PROGNOSIS AND TREATMENT OF LATERALSPINAL CURVATURE.

A. R SHANDS, M. D.,Washington, D. 0.,

Professor of Orthopedic Surgery, Medical Department ofColumbian University, etc.

Reprinted from Virginia Medical Semi-Monthly,

April 8, 1898.

PROGNOSIS AND TREATMENT OF LATERALSPINAL CURVATURE*

A. R. SHANDS, M. D., Washington, D. C.,

Professor of Orthopedic Surgery, Medical Department ofColumbianUniversity, etc.

When one has to examine a case of lateralspinal curvature, he must be prepared to ex-press an opinion as to the prognosis, hence it isvery important that one should be thus pre-pared, for he is sure to be asked, “Will she growout of it?

Before this question can be intelligently an-swered, many conditions must be taken intoconsideration. If the case be one in whichrotation and fixation of vertebrte exist, an un-reserved opinion in the negative may at oncebe given, but if the case be one in whom onlylateral deviation exists, or complicated by rota-tion, that can be corrected by extension, a fa-vorable opinion can be given, provided duecare and attention to treatment be given. Inno instance can it be said that a patient, witha well marked case of lateral curvature, will,untreated, grow out of the deformity.

Probably the prognosis is less favorable whenthe deformity is due to rickets than in any otherclass of cases. This one should readily appre-ciate when the numerous unfavorable circum-stances incident to such cases are considered,the tender age of the patients when the injuri-ous effects of rickets are most active preclud-ing any thorough form of treatment and en-

*Read before the Medical Society of the District ofColumbia, April 14th, 1898.

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couraging the rapid development of the de-formity. Fortunately, these cases are rare.

Curvatures arising from partial paralysis—-anterior polio-myelitis—of the spinal musclesare very unfavorable.

The age of onset is a factor of greatest im-portance in the prognosis; the later in child-hood it is developed, the more favorable theultimate result.

In considering the clinical history of lateralcurvature, it is a well recognized fact that theperiod of spontaneous arrest is at the cessationof growth.

Sex is an important factor in prognosis; thedeformity assumes much more severe and rapidform in girls than in boys, owing to their lackof muscular development and feeble health,often aggravated by disorder of menstruation.Lateral curvature is more common in girlsthan in boys; from the numerous authoritiesI have consulted, I find the average proportionis eight girls to one boy. This fact is, to mymind, the strongest argument in favor ofgymnastic treatment, to be spoken of at lengthlater.

Condition of general health should alwaysbe taken into consideration as a very impor-tant factor. Persistent anaemia, chlorosis, dis-orders of menstruation, all of which are sooften found in these poorly developed girls thatare victims of lateral curvature, not only aidin the rapid development of the deformity,but prevent, to a great degree, the execution ofan active course of treatment for muscular de-velopment. The most unfavorable subjects ofall are girls in whom ill health is tinged withhysteria. Patients with long, yielding, narrowspines, that can be put into almost any shape,

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are very unfavorable subjects when the deform-ity once gets a start.

Occupation is to be considered always. Itwas stated above that a very small proportionof boys are afflicted with lateral curvature;when it does occur in boys, it is almost alwaysseen in those that have faulty occupations,those that have to carry heavy weights on theirbacks or shoulders.

The site of the curvature is a matter of im-portance; those in the lumbar spine beingmuch less favorable. Curvatures with longradii are much more amenable to treatmentthan those with short; when the radii areshort, there will be an early development ofcompensating curves which adds to the com-plexity of the case. More attention should begiven to the flexibility of the spine than to theamount of the lateral deviation present; aspine in which the deformity will disappear toa marked degree by suspension is favorable fortreatment. When rotation exists, as is evidencedby the altered conditions of the ribs and chest,prognosis is nil as to much improvement. Achecking of the progress of the deformity hereis all that can be hoped for, and this only bymost vigorous treatment. One cannot be toocareful in noting amount of rotation presentbefore giving his opinion as to prognosis. Thetest should be thorough suspension of the pa-tient to relieve the superincumbent weight andto have the patient assume the “ key-note” po-sition ; the latter test enables one to see howmuch of the deformity the patient can volun-tarily overcome, and will show very markedimprovement if the vertebrae are not fixed intheir distorted position.

The “key-note” position is as follows: “Pa-

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tient stands erect and extends the arm corre-sponding to tiie conclave side above the headto the extreme limit, while the arm of the cer-vix side is extended to the right angle to thebody.” This is really a voluntary self-exten-sion; in spines with very well marked curva-tures where no rotation exists, almost as muchimprovement can be produced as by forciblesuspension by means of the Sayre apparatus.

This method of examination should not onlybe the “key-note” to the conditions of the pa-tient’s spine, but should serve as the “ key-note” to the treatment. How rational itshould seem to one that if a patient can vol-untarily overcome by muscular action of weakmuscles a certain amount of the deformity,how much more should she overcome by de-veloping these weak muscles that are responsi-ble for the condition. If we reflect for a mo-ment what wonderful muscular developmentsare accompanied by athletes, we should appre-ciate what should be expected by developingweak muscles.

While it was not intended that this papershould depart from its text—Prognosis andTreatment of Lateial Spinal Curvature—a fewwords on an etiological factor of such great im-portance as lack of muscular developmentsurely will not be much out of place, as it is insuch close relation to the treatment. The factthat lateral curvature is eight times more com-mon in girls than in boys, is very significantthat lack of muscular development is by farthe most important etiological factor in thisdeformity. When one considers how very dif-ferent are the customs, amusements, games,etc., of a boy from those of the average girl, itis readily understood why there is such a dif-

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ference in their muscular developments. Thenearer a girl approaches a boy in her amuse-ments, the more athletic her games will be andthe less likely she will be to have lateral curva-ture. My observation has led to believe thatspinal curvature is confined to city-bred chil-dren ; I have not seen a case of this deformityin a girl that has been reared in the countrywhere children spend most of their time outof doors; such children almost always adoptamusements of a most decided athletic nature,such as horse-riding, long walks, games of ten-nis, croquet, etc. In my native section of thecountry it is exceptional to see a girl that hasnot learned to row a boat, and I know of noform of athletic exercise that is better calcu-lated to develop spinal muscles than rowingwith the oars; in fact, this exercise will developevery muscle in the body, the forced expansionof the lungs thereby being a most excellentfeature.

It was stated above that the more like a boya girl is the less likely she is to have spinalcurvature; this statement is based on the ob-servation of many cases. It is a well recog-nized fact, that when girls have brothers nearher own age she finds, as a rule, their amuse-ments very congenial, causing them to leadmuch more of an out door life than they woulddo otherwise, and as a rule such girls havemuch better muscular developments than theaverage girl. In looking over my case-book, Ifind that in thirty cases', with but five excep-tions, these patients are girls that either hadno brother or none near their own age. Fourof my worst cases were cases of a single childof a widowed mother; these children had been

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kept constantly at school and having theirmothers as their playmates.

In a recent issue of Pediatrics, March Ist,1898, there is an excellent editorial on the sub-ject of “ Physical Training of Children.” Itsets forth in very forcible language the impor-tance of this subject in our schools. It is withgreat satisfaction that we note of late years thatsystems of athletic exercises are being estab-lished in the public schools for the develop-ment of childrens’ bodies as well as their minds;and if proper attention is given by competentinstruction in the schools, it will surely tend toreduce the number of lateral curvature pa-tients. The author of the editorial above re-ferred to quotes from the report of the directorof the physical training in the public schoolsof Washington, D. C., the following significantlanguage: “It is impossible to test the fullmeasure of success or failure of our efforts. Itis in the remote future with school days longpast that the lasting influence of such workwill be felt by the individual child. That thebodies of our children are better formed, bettercarried, and more gracefully used there is nodoubt. I wish to insist in urging systematicdaily medical instruction as a means of im-proving the physical condition of the child andreducing the possibility of contagion. It needsthe critical eye of the medical expert to detectcases of nervous disorders, low nutrition anddiseases in their incipient stages.”

I wish to add that it is a matter of greatestimportance that these children should havetheir spines subjected to the closest inspectionto detect incipient lateral curvature, for in theearly recognition of these troubles rest ourhopes of curing them, or, at least, of prevent-

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ing their further development. “As the twigis bent the tree is inclined,” is surely a proverbapplicable here.

The conclusion that one should reach as tothe prognosis is, first: that it depends moreupon the amount of rotation present than tothe extent of the curvature; secondly, curva-tures submitted to treatment early, even whenquite pronounced, may be corrected in largemajority of cases, provided the patient’s healthremains good and you can secure their heartyco-operation throughout the entire course oftreatment. The treatment, to be efficient, mustbe continued for a long time, and the patientmust enter into it with heart, soul and body.The trouble being simply a distortion of growthand not a disease that threatens the life of thepatient, who becomes accustomed so graduallyto her deformity, it is often a difficult matter toget them sufficiently interested in the treatmentto carry it out conscientiously. This, of course,is not much the case with older girls.

It is a great mistake to think that little canbe done to improve the deformity in these cases;on the contrary, a great deal can be done, iftaken in time; and by this, I mean before thespinal column becomes fixed in a distorted po-sition. As long as the spine is flexible, a greatdeal can be done in way of improvement; atany rate, the progress of the deformity shouldbe checked, for just as long as the spine is flex-ible, it is going to increase until it becomesfixed; hence one should aim to have it becomefixed in best possible position.

The treatment of lateral curvature should beconsidered from two standpoints, viz.: preven-tive and curative. Children should be in-structed how to carry themselves and to avoid

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all faulty positions that will throw extra strainon the muscles of one side of the spine to thedisadvantage of the other side. Excessive useof the right arm should be avoided; note thefact that nearly every case of lateral curvatureis to the right side. Faulty positions in writ-ing should be corrected, and above all, bad po-sitions in sitting; especially should this belooked after in school children, whose chairsand desks should be so constructed as to givegreatest possible support to their spines. Noth-ing is more prolific in the production of spinalcurvature than long piano practicing, on anordinary piano stool. It seems almost impos-sible to impress upon the laity the fact that theuse of stiffened corsets, by preventing normalaction of the spinal muscles, will aid in theproduction of this deformity.

Faulty positions in children during sleepshould be looked after by their parents; chil-dren should not be allowed to sleep all of thetime on one side ; supine position with no pil-low is best position for sleeping child. Whenthere is deformity, the child should sleep onthe side of the concavity, for in this way themuscles of that side are put on a stretch whichin turn will correct a certain amount of theconvexity on the opposite side.

In all of the old text-books it is stated thatthe treatment should consist of spinal bracesand gymnastic exercises, making the lattersecondary. At present all of the authoritiesare recommending just the opposite; in fact,the most eminent authorities condemn me-chanical supports as being positively injuriousin the early stage.

Mr. Bernard Roth, of London, in a paperentitled “Cases Illustrating the Absurdity of

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treating Ordinary Lateral Curvature (Scoliosis)by Spinal Supports,” read at a recent meetingof the American Orthopedic Association, con-demns mechanical supports as being absurd,and, in support of his view, reported a largenumber of cases treated exclusively by gym-nastic exercises with perfectly satisfactory re-sults. He favors daily exercises of the mostvigorous kind for the rapid development of theweak muscles. He never uses spinal supportsexcept in severe cases of infantile paralysis ofthe erectorse spinal muscles, where, by no vol-untary muscular effort, the patients can placethemselves in an improved posture.

Dr. Jacob Teschner, of New York, in anarticle recently published in ‘‘Annals of Sur-gery,” sa37s: “Objection to all supporting ap-pliances is, that each and every one will, to agreater or less extent, interfere with the mo-bility of the spine, and in that manner depriveback, chest and abdominal muscles of that per-fect freedom of action which is a necessary andpowerful adjunct in the successful treatmentof deformity; the aim is and has been to correctthe deviations from the normal by such exer-cises as will educate the different groups ofmuscles to sufficient and proper exertion to en-able the patient to assume as nearly as possiblea normal attitude. This muscular educationis dependent upon strength and development,without both of which wr e must largely fail toobtain that proper and vigorous muscular ac-tion upon which any beneficial result fromcorrective exercises must depend. Therefore,it is necessary and imperative, in all caseswhich require or are amenable to treatment toattain the highest type of development possibleof the entire body, to render the spine mobile

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in all directions, and also to develop the fullstrength of each patient. Individual work onlycan accomplish this end, because it is of thehighest importance to carefully watch everymovement of the patient, and to immediatelycorrect any and all errors in attitude, deport-ment and exercise.”

One could not possibly give worse advice toa patient with an incipient lateral curvaturethan to advise her to take a course of exercisein a gymnasium, or institute of physical cul-ture. The surgeon should personally train thepatient to do such exercises as are best suitedfor each individual case and not trust them toan athlete in a gymnasium who knows nothingof the anatomy of the spine. Improper exer-cises are just as powerful a factor to do harmin such cases as proper exercises, carefully andsystematically given, are to do good. Physicalculture institutes are very good to prevent theoccurrence of lateral curvature by developingthe whole muscular system, but patients withincipient curvatures are nou fit subjects for suchinstitutions.

Before beginning a course of treatment oneshould make very careful notes as to the con-dition of the patient, for if accurate measure-ments are not made at that time it is very easyto be deceived as to any improvement. Thereare many systems of measurements in voguefor this purpose, all of which are more or lessaccurate, and serve the purpose well, if care istaken in following them out. The writer hasfound the following method very useful andaccurate: First mark with a dermatographpencil the spinous processes, have the patientassume the key-note position, then stretch acord from tip of the coccyx to the seventh cer-

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vical vertebra, and note the point of greatestvariations of the spinous processes from thiscord. It is unfair to the patient to take suchmeasurements without having her to assumethe best voluntary position; of course notesshould be made of both positions. Note thedistance of the angles of the scapulae from thiscord; with a lead tape take a tracing of thechest at the point of greatest deformity; thisshould be done with patient bending forwardas far as possible with feet and knees togetherin a line with the vertical axis of the body.

It is not the intention of the writer to givea detailed account of the exercises which shouldbe used to carry out the method of treatmenthe has been advocating in this paper, for noth-ing could be gained by it, as he has nothingoriginal to offer in this line. The literature onthis subject is very abundant, from which anyone interested in the subject can select suchexercises as he thinks best suited for each indi-vidual case.

There are one or two points that should re-ceive special attention, as they are applicableto every case that offers anything in the wayof improvement—viz: Suspension, thoroughself-suspension, such as assuming the key-noteposition in the most vigorous manner, andforcible suspension by means of the Sayre ap-paratus. This attitude expands the chest asthe working of a pair of bellows, and at thesame time stretches the faulty spinal musclesas well as those attached to arms and forearms.This is in reality an exaggeration of Sylvester’smethod of resuscitation. Faradism and mas-sage are most excellent adjuncts to the gym-nastic method of treatment; best to applythem immediately after the exercises.

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My method of treating these cases is to drillthe patient in the exercises at my office at onceon alternate days, and at the end of two weekshave them do them every day for a week or tendays.

It is then insisted that the exercises be con-tinued at home, doing them night and morn-ing, having the patients make them a part oftheir toilet. This should be done for severalyears in the average case, having patient tocall to be examined and remeasured every twoor three months, which will enable you to seewhether the deformity is increasing or decreas-ing. I begin my patients with one-pounddumb-bells, and have them increase the weightas the muscles are developed, always usingthe heaviest that do not produce very muchfatigue.

This paper would be incomplete without afew words about use of spinal supports. Thereare cases of weak and painful spines that haveto be supported with braces for the comfort ofthe patient, but these supports should in noway be considered a part of the treatment, andshould be worn just as little of the time aspossible. There are cases that require bracesfor cosmetic effects; these are old cases, withprominent deformities, that have become fixedin their distorted positions. By properly con-structed braces, very prominent deformitiescan be almost entirely disguised.

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