Concerning the treatment of the various scolioses and kyphoses by massage and gymnastics I may here speak quite briefly. The great importance - in certain cases the paramount importance - of medical gymnastics in the treatment of these deformities is generally known and recognised by doctors, gymnasts and others, and the technique of both manual and mechanical gymnastics used in the treatment of the deformities belonging to this large group is so well developed that very little can be added from the special standpoint of the orthopaedist to what has been already stated elsewhere in this work (Arvedson, Zander). Nevertheless some indications from the special orthopaedist's standpoint of the general principles of treatment of scoliosis and other deformities are not out of place here.

In contemplating the great difficulties which are met with in the treatment of marked scoliosis and the consequently slight results usually obtained, even after long-continued and energetic treatment, we must consider that prophylaxis is the most important point of attack against it. Pure prophylaxis against these deformities belongs more to school and general hygiene and the bringing up of children than to medical gymnastics, and must therefore be left on one side. We may be reminded how enlightened schoolmasters, doctors, and gymnasts have tried during the last half-century by improved school furniture, school premises, and schemes of instruction, to prevent habitual forms of scoliosis arising, and how in improving the standard of physical development (by gymnastics, sport, games) we find more and more a means of counteracting this as well as many other conditions of ill-health directly or indirectly produced by one-sided systems of upbringing under unsuitable conditions. Progress in this direction is beyond dispute, although it will be many decades before we can truly interpret the results. In any case, marked scoliosis arises in so many cases that we have reason to consider how we can make use of medical gymnastics according to the above-stated indications for the treatment of all deformities.

When a spinal curvature has actually developed, the primary aim of treatment is to restore the pathologically curved spine to its normal form, which is without lateral curves and with the ordinary physiological curves in the sagittal plane.

This aim meets with several serious difficulties, depending upon the degree and general characteristics of the curve. Momentary restoration to normal is of no great difficulty in scolioses which have not yet become fixed, and the patient himself after some expert instruction can accomplish this by greater or less strain of his muscles of deportment. In the higher degrees of deformity difficulties accumulate in quick succession. All the parts belonging to the spine and its functions undergo changes due to the permanent faulty position; these by degrees become permanent, and more and more insurmountable by the power of the muscles alone. Thus joint capsules, ligaments, and muscles contract on the concave side and become stretched on the convex. Finally, in every true scoliosis the vertebrae, with their arches, processes and joint surfaces, undergo considerable changes of form, while as the last and worst step in a progressive case, the form of the ribs and their situation relatively to each other become altered, so that severe deformities arise.

So long as the pathological changes only affect the soft parts and the skeleton has not yet undergone obvious changes of form, the above-mentioned chief indication can be fulfilled, although some; times only with great difficulty, by the help of physical treatment which lies at the disposal of practical medicine. If the skeleton has, on the other hand, undergone great changes of form, we cannot attain the primary object, at least not directly, by the use of external mechano-therapeutic means.

If we examine closely the expedients of mechano-therapeutics, by which we can at least temporarily restore the spine to its normal form, or, in a word, correct it, we find different groups of expedients.

Thus we find in the Ling medical gymnastic system a great number of movements, in most cases very rational, carefully thought out, and adapted to the treatment of spinal deformities. In the use of these simple gymnastic movements one gymnastic school sees the sovereign means of treatment for all scolioses, and is of opinion that these Ling gymnastic movements, which can be used everywhere and without any considerable apparatus, are quite sufficient to obtain all that can be obtained in the treatment of these deformities. This idea is quite incorrect. It is no doubt true that the slight scolioses in school children, who form the greater number of the cases treated in our Swedish gymnastic institutions, can be affected by exclusively manual correction and active muscular exercises with only manual resistance, and will show great progress in their earlier stages. By examining our resources and the actual purpose of the treatment we soon find that in severe cases of scoliosis these means are not so effective as gymnastic enthusiasts would willingly believe.

It is by the combination of two chief means that we try to influence a spinal curvature in order to restore it to normal form. On the one hand, we can make use of external means for the correction of deformity in the form of external pressure, so applied that it can correct the deformity; on the other hand, we can take the patient's own muscles into use to produce correction with their help. In Ling gymnastics the external effect is produced by the manual pressure of the medical gymnast, and the resistance necessary in the active muscular exercises is given manually. If this direct, immediate human force were sufficient under all circumstances, the Ling medical gymnastic system would be enough for the treatment of all scoliosis, at least in so far as it aims at restoring the spine to its normal form. Further, this manual method of treatment should certainly eclipse every other system of treatment for scoliosis, since it has the advantage that movements as well as pressure and resistance can be individualised to an almost unlimited extent; and, as very little apparatus is needed for its performance, it can be carried out anywhere, not necessarily in expensive institutions for the purpose.