The curvatures with which the masseuse has to deal are :

Lateral (scoliosis).

Posterior (kyphosis). Anterior (lordosis).

Angular curvature, being a disease of the bones of the spine, does not come within her province.

Lateral curvature, with or without rotation, is the one which most frequently comes under her notice, because, though round backs are very common, massage is not so commonly ordered for them, and because posterior curvature frequently develops lateral, and for the latter treatment is sought.

In this curvature the spine bends sideways. There may be a long C-shaped curve, reaching from upper dorsal to lumbar region, or a short C, taking in a certain number of upper dorsal vertebrae or lower cervical and upper dorsal (cervico-dorsal), or it may be lower dorsal and lumbar vertebrae (dorso-lumbar). Sooner or later a secondary or compensatory curve is added to the primary, making an S-shaped or sigmoid curve. This second curve is in the opposite direction to the first ; that is, here is a curve with the convexity to the right in one region— say the upper dorsal—and a curve in the lumbar region, with the convexity to the left. In this case the right shoulder is raised, the scapula is pushed up and out by the curved spine, the right hip is depressed, and there is no definite line at the waist. The shoulder on the left side, from lack of support, droops, the hip projects, and the waist-line is abnormally defined. Opposite to the convexities are concavities. There are thus on the back two protuberances and two depressions. There is also asymmetry of the flanks, the one on the drooping side being flat from wasting of muscles and the other appearing more than usually round. There may be three or more curves. There are many theories as to the cause of lateral curvature, which it is unnecessary to go into here. Softness of the bones, general weakness, weakness of the muscles of the back and ligaments of the spine, predispose to it. The exciting causes are faulty positions, such as standing continually on one leg, sitting always on one buttock, or with always the same leg crossed, sitting at too low a table when writing or studying, continued over-fatigue ; or it may be caused by a short leg, the loss of a limb, paralysis, flat-foot, wry-neck, or diseases altering the shape of the thorax.

The dorsal curve in the majority of cases has the convexity to the right, and the lumbar curve the convexity to the left. Where there is structural defect, as in a short leg, the legs must be made equal by a thick sole to one shoe ; but this is arranged by the surgeon. What is required from the masseuse is that she strengthens the weak muscles of the back, and so enables them to pull the spine into place, and that she should instruct and encourage the patient to correct faulty positions. She may commence her work with full confidence of a successful issue ; the very worst cases are improved, even where there is structural defect. Where the trouble is purely muscular a complete recovery may be counted on, which is not wonderful if one considers that weak and wasted muscles are nourished and exercised. But if this happy result is to be brought about by the efforts of the masseuse, the work must be well and intelligently done, anatomy of the spine and pelvis and the action of the muscles understood. When a surgeon sends a masseuse to a case it is in the belief that she understands her work, and it behoves her to do so, as he may give her no definite instructions. It is impossible before a back is seen to know exactly what work is required, for there is much difference in the number and nature of curves. There may be deviation without rotation, or deviation with more or less rotation, or rotation without deviation, or with scarcely perceptible deviation, or deviation so slight that only a trained and accustomed eye can detect it. To take the last-named first : When the patient is placed in the prone position, with arms by the sides, the weight of the head and shoulders being thus taken off the spine, the curve disappears. The manipulations used are symmetrical ; there is not sufficient stretching and contraction of muscles to require a difference of movements on either side. The ordinary movements for the back are first done : in this way the transverse muscles are worked up ; then, to get at the deep muscles, the longitudinal, the erector spinae and its continuations, and the multifidus spinae.

Fig. 101.—Friction on the Long Muscles of the Spine.

1. Friction with thumbs on muscles in the vertebral groove, between the spinous and transverse processes on each side, from occiput to sacrum. The circles to be carefully and firmly made, and the muscles felt to work on each other under the thumb.

2.   The first and second fingers are separated and drawn down rapidly and firmly over the same region.

3.  With both index-fingers working alternately, a firm to-and-fro movement is made from the seventh cervical vertebra down on the supraspinous ligament.

4.   Kneading with palms and with heel of hand to be repeated all over the back ; tapotement all over the back.

5.  Hacking.

6.  Flail.

7.   Clapping.

8.  Vibration on each side of the spine with knuckles. The hand is closed and the knuckles are moved slowly from above downwards ; a vigorous trembling movement is communicated from the operator's arm.

The upper part of the back is covered ; the sacrum is stroked and the glutei kneaded with fingers and thumbs and heel of hand, followed by hacking and heating. The back is done in two divisions, to prevent too much surface being exposed.

The patient is turned, and lying quite flat, with the chest expanded by the shoulders being held well back and kept close to the couch, the chest is massed as on p. 170.

Exercises.—Still lying on the back, the patient does the following active movements :

1.  (a) Arms extended downwards by the sides, palms upwards ; the forearm is flexed on the arm ; the little fingers touch the outer border of shoulder. (6) Return to first position. Deep inspiration when flexing ; expiration when extending.

2.   (a) Arms extended outwards ; (b) forearms flexed on arms. Inspiration during the outward movement; expiration when flexing.

3.   (a) Arms extended upwards, close to head ; (5) brought down with forearms flexed. Inspiration when extending ; expiration when flexing

4.   (a) Arms extended forward ; (b) brought back with forearms flexed. Inspiration and expiration as before.

5. Circumduction of arms. Inspiration during forward and upward movement ; expiration during backward and downward movement.

These exercises are done slowly. They act on the pectoral muscles, the latissimus dorsi, and all muscles attached to the scapulae.

Circumduction of legs. Position the same. The leg is lifted, with knee extended. It is carried inwards, upwards, outwards, and brought back in a circle to the first position. This exercises all the muscles of the hip and the extensors of the leg. It is at first repeated three times, then five, then ten. When the patient's strength permits, they are performed standing, and others are added.

In a more advanced case the condition is evident, and the asymmetry immediately strikes one. In the prone position the curves are not so marked, but they do not disappear; the two protuberances, the two depressions, the uneven shoulders, and the uneven hips, are all apparent. A cushion is put under the patient's stomach, to relax the muscles of the back. The arm of the raised shoulder is depressed and close to the side; the arm of the depressed shoulder is elevated and close to the head ; the forearm may be flexed and the hand pronated under the forehead.

The. massage is the same as in the previous case, but modified to suit the altered shape of the back. The spine is stroked in the same way. In kneading with the palms, the hands are managed so that pressure is not made on the concavities.

The convexities are then kneaded with the heel of hand, and on the concavities finger-kneading is used. It is easy to well work up the muscles with the fingers without pressure on the depressed ribs, while in kneading with heel of hand there is just the danger of pressure.

Tapotement only on convexities.

The chest is manipulated as before described.

Exercises.—1. Standing or lying. Circumduction of left arm backwards.

2.   Circumduction of right leg.

3.  Standing. Right hand on ribs under armpit, fingers pointing to spine ; left arm elevated ; forearm flexed over head ; fingers touch right ear ; the shoulder is bent as far as possible over right hand.

4.   Standing. Left hand pressed against lumbar curve, fingers pointing backwards; right arm depressed; trunk is bent over left hand. In this and above movement the knees are straight, and both feet kept on the floor.

5.   Standing. Knees straight ; arms elevated ; feet a little apart ; the trunk is bent from the hips till the fingers touch the floor, or as near so as can be accomplished ; the trunk is slowly raised to first position. This exercises erector spinae, glutei, rectus abdominis, psoas, iliacus, and muscles of thigh.

6.   Lying prone, with trunk hanging over end of couch (ankles strapped to couch or held by operator). The head and trunk are raised to the horizontal or beyond. This exercises erector spinae and complexus. These two exercises are used in all curvatures.

7.   Lying prone. The operator presses lumbar curve with one hand, and abducts the leg with the other ; the patient is steadied by clasping the couch.

If the dorsal curve is to the left, all one-sided exercises are reversed.

Rotation.—In lateral curvature with rotation the spine has not only deviated from the middle line, but some of the Vertebrae have turned or twisted ; that is, the spine has curved with the convexity, say to the right, in the dorsal region. The bodies of the vertebrae having more freedom of movement than the processes, because of not having muscular attachments as the processes have, turn more to the right than the processes do. The consequence of this is that the left lateral processes are carried downward, with their attached ribs. This causes sinking of the muscles that are supported by these ribs. The spinous processes also turn to the concavity ; the right lateral processes are raised, with their attached ribs and muscles. Much deformity is the result. If the second curve be in the lumbar region there are no ribs, but the muscles are bulged out on one side and sunken on the other. The appearance of the back is quite different to the one last considered, and there is a difference in the appearance of backs with even the same class of curvature. Each one must be critically examined before being worked on. In rotation, which is true scoliosis, the curves are not lessened in the prone position ; the protrusion of the shoulder and hip are frequently on the same side ; the ribs are very prominent on the convex side, forming a bow ; they push the scapula up, out and away from the middle line ; the intercostal spaces are widened. In front the ribs of this side are depressed ; the lower end of the sternum inclines to the de pression ; the clavicle is crooked.

On the concave side the ribs are depressed at the back, the intercostal spaces are narrowed, the shoulder droops, the ribs are prominent in front, the pelvis is tilted, the ilium on the side of the lumbar curve is thickened—in fact, the whole thorax and pelvis may be deformed.

The work in such altered conditions necessarily differs from that used in mere deviation. There should be more care exercised, if possible, for harm may be done and rotation increased by making pressure in a wrong direction. In these cases pressure on bone is necessary. In kneading with the heel of hand from the spine outward on the dorsal convexity pressure is made on the ribs ; at the same time, the other hand is placed under the depressed ribs, and they are pressed upwards, the fingers underneath, as it were, lifting them, so that while working, a moulding or straightening process is kept up. When kneading the dorsal concavity, the work is not commenced at the spine, as usual, but at the side, and terminates at the spine ; in this way downward pressure on the concavity is guarded against ; the other hand rests with pressure on the convexity. If the lower curve is in the dorsal region, the same plan is followed ; if in the lumbar region, there are no ribs to consider ; the heel of hand is used to the convexity, and finger-kneading to concavity. In working on the muscles in the vertebral groove, friction with the thumb is done only on the convexities and with fair pressure ; if done on the concave side it would tend to increase rotation by downward pressure. Instead, these contracted muscles are worked with an upward pushing movement of the thumbs towards the spinous processes. This movement while kneading the muscles makes pressure against the spinous processes and assists in untwisting the vertebrae. Pressure is made with thumbs outward from spine on intercostal spaces on convexity. It is difficult to get at the long muscles on the inner side of the curve : it may be necessary to put a small pillow or pad under a shoulder or hip, or to turn the patient somewhat on the opposite side, with trunk slightly curved for the moment. In all cases the chest muscles are manipulated and exercised ; care is taken to avoid pressure on the depressed ribs.

Exercises.—With some modifications, all the foregoing exercises are used, to which are added others to correct the rotation,

1.   The head is rotated slowly from right to left as far as possible. (Untwisting exercise.)

2.   Sitting in order to steady pelvis, trunk is slowly rotated as far as possible to the left. (Untwisting exercise.)

3.   Standing. Both arms are extended to the right, then moved quickly to the left. (Untwisting exercise.)

4.  Operator presses summit of curve, while patient elevates and extends backwards the left arm.

All the exercises given here are ' active '; most of them can be made ' resistive,' and, if necessary, given passively at first. It is of the highest importance that the condition of the spine and ribs and the action of the muscles should be understood by the masseuse.

The object of the special exercises used in rotation is to draw the processes into place if possible. The transverse muscles having their insertions into the shoulder and humerus —that is, the trapezius, rhomboids, and latissimus dorsi—are attached to the spinous processes', therefore these muscles should be exercised on the side of the dorsal convexity, in order to raise the processes, while the chest muscles are exercised on the side of the concavity, in order to draw the too prominent side of the chest back ; consequently the arm on the convex side is circumducted forwards, and the arm on the concave side is circumducted backwards.

The. erector spinae and multifidus spinas are the muscles principally concerned in keeping the spine erect. It will be seen that the erector spinae being attached to the processes in the whole length of the spine, to the ribs as far out as their angles, as well as to the sacrum, ilium, and cranium, is a tremendous power on the spinal column.

FIG 102.—1, Origin of erector spinae muscle; 2, longissimus dorsi; 3, trans versalis cervicis; 4, trachelo mastoid ; 5, sacro-lumbalis; 6, accessorius; 7, cervicalis ascendens ; 8, complexus; 9, multifidus spinae.

FIG 103.--Origins and Insertions of Erector Spinae Muscle and Its Continuations and Complex

* Origins of muscles are coloured red and insertions blue.

The exercises may be performed with Whitley's, Dowd's, or any of the exercisers now in use. Care and intelligence are needed. It is clear that grave injury may be done to a patient by increasing a curve or rotation through ill-directed exercises. Patients with spinal curvature are quickly fatigued, and fatigue is most harmful to them ; discretion must therefore be used in giving treatment, beginning with fifteen minutes and gradually lengthening the time. The surgeon fixes the maximum.

The patient must not turn or twist the body in making or overcoming resistance.

The patient should rest in a recumbent position—prone or supine--after massage and exercises. From half an hour to an hour is long enough. Resting half an hour at a time four times a day is better than long-continued rest. If a corset or any sort of support is worn, it should not be replaced after massage till the patient has rested. Flat-foot is frequently associated with curvature.

The erector spinae consists of seven muscles, which extend from the pelvis to the back of the head. It arises from the back part of the crest of the ilium, the posterior iliac spines, nobs of sacrum, all the sacral, lumbar, and two or three lower dorsal spines. Below the last rib it divides into two columns. The sacro-lumbalis is the outer column ; it inclines outward, and is inserted by tendons into the lower six or seven ribs near their angles. This muscle is continued upwards by the musculus accessorius, which arises internal to it from the upper border of the lower six ribs, and is inserted by tendons into the angles of the upper six ribs and the transverse process of the seventh cervical vertebrae.

The cervicalis ascendens arises from third to sixth upper ribs internal to the accessorius, which it continues upwards, and is inserted into the transverse processes of the fourth, fifth, and sixth cervical vertebrae.

The longissimus dorsi is the middle column ; it is inserted by tendons into the transverse processes of all the dorsal vertebrae and upper articular processes of lumbar vertebrae and to the lower nine or ten ribs, between their angles and tuberosities and to the lumbar fascia.

This muscle is continued upwards by the transversalis cervicis, which arises from the transverse processes of the first four or five dorsal vertebrae, and is inserted into the transverse processes of the cervical vertebrae from the second to the sixth.

The trachelo-mastoid continues the longissimus dorsi to the head ; it arises from the transverse processes of the four or five upper dorsal and the articular processes of the three or four lower cervical vertebrae, and is inserted into the mastoid process beneath the sterno-mastoid and the splenius.

The spinalis dorsi, which forms an inner column, separates from the longissimus dorsi in the upper dorsal region ; it arises from the two upper lumbar and two lower dorsal spines, and is inserted into the dorsal spines from fourth to ninth.

It will be seen that these muscles overlap each other in the whole length of the trunk.

The multifidus spinae, the most deeply seated of the spinal muscles, reaches from the sacrum to the axis ; it lies in the vertebral groove beneath the erector spinae and the longissimus dorsi, and arises in the first place from the back of the sacrum, the inner side of the superior posterior spine of the ilium, the sacro-sciatic ligament, and from the overlying tendon of the erector spinae. In the lumbar region it arises from the upper articular processes of the vertebras, in the dorsal region from the transverse processes, and in the cervical region from the articular processes of the four lower cervical vertebras. It is inserted into the whole series of spinous processes, the muscular bundles overlapping each other as they pass from their origin upwards and inwards to their insertion in the spinous processes above them, some to the next process, and some missing one, two, or three processes.

In no cases is deep breathing more necessary than in spinal curvatures, because of the deformity of the thorax and the delicacy and anaemic condition of most of the patients. Before commencing the daily massage several deep breaths are taken, also when the massage is finished and between the exercises. If the patient has not already learned to breathe deeply, the first lessons are better given lying on the back. The abdominal muscles are first retracted, the chest expanded by the shoulders being kept well back ; the hands may be placed on the hips or crossed behind the back. The air is taken in slowly through the nose, held for a few seconds, and let out slowly through the mouth. It is well for the air to escape with a hissing noise ; the masseuse can then better gauge the amount taken in. Resistance may be given by hands laid on the chest in front or placed on the lower ribs, fingers to the back and thumbs below sternum. The general health requires attention. The patient should be encouraged to follow the doctor's instructions as to open-air exercise, food, rest, clothing, etc.

In posterior curvature the back is bowed backwards, in the dorsal, cervico-dorsal or lumbo-dorsal region; the head bends downward and forward, the shoulders fall forward, the chest is flattened and narrowed, the muscles of the abdomen are contracted and shortened as the long muscles of the back are stretched and lengthened. It may be the result of short sight, or, in the case of an adult, of occupation, such as fatigue from bending forward over some work for hours. In any case there is weakness of the muscles of the back.

The patient lies prone, with arms by sides. The ordinary movements for the back are first done ; in this way the trapezius, latissimus dorsi, rhomboids, are worked up ; then, to get at the deeper muscles, the long extensors of the back, the erector spinae and its continuations :

1.   Friction with thumb on each side from occiput to sacrum between the spinous and transverse processes in the vertebral groove. The circles should be carefully and firmly made with the thumb, and the muscles felt to work on each other under it.

2.  The first and second fingers are separated and drawn down rapidly, and with fair pressure, over the same region.

3.  With both index-fingers working alternately, a firm to-and-fro movement is made from the seventh cervical vertebra down, between the spinous processes on the supraspinous ligament.

4.   Kneading with heel of hand all over the back from the spine outwards.

5.   Hacking.

6.   Flail.

7.  Clapping.

8.   Rolling effleurage, pressure towards axillary glands. Before turning on back, the patient to raise head and

shoulders from couch several times, the ankles being held or strapped. This may also be done with the head and trunk hanging over the end of couch.

For the chest (the patient lying supine) :

1.   Kneading with heel of hand or ends of fingers on pectoral muscles from middle line outward.

2.   Thumbs drawn with pressure over intercostal muscles outward from middle line.

3.  The hands rest on the chest, fingers pointing to neck. The patient breathes deeply against their resistance.

4.   Stroking from sternum to pubes many times, over recti muscles.

5.   Kneading of recti muscles with fingers and thumbs.

Exercises (still lying on back).—1. Outward circumduction of extended arms.

2.  Artificial respiration (Sylvester's method).

3.   A simple exercise of Blaikie's is good, the patient standing with knees straight, arms folded at the back, head drawn back, chin tipped till the eyes look at the ceiling over the head ; rest a few moments, say while two or three deep breaths are taken, straighten trunk and repeat.

This movement expands the chest and straightens the back, and may be made more effective by resistance being made with the hand of the operator against the back of the patient's head. All the muscles of the neck are also strengthened.

Sponging the back with cold water, or with first hot and then cold water, before the massage is given is helpful. Lateral curvature is often associated with posterior.

In anterior curvature the back bends inwards, at the lumbar and lower dorsal region, making a ' hollow back.' It is caused by hip-joint disease, talipes equinus, paralysis and rickets. The muscles of the back are shortened in this curvature, and the muscles of the abdomen are lengthened. It is very awkward to work on a back deformed in this way, it being difficult to get hold of the contracted muscles ; any movements that can be made available may be used. The glutei are well kneaded, the back of the thighs, and the muscles of the abdomen.

Exercises.—1. Patient, lying on back, to rise into sitting position without aid of arms ; return slowly and repeat. This exercises the rectus abdominis, psoas, and iliacus muscles.

2.   Lying on back, knees straight, legs are raised to a right angle with the trunk ; the psoas, iliacus and extensors of the thigh are thus strengthened.

3.  Circumduction of extended leg to act on all muscles of the thigh.

4.   Patient standing, knees straight, feet a little apart, arms elevated with fingers touching, to bend trunk from hips till the fingers are as near the floor as possible. Raise trunk with arms in same position ; repeat.

In this exercise, the erector spinae, the recti abdominis, the glutei, psoas, iliacus, and quadriceps extensors are brought into use.