—Too often the condition is regarded as so trivial that it is likely to be outgrown, or else is quite disregarded, or, on the other hand, occasionally it is regarded as one of gravely serious import and maltreated or overtreated on this account. In the majority of instances scoliosis is a self-limited condition, whose limit may be reached at variable stages of deformity in different individuals. In slight cases any serious illness may cause such muscular weakness as to permit of serious increase of distortion. Therefore, the patient’s general condition is to be taken into account just as much as the shape of the back.
Treatment.
—If one may be permitted a Hibernicism, the proper treatment for scoliosis is prevention. This may be made to include the earliest possible recognition of trifling deviations from the normal. It should be made to include, in general, supervision of school desks and the way in which children work at them, as well as of children’s games and exercises, in which it should be made a point that they be taught to make as much use of one hand as of the other. It should include also supervision of children’s methods of seating themselves at the piano or at the sewing table, as well as the posture which they assume during sleep, while they should be taught to stand and walk properly and to avoid a too early use of corsets. Active treatment should consist, first, of correction of bad postural and other habits by methods as vigorous as are military drill and discipline. Patients tire easily after such exercise, and sufficient rest should be taken, the patient lying symmetrically upon the back. There is usually opportunity with young children for great ingenuity in devising suitable exercises without making them too irksome. They should be taught to play games at least as much with the left hand as with the right. Gymnastic exercises, especially those with dumb-bells, will be found effective, and it is advisable to have a heavier dumb-bell in the left hand than in the right. The more severe cases should be handled with great care in order not to overdo that which should be done. Each case should be studied by itself, which means that such cases should not be taught in classes. Roth calls that “the key-note position” which is closest to the normal that the individual can voluntarily and comfortably assume. From this as a basis the surgeon should work up. Perhaps as much can be done without apparatus as with it, particularly if will power is concentrated on the effort. This is harder with the young, but pride may sometimes be appealed to as a substitute for volition. As strength is gained more strenuous gymnastics may be prescribed, including suspension from rings or the simple horizontal bar, while much heavier dumb-bells may be used, as taught by Teschner.
Mechanical corrective treatment is directed mainly to stretching shortened ligaments and contracted muscles. For this purpose many forms of apparatus have been devised. Their principal benefit lies in increasing backward flexibility at the point where curvature is most pronounced. As a substitute for such apparatus, and in private houses, padded stretchers or lounges may be supplied on which patients may lie either quietly or during massage. Finally the matter of corrective corsets and braces remains to be considered. External support takes away from the muscles and ligaments their functions and work. Nevertheless in some cases this is necessary. No appliance of this kind that may be supplied should be continuously worn. It should be removed for work and exercise, as well as for toilet purposes. Recumbency in bed is much better than too vigorous bracing. Only in old, neglected, or peculiar cases should it be considered necessary to resort to much external aid.
CURVATURES FROM OTHER SOURCES.
The relaxation and debility of old age permit of such deformities as rounded and stooped shoulders, certain degrees of kyphosis, and sometimes even pronounced stooping and deformity, whose merely senile causes are more or less combined with rheumatoid arthritis of the vertebral and costovertebral joints. These features are accompanied by more or less pain or difficulty in locomotion. Many instances of ischias scoliotica, referred to in the preceding section, would find a place among these clinical pictures. Postmortem there are found exostoses, synostoses, or ankyloses sufficient to account for the deformity. Rickets also causes skeletal deformities, in which nearly all the bones may participate, the spine rarely totally escaping. In such cases various typical and atypical deformities may be met.
Paralytics may show various curvatures, as do also subjects of pseudomuscular hypertrophy and syringomyelia. Lordosis is seen in pregnancy and in congenital hip dislocation, where it is purely compensatory in each instance and does not outlast its real cause. In fact it may be encountered as a compensatory feature of any other kind of spinal curvature.
A still more marked condition of chronic ostitic changes is seen in spondylitis deformans, which differs little from arthritis deformans of other joints, save that in these cases it usually spares the joints of the extremities. It has been known as a rare sequel of gonorrhea, even in the young. Osteophytic outgrowths occur frequently and fuse together, causing ankyloses and sometimes great deformity, even to the extent of making the spine assume a right angle with the extended limbs. Considerable pain is frequently experienced during the course of these very slow changes. The entire spine becomes more or less rigid, consequently there is little or no angular prominence, while the ribs become immobilized as well. For this condition there is little or no treatment of any avail. Sometimes paralysis supervenes and the condition is not infrequently fatal.
Acute osteomyelitis of the vertebræ is occasionally noted. It occurs nearly always in young and growing children, and is most common in the lumbar spine. It is essentially the same here as occurring in the long bones or their joint ends, and has been described in the previous chapter. Its symptoms may be severe, and it is not infrequently followed by abscess. When such abscesses point posteriorly they may be recognized and incised. When, however, pus takes the anterior path it will probably escape detection, at least until too late. The prognosis is often unfavorable.