seen a fatal result from the administration of anesthetics, we all know that it is possible, even when every precaution is observed.

Is it surprising that one with the experiences I have related, should ask, why has chloroform been almost abandoned by the surgeon? It may be a question whether there are not compensations in its use, which call for a re-consideration of the relative value of the two anesthetics, and a larger use of chloroform in surgery.

The Function of Therapeutic Exercises in Lateral Curvature

HENRY O. FEISS, CLEVELAND, O.

In the condition called lateral curvature of the spine, it is important to remember that we are dealing, not merely with a local deformity, but one which implies a general change in shape in the entire torso, and often in parts more distant, so that we must not be tempted to direct our efforts upon the spinal column taken by itself.

It is also important to remember that we are dealing with a non-organic condition in the great majority of cases, a condition brought on, not by disease in the bones, not by disease in the soft parts, but by muscular weakness and insufficiency, or by disproportion between muscular strain and ligamentous maintenance.

The condition usually takes place as a a result of faulty position, faulty in being insufficient for purposes of shapely balancing. Then if the position or attitude which was physiological in the start is prolonged so much as to become habitual, lateral curvature results.

At the start habitual cases are usually manifested by long sweeping curves of the spinous processes, with or without a prominent hip, and usually with a slight dorsal convexity on one side of the thorax. It is this developing type in which therapeutic exercises have a most important scope, for such a curve is often the beginning of a more marked and rigid deformity, so that to get hold of these cases early is most satisfactory. We often find that in these early cases mere mental stimulation is enough to bring the torso into symmetry and beauty of contour. If such mental stimulation is sufficient, a few active or passive motions carried out systematically at regular intervals for a certain period of time may indeed be all that is required to divert nature's progress

from the pathological path back into the physiological. This mental effort cannot be emphasized too strongly, as a person carrying out certain therapeutic exercises with a view to holding himself correctly, will at times, when he is not exercising, unconsciously attempt to hold himself in what he is taught to be the best possible attitude. If the effect of these exercises is to be gotten quickly it implies that the beginning deformity has not come into a fixed stage, that all motion between the vertebrae, which is normal is still present, that ligaments are still firm and of symmetrical strength, and that the muscles are not too far weakened.

We come next to a type which represents a stage when distortion has actually begun, and just begun, when the dorsal region of the spinal column, with the thorax attached, has twisted as such upon the underlying torso, and when the long convex sweep has already become fairly permanent, so that even if the patient is reminded to straighten himself up, and taught how, the deformity cannot be quite obliterated. The function of exercises in these cases is a more direct one. Whatever the cause of these cases be, we can always figure on a symmetrical muscular strain, because even if muscular weakness has not been a factor in the etiology, this muscular weakness is bound to come in time, to one side or the other in different sets of muscles, because the origin and insertion points gain different relative positions on the two sides. This, indeed, is rather an unbalancing than a true weakness, and may be regarded as such. The function of exercises here is to make up for the insufficiency by cultivatig the individual use of certain muscles or sets of muscles, as well as to bring about a subjective understanding for using these muscles actively, so that the total result is towards a symmetrical balancing of the body. If deformity is at all marked, as in the ribs, or in the column itself, we resort to manipulative methods applying pressure and leverage force in such a way as to counteract the vicious tendencies of nature, using of course, the simplest possible measures.

We next come to a set of cases which may be regarded as less hopeful, but in which radical improvement is still implied, providing the condition is well enough understood, that the separate elements may be analyzed and worked upon with more individual care. We find in these cases a rather marked lateral dorsal curve of the spinous processes, and a sharp posterior rib deformity on the convex side of the curve. Marked folds usually appear under the opposite scapula, and over the corresponding

FEISS-THERAPEUTIC EXERCISES IN LATERAL CURVATURE 49

hip, which is also prominent. There may be inequality in the length of the legs and sloping of the pelvis. This is only a rough description of a very common type. If we dissected such a torso we would find that the fronts of the bodies of the dorsal vertebrae have rotated towards the side of the convexity of the curve and that the lumbar vertebrae have rotated in the opposite direction, but we need only look at the rib prominence to see how fixed and permanent the pathological anatomy has already become. The principle of dealing with such a case is somewhat different from those in which the prognosis is more favorable, for in these the curves and contours have already affected the shape of the bones to greater or less degree. We must in the first place assume that asymmetry once begun, the tendency for greater asymmetry becomes proportionately greater. In other words, the fact that the patient is already deformed is usually a pretty good sign that the deformity is going to get worse and that we ought to do everything possible to counteract this tendency. In the second place we ought to understand that even if we cannot mould the patient's back into its original shape we may be able to give it an apparent symmetry which for practical purposes may be all that is required. For example, given a definite and fixed curve in the spinal column we may not be able to obliterate that curve, but we may be able to give a compensatory curve which throws the body into a better balance. We can further by stretching the spinal column with appropriate apparatus bring about a general obliteration of all the curves by doing which we are at the same time stretching many of the tightened muscles and fascia which span an arc of the curve, like the bow-string of a bow.

If we gain a definite amount of flexibility especially in the lumbar region, and it is only in this region that we can hope for much gain, we can often bring about sufficient play to let the rest of the spine assume a more symmetrical attitude. In the dorsal region we can never hope, after the column has become fixed, to regain a great amount of flexibility in toto and our aim is usually to make the lateral curve turn so as to become a posterior convexity.

All force brought to bear upon the rib deformity ought to be exerted with a view to doing everything possible to bring the column itself back into the straight. This not only means a correct application of the force itself, but the correct application of counter force or resistance, because the whole thorax takes part in the deformity and if the resistance is not furnished in the cor

rect relation to the pressure this very resistance may do more harm than the correcting force is doing good. An admirable way to bring about correct pressure is to put the whole body on a stretch and then apply pressure upon the rib deformity, or second, to hyperextend the body and bring the force to bear in that way. In the ribs, the most we can hope for at first by application of pressure is to gain a flexibility which will permit the straightening column to pull correctly upon the convexity in the

ribs.

purpSTON MEDI

It is not our go into the details of the application of the various kinds excercises which may be used. We wish simply to hint at the relation between the function and the application and we may be able to see from this sight sketch that the first function is to cultivate the Rive forces in the muscles both by mental stimulation and local practice, secondly, to bring into play a certain power of mobility in such joints which has become comparatively fixed by the pathological process, and thirdly, to stretch all factors, which on account of their tightness would interfere with such mobility as we are able to gain.

The Management of Occipito-Posterior Positions.

BY ARTHUR H. BILL, M. D., CLEVELAND

State House-Surgeon of the New York Lying-In Hospital

There is perhaps no one thing in obstetrics which is more annoying to the physician than a presistent occipito-posterior position, so that in general discussion of obstetrical problems, one of the first questions asked, as a rule, is "how do you handle posterior positions?"

In this short paper I shall not attempt to discuss the various methods employed for preventing these positions and for correcting them when already present, previous to the onset of labor and during labor before the rupture of the membranes,-I mean such methods as postural treatment, external and combined manipulation, etc., but I shall confine myself to those occurences of posterior position which, in the course of labor, form such an obstacle that it becomes necessary to resort to operative interference for the accomplishment of the delivery. It is in these cases that there is such a marked difference of opinion and uncertainty as to the safest and best method of procedure, and on account of this uncertainty there is usually a tendency to let the case take its own course and only interfere, often too late, when this is an

absolute necessity in order to save the life of the mother or child. Of the more important methods the following may be mentioned (1) the interna! procedure known as podalic version, which, however, only comes into consideration in cases in which the head is unengaged, and in these cases there is in all probability a contraction of the pelvic inlet, which would in itself entirely govern the method of procedure, and perhaps form a contraindication to the version. Then too the version is often impossible on account of the extreme degree of contraction of the uterus. For these reasons it would seem that the cases in which podalic version could be performed, for the correction of the faulty position alone, are rare indeed. (2) The various methods of delivering with the aid of forceps. Of these may be mentioned

(a) That in which no attempt whatever is made to rotate the head to an occipito-anterior position. Here the forceps are applied in the axis of the pelvis and irrespective of the head, and are kept in this position grasping the head obliquely, unless spontaneous rotation occurs, which however is usually not the case, for the forceps when applied in this postition form in themselves an additional obstacle to the rotation. If the head fails to rotate, which is usually the case, it is delivered in the posterior position. In connection with this method, it is noteworthy that in the clinics in which it is in vogue, namely in Germany and Austria, the number of lacerations of the perineum and of episiotomies is exceedingly large, as is natural to suppose when a head is delivered with the occiput to the rear.

(b) Another method used considerably in this country, as well as in certain foreign clinics, consists in applying the forceps in the same way as in the previous method, namely with regard to the pelvis, and in attempting to rotate the head at the same time. as the traction is made. Here it is evident that forceps applied obliquely to the head, that is to one of its longer diameters, are in no position to act well as rotators, for, when the attempt is made, they frequently slip around the head instead of turning it, and thus cause injuries to it, and furthermore the wider separation of the blades is conducive to lacerations of the maternal soft parts.

(c) A third method is the one first described by Scanzoni of Prague in his textbook of obstetrics and commonly known as the Scanzoni maneuver. This maneuver, which was strongly opposed in Germany, as well as in Prague and other parts of Austria, was taken up and developed by the French, especially in the Tarnier and Baudelocque Clinics in Paris. It consists of two