In the event of a child corning under medical observation at a time when kyphosis is developing, the main point is to insist on the child assuming a position such as to produce a lordosis of the spine. In the former class, the suspension method recommended by Rauchfuss is best applied, or a cushion, 5-10 cm. thick and 30 cm. long, filled with cotton or horsehair is placed between the mattress and back in the waist line region so as to induce lordosis of the lumbar region of the spine, which is particularly endangered in rachitis.
The reclining orthopaedic beds, recommended by Lorenz for spondy litis, but also admirab]y suited to rachitic kyphosis, give, however, much better results than such makeshifts, because of the simplicity of con struction. The technic adopted at our hospital is as follows: The infant, clad entirely in a bandage of webbing, lies on the abdomen. Both thighs arc placed on a cushion 20 cm. high and fastened there with a strap. The child's trunk rests with its sternal portion on a second cushion likewise 20 cm. high (Fig. 66). The aim is to obtain the most pronounced lordosis of the spine possible. A large piece of common pad ding (1-2 cm. thick) is cut out so as to cover the posterior and lateral surfaces of the head, neck, trunk, and pelvis. This layer of padding is fastened to the child with gauze bandages, all folds and wrinkles being carefully eliminated. A plaster-of-Paris bandage is now applied. Four to six bandages are sufficient to make a bed for an infant.
In general, transverse and longitudinal turns are applied over the body of the child as far as it is covered by the padding. Finally, several turns are carried over the front part of the patient's trunk so as to secure a snug fit of the plaster cast.
To strengthen the bandages, ten small wooden splints applied in transverse and longitudinal directions alternately may be added.
After the bandage hardens, the child is placed in a recumbent posi tion. The webbing and plaster bandage are cut open along the abdomen and the child taken carefully out of the cast. The borders of the plaster bed arc now straightened. Provision must be made for free and unlimited use of the arms and for a space around the anus to permit defecation (Fig. GS). The overlapping padding is pulled outward over the borders of the plaster bed so as to have the edges padded all around. Padding and webbing are fastened to the plaster bandage with a couple of stitches to render later displacement impossible. The bed is then hardened by
a heater. In twenty-four hours two to four bandages are added to the outside of the bed, saturated with isinglass, thereby materially increasing its durability.
At first, such a bed is made use of for a couple of hours only. Later on, when the child has become accustomed to it, it is applied day and night.
At intervals of from one to two weeks the lordosis-producing effect can be increased by placing small cotton pads under the lumbar portion of the spine, gradually exchanging them for larger.
These beds may also be made of celluloid and steel wire. Such beds are much lighter than plaster-of-Paris beds and the child, with its bed, can therefore be carried around by the nurse much more easily. They are also waterproof and therefore much cleaner than the plaster beds. Because of the special experience necessary to make and fit them well, an extensive description of the orthopedic technic may be omitted.
Placing the kyphotic child in a position which results in a very pro nounced lordosis of the spine, as described above, is the first and easiest step in the treatment. It is much more difficult to strengthen the already over-extended and therefore weakened muscles of the back. Massage of these muscles (twice daily for five minutes, rubbing and stroking alternately) may be performed at any age, but gymnastic exercises cannot be carried out in infants. As a substitute the children can be placed on the abdomen several times a day for a quarter of an hour, and by holding toys above the head may be induced to perform motions which tend to increase the lordotic attitude. As soon as the children grow older, starting with the second year, Epstein's easy chair may be successfully employed to strengthen the muscles of the back. Spitzy was the first to call attention to the excellent effect of crawling motions for strengthening the muscles of the back.
The "Round Shoulders" of School Children Later on in childhood, especially during the school period, a type of kyphosis makes its appearance which, although embracing the dorsal and lumbar portions of the spine as in rachitic kyphosis, exhibits the most marked projection a little higher up, usually in the centre of the dorsal portion of the spine and not in the lumbar portion. This atti tude, of which Fig. 67 is an excellent reproduction, is the most common of all kyphoses.