* I-/  '
 
NLM  0Q135T3fl  1
ARMY MEDICAL, LIBRARY

        WASHINGTON

           Founded 1836
Section..
Number .3si..^f..L.
Fobu 113c, W. D., 8. G. O.
 (Revised June 13, 1936)
NLM001359381 
£u::
ft 
 
THE CORRECT
    PRINCIPLES OF TREATMENT

              FOR

ANGULAR CURVATURE
OF
THE  SPINE.
         BY

BENJAMIN LEE, A.M., M.D.
    PHILADELPHIA:
J. B. LIPPINCOTT & CO.
        1872. 
187?
Entered according to Act of Congress, in the year 1872, by



          BENJAMIN  LEE,  M.D.,



In the Office of the Librarian of Congress at Washington. 
PREFACE.
   The little volume entitled " Contributions to the
 Diagnosis, Pathology, and Treatment of Angular
 Curvature  of the Spine," which I had the honor
 to lay before the profession a few years since, has
  een  for some time  out of print.   In the mean
 time  our  knowledge  of this  affection  and  our
 means of treating it have not made such advances
 as to render the  doctrines then advanced obsolete
 on the one hand, nor, on the other, has the great
 body of practicing physicians become  so familiar
 with them  as to make their repetition unnecessary.
 It has occurred to me, however, that the informa-
 tion  which appears  to be called  for by the fre-
 quent inquiries addressed me by members of the
 profession,  in   regard  to the  subject,  might  be
placed within still smaller compass, omitting much
that  was merely  argumentative or  indirectly per-
sonal,  I have, therefore, determined to reproduce
only that one  of the former collection of papers
which was  devoted  to the  consideration  of the
                                      (iii) 
IV
PREFACE.
principles on which the disease can be most suc-
cessfully combated and the means for their prac-
tical  application,  supplementing  it with  a more
complete and minute  explanation of  one of the
modes of treatment there alluded to, in the shape
of  a  clinical  lecture  since delivered  before the
Medical Society of the State of Pennsylvania.
   I confess, not  unwillingly, that  I find myself
able  to  improve  in  not  the slightest  degree on
the principles unfolded in  the first essay, and to
but a very trifling extent  on the details of their
material embodiment.  A constantly widening field
of  experience and observation  only confirms me
in my adherence to the conclusions then reached:
first,  that an  early recognition of the disease  will
in a  great number of cases enable  us  to arrest it
before deformity has been produced;  secondly,  that
mechanical  treatment is of vastly greater impor-
tance than  medication; and thirdly, that the form
of  mechanical  treatment which gives  by  far the
most uniformly satisfactory results  is that of con-
stant antero-posterior support by  portable instru-
ments,—assisted  by occasiorial modified suspension
by means of fixed apparatus.
   A  recent English  writer  well speaks of the
" sterling value of an early, accurate diagnosis"  in 
PREFACE.
V
this affection. In the humble hope of assisting the
busy  practitioner  in  the attainment of this most
desirable  end, I have appended a table which will
indicate at a glance the diseases with which angu-
lar curvature is most frequently confounded in its
initial stage.
   Especial attention  is  invited to the fact (which is
presented with  the utmost  confidence) that pain
and tenderness in  the back, which are described as
early  symptoms in all the systematic works  on
surgery, are almost never present,—the first mani-
festation of the existence of the disease being pain
on the anterior aspect of the trunk.
  1503 Spruce Street, Philadelphia,
          April 26,  1872.
1* 
 
            I.
ANTEROPOSTERIOR SUPPORT. 
  Recommended for publication  by the  Committee  on  Prize
Essays of  the American Medical Association,  the  accidental
disclosure of the author's name having  excluded it from compe-
tition.
  Extracted from the Transactions of the Association for 1866. 
                 I.
ANTEROPOSTERIOR  SUPPORT.
  The principles  upon which angular curvature,
or ulcerative inflammation of the spinal column, is
to be treated, are threefold :
   ist. Pathological—Dependent upon the nature
and seat of the disease.
  2d. Mechanical—Following  necessarily  from
the laws of physical science, and
  3d. Anatomical—Growing  out of  the  con-
formation  of the  vertebrae and their mutual  re-
lations.
  Each of these  principles  has so direct, logical,
and  essential a bearing on  the  other  two, that
they need but to  be placed side by side in  order
to crystallize into an argument.  Any attempt to
ameliorate the disease  in ignorance or  neglect of
these cardinal  points, and of their relative  inter-
dependence, must fall very far short of that happy
result which is, in most cases, attainable by pur-
suing a  plan  of treatment  strictly based  upon
them.  '
                                    (9) 
ANTERO-POSTERIOR SUPPORT.
  First, then, we consider the Pathological element
of the problem.
  The essential lesion of this affection is ulcerative
inflammation or  caries of the bodies of one or more
vertebras, or an analogous condition of one or more
of the intervertebral substances, or both combined.
This condition of the intervertebral substances is
called " disintegration"  or " softening," though it
is  difficult to conceive  of a reason why the  ex-
pression,  ulcerative   inflammation, is  not  appli-
cable here also.   The disease may commence in
either situation.   Dr. Bauer, of Brooklyn,  relates
a case * in which the autopsy revealed advanced
degeneration  of cartilages  which  were  remote
from  the  carious  vertebras, while the  diseased
action  in  the  vertebras affected  had evidently
progressed  from the surface towards  the  centre.
The progress and form of the curve, in many in-
stances, seem to  indicate  these  portions  of  the
column as the sole seat of disease. (Writers who
deny the occasional  origin of the inflammatory ac-
tion in these substances  on the ground of their  car-
tilaginous  nature, forget that they are  not  simple
cartilage, but j^w-cartilage, in which  the  fibrous
element largely predominates^ Not only this—
they  ignore the researches of  one of the most
distinguished of modern pathological  anatomists.
When Rokitansky pronounces the deposit found in
* Lectures on Orthopaedic Surgery, p. 67. 
ANTERO-POSTERIOR SUPPORT.
a carious vertebra to be tuberculous, he is simply
expressing an opinion as to the nature of this de-
posit, from which any physician, in the present state
of our knowledge of this pathological element, has
a right to dissent. But when he states that inflam-
mation sometimes commences in the intervertebral
substances and extends from them to the contiguous
vertebras, he is announcing a fact which  he has the
means of verifying, and which  cannot be over-
thrown by the exhibition of any number of merely
negative dried specimens  on the shelves of a mu-
seum.  That he does state this most unequivocally
is apparent from the  two following quotations.
Treating of inflammation of the vertebras, he says:*
" It  is very commonly the  primary disease, but
sometimes it is brought on by previous inflamma-
tion and suppuration of the ligamentous apparatus
of the column and of the intervertebral  substance!'
Again, speaking of inflammation of fibro-cartilages,
he makes the following assertion :f "An inflamma-
tion is sometimes met  with in  the  intervertebral
cartilages which terminates sooner or later in sup-
puration, and  is  generally, in the end, combined
with inflammation and caries of the bodies of the
vertebras." So careful  a writer and close an ob-
server would  scarcely hazard a positive assertion
* Manual of Pathological Anatomy, vol. iii. p. 192.
f Ibid., p. 215. 
ANTER0-POSTERIOR SUPPOR T.
of this kind, had he  not  actually seen that which
he describes.
   Mr.  Bampfield  says  unhesitatingly*:   "Dis-
sections prove that the most dangerous  and fatal
consequences ensue from inflammation of the in-
tervertebral  substance, terminating  in its  ulcer-
ation, which brings in its train caries  of the  sur-
faces of the vertebras  to which  it is attached;"
and, further on: f "I am induced to believe, from
appearances on dissection, that the inflammation
primarily  attacks  the intervertebral substance  in
the generality of cases of angular projection."  Mr.
Copeland % and Sir  Benjamin Brodie §  both ad-
vance  the opinion  that certain cases originate  in
intervertebral inflammation, which  has always, in
their belief, a strong tendency to ulceration.
  This point, however, has not so material a bear-
ing upon the treatment as the question of the sim-
ple or tubercular nature of the destructive action.
Of course, if we admit the presence  of a foreign
and noxious deposit  in the structure of the  bone
as the  exciting  and promoting cause of  the de-
structive  inflammation, we  at  once strike at  the
root of all mechanical treatment, whether this con-
sist in the wearisome  confinement to the prone or
* An Essay on Curvatures and Diseases of the Spine, p. ico.
-j- Loc. cit.
% Copeland on the Spine, p. 42.
§ Brodie on the Joints, p. 170. 
ANTERO-POSTERIOR SUPPORT.
supine posture, or in  the employment of instru-
mental support. Among the standard authorities, I
find that Erichsen,* while prefacing his article on
this subject by stating his belief that this " affection
consists essentially in tubercular infiltration of the
bodies of  the  vertebras," makes subsequently the
following admission:  " It must not, however, be
supposed,  that  abscess  necessarily forms  in all
cases ; indeed, the formation  of matter will, I be-
lieve, chiefly depend upon whether the disease of
the vertebras be tuberculous  or not.  Simple co?i-
gestive or inflammatory caries of the spine may take
place to a very considerable extent, and yet no
suppuration occur, the bodies of the vertebras un-
dergoing erosion  and absorption,  and coalescing
so as to become fused  together  into one  soft and
friable mass  of bone, across which bridges of os-
seous tissue  are sometimes  thrown  out, so as  to
strengthen  the otherwise  weakened spine.  In
these cases,  masses of  porcelanous deposit will
not unfrequently  be  found intermixed with and
adherent to the carious bone.   Indeed, this anchy-
losis and fusion of the bodies of the diseased ver-
tebras may be looked upon  as a natural  mode  of
cure of angular curvature  of the  spine,  the only
way in which it can take place, when it has ad-
vanced to any considerable extent."
  The evident meaning  of this passage is,  that
* Science and Art of Surgery, p. 640.
             2 
 14      ANTEROPOSTERIOR SUPPORT.

 only those cases are  tubercular  which  develop
 abscess, and that these cases are  generally fatal.
 Now, as a large  proportion  of cases  terminate in
 anchylosis  and  spontaneous  recovery,  with  a
 degree  of deformity varying with the character
 of the  mechanical treatment, it follows that just
 such proportion  of  cases  are those of simple
 caries.  Quotations  might be multiplied  to show
 that the once  universal belief in  the necessarily
 tuberculous nature of  this disease by no means
 receives the general  assent  of the thinking por-
tion of the profession to-day.^  Mr.  Barwell, whose
 work is  now  a classic, says, in discussing bone
tubercle generally:*   "Tuberculous   deposit  in
bone is,  I believe,  very  rare;  when   it  does
occur, it  is a residt and not a cause of  osteitis.
 •  •   •  •   ..  .  Many an old and desiccated puru-
lent deposit in bone has been mistaken for tuber-
cle; the position in  spongy bone which favors
pressure, the assumption therefore of a peculiar
 form by the dried concretion,  and the fact that
such pus  consists of  broken-down and  disinte-
grated cells with granules, etc., render the distinc-
tion extremely  difficult.  I  must  confess  that  I
could accept  no case as undoubted  tuberculosis
of bone unless some of the deposit was in a state
 of crudity.   It must be  remembered that when we
find tubercles in other organs, even though  most of
* Treatise on Diseases of the Joints, 
A NTER O- POS TERIOR S UPPOR T.
the material maybe in the furthest advanced stage
of softening, some will very nearly always be crude ;
but I am not  aware of any observations of crude
tubercles in bone."
 •''That the disease occurs oftener in those whose
nutrition is enfeebled or  depraved, as  the  result
alike of hereditary vice  of constitution, of expo-
sure, or of deficient or improper alimentation, no
one  will deny;  but the converse of this proposi-
tion, viz., that it may arise in those whose systems
are entirely free from taint, original or acquired, as
simply the result of local injury, I am fully  pre-
pared to maintain.)
   The portion of the vertebra which  is most fre-
quently attacked by the  disease has a very direct
bearing upon  the treatment.  All authorities agree
in telling us that its usual seat is the  body of the
vertebra and the intervertebral cartilage, the pedi-
cles and the processes rarely being affected. 'Now, a
moment's reflection suffices to show that, in those
cases where there is posterior projection, the ante-
rior portion of the  bodies must  be destroyed  to a
greater or  less extent; for it is impossible for such
a projection to take place as long as the anterior
surfaces of contact are integral.  But posterior an-
gular curvature does take place, in by far the greater
number of cases, at a very early stage of the  dis-
ease, so much so that it has given the  name to the
affection.   Hence the conclusion  is  obvious that
the anterior portion of the bodies of the vertebras 
t6      antero-posterior support.
or of the intervertebral substances is the most fre-
quent point of invasion.  There are two sufficient
reasons why the bodies should be affected oftener
than the processes:  First, because they are  com-
posed  almost entirely  of soft, spongy,  reticulated
bone, well supplied with blood-vessels, which is, in
all parts of the frame,  more subject to congestion,
inflammation, and ulceration than the compact os-
seous tissue, of which the pedicles are  almost en-
tirely, and  the processes to a considerably greater
degree than the  bodies, composed.  The pedicles
thus form  an almost insuperable obstacle to the
direct  advance of the disease from the bodies to
the oblique processes.   Secondly, because it is on
this  portion of the spinal column that the entire
weight  of the trunk, head, and  upper extremities
is sustained, and  hence on it must fall  all vertical
shock and  concussion.  The oblique  processes, it
is  true, act to  some extent  as decomposers of
shock,  especially when it occurs somewhat out
of the strictly vertical direction, but owing to the
oblique adaptation of  their  articulating  surfaces,
and  the fact that they admit of a slight degree of
motion upon each other, they rarely suffer serious
injury from this  cause.   The  contiguity of the
viscera of  the abdomen and  chest, and  of those
extremely  vascular  membranes, the  peritoneum
and  pleura, may suggest a  reason why the  ante-
rior  portion should  be more frequently  attacked
than the posterior;  although the preponderance 
anteroposterior support.
17
 of the body anteriorly, producing increased press-
 ure in that region of the column, might in itself be
 considered a sufficient cause.j
   Secondly, the Mechanical Element becomes of
 consequence from the deformity to which the dis-
 ease gives rise.
 (  The natural  support of the head and trunk fail-
 ing, we must supplement it by means of artificial
 support.  Not,  it is true, with  the  object of re-
 moving the deformity,—although that result may
 sometimes be incidentally attained in the prosecu-
 tion of the main design,—but with a view to the
 relief of the irritation produced by the constant and
 severe pressure at the  seat of disease, which press-
 ure  is the main obstacle to a natural process of
 healing.   This  pressure can only be relieved by
 diminishing  the abnormal  curvature, by placing
 the  column  in a position  more nearly  approxi-
 mating its natural curves, and  maintaining it con-
 stantly in that position.  The mechanical  problem,
 then, is  simply, as far as may be  possible, to
 straighten out the curved spine.vy
  The true  method of applying force  to  restore  a
 curved spine to its  normal  direction was  first  dis-
 tinctly enunciated, so far as I am  able to  discover,
by Mr. Lonsdale, in the preface to  his work en-  s^
titled Observations  on  the  Treatment of Lateral
 Curvature of the Spine, published in the year  1847,
and although he had in view simply the variety of
curvature  of which  he was  treating, the  principle
                       2* 
i8
antero-posterior  support
applies with even greater aptness to the angular
deviation in consequence of the anatomical pecu-
liarities  which I shall  presently point  out.  " It
appears  to  me,"  he writes  on page v  of the
preface,  "that  the principle of extension  is not
the best to  act upon to  bring the spine from the
curved into the straight position; nor do I think
it the  most scientific, for the force tells mechani-
cally with  the  least advantage,  and requires  that
most  powerful means be exerted to produce the
desired effect.  All  curves,  no matter of what na-
ture the body in which they exist, are  more easily
rectified by applying the force in an opposite di-
rection, by unbending them rather  than by pulling
upon them at their two extremities; in the former
the advantage  of a  lever power is gained, in the
latter an extending  force only can  be employed,
at the same time that it tells in the least favorable
direction.  This principle is equally applicable to
curvature of the spine where the vertebral column
has been bent  or  thrown out of its natural erect
line by mechanical causes only. The spine, though
composed of many  small bones, is  similarly cir-
cumstanced to a single  long bone, that may yield
or become  curved  from  its structure  being too
weak to resist any mechanical weight it may have
to support, or that may be made to tell against it.
The effect  produced is the  same in both  cases
though the causes are not precisely similar. Taking
this view of the subject, it appears  to me that the 
ANTERO-POSTERIOR SUPPORT.
treatment of a curvature of the spine, depending
on  simple weakness, unaccompanied with disease
of the bones  or ligaments, should be conducted
upon the same principles as when the curvature
exists in a single bone only."
  Lonsdale was deterred, as we see, from applying
the principle he thus clearly enunciates to the case
of angular curvature by the  fear of injury to the
diseased vertebras, owing to a failure to appreciate
the precise pathologico-anatomical conditions, and
all subsequent English writers seem to have shared
his apprehensions, for we  find  Mr. Heather Bigg,
" Anatomical Mechanist to the Queen," etc., in a
treatise on what he styles Orthopraxy, just issued
from the press of John Churchill, London, after de-
scribing an instrument for making pressure against
the  dorsal curve, in cases of posterior curvature
dependent on  mere  debility,  saying of Pott's dis-
ease, that "any attempt  to make the same amount
of pressure below the axis of  curvature would here
lead to most disastrous results."*
   Fortunately, American medical science is pretty
well out  of  the leading-strings of  its European
nurses, and dares to think for itself.  The problem
was now fairly before it  in both its equations : the
Pathological, the nature and seat of the disease,
with the resultant  deformity; the Mechanical, the
  * Orthopraxy: the Mechanical Treatment of Deformities, De-
bilities and Deficiencies of the Human Frame, p. 245. 
20
ANTERO-POSTERIOR  SUPPORT.
true method  of employing  force  in accordance
with the laws of physics, in  order  to unbend the
curve.
  Anatomy furnished the key to its solution, and
it was grasped by an American physician.  Dr. H.
G. Davis, of New York, whose suggestions on this
subject, as well as in relation to the treatment of
the cognate affection, disease  of the hip-joint, have
laid the  profession and humanity under a lasting
debt of gratitude, published a paper in the Ameri-
can Medical  Monthly  for  March,  1856, entitled
" Deformities and their Remedy."   In the course
of this article, he holds the  following  language:
" The common mode of constructing apparatus  to
sustain the weight of the  body on crutches is en-
tirely useless, as the  crutch  impinges directly
against the bundle of nerves and blood-vessels that
meet in the axilla, upon which the weight of the
arm cannot even be borne, much  less that of any
additional portion of the body.  I think, however,
that this difficulty has been seen by surgeons, but
there  was not found any other point where  sup-
port could  be applied.   It was  rather a choice be-
tween  two evils, that  of no support, or in  this
way."   In a continuation  of  the same article in a
subsequent number of the MontJUy, he enunciates
as I believe, for  the  first time, the true principles
of treatment for  "Angular Curvature," as follows:
"As the treatment  of  angular  distortion of the
spine, the result  of ulceration of the vertebras  is 
ANTERO-POSTERIOR SUPPORT.
21
 mechanical,  so far as  restoring or  retaining the
 figure erect, it will be advisable to  examine cur-
 sorily the form and points of support of the verte-
 bras, as involved in this kind of surgical treatment.
 As far as  our purpose  is concerned,  it will be
 necessary only to mention  the body (the seat of
 the disease  usually), the  oblique and the spinous
 processes.
   " The body and the oblique processes afford the
 only perpendicular support; the distortion is  pro-
 duced by the removal of the body of the vertebras
 by ulceration.  As the line of perpendicular  sup-
 port falls between the body and the articulation of
 the oblique processes, the weight  of  the trunk
 above approximates the bodies of the two adjoin-
 ing vertebras, as  the  diseased  one  is  removed by
 absorption; the oblique processes, now sustaining
 the greater part of the  weight, act  as fulcrums
 upon which the vertebras are tilted or rotated;  thus
 the spinous processes above and below are sepa-
 rated from  that of the diseased one, the articula-
 tion of  the  oblique processes  being  the centre of
 motion.
   " It is this form of the vertebras which enables
 us to make  use of the whole column  as a lever to
 restore  it.   By apparatus we are enabled to throw
 the entire weight of the  superincumbent body upon
 the oblique  processes, and separate the  bodies ad-
joining  the  diseased  one from it,  the  contact of
 which was constantly irritating and producing ab- 
22
ANTERO-POSTERIOR SUPPORT.
sorption.   By  this  mechanical arrangement the
spinal  line is brought  into  its natural position.
This replacement is advantageous, not only by re-
storing the figure,  but,  by  the  removing of all
mechanical  irritation and pressure,  it, in many
cases, stops the disease at the same time; the pro-
cess of reparation commences upon the applica-
tion of the apparatus.  The apparatus should con-
fine the  parts  quite immovably in their normal
position, and retain them there until recovery has
taken place.   Thus supported,  I have seen a large
majority of cases restored without  the  use of any
constitutional treatment,  with the exception of air,
diet, and exercise.  As the  ulceration seldom ex-
tends  to the oblique processes, we  are  always en-
abled to use them to sustain  the weight of the
body above."
  Thus,  we  have  the   demonstration  complete:
Pathological Anatomy shows us  an intervertebral
cartilage in a condition of congestion or softening,
yielding  to the pressure from above; the body of
an  inflamed  or ulcerated vertebra crumbling an-
teriorly under  the  superimposed  weight of the
head, trunk, and  upper extremities, and thus pro-
ducing a posterior projection of the spinal column.
Mechanics indicates the true  method of redressing
this distortion, and thus relieving the pressure
provided the necessary conditions are present for
applying the force;  and Physiological  Anatomy,
scientifically interpreted,  triumphantly steps  in  to 
ANTERO-POSTERIOR SUPPORT.
23
point out  the oblique processes, happily protected
from the ravages of disease, as the precise means
desired.   More fortunate than  Archimedes,  we
have found our fulcrum.   A world of suffering and
disease may now be moved.  I say a world of suf-
fering ; and that I  use the expression advisedly, let
an English writer testify.  Mr. Bampfield, in  his
essay already alluded to,  says:*  "When the per-
version of the  natural  situations  of the viscera, of
the great blood-vessels, of the ganglionic system of
nerves, and of the thoracic duct, is contemplated;
when the  structural alterations and deviations of
the lungs, heart, liver,  and some other  of the vis-
cera, aorta descendens, venas cavas, thoracic  duct,
and some of the nerves, are considered ; when  the
derangements of  the spinal  cord and  the spinal
nerves, of the abdominal  and  intercostal muscles,
and  diaphragm, and  the curved and   shortened
spine, are  weighed; when we view the spinal mar-
row, thus  deranged, as the principal source of sen-
sation  and motion, and know the spinal nerves  are
distributed to all  the viscera contained within  the
thorax, abdomen, and pelvis, and  supply them with
the nervous energy necessary  to their  important
functions,  as well as to the muscles of the upper and
lower  extremities, back, chest,  diaphragm, and all
the other constituent parts, besides possessing a
connection with the nerves of the brain through
* Op. cit., p. 40. 
24
ANTERO-POSTERIOR SUPPORT.
the ramifications of the  great sympathetic;  when
we reflect  on the aggregate of disorder and  dis-
placement  of the  framework and the  frame, we
cannot be astonished  at hearing an appalling cata-
logue of maladies which are attendants or conse-
quences  of spinal deformity and disease,—a cata-
logue whose history and  treatment  to  pursue and
dwell  upon  in  this  dissertation, would  make  it
almost endless, for I have known the head affected
with  severe   pain, occasionally predisposing to
phrejtitis and death; the eyes affected with convul-
sions and imperfect vision; the ears with deficient
hearing; and I  have witnessed as companions to
curvatures of the spine, dyspnoea, asthma, conges-
tion and  inflammation of the lungs;  imperfect oxy-
genation of  the  blood; palpitation of the heart;
aneurisms of the aorta;  a corded tightness across
the epigastre;  gastrodynia; indigestion ; loss of
appetite, or  a vitiated state of it;  torpor of the
liver, or deficient secretion of the  bile; constipa-
tion;  discolored  feces; morbid secretions of the
kidneys, involuntary discharge of urine  and  feces;
a variety of nervous feelings ; epileptic fits  ; numb-
ness and coldness of the extremities ;  tic-doulou-
reux-like pains about the joints of  the  lower ex-
tremities and muscles, and of the posterior part of
the ilium,  paralysis of the upper and  lower ex-
tremities, and an almost  universal torpor."  An
appalling catalogue, truly, and  yet  for  its  correct-
ness I can myself vouch  in almost every particular 
ANTERO-POSTERIOR SUPPORT.
allowance being made for modern alterations  in
the nomenclature of disease.

                     Fig. i.
  But to return to our demonstration.  The accom-
panying illustrations indicate the manner in which
                       3 
26       ANTERO-POSTERIOR  SUPPORT.

the oblique processes may be made to take  the
place  of the bodies  as the supporting column of
the trunk.  Figs. I and 2 are taken from an Ameri-
can reproduction of the anatomical plates of Bour-

                      Fig. 3-
gery and Jacob.   The bodies of two lumbar verte-
brae are here represented with the processes of the
left side only.  In Fig. I their position is such as 
ANTERO-POSTERIOR SUPPORT.
would result from partial destruction of the inter-
vertebral substance anteriorly, permitting the op-
posing surfaces of the bodies to come  in  contact.
In  Fig.  2  they  are maintained nearly in  their
natural position, the support being through the ob-
lique processes.   Fig. 3, from Richardson's Human
Anatomy, gives a lateral view of six inferior dorsal
vertebrae ; a dotted line shows  the new column of
support.   The oblique direction of the planes of
articulation  of the  oblique processes, well shown
in this illustration, makes them more available as
points of leverage  for  our antero-posterior  force
than if they presented  the horizontal plane of the
articulations of the bodies.  This  will  be under-
stood by reference  to  the accompanying diagram
(Fig. 4).    Let the  horizontal lines  ab  and ef
represent the forces exerted by an instrument at
the  extremities of the spinal   column.   On the
principle that action and reaction are equal, the re-
sistances to these  forces  will  be  represented by
ac and eg, respectively, and the resultant of these
resistances will be  dh,  acting at the centre of the
articulation  of two oblique  processes.   But  its
direction relatively to the plane  of this articulation
being  oblique, it  may be  decomposed  into  two
forces, hm and hn, of  which hn only will  exercise
any force of displacement.  The strain on the liga-
ments is thus  very materially  lessened,  while, at
the same time, the surfaces  of  contact are nearly
doubled. 
28
ANTER 0-POS TERIOR S UPPOR T.
Fig. 4-
  Being thus provided with a satisfactory fulcrum
for our spinal levers, it is evident that  our instru-
mental  levers, which  are to  act  upon them, must
have their point of action at the same relative posi-
tion.  In other words, that pressure must be made
against the curve at, or just below, its apex.   But
here we are met with the  practical difficulty, that
the integument immediately covering the project-
ing spinous processes  is too  delicate to admit of 
ANTERO-POSTERIOR SUPPORT.
any pressure sufficient to  accomplish our  object.
Can we avoid pressure  upon these  spinous  pro-
cesses, and still  meet the indication ?   Anatomy
again helps us to a solution.  In Fig. 5 we have
the upper surface of a dorsal vertebra; (1) being

                      Fig- 5-
the body, (2) the spinous process, (3) the foramen
for the passage  of the spinal  cord,  and (4)  the
transverse processes.  These latter, it will  be no-
ticed, project laterally far beyond the body of the
vertebra, and being, moreover, protected by a thick
cushion  of muscles, which fills  up all the inter-
space  between  them  and  the  spinous process,
afford an admirable surface of resistance on either
side, leaving ample room for the spine to project
between.
   Having thus established our principles of treat-
ment on a rational and scientific basis, it only re-
                       3* 
30      ANTERO-POSTERIOR SUPPORT.

mains to indicate the best means of applying them.
I am not aware that Dr. Davis has  published any
description of the apparatus which he makes use
of to carry out the theory he originated.
  The instrument which I am in the habit of em-
ploying, and with the results of which I have every
reason to feel  satisfied, was first introduced to the
notice  of the profession  at large  at the session of
the Medical Society of the State of New York, in
1863, by  Dr.  Charles  F. Taylor,  of New York
City, in a paper entitled the " Mechanical Treat-
ment  of Angular Curvature, or  Pott's Disease of
the Spine."  '
  It is proper  to remark, however, that Dr. Taylor
had been, for  several years previous to  the pub-
lication of this  article, engaged in perfecting his
invention, and that most of  the  leading  practi-
tioners  of New York were  already familiar with
his  treatment.  I give the description of the instru-
ment, principally in his own words, introducing
my own remarks in parentheses :
  "A broad band  passes  around the trunk low
down, so  low  that  in front  it almost touches the
thighs  in sitting.  It passes just above the pubis
and entirely below the abdomen, so that the abdo-
men is sustained upward, instead  of being, as in
most instruments, pressed downward.  There are
two pieces or levers passing up the back, not over
the  spine,  but  each  side  of it, so that it  is firmly
held from lateral   deviations.  At the  top  is  a 
ANTERO-POSTERIOR SUPPORT.
 cross-piece, in the form of two T's, with the small
 ends  united.   The  object of this arrangement is
 that the straps may pass directly  forward and
 around  the arms, and  thus  prevent  a great loss
 of force  by diagonal action; and also  that they
 shall touch the person only where the pressure is
 needed,  namely, on the forward part  of the shoul-
 ders.  This arrangement entirely obviates the pain-
 ful  and  dangerous ligaturing of  the arms which
 would occur if the straps passed forward from one
 point."  (This object may be still further promoted
 by making the lower arms of this scapular or cross-
 piece spread outward until they reach the line of
 the axilla.  I  usually direct it to be made twice as
 wide at the bottom as at the top,  thus producing
 no lateral pressure  whatever, and removing  all
 danger of abrasion in the axilla.) " At a part of
 the  instrument  opposite the  seat  of disease, the
 point where we make our fulcrum, the pads are
 placed.  These  pads are very important.  They
 are made of chamois-skin  or  Canton flannel, and
 are  filled, not  with cotton,  which  soon packs and
 becomes  hard, but  with long, elastic African  or
 East India wool, which has no felting qualities.
   " These pads are  not permanently attached to
the  instrument, but are made  separate  so that
they can  be removed as often  as they become
at all  compacted.   The shoulder-straps and the
band around the hips are  likewise provided with
similar removable  pads to protect the skin  from 
ANTERO-POSTERIOR SUPPORT.
pressure and  abrasion.  It will thus be seen that
the instrument, like  the  spine itself, acts like a
double  lever with  a common  fulcrum  at  the
curvature;  this  action  is  directly  backward at
the hips  and shoulders,  and  directly  forward at
the middle of the back, or wherever the diseased
part is  located.  Thus the posterior portion, the
only healthy  portion  of  the  diseased vertebra, is
made to support a part of the weight of the body,
and the intervertebral cartilage and  bodies of the
vertebrae,  where the disease exists, are  relieved 01
pressure.  .  .  .  The  instrument is provided with
several  hinges,  stop  hinges  in front but free to
bend  backward, which   allows  the most  unre-
strained use of the muscles of the back.  When-
ever the  spinal muscles  are  brought into action,
instead of acting against unyielding resistance, the
instrument  bends  freely  backward, thus stimu-
lating and encouraging  muscular action, as the
patient, when  free to  do so,  involuntarily makes
frequent effort to gain momentary relief from the
instrument by attempting to straighten himself up.
Indeed, the spinal muscles, by alternate action and
rest, actually alternate with the instrument in sus-
taining the weight of the body and overcoming the
curvature.  It has proved to be useful in causing the
development of the spinal muscles instead of bindino-
them up and causing their atrophy, as results from the
use of instruments which prevent muscular action."
  In this  last-mentioned  respect, Dr. Taylor's in- 
ANTEROPOSTERIOR  SUPPORT.
strument goes  a step  in  advance of Dr. Davis's
proposed plan  of treatment.  The  latter says, it
will be remembered, " the apparatus should  con-
fine the parts quite immovably in their normal posi-
tion, and retain them there until recovery has taken
place;" thus making no provision for the exercise
and development of these important accessories.
I have seen a back that was almost bare of mus-
cular tissue, in  consequence of the  wasting strain
produced by the deformed position of the trunk,
become quite well developed in the course of a few
months under the simple use of this instrument.
  The uprights or levers, described above by Dr.
Taylor, should  be made of steel, sufficiently strong
to sustain the entire weight of the trunk, and thus
resist completely any effort, voluntary or involun-
tary, at  flexion anteriorly, while  at the same time
they should be of such temper that the physician
can, if furnished with the proper  appliances,  bend
them to suit the varying requirements of the case.
Above all things, they should  not be—what every
instrument-maker is most desirous to make them—
elastic.  " Spring," as  they call it, is the very last
quality to be sought in a spinal splint. In the treat-
ment of this disease there can  be no compromise.
The instrument which fails to  give  complete sup-
port had better not be worn, as it will only embar-
rass and annoy the patient by its weight.  It may
seem  a  paradox, but it is nevertheless true, that,
after reducing the weight to a certain point, every 
ANTERO-POSTERIOR  SUPPORT.
ounce taken off from the effective part of an instru-
ment only makes it so much the heavier. As long
as the spine is well  supported at the seat of disease,
the weight of the instrument is unnoticed; but as
soon as an irrational desire for lightness and beauty
diminishes the strength of the latter below the point
of due resistance, it at once becomes an annoyance,
and the less efficient the support the greater is the
intolerance of it.  Each upright is usually furnished
with two hinges, as described by Dr. Taylor, and
the portion between these hinges being made wider
and lighter than the rest, forms the pad-plate.  Im-
mediately beyond  each hinge is a  screw passing
through the upright and pressing against the pad-
plate.  This renders the instrument  capable of the
nicest  adjustment,  the pressure  of the pad being
regulated by these screws.  While these screws
afford a most admirable means of adjusting the in-
strument with little trouble, and without  removal
from  the  person, they are, however, open to the
objection of weakening the uprights at  their points
of penetration. To compensate for this local weak-
ness, the entire instrument must  be made stronger,
and therefore heavier.  Where  a patient  is very
young or very weak,  this increase  of  weight is a
decided objection.  To obviate this,  I have devised
the following mechanism:  For  the two screws I
substitute two very thin steel  or brass slides, one
end of each of which  is welded around a piece of
wire,  thus forming a  wedge.  These  slides pass 
ANTERO-POSTERIOR SUPPORT.
 under the hinges, and are  retained in place by a
 fine screw penetrating the centre of the pad-plate,
 up and down which they play by means of a slot.
 Now, it is  obvious  that  the wedge being  drawn
 between the pad-plate and the upright will increase
 the pressure of the former at either end as may be
 desired, and that the nearer it is approached to the
 hinge the greater will be the increase  of pressure.
 If it is desired to limit the pressure  to a certain
 degree, as in the case of lordosis, I cause the up-
 right to pass through the free end of the slide, and
 place a small button on the  underside of the latter,
 which, working in a slot  in the pad-plate, effectu-
 ally controls it. Support is  afforded to the usually
 distended  and  pendulous abdominal walls  by an
 apron attached below to the strap of the hip-band,
 and buckling to the uprights  behind.  Where it
 appears desirable, this apron may be carried suffi-
 ciently high to exert a moderate amount of pressure
 on  the  projecting sternum and thorax anteriorly.
 Care must be  taken, however,  not to embarrass
 respiration.^'
  The instrument is seen applied in Fig. 6,  which
 is copied from  a photograph of
  Case I.—Joseph Armstrong, of  Pottsville,  Pa.,
July 21st,  1865, set. 17 years.   Began  to work in
the mines when quite a small boy.   Had  a "hard
boss,"  and was  obliged to lift heavy weights.
Afterwards  worked  in a foundry, where also  he
had much severe lifting to do.   About four years 
36      ANTERO-POSTERIOR SUPPORT.
since, discovered  a small  projection of the spine
about the middle  of the back, and very soon after
found that he was losing  strength.   At this time
he" began to suffer from pain in the right side and
hip,  and to be unsteady  in his  gait, frequently

                     Fig. 6.
falling.   During the first six months, was  subject
to " cramping pains" in the stomach and bowels,
at one time lasting a week and confining  him to
the bed.  The deformity steadily progressed, and
his general health became more and more impaired, 
ANTERO-POSTERIOR SUPPORT.
 until the third year of the disease.  He then came
 to Philadelphia and consulted a distinguished  sur-
 geon.  By his advice he went to one of the  first
 instrument-makers of the  city, who provided  him
 with a brace of the ordinary construction.  This
 gave him  so much  pain that he was able to wear
 it only  four  weeks,  during  which  time  he ex-
 perienced  no relief whatever from its  use.  Since
 then, a period of nearly a year, his condition has
 continued  to grow worse.
   Present  Condition.—Face  anaemic, considerable
 emaciation ;  is very feeble, not being able to walk
 a square without resting.   Considerable dyspnoea
 and frequent palpitations.   The four lower dorsal
 vertebras form a curve of great prominence, which
 is complicated by an  extreme lateral deviation to
 the  right.  He walks much  bent, with the right
 hand resting on the knee.  Habitual position when
 at rest, the chest supported on the seat of a chair,
 while the knees are braced against the round.
   I applied the splint at the above date.   The ac-
 companying  cut is after a photograph taken six
 months  later, in  January of the present year.  At
 that time he  expressed himself as rapidly gaining
 strength.   Had  a  good  appetite; could walk  a
mile; his carriage was so erect that his old friends
often passed  him in the street without recognizing
him.  The lateral  curvature  was almost  entirely
corrected.  Color better.  Is gaining flesh. Suffers
from neuralgic pains in  both legs, more severe in
                       4 
38
ANTERO-POSTERIOR SUPPORT.
the right.  This has been a troublesome complica-
tion of the case, but is diminishing.  The palpita-
tions have ceased entirely.  He now feels himself so
far restored that he has opened a small store.

   When the cervical vertebrae are the seat of dis-
ease, it becomes necessary to find a point  above
the level of the shoulders against which to exert
pressure anteriorly.  The only available point for
this purpose is the chin.  To reach it, the following
modification of the instrument is necessary.  The
scapular is  made  with lower arms  only, and the
straps  are attached  above at the angle where the
arms are given off.  In the centre of the scapular
is  placed a keeper, for the reception of an upright
which  carries  the  occipital bow.  This  upright is
three or four inches  in length, and furnished with
holes which,  corresponding with  a hole  in the
centre  of the  keeper,  enable it  to be  securely
fastened  by a screw at any desired height.  The
occipital bow, covered with  silk  or  velvet, and
slightly padded, passes up under the occiput to a
point a little above or  below the level of the ears
on either side, and is armed at its extremities with
two small hooks or flat rotating buttons.  Unless
the atlas and axis  are supposed  to  be involved in
the disease, this piece rotates on the upright, thus
giving  ease  and freedom  of motion to the head;
but if that be the case, all lateral  motion should
be avoided, for fear of  rupture of the lateral liga- 
ANTERO-POSTERIOR SUPPORT
39
 ments, possibly weakened by ulceration. The chin-
 piece may be either a leather  strap or a light steel
 band, covered and padded where it makes pressure,
 and with an opening in the middle to receive the
 point of the  chin.  At either  end of  the strap are
 eyelet holes, or if the steel band be  used, several
 narrow transverse openings, to admit the button on
 the occipital piece, which, being turned, makes it
 perfectly  firm.   I prefer the  latter,  as it  can  be
 made narrower than the leather, is  more secure,
 and does not compress the cheeks so much.  •/
   The  little fellow from whom the drawing  on
 page  41 was made presents the  following his-
 tory:
   Case II.—C. W. H., seen in  consultation with
 Dr. S. Weir Mitchell, September 9th, 1865, native
 of Philadelphia, ast. 2 years 9 months.  At birth
 was considered by the  attending physician to be
 hydrocephalic.   This tendency rapidly developed
 until, at the age of six months,  the  head had
 become very large, and there was evidently water
 on  the  brain.  For several months  his  life was
 despaired of.  From  this  condition,  however,  he
 at last began slowly to  recover until his  health
 became tolerably good.   At the age of eighteen
 months, he fell to the floor from a high counter in
 his father's store, striking the back  of the head
and upper part of the spine.  Toward the end of the
second  month after this fall, his mother observed
that he seemed to suffer on being moved, so that 
40
ANTERO-POSTERIOR  SUPPORT.
soon every attempt to lift him, especially the move-
ments incident to dressing and  undressing, caused
immediate and  violent  fits  of screaming.   His
mother writes:  " If laid upon his back, he  seemed
to suffer most intense agony,—he was very restless
at night, lifting his head and  letting it fall again as
if too heavy for the spine to bear, and crying out
very often.  Indeed, we never had a good night's
sleep until he  began to wear  your  instrument."
He made  no  attempt at walking  until he was two
years old, and then very feebly, stooping at the hips
and dragging the feet.   About two months  later,
it was noticed  that he  held his  head stiffly, and
used his right arm very  awkwardly.  In the course
of six or eight weeks from this  time, a prominence
of the spine  was observed  for the first  time just
above the level of the  shoulders.  By the advice
of a female hydropathist he was " packed!" for the
space of about  six weeks,  with  what amount of
benefit may be  imagined.   He  was then provided
with an ordinary spinal brace, but still continued
to grow worse.  At the date of coming under my
care his gait  was extremely unsteady, his appetite
irregular,  his sleep disturbed, and his disposition
excessively irritable.  Paralysis of the lower  limbs
had  evidently commenced, and before I  could get
an instrument made for him, he  had entirely lost
their use.  The upper  dorsal and two lower cer-
vical vertebrae  were affected, quite a prominence
existing at that point,  and  the  cervical  column 
ANTERO-POSTERIOR SUPPORT.
Fig. 7.
 
ANTERO-POSTERIOR SUPPORT.
 being directed forward at a sharp  angle  from it.
 Fig.  7 shows the  instrument as  worn  by  this
 patient.  The improvement in his general health
 on its application was immediate and marked.  He
 became cheerful, his nights restful, his appetite con-
 stant, and  his movements, so far as the head  and
 upper extremities were concerned, natural.  The
 paralysis of the lower limbs is slowly passing off
 Dependent, as I believe it to  be, not on compres-
 sion of the cord, but on  meningeal  congestion or
 inflammation, it is not to be expected that it should
 diminish pari passu with the improvement in other
 respects. (The further progress of this case will be
 found detailed  in the paper  on  " Suspension" as
 Ca&sJNTo. i.)
f  The lateral deviation which accompanies many
 antero-posterior curvatures differs from true lateral
 curvature  in the  fact that  it is  rarely associated
 with  rotation of the bodies of the vertebrae.  It is
 a simple yielding to one side, probably on account
 of the greater  relative destruction of the corre-
 sponding side of the affected vertebra, or, it may
 be, of the ligaments of the opposite side.   It
 usually begins  to improve very soon under  the
 application  of  antero-posterior  force, and often
 disappears  entirely  without any other appliance.
 Its presence, however,  of  course  necessitates  a
 greater degree of pressure upon the opposite side
 of the vertebral prominence, and for the  relief of
 this, as well as to hasten, in some cases, the restora- 
ANTERO-POSTERIOR SUPPORT.
43
Fig. 8.
tion to  the  erect posture, I sometimes add  to  the
instrument the contrivance depicted in Fig.  8.
  It consists of a  firm  steel  upright having  a
broad padded crescentic top, and provided with  a
cross-piece.   The upright is riveted to the hip-band
on  the  side toward which  the  trunk yields, at  a
point immediately under the  centre of the axilla, 
44
ANTERO-POSTERIOR SUPPORT.
and is of such  length that its  upper crescentic
border touches  the axilla  without making  any
upward pressure, the action being purely lateral.
The cross-piece is riveted to the upright at a point
a little below the seat of greatest curvature, and
extends horizontally until it reaches the anterior
and posterior planes of the body.  A broad rhom-
boid binder, stiffened in its  vertical  diameter by a
thin whalebone, passes around the convexity of the
opposite side, and buckles by straps to either end
of the cross-piece.  A simple lateral force is thus
exerted without  compression of the thorax, usually
contributing much to the comfort of the patient as
well as to the removal  of the deformity^y
  Case III.—Miss A. K., aet. 13 years, was  placed
under my care by Dr. J. T. Carpenter, of Pottsville,
Pa., in March, 1865.  Rather more than three years
before,  her gait became stiff and peculiar,  her
strength notably diminished, and she evinced a
constant desire for  extraneous support by leaning
against articles of furniture.   Before long a slight
prominence was  discovered  in the lower part of
the back,  and in a few weeks she began  to suffer
pain in both legs, especially the right,  and to have
cramps in the spinal muscles.
  The  deformity progressed steadily  though  not
rapidly, the  general health  slowly deteriorating
until  she  became quite feeble and emaciated.   At
the time I first saw her, the spine presented  a large
irregular  curve,  involving  the five lower dorsal 
ANTERO-POSTERIOR SUPPORT.
vertebrae, with considerable tendency to lordosis,
and extreme  lateral  deflection to the right.   She
walked  habitually with the right hand resting on
the right thigh,  or dragging down  her dress from
the hips with both hands  in order to support the
trunk and  shoulders.  She walked with difficulty,
and could not go a rod without being compelled to
sit down and rest.  The application of  the instru-
ment afforded relief to the pain and difficulty of
locomotion  in  a  surprisingly short  time,  and
her  improvement has  been constant  ever since.
To-day, January 27th, 1866, ten months after it was
first  put on, she  has  walked three  miles in the
course of the morning, without any very serious
fatigue.   She has a  good  appetite, healthy color,
and  is gaining flesh.  Her gait is  firm and com-
paratively  natural, although the tendency to lor-
dosis, which  still exists, makes  her a  little  more
erect than is graceful. The  lateral deviation yielded
in a  marked  degree  to the antero-posterior force,
as usual,  but only up to a certain point; and to
keep it at this  point  required a great degree of
pressure on the opposite side of the prominence.
The lateral action was therefore added after she
had  been about six  months  under  treatment, and
has had the  effect of still  further  remedying this
phase of the  deformity.
  Dr. Taylor has recently suggested a modification
of the instrument (Fig. 9) to meet the peculiar de-
formity known as lordosis, referred to  in the case 
ANTERO-POSTERIOR SUPPORT.
Fig. 9.
above related.  This consists in dispensing with the
lower hinge, and causing the lower lever to  fit  in
directly under the  projecting shelf formed by the
spine and ribs, following  closely the curve of the
lumbar column, except just at its centre.  Instead
of a small pad-plate just at the seat of disease, the
lower lever is provided for its entire  length with a
thin steel plate, which is well padded.  The press-
ure  is thus made upward as  well as forward  at
the point of projection, and the tendency is to open
out this secondary curve, as if by a wedge. 
          ANTERO-POSTERIOR SUPPORT.       aj

   Whatever be the nature of the deformity,  and
 whatever the modification of the instrument,  it is
 essential  that  the  latter should be  kept acting
 forcibly in  order to be of any  service.   If worn
 loosely, it fails of its object, and  is simply burden-
 some.  To  this end, the pressure of the pads must
 be considerable, and much care is therefore requisite
 to  keep the skin  underneath  them in  a healthy
 condition.  The danger is not of simple excoria-
 tion,  but  of that diminution of the vitality of the
 skin, which results in passive congestion and solu-
 tion of continuity from  simple disorganization,  and
 which, when it affects the deeper-seated tissues, has
 received the name of bed-sore. To  guard against this
 result, parts subject to pressure should, at least once
 daily, be carefully bathed in cool water.   Friction
 of the surface and  kneading of the  deeper tissues
 with the fingers  should be employed to promote
 the capillary circulation and stimulate the sentient
 nerves, and  applications  of astringent  solutions
 should  be made with  a  view  to hardening  the
 integuments.  If an ulcer be formed, it should  be
 coated daily with a mixture of collodion and cas-
tor oiLJof which the prescription is subjoined.*
  While to  Dr. Davis belongs the credit of having
 first distinctly pointed out the anatomical fact which
* R.—Collodion,^';
     01. ricini, V(\y.  M.
  S. Apply with a camel's-hair pencil. 
ANTERO-POSTERIOR SUPPORT.
enables us to treat successfully this most distress-
ing malady, the fallacy of the prevailing style of
apparatus, viz., that which relies for  its action on
counter-extension by  transmitting the weight of
the head and trunk from the axillae to the pelvis,
was long ago exposed  by  Prof. J.  K. Mitchell,
of the Jefferson Medical  College of  Philadelphia.
In an editorial foot-note  to  Mr. Bampfield's prize
essay On the Curvatures and Diseases of the Spine,
already alluded to, and republished by him in  this
country, in 1845, he says: " I may here repeat that
the axilla, being  a movable point, affords no good
means of support, and that there are many objec-
tions to throwing the weight  of the  head  and
shoulders on the pelvis."   These objections he
had alluded  to  nineteen years  before in a com-
munication which appeared in the first number of
the North American Medical and Surgical Journal,
asserting that this  class of instruments "so bind
down the muscles  of  the trunk, so compress the
abdomen and chest as to  be sometimes  useless
and often  prejudicial."   The plan of  treatment
which he adopted to  avoid  these  difficulties, and
which is fully described, with illustrations, in the
article  referred to,  consisted of  a  revival, in  a
modified form, of the old method of suspension.
   The apparatus may be found  described, almost
exactly, in the fourth  volume of the Jlfemoires de
VAcademie Royale de Chirurgie de Paris, in  a con-
tribution by M. Le Vacher, in the  year  1768; the 
ANTES0-POSTERIOR  SUPPOR T.
difference between his mode  and  that  of  Prof.
Mitchell being, that the former attached his mechan-
ism to a corset, worn on the person, while the latter
found his point of support altogether outside of the
body, and was thus enabled to make use of the
entire weight  of the trunk and lower extremities
(and in some  cases even  of the upper) as an ex-
tending force.  In no other way can the principle
of extension be made available.  That it can be
made available in this way, both  in angular and
lateral curvature, the very interesting and success-
ful  cases  published by Prof. Mitchell sufficiently
attest.   It is difficult  to conceive why so valuable
a means, so well introduced and so ably supported,
should have been allowed to fall into such complete
disuse.
  The medicinal treatment  of this affection  does
not fairly come within the purpose of this paper,
and, in  fact, I have little  to say of it save in the
way of deprecation.
  Suppurative counter-irritation is mentioned only
to be condemned.
  The gastric and ventral pains are not produced
by worms, and  therefore  do not demand vermi-
fuges.   They  are not  dependent upon  disease of
the mucous membrane, either organic or func-
tional,  and  therefore  will not  yield to  bismuth,
nitrate of silver, or the acids.   They are probably
the result of spasmodic contractions  of the mus-
cular coat of the stomach  and  intestines, and, like
                       5 
ANTERO-POSTERIOR  SUPPORT.
all spasm, may be temporarily relieved by opiates,
alone or combined with chloroform.  In my ex-
perience the combination known  as  chlorodyne,*
for which  I append  a prescription, is the  most
efficacious for soothing this distressing symptom,
but  nothing will  permanently  benefit it,  except
cessation of the central irritation.
  The furred tongue, foul breath, deficient appe-
tite, and  other evidences  of imperfect digestion
which so often accompany true spinal disease  do
not  invariably indicate, as  they almost invariably
receive, a course of tonics and stimulants.   Gentle
purgation, systematically followed up, will  often
be  attended with  the happiest results when the
other plan has failed.  When a medicinal tonic is
evidently required, some combination of cinchona,
iron, and phosphorus  will be found to meet the
indications most nearly.   Phosphoric acid  lemon-
ade  is a grateful beverage, and well  calculated to
supply waste both of bone and nerve.  One tonic,
however, may and should be administered very
* R.—Liq. morphise sulphatis (gr. j ad ^j) ^ss ;
     Tinct. cannabis Indicse (gr. ij ad £j), zj ;
     Syr. gum. acacise, ^j;
  Misce et adde
     Chloroformi,
     Spt. ether, sulph., Ha ^ss ;
     Tinct. capsici,
     Acidi hydrocyanici (dil.), all ^j.  M.
  S. From five to thirty drops in a little water. 
ANTERO-POSTERIOR SUPPORT.
51
freely—open  air.   Large doses  of this invaluable
remedy (the  action of which is much heightened
by the stimulus of the direct  rays of the  sun), in
connection with  a due regard  to other hygienic
precautions and efficient mechanical support, have
usually sufficed, in my experience, to remove all
the general symptoms without resorting to medi-
cation at all.  |  When there are indications of acute
inflammation in either the vertebras or the menin-
ges, the recumbent posture should be resorted  to
for a considerable portion of the time ; and much
good may alscr be accomplished by the daily appli-
cation of the  spinal ice-b_ag.
   Such collateral or sequential affections as paral-
ysis, psoas abscess, secondary abscess, etc., do not
come within the scope of this  essay.  The first,
however,  I may be justified  in alluding to, simply,
as it has  been  made  the  ground  of a severe, but
unfounded, criticism  upon  the action  of  the  in-
strument  I  have  been describing.   It  consists
in the suggestion of the possibility that the ver-
tebras  may  be separated with such  rapidity  at
the seat of ulceration  as to make a more or less
wedge-shaped opening into the cavity of the spinal
canal, into which  the  cord  may protrude, and  in
the event  of  a  temporary intermission of the use
of the support, be subjected  to compression be-
tween  the ulcerated surfaces  of the  bodies, thus
inducing paralysis.  Those to whom this fear sug-
gests itself should  bear in mind the following facts, 
ANTER0-POSTERIOR SUPPOR T.
which, taken together,  render the occurrence of
such an accident infinitely improbable, not to say
impossible.
  ist. That at least one-fourth of the spinal column
is composed of highly elastic fibro-cartilage,—a por-
tion of which is indeed mere pulp,—and that on the
relief from superincumbent  pressure, this elastic
fourth portion  would  be the first  to  regain  its
normal  position and consistence,  and that, more-
over, by virtue of its elasticity, expanding down-
ward  as well as upward, it would tend  to  retard
this dreaded gaping open  of the" diseased ver-
tebrae.
  2d. That not the vertebral column alone, but
the entire  thorax,  participates  in the deformity,
that the ribs are  approximated one  to  another,
and the thorax to the  pelvis, and that the inter-
and intra-costal and the powerful  abdominal mus-
cles, having become contracted from position, must
first be stretched out to their normal length, along
the whole  anterior surface of the trunk, before the
spine can become again erect./
  3d. That in-like manner  the prevertebral mus-
cles in  the cervical, and  the  psoas  masses- in the
lumbar region interpose to  prevent this sudden,
violent  separation;  and  that the elastic anterior
ligament is exerting a force in the same  direction
all the way down the front of the  column.
  4th. That1 nature, ever watchful, is ready to take
advantage  of the  slightest opportunity for  repair.
Abhorring a. vacuum as much in the interior of the 
ANTERO-POSTESIOR SUPPORT.
53
body as externally to it, as soon as she finds relief
from the pressure under which the inflamed verte-
bras have been rapidly  melting away, she ceases
to busy herself with absorbing and removing de-
tritus, and makes an effort, not always successful,
it is true, but  generally so, at building up a new
structure to take the place of that which has been
destroyed, and thus fill up the chasm as fast as the
elastic cartilages and slowly yielding muscles and
ligaments permit it to be produced.
   And, having thus considered the obstacles which
nature interposes to the formation of this  trap for
the  unsuspecting cord,  let them  recall the safe-
guards which  surround that cord.  It does  not
hang carelessly swinging  in  space, but  is firmly
stayed in its central position  by the dentate liga-
ments which pass from its  dense, closely-fitting
tunic, the pia mater, out to the dura mater (itself
protected  exteriorly by  a  layer of adipose and  a
venous plexus), as well  as  by those prolongations
of its own substance which constitute the roots of
the spinal nerves; while the interspace is filled by
the reduplicated  arachnoid, by areolar tissue, and
by  several ounces of fluid.  So complete is  this
protection, that deformity may go on to the utmost
limit, the  spine being bent even at  a right angle,
and  yet no  compression of the cord, as indicated
by paralysis, shall take place.  /
  This last-mentioned fact indeed constitutes  the
dangerous point  of the criticism.   The  paralysis
                       5* 
ANTERO-POSTERIOR SUPPORT.
which  accompanies  angular curvature is  not,  in
ninety-five  cases out of a hundred, caused by un-
due pressure of the bony envelope, but by inflam-
mation or congestion of these membranous invest-
ments.  This is proved by the fact that there is no
relation whatever between the frequency of the
occurrence of paralysis and the growth or degree
of the  distortion,  the  most  horrible  deformity
taking place without  disturbing  in the least the
function  of locomotion  in many cases, while  in
others, complete paralysis may  supervene before
there has  been the slightest  deviation from the
normal curve; by the rational signs, which are
those of meningitis, rather than of compression of
the cord ; and by the  fact that recovery from par-
alysis is often seen, even while the deformity is on
the increase. Nor, on the other hand, will a diminu-
tion of the vertical pressure at the seat of  disease,
or even of the  deformity itself, necessarily prevent
an extension of the inflammatory action from the
osseous  to the  membranous  tissue.   Any  case,
therefore, even while being rationally and success-
fully treated,  is  liable to  an access  of paralysis.)
How unwarrantable to attribute  its occurrence to
the mode of treatment!   I feel that  this question
may safely be left to the candor of the profession,
and  dismiss it with the  following quotation  from
Prof. Mitchell's paper already alluded to : "Where
there is advantage to be derived from machines, I
use them without much regard to such theoretical
objections." 
         II.
MODIFIED SUSPENSION. 
  From the Transactions of the Medical Society of the State of
Pennsylvania for the year 1870. 
             II.
MODIFIED SUSPENSION.
  There  is no single characteristic of the human
form which more entirely commands'our admira-
tion, and   more strikingly  distinguishes  it  from
those of the various  families of the brute creation,
than its  erectness.  So universally  is  this  fact
recognized, that it has been incorporated into our
language.    Considering  an erect  carriage and  a
well-poised head as  an index, and hence a  type,
of a perfect physical organization, we, in common
with the Germans, have carried the idea  into the
domain of ethics, and designate the individual who
exhibits, in his dealing with his fellows, a healthy
and undistorted moral nature, an upright man.
   It is to the  spinal  column, and  its  mode of
articulation with the pelvrs and  the head, that
this  noble peculiarity of our  race is due.   Any
diseased action in either the essential  or accessory
constituents of this important organ  must sooner
or later result in  the  impairment of this distin-
guishing  feature.  Three  deductions have  been
                                     (57) 
58          MODIFIED SUSPENSION.

made from  this well-understood fact, which have
been shared, at different times to varying degrees,
by the medical profession and the general public.
  I. That a loss of erectness of figure, as a rule,
indicates spinal  distortion, and  hence diseased  ac-
tion in either the spine or its  motor apparatus.
  2. That the distortion is not only an indication,
but an actual element, of the  disease, directly tend-
ing to aggravate and perpetuate the morbid condi-
tions ; and hence,
  3. That  a restoration of the  distorted spine to
or  towards  its normal position is  an  important
means of checking the destructive processes and
restoring it  also to a healthy  state.
  It is on this last  proposition that the mechanical
treatment of spinal  distortions is rationally founded.
Two methods of effecting the result which  it con-
templates early suggested  themselves.   They may
be  designated  as the  method of counter-extension
and the method of counter-pressure,—the first  being
an  effort to straighten out  the curved spine by
traction  in  the  line of its  axis, acting in opposite
directions from  its  two extremities;  the second, to
unbend the  curve by forces applied at right  angles
to the line of its axis,—in one direction  at its two
extremities, and  in the opposite direction against
its  point of greatest convexity.  Both  methods
may be practically  carried out in two ways: either
by  means  of apparatus  worn  upon the  person,
indifferently called  braces, supporters,  assistants, 
MODIFIED  SUSPENSION.          59
splints, etc., which I shall designate as spinal instru-
ments, or through the medium of apparatus acting
from  some fixed  point of support  outside of the
person, which I shall call spinal machines.  I  have
already  assigned  my  reasons for  believing  that
spinal instruments  should  be made  only on the
principle of counter-pressure.  My object now is
to indicate the perfect applicability of  the principle
of counter-extension to the construction of spinal
machines, and to call  attention  to the  rapid and
admirable results  attainable by its means.
   I am well aware that for years past it has been
the fashion for medical men to decry extension of
the spine by machineiy as  unscientific and danger-
ous, those who write with special reference to these
affections  treating it with   contemptuous ridicule,
while systematic authors entirely ignore it.  It has
had powerful advocates, however, on  both sides of
the water.  Among the more important in  Eng-
land may be mentioned Darwin,* Shaw,f and Shel-
drake,! and, in this country, Kissam, of New York,
and Prof. Mitchell,§ of this city, the latter of whom,

  * Zoonomia, or the Laws of Organic Life.  By Erasmus Dar-
win.  Vol. iii. p. 140  et seq.
  f Observations on the Causes and Early Symptoms of Defects
in the  Form of the Spine, Chest, and Shoulders.   By John Shaw.
London,1827.
  % A Treatise on Diseased  Spine and on Distorted Spine, with
Cases  to illustrate the Success of  a New  Method of Cure.   Lon-
don, 1816.
  § North American Medical and  Surgical Journal, No. 1, 1826. 
60         MODIFIED  SUSPENSION.
with that carelessness of purely  theoretical  criti-
cism which characterized the man, was particularly
enthusiastic in its support, and, I  may add, as suc-
cessful in its employment.  A surgeon of many
years' standing in the navy of the United States is
a living monument to the admirable results which
that physician obtained by this means in cases of
spinal caries.
  The plan which  he adopted was the seemingly
rather severe one of suspension by the head in the
erect posture, the weight of a portion of the trunk
and of the lower extremities being the extending
force.  This differed altogether from that of Shaw,
who placed his patient in a recumbent posture and
applied traction at the head and pelvis, and, to a
considerable extent,  from those of  Darwin and
Sheldrake,  who, though  they  relied uporr the
weight of the body for their force, had their patient
supported upon an inclined plane.   Nevertheless,
the  idea was not  a  new  one with  him,  by any
means ; for we find Bampfield saying that " in the
erect state of the body the spine can be stretched
by  swinging by the head or by the hands," and
that, " if it be  the intention  to stretch the upper
half of the  spinal column, swinging by the head
will more  particularly effect  it, whilst the weight
of the lower extremities will also extend the lower
vertebrae in  some  degree."  The portion  of the
appliance which Dr.  Mitchell  used, which was
claimed  by him  as his own  idea, as I understand 
            MODIFIED  SUSPENSION.          61

it, was the go-cart provided with the means of sus-
pension, which had for its object the conjunction of
locomotion with extension, and which  he termed,
appropriately enough, his "spine-car."   It is to this
plan of extension by partial or complete suspen-
sion in the vertical position, whether in the stand-
ing  or sitting  posture, that  I desire for a few
moments to call the attention of the society.  And,
first, I wish to point out certain weak points in the
treatment of spinal caries by  counter-pressure in
which I consider  that  it is most_advantageously
supplemented by this method. /Our avowed object
in making use of  antero-posterior  force in a hori-
zontal plane  is to substitute the oblique articula-
ting processes, in  great  measure, for the vertebral
bodies at the seat  of disease, as the axis of sup-
port for the weight of the head and trunk.  Now,
while it  is true that these processes are of  com-
paratively firm texture, and almost invariably free
from disease, it is also certain that the constant en-
durance  of a weight so much greater than that
which nature intended them to bear must be  at-
tended, in time, with a certain amount  of absorp-
tion of their tissue.  Besides  this, their opposing
surfaces are so oblique  that much of the weight
will necessarily fall upon  their ligaments, which
must become more or less  relaxed, and thus per-
mit the processes to slip by one another, distorting
the articulation, and diminishing the height of the
patient.  This  is  one  unfortunate  result of this
                        6 
62
MODIFIED SUSPENSION.
method.   The other consists in  the  fact that we
have no means of determining at what point in the
column, intermediate between our opposing forces,
either above or  below the seat of the projection,
the pressure applied against  the  spine in an ante-
rior direction shall cease to exert its force.  Theo-
retically, it should  do so just where  the abnormal
projection meets the normal line of the column.
But if there happen to be a weaker point than this,
the force will  be transmitted  to that  point, and we
shall  have an incurvation produced which,  when
below the projection, assumes the very troublesome
form  known  as lordosis.   This  is a second evil,
which can neither  be  prevented nor  corrected by
apparatus worn upon the  person.  But  I think it
will be acknowledged that extension by suspension
—taking  off  this  destructively  abnormal weight
from  the  processes, and gently stretching out the
consecutive curve—is admirably adapted to palli-
ate, if not to entirely remove, these difficulties.,
   Again, the degree of  pressure which we are
compelled to  make use of in redressing the curve
is sometimes  so great as  to  provoke a superficial
abrasion of the  cuticle.  This is  especially apt to
be the  case  in warm weather.  Other causes, too,
may render the surface intolerant of pressure, such
as  abscess, the use (or abuse)  of setons, issues,
moxas, et id omne gciius,  hyperaesthesia of the
integuments, and eruptions.   Under such circum-
stances, modified suspension furnishes  an admir- 
            MODIFIED SUSPENSION.          63

able substitute for instrumental support for a suf-
ficient length of time daily to give an opportunity
for reparation of the surface.,' It is also especially
adapted to caries in the cervical region, affording
the patient the most complete and  delightful relief
from  the  agonizing  pain or wearisome discomfort
which the weight of the head  gives  rise  to, and
accomplishing much  for  the  restoration  of the
deformity.
   I present, for the inspection of the society, three
different pieces of apparatus, or machines, in which
this principle is applied.   And, in order that mem-
bers may the better  appreciate  the mode of appli-
cation, and the entire ease  with which they are
used, some of  my patients who have been  treated
in this manner have  kindly consented to be  present
and allow me to demonstrate their action with their
assistance.

   Case I.—The little patient whom I now intro-
duce  to you is 7 years old, rather short of  stature,
as you see, but ruddy and well nourished, having
the complete use of his limbs, walking freely, fear-
lessly, and naturally.  When he  first  came under
my care,  five years  since, he was  completely par-
alyzed in the muscles of the  lower extremities and,
to a great extent, in those of the trunk, as indicated
by inability to move even the terminal phalanges
of the toes, or  to maintain the sitting posture.  His
condition  was, in fact, altogether a  critical one. 
64
MODIFIED SUSPENSION.
The cervical portion of the spine being the seat of
caries, and two vertebrae having been, to a consid-
erable extent, destroyed, the  head was tilted back
until  the occiput rested  on the shoulders, and  so
firmly that it was impossible to insert the finger
beneath it, while the skin of this  region was  ac-
quiring that moist, mucoid character often noticed
when cutaneous surfaces are kept in constant appo-
sition. He suffered  from constant dyspnoea, respi-
ration being to a great degree diaphragmatic; had
frequent  attacks  of spasmodic gastralgia;  was
greatly emaciated;  passed sleepless  nights;  and
was,  as  may  be imagined,  excessively irritable,
allowing  his mother and nurse not  a moment's
ease.   The application  of a splint, provided with
a head-piece for producing erection of the cervical
spine by means of antero-posterior  force, very soon
relieved all his most pressing symptoms, but it was
some months  before he  acquired sufficient muscu-
lar power in  the legs to be able to move the toes.
At this time  my attention  was called by Dr. S.
Weir Mitchell, in consultation with whom I first
saw the case, to his father's  experiments and suc-
cesses in the employment of suspension. Although
greatly prejudiced against its use, I felt that at
least  no  injury could ensue if it  were employed
with proper precautions, and determined to give it
a fair trial, considering  that a desperate case justi-
fied what  I then viewed  as a desperate remedy.  I
therefore  had  made for him  this steel rod, bent at 
MODIFIED SUSPENSION.          65
 right angles and  provided at its lower end, for a
 distance of about eight inches,  as you see, with
 ratchet teeth on one side.  The horizontal portion
 of this  rod, carrying a steel bow, to which the chin
 and occipital strap could  be attached, passes over
 the head, while the vertical serrated portion is re-
 ceived  into a keeper screwed to the back of the
 little chair in which he ordinarily sat.  The  straps
 being  adjusted to  the head, I am  enabled, by
 means of a pinion-key introduced  at the  back of
 the keeper, to elevate the rod, and thus extend the
 cervical spine at  will.  Conscious of relief, from
 the  complete removal of the weight of the head
 from the ulcerated and sensitive vertebras, the little
 fellow, to my surprise, became at once reconciled
 to so singular a position, and even enjoyed it. The
 paralysis now began to diminish with notably in-
 creased rapidity, so that he was soon able  to sit
 alone, and  could move the legs  slightly.  With a
 view to give him an opportunity of exercising these
 reawakened  muscles,  and of associating amuse-
 ment with the necessary confinement, I therefore
 had a little rocker constructed upon which his chair
 could be fastened.   This you  now see before you.
 Placing him upon it, adjusting the straps, and mak-
 ing extension, you see how completely the head is
 supported,  and yet with what freedom and fearless-
 ness he rides, turning his head from side to side at
pleasure, and bringing almost all the muscles of
the trunk and lower extremities  into active, though
                       6* 
66          MODIFIED  SUSPENSION.
gentle, play.  This amused  him, and  he  often
spent two or three hours a day upon it, with the
effect of greatly increasing his muscular power.
He was still, however, unable to walk.  In  order
to teach him to stand and to encourage the natural
movements  of the legs, I then had this car or per-
ambulator constructed (simply the child's go-cart,
formerly so  much in vogue for infants learning to
walk), with  a keeper attached to  it posteriorly to
receive  the  ratchet-rod.  In this  he was at once
able to  stand  up without risk of falling, and soon
began to take  steps.   The paralysis being com-
pletely relieved, the general health restored, and
the  position of  the  head greatly  improved,  his
mother's anxiety was now aroused with  regard to
that inevitable accompaniment of carious destruc-
tion of cervical vertebras,—distortion of the thorax
anteriorly, and  projection of the lower end of  the
sternum, unquestionably a very unseemly and dis-
tressing  phase  of the deformity.   To remedy this
defect as far as  possible, by bringing the pectoral
and other muscles of the thorax into action at  the
same time that spinal extension was  being carried
on, I devised—partly in  imitation  of Dr. Mitchell,
and partly acting on a hint contained in a little
German work on  the " Treatment of Deformities
by Curative Gymnastics," by Dr. Nitsche, director
of  the  " Orthopaedeon" at  Dresden—the  spinal
swing, a  specimen of which  I have  caused  to be
erected here for your inspection.   The contrivance 
MODIFIED SUSPENSION.




         Fig. 10.
67
 
68
MODIFIED SUSPENSION.
for the support of the head is  the same as in the
other machine, viz., the steel bow with the double
strap for the chin and occiput,  in which  the head
is exactly balanced.  But the elevating apparatus is
now entirely different.  Instead of the ratchet-rod,
we  have a stout cord or rope, and in  place of a
key and spring as an extending force, the patient's
own hands and strength of arm.  It is not  neces-
sary to  have a frame constructed like this  before
you.  A pulley may be firmly  attached to a joist
in the ceiling or  over a doorway;  the  former is
preferable, as  giving greater length of rope, and,
therefore, more freedom and variety of motion.
Over this pulley passes the rope.  One end of it is
firmly attached to  the steel  bow over the  top of
the  head; the other hangs down in front  of the
patient's face, and  is  provided with two movable
ovoid blocks, which, sliding  on the rope, serve as
handles.  These are  placed  from  three  to five
inches apart, according to the size of the patient,
and retained in position by a knot under each. The
lower one should be about on a level with the top
of the patient's head.  Now, it is evident that, the
head-straps being  applied, as soon as the patient
makes traction  upon  the rope by  means  of the
handles  the force  is  transmitted over the  pulley
directly to the head, which is thus drawn upward,
and that the weight is equally shared by the head
and the  hands;  so that, when  the feet  are raised
from the floor, just one-half the patient's weight, 
MODIFIED SUSPENSION.
69
less that of the head, is supported  by the cervical
spine.   It  is also plain that, when the disease is
below the line  of attachment  of the arm to  the
trunk, the entire weight  of the body below that
point will be our extending force.   The apparatus
being  under the patient's control, however, it is
optional with him what amount of force he shall
make use of.  In the case of children, it is oftener
necessary to caution them against using too much
than to urge to use more.  You see this little fel-
low gradually drawing  himself up  on his  tiptoes,
and now actually lifting his feet and  allowing me to
swing him back and forth, not only without pain,
but with  positive enjoyment.  Under the use of
this machine for from one  to two hours a day, there
has been  a gradual amelioration  of the thoracic
distortion, the ribs assuming a more natural  posi-
tion, and the sternum falling more towards  its nor-
mal inclination, while the 'general capacity of  the
chest has increased.  A tendency to  chronic and
occasionally acute pulmonary catarrh, which  more
than once  threatened  to  prove fatal, and which I
was inclined to attribute  in  part,  at  least, to  the
compressed condition of the lungs, has also almost
entirely disappeared.

  Case II.—The young girl whom  I now bring
before you  has been  under my care since  Sep-
tember last.  She is 17 years of age.  Her parents
are both living.  The father suffers from chronic 
70
MODIFIED SUSPENSION.
rheumatism, but  I  am  not able  to  discover any
history  of strumous antecedents.  About  a year
before  her physician called me  to  see her, her
health  having been  previously all that  could  be
desired, she began to suffer from pain in  the back.
This increased steadily, and in about six weeks
wandering  pains  began to develop themselves in
the head, radiating from the temples.  Before long
she observed  that,  after sitting for any  length of
time, she became stiff and could walk  only with
considerable difficulty.  So great was this rigidity
on rising in the morning, that it took at least two
hours  for her muscles (the flexors of  the thigh
more particularly) to become  sufficiently relaxed
to enable her to walk with any comfort.   She grew
steadily worse all winter,  and early the  next sum-
mer was obliged to give up her  trade, which was
that of  envelope-folding,  in consequence of the
frequent falls which  she had when walking in the
street.   These falls were caused by a sudden spas-
modic contraction of certain of the flexor muscles
of the thigh (principally  the psoas and  pyriform,
presumably) of the  left side, accompanied by ex-
cruciating pain in the  hip.  This pain and spasm
also often attacked her during sleep, causing her
to wake with  a scream.  By this time  the head-
ache had become very severe, and  was often at-
tended  by obstinate  vomiting.  When I first saw
her it was almost constant, as well as the pain in
the hip already referred to.  She was much emaci- 
MODIFIED SUSPENSION.
71
ated, without appetite, not  able to stand erect, or
to walk across the  room unassisted.   Her physi-
cian had run through the  whole list of anodynes
without succeeding in relieving  the pains,  and
greatly to the disgust of her stomach.  I felt not
the slightest doubt, from the symptoms, history,
and  attitude of  the patient, that there was seri-
ous inflammatory, and probably ulcerative, disease
going  on  in the spinal  column;  but it was im-
possible to  discover  its seat, no  projection of a
spinous process  having yet taken  place.   From
the absence of gastralgia, I concluded that it was
below  the dorsal region, and from the intense pain
in the hip,  that it  was quite low  in  the  lumbar
region.  I  suggested  to her physician that, the
location  of  the  diseased action  not being  posi-
tively  indicated,  it would be well to wait a short
time before  applying anything in the shape of a
brace,  and meanwhile to give what relief we could
by the use of suspension.   Accordingly, I caused
a spinal swing to be put up directly over the couch
on which she lay, and directed her to use it three
times  a day for ten minutes, gradually increasing
the time as she became accustomed to it.  This
she did very rapidly, owing to the agreeable sensa-
tion of rest  which  the act of extension gave her.
By the end of a week I was rejoiced to  find her
almost free  from pain, with no vomiting, and quite
a  creditable appetite.   The  rigidity of the limbs
was diminishing, and she  could walk  with  some 
72          MODIFIED SUSPENSION.

ease.   By the end  of  the third week, however, I
felt confident that I could detect a slight bulging
of the last lumbar  vertebra, and at once ordered
a splint to be made, to give  support in that region.
In a week from this time she walked  to  my office
and back, a distance  of half a mile,  in order to
have it applied.  Her improvement  was now so
rapid that at the end of three months she resumed
work for half a day, and for the past four or five
months has  been working her full time, although
somewhat against my advice.  During the winter
she has once even ventured  to go to a ball and in-
dulge her terpsichorean tastes.  Her menses, which
were suspended for several  months, returned soon
after the application of the  splint.  She  continues
to use the swing, and, as you see, although quite
heavy,  is not afraid to bear  her weight strongly
upon the head-straps.  She  generally uses it, how-
ever, in the  sitting  posture,  with weights attached,
in order that she may be able to employ her hands.
I do not need  to say  anything as to  her  present
condition.   Her firm,  elastic step, rosy cheek, and
bright eye, testify plainly enough what her  general
health is.  Her treatment,  I  may add,  has been
purely  mechanical,  no internal  remedies  having
been used.

  Case III.—This  lad, the  last case which  I shall
detain you to see,  is  fourteen years  old.   I  first
saw him in  November last.  He was then lying 
MODIFIED SUSPENSION.
n
about  the  house,  good  for  nothing,  pale and
anaemic,  and—having  been obliged  to give up
going  to school, in which he  was  much  inter-
ested—very despondent.  He complained of head-
ache, pain in the  hips,  running down one limb to
the  knee,  morning  rigidity, and exhaustion on
walking a  very  short  distance,  so that he  could
not  go a square without stopping to sit down to
rest.  In this  case, also, not a  trace of posterior
deviation existed; but, upon causing him to stoop
forward, a slight yielding towards the left appeared
in the upper part of the lumbar region.   Profiting
by my experience in the  last case, which was then
just  beginning to feel  the benefit of the brace, I
determined  to give him  support  at once,—not
emulating the  caution of the practitioner of whom
I recently  heard, who, when consulted in  a case
of suspected spinal disease, gravely informed the
anxious mother that it  might be necessary to wait
two  years before it could  be  determined whether
such were  the case  or not.  A spinal swing was
put up for  him the  next day, and so rapid was his
improvement  that in a week he was able  to walk
to my office,  a  full half-mile,  to have his  splint
applied.  In three months  he was at school  again,
and  has recently obtained  my permission to play
base-ball.   He also, as you see, has no fear of
hanging,  if allowed to be his  own  executioner.
This case is one of the deepest interest, from the
gratifying fact  that not  a particle of deformity has
                       7 
74
MODIFIED SUSPENSION.
made its  appearance.   I  hold that the success of
the treatment fully substantiates  the correctness of
the diagnosis, and that this  boy is another living
witness to the truth of the  principle for which I
have  long  contended—that  inflammation  of the
spinal column is perfectly recognizable  before it
has  reached  the  stage of caries  and deformity,
which evils may  therefore, under favoring circum-
stances, be  entirely averted.  That it requires no
education as a specialist to make  the diagnosis in
such  cases, is sufficiently proven by the  fact that
the  physician in whose  practice  these  two very
interesting cases occurred had  in both  instances
become  reasonably well  convinced  of  the true
nature of the disease  before  soliciting my assist-
ance.

  This mode of treatment is  equally applicable to
lateral curvature.   In the incipiency of that affec-
tion, indeed, it may unaided  be adequate to work
a cure.   By causing the patient  habitually to take
hold  of the higher handle with the hand  corre-
sponding to the depressed shoulder, that shoulder
is thus, for the time being, elevated and its muscles
thrown  into  more  powerful  action than those of
the opposite side,  while  the curve of the  spinal
column, if not too rigid, is entirely reversed, and,
under any circumstances,  diminished.
  The advantages of the  mechanical treatment in
such affections, judiciously combining the  use of 
MODIFIED SUSPENSION.
75
instruments and machines, over that which con-
sists in confinement to the horizontal posture and
the  establishment of  exhausting  purulent dis-
charges, are incalculable.  While it  is, to say the
very least, as successful in preventing and control-
ling deformity, it affords to constitutions  which so
pressingly demand  them, those sovereign tonics,
exercise and the open air. 
The Differential Diagnosis of Spinal Arthro-Chondritis,					
DISEASE.	Seat of Pain.	Character OF PAIN.	Immediate CAUSE OF PAIN.	Epigas-tric ten-derness.	Mornihu rigidity WITH STOOPING.
Spinal Arthro-Chondritis	Radiating from epigas-trium or in one side	Paroxysmal; spasmodic ; excruciating; often nocturnal	Motion; shock; muscular contraction	Absent	Always present
	Epigastrium	Paroxysmal; spasmodic; acute	Exhaustion	Absent	Absent
Gastritis (chronic)	Epigastrium	Acute; not paroxysmal	Prehension of food	Always present	Absent
Worms (in alimentary canal)	Upper abdo-men	Paroxysmal ; spasmodic; acute	Not assigned	Frequent	Absent
Ulcer of Stomach	Epigastrium; ensiform cartilage and back	Paroxysmal; acute	Prehension of food	Always present	Absent
Cancer of Stomach .	Epigastrium	Dull or lanci-nating	Prehension of food	Always present	Absent
	Umbilicus or epigastrium	Paroxysmal ; spasmodic ; acute	Not assigned	Always present	Absent
Hip Disease (early stage) .	Knee; front of thigh	Paroxysmal ; spasmodic; excruciating; nocturnal ex-acerbations	Motion; shock; muscular contraction	Absent	Always present
Spinal -Rheumatism (chronic) .	Back	Constant; dull	Motion	Absent	Rare
Lateral Curvature of Spine .	Rare; back	Dull	Fatigue	Absent	Absent
Spinal Irritation (so called)	Back and abdomen	Constant; dull	Not assigned	Frequent	Absent
(76) 
the Initial Stage of Angular Curvature.—In Tabular Form.
Muscu-lar spasm.	Muscular contractions of lower ex-tremities.	Tumid Abdo-men. Very con-stant.	Labored or jerking RESPIRA-TION.	Paral-ysis.	Vomit-ing. Rare; of food	Diar-rhoea. Rare	Consti-pation. Rare except with paralysis	Usual limit of AGE.
Local; always present	Not symme-trical ; invert-ing foot; al-ways present		Usual; often hic-cough	Common; asymme-trical				Below 12
General; frequent	Absent	Absent	Absent	Absent	Absent	Absent	Frequent	Above 35
Absent	Absent	Absent	Absent	Absent	Fre-quent ; of glairy mucus	Frequent	Rare	None
General; frequent	Not symme-trical ; rare	Con-stant	Absent	Rare; us-ually sym-metrical	Rare	Rare	Frequent	Below 12 i
Absent	Absent	Absent	Absent	Absent	Always present; often bloody	Frequent stools ; black	Rare	Above 16
Absent	Absent	Absent	Absent	Absent	Always present; some-times bloody	Frequent stools; black	Rare	Above 35
General;	Absent	Absent	Absent	Frequent;	Absent	Absent	Invari-	None
frequent				commenc-ing at wrist			able	
Local;	JNot symme-	Absent	Absent	Absent	Absent	Absent	Absent	Below 12
always present	trical ; evert-ing foot; al-ways present							
Absent	Not symme-trical ; fre-quent	Absent	Absent	Absent	Absent	Absent	Absent	None
Absent	Very rare	Absent	Absent	Absent	Absent	Absent	Frequent	From 12 to 18
General ; frequent	Symmetrical; occasional	Rare	Rare	Frequent; usually symme-trical	Frequent	Rare	Frequent	Above 14
 
 
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