Fig. 230.—Diagram of attitudes in Klapp's four-footed exercises for Scoliosis.

Exercises for Lateral Curvature.—The particular exercises given must be carefully selected to meet the indications present in each case, the movements prescribed being designed to strengthen the weak muscles and ligaments, to increase the mobility of the spine as a whole, and to correct the deviation that exists. The exercises should be taken twice daily, preferably in the morning and afternoon, and after each spell the patient should rest for an hour, lying flat on the back. During the exercises the breathing should be carefully regulated, and at the end of each movement one or two deep breaths should be taken. Each movement should be carried out slowly, the number of times it is repeated varying from four to twelve or more, according to the nature of the exercise and the strength of the patient. The exercises should be stopped if the patient feels fatigued. Hot-air baths and massage are useful adjuvants to all forms of exercise.

Special Exercises for Thoracic Curvature with convexity to right.—1. Stand with arms by side; palms directed forward; shoulders braced back. This is referred to as the “best standing position” or original position. 2. Slowly raise arms from sides until level with shoulders, with palms directed forward; carry left arm straight upward—“the keynote position.” Then slowly lower left arm to level of shoulder; lower both arms into original position. 3. Assume keynote position: slowly bend body forwards at hips until stooping position is reached, with legs kept quite straight, head bent slightly backwards, and eyes directed forward. Gradually return to keynote and original positions. 4. Keynote position: slowly bend whole spine to right; resume keynote and original positions. 5. Keynote position: turn body forward sideways. 6. Keynote position: rise on to balls of toes. 7. Keynote position: rise on to balls of toes; bend knees; back to original position in reverse order. 8. Patient suspended from bar or rings, the left end of the bar or left ring being three inches higher than the right. (a) Draw right knee upwards and forwards against resistance. (b) Draw legs apart against resistance. (c) Draw legs together against resistance. 9. Patient lying on back. (a) Bend right knee- and hip-joints against resistance. (b) Extend right knee and hip against resistance. (c) Rotate right hip against resistance. 10. Patient lying on face with pillow under chest; slowly raise arms to keynote position. While limbs are firmly held by a nurse, raise the body backwards and to the right. 11. Same position: make swimming movements. 12. Patient astride a narrow table or chair, without a back. (a) Repeat exercises 3, 4, 5, and 11. (b) Bend body forwards, backwards; and rotate to right and left against slight resistance made by nurse grasping patient's shoulders.

Klapp's “four-footed” Exercises.—Rudolf Klapp has devised a series of exercises designed to strengthen the muscles and ligaments of the spine, and to increase the mobility of the column. To take the weight of the body off the spine, and to render both ends of the column mobile, these exercises are carried out in the “all-fours” attitude, the patient crawling in imitation of a quadruped, that is, in such a way that the hand and knee of one side are approximated, while those of the other side are separated; in other words, the hand and knee of one side should not move forward simultaneously ([Fig. 230]). With each step the spine is curved laterally, the concavity of the curve being towards the side on which the hand and knee are approximated. The exercises, for a case of dorsal curvature with the convexity to the right, for example, are graduated as follows: (1) The child crawls in a straight line till he has acquired the “quadruped gait”; (2) with each step forward the head is inclined towards the side on which the hand and knee are approximated; (3) at each step the hand and knee which are wide apart are brought over and cross the limbs on the other side; (4) to open out the concave left side, he crawls in a circle towards the right. The exercises are practised morning and afternoon for from fifteen to sixty minutes at a time. If there is a marked double curve, it is best neutralised by imitating the “pacing” action of a quadruped, i.e., the limbs of the same side moving forward together. The hands, knees, and toes should be protected by suitable gloves and leather pads. Hot-air baths and massage are useful adjuvants to the exercises.

Abbott has introduced a method of treatment applicable to cases in which the deformity has become permanent. Under general anæsthesia, the patient being slung in a bracket-frame with the spine flexed, the curvature is over-corrected and a plaster-case is then applied to maintain the attitude; the plaster-case is renewed at intervals of two or three months.

CHAPTER XIX
THE FACE, ORBIT, AND LIPS

THE FACE

Congenital Malformations.—The description of the various congenital malformations of the face will be simplified by a brief consideration of its development.