A great many writers have written extensively on the faulty position assumed by children during school hours, due greatly to the kind of desks and seats used by them; nevertheless, in many schools

the same conditions exist to-day as existed ten and fifteen years ago, and it is the part and duty of the family physician and specialist to place such matters before the school commissions and thereby endeavor to obtain proper school furniture. Surely, when a condition affects 25 per cent. of the school children in all parts of the civilized world, it is a condition which demands the closest attention. If the general practitioner will work with the specialist to carry on a vigorous and continuous crusade against any condition which may cause deformity, we will have this problem greatly simplified.

In my opinion, the most serious cause of scoliosis which we have to combat in rachitis. Often it is difficult to determine exactly

when rachitic symptoms FIG. 1.-After Klapp. really begin; but when the

case presents the prominent abdomen, associated with constipation, restlessness at night, impaired digestion, faulty assimilation and consequent muscular weakness, we may be quite sure that changes in the bones are soon to follow, unless we resort to preventative measures. As has been mentioned, such cases attain the upright position rather late, and if deformity appears before the eighteenth or twentieth month it is likely to be a kyphosis. In order to prevent this such children should be kept in the prone position, preferably strapped into a plaster-of-paris form, which has been moulded to the back in a position of slight lordosis, while at the same time proper attention is paid to the general health. The same measures pertain to the prevention of rachitic lateral curvature, and if carried out until all symptoms of rachitis have disappeared will give satisfactory results.

TREATMENT.

Since we have two distinct types of scoliosis, it will be necessary to take up the treatment

of each separately. Exercises and gymnastics, corsets and braces play important parts in the treatment of lateral curvature, but the value of each varies greatly according to the theories held by each individual orthopedic surgeon. However, there are two very important and fundamental points that we must constantly keep in view, and these are: First, to correct the deformity and limber up the vertebral column as much as possible; and second, to develop the muscles of the back so that they may be able to support the spine in the correct position.

I will not attempt to discuss the different methods used abroad and in this country, but will merely give the course of treatment as it is given in my institution. Time, energy and perseverance are requisite in the treatment of every case of lateral curvature, and the cooperation of the patient and parents aids greatly n attaining a successful

issue.

The Treatment of Postural Scoliosis. In these cases, as no changes have taken place in the bones or soft parts, it is merely necessary to correct the faulty position and build up the weakened muscular system; this is easily done with massage and gymnastics, without the aid of either braces or corsets. Every case of scoliosis is first treated with hyperemia, as advocated by Bier. The patient sits with the back to a pentagonal cabinet which has an opening, oval in shape, cut in each side just large enough to allow the bared back to fit into it from about the sixth or seventh cervical to the fifth lumbar vertebra, and about three inches on each side of the spinous processes. These openings are edged with a heavy piece of felt about two inches wide, which forms a close joint with the back and prevents the hot air from escaping. In the centre of the cabinet is a gas burner with a radiator so arranged as to throw the heat first to the bottom and sides of the cabinet. The temperature is raised from 120° to 230° F., and the application lasts from fifteen to twenty minutes. Bier has proven very clearly how valuable hyperemia is as a therapeutic

FIG. 2.

agent, and in cases of scoliosis it not only tends to limber up the vertebral column, but also to increase the nutrition of the back muscles by increasing the flow of blood to those parts. After the patients have had the hot-air application and their backs massaged for ten or fifteen minutes, they are then put through a course of simple gymnastics for half an hour. It is a great mistake to make exercises complicated; the simpler the better, and any form of simple sitting-up exercises will do all that is required. The main point is to educate the body to involuntarily maintain the proper position.

ments.

Treatment of Structural Scoliosis.—In this type we have a much more difficult problem to solve: the changes in the bones, muscles and ligaments have taken place and motion is limited, which present three difficult tasks to be overcome. These are: First, the lateral deviation; second, the rotation; and third, the contracted and atrophied muscles and ligaI first obtain as great extension as is possible with an extension frame similar to that devised by Hoffa, with the patient sitting on an inclined seat. Then a plaster-of-paris corset is applied over a thick gauze undershirt without any padding having been placed over prominent parts, it is moulded snugly over the hips and shoulders, the shoulders being incorperated; before the last roller is put on a piece of canvas three inches in width and extending from top to bottom of the corset is placed just over the spinous processes, and two pieces of canvas two inches wide, with shoe-hooks along one edge, are placed on each side of the sternum from top to bottom. The last roller is then applied, and when the plaster has set the corset is cut down in front between the pieces of canvas; the piece on the back acts as a hinge, and it is removed. After rounding off the edges and smoothing over the rough surfaces it is ready to be worn, and when applied is laced up in front over the shoe-hooks with elastic lacings, which cause constant pressure laterally. This corset was devised by Gerson, of Berlin. In addition, I place a thin pneumatic cushion over the knuckle posteriorly and one over the opposite anterior projection; by so doing the pressure on these parts is increased and there is a tendency to untwist the rotation, besides correcting the lateral displacement. A light, well-fitted undershirt is always worn under the corset.

After the corset is finished the patient has a daily application of hyperemia for twenty minutes, and then goes through the exercises. The first and most important exercise is a form of crawling on the floor with the hands,

knees and toes protected with pieces of leather. If one has ever noticed a young dog or a cow when they walked slowly he may have noticed that when the fore foot and hind foot on the right side are brought together, before the next step is taken the spine is always bent with the convexity to the left, and when the next step is taken and left feet are approximated the convexity will be toward the right; therefore, with each successive step the spine is bent to one side and then the other. If a child goes through these motions while crawling, the same mobility of the spine will be brought about. This active method of limbering up the scoliotic vertebral column was first introduced by Klapp, of Bonn, and I have used it in a modified way with excellent results.

The patient is first placed with the hands and knees on the floor; the thigh of one side is then flexed as much as possible, or until the knee is near the axillary space, while at the same time the arm of the same side is flexed at the elbow, and the elbow is made to touch the side of the thigh by bending the body to that side; at the same time the arm of the opposite side is fully extended forward along the floor and the leg of the same side extended backward as far as possible, with the knee straight and the foot fully extended. The second position, which consists of extreme flection of the previously extended extremities and extension of those previously flexed, is then assumed, and so on, the third being similar to the first, the fourth to the second. Figure 1 shows the position the patient should first assume. After some days, when the patient has learned this part of the exercise thoroughly, sheis then taught to crawl in a circle, bending always toward the convexity; that is, a child with a right dorsal convexity should always crawl in a circle and bend toward the right, and with a left convexity always toward the left. This bending toward the convexity may be increased if the fully extended extremities are adducted to their limit and the head turned and bent toward the convexity, as is shown in Figure 2.

The first two beneficial points to be noticed are that the lateral deviation is greatly corrected and that the muscles of the back are rapidly developing; also that the spinal column is more movable. If the patient is examined while in the second position, it will then be noticed that the ribs on the concave side are widely separated, resembling the sticks of an open fan, while those of the convex side are pressed nearer together. This compression of the ribs on one side and their separation on the other tends to correct their deformity,

FIG. 3.

and by so doing increase the thoracic capacity on the convex side. The gradual correction of the curve and change in the angle and position of the ribs tends to untwist the rotated vertebræ and bring their spinous processes nearer the median line. It is quite remarkable to note how rapidly the muscles develop, and after a six weeks' course they feel like good stout cords on each side of the spinal column, especially the convex.

The crawling is kept up for twenty minutes, after which each patient lies face downwards in a correcting frame or box, which is shown in Figure 3. A padded upright is placed at the base of the neck on the concave side for counter-pressure, and a heavy leather strap attached to the frame holds the hips stationary. Wide elastic bands are then placed around the convexity and the anterior projection of the thorax. The first band runs from the side of the frame below, upward and around the convexity, then downward and through a slit in the bottom of the frame to the same side, where it is drawn taut and fastened. The second band runs from the top of the frame on the opposite side, down and around the anterior projection, then upward and to the same side, where it is drawn taut and fastened. These bands, by their elasticity, bring an oblique-lateral pressure on the projections, which tends to untwist the rotation as well as correct the lateral

deviation.

Figure 4 shows the frame applied. The patient is instructed to take deep breaths so that more pressure will be brought to bear in both directions; this also helps to correct the thoracic deformity. Fifteen minutes to a half hour a day is sufficient. The patient is then taken out of the frame and goes through a light course of sitting-up exercises, such as bending at the hips with the

knees straight, raising the arms fully extended above the head, etc. Swing on rings, hanging from ladders, and pulleyweight exercises are beneficial for those whose general muscular system is weakened. Too great stress cannot be laid on the proper use of gymnastics. After we have been able, in a measure, to correct the deformity, our principal point is to enable the patient to maintain the improved posture, and the only possible means of doing this is to thoroughly develop the muscular system, unless we wish to condemn patients to wearing a brace or corset all the rest of their lives, which is anything but desirable. When the exercises have been gone through with, the removable plaster corset is reapplied and the patient dismissed for that day. During the first six weeks the corset is to be worn night and day, being taken off only for gymnastics and hygienic reasons. After six weeks or two months, another corset is made with the patient in the best corrected position, and is to be worn only during the day. New corsets are made at intervals of about two months. The length of time they are to be worn must be determined by the improvement in position and by the progress in muscular development. It is a great mistake to keep a brace or corset on too long, for the muscles after a time rely on the artificial support, and atrophy consequently sets in. Many cases of scoliosis are extremely combative and tax the patience and perseverance of the surgeon as well as the patient to the utmost, but if the lines I have endeavored to lay down are strictly and energetically carried out, there is no reason why others should not obtain as satisfactory results.

LITERATURE.

Hoffa: "Lehrbuch der Orthopädischen Chirurgie," 5te Auflage.

The operation for extraction of senile cataract is performed in so many different ways, at least in some of its details, that a brief consideration of the subject should not prove uninteresting or unprofitable. This paper is based on the writer's experience of seventeen years in eye sugery, personal observation of the work of many operators in this country and abroad, and careful study of numerous text-books.

First in order as well as in importance, is preparation. It will be assumed that the cataract is ripe, or practically so, although, exceptionally, operation on unripe cataracts is perfectly justifiable. The patient's condition should be rendered as good as possible by careful attention to the control or removal of unfavorable symptoms, like cough, incontinence of urine, etc., and the building up of the general health. The bowels should be emptied thoroughly the day before the operation, the body bathed and perfectly clean clothes given for the person as well as for his bed. Lachrymal disease or conjunctivitis must be cured or eradicated. Just before commencing the operation, the lids and face should be washed with green soap and warm water, attention being given to the lashes. Some operators also advocate washing these parts with a strong bicloride solution. In Berlin University Hospital the eyelashes are cut off. In one case in which the writer did this he experienced some difficulty in trying to lift the lid out and down over the wound, which could have been done easily had the lashes been left alone..

It is impossible to render the conjunctival cul-de-sac sterile. To use the strong solutions and vigorous scrubbing employed in preparation for operations on other parts of the body would, by the irritation and congestion produced, increase rather than decrease

the liability to infection. It is well, however, to irrigate the eye with normal salt, boric acid or weak bichloride solution, the latter not exceeding in strength 1 to 6,000. Some of my patients have used a very weak bichloride or argyrol solution a few days before the operation. Covering the face and forehead with gauze is a common procedure, a hole being made over the eye large enough to admit of free manipulation.

It goes without saying that the surgeon's hands should be thoroughly sterilized, notwithstanding the fact that they do not come in contact with the wound. He should wear a sterile gown and cap. Mellor, of Vienna, and others also wear a gauze mask over the mouth to ward off the danger of infection from the surgeon's breath.

All dressings should be sterile, and instruments likewise. Every instrument used in the operating-room at Moorfields is boiled, but many surgeons, fearing the effect of this upon the edge of knives and scissors, simply immerse them in alcohol. Others rely on carbolic, soda or other antiseptic solutions. The writer's preference is to boil everything but the cataract knife, the blade of which is held in boiling hot water fot one minute.

Very nervous patients and those hard to control should be put under a general anesthetic, but in most cases it is preferable to employ local anesthesia. While 1 per cent. holocaine and other similar solutions are occasionally used, most ophthalmic surgeons prefer cocaine, from 2 to 10 per cent. weaker solution is hardly sure of properly anesthetizing the cornea; the stronger is much the more likely to prove satisfactory, in many cases even rendering the iridectomy painless. Three or four instillations at intervals of three or four minutes usually suffice.

The

special attention to the kinds of instruments well adapted, as well as those ill adapted, to the purpose intended in this operation. While Critchett raises the upper lid with one finger of the hand holding the fixation forceps, and some others have their assistants separate the lids with fingers or retractors, most operators use a speculum. The best of these are the wire stop-speculum after the von Graefe or Noyes model, or the solid plate of Lang. The latter has the advantage of keeping the lashes away more perfectly and also obviates the possibility of getting caught in the wound, which might happen with the wire if the patient violently contracts his lids when the surgeon is removing the speculum. One worked with a screw is under better control than one with a ratchet. It is important, also, that it be curved sufficiently to be as much as possible out of the way of the operator.

The fixation forceps should be provided with a catch easily worked. The writer for years used one without a catch and found it quite satisfactory. The advantage of the catch is that the hold is more secure, but if the catch is not easily worked it may cause considerable embarrassment.

The cataract knife should be narrow, very sharp and have a perfect point. A dull knife, or one that does not penetrate readily, may be the cause of failure. Many operators use a new knife or one that has just been sharpened for every operation. Landolt points out the objection to metal handles-the unnatural feeling. Ivory and bone are better. He also says the handle should not be of a shape that turns too easily in the fingers, but it should have flat surfaces that admit of a firm and steady grasp.

Iris forceps may be straight or curved. They should not be too long, but should be so constructed that the iris may be securely held. The ordinary curved iris scissors may be employed or the special scissors of DeWecker.

The capsulotome or capsulotomy knife is really small sharp hook which cuts the capsule readily. Collins and some others prefer a special forceps by which a portion of the capsule is removed. While this, if successful, makes a secondary or capsular cataract less likely to occur, this method involves so much danger of dislocating the lens and losing

it in the vitreous that it has not been very generally adopted. generally adopted. The uses of these and the other instruments mentioned will be made more clear in describing the steps of the operation.

The question of assistance is very important. Some men succeed well by themselves, preferring no assistants at all to those who are untrained or unknown to them. Haab says

one assistant is indispensable, two are better, and in some cases he uses three-one to hand him the instruments, another to hold the patient's head, and a third to keep the speculum from pressing on the eyeball and to steady the ball or clip off the iris in making the iridectomy. In my judgment this is important, for where the eyeball is not kept still by fixation forceps a violent movement when the iris is seized by the forceps might tear that membrane and cause much hemorrhage, traumatism, etc. (The writer once witnessed just such an accident.)

Having carefully adjusted the speculum in a way not to press on the eyeball or cause much tension on the lids, the operator should tell the patient to look up, down, right and left a few times to see that he has good control of the movements of the eye and will not be likely to fail to look in the desired direction, when asked at a critical moment in the operation. The conjunctiva and subjunctival tissue are then seized with the fixation forceps in the left hand just below the cornea, nearly in the middle line (the surgeon, if right-handed, standing behind the patient's head when operating on the right eye, and in front to the left side in operating on the left eye; if ambidextrous, either behind or in front for both eyes), the cataract knife held in the right hand with the cutting edge upwards is entered at the corneo-scleral junction, outer side, about the width of the blade above the equator, is pushed across the anterior chamber and made to emerge at a corresponding point on the other side, cutting upwards with point and heel as the knife is pushed forwards and slowly pulled backwards, the last part of the incision being made by a series of short sawing motions until the flap is completed, always keeping as closely as possible to the sclero-corneal junction. The objection to doing this too rapidly is that very sudden emptying of the anterior chamber might cause dislocation of the lens, loss of vitreous, detachment of the retina, or intraocular hemorrhage. On the other hand, making the incision too slowly allows all the aqueous to escape by the time the cut is finished. A medium course avoids the dangers of the first method and the embarrassment of the