A Clinical-Surgical Lecture 
DELIVERED IN 
BELLEVUE HOSPITAL AMPHITHEATRE, 
December 2j.th, 1879, 
RY 
LEWIS A. SAYRE, M.D., 
Professor of Orthopiedic Surgery in' Bellevue Medical College. 
STENOGRAPHICALLY REPORTED FOR GAILLARD'S MEDICAL JOURNAL, 
FOR JANUARY, 1880. A Clinical-Surgical Lecture 
DELIVERED IN 
BELLEVUE HOSPITAL AMPHITHEATRE, 
December 2pth, 1879, 
BY 
LEWIS A. SAYRE, M.D., 
Professor of Orthopaedic Surgery in Bellevue Medical College. 
STENOGRAPHICALLY REPORTED FOR GAILLARD'S MEDICAL JOURNAL, 
FOR JANUARY, 1880. 
A. G. Sherwood & Co., Printers, 76 'East Ninth Street. 
1880. 
NEW YORk-r A CLINICAL-SURGICAL LECTURE. 
DELIVERED IN BELLEVUE HOSPITAL AMPI- 
THEA TRE, DECEMBER 2pth, i8yp. 
BY 
LEWIS A. SAYRE, M.D., 
Professor of Orthopaedic Surgery in Bellevue Hospital Medical 
College, New York. 
Lateral Curvature of the Spine. 
Gentlemen :—On account of the stormy weather we 
will not have as many patients to illustrate our subject as 
we had expected. 
Lateral curvature is a deformity exceedingly common in 
all countries, and particularly so in this. It occurs most 
frequently in young girls about the age of puberty, and it is 
a result, commonly, of unequal contraction of the muscles 
of the two sides of the body. The spinal column is acted 
upon by the muscles of either side, and if these act In har- 
mony with each other it retains its normal outline ; but if 
certain muscles on one side of the trunk become parlyzed, 
or if on the other hand they become unduly developed by 
exercise, the harmony of action between the muscles of the 
two sides is destroyed, and this is a sufficient cause to pro- 
duce rotation of the spine. 
Another cause is inequality in the length of the lower 
limbs, due for instance to a fracture of the femur or tibia 
union having taken place with shortening of the leg ; or to 
disease of the hipjoint from which recovery took place with 
shortening, causing, when the patient stands upright, ob- 4 
A CLINICAL-SURGICAL LECTURE. 
liquity of the pelvis and a corresponding curve of the spine. 
If you put a book two inches in thickness under one foot, 
and stand with the other foot upon the floor, you will 
observe an obliquity of the pelvis, the right side—if the book 
be under the right foot—being more elevated than the left, 
with a curve to the left in the lumbar portion of the spine, 
and a compensating curve in the opposite direction in the 
dorsal region. This position of the spine is assumed in 
obedience to the laws of gravity, for if, while one limb is 
shorter than the other, you should try to keep the spine in 
a vertical position, resisting the instinctive tendency to the 
formation of a compensating curve, you would lose your 
balance and fall. Now, take your foot off of the book and 
put it upon the floor on a level with the other, and you have 
gotten rid of the lateral curvature ; and in the treatment of 
lateral curvature which is due merely to inequality in the 
length of the limbs, all that is necessary is to put the soles 
of the shoes on a level with each other, and this can be done 
by thickening the sole of the shoe worn upon the foot of 
the shortened limb. 
Carelessness on the part of young girls in assuming 
awkward positions is an ordinary cause of lateral curvature ; 
the simple habit of standing on one limb more than on the 
other is sometimes a starting point for the development of 
lateral curvatue of the spine. 
Usually the first sign of spinal curvature, called rotary or 
rotatory lateral curvature, that is noticed is the prominence 
of one shoulder blade and the apparent general deformity ; 
but often, long before this attracts attention a measurement 
of the distance from the umbilicus to either nipple would 
show one to be nearer the median line than the other, a re- 
sult of the rotation which is taking place. As this rotation 
takes place the latissimus dorsi of one side is put upon the 
stretch and by contraction tends to bring the spine into a 
lateral curve. As the deformity goes on, the muscles which 
act in opposition to its progress become weaker and weaker 
and the muscles producing it, by constant exercise grow 
stronger and until in some cases the ribs descend even into the A CLINICAL-SURGICAL LECTURE. 
5 
ventrum of the ilium, and the angles become much more 
prominent. 
A great variety of mechanical contrivances for the cure 
of the deformity have been tried, as you may judge from the 
number and variety of the instruments which I here show 
you. More inventive genius has been displayed by surgeons 
in trying to construct apparatus for the relief of this deform- 
ity than of any other deformity of the human body. I have 
here only a sample of the different kinds of instruments 
which have been invented for this purpose, of which I have 
a cart load or two at home. They are all constructed on 
the general principle of exerting lateral pressure against the 
projecting processes with the object of forcing the spine into 
a vertical position. This pressure upon the projecting 
points has been so great at times as to gall and make sore 
a spot equal in size to that of the compressing plate. 
Here is an instrument that I took from a young girl in Am- 
sterdam. You can see the marks of the blood still 
upon the side of the plate which exerted pressure against 
one of the projecting processes. She had worn it 
for years without being straightened by it ; and, indeed, it 
is impossible to straighten the spine of these patients by such 
lateral pressure so long as there is a band, such as you see 
on these instruments, passing over the shoulders and 
keeping them pressed down. If the lateral pressure 
be sufficient even to fracture the ribs, you cannot ex- 
tend the spine while these straps press down on the clavicle, 
preventing elongation of the spine. Dr. Judson demon- 
strated by this articulated vertebrae I now show you that 
by extension of the spine the rotation was more or less com- 
pletely overcome (according to the length of time it had 
existed,) and the lateral curvature almost entirely disap- 
peared. Dr. Mitchell of Philadelphia, many years ago tried 
extension in the treatment of lateral curvature of the spine, 
but to Dr. Benjamin Lee, of Philadelphia, is due the credit 
of suggesting self-suspension in the treatment of this 
deformity, and if he had applied to the body in this improved 
position, an accurately fitting mould to retain it, he would 6 
A CLINICAL-SURGICAL LECTURE. 
have accomplished the object desired. In the majority of 
moderate cases, where the bones have not become perma- 
nently changed in form and structure, self-suspension and 
proper gymnastic exercises alone will suffice to overcome 
the deformity ; but if the deformity have reached a stage 
in which the ligaments are changed in form, and the angles 
of the ribs have changed, this simple method of treatment 
is not sufficient to effect a cure. 
Here you see a case previous to suspension ; mark how 
great the deformity. After suspension, what a change ! 
How great the improvement in the position of the patient ! 
There is no amount of screw or lever power,—there is no 
mechanical treatment whatever that can make so great a 
change in this figure as self-suspension has done. 
Now, as soon as self-suspension is discontinued they will, 
of course, relapse into their former shape, and something is 
necessary to retain them in the improved position which 
self-suspension gives them. For this purpose I have found 
nothing that will bear comparison in usefulnes with the 
plaster-paris Jacket applied over a closely skin-fitting shirt. 
I have explained to you at former lectures how to apply the 
Jacket, and I will not take time to repeat it here. In young 
ladies a pad should be put over the breast, under the skin- 
fitting shirt, and removed after the application of the plas- 
ter jacket. The object of this is to allow development of 
the mammae. The dinner pad, as you know, should not be 
omitted in either girls or boys. If there be any sores on bony 
prominences, as on the crest of the ilium, caused by the 
pressure or chafing of the instrument which the patient had 
been wearing, a pad of cotton should be put over them, out- 
side the shirt, before applying the plaster jacket. Self- 
suspension should then be continued twice daily, the 
patient, after applying the head gear, pulling himself up by 
a rope which passes over a pulley, until he feels comfortable, 
and never go beyond that point, no matter whether he be 
lifted sufficiently for the toes alone to touch the floor, or 
not. Under no circumstances permit him to be pulled up 
while his arms are by his side, for it might strain the liga- A CLINICAL-SURGICAL LECTURE. 
7 
ments of the neck and cause serious injury. But by extend- 
ing the arms full length, and applying one hand over the 
other he can pull himself up until he feels comfortable, and 
stop as soon as he begins to experience the slightest feeling 
of discomfort. 
A surgeon of this city, in a recent lecture says that he 
approves of the plaster jacket treatment, but that he thinks 
the hanging of the patient in applying the jacket, a very 
serious objection ; but if you observe what I have said and 
strictly follow the rules I have given I think you will find no 
such objection to exist. Mr. Miller, of London, devised a 
way to apply the jacket with the patient in a horizontal po- 
sition, but the spine is not sufficiently straightened by the 
horizontal position alone; it must be farther straightened 
by extension applied to the arms and legs. In order to 
prevent the plaster from setting too quickly when applied 
with the patient in a horizontal position, a gum has to be 
put with it, which makes it impervious to air, a very objec- 
tionable fact ; but the plaster applied during suspension of 
the patient does not require to have any ingredient added 
to make it “ set,” and is perfectly porous and pervious to 
air after becoming set. 
Some surgeons have tried to overcome the deformity of 
lateral curvature by keeping the patient in a horizontal po- 
sition for some time, and it may be said that this method 
of treatment has been carried to its perfection ; yet I have 
seen patients kept in that position for thirteen years, and 
yet the deformity was not relieved ; and in many cases 
according to the statements of the patients and their friends 
—the deformity has steadily increased notwithstanding the 
horizontal posture hid been preserved. 
When a person comes to you to have a plaster jacket 
applied for the first time in a casj of lateral curvature you 
should have him suspend himself day by day for a while, be- 
fore you apply the jacket, so that the spine may become as 
straight as it may by this means, and save you the work of 
applying a new jacket every two or three days at first, 
because of the continued improvement in the shape of the 8 
A CLINICAL-SURGICAL LECTURE. 
spine. The jacket having been applied the patient then 
continues practicing daily self-suspension until he “ pulls 
himself out of his jacket, ” so to speak, and it has been my 
custom, heretofore, then to put on a new one ; but within 
the past month I have adopted what I consider a 
more preferable way than to remove the entire jacket and 
apply a new one. When the deformity becomes so far 
diminished that I can put my hand between the body and 
the jacket at the projecting or bulging point over the 
deformity, I simply cut this much out, leaving the remain- 
der of the jacket in position, and, during suspension, apply 
new material in the space thps cut out, and which fits snug- 
ly to the projecting deformity. The old jacket should be 
dampened around the part which has been cut out, before 
applying the new plaster bandage, so that they will adhere 
to each other. On applying the new bandage, it should be 
passed around the body once in order to give good leverage, 
after which you merely carry it across the chasm, and two or 
three inches to either side, when it is folded back upon itself, 
over-lapping the lower portion, thus continuing until the 
chasm is filled. This, as I said before, I consider a great im- 
provement on the old method, for it is more easily done, and 
saves time and expense, and seems to be much more effi- 
cient. 
Now, I wish to impress upon your minds this fact, that the 
object of the plaster jacket is not to strengthen the muscles ; 
it is simply to retain the spinal column in the improved 
position which it assumes during self-suspension, and after 
applying it the muscles are to be strengthened by continued 
daily self-suspension, as I have already explained. But the 
statement has been made by some, and recently by Mr. 
Bernard Roth, of Brighton, England, in the British Medical 
Journal for December 6th,. 1879, that in lateral curvature the 
muscles become weakened under Dr. Sayre’s method of 
treatment. Mr. Roth says :—“ Sufficient attention has not 
been directed to the effects produced on the nutrition of the 
spinal muscles by the application of Sayre’s plaster jacket 
in slight and moderate cases of lateral curvature of the A CLINICAL-SURGICAL LECTURE. 
9 
spine. As far as I know, Mr. Golding Bird is the first sur- 
geon who has pointed out (see British Medical Journal, Oct. 
nth, 1879), ‘ the dorsal muscles invariably waste from 
want of use under the jacket.’ I can not understand how 
this important fact can have been overlooked so long. It 
is well-known that a limb kept immoveably fixed in a splint 
for six weeks or longer will show, at the end of that period, 
a decided amount of wasting of its muscles from want of use. 
How much greater must be the wasting in the erector 
spinal and other dorsal muscles when a Sayre’s jacket has 
been worn for six months or longer ! Mr. Golding Bird 
goes on to say that, in lateral curvature ‘ the muscles are 
called upon the moment the jacket comes off; so that, if 
they are wasted the patient will be often utterly unable to 
keep himself erect on the removal of the jacket until his 
muscles are again in working order.’ I maintain that the 
dorsal muscles were not ‘ in working order’ before the plaster 
jacket was put on. Muscular weakness is a potent, ifnot the 
chief cause in the production of lateral curvature. Now, would 
it not be more in accordance with common sense to strengthen 
these weak muscles in cases of slight or moderate lateral 
curvature, than to apply Sayre’s bandage, under which they 
invariably waste,’ as Mr. Golding Bird admits ? In severe 
cases of lateral curvature, and in Pott’s disease (caries) of 
the spine, the plaster jacket is the only possible and the 
best treatment, because whether the muscles continue to 
waste or not is of little or no importance here. “ Dr. Sayre 
advises daily extension of the patient, and Mr. Golding Bird 
appears to consider this an efficient means for exercising the 
spinal muscles. I do not think this can be at all proved. * 
* * * 
“To sum up, I can only re-echo a remark made by 
Dr. Sayre during his recent visit to Brighton, ‘ that his 
plaster jacket was-the only treatment for spinal caries and 
bad lateral curvature, but that for slight lateral curvature 
he quite agreed to a treatment for strengthening the 
spinal muscles without the use of his plaster bandage.’ ” I 
not only made this remark at Brighton; but have also 10 
A CLINICAL-SURGICAL LECTURE. 
taught the same in all my lectures and writings on this 
subject. 
Now, the only real objection to my plan of treatment of 
lateral curvature, which Mr. Roth would make in this criti- 
cism, amounts to this, that the muscles waste from want of 
use under the jacket, notwithstanding self-suspension is 
made daily. I will not ask you to accept my statement 
alone in proof that they do not waste, but will read to you 
a letter from Dr. Skene, of Brooklyn, in which he gives the 
history of a case of lateral curvature that he sent to me for 
treatment. It is as follows : 
Brooklyn, Dec. 3d, 1879. 
My Dear Dr. Sayre :—Our mutual friend and patient Miss 
, enjoyed good health until 1875, when she was 21 
years of age. At that time she was placed under the care 
of a dentist who undertook to straighten her teeth that 
were irregularly placed. This treatment was continued for 
two years, and during that time she suffered almost con- 
stant pain. Her strength gradually failed, and during the 
last half of 1877 she had slight pains in her back. These 
pains increased gradually until February, 1878, when she 
was then obliged to rest most of the time on her back. 
About the end of February, 1879, she consulted me about 
her health and I found a well marked double-lateral curva- 
ture of her spine. Before being aware of her spinal trouble> 
I tried to improve her general health by treatment, but 
without the slightest benefit. The rest of her history is 
well known to you, and I now only add that from the day 
that you dressed her in the plaster jacket (April 16th, 1879) 
she was completely relieved from all pain and resumed her 
usual habits of happy activity. She gained flesh and 
strength with astonishing rapidity. The jacket was worn 
from April 16th to Decemeber 1st, 1879, a°d during that 
time she has been perfectly comfortable and well. She has 
spent much of her time in my family and among my friends, 
many of them doctors, and no one has ever observed that 
she either had spinal disease or wore a plaster jacket, and 
some have doubted the fact when I have told them. A CLINICAL-SURGICAL LECTURE. 
11 
“When I say that she has been comfortable, I do not 
mean simply that she was free from pain, but that the jacket 
caused her no more trouble than her corsets would have 
done. She changed the vest worn even under the jacket with 
facility whenever she desired to do so, a very important 
item in the summer weather. 
“ I have just examined her to-day, December 3d, 1879, 
and find that she is perfectly cured and dashes around with- 
out her jacket with all the elasticity and grace of her girl- 
hood. The treatment has astonished me, and the result is 
perfection. I would congratulate you, but that is unnecessary, 
the young lady is a monument, more valuable than a marble 
one, to the honor of your art. Permit me, my dear Doctor, 
to offer my sincere thanks for the kindness bestowed upon 
my friend and patient, and believe me to be gratefully 
yours, Alexander J. C. Skene.” 
That, gentlemen, is a medical man’s testimony in regard 
to the non-wasting of the muscles under the jacket, and 
this is a matter of daily experience with me. Many cases 
become perfectly cured inside of a year, and are not com- 
pelled to use any jacket at all afterwards. 
I now show you a case which has been under treatment 
for sometime, and will read to you the history as it was 
taken by Dr. Roberts. 
Double Rotary Lateral Curvature of the Spine. 
Chas. A. Rice, 246 West 43d Street, New York. Patient 
was 20 years and 4 months of age when he came under the 
treatment of Dr. Sayre, which was on the 23d of January, 
1879. Parents of patient, two brothers and a sister, are 
healthy, and so far as known, have no abnormal curvature 
of the spine. 
Patient was a healthly child up to two years of age, when 
he had an attack of diptheria. Sometime after his recovery 
parents detected lateral curvature of his spine. At this 
time he also had paralysis of his left lower extremity. No 
treatment was directed to the spine at first, but electricity 
was applied to his leg for a short time. Subsequently his 
leg was rubbed and manipulated by a nurse. At seven 12 
A CLINICAL-SURGICAL LECTURE. 
years of age he fell out of the open door of the second story 
of a barn, to the ground, striking somewhat upon his side. 
The result was, he was laid up for two months. After this 
his lameness was more apparent, and he was obliged to use 
a cane to aid him in walking. His lameness, and the 
lateral distortion of the spine, gradually grew worse. 
Between the ages of 10 and 12, electricity was applied to 
his leg with some regularity. At twelve years of age he 
went to an Orthopedic Institution in this city. A splint 
was first applied to his left leg, extending from the hip all 
the way down, so as to keep the limb stiff when walking, but 
so arranged that it could be bent when sitting down. This 
was worn for two years. About the same time a brace was 
applied for the relief of the spinal deformity, but patient 
could not wear it, as it did not support the projecting portion 
of the spine and pressed too much upon his sides. 
Patient left off all treatment before he was quite thirteen 
years of age, but continued to wear the leg splint applied 
by him until he was fourteen. He then entered another 
hospital in this city on June 23, 1873, at the age of fourteen 
years. 
Long leg splint was removed and a short ankle splint 
applied in its stead. A cork sole and heel an inch and a 
half thick which had been worn on the shoe of the left foot, 
was also removed. A spinal brace of the pattern in general 
use at this hospital was now applied, and worn night and 
day, except when removed for sores to heal up. Patient 
remained in the hospital a year, but continued to wear the 
spinal brace after he came out, although he soon abandoned 
the ankle splint and has since never worn one. He went 
to the country and remained three years. When he returned 
to the city he went to the hospital and had another brace 
applied which was made after the same pattern as the one 
previously worn. From this time until patient consulted Dr. 
Sayre, he continued to attend the hospital as an out patient. 
January 23d, 1879. Patient seen for the first time, and 
presents a greatly exaggerated double rotary lateral 
curvature of the spine, as shown in the accompanying photo- 
graph. (Fig 1.) There are several sores due to pressure A CLINICAL-SURGICAL LECTURE 
13 
of brace ; one upon left scapular, one over top of each 
shoulder, and one or two minor ones. 
(Fig. I.) 
(Fig- 2.) 
Self-suspension diminishes deformity considerably as seen 
in photograph No. 2. But as soon as it is discontinued he 
says he feels pain in his back and left side, with great dis- 
comfort, and a sense of weakness. He was recommended 
to practice self-suspension twice daily until the sores were 
healed up, and then to have the plaster jacket applied. 
In the latter part of February, 1879, the first plaster 
jacket was applied while the patient was self-suspended be- 
fore the class at Bellevue Hospital. This increased his 
height two and one-half inches ; but as it did not fit him 
comfortably, it was removed in a few days and a new one 
applied which gave him perfect ease. 
April nth, 1879. Patient returned, very much improved 
in general health, and the daily self-suspension had so im- A CLINICAL-SURGICAL LECTURE. 
proved his form that the jacket gave him no support, and a 
new one was required to retain his improved position. He 
says he feels better than when he came under treatment, 
and the sense.of pressure or weight on his left shoulder has 
entirely disappeared. The crutch of the brace which came 
up under the right axilla had always been a source of great 
discomfort to him ; but now as there was no under pressure 
in this locality he felt greatly relieved. New jacket applied. 
September 24th, 1879. Patient returned greatly improved. 
After a bath a new jacket was applied by Dr. L. H. Sayre. 
December 20th. New jacket applied by Dr. C. H. H. 
Sayre, general health greatly improved, says he can now 
walk and work nearly all day. As the projection is still 
very great over angle of ribs on left side, I propose to re- 
move a portion of the jacket over this part and then when 
he is self-suspended apply a fresh roller bandage of plaster 
paris over the vacuum thus using the old jacket as a ful- 
crum to aid in removing the deformity instead of applying a 
new jacket. 
You see his present position with the projecting hump 
(Fig. 5-) 
(Fig. 3-) 
over the angles of the ribs on the left side. (See Fig. 3.) A CLINICAL-SURGICAL LECTURE. 
15 
We now cut out this projecting bulge, as seen in dotted line be- 
ginning at the upper border of the jacket a little to the right of 
the median line, and continue downward and outward, a dis- 
tance often inches, then curve upward and forward, and cut 
back to the top of the jacket again, taking a triangle piece out 
about ten inches in length and ten inches across its base, which 
is above. (See Fig. 5.) We now let the patient suspend 
himself, when we wet the plaster jacket a few inches on 
either side of the opening that has been made in it, take 
freshly prepared plaster bandage roller, and carry it com- 
pletely around the body once at the 
lower end of the opening, after 
which we carry it but two or three 
inches beyond the opening, when it 
is reversed and carried the same dis- 
tance on the opposite side. This we 
continue to do until the opening is 
completely covered. On removing 
the bandage to carry it to the op- 
posite side it is held in position by 
an assistant, who at the same time 
rubs it with his hand to smooth it, 
and make it set. Now observe how 
marked the change in the shape of 
the patient. (See Fig. 4.)* The 
patient states that this application 
gives him a degree of comfort greater 
than ever before.t 
Fig- 4-) 
* December 29, 1879, Mr. Rice again presented himself at the Lecture 
room, and stated that the improvement in his last jacket had given him more 
comfort than he had had for many years. 
f These figures are all cut from photographs by Mr. Mason, Photographer 
to Bellevue Hospital. The cuts are made by Mr. R. S. Bross, 14 and 16 
Ann Street, New York.