Lower Extremities.-Considerable motor paralysis of left lower extremity. Considerable contracture of right lower extremity. Patellar reflex is lively

on both sides, particularly on left. Achilles reflex lively on left, diminished on right. Plantar reflex present, flexor response, bilateral pes cavus. No incoördination. Loss of deep sensibility in both

lower extremities.

May 21, 1901: Patient drinks large quantities of water. Complains of thirst and of frequent micturition. The examination of the visceral organs is negative.

The picture remained unchanged until patient died of respiratory paralysis August 4, 1901. Autopsy. Only the brain was removed. The dura mater was found to be the seat of multiple tumors of various sizes, from a split pea to a cherry (Fig. 6). The larger ones produced depressions on the cortex. One hundred individual tumors were counted, but there were many more.

(4)

The larger ones were found: (1) On the mesial surface of the left frontal lobe. (2) Just anteriorly to the right para-central lobe and in the middle of the right Rolandic area. (3) Over the left calcarine fissure. The entire falx was a tumor mass the size of a hen's egg, pressing on the mesial surface of the hemispheres. Only here were there evidences of retrograde metamorphosis.

The fifth, sixth, seventh, and eighth nerves of the right side were pressed upon.

A tumor was found in each pontomedullo-cerebellar space. (Fig. 7). These tumors were of firm consistency; the surface nodular. They were approximately the size of a plum; the right was larger than the left.

The third, fourth, and fifth nerves of the right side were not found.

The right sixth nerve showed a nodular swelling the size of a split pea, and the left sixth nerve was the seat of minute swellings and tortuosities. Similar varicosities were also noted on the seventh, eighth, ninth, and tenth nerves of both sides.

Histologically the tumors of the ponto-medullo-cerebellar spaces and the varicosities and tumefactions of the basal nerves, showed the typical characteristics of neurofibromata.

The dural tumors were psammomata of the fibrous and alveolar variety; the first showing typically fibromatous.

structure, and the others groups of round cells, separated by an alveolar network. Nowhere evidences of sarcomatous degeneration. The pyramidal and sensory tracts of pons and medulla were unaltered. The processus cerebelli ad pontum showed atrophy and sclerosis.

CASE V. (Preliminary report.)-Male, forty-two years old. Disease began six years ago. Tinnitus in left ear and occasional headaches. Later impairment of vision and uncertainty of gait. Static and locomotor ataxia; deviates to left side; left hemiasynergia and hemiataxia; exaggerated reflexes; deafness of left ear; paresis of left seventh; paræsthesias in left fifth; choked disk; operation by Dr. Geo. Woolsey. Removal of tumor from left pontomedullo-cerebellar space. Death.

Patient was a Jewish pedlar, aged forty-two years. No syphilitic history. Eight years before head trauma (struck with fist). Six years before annoy

ing tinnitus in the left ear; later diminution of hearing. Past four years subject to occasional occipital headaches and vertigo. During past year headaches. and vertigo much worse, with cloudiness of vision. For the last six months there has been unsteadiness of gait.

Status Præsens: Watch tick not perceptible in left ear. Tuning fork vibrations very faint to aërial and bone conduction on the left. Paresis of left seventh nerve, more apparent in upper branchwith slight quantitative electrical changes. Parasthesia in sensory distribution of left fifth with objective sensory disturbances. Moderate dysarthria. Pupils unequal, left wider than right. Reactions present. Amblyopia. Choked disk. A slow nystagmus in extreme positions. Hemiasynergia and hemiataxia of left side. Station: falls. to left. Progression: deviates to left. Tendon reflexes active. Knee-jerk exaggerated; the left more than the right. No ankle clonus. Skin reflexes. present. No Babinsky.

Operation May 7, 1903, by Dr. George Woolsey

Fig. 7.

The occipital bone was trephined on the left side on its postero-inferior surface. The finger passed along the under surface of the cerebellum located a nodular growth in the left ponto-medullo-cerebellar angleabout the size of a hen's egg. The tumor was broken up by gentle manipulations with the index-finger and removed in fragments.

Patient died twelve hours later, never having reacted, with symptoms pointing to implication of the cardiac and respiratory centers.

Histologically, the tumor was a neurofibroma. Conclusions.-The foregoing cases show a common origin from cranial nerve trunks. Their pathological structure is of a kindred nature-neurofibromatosis. pure or in various stages of metamorphosis and trans-formation. The locality is almost identical-the angle formed by the junction of pons, medulla, and cerebellum. Their symptomatology, because of this. localization, is, in the essential features, analogous

721.

3. Henneberg und Koch, “Über ‘centrale' Neurofibromatose, etc.," Archiv für Psychiatrie und Nervenkrankheiten, Bd. 36, S. 251.

4. V. Hartman, “Die Klinik der sogenannten Tumoren des N. acusticus," Zeitschrift für Heilkunde, 1902, S. 391.

5. Sternberg K., "Beitrag zur Kenntniss der sogenannten Geschwülste des N. acusticus," Zeitschrift für Heilkunde, 1900. Bd. XXI, S. 163.

6. Fraenkel and Hunt, "On Neurofibromatosis,' MEDICAL RECORD, June 13, 1903.

7. Adrian C., "Multiple Neurofibromatose," CentralBd. blatt für die Grenzgebiete der Medicin und Chirurgie. VI., 3-8.

THE PRESENT STATUS OF THE TREATMENT OF LATERAL CURVATURE.

BY JACOB TESCHNER, M.D..

NEW YORK.

MULTIFARIOUS papers exploiting ideas and opinions upon the question of treatment of lateral curvature appear from time to time, showing the unsettled state of affairs regarding the proper treatment and result in this condition. The late Dr. A. M. Phelps says: "Lateral curvature of the spine arises before us each year like a specter. From every clinic in the country the orthopedic surgeon is deluging societies and medical journals with literature upon the subject. It is interesting to note that from the earliest records we can find upon the subject down to the present time the positive position of the author is only to be retreated from a year or two later.

It is high time in the writer's opinion concisely to lay before the general practitioner especially the true status of the treatments to which their patients are subjected and what they can expect in results. Ten years ago our faith rested upon mechanical supports which we gave our patients in the shape of braces of all varieties of construction, plaster, and leather corsets, etc., and supplemented their uses by suspension and Swedish movements or some other show of exercise. The mechanical apparatus was to act as a retaining appliance, and the little exercise, which was supposed to act in a corrective direction was absolutely nullified by the retaining or supporting device. Some few began to hope for benefit in forcible redressment, and added that form of treatment to the one before described.

In 1895, after exhaustive experimentation and study, the writer published his paper on "The Treatment of Postural Deformities of the Trunk by Means of Rapid and Thorough Physical Develop" in which he demonstrated beyond a doubt the superiority of the method of treatment devised by him, in that the results were not conjectural, but visible and rapid.

ment,

In that paper the author was the first to state, against the concensus of opinion of orthopedic surgeons that rotation, even when bony and ligamentous changes had occurred, could be overcome. He strictly forbade the use of any retaining, immobilizing or supporting, apparatus of any kinds, because "each and every one will, to a greater or

lesser extent, interfere with the mobility of the spine, and in that manner deprive the back, chest, and abdominal muscles of that perfect freedom of action which is a necessary and powerful adjunct in the treatment by gymnastics.'

Since 1894 the results, even in the severe forms of curvature, have been uniformly good in hundreds of the author's cases.

How was this method received by orthopedists? What have they done since? What opinions do they hold, and what are they doing now? And what are their objections to carrying out this method in their practices? Writings and publicly expressed opinions supply some of the answers.

The method was looked upon as novel and amusing by some, too troublesome and taxing in its application by others, and still others saw its value but remained discreetly silent. Since then much has been written showing the trend of opinion that braces should be avoided whenever possible, surgeons gradually depending more and more upon exercises indifferently taught by incompetent per

sons.

In 1900 an indefatigable worker, Dr. Robert W. Lovett of Boston, with the collaboration of Prof. Thos. Dwight of Harvard Medical School, and Professor Hollis of Harvard University, gave the subject of "The Mechanics of Lateral Curvature of the Spine" his closest attention, studying the mechanics upon the cadaver and artists' models. Drawing his conclusions, under the caption of "Treatment," he says: "Of course, theoretical conditions such as those given above are of value only in so far as they may influence prophylaxis and treatment." Under this caption, while he states that "the writer has endeavored to deal only with the broader aspect of the question and to avoid generalizations from clinical experience," his only reference to clinical experience is the following, viz., "It is easy to see from this point of view why symmetrical gymnastics such as those described by Teschner, are of so much value; and it also explains, what many of us have found out empirically, that it is desirable to hold and exercise the spine in positions of extension." He further says: "By calling upon the intrinsic property of the spine to reverse in extended positions the rotation acquired in flexed positions, it would seem that we were pursuing a most rational course. Under the caption of "Gymnastics," he says: "Safety lies in prescribing only exercises of which one can estimate the anatomical effect."

That his conclusions are correct there can be no doubt; then why not carry out the deductions and apply them in practice in the treatment of patients?

In 1901, in an article' upon the treatment of fixed scolioses, he advocates forcible correction as preliminary only to gymnastic treatment, and he "would not wish to be understood to advocate the use of corrective plaster jackets except as a temporary means to secure a better foundation for better gymnastic or, if necessary, mechanical treatment." In arguing in favor of forcible correction and retention in plaster he says that "forcible correction is admittedly in its experimental stage.'

Dr. E. H. Bradford of Boston, in speaking of fixed cases, says: "This difficulty makes corrective treatment of advanced cases of scoliosis impossible, as osteotomy is not feasible in lateral curvature, and the amount of pressure necessary for altering the shape of grown bones in the trunk is so great that correction becomes impossible. . The sur

gical indications for treatment of lateral curvatures are now well understood. It is generally agreed that when the muscles are weak, and a faulty atti

tude favored by weak muscles, the muscles should be developed."

Upon this follows the statement that "during the growing period faulty attitudes should be prevented by retaining apparatus if necessary. . . . In other words, the practitioner needs to consider: (1) Measures to promote flexibility in a localized position of the spine. Means for the greatest possible rectification of errors. (2) Gymnastic exercises of such muscles as may be needed in given cases to maintain corrected attitudes. (3) Appliances preventing faulty positions of the spine. (4) Means of recording condition and progress of the case.

"In practice the cases may, for convenience, be classified as follows: Cases needing correction, demanding considerable pressure and the use of a removable jacket, with or without exercises. Cases requiring flexibility and passive exercises, conducted by the surgeon or nurse. Cases suited for flexibility exercises done by the patient. Cases needing developing exercises measured by graded work and strength tests. Cases needing measures for improvement in carriage recorded

by measure and photograph, to be kept under observation. . . . In the treatment of cases coming under his care, the surgeon will find the greatest difficulty in his attempts to increase the flexibility of the spine, as the development of muscles is pretty well understood.

Then follow the descriptions of devices for acquiring flexibility. "For means of muscular development, dumb bells can be made to answer every requirement under proper guidance. The use of heavy exercises with the addition of heavy bars is of the greatest assistance, as has been shown by Teschner and Erich."

In the second edition of Bradford and Lovett's "Orthopedic Surgery" mention is made of heavy gymnastics, and they say: "This has been thoroughly carried out by Teschner of New York."

After reading Dr. Lovett's second paper and the above-mentioned one of Dr. Bradford, where should one look for the cause of such an indefinite attitude?

Neither of the gentlemen has ever seen a demonstration by the author of this method, and as no one can be expected to obtain results by it unless he has not only seen it but has also been properly trained in its application, the cause is obvious.

Had he had the necessary training Dr. Lovett would never have advocated forcible correction and retention in plaster jackets as a foundation for gymnastic treatment, knowing that such a preparation must necessarily weaken the muscularity of the patient and give a very poor foundation. When one sees what has been accomplished in reducing a deformity in a case of severest type in a very short time (Figs. 1 and 2) by the author's method, why should a case be subjected to forcible correction which is "admittedly in its experimental stage"?

As an illustration of what has been accomplished in a case of the severest type of fixed rotary-lateral curvature, an example of the class of cases in which Dr. Bradford says that correction becomes impossible, reproductions of photographs of a patient of this class, whose spine was thoroughly rigid and who, by reason of his deformity, suffered from dyspnoea,

Fig. 2. Back of patient showing improvement in the curve-obliteration of the depression under the right scapula, the widening of the entire back, and the equalization of the hips. May 27, 1899.

tain corrected attitudes" be selected for gymnastic exercises, when all the muscles of the trunk and lower extremities coördinately control attitude? What appliance have we that has the virtue of "preventing faulty positions of the spine"? If there be such an apparatus the whole question of treatment is solved.

In his classification, for convenience in practice, he mentions "cases needing correction demanding considerable pressure," when he previously stated. that correction by pressure was practically impossible. He mentions mentions cases requiring flexibility exercises done by surgeon, nurse or patient.

All cases require increased flexibility, and why if, as he states that "the surgeon will find the greatest difficulty in his attempt to increase the flexibility of the spine, as the development of the muscles is pretty well understood," should it be left to the patient or nurse? Is either of them more competent than the surgeon? Is the fact that "the development of muscles is pretty well understood." a barrier to the acquirement of flexibility?

He also mentions cases "needing developing exercises" and "cases needing measures for improvement in carriage recorded by measures and photographs," etc. Does he mean to imply that the

As for the moral effect upon the laity. the dignity of a physicians in no way impaired by any plan of treatment which he may personally apply, providing that he himself have a sufficient amount of

skill properly to apply that plan of treatment in an intelligent and thorough manner.

There are several orthopedists in this city and elsewhere who. pinning their faith to the method described by me, attempt it without the slightest knowledge of its. proper application, and generally through the medium of a masseuse or Swedish gymnast who knows still less than the physician who orders it.

It is a very common occurrence to have a woman call upon me with a card or letter of introduction from a prominent orthopedist, announcing that she is a gymnast in charge of Dr. Blank's curvature cases, and that he would be indebted, if this person could be shown how to treat these cases by the system of heavy gymnastics. the paper before alluded to I distinctly say: "This system of work should only be applied by the physician, and he must himself have been trained to the work, to intelligently guide those whom he seeks to benefit. The work must be careful, systematic, and regular. Perfunctory work will not do."

and education of muscles whether they be recorded

or not.

He does say, however. "The use of heavy exercises with the addition of heavy bars is of the greatest assistance, as has been shown by Teschner and Erich " For this we must

give him due credit.

Whitman, in his work on Orthopedic Surgery,' says: "One of the most effective systems of treatment of lateral curvature is that advocated by Teschner of New York." Dr. Whitman has seen demonstrations of the system and has taken advantage of opportunities to see patients treated and has been shown results. Hence his statement.

How many cases to which he has given his personal attention. as the author does in his cases has he treated by this system? It is reasonably certain that the answer will be, not one. And why? Not that the results could not be obtained, but because of the frequently expressed opinions which make this method impracticable. (1) It is laborious and taxing-mentally and physically -in its application. (2) The inability to demand and receive a sufficient fee for the time expended with a patient. (3) The time to be devoted to a proper training. (4) And the greatest drawback to its adoption being the supposed moral effect that it would produce upon the laity, of a physician of high standing falling to the level of an instructor in gymnastics.

Fig. 6. Front view, showing chest development, reduction of the costal prominence, of the left hip and the straightening of the trunk. May 27, 1899.

but has become more and more enthusiastic as to its value by reason of his results and their rapidity, and is firmly convinced that it will in time be the only mainstay of physicians who treat scoliosis.

Under these conditions, does the general practitioner do his full duty toward his patient by shifting