The following notes on scoliosis and flat-foot are really designed to give the masseur and medical gymnast an easily-acquired foundation for his knowledge of the subject. It would be advisable for doctors to read carefully through Arvedson's, Haglund's, and Zander's contributions to this work.

Scoliosis is an extremely common complaint, most often occurring in girls from ten years old onwards. The commonest causes which contribute in varying degrees to the development of this deformity are anaemia and general weakness, especially weakness of the muscles, rickets, and a bad position at school. Infantile paralysis, pleural effusions, etc., are less common causes.

The examination of this condition is not particularly easy, and it is best for the patient to be undressed.

We first measure the distance on both sides between the anterior superior iliac spine and the tip of the external malleolus, or, in my opinion the best plan, between the anterior superior iliac spine and the floor, being very careful to see that the patient is in a correct position while this is being done.

Fig. 182.

In the majority of cases we then find that this distance is shorter on the left than on the right side, so that the transverse (frontal) axis of the pelvis is therefore also oblique.

We have thus a static cause for the development of scoliosis according to the diagrams above (Fig. 182). (The skeleton is viewed from behind.)

No. 1 shows that R (the spine) would take an oblique direction and the head be held to one side if the angles at the oblique (trans verse) axis of the pelvis, B, remained at right angles and if R remained unbent.

No. 2 shows how the C-shaped scoliosis arises from position No. 1 owing to the patient's effort to bring the centre of gravity of the trunk over the centre of the supporting surface.

No. 3 shows the double S-formed scoliosis, with a compensatory dorsal curve D and a primary lumbar curve L, which arises from the C curve as a result of these efforts and in accordance with anatomical, physical, and physiological conditions.

Of the two forms of scoliosis the C curve, which is often a transition stage, is less common than the double S curve, and the convexity in most cases is to the left.

The double S curve is the most common form of scoliosis, and the convexity in the lumbar region is usually to the left, that in the dorsal region to the right.

It is best to accustom oneself to denoting an S curve by first naming the primary lumbar curve according to the direction of its convexity (left or right), then the secondary dorsal curve; thus in most cases left lumbar and right dorsal scoliosis. At the present time there is some confusion in this respect.

A C curve is denoted according to the convexity as a left or right C curve.

The next step in the examination is to mark with pencil on the skin the positions of the spinous processes from the last cervical to the last lumbar vertebra; then to mark the position of the middle of the first sacral vertebra in the upper part of the hollow between the two iliac crests. While this is being done the patient stands with heels together in a slightly stooping position. When the marks have been made they are united by a line which makes the curves of the spine stand out clearly.

The patient then stoops as much as possible without bending the knees, and by standing in front and leaning over him one gets a good view of the whole surface of the back and of any changes present in the posterior part of the ribs.

It then remains to be ascertained, with or without special-apparatus, how far the curves deviate from the middle line; how much the shoulder on the side of the dorsal convexity is raised in comparison with the other; to compare the broader convex with the narrower concave side of the back; to note the difference in the lateral contours of the trunk; whether the hip on the convex side of the upper curve protrudes; whether a possible shortening of one of the diagonals of the thorax or any kyphosis is present; and to observe, by comparing the lateral contours of the neck, whether the scoliosis also affects the cervical region.

To form a correct idea of the case it must be borne in mind that the bodies of the vertebra? deviate more from the vertical {to the same side) than do the spinous processes.

One next proceeds with the examination by letting the patient take the hanging fundamental position, or by putting him into the suspension apparatus. In very slight cases, which are called scoliosis of the first degree and which are the most frequent, the patient's own weight is sufficient to make the lateral curve vanish and to give the spine its normal form for the time being.

In scoliosis of the second degree the pathological curves do not disappear entirely when the patient takes hanging position, but no very great changes in the form of the thorax are present.

In scoliosis of the third degree, the severest form, the thorax is seriously deformed, extremely immobile, the scoliosis very often combined to a serious extent with kyphosis, and there is always diagonal compression of the thorax in one direction. In these cases we find sharp curves, indicating wedge-shaped deformity of the vertebrae, and the ligaments on the concave side shortened, those on the convex side lengthened. The muscles have undergone similar changes, and are thin and atrophied on the convex, shortened on the concave, side.

The aim of the treatment is to make the spine (which is always stiffer than normal) more mobile, to put it into its normal position, and to fix it in this position. These various endeavours must go hand in hand with one another.