In aggravated cases, the patient may suffer from shortness of breath on exertion, and the respiratory difficulty may react on the heart, causing dilatation of the right side, palpitation, and precordial pain.
Sometimes, and particularly in males, the primary curvature is in the lumbar region, and the convexity is to the left. The deviation of the lumbar vertebræ produces a prominence in the left flank which masks the outline of the iliac crest on that side, while the right flank shows a deep furrow and the right half of the pelvis is unduly prominent. There is a slight compensatory curve to the right in the thoracic region, and the right side of the chest projects backwards. The brachio-thoracic triangle is much more marked on the right than on the left side.
Diagnosis of Adolescent Scoliosis.—In many cases the patient is brought to the surgeon on account of pain and weakness in the back before any distinct deviation has developed, and, unless a careful examination is made, the real cause of the symptoms is liable to be overlooked.
The patient should be stripped and examined in a good light in various attitudes; for example, standing in an easy position, standing as straight as she can, and sitting on a flat stool. She should also be asked to read from a book and to write, in order to exhibit her usual attitudes. In early cases, an inequality in the level of the angles of the scapulæ is often the only physical sign to be detected. It should also be observed whether the line of the spines is altered when the patient hangs from a horizontal bar or trapeze. Any backward projection of the ribs on one side is rendered more obvious if the patient folds the arms across the chest and bends well forward, while the surgeon looks along the back from behind.
Pott's disease may be excluded by the absence of rigidity. Any mechanical cause of deviation of the spine, such, for example, as inequality in the length of the limbs or contraction of the chest after empyema, must be sought for. Scoliosis that depends upon inequality in the length of the limbs or tilting of the pelvis, disappears on sitting.
Treatment.—The treatment of postural scoliosis implies a comprehensive programme, including attention to the general health, habits, and exercises out of doors and in the gymnasium, clothing, etc., all requiring supervision over a period of months, or even of years. The object of the treatment is to correct the deformity before the position has become fixed by rotation of the vertebræ and alteration in their shape. The child must not be allowed to assume awkward attitudes while reading, writing, or playing the piano; she must sit on a low chair, the seat of which slopes slightly downwards and backwards, and the back rest of which reaches as high as the shoulders, and is at an angle of 100°–110° with the seat. The feet should rest on a sloping stool, and when the child is reading or writing, a desk sloping at an angle of 45° should be used. In weakly girls approaching the period of puberty, special care should be taken to avoid compression of the trunk by tight corsets. Adenoids or other sources of respiratory obstruction must be removed; and if the patient is myopic she should be provided with suitable glasses. Standing should be avoided, as there is a great tendency to throw the weight on to one leg; but walking, running, and other exercises which bring both sides of the body into action equally are permitted under supervision. Horse-riding is a suitable form of exercise, but girls must ride astride; cycling is not to be recommended.
In mild cases—that is, those in which the curvature is obliterated when the patient is suspended—the prophylactic measures above mentioned must be rigidly enforced, and gymnastic exercises should be prescribed. The exercises should not be commenced, however, until, after a period of rest in bed, all pain and feeling of tiredness in the back have disappeared.
In cases in which the curvature is not affected by suspension, the deformity is usually permanent, but by suitable exercises it may be prevented from becoming worse, and the patient may be educated to disguise it to a considerable extent. Training is also directed towards regaining the muscular sense; with the eyes shut before a mirror, the child should endeavour to assume the correct posture; on opening the eyes, the faulty attitude is seen and corrected. Forcible correction by means of successive plaster jackets, applied in the flexed position, somewhat on the lines employed by Calot in Pott's disease, has yielded results which may be described as encouraging. Only in very advanced cases should the patient be allowed to wear a supporting jacket; such appliances have no curative effect, and can only be expected to relieve symptoms.