The treatment of organic or structural scoliosis is more complicated
for it must be remembered there are two elements of the deformity
demanding correction; one, the lateral curve to be corrected by a side
force, and the other, the rotation of the vertebræ to be corrected by
a twisting force. I find both osteopathic manipulation and gymnastic
exercises are of great value in the correction of this deformity as
they help to loosen the curve and develop the musculature but used
alone good results can rarely be obtained especially in obstinate
curvatures. I believe that I have improved nutrition and probably
prevented further deformity by treatments and exercises, but I am
quite positive that it is not possible to correct an organic scoliosis
without the forcible correction used in the Abbott method.
As the details of treatment are tedious to follow, we will take for
example a case of right dorsal curvature presenting a marked hump
deformity, with a compensatory curve to the left in the lumbar region,
as this is the most common type. I might say here that whether or not
a compensatory curve is present, makes no difference, as treatment
is directed entirely to the primary curve on the assumption that
overcorrection of it will cause a secondary curve to disappear by
compensation.
The patient is prepared by putting on a snug fitting undershirt and
sewing pads of saddler’s felt over all bony prominences, especially
the crest of the ileum and anterior superior spine. Sometimes I take a
piece of felt of four or five inches wide and long enough to go around
the entire pelvis, just high enough to cover the brim, and fasten it in
front with adhesive. Next I make a bunch of pads two or three inches in
thickness and large enough to fill up the concavity of the left side,
and first sew them together, and then with a few stitches fasten them
to the undershirt thereby filling up the space on the concave side.
The edges of the pads should, of course, be trimmed down to conform
with the general contour of the body, the main thickness being in the
middle. I then sew a single pad on the right side of the thorax in
front and a little to the right side.
[Illustration: Patient suspended on canvas hammock in regular Abbott
frame ready to apply cast for a right dorsal curvature. Notice manner
of applying the correcting canvas straps.]
The patient is now ready for the Abbott frame and is placed on a
canvas hammock about twelve inches wide, which is cut on the bias so
the right side is three inches shorter than the left. The hammock
can be adjusted to the desired degree of flexion by a ratchet at the
foot of the regular Abbott frame. The limbs of the patient should be
elevated to increase the flexion as this has a tendency to unlock the
articulation and thereby help in overcoming the rotation. Next a canvas
bandage four inches wide is passed around the patient under the axilla
of the concave side and fastened to the frame on the opposite side, and
another one is placed around the pelvis and fastened to the same side
of the frame, both on a level with the body plane. A third bandage is
next placed around the point of greatest convexity and fastened to the
opposite side of the frame in such a way that it can be tightened and
a direct pull be made on the curve. Before tightening the last bandage
the left arm and shoulder should be brought up high beside the face and
pulled backward toward the floor as it is this twisting force that
produces some rotation of the thorax. The correcting bandage is now
tightened being careful not to cause the patient too much discomfort.
[Illustration: Cross section sketch of a right dorsal curvature showing
deformity in the thorax and rotation of the vertebræ, also windows
which are cut in the cast to allow expansion in these two directions
and the directing force of the pads. These are placed over the angles
of the ribs. Arrows show directions of the various forces.]
I always use ordinary absorbent cotton for padding, which is held in
place by the regular gauze bandage. The plaster of Paris bandages
should be applied high up under the left shoulder and well down over
the sacrum and innominate bones and should be of a uniform thickness
of half an inch. Sometimes I carry the plaster over the right shoulder
to hold it down and back, though not always. I always let the cast set
pretty well before removing the patient from the frame and if it has
been applied in the morning I find it best to wait until afternoon
before trimming and cutting the windows because there is less danger of
breaking it. In trimming I always smooth up the edges, lower the right
shoulder, but keep the left well up, trim off enough at the bottom in
front to allow the thighs to be readily flexed without obstruction,
and leave it low behind so as to maintain the flexion. Next, two holes
or windows are cut in the cast, one over each area where the pads
were inserted, and remove them. The hole in the back on the left or
concave side permits expansion of the chest to the back, while the
hole on the right side in front allows the ribs, which are posterior,
to move forward under pressure or the pads to be inserted at the
posterior angle or backward prominence of the ribs of the convexity.
The canvas bandages or straps around both the axilla and pelvis are
removed, but the one about the convexity of the curve is left in place
so as to assist in the after treatment. The patient usually suffers
some discomfort such as difficulty in breathing and the inability to
move the body freely, and should remain in bed a day or two after the
cast has been applied. Usually they sleep very poorly the first few
nights, but the spine soon gives under the pressure and they become
comfortable. When the cast has become quite comfortable an assistant
pulls on the canvas bandage which was left around the convexity, while
pads are inserted so that the greatest pressure is exerted on the angle
of the ribs to further overcome the rotation and decrease the lateral
deformity. Also heavy felt pad may be inserted over the bulging ribs
in front of the left side to push them back. Care should be taken that
too much pressure is not brought to bear on the side of the convexity
because if more pressure is exerted here than on the angles of the
ribs, it will tend to increase rather than decrease.
Casts should be worn for different periods, some being changed in a
month while others can be worn for three months. It is entirely a
matter of judgment. My best results have been secured by only slightly
correcting the curvature at the time the cast was applied, and relying
more on the proper insertion of the pads. Often at the end of a month
or six weeks, in selected cases, I have split the cast down the front
and removed it by springing it apart, and administered osteopathic
manipulations to the spine freely in all directions, thoroughly
loosening up the muscles. Then I replace the cast and hold it together
in front with moleskin adhesive and insert the pads as before. I repeat
this procedure three times per week for another month, together with
daily exercises each morning and evening of drawing the left shoulder
up and forward while in the cast to develop the muscles of the left
shoulder girdle. The treatments and exercises certainly do build up
the spinal muscles for it must be realized that they have suffered in
nutrition to a great extent as a result of wearing the cast. Next the
cast can be worn during the day and removed at night, and gradually
it can be left off several hours at a time. If no bad results occur
it can be left off for longer periods until finally its use can be
discontinued. However, the patient should still be under observation
once a week for a couple of months to determine any recurrence of the
deformity. The resumption of active corrective treatment, or increasing
relaxation in gymnastic work, will, of course, depend upon the progress
of the case.
In the more obstinate cases, casts should be applied as long as further
correction can be obtained. The procedure is entirely the same, only
the time required for correction is longer, sometimes a year or year
and a half, and when overcorrection has been maintained, it is better
to use a removable jacket made of celluloid or light stiffened leather,
with large windows cut over the region where pressure is to be avoided,
than the removable cast described above.
In closing let me say that this method of correcting lateral curvature
is best adapted to patients during their growing period and though it
may be employed in older cases you will usually be disappointed in the
final result. The only reason I can see for treating older cases is
purely mercenary.