained
sitting
individual
The
result
is,
that the school child ceases to
lean against such an uncomfortable arrangement, and sits

worse than before.
An upright, well-padded dining-
room chair often answers every requirement. In writing,

the patient's trunk usually requires to be more vertical
than for reading and it is essential that not only the
trunk, but also the arms should remain perfectly symmetrical.
A sloping desk is absolutely required and if
the ordinary sloping handwriting is insisted upon, the
paper should be placed obliquely upwards from left to
right, and exactly in front of the patient.
(See page 3
for further remarks about writing.)
The Glendenning
adjustable modern school desk and seat, manufactured by
the North of England School Furnishing Co., Darlington
(London agent Mr. Thomas Ison, 101, Hampstead Road,
N.W.), will be found most beneficial for patients of school
age, and even for many adults who have much writing
to do.
The advantage of this desk is that, while fbr
writing the slope is at 15 degrees, for reading the lower
portion of the writing-desk turns up, and gives a slope
of 40 degrees, which has been found by eye-surgeons to
be most restful for the eyes, which are by this device at
the same distance from the top and bottom lines of a
page of print (see figs. 1, 2, 3, 4, 14, and 15). Patients
who have severe backache, especially adults, find a couch
with a movable back, which can be fixed at various
;
'
THE TREATMENT OF
32
more
always he an
during reading, but there should

easel table, attached or not, to support the
angles,
restful
Fig. 15.
Fig.
14.
By the application of aB, the desk and seat may be

raised or lowered to any desired height.
Desk top slides horizontally.
Writing slope at 15, reading at 40.
Explanation.
key to
book
(see
fig.
16).
A and
For pianoforte
playing,
the
same
rules apply, the ordinary music-stool should be discarded,
and a high-backed chair employed, which will
also
come
Fig. 16.
which represents a good

North
In all cases, the
England School Furnishing Co.).
in useful for
meals (see
fig.
18,
music-stool with back, also manufactured by the

of

seat of the chair or
up
tilted
in
front,
33
couch should be horizontal, and not

as
frequently
is
seen
in
so-called
and the patient's feet should always be

I
supported, either by the ground or by a footstool.
couches
spinal
allow violin playing, provided the patient never stands, but

always sits symmetrically, with the back well supported
by a narrow longitudinal cushion which allows of the
complete freedom of movement of the right arm.
Fig.
Fig.
17.
18.
PRACTISING.
Position
Position on Glendenning'i
Patent Music Chair.
on ordinary musicstool.
When we
find a leading surgeon, not only advocating
shoulder-braces, but even inventing a
new
one,
still
more
than most of its predecessors, because of its

greater strength, from being manufactured of solid rubber
bandage,* one feels inclined to rub one's eyes and to
ask whether scientific orthopaedic surgery is really advancing, or whether we have gone back half a century or
more. John Shaw, that enlightened and able author of
a more rational treatment of Lateral Curvature, f criticised
injurious
shoulder-braces as follows
" The effect which this instrument
:
(shoulder-brace or
May 3rd, 1884 " On a New Form of Shoulder-brace

Treatment of Stooping Habits, Incipient Lateral Curvature, etc."
" Further Observations on the Lateral or Serpentine Curvature of the
JBeing a Supplement to the Work on Distortions of the Spine
Spine.
and Bones of the Chest." London 1825.
* See the Lancet,
for the
THE TEEATMENT OF
34
produces in ordinary cases may be

easily comprehended. ... If the shonlder-blades be brought
close to the spine by the straps of the brace and kept
constantly so, there can be no use for the several strong
muscles which pass from the spine to the shoulder-blades.
They must consequently waste and become nearly useless,
while those on the forepart of the chest, being excited
and
to resist the straps, will become increased in power
hence, when the brace is taken off, not only will the
shoulders fall forward, as in a delicate person, but the
muscles on the forepart of the chest will predominate
over those by which the shoulder-blades should be held
back, and pull the shoulders forward." This was written
upward of seventy years ago, and is so complete and
simple a refutation of any supposed efficacy of shoulderstraps for stooping habits, that I have little to add
I have observed in numerous instances where
to it.
shoulder-braces have been worn for several months or
longer, and where, from misplaced perseverance and
severity, they have been worn extra tightly, that the
unfortunate wearer has tried to obtain relief from the
excessive pressure of the straps over the coracoid process,
and adjacent clavicle on each side, by throwing the whole
trunk backward by undue arching of the loins, with the
result of producing severe lumbar lordosis in addition
to the dorsal cyphosis (stoop) for which the apparatus
was being worn. I am quite aware that dorsal cyphosis
'
common
back-collar
')
is
generally accompanied by compensatory lumbar lordosis,
but in these cases to which I refer, the lumbar hollow

is much severer than usual, and causes an exaggerated
thrusting forward and prominence of the abdomen.
Of
course, I am referring to the cyphosis of muscular debility,
and not that due to diseased bone (spinal caries). In spite
of these facts, many medical men of the present day, are
in the habit, not only of allowing, but even of advising
patients to wear these instruments. The only way in which
shoulder-straps might be worn with benefit not that I
ever
recommend them
anecdote, which
is
also
by the following
culled from good old John Shaw :
is Avell
illustrated

Aii
eminent surgeon was consulted
35
by a gentleman,
who became one of our first tragedians, as to the best

mode of correcting a stoop which he had acquired. The
surgeon told him that neither stays nor straps would
do him any essential good, and that the only method of
succeeding was to recollect to keep his shoulders braced
back by a voluntary effort. But the tragedian replied that
this he could not do, as his mind was otherwise occupied.
The surgeon then told him that he could give him no
further assistance.
Shortly after this
conversation,
the
ordered his tailor to make a coat of the finest

kerseymere, so as to fit him very tightly when his
Whenever his shoulders
shoulders were thrown back.
fell forward, he was reminded by a pinch under the
actor
arms that
his coat cost
him
made
six guineas,
and that
it
was
being thus forced, for

of very fragile materials
the sake of his fine coat, to keep his shoulders back,
He then showed
he soon cured himself of the stoop.
himself again to the surgeon, who ever afterwards, when
;
consulted whether young ladies should wear shoulderstraps, permitted them on condition that they were made
of fine muslin or valuable silk, for tearing which there
should be a forfeit
I am totally opposed therefore to all mechanical conthe patient in an improved
posture while writing, reading, etc., whether by means
rests, which
or rather forehead
of braces, stays, or head
trivances for trying to
fix
have been strongly advocated by several Continental

My results, Avhich are far more rapid and so
much more successful than those obtained by other methods
of treatment, are obtained by the re-education of the
patient's muscular sense for the improved or normal
posture, and by regulated muscular exercise, without the
employment of any mechanical restraint.
Short sight or any other deficiency of the eyes must
be corrected at once, by suitable spectacles, etc., as it
would be useless to urge a patient to hold himself erect,
who had always to poke the head forward for reading
last
surgeons.
or looking at anything.
THE TREATMENT OF
36
Standing at lessons or at other occupations should

always be avoided if possible when inevitable, the patient
ought to stand equally on both legs, with the heels three
Standing on one leg is most inor four inches apart.
jurious, as it at once throws the spine into a serpentine
position, increasing the Lateral Curvature.
Eor the same
reason sitting with the thighs {knees) crossed should never
be allowed, because this position of the legs causes a
tilting of the pelvis and an exaggeration of any lateral
curves present in the spine.
A considerable number of scoliotic patients will be
found to bite their nails this habit often retards rapid
improvement of the spinal curvature by causing the
patient to stoop.
This trick is most readily cured by
the wearing of gloves constantly day and night till the
nails have been allowed to grow to a respectable length.
A horse-hair mattress with a low pillow is all that
need be advised for the night, in addition to having the
window always open for a few inches at the top.
It is essential that no article
(6) Attention to dress.
of clothing should interfere with the resumption of an
improved or perfectly normal position of the patient's
spine and trunk.
This can be tested by making the
patient stand in the best possible position with the back
to the wall, and with the clothes opened in front, as
already described on page 27.
In girls up to puberty,
and even later, three articles of dress are generally
sufficient
viz., a pure wool combination next the skin,
thick for winter, thin for summer, a lined knickerbocker
or divided skirt with bodice attached, all of wool, and
an outer dress.
An extra- thick knickerbocker, with
gaiters meeting it at the knees, should be worn in
very cold weather.
It is a great mistake to employ
;
suspenders for the stockings in children where there is

the slightest tendency to round shoulders or Lateral
Curvature these suspenders are nearly always attached
to bodices or stays, which in their turn are prevented
:
from being dragged down by straps over the shoulders

it is these shoulder-straps which do the harm, not only
37
by dragging the shoulders down and forwards, but also

by compressing the anterior thorax. For this reason, as
long as the hips are not sufficiently developed to allow
of a suspender-belt being worn round the pelvis, it is
much more sensible to wear the old-fashioned knitted
woollen or silk garters, which are fixed by a few turns
round the leg, either above or below the knee, which
leave scarcely any mark on the skin, and do not in the
least interfere with the circulation of the lower extremities.
In women, there should be no red zone of
pressure on the skin of the thorax or abdomen, produced
by stays or injudiciously placed tight petticoat bands
the latter should be shaped and made to fit round the
j>elvis, so as not to compress the lower ribs above the
Stays with very little whalebone
hip-bones (iliac crests).
or
and with
steel,
vertical
slip
of
elastic
webbing
expanding transversely, inserted on each side, or the

Jaeger knitted stays (Feodora or Melita patterns), are
advised whenever the breasts are at all developed. Such
stays admit of the full expansion of the lower ribs, and
are worn, not with the object of supporting the spine,
but for steadying the mammae and keeping the outer
dress neat and without folds.
In scoliotic boys and men, braces should be left off at
and either a cricketing-belt worn or a special

arrangement made in the trousers, known as the " French
bearer," which is tightened or loosened as desired by a
both belts and
couple of straps on each side behind
trouser-straps should be just below and around the
hip-bones (iliac crests), and not above them.
In both sexes broad, properly-shaped, and low-heeled
boots and shoes should be worn, preferably the latter, to
allow of the fullest freedom to the movements of the
once,
ankle-joint.
Systematic training of the spinal and other muscles,

including the development of the thorax. At first, attention is to be directed to correcting the antero-posterior
when these are improved, then
curves of the spine
(d)
only
is
it
possible
to
carry out
special
exercises
for
;;;
THE TREATMENT OF
38
further correcting the lateral curves, which undoubtedly

improve while the anteroposterior curves (stooping) are
The following is a prescription

mainly being treated.
of twelve exercises with which I commence the treatment of cases of Lateral Curvature of the Spine
arms by the sides of the body
1. Lying on back
palms upwards
slow, deep inspiration by the nose
slow expiration by the mouth (repeated four times).
exercise with the arms extended upwards
2. Similar
by the sides of the head (repeated four times).
head (neck) rotation on axis
3. Same position as 1
to right and left alternately
also lateral flexion of
head (neck) to right and left alternately (repeated four
:
times)
Lying on back simultaneous circumduction of both

shoulder- joints from before backwards elbows and wrists
kept extended (repeated twenty times).
one hip circumduction from within
5. Lying on back
out, and from without in
knee kept extended (repeated
4.
ten times).
Lying on back
simultaneous quick extension of
arms upwards, outwards, and downwards, from a
position with the elbows flexed and close to the trunk
6.
the
flexion of the elbows being slowly executed (repeated six times).

one hip circumduction from within
7. Lying forwards
out, and from without in; the knee kept extended (repeated ten times).
45
8. Sitting on couch, with back at an angle of
ankle circumduction down, in, up, and out, while the
(repeated
toes are directed inwards
the whole time
Also foot abduction, patient resisting;
twenty times).
and foot adduction, surgeon resisting (repeated eight
the
times) (for flat-foot and

9.
weak
ankles).
Patient astride a narrow table or chair without back,
with arms down and hands supinated
lumbar
vertebra;,
taining
the
best
patient resisting
possible
posture,
extension, surgeon resisting by his
trunk flexion at
mainfollowed by trunk
;
slightly while
hand
still
against the

back of patient's head or neck
also trunk
39
on
while the
surgeon gently resists by grasping the patient's shoulders
its
alternately
axis
to
the
right
and
rotation
left,
(repeated three times).
with arms extended upwards, stands with

and heels against a vertical post with pegs
on each side, which he grasps, The surgeon gently pulls
the patient's pelvis forwards by his hands on the sacrum,
and then the patient moves back the
patient resisting
pelvis to the post, surgeon resisting.
At no time are
the patient's heels to be raised from the ground. Also
pelvis rotation on its axis to right and left alternately,
surgeon resisting with his hands on each side of pelvis
10. Patient,
back,
head,

11.
Lying on back, with arms extended upwards by
the sides of the head
flexion of both arms, surgeon re-
sisting
by grasping the hands, followed by extension,
patient
resisting
(repeated
three times).
(The patient's
knees, flexed over the end of the table, fix his trunk.)
Lying on back, with head and neck projecting beyond the end of the table arms by the side of the body,
palms up
the head is slowly flexed by the surgeon's
hand on the occiput, patient resisting, followed by head
12.
extension, surgeon resisting (repeated three times).
With women and
children the last four exercises are
out by the surgeon, while trained

do the remaining eight under his
supervision.
Boys above fifteen years, and men patients,
are treated alone, and the surgeon goes through the
whole prescription with them. The patient should rest
for a minute or two between each exercise, except the
first three, on a couch with movable back fixed at an
angle of 15 (see fig. 16), or an ordinary chair properly
arranged.
It is important, while practising this prescription of exercises, that respiration should not be
interfered with by involuntary fixation of the chestwalls.
The patient should therefore always count aloud
(e.g., 1 to 5 or 10)
during the execution of all the
exercises, except those of breathing.
Six to twelve, firm
personally
female
carried
assistants
THE TREATMENT OF
40
" strokings "
from
above down, of the

patient's back, by the assistant's palms, at the end of
the sitting, generally remove any aching caused by the
These strokings are also usefully employed
exercises.
The exercises should be
at home so relieve backache.
done slowly, and great care taken that the head and
trunk remain the whole time in the best position. This
prescription requires above three-quarters of an hour to
go through, and should be followed, if the patient is at
all tired, by a short rest in a good position, with the
back supported.
longitudinal
The
prescription
repeated daily
and, as the patient

more power and begins to assume the
gradually gains
is
improved position more readily, and with less exertion,

In a
other and severer exercises are gradually added.
day or two, if the patient is not over-fatigued, the
following standing exercise is done
The patient, with
the feet slightly apart and the backs of the heels fixed
against a ledge or wall, rests with the front of the thighs
just above the knees against a low padded horizontal
bar, or the padded seat of a chair which is fixed, while
:
the surgeon then

holding himself as erect as possible
slowly flexes the patient's trunk by pressing his hand
against the back of his head, patient gently resisting
and then the patient slowly recovers the vertical position
against the surgeon's resistance
also trunk rotation on
axis alternately to the right and left, while the
its
surgeon gently resists by grasping the patient's shoulders
;
(repeated
three
times).
This
being,
in
fact,
exercise
No. 9 described above, in a standing instead of a sitting

This exercise is shortly described as " Thigh
posture.
opposite standing, trunk flexion, patient resisting, and
also trunk hoisting,
trunk extension, surgeon resisting
;
surgeon resisting."
Usually at the end of a fortnight, a severer exercise
can be tried, known as " Forwards lying, heels fixed,
trunk extension and flexion ; also trunk twisting," carried

out as follows
The patient lies prone, with the pelvis
and legs supported and the heels fixed (the latter by
:
41
on them, or by means of a broad buckled

padded
table, while the head and trunk to the
strajD) on a
level of the hip-bones (iliac crests) project beyond the
The patient slowly raises the trnnk
edge of the table.
into the same horizontal position as the legs and pelvis,
and slightly higher, and then as slowly allows the trnnk
The surgeon
to be again flexed by its own weight.
easily increases the severity of the exercise in a few days,
by more or less pressure according to the strength of the
jiatient, with one hand at the back of the patient's head.
some one
sitting
After repeating this movement three times, the patient

slowly rotates the trunk on its axis, while the surgeon
gently resists by grasping the patient's shoulders
this
also is repeated three times.
On first practising this
exercise, the arms are kept down close to the outer
aspect of the thighs with the palms directed towards
the ground
after a day or two, both arms are directed
upwards by the sides of the head, grasping a stick
or a roll of }3aper.
Another severer exercise which can
also be practised now is shortly described as " Long
sitting, feet fixed,
trunk extension and flexion ; also
trunk twisting"
Here the patient sits on a padded
table, with the legs together and the knees extended
an assistant sits on the legs below the knees, or a strap
is used over the ankles to fix them
the patient, while
maintaining the best possible posture, slowly extends
the spine against the surgeon's resistance (applied by
his hand against the back of the patient's head or between the shoulder-blades) till the trunk is in the same
horizontal plane as the legs
the patient then slowly
and gently resists, while the surgeon raises him into a
vertical j^sition of the trunk
this is repeated three
times.
Next the patient, while sitting in the best possible
posture, slowly rotates the trunk on its axis to the right
and left alternately, while the surgeon gently resists by
grasping the patient's shoulders
this also is repeated
;
three times.
At
this stage of the treatment, a
commencement
is
in increasing the severity of the hip circumductions
made
(see
THE TREATMENT OF
42
Exercises, Nos. 5 and 7), by applying half-pound to onepound shot-bags to the ankles, which weights are gradually
increased
up
to three, four, or five pounds, according to the
by the end of the three months' course of

Youths and men usually work up to tendaily treatment
pound shot-hags during this same period. At the end of
patient's age,
the
first
month's treatment (twenty-four
visits),
the antero-
posterior curves of the spine have in most cases become

sufficiently improved to allow of the " keynote " position
arms being employed (see page 26). A fresh examination of the patient's back is therefore made, and
In most
the best position of the arms decided upon.
of the
Lateral Curvature, this " keycases of ordinary reversed

"
position will be one with the right arm directed
note
vertically
arm
upwards by the
side of the head,
and the
left
outwards or grasping
especially those with
severe osseous deformity of the ribs and vertebrae, the
the
best
either
right
directed
wrist
obtainable
in
horizontally
other
posture
cases,
(" keynote "
position)
often
is
one with the elbows firmly clasped above the head.

Female patients usually continue the daily repetition
of these exercises during the menses, except that the hip
circumductions are omitted for the first two or three days,
as these movements tend to increase the menstrual flow.
Where monorrhagia or dysmenorrhea is present, it is
sometimes necessary to leave off the exercises altogether
for a day or two.
As a general rule, it is better to
accustom the patient to practise most of the exercises
all through the period of menstruation.
While on the
subject, it may be stated that flexions of the uterus are
no hindrance to the treatment, as none of the exercises
described are violent or jerky in their execution
and
from the fact that respiration is never alloAved to be
impeded, by the previously mentioned simple device of
;
making the patient constantly count aloud, any overcan always be prevented with ordinary care.
have often, with the permission of the gynaecologist,
given a patient the usual three months' course of daily
treatment, with the usual beneficial result both to the spine
exertion
I
43
and the general health, even while a pessary was beingworn. For the same reasons viz., the absence of violent
and jerky movements and the counting aloud ordinary
heart disease, which is now so successfully treated by the
Nauheim Method, is no bar whatever to the treatment I
employ for Lateral Curvature indeed the heart trouble is-
alleviated
in
almost eAêry case when complicating the
spinal curvature.
Duration of the treatment under the personal daily

In cases of " non-osseous '
supervision of the surgeon.
"
"
Lateral Curvature, one or two months'
or
postural
daily perseverance in the treatment (twenty-four or forty-
eight visits) will effect a cure of the deformity ; while in

with " osseous " or " incurable " deformity, three
cases
months' daily treatment,
will,
in
the
majority of
vast
cases, effect all the improvement that is possible

viz.;
a strong and straighter back, with arrest of further increase of the deformity of the ribs and vertebrae
this
;
is
what
describe
severe cases,
as
"a
practical
esrjecially those associated
require as long a treatment as
six
Some very
cure."
with
months
much
pain,,
but this
is
very exceptional, as will be shown later on. The great

advantage of this treatment of Lateral Curvature, over
that by spinal supports and lying down for many hours
daily, is that it always tends to improve the general
health of the patient, notably in delicate, anaemic, and
badly nourished boys and girls, at the onset of puberty.
Care should be taken
(e) Attention to general health.
to improve the general health in every possible way.
I invariably make it a rule to have patients weighed
before commencing treatment, taking care to have the
clothes worn at the time of weighing, weighed the same
night at home, so as to obtain the net weight.
It is
remarkable what a larsê increase of weight occurs during
the usual three months' course of treatment.
Ar ery
frequently patients gain in weight at the rate of half
a pound to a pound or more every week, and it is not
at all uncommon for twelve or fourteen pounds, gain of
weight to be obtained by the end of the three months'
THE TREATMENT OF
44
If the appetite is poor, a good basin of bread and-milk, or oatmeal porridge with milk or cream, should
be ordered for breakfast, and patients made to persevere
in taking a good breakfast, even if they complain of
nausea or discomfort at first. After a few weeks, patients
begin to enjoy their food as the result of the muscular
development and the increased capacity of their lungs.
This especially applies to young ladies who have been
in the habit of taking only half a slice of dry toast and
a cup of tea, or something equally absurd, for breakfast.
course.
Pain or Backache (see also page 20). Patients with

constant wearying backache, generally in the loin muscles,
when
prevents or interferes with

simple water compress
applied as follows
A soft towel or handkerchief, folded
into an oblong about eight inches by six, is dipped into
warm water, squeezed moderately dry, and placed over
the painful spot. This is kept in position by a thicker
dry towel folded longitudinally, which should be sufficiently wide to overlap the wet compress by at least an
inch above and below, and fastened in front of the thorax
especially at
sleep,
are
night,
much
it
by a
relieved
no oil-silk should be
by tapes or safety-pins
Some patients prefer the compress applied cold
used.
but
this matters little, as it soon assumes the temperature of
the body. If properly arranged, the wet compress ought
to be quite dry by morning, when applied overnight.
When the pain is distinctly localised, as below one
shoulder-blade, or over one or several vertebral spinous
processes, and is neuralgic in character, I have found
the employment of an acupuncture instrument, such as
Dr. Brindley James's, frequently useful in effecting an
immediate, and sometimes a permanent cure of the
neuralgia.
A daily morning bath, with cold or tepid
water, if the patient's powers of reaction are low, should
if a
always be insisted upon as a good general tonic
biscuit and a piece of chocolate are eaten in bed before
Singing,
getting up, a good reaction is generally assured.
by helping to develop the thorax, is always beneficial.
At least one and a half to two hours' daily outdoor
;

exercise should
45
be prescribed
running, and joining in
games, especially lawn-tennis in summer, and hockey and
lacrosse in winter, are very beneficial after the commencement of treatment of course, in moderation at
first
any fatigue which ensues is really helpful, if it is
overcome by resting for a quarter or half an hour
only that amount of walking or exercise
afterwards
which induces fatigue or pain, lasting hours, does harm.
In such cases, the walk, etc., must be curtailed.
Bicycling is one of the most useful of outdoor exercises,
;
and is far more suitable for scoliotic girls and women

than the present fashion of riding on horseback on one
side
I generally prescribe bicycling by the end of the
first month's treatment, when the patient has generally
been trained to hold himself or herself more erect and
with much less effort.
If horse exercise is strongly
desired for lady patients, it can only be allowed at the
end of the three months' course of treatment, and then
only provided the young lady rides alternate days on
the " near " and " off " sides, so that both sides of
the trunk are equally exercised.
Boys and men may
always be allowed to ride at the end of the first
month's treatment, as the stride position is perfectly
:
symmetrical.
{/) Subsequent
home treatment
to
prevent relapse in
improvement or cure that has been obtained by the

surgeon.
To keep up the improvement and to prevent
relapse in a cured case, it is important to continue to
enlist the patient's co-operation and interest in his or
her own case, on ceasing the personal treatment of the
surgeon
and for many years I have been in the habit
of giving patients, on leaving, a written home prescription
of movements, of which the following is an average
example
Home Prescription. Half an hour twice daily for six
months, then once daily for another six months.
1. Lying
on back, arms directed upwards by the
the
side
of
the
expiration
head,
full
slow
by the nose
same with arms down
inspiration
by the mouth
also
..
46
THE TREATMENT OF
by
sides
of
the trunk,
palms upwards
(repeated
three
times)
with the arms directed

head and holding a stick
(or other position of the arms constituting the " keynote " position), trunk lumbar flexion and extension;
also trunk rotation on its axis to the right and to the
left
also the same trunk movement with the arms
down by the sides of the trunk, palms forwards (reSitting
2.
astride
upwards by the
chair,
of the
sides
peated three times).

3. Lying
on back, arms down by the sides of the
trunk, palms upwards head rotation on axis to the right
and to the left also head lateral flexion to the right
and to the left (repeated four times).
4. Lying prone on the ground
heels fixed by some
one holding or sitting on them, or by means of a
strajo fixed on the ground
arms as in 2 trunk-raising
(extension) and trunk-lowering (flexion)
also trunk
rotation on its axis to the right and left (repeated three
times)
5. Lying
on back, with arms by the sides of the
trunk, palms upwards, one hip circumduction from
within out and from without in; the knee kept extended the whole time (a shot-bag, weighing five to
ten pounds for children and women, and ten to twenty
pounds for youths and men, is attached to the foot
to increase the severity of the exercise).
(Repeated ten
;
times.)
Lying on back; slow simultaneous circumduction

elbows
both shoulder- joints from before backwards
and wrists extended the whole time (repeated twenty
6.
of
times).
Lying prone on the ground, Avith heels fixed as in

trunk kept raised from the ground (extended)
4
simultaneous extension of the arms upwards, outwards,
and downwards, from a position of elbows flexed and
close to the trunk (repeated four times).
with back against door, feet together,
8. Standing
arms directed upwards, and hands grasping two - pegs
7.

fixed into the lintel above the door
pelvis
47
rotation on
and to the left (repeated

same exercise hanging with the
feet raised off the ground and the sacrum kept touching
the door
The " orthopedic
hanging-peg.," of which fig. 19 is a sketch, is manufactured by Mr. Ison, of 101, Hampstead Road, London,
N.W., and Mr. Stevens, of 83, Waldegrave Road, Brighton.
It is easily fixed by four screws into the lintel of any
and if this is too high for the patient, a block of
door
vertical
axis
twelve times)
the
to
right
also the
Fig. 19.
wood
or a hassock under the feet brings the pegs within
reach.
9. Lying prone, the forehead supported on the hands,
placed one above the other; one hip circumduction from
within out and from without in the knee kept extended
the whole time (a shot-bag, weighing five to ten pounds
;
for
women, and ten
children and
youths and men,
to
twenty pounds for
attached to the foot to increase the

severity of the exercise).
(Repeated ten times.)
10. "Walking forwards and backwards, with the arms
directed upwards by the sides of the head and holding
a stick (or other position of the arms, constituting the
is
keynote position) also with the arms directed downwards

with the palms forwards. (One hundred steps in each
;
position.)
This home prescription is practised usually, as stated

above, for half an hour twice a day for six months, and
then once daily for another six months. At the end of
the twelve months my rule is to examine the patient
and
if the improvement or cure previously effected shows

no relapse, I usually prescribe a much-abbreviated home
prescription for five minutes daily for the next two years.
THE TREATMENT OF
48
The second home prescription consists of the three exercises

Nos. 4, 8, and 7, of the old or first home prescription,
practised in this order every morning immediately before
or after breakfast.
to
In
all cases it is
persevere in the maintenance
some years.
The Treatment of
of
As
absolutely necessary
good
positions
upwards
for
50 per
Spine are
associated with flat-foot (see page 21), it will be convenient to describe here the treatment I employ for the
In the treatment of flat-foot we have to
foot trouble.
aim at the restoration and maintenance of the previously
depressed plantar arch, and the strengthening of the leg
muscles which tend to produce and preserve the normal
arch of the foot. We have therefore to discuss: (a)
mechanical means for replacing and maintaining the
plantar arch, and (b) therapeutic methods for strengthening the weak tibial muscles.
(a) Mechanical means for replacing and maintaining
The boot or shoe should be broad
the plantar arch.
enough across the metatarso-phalangeal articulations, and,
if
made to order, a tracing should be taken of the
stockinged foot. When the toes are much deformed or
displaced, the stocking should be digitated and the toes
well spread out on the ground while the tracing is made.
The so-called anatomically shaped foot-gear is only to
be worn that is, besides being rights and lefts, the shape
of the sole should be such, that a line drawn through the
axis of the heel from behind forwards, should, if prolonged, pass over the place occupied by the little toe.
The heel of the boot should be low and broad, not more
than double the thickness of the sole in front. Formerly
I employed, for raising the depressed arch, a pad made
of superimposed layers of felt; and this, combined with
treatment for improving the muscular power, often had
good results every now and then, however, a case proved
very obstinate. I have discarded pads altogether for the
last thirteen years, except in very rare instances, and I
no longer advise laced-up boots being worn indeed, the
cent,
of
cases
of
Flat-foot.
the
of
49
more freedom left to the movements of the ankle, the

better, and I therefore recommend shoes.
This has been
recognised of late years by all experienced cyclists, who
invariably prefer shoes to boots for cycling.
Instead of
a pad, which, if efficient, tends to bruise and irritate

the already tender instep, I employ an increased thickening of the sole opposite the ball of the great toe, and on
the inner margin of the heel, a modification of the method
of my friend, the late Mr. H. O. Thomas, of Liverpool.
His theory of the mechanical production of flat-foot
appears to me to be the most rational it is that, in the
normally constructed foot, the lower end of the tibia is
placed too much toward the inner border of the foot>
so that the tendency of the tarsal arch is to give way
under the pressure of the Aveight of the body, and this
has to be constantly combated by the effort of the strong
If we had to create
leg muscles inserted into the foot.
a new foot and leg, simply with the view of preventing
flat-foot, Ave should plant the lower end of the tibia rather
more toward the outer margin of the foot. The device
of the wedge-shaped sole, with the base inside, and the
apex outside, tilts or rotates the foot on its longitudinal
or antero-posterior axis, and carries the lower end of the
tibia toward the outer margin of the foot, and thus removes all or most of the pressure of the weight of the
body, as transmitted through the lower end of the tibia
from over the tarsal arch, in the same way as in the
;
The increased
imaginary newly created foot and leg.
thickness of sole is from one-fourth to one-half inch,
according to the age of the patient and the severity of
an addition of a corresponding one-fourth or
the case
one-half inch is added to the inner margin of the heel,
and this thickness gradually diminishes to nothing at
the outer margin, Avhich should be protected by a thin
plate of iron or steel studs, to prevent further differences
The
of level of the two halves of the heel from wear.
same remarks apply to the increased thickness of the
sole, Avhich gradually tapers to nothing at the tip, as
This wedge sole can be
well as at its outer margin.
;
THE TREATMENT OF
50
applied to boots and shoes already being worn.

that the benefit frequently obtained
the depressed instep,
is
I believe
by valgus pads under
really due to the
patient being
forced to walk on the outer border of the foot, to avoid
the discomfort and annoyance of the pad pressing against

the tarsal arch.
Boots made, and so much advertised,
with movable or spring-like waists, are useless, and even

injurious, if the spring is prolonged to the outer margin
of the sole, where the foot ought to rest entirely on the
ground. As the chief movement of the foot in walking
is at the metatarso-phalangeal articulations, it would be
an advantage if this portion of the sole could be made
of a more yielding leather.
Where the displaced arch cannot be restored except
by brisement force, and where the discomfort of the
patient is severe, I would recommend this being effected
by Thomas's club-foot wrench, under anaesthetics, and
the foot kept in a suitable splint in the improved position
till all symptoms of the traumatism have disappeared.
(b) Therapeutical methods for strengthening the weak
tibial muscles which support the plantar arch.
I know
on
the
toes
with
the
better
exercise
than
walking
of no
heels raised an inch or so, taking care that they are not
raised too much; for when the longitudinal, or long axis
of the foot behind the metatarso-phalangeal articulations,
is
raised too vertically, there
is less
work
for the muscles,
as much of the weight of the body is transmitted through

the bones of the tarsus and metatarsus, standing on end.
It is a good plan to order the patient to walk fifty steps
on the toes before and after each meal, at first, and then
always to walk with the heels raised when indoors,

the wedged-soled shoes are not worn.
if
employ for flat-foot are the follow"

Sitting, foot inward circumduction, repeated
ing
(1)
forty times" The patient, sitting on the floor or couch,
with the back supported and the knee extended, circum-
The
:
chief exercises I
ducts the foot down, in, up, and out, while the toes are
directed inward the whole time the knee and hip should
The leg should rest on a small
be kept perfectly still.
;
51
pad just above the tendo Achilles, to leave the foot free
or on the knee of the surgeon, who sits opposite, and to one
side of the patient.
(2) " Sitting, foot adduction (surgeon
resisting) and abduction (patient resisting), repeated twenty
The patient
placed in the same position as

before
the surgeon fixes the leg just above the ankle
with one hand, while the palm of the other exerts a
gradually yielding resistance to the patient's effort to
adduct and invert the foot.
On the completion of the
adduction, the patient strives to maintain this position
of the foot while gradually yielding to the pressure of
the surgeon's hand gently pushing the foot back to the
commencing position. (3) " Standing, toes in, heels out,
raising and lowering heels, repeated forty times."
The
patient stands with or without shoes, with the great toes
touching, and the heels separated, so that the feet are at
an angle of about 30 degrees (i.e., rotation inwards of
times."
is
the legs from the hips)

he has then to alternately raise
and lower the heels, while forcing the ankles outwards
as much as possible the whole time.
(4) " Walking on
;
the outside edges of the feet ivith the soles directed inwards," requires no explanation. Patients with flat feet
frequently assume this last position instinctively, to give
relief to the overstrained ligaments, and this should be
encouraged.
In cases of extreme muscular weakness, massage of
the leg muscles for half an hour, once or twice daily,
should be employed.
For the technique I can refer
those interested to my article, " Massage," in Heath's
" Dictionary of Practical Surgery." Such severe treatment as the removal of a wedge-shaped jriece of bone
from the tarsal arch, does not appear justifiable and I
can only repeat, what I stated in the first edition of this
book, that I have not yet seen a case which offered
reasonable probability of this treatment being of permanent benefit to the mutilated patient the effects of
the treatment I advocate for flat-foot begin to be felt
within a week or two by the patient, and I seldom see
cases where all pain and discomfort have not disappeared
;
THE TREATMENT OE
52
within one month's daily treatment, some even within a

few days.
For the cure of the deformity, even slight
cases require several months' home treatment after ceasing
the surgeon's personal treatment and for severe cases, I
generally find a year or more of perseverance with the
:
wedged soles and home prescription, is necessary.

I
append a typical case, illustrating the treatment above
described.
wife of an M.P., consulted me July 7th,

Two years ago she
with the following history
began to have discomfort in the feet after walking
" a feeling as if the ankles were too soft."
The discomfort increased for six months, when she became a
vegetarian and for a time the pain in the feet was less.
Since then the pain has become gradually worse up to
the present.
The patient is an active, extremely inshe can only
tellectual woman, fairly well nourished
walk up and down stairs or a few yards out of doors,
I found both
and that with considerable discomfort.
feet severely flat (see page 23), with the pain and aching
just under the arch of the instep, and described as " a
dull, aching soreness " which " becomes acute pain at
times "
standing still causes even more pain than
walking.
On August 25th viz., six weeks later the
patient wrote
"I am following your prescription as far
as I can, and feel much better." Again on November 18th,
Mrs.
1884,
four months later, " I
am
a great deal better.
When
was trying to school my impatience

to resignation to a walk of not more than a hundred
yards at a time
now I can walk two miles without
much fatigue, and I am astonished at the elasticity and
I consider myself a
youthfulness of my movements.
walking advertisement of your surgical capacity " This
lady has continued well up to the present time, upAvards
I
was
in
London,
of fourteen years.
Duration of the author's treatment of Lateral Curvature

by "Posture
ment
and 'Exercise"
The
usual course of treat-
in an average case consisted of three months' daily
treatment
that
is,
72
visits.
In Table VII., I give the
53
number of visits, each of the 1000 cases in the Appendix

made while under my personal treatment.
TABLE
VII.
NUMBER OF TIMES PATIENTS ATTENDED UNDER THE AUTHOR'S TREATMENT.

634 patients attended 72 daily visits.
24 to 32 daily visits.
129
48 68
104
49
32
21
,.
12 weekly visits.
116 to 216 daily
17
81 96
36 43
i-i
visits.
6
18
36 alternate day visits

6 weekly visits.
1000
It will be seen that 634 patients attended the full

In early
course of 72 visits (three months' treatment).
i.e., incurable
deformity,
cases, with little or no osseous
one to two months' daily treatment (24 to 48 daily visits)

has sufficed, and this accounts for 265 other patients.
Adult male patients have usually been treated on 36
alternate days (6 cases) or by weekly visits (22 cases).
The remaining 73 cases, with 6 to 18 daily visits, and
with 81 to 216 daily visits, have been exceptional patients,
with whom the treatment has been either interrupted
too soon, or from intercurrent illness unduly prolonged
or repeated.
Result of the author's treatment of Lateral Curvature

by " Posture and Exercise. "Some surgeons have tried
to explain the success I claim, by maintaining that I
only undertake slight cases of Lateral Curvature with
any prospect of permanent benefit but this is, I consider, completely refuted by a reference to the Tables I.
deto VI., giving the amount of osseous
i.e., incurable
formity present in the 1000 cases of the Appendix. A
further proof, if any were necessary, is given in the
following Table, VIII., which gives the previous treatment
;
202 cases of the Appendix, which were undoubted

failures while under the treatment of other surgeons,
or they would not have come under my care.
of
THE TREATMENT OF
54
TABLE
VIII.
PREVIOUS TREATMENT BEFORE COMING UNDER THE AUTHOR'S CARE.

Time not given
35 patients.
For
16
,)
year previously
2 years
,,
!>
)!
10
,,
Treated by spinal
steel supports.
!>
17
,.10
.,11
20
25
104
Treated by spinal supports of different kinds.
Time not given

For 1 year previously
20
1
,,
2 years
4
1
several years
Treated by spinal felt (poro-plastic) supports.
8 years
11
.,
12
16
20
24
40
.,
_1
48
Time not given

For 1 year previously
2 years
,,
.,
29
7
4
1
44
Treated by spinal plaster-of-paris supports.
Time not given
For 2 years previously
4_
6
* Including steel, felt (poro-plastic), plaster of paris (Sayre's jackets), etc.
I have omitted from Table VIII. previous treatment

by ordinary or Swedish gymnastics, suspension by the head,
massage or rubbing, Barwell's bandages, and the innumerable varieties of shoulder-straps and braces, because nearly
every patient had undergone one or other of these
55
equally useless forms of treatment, before

coming under my care. There are in Table VIII., 202
cases which had worn some sort of spinal support
of
these 104 had been treated by steel spinal supports of
every conceivable shape and design, for a varying number
of years
thus 16 patients had one year's previous treatment, 17 patients two years', and so on till we come
to 5 cases which had been treated for six years, 2 cases
for seven years, 1 cases for eight years, 2 cases for ten
but
simple,
and
years,
five
twenty, and twentyOnly 44 patients had been
lastly 1 case for eleven,
years
respectively.
treated by felt (poro-plastic) spinal supports for varying

periods up to four years, and 6 patients by plaster-of-
parls (Say re's)

to three years.
treated
spinal
supports for varying
up
some 48 patients had been each
Finally,
by two or more
periods
different kinds of spinal supports,
which include patients who have
been
treated
during
respectively nine, eleven, twelve, sixteen, twenty, twentyfour,
and, most astonishing of
all,
forty years (see case
No. 261, page 74). In all these patients the spinal supbeen completely discarded from the first day
of my treatment, and with the most satisfactory results.
The next Table, IX., gives the result of the author's
treatment in the 1000 cases given in the Appendix.
port has
TABLE
IX.
RESULT OF AUTHOE'S TREATMENT BY

,
"
POSTURE AND EXERCISE."
/869 patients were much improved

improved
had relapsed
"elapsed
were not improved
I 75
r f
47
.,
1000
Of
the
"much improved" and "improved"
'12 patients were keeping well 6
92
5"
'46
)>
S)
2 years
..
46
;,
207.
326
,.
.,
10
patients
months afterwards
year
THE TREATMENT OF
56
As
am
convinced
that
vertebrae, even the slightest,
deformity
osseous
of
the
to that extent incurable,

" cured " as the result of
is
have not ventured to put

treatment in any case, although some surgeons
would have placed " cured " instead of "much improved"
By " much improved"
in most of the cases so described.
I mean the best possible result that I was able to prognosticate when first consulted about the patient namely,
a strong and much straighter spine where the " most improved posture " of the consultation, has become the
" habitual " one, with disappearance of the backache if
previously present, with improvement in the general health
where this has been failing, and, finally, with arrest of
I
my
further increase of the osseous
i.e.,
incurable
deformity
and vertebra?. Of course, the most complete

the Appendix, are those which have been seen
by me, or have reported themselves to me, after one or
more years. Unfortunately, like other medical men, I
of the ribs
cases
in
often find
strong,
that
when
patients
become well
have
and
spend a
they or their friends are unwilling to
further fee for having their cure
confirmed.
By
".im-
proved," I distinguish those cases where arrest of further

increase of the osseous deformity has been effected, but
where pain has still persisted more or less, or where patients
have not held themselves as erect as they were expected
to do.
From Table IX., we see that 869 patients (869
per cent.) were practically cured i.e., much improved
75 patients (7*5 per cent.) were improved, and 56 patients
(5*6 per cent.) were more or less failures.
Of the latter
47 (4* 7 per cent.) were apparently successful at first,
but then relapsed, and 9 patients (0 9 per cent.) were
not improved from the first commencement of the treatment. Most of the failures have been due to want of
intelligence,
want
of
perseverance,
or
want
of
amour-
propre or vanity in the several patients.

The most successful cases I have to deal with viz.,
those who put the greatest energy into their treatment
are often children from 8 to 12 years, young men
who have run some risk of being rejected as physically

unfit
at
the competitive examinations for
army
57
officers,
women engaged to be married. Patients

who have suffered much from many physicians, I
mean those who have worn spinal supports previously to
and
young
my
coming under
well,
care,
have almost invariably done very
they appreciated
because
recently
their
obtained
326 of the 944

from mechanical restraint.
"much improved" and "improved" patients were found
to be keeping well, mostly by examination, within ten years
of the course of treatment being completed under my
personal care 207 patients having been examined during
the first three years only, as I do not usually examine
after that period except for some special reason.
429
patients (42'9 per cent.) were sent direct to me by 202
medical men, to whom I desire to convey my thanks.
The following cases are illustrative of the Treatment
by Posture and Exercise
Case I. Miss W., cet. eighteen years, a student at one
of the London academies of music, was brought to me
on March 4th, 1882, with the following history
Three paternal aunts had spinal curvature, one much
deformed the patient is one of sixteen children, of whom
ten are living. Two younger sisters, aged sixteen and
fourteen years respectively, stoop considerably, but have
no Lateral Curvature. Up to fourteen years old (four
years ago) the patient was strong and never complained
of her back.
She then began to stoop and have backache, especially after long walks
the pain in the back
Avould last till she went to bed.
There was no illness
or rapid growth to account for this weakness of the spine.
The backache gradually became worse and three years
ago the patient was examined by one of the surgeons of
the Sussex County Hospital, who said the spine was not
straight, and she was ordered to lie down for two hours
daily.
At the end of another year, the same surgeon
found the curvature decidedly worse, so an ordinary
steel spinal support, with pelvic band and shouldercrutches, was applied.
This instrument has been worn
for two years up to a month ago, the mother assuring
freedom

THE TREATMENT OF
58
me
daughter had become worse both in her

On examinafigure and the backache during that time.
viz., the whole
tion, I found ordinary letter C scoliosis
spine convex to the left, the right shoulder-blade being
more than two inches below the level of the left one;
also moderately severe " gorilla " type of the anteroThere was a trace of osseous
posterior spinal curves.
incurable deformity of the left ribs posteriorly,
i.e.,
and moderate osseous i.e., incurable deformity of the
lumbar vertebrae, indicated by the greater prominence of
the left erector spinse muscle, when the trunk was
flexed.
Although the patient looked so deformed, she
could be placed in an almost normal position, and
maintain that position by a great voluntary effort for
Her feet and knees Avere normal.
a few seconds.
Sitting for half an hour any time of the day would
bring on severe backache.
I was interested to hear
that whenever she wished to sing extra well, she left
off the spinal support for the occasion.
Her dress and
stays were much too tight round the thorax, so that
scarcely any respiratory movement took place in the
lower half of the thorax. I gave her directions about
position, and a few simple exercises for developing the
thorax, and ordered the spinal support to be given up.
Nine months later viz., on December 18th, 1882 I saw
the patient for the second time.
Both she and her
mother considered there was some improvement, notwithstanding severe backache for the last fortnight. Her
professor of singing has complained of her want of
"breath." On examining the spine, I found it in the
same state as when I saw her the previous and first
time.
Two days later December 20th six photographs
were taken, which speak for themselves (see photographs
in Frontispiece, 1 to 6).
Photographs 1, 2, and 3, are
that her
the
three views, posterior,
lateral,
and
anterior,
of the
and photographs 4, 5,
her habitual position
and 6, are the corresponding three views of the patient
in the best possible position in which I could place her.
In all six photographs she was standing without boots,
patient
in
59
with the feet close together and the knees fully extended,
while the pelvis was placed symmetrically in relation to
the feet. These photographs were almost instantaneous ;
yet it cost her considerable effort and backache to maintain the improved position in which I placed her for
the few seconds necessary. My prognosis was that the
patient could he so strengthened by three months' daily
treatment, that this temporary improved position, involving such great effort when the photographs were
taken, would become a permanent one without any effort
at the same time that all pain would disappear, and
further increase of the osseous deformity would be
arrested that is, a "practical" cure.
On December 23rd
the patient began daily treatment, visiting my house
for three-quarters to one hour daily.
The following are
extracts from my Case-book
" January 15th, 1883.
Seventeenth visit for treatment.
Yesterday and the day before she was without backache
the whole day. This is the first time for more than two
years that there has been a day altogether without backThe patient's professor of singing saw her to-day,
ache.
and, without anything being said to him, at once observed
the marked improvement in her figure, and, on trying her
voice, found there was an increased power of " breathing."
" January 16th.
The patient tells me the dressmaker
has had to let out her dress more than five inches across
the chest.
Her
appetite
is
much
better,
especially
at
breakfast.
" February 23rd. The patient has not had any backache for the last ten days.
" April 9th.
On examination I found the habitual
position very
much
improved, scarcely any difference in
the level of the shoulder-blades, and the antero-posterior

The patient assumes the
spinal curves almost normal.
best possible position with great ease.
"April
if
11th.
this lasts till
The patient
is still
without backache, and
to-morrow, that will be four clear
passed without aching in the

coming to me for treatment.
back.
She
is
to
weeks
cease
THE TREATMENT OE
60
"April
The patient was exhibited before the

Clinical
London, and the Medical Times and
Gazette of April 21st, 1883, reported, " The young lady,
the subject of the Lateral Curvature, was exhibited,
and went through the various phases of the
medical
gymnastics which had been practised with the view of
bringing about a cure. The muscles, when in action in
the different movements, came out very strongly. The
case seemed to have undergone marked improvement."
Two years afterwards this young lady went on the stage
of one of the leading London theatres, and continued
IStJi.
Society of
'
'
acting
for
several
Clinical Society's
years
Spine was appointed on

first
till
she married.
When
Committee on Lateral Curvature
March
the
of the
1887, nearly the

letter I received from the Hon. Secretary was one
requesting
me
to
11th,
exhibit this patient before the
Com-
The young lady most kindly consented, and she

was thoroughly examined by all the members of the
Committee on April 15th, 1887. She also informed the
Committee that the dressmaker of the theatre had never
found fault with her figure when trying on new dresses.
The Committee were satisfied that there had been no
relapse since the patient had been exhibited at the
mittee.
This
meeting four years previously.
was a severe test of the permanence of the cure I had
been able to effect, because this young lady at the time
she saw the Committee at my house, was not only acting
every night in two pieces, but was rehearsing for several
hours daily in a new play, which was soon afterwards
.successfully placed on the stage.
This patient was last
examined by me in January, 1897, some fifteen years
after she first consulted me, and I Avas able to assure her
that there had not been the slightest relapse of the
Lateral Curvature of the Spine during all those years.
Case II. (see No. 221, in the Appendix of 1000 cases).
Miss E. L., a?t. 17 years, from Jersey, consulted me on
April 24th, 1888, with the following history
About
eight years ago " the right shoulder was observed to be
growing out," the only ascertainable cause being a very
Clinical
Society's

61
rapid growth. The family doctor, on being consulted,

advised nothing being done, as "it would all pass away."
Four years ago, the patient in the meanwhile having
become more deformed, a steel spinal support was applied
and worn
for six months; this was then replaced by a

four Sayre's plaster-of-paris jackets, applied at
intervals of three months; then a poro-plastic spinal
series
of
support was applied, and had been worn for two years
to the time of consulting me.
In spite of the continuous mechanical treatment of the last four years, the
young lady had become
terribly deformed, as can be
easily seen from the rough
sketch of the back (fig. 20),
and from the reduced co23ies
up
of the tracings of the ribs
posteriorly
the loins
(fig.
(fig.
and of
which I
the method
21),
22),
took according to
described at page 12.
These
show the extreme deformity

of
the
right
ribs
y level of
behind,
and the serious prominence
iliac crest
Miss E.L. April
24 th
of the left iliac crest (hip-
bone).
The
are likewise
and
ribs anteriorly
much
deformed,
thorax is
whole
consequently most unsymthe
metrical.
When
Rough
sketch of back of Case II., with

extreme Lateral Curvature (habitual posture).
the patient was placed in the best possible
posture, with the back against the door, her stays, dress,
and jacket, would not meet in front for three or four

inches.
Her
general health at the time of the consultation
was only " pretty
"
good, and the patient complained of
frequent pain in the back and beneath the left shoulderI gave as my prognosis that three months' daily
treatment would effect all that could be done in such a
bad case viz., a slight improvement in the spine, a better
figure, a much stronger back, and a marked improvement
in the general health, and at the same time, an arrest of
blade.

62
THE TltEATMENT OF
further increase in the osseous deformity of the ribs and

vertebrae.
The patient came under my care a day or
two afterwards, the spinal support being of course left
and the following notes of the progress

of the patient are taken from my Case-book
"May 16th, 1888. Eighteenth visit for treatment; the
patient began to-day the severest exercises (see page 40)
she is doing extremely well.
"May "M)tli. Twenty-ninth visit for treatment; examined;
off
altogether

'
keynote
position
'
is
one with
the
left
63
arm
upwards and the right arm directed outwards.

slightly more movement in the spine, which
little less
curved
" July 21s^.
The spine
the patient
already
is
much
Seventy-first visit for treatment
directed
There
is
is
also a
stronger.
;
examined.
and has
further improved in straightness,
is
increased movahility;
still
the same 'keynote.'
"July 23rd. Seventy-second and last visit for treatment. A home prescription similar to that described on
page 45 was given to the patient, to be practised for half
an hour twice daily at home for the next twelve months."
On December 9th, 1888, more than four months after
leaving England, the patient Avrote to me as follows
" I am pleased to say that I keep up very well.
I do
Fig.
tor
22.
.?*,
spivcc
1z
pi6 /
*/, title
m* ^.
4fc
V*
Miss EJL.tet.TI years

April 24"'1888
({natural size)
%
Tracing of loins midway from ribs to iliac crests in flexed
position of trunk, in same patient as figs. 20 and 21 (half
natural
my
size).
exercises, either in getting
and before going to bed."
(It
up or during the morning

would be better, I think, to
do the second half-hour of the home prescription before

the midday meal, or at all events before evening, when
most patients feel tired out and incapable of throwing
much vigour into the carrying out of their treatment.)
"All my dresses were much too narrow across the chest

Mv general health has
and too short in the waist.
much improved, and also one thing I am most thankful
for is that those pains I used to have in the left side
have entirely disappeared."
Case III. (see No. 224 in the Appendix of 1000 cases).
Miss M. B., cut. sixteen years, the fifth of eight children,
all delicate, was sent to me on April 27th, 1888, by the
advice of Mr. C. Heath. Her previous history was that,
.
THE TREATMENT OF
64
three years ago, the right shoulder was observed to be
"growing out "

support, which
she was
was worn
at once
put into a
steel spinal
The deformity
becoming much worse, the patient consulted a London
orthopaedic surgeon,
who
for
two
years.
prescribed
another steel spinal
support, which was being worn when I was consulted.

The friends described the patient as becoming rapidly
worse during these three years, since they

the curvature.
Fig. 23.
and
25,
the case,
do
the
first
observed
Eigs. 23, 24,
sufficiently illustrate
exhibiting as
severe
they
deformity of
the right ribs posteriorly, and

the extreme deformity of the
left loin, caused by the rotation
backwards of the
left
trans-
verse processes of the lumbar

vertebrae,
which form a severe
curve with convexity

This young lady
three
came for
months' daily
treatment.
On July 9th,
1888, the father wrote: "I
beg to congratulate you on
the great success in your
treatment of my daughter "
lateral
to the left.
MssMB.
A}iril
vet. 16 years
2] - 1888
Rough sketch
back of Case III.

with severe Lateral Curvature (habitual,
of
posture).
and on January 12th, 1889,

nearly six months after the
patient left
my
personal treat-
ment, he wrote "I am pleased to tell you that my dear

daughter is very much better for the three months' treatment under your care; she walks more uprightly, and
:
does not become so easily fatigued, as she did before she
went under your
now
care.
Her deformity
is
scarcely notice-
walks along, and she is in good health

and spirits. ... I was truly delighted for her to leave oft"
that wretched instrument which had been made for her,
by the order of the surgeon she had previously been to,
and which was not only a great disfigurement, and a
able
as she
65
very heavy tiling for her to be always carrying about,

but never did her the slightest good.
On February 12th, 1892, three and a half years after
the completion of her
treatment, I examined
the back, which con3
most
with
factory,
tinues
satis-
arrest
of further increase of
the osseous deformity.

The patient is engaged
to be married, with
my
full consent.
^
a
V3
JO
/&&
f
s
c
.V'
the
1000
B^
"\"K
the
patient
for
Curvature
Lateral
five years previously,
when, according to
the statement
of
q=!
o>
_fl
-i
J-
fe
0)
H<S!
'
JH-4
+=>
03
03
<yj
<S
o a
csls
->,
so
n.
k
\
\
c3<^
<M
*CO
CO
m &b
fl*
O to
\^
<4H
OS
a.
fl
oc-_g
sur-
geon in London This

gentleman had commenced the treatment
of
'>5
Miss
hospital
4~
<D
of
A. L., aged seventeen

years and a half, was
sent to me on October
20th, 1885, by a well-
known
ft
T3
Appendix
cases).
"K
Case IV. (see No. 10

in
*co
c3
10
3".
**
-rH
fl
si
S
s
s=Jl
1-
to
vs
""
c3
fi
^"^
.2
CO
&
CO
her
O
was not
.s
more deformed than
H
her
younger sister,
whose photograph is
given in fig. 26. She
wore a succession of Sayre's plaster-of-paris jackets,
followed by a poro-plastic felt spinal support, which she
was wearing when she came to me.
She also wore a
jury-mast arrangement for twelve months during these five
years, and she was, in addition, suspended by the head
aunt,
she
c3
Jh

THE TREATMENT OF
66
and neck for ten minutes daily in the " gallows."

All
this treatment failed to prevent the development of the
very serious deformity with which she came to me.
" Present
anaemic,
and
(Octoher
state
extremely
20th,
delicate,
young woman, with
deformed
much
1885)
depressed
she has never had
hackache, which is frequently the case even in the most
deformed patients
her general health is said to be
good.
The spine presents extreme Lateral Curvature, with
dorsal (upper) convexity to the right.
The lower angle
the left shoulder
the right scapula, and the left iliac crest, are very
prominent. The antero-posterior curves of the spine are
much exaggerated. When the trunk is flexed to the
of
full extent, the right ribs posteriorly are
very prominent
Fig. 25.
Tracing of loins midway from ribs to

trunk, in same patient as
figs.
iliac crests, in flexed position of

size).
23 and 24 (half natural
(See fig. 27.)

This is a
compared with the left."
tracing taken by my scoliosiometer from the lower angle
as
of the left scapula across the spine to the corresponding
angle of the right scapula the left erector spinse muscle

much raised by the corresponding convexity to the
is
(See fig. 28.)
The tracing
left of the lumbar vertebrae.
taken opposite the third lumbar posterior spinous
is
;
process.
When
was
placed in the best possible

posture, the poro-plastic felt jacket and her dress would
My prognot meet across the chest by several inches.
nosis was that a course of three months' daily treatment
would effect all the improvement possible i.e., an improved figure, strong spinal muscles, and most probably
the
patient
arrest of further increase of the osseous
i.e.,
incurable
67

THE TREATMENT OF
68
at the same time

deformity of the ribs and vertebrae
she would be independent altogether of spinal supports
and become a much more useful member of society.
On November 3rd, 1885, I took a series of nine photographs, figs. 29 to 37 inclusive, which almost explain
Pig. 29 shows the felt jacket being worn,
themselves.
Pig. 30 shows the felt jacket being
posterior aspect.
Pig. 31 gives the patient in her
anterior
aspect.
worn,
habitual position, seen from behind, and may be compared with fig. 29 to demonstrate how little effect the
an improved posture.
felt jacket had in maintaining
Pig. 32 is the same as fig. 31 seen anteriorly, and may
Pig. 33 shows the
be compared similarly with fig. 30.
;
Fig. 28.
&
V*
rhfr <*
lumbar
spine
'*,
Miss A.L., aged seventeen and a half years, October 20th, 1885 (actual
patient in her habitual position, viewed laterally.
size).
Pig. 34
placed in the "best possible"

or most erect position, and demonstrates that the felt
jacket is several inches too tight under such conditions
this figure should be compared with fig. 30.
Pig. 35
gives the patient's trunk flexed, and is a gauge of the
amount of osseous or incurable deformity of the ribs
it may be usefully compared with fig. 27,
posteriorly
proving how very accurate are the scoliosiometric tracings
taken by my method in this flexed position.
Pinally,
figs. 36 and 37 give the anterior and posterior views of
what I describe as the " keynote " position i.e., the best
position in which the patient can, by voluntary effort,
directed by the surgeon, place herself while undergoing
methodical exercise.
the
represents
patient
few days
later
69
exhibited the patient before the
London, and the following day I

commenced daily treatment by " posture and exercise."
On December 12th, 1885 (twenty-fifth visit for treatment),
the patient informed me that she felt much stronger, and
that her friends already observed a marked improvement
in her figure.
On the completion of her course of three
months' daily treatment (seventy-two visits), she was
again presented to the Clinical Society on March 12th,
Society
Clinical
of
1886.
The patient persevered with a home prescription of

treatment for a year (half an hour twice a day for the
first six months, then once a day for another six months),
when I exhibited her again before the Clinical Society,
March 7th, 1887. I was able to demonstrate that there
had been no further increase of the osseous deformity,
and that my prognosis had so far been fulfilled.
On
December 4th, 1888, two and three-quarter years after

the completion of the three months' course of treat" The deformity is no
ment, the patient's aunt wrote
worse.
When she has time she is able to take long
walks." I did not see her again till I asked her to come
and visit me on June 5th, 1895, after an absence of eight
:
years,
when
found there had been no increase
of osseous
deformity, as tested by the tracing of the ribs posteriorly

her general strength and health have kept good during
the ten years since she ceased treatment
in fact, considering her extreme deformity and weakness at the time
she first came to me, I do not think she could have done
;
better.
Case V. (see No. 26 in the Appendix of 1000 cases).

The younger sister, Louisa L., of Case IV., aged fourteen
years, was brought to me on February 8th, 1886, with
well-marked Lateral Curvature of the Spine, but with
only slight osseous i.e., incurable deformity of the ribs
and vertebras; see habitual posture in fig. 26.
This
girl underwent only one month's daily treatment by
posture and exercise," which sufficed to cure her. This
was confirmed when she was shown at the meeting of
'
70
THE TREATMENT OF
More than a
the Clinical Society, March 11th, 1887.
year later the aunt reported, " She carries herself most
Seven years later, May 31st, 1895, the
same relative wrote that the patient " had grown a fine
young woman," which I was ahle to verify for myself
when she accompanied her sister in June, the same year.
Will not any impartial surgeon agree with me in believing that if the unlucky elder sister had received the
same treatment at the corresponding stage of her deformity, she would have had eventually as straight a
figure as the younger girl ?
Case VI. (see No. 680 in the Appendix of 1000 cases).
Miss M. W., aged sixteen years, the youngest of eleven
children, was brought to me on January 10th, 1891, with
the following history
When five years old, a well-known
London surgeon ordered her a poro-plastic felt spinal
jacket, as well as to lie down several hours daily.
Getting worse after three years of this treatment, she
was taken seven years ago to an orthopaedic surgeon, who
has treated her up to the present time. At first he kept
the patient lying prone strapped down all day; during
the night a steel spinal support was worn, as it was
found that she could not sleep if the strapping down in
After two
the prone position was continued at night.
uprightly."
or three years of this treatment, her legs
became
so
weak
that she had to
use crutches.
year ago, after six
years of this treatment, the surgeon gaAê the mother to
understand that he could not do anything more for her
daughter.
" Present state, January 10th, 1891 A delicate, emaciated
:
young woman, who came tottering into my consultingroom on crutches, helped on one side by an elder sister.
She is wearing a heavy steel spinal support.
She, like
has
seldom
had acute backache. Spine. There
Case IV.,
extreme Lateral Curvature, with dorsal (upper) conSee fig. 38, which is a rough
vexity to the right."
this shows the great prominence
sketch of her back
of the lower angle of the right scapula and of the
The antero-posterior curves of the
left
iliac
crest.
is

spine are
much
SPINE.
exaggerated, exhibiting what I
as the " gorilla " type, with very
71
describe
prominent abdomen.
39 and 10 represent the scoliosiometric tracings

of the ribs posteriorly and the erectores spinge muscles
Pigs.
Fig. 38.
Level of iliac crest
jf--
Opper end
of gluteal cleft
Miss M. W., January 10th, 1891.
the tracing of the ribs posteriorly presents

When the girl
extreme torsion of the dorsal vertebrae.
was placed in the best possible position, her dress and
spinal support were much too tight, not meeting within
respectively
THE TKEATMENT OF
72
My
three or four inches.

of
three months'
prognosis was that a course

would effect all the
daily treatment
'**
i
Tfe.
improvement possible *.<?., increase her strength and

improve her health, so that she would be able to walk
73
without crutches, and that probably further increase of

the osseous deformity would he arrested.
The patient
completed her course of three months' daily treatment
(seventy
two
visits)
April 14th, 1891, when

I dismissed her with
a home prescription for
twelve months.
Two
days later the mother
" She has to
wrote
thank you for her
strength and power of
walking ahout."
On
Octoher 1st, 1891, the
" My
patient wrote
sister says I hold my:
much
self
my
and
(home
better,
exercises
prescription) are
easier
much
me now."
to
o
6
fa
On
examination
at
the end of the year,
April 13th, 1892, there
had been no further
increase of the osseous
deformity,
when tested
by
the
tracings.
Eighteen months later
I was informed she
was able
miles
of
the
of
in
to
walk four
the
course
day without
mechanical help
the
spinal
support
or
On January
I saw the patient

was pleased to find
her looking remarkably well, and that since I examined
her first, four years before, there had been no increase
of the osseous deformity.
At that time she looked so
crutches.
15th,
1895,
again, after nearly three years, and
THE TREATMENT OF
74
and weak, that I do not think her life could have

been much prolonged, if the instrumental treatment she
was then undergoing had been continued. A marvellous
change for the better took place as soon as she was
treated on what I presume to call "common-sense"
ill
has now every prospect of a

her, in spite of the terrible
before
strong and happy life
deformity with which she is afflicted, which deformity
surgical
might
principles
so
easily
properly treated
she
have
when
been prevented,
the Scoliosis
first
had
she
been
set in.
Case VII. (see No. 261 in the Appendix of 1000 cases).

Mrs. A., aged fifty-seven years, consulted me July 27th,
1888.
This is the most extraordinary case of maltreatment of Lateral Curvature by spinal supports I have ever
come across, as far as duration of treatment is concerned.
This
lady
had worn
steel
spinal
supports for
nearly
years.
Her son, a medical man, wrote to me
mother has worn a support for many years, and
has suffered an incredible amount of pain from the deformity, which would seem to be of a neuralgic character,
coming and going suddenly."
History. When the patient was fifteen years old, a then
well-known orthopaedic surgeon ordered a steel spinal
support.
This was worn till she was married, and then
Twenty years ago, another
left off for a few years.
surgeon prescribed a new kind of steel support, which
has been worn constantly ever since, under the same
forty
"
My
surgeon.
" Present
state (July 27th, 1888)

A fairly wellnourished woman, with severe Lateral Curvature, with
dorsal (upper) convexity to the right (see figs. 41, 42,
and 43, which show respectively the rough sketch of
the back and the scoliosiometric tracings of the ribs
posteriorly, and of the loins opposite the third lumbar
vertebra).
She can be placed in a much improved
position, as the spine is still fairly movable, in spite of
the osseous deformity."
The patient commenced three
months' daily treatment, October 3rd, 1888, and by
November 16th (fortieth visit) she had improved so
:
much
75
have been for the last eight clays entirely

such a long relief had not occurred for
free from pain
as
to
Fig. 41.
J
I
Upper end
of gluteal cleft*.
Mrs. A., July 27th, 1888.
many
at
years
the end
This lady left me much improved

There were,
three ^months' treatment.
past.
of
THE TREATMENT OF
76
however, from time to time, relapses of
the neuralgic
and in May, 1889, she came for a

further course of two months' daily treatment (fortyeight visits), and was again considerably relieved.
In
October, 1889, four months after leaving me the second
pains in the back,
time, she wrote "I am very much better and stronger."

This patient continued to suffer at intervals from the
neuralgic pain in the back in spite of all remedies, but
she was able to get about better, and to enjoy a sense
of freedom which she had not experienced for nearly
forty years.
From the first day this lady consulted me
she left off her spinal support, and never wore it again.
:
SPINE.
77
Like other patients, she felt very limp, as if she would

but the spinal muscles soon
fall to pieces, for a few days
;
commence to do their duty, and it is seldom a patient

has any desire to have a spinal support reapplied after
THE TREATMENT OF
78
the
and
first
week
or
two
of the daily treatment
by "posture
exercise."
Miss M. M., aged forty-one years, came

16th, 1894, with the history that, at twenty-
Case VIII.
to
me May
FlG.
44.
/
/
/
\
Level of
crest
ittac
Miss M. M.,
May
16th, 1894.
one years of age, the same surgeon who had treated

Case VII. had ordered her a steel spinal support, which
she was still wearing, having, of course, had it renewed
several times during the twenty years' treatment.
Some
eight years ago, the surgeon told the patient he could
79
do nothing more for her, beyond advising her to continue

the spinal support, and this advice she followed.
" Present state :
tall, thin woman, who declares she
can do nothing* without the spinal support. The spine
curved with the whole

convexity to the left (see
fig. 44, giving a rough sketch
of the back), while the left
is
and the left

muscle
are
both too prominent (see the
scoliosiometric tracings,
The spinal
figs. 45 and 46).
support and dress do not
meet for four inches in front
ribs posteriorly
erector
when
spina?
she
placed
is
possible
best
in
the
position."
once removed the spinal

which was of the
usual type, with sub-axillary
at
support,
crutches.
The
me
end
at the
months'
patient
left
the three
of
treatment
daily
(seventy-two
greatly
visits)
improved in every way.

I
heard from her on January
My
good
when
she wrote
general health is very
indeed.
I am happy
21st, 1895,
"
my
to say the pain in
has
almost
entirely
and I
walk more than
peared,
for
years.
am
I
back
disap-
able
to
have done
Your treatment has
immense deal
certainly
clone
me an
of good."
examined this patient for the last time on October 16th,

1897, upwards of three years since she ceased being
under my personal daily treatment.
There had been no
further increase of the osseous deformity the back looked
I
THE TREATMENT OF
80
practically symmetrical,
and the patient reported herself
in the best of health.
Here, again, a victim to spinal
supports for twenty

years became a re-
formed
character,
as
far as health, strength,
and
figure
by
cerned,
are
con-
com-
paratively short course

(three months) of daily
treatment.
Summary of
Prognosis
and Treatment.
osseous
If
1.
de-
formity of the ribs and

vertebrae be present,
even to a slight extent,
complete cure of the
the Spine is impossible.
2.
Many
apparently
cases
of
severe
the Spine have no
osseous deformity, and
can be at once restored
temporarily to a good
position.
The
ciety's
Clinical
So-
Committee on
the Spine classified all
Lateral Curvatures as
(1) eases without osseous deformity, and (2) eases with osseous deformity, according as there is or is not bony deformity present (see their
Report in
3.
vol. xxi. of Clin. Soc. Trans. 1888, p. 301).

patient with confirmed Lateral Curvature of the

Spine, with or without osseous deformity,
to the vicious jjosition, that attempts
to
improve the form
is
81
so habituated
on his or her part
of the spine, except by the surgeon's
directions, generally increase the deformity.
Daily exercise of the spinal muscles is absolutely

necessary to the successful treatment of Lateral Curvature.
5. Good or the best possible positions should be always
assumed, not only at meals and at lessons, but whenever
4.
This is practicable in slight cases

otherwise occupied.
with ordinary high-backed chairs in some cases with much
backache, and especially in adult cases, a couch with
;
moulded back, is useful.

be directed to the dress (including stays, braces, etc.) in both sexes, so that it presents
no obstacle to the expansion of the thorax anteriorly, and
to the patient maintaining an improved or an erect position.
cases of
7. The feet should always be examined in
is
as
so
Lateral Curvature,
frequently concurrent
flat-foot
with the spinal deformity, and requires to be attended to
at the same time.
8. A moderate amount of outdoor exercise, as bicycling,
tennis, hockey, cricket, and walking, is most beneficial
in helping to brace up the muscular system and to improve
the general health.
9. Lying on the face or back does not tend to cure
Lateral Curvature, as it does not strengthen the spinal
muscles, having really the opposite effect of weakening
them as the result of disease. Lying for fifteen or thirty
minutes is useful when it rests the patient; but if it be
continued for several hours daily, as still so frequently
prescribed, only harm results from the physiological
activity of the spinal muscles being prevented.
horizontal seat, and movable and
6.
Special
10. Steel
attention
spinal
is
to
supports,
Sayre's
plaster-of-paris,
or
poro-plastic felt jackets are never to be employed, except
due to paralysis
and even in those cases,
in those rare cases of Lateral Curvature

of the erectores spinse muscles,
mechanical supports often
be of the slightest use.

11. The more attention is paid to the avoidance of
vicious, and to the maintenance of good positions, and the
fail to
82
TREATMENT OE LATERAL CURVATURE OF THE
SPINE.
more carefully and conscientiously the patient carries out

the prescribed exercises, the better and quicker are the
results obtained.
12. Slight cases of Lateral Curvature of the Spine
without any osseous deformity can generally be cured
by one month's daily treatment (24 visits of threequarters of an hour each) by " Posture and Exercise."
Other cases, on an average, require three months' treatment (72 visits) for three-quarters of an hour daily, to effect
either a cure in those cases which can be cured (postural
or non-osseous cases), or the utmost improvement possible
in others where there is more or less osseous deformity
present (osseous cases).
I attach the greatest importance
Several surgeons, to my knowledge,
to the word daily.
have supposed themselves to be carrying out my treatment by seeing a patient once a week, or once a fortnight,
relegating the treatment in the intervals to a relative or
a nurse as may be easily imagined, their results have
been less successful than mine.
13. The age of the patient has little or nothing to do with
the success of the treatment I employ .all that is required
is the willing and persevering co-operation of the patient.
;
In
14.
all
cases,
constant
attention
to
position
and
daily perseverance with a
Home
Prescription of prescribed
exercises are required at
home
for at least a year, better
for three years, afterwards, to confirm
provement and
the cure or im-
to prevent relapse.
carrying out for about

three-quarters of an hour daily of the treatment by
" Posture and Exercise," will enable surgeons to cure,
15. Lastly, the
conscientious
or practically cure, the vast majority of cases of Lateral
Curvature of the Spine on an average in three months
from the commencement
of the treatment.
16. I will conclude with an extract of a criticism in

the Lancet of August 3rd, 1889, on the first edition of my
book "It is to be hoped, that the publication of this
little book will do something to check the unscientific
and often disastrous treatment of Lateral Curvature of
:
the Spine by spinal supports and prolonged rest."
PLATE
F'g. 10.
Trace of osseous deformity.
Fig-
Case No. 909.
Aged 7
years.
(Actual
size.
11
Moderate osseous deformity.
Case No. 985.
Aged
13 years.
(Actual
size.
Fig. 12.
Severe osseous deformity.
Case No.
Extreme osseous deformity.
10.
Miss A.
Case No. 224.
L.,
aged 17i years, October 20, 1885.
Aged
16 years, April 27, 1888.
(Actual size
(Actual size.)
II.
APPENDIX.
A SERIES OE
ONE THOUSAND CONSECUTIVE CASES
OF
LATERAL CURVATURE
OF THE
SPINE
{SCOLIOSIS)
WHICH WERE UNDER THE AUTHOR'S TREATMENT BY "POSTURE AND
EXERCISE" IN PRIVATE PRACTICE FROM JULY 27, 1885, TO
NOVEMBER 24, 1892, AND SUBSEQUENT TO A SERIES
OF TWO HUNDRED CASES READ AT THE
ANNUAL MEETING OF THE BRITISH
MEDICAL ASSOCIATION IN
1885.
THE TREATMENT OF
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141
January, 1903.
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1

LATERAL CURVATURE OF THE

six photographs of Case

were taken the same morning before com-

and 3 represent the "habitual" posture

AN ANALYSIS OF 1000 CONSECUTIVE CASES TREATED BY

Publishers having asked rue to issue a second edition

work on the Treatment

the Spine which was out of print, I thought

practical use to medical

ing out the rational treatment of this deformity.

the ten years

book was published.

Curvature of the Spine treated by

than doubled, and

the ribs and verte-

utility of the book.

read a short paper at the

made to the Appendix, which

the prognosis and treatment of

have undergone con-

siderable modification during the fourteen

been engaged in orthopaedic practice, this monograph

mainly based on the

Spine " which I contributed to Mr. C. Heath's " Dictionary

the British Medical Journal, " The Treatment of Lateral

Curvature of the Spine,"

and " Scoliosiometry,

Accurate and Practical

Spine," October 27th, 1888; and on the paper read before

ment without the Use

xvi. Clin. Soc. Trans., 1883).

Definition of Lateral Curvatu.be of the Spine (Scoliosis)

Postural Class or Stage

the Mangle" Types

Method of recording the Amount of Osseous Deformity when

Author's Method of Examination for Lateral Curvature

pte-education of the patient's

Improved Position to be maintained at all Times, while

Erect or Improved Position

Relaxed or Over-extended Condition of the Elbow- joint

Training of the Spinal and Other Muscles,

including the development of the thorax

First Prescription of Medical Gymnastic Exercises

Duration of the Treatment under the Personal Daily

Attention to General Health

Treatment of Pain or Backache

to prevent Eelapse in the

Improvement or Cure that has been obtained by the

The Treatment of Flat-foot

Duration of the Author's Treatment of Lateral Curvature by

Result of the Author's Treatment of Lateral Curvature by

Summary of Prognosis and Treatment

One Thousand Consecutive Cases of

Curvature of the Spine (Scoliosis) which were

LATERAL CURVATURE OF THE

Curvature of the Spine

characterised by lateral deviation

and distortion or rotation of the spinal column, nearly