In the 1960’s, Alice Kramden was my television hero for standing up to her loser husband on The Honeymooners.
“One of these days, Alice,” Ralph would threaten when she called him out on another failed scheme to get rich quick. “Right in the kisser,” he’d bellow, “You’re going to the moon!”
But Alice cut him off at the knees, every time.
“You men kill me,” she scoffed. “You’re all alike. All you do is yell and scream and give orders. You men just think that you own this world!”¹
Ralph was always getting himself into trouble. He got fired from his bus driver job. He blew his chance to win $90,000 on a game show. He found and spent a suitcase full of money that turned out to be counterfeit.
Once, Ralph told Alice he couldn’t have dinner with her family because he wasn’t feeling well, then went bowling on the sly with his friend, Norton.
“I’m dyin’,” Ralph whined to Norton when he snuck home, now truly injured, before Alice got back from dinner.
“My back is killing me,” he bellowed, while his friend coaxed him into a chair.
“You deserve it, Ralph,” thought my smug, my sanctimonious eight-year-old self. “You deserve that aching back.”
Then I got one of my own.
***
When I turned twelve, my mother took me to the Hillsdale Mall to buy my first two-piece bathing suit. It was hot pink with a halter top, and the only thing I wanted for my birthday. My father was skeptical.
“Try it on and come outside to show us,” my mother told me.
I walked onto the back patio where my parents sat, my orthopedist father holding an amber drink.
“Hmm,” said my mother, looking at my body freshly liberated from a decade of Speedos.
“Turn around,” my father instructed me, and then stood up.
“Touch your toes,” he directed, and ran a firm index finger along my spine.
“Is one of her hips,” asked my mother, “higher than the other?”
My father drove me to his office that afternoon to take x-rays of my back. We looked together at the developed films, holding them against a square light box above his desk.
“See this?” My father asked, tracing with a finger the wide s-curve in the bones at the base of my spine.
“This is supposed to be straight.”
Apparently, my two-piece suit had exposed more than my adolescent belly; it also disclosed a fault in my back.
***
The human spine is an engineering marvel whose faceted vertebra and gel-filled discs ideally form three perfect curves: the cervical, thoracic and lumbar. Cunningly arranged vertebral columns shape the human body, allowing us to stand stable and erect, and to perform tasks and movements critical to our survival.
Although wondrous in concept, the spine is often imperfect in execution. Congenital, degenerative or neuromuscular conditions may cause the back to hunch, sway, or swerve side-to-side in a distinctive s-curve that the Ancient Greeks were the first to call “scoliosis,” or “crooked.” Instances of spinal deformity have been recorded as far back as 3500 B.C., and routinely feature in ancient mythology, medical texts, and art. One Bronze Age fresco from Santorini famously depicts a boxer with a pronounced swayback. Alexander the Great reputedly suffered cervical and spinal anomalies a thousand years later. “Curvature of the spine,” Hippocrates wrote in 400 BC, “occurs even in healthy persons in many ways, for such a condition is connected with its nature and use; and, besides, there is a giving away in old age and on account of pain.”
Scoliosis is the most common spinal deformity in humans, and ten times more so among females than males. Believed to afflict two to three percent of the world’s population, it accounts for twenty percent of all reported back conditions, and is newly diagnosed in three million people each year in the United States alone.
Frequently painless at onset, the condition commonly and problematically presents in early adolescence. Because children between the ages of ten and twelve are newly protective of their privacy and increasingly interested in bathing and dressing in seclusion, they often mask their bodies from the very adult eyes that are capable of identifying the disorder.
***
“Can you fix it?” I asked my father, as we looked at the pictures of my flawed spine.
“No,” he answered, “but I can make sure it doesn’t get any worse.”
“With an operation?”
“With a brace,” he said.
“What’s that?” I asked.
“Well,” he admitted, “It’s not ideal.”
***
Despite 3000 years of documented experimentation, no cure for scoliosis has ever been identified. The Hippocratic scholars believed crooked backs could be corrected through a vigorous regimen of dietary restraint, spinal manipulation and axial traction. Hippocrates pioneered the latter process by inventing incrementally invasive methods. In the first instance, patients were tied to a ladder and shaken upside down or right side up, depending upon the precise location of their deformities. As Hippocrates cautioned, “it is difficult to perform [this] extension at the neck, because the patient might suffocate.”
Patients with more pronounced curvatures were treated on a Hippocratic Bench: a contraction made of boards and straps that pulled sufferers’ top and bottom bodies in opposite directions while a physician would “sit upon the hump” and “raising himself up…let himself fall again upon the patient.” Reputedly, the Bench was sufficiently extreme in concept and affect to later inspire the invention of the medieval rack and related instruments of torture.
In the eighteenth and nineteenth centuries, Swiss and French physicians improved on Hippocratic techniques by designing traction beds and chairs with adjustable springs to elongate twisted backs. By the late 19th century, however, ladders, boards, beds and chairs were discarded in favor of rigidly unforgiving body braces.
Ambrose Paré, a 16th century French army surgeon purportedly designed the first such orthotic by welding iron plates into adjustable corsets. Although Pare’s brace and subsequent refinements did not actually correct afflicted spines, they did appear to arrest curvature progression, particularly in young patients. By the middle of the 20th century, body bracing was almost exclusively prescribed for children and adolescents, designed to be worn until the patients’ spines stopped growing. The gold standard for treating juvenile scoliosis, the orthotic exemplar of patient discomfort and public obloquy, was the steel-barred, exquisitely mortifying and righteously immobilizing Milwaukee brace.
***
I had my brace fitting at Baldwin’s Medical Accessories in San Mateo, a narrow shop on South B Street full of wheelchairs, walkers and other implements for the anatomically flawed like myself. A little bald man inside directed me to remove my shirt and pants, step into a cotton body stocking, and stand firmly in place while he wrapped strips of wet plaster around the full length of my torso.
“Hold still until it dries,” he told me, “and try not to breathe hard.”
Thirty minutes later, after I’d fully rigidified, the man used a whining saw to cut a vertical line through the cast, pulling it open and off of me.
“All right,” he said to my mother, who’d been seated throughout on a plastic chair by the front door, “we’ll let you know when it’s ready.”
Three weeks later, I came home from school to find a Milwaukee brace propped on my bed. On its brazen bottom was a circle of molded plastic, meant to be sealed tight around my pelvis with Velcro straps. Two vertical steel rods jutted from the back of the circle, and one from the front, all three joined to a metal chest plate and rigid chin cup that buckled with a throat strap. No doubt anticipating an immediate balk, my mother had attempted to soften my first encounter with this tortured construct by dressing the brace in my yellow shorts and a t-shirt.
“I’m not wearing it,” I assured her, pointing an outraged finger at the appalling instrument on my bed, this immediate and essential enemy, this vivid proof of my new and apparently drastic imperfection.
“I’m not wearing it,” I announced to my father when he returned from work that night.
As a rule, my mother and father would not tolerate rebellion from their children, and did not brook our fresh tongues. So I was surprised they didn’t immediately chastise me for refusing the brace. That they did not rebuke me for failing to appreciate the logic behind my father’s prescription, or the expense entailed by its fulfillment.
Instead, they cut a deal with me.
***
First fabricated in 1946, the notoriously cumbersome, singularly humiliating Milwaukee brace was designed to be worn 23 hours a day until patients reached skeletal maturity. Noncompliance with the prescription was almost universal. The throat straps and chin cup chafed teenage skin into newly dramatic displays of acne. The tight pelvic circle impeded breathing and exercise, the steel rods banged into desks and doors, the Velcro straps rubbed backs and bellies raw, the rigid structure didn’t fit under tight adolescent clothing.
Orthopedists continued to prescribe the brace nonetheless, firmly believing that scoliotic curves would progress and cripple if left untreated. Children who resisted the cure were dismissed as “psychotic” or suffering from “pre-existing emotional conditions.”
Finally in 1969 an otherwise docile twelve-year-old in Delaware refused to try her Milwaukee brace despite “extensive counseling” and “vigorous” parental exhortation.² Although they thought her “unreasonable,” a medical team at the Dupont Institute responded by devising the Wilmington Brace, which jettisoned the steel rods and chin cup in favor of a tight plastic jacket more easily concealed by clothing.
Although a vast improvement on the tortured Milwaukee model, even the Wilmington was widely disliked, driving the fanatically profit-hungry medical device industry to design ever more refined bracing models that softened outlines, minimized wear times, and reduced device loads.
The scoliosis blogosphere nonetheless indicates that parents and their body-conscious teenagers remain in pitched battle over compliance. “Help!!!!,” a mother recently wailed on one well-populated site, “my 13 yr. old daughter won’t wear her brace.” Have you told her, answered a concerned reader, “that she will have a hump back if she doesn’t wear it??? Just keep on telling her it will Help her sooooo much!!!”
Desperate parents resort to barter. “We offer small rewards, like a fish tank or a kitten, to our strong-willed daughter,” suggested a frantic father. “What my mother did to help me with mine,” posted a veteran of the Wilmington model, “was to bribe me. For every month that I wore it constantly, I would get like clothes, jewelry, something as a reward.”
One questionably credible adolescent promised, “u really start getting used to the brace and u learn to love it! I wear jeans and tight shirts and everyone tells me I look great.” “My daughter,” crowed “Kayla’s mom,” wears “her brace 23/7! I’m very proud of her effort.”
“Keep telling URself that, Kayla’s mom,” a skeptical blogger posted down the chain, “BM&Y she probably takes it off on the way to school.”
***
I broke my left wrist twice, my right once, my nose, three fingers, a thumb, my toe. I was a careless ice-skater, popped incompetent wheelies on my Stingray, used my fingers to return tetherballs when I should have held a fist, tripped in the North Hillsborough School relay race, dove into the shallow end of the rec center swimming pool.
“Anne,” my father would say, frowning over my fractured arm or swollen finger, “you have to be more careful with your body.”
“Anne,” he would scold, “don’t break this wrist again.”
My father repaired me so often and well that when I broke a newly emerged front tooth falling off Jeannie Karel’s porch, I was stunned he deferred to a dentist for the fix.
Being in his examining room, being the sole object of my busy father’s concern and care, was an intimate and hallowed experience. I would sit on the green-cushioned table and watch him cut tubes of linen for underlayers, soak rolls of coated muslin in water, wrap wet plaster around my aching limb and then, his head bent over the slow and quiet task, his gloved hands cradling the broken part of me, bind and fashion a cast that would make me well again.
But my father didn’t make the Milwaukee brace he’d prescribed for me, and wearing it would not make me whole. At best, the instrument would halt the curvature, and do so at the expense of my emerging sense of personal dignity. Perhaps because it was such an imperfect, such an outlandish correction, my parents announced their first-ever concession to my childhood recalcitrance.
I would not have to wear the brace to school, my father allowed.
“But,” he insisted, “you need to put it on as soon as you come home, and wear it until you get dressed for school the next day.”
The instrument was retributive. Its straps rubbed and tormented my skin, and the chin cup ground a yellow bruise along my jaw. The sharp thoracic girdle opened a cut on my back that wouldn’t heal, the spinal bars dug into my shoulder bones, the rigid metal collar prevented me from turning my head. I would not allow my friends to see me in the brace, shunning after-school activities and weekend gatherings with boys.
Every few months, my father would take me back to his office for new x-rays, and we would stare at them together on the light box to see if the curve in my spine was deepening.
“Can we stop?” I would ask him.
“Not yet,” he’d say.
Finally, after eighteen months, he let me take it off.
“Your back has finished growing,” my father explained. “It won’t get any better, but it shouldn’t get any worse.”
“You’ll have to pay attention, though,” he cautioned me. “You’ll need to listen to your back.”
“What should I listen for?” I asked.
“For pain,” he said, and then he tapped my arm, to make sure I was listening to him.
***
Once liberated from the social ignominy and structural challenge of a brace, I fully reoccupied my nascent adolescence. I stopped wearing turtlenecks when the bruise on my jaw faded. I explained away the marled scar the plastic girdle had left on my back by claiming I’d fallen off a fence taking a shortcut through the Henderson estate. I brought my new pants to Sunrise Cleaners on Third Avenue, and asked them to shorten each leg a different length to account for the undeniable hike in my right hip. I went to previously impossible slumber parties, wore midi shirts, and got to second base with Bobby Foster.
I revered my father, but I’d listened to him long enough. As far as I was concerned, my scoliosis story was over.
***
My disregard for future implications wasn’t exceptional, nor was it entirely unrealistic. In 1483, Richard III daringly usurped the English throne despite his famously twisted and disabling spine. He was deposed by Henry VII, some of whose own powerful descendants – including Queen Elizabeth II and her granddaughter, Princess Eugenie – thrived notwithstanding painful backs and misshapen spines. Herman Melville wrote Moby Dick while suffering chronic pain from ankylosing spondylitis, a spine-crooking autoimmune disease. Elizabeth Taylor developed a significant scoliosis as a teenager, but powered through the diagnosis to become a legendarily beautiful and ubiquitous movie star. Usain Bolt, the greatest sprinter of all time, achieved Olympian accolades and ridiculous speeds in the 100 and 200-meter distances despite a pronounced lumbar curvature since birth.
True, the socio-medical gestalt that dominated my childhood landscape advocated immediate and protracted intervention for postural irregularities; upright spines were thought to encourage upright lives. As two renegade orthopedists recognized in the 1969 “Journal of Bone and Joint Surgery,” however, the vast majority of scoliotics “led normally active and productive lives,” despite their curving spines.³ They “worked, married, and engaged in activities little different from those of the normal population.”
I intended to be one of those people.
***
Perhaps my scoliosis had always irritated and inflamed the surrounding nerves, long pressuring my facet joints and discs to the point of pain. Perhaps my back had hurt forever and I didn’t notice because other things hurt more: The wrist I broke again. The shoulder I dislocated. The sunburns I consistently cultivated. The strep throat that dogged me through college until I resolved it with an equally uncomfortable tonsillectomy. “Of two pains occurring together not in the same part of the body,” the Hippocratic scholars observed, “the stronger weakens the other.” After I junked my brace, my back was the weaker cousin to all other sources of physical or psychic pain for a full ten years.
During my first week of law school, I joined the softball team. At batting practice a few days later, I swung and felt a tweak. A slight crackling at the base of my spine that registered as something novel in my broad repertoire of physical discomfort. When I turned to run, that brief shiver, that frizzon of vulnerability exploded into a spectacular and breathtaking pain that gripped my torso and raced down my legs, made me scream and horrified my teammates, cast me prostrate onto the stubby infield grass and in a single moment destroyed my fully committed belief in personal immortality. At long last, my back had claimed my complete, outraged and agonized attention.
***
On any given day, at least ten percent of the world’s population experiences lower back pain. Forty percent of adults in the United States report lumbar distress at some point in their lives, and nearly 25% experience it monthly. Sufferers are more likely than not to have a recurrence, and those who do will invariably endure intervals of back pain for the rest of their lives.
In ancient days, back pain was a “fleeting” concern, loosely associated with injuries incurred on battle and sporting fields, or with sorcery and inclement weather. In the premodern era, doctors believed spinal discomfort was merely a symptom of other, more readily diagnosed diseases like rickets or tuberculosis. Beginning in the 18th century, however, medical professionals began to treat back pain as a stand-alone condition, often triggered by physically demanding work. Servants who remained on their feet for long periods of time, for example, and weavers who vigorously attended their looms were often observed to suffer “pains in the loyns.”⁴
As the world industrialized, mechanizing the workplace and accelerating the work pace, chronic back pain reached epidemic proportions. Mariners, miners, railway workers, machinists, stenographers, file clerks, men and women alike, increasingly complained of discomfort. Some sufferers were suspected of malingering. Others were accused of being derelict, lazy, or unfit. Regardless, by the mid-20th century, spinal health had reached a pinnacle of diagnostic focus for the simple reason that everyone’s back hurt like a son of a bitch.
***
It was a week before I could stand upright again. I lay on the floor in torts class, and stretched out on the upper risers for my criminal and property law lectures. My section mates took turns running meals up to my dorm room, where I furiously languished in bed between classes. My back was insanely sensitive, a messenger of appalling pain, making me yelp if I rose too quickly to use the bathroom or turned the wrong way to take a drink of water, sending searing neural barbs up my torso and the left side of my face, numbing my fingers, jolting my right trapezius, sparking my left rhomboid.
“You have a condition,” my father said when I called to complain. “You need to rest.”
“Dad,” I explained, “I have school.”
“What you have,” he answered, “is a scoliosis.”
“Here’s the rule,” he told me. “If your back hurts, don’t use it.”
“What if it always hurts?” I asked him.
“If you follow the rule,” he promised, “it won’t.”
***
Rest and related ministrations are the most common prescription for back pain, predating my father’s medical training by several thousand years. Galen of Pergamon counseled immobilization and massage for backaches, while Plutarch philosophized,
“What kind of pain, what deprivation… can solve a disease as
easily and simply as a bath taken on the nick of time, or wine
administered when the patients need it?”
The Stoics were even more hands-off when it came to physical discomfort. Epictetus claimed that “pain is neither intolerable nor everlasting, if thou bear in mind that it has its limits, and if thou addest nothing to it in imagination.” “Just remember,” declared Marcus Aurelius, “you can endure anything your mind can make endurable.”
Inactivity and fortitude, however, don’t necessarily resolve spinal distress. Ancient and pre-modern cultures also resorted to cupping, blistering, bleeding, leeching, cauterizing, and the like in a futile attempt to resolve back and other aches. Medical interventions were supplemented by folk remedies and superstition. In northwestern Scotland, “the mother or child of a breech birth were believed to have special power in their feet to treat lumbago,” while in Derbyshire the legs of people with sciatica were smoked in a “fie of fems.”⁵
Although contemporary medicine has abandoned cupping and magic as viable substitutes for relaxation, individuals who cannot resolve back pain through bed rest are regularly dosed with powerful analgesics and anti-inflammatories, coached through hours of spine-tweaking physical therapy, and subjected to a dizzying array of questionably helpful surgical solutions: spinal laminectomies, discectomies, nucleoplasties, spinal fusions, artificial disk replacements.
While no modern treatment is reliably effective, “rest”, as my father often observed, “definitely beats the alternatives.”
***
I kept my head low and back healthy until my first child was born. Weighing in at six pounds, she presented no initial problem for my scoliotic spine. She ate, though, and she grew, and nine months into scooping her out of her crib, hoisting her on my hip as I scrambled around the house, lifting her in and out of the baby swings at Alta Plaza Park landed me flat on my back in her nursery one fine July morning. I immediately recognized the atrocious, the barbaric pain that catapulted up my back, exploded inside my skull, burned its way down my arms, flickered along my legs and crimped my aching toes. It was gob-smacking, immobilizing, and less infuriating than terrifying this time around. Because now there was a little baby sitting next to me on the carpet, waiting for her breakfast and listening to me howl.
“Lie down, Anne,” my father told me when I made it to a phone.
“Dad,” I explained, “I have a baby.”
“If you want to be of any use to her going forward,” he answered, “get in bed.”
But my daughter was hungry and my husband had left for his office. I was scheduled for the grand jury that morning and had court appearances in the afternoon. I had a job and friends and a life, a tiny house with a patch of grass to weed and a roof that needed fixing, groceries to buy and a movie I wanted to see. So I listened to Epictetus instead of my father. I ignored the pain; I imagined myself well. I moved slowly, I turned carefully, but I moved and turned all the same. My back was a treachery and a torment, but I made it through the day, then the week, and then the week after that until the pain gradually, reluctantly receded.
“Are you resting?” my father would ask when we spoke.
“It’s working itself out,” I answered.
“No it’s not,” he assured me.
He was right. When the crisis abated my back hurt a lot less, but it still hurt. And periodically, cataclysmically, it crashed again. In my thirties, episodes of lumbar agony were acceptably rare, interspersed with years of relative comfort, limitless activity and blissful disregard for my father’s advice. In my forties, however, my back blew up annually; in my fifties, it felled me every few months.
Sometimes I could pinpoint the moment, the precise behavior that triggered a recurrence; I ran too far, I fell on a hike, I wouldn’t leave the dance floor, I overpacked a suitcase, I carried children in both arms. Usually, though, the pain was an arbitrary peril, a menace that rolled with me out of bed in the morning, grabbed me when I bent to tie my shoe, attacked when I stood too quickly from the table. My willful indifference had gotten me nowhere in the end; my aching back was no “fleeting” distress. It had become, instead, my constant companion, an outrageous and unwelcome component of everyday life.
***
I was boundlessly resentful of my tortured back, and berated myself for complicity in its discomfort, for foolishly sacrificing the healthier back I might have had, for not valuing in my youth the body that increasingly failed me as I aged.
The truth is, though, despite years of focused treatment and fulmination, “modern medicine has not solved the problem of backache.”⁶ Absent an immediate and identifiable trauma, no one really knows what causes backs to whinge.
And what if I had been more careful? What if I’d remained inert instead of active, closed the curtains rather than pursue my pleasures, disregarded my ambitions in the elusive pursuit of a pain-free future? Kierkegaard famously wrote that there are always “two possible situations — one can either do this or that. My honest opinion and my friendly advice is this: do it or do not do it — you will regret both.”
Richard III, certainly understood the limits of remorse. “Look,” he explained to the mourning Lady Elizabeth after he murdered her two young sons, his own brother, and at least nine others to gain the English throne in Shakespeare’s telling; “what is done cannot now be amended. Men shall deal unadvisedly sometimes.” Reflecting upon her own trial-and-error life centuries later, Katherine Mansfield plangently agreed: “Regret is an appalling waste of energy; you can’t build on it, it’s only good for wallowing in.”
Indeed, senescence with its attendant debilities, its inherent pains and losses, will dispatch us all in the end no matter how maniacally we guard our younger, healthier selves. Before her death, Richard’s distant and less bloodthirsty cousin, Elizabeth II, eventually withdrew from most public appearances because, in part, of “severe twinges” in her own aching back. “Nothing,” the British monarch later observed, not faith, not charity, not our most beguiling fantasies nor our doctors’ best advice, “can slow the passage of time.”
My back and I had lived the youth I chose. It was only fair that my back dictate our mutual discomfort in old age.
***
When I visit my 92-year-old father, he reclines on a sofa in the den while I lie prone on the floor beside him.
“I know why I’m lying down,” my father says to me. “But what’s the matter with you?”
“My back hurts,” I explain.
“I’m not surprised,” he answers looking down at my face with his exacting blue eyes.
I know what’s coming. I’ve heard it dozens of times.
“I tried to tell you,” he says.
“I know you did, Dad.”
“I tried to help,” he continues.
“You really did, Dad.”
“But all I got from you,” he says, waving his hand at me, “was a lot of backtalk.”
¹ “A Woman’s Work is Never Done,” The Honeymooners (1955)(Television)
² Fayssoux, R. S., Cho, R. H., & Herman, M. J. (2010). A history of bracing for idiopathic scoliosis in North America. Clinical orthopaedics and related research, 468(3), 654–664. https://doi.org/10.1007/s11999-009-0888-5
³ Collis, D., & Ponseti, I. (1969). Long-term follow-up of patients with idiopathic scoliosis not treated surgically. Journal of Bone and Joint Surgery, 51, 425–445.
⁴ Ramazzini, B. (1713) “De morbis artificum diatriba [diseases of workers]
⁵ Allan D. & Waddell G. (1989). An historical perspective on low back pain and disability, Acta Orthopaedica Scandinavica, 60:sup234, 1-23, DOI: 10.3109/17453678909153916
⁶ Allan and Waddell
Image by Pawel Czerwinski on unsplash.com, licensed under CC 2.0.
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