If the immediate results of even the most energetic scoliosis gymnastics are not too brilliant in a bad case, it is all the more important to find means to maintain the result attained. With the knowledge we possess of the nature of scoliosis, we must take for granted that it will have a great tendency to recur as soon as it is left without this treatment. Such is the case, and the existing results of scoliosis treatment are in reality by no means so good as the reports from different orthopaedic institutions state. These statements refer to the patient's condition at the end of the treatment, before the tendency to relapse or for the improvement to diminish has asserted itself. The following may be stated concerning the means we possess of maintaining the result.

While scarcely anyone denies the sovereignty of medical gymnastics (in its widest sense) in the treatment of scoliosis, in so far as it aims at mobilisation and correction, the means of maintaining the result have, on the other hand, been much disputed.

Since one rightly assigns to gymnastics which aims at development of muscle the greatest importance in mobilisation and correction, one must also assign to the trained muscles a great power of maintaining the result obtained by energetic gymnastic treatment of scoliosis; and the gymnastic enthusiast is ready to declare that the muscles after a well-carried out course of gymnastics are in such a condition that often a relapse need not occur. If this belief is sanguine, it is certainly obvious that continued gymnastic treatment is the best means of maintaining the result attained. Unfortunately for most people, insurmountable practical difficulties arise in continuing expensive gymnastic treatment for long periods, and the purely active self-correcting exercises which are learnt during a long treatment are seldom carried out energetically enough after the patient is left to himself. Other means of maintaining the result attained have therefore been sought. This brings us to the orthopaedic supporting apparatus - spinal jackets for scoliosis. Although the use of spinal jackets, as of all other orthopaedic apparatus, to be effective, must be directed by qualified medical practitioners, a few words on this important question may be appropriate here.

The idea of keeping upright, by means of a supporting apparatus, a spine or chest which threatens to sink together is, of course, very old, and the need for the method in certain forms of scoliosis, such as the paralytic, severe rachitic, etc., is quite clear. The wearing of a mechanical apparatus has in such cases been the only: means of making the patient's life endurable. Although spinal jackets arc in certain cases necessary and have for long been used, they have nevertheless certain great inconveniences, however well they may be made and planned. Although this is not the place to speak of the construction of spinal jackets, it may here be mentioned that the making of these supports has recently greatly improved, whereby the inconveniences have to some extent been diminished and the effectiveness increased. However well constructed a spinal jacket may be, there remain certain definite inconveniences, such as the difficulty of wearing a heavy apparatus, the difficulty of making it fit, and, more than all, the fact that a spinal jacket puts out of action a certain number of muscles, with the result that the muscles atrophy. Over-estimation of these drawbacks on the one hand has led to the total disuse of jackets in all forms of scoliosis except the paralytic, in which, of course, the indication for a jacket is absolute; the under-estimation of these drawbacks combined with over-estimation of the power of the jacket really to support the spine has, on the other hand, led to their too frequent use.

Towards the end of last century the treatment by spinal jackets assumed an entirely new position. About the year 1880 Sayre's treatment by plaster jackets came into general use, and one saw with great surprise how patients could walk about without the slightest difficulty and feel quite well, wearing a plaster jacket which encircled the thorax and pelvis, sometimes even the shoulders and neck. In these circumstances it was only too natural to attempt to maintain by means of such a jacket the correction of a scoliosis obtained by energetic (or even violent) treatment. At the same time the study of functional adaptation had begun and its special reference to the study of the skeleton, the so-called Wolffian law of structural change, according to which a bone with altered function takes on changes of form more suited to its new functions. According to this theory, which is of extreme importance to the whole of modern orthopaedics, it was argued that if one can by external means keep the spine and thorax for a considerable time in a corrected position the deformed bones, as well as the soft parts functionally connected with them, will undergo changes and by degrees approach more and more to the normal. The means of maintaining the correction was the spinal jacket, especially the fixed plaster jacket which could not be taken off. This was therefore brought into use in the treatment of scoliosis with a purely curative aim, and not only as a necessity in severe cases where complete sinking together threatened. Since many of those who treat scoliosis opposed the jacket treatment from the beginning as involving certain risks, from this time and for nearly twenty years after, orthopaedists may be divided into two classes : those who pinned their faith to jackets and the gymnastic enthusiasts who opposed this treatment. The upholders of the jacket treatment do not necessarily exclude gymnastics from their treatment, since it is impossible to do so, but they make use of jackets to a very large extent along with gymnastic treatment.

From the study of functional adaptation which was beginning to manifest its utility in connection with orthopaedics, the adherents of the treatment by spinal jackets considered that the usual treatment of a marked scoliosis should consist of mobilisation and correction, for the attainment of which some forms of medical gymnastics were indispensable, followed by fixation for a reasonable time in the corrected position. The forces of nature would then inevitably restore the deformed parts, bones as well as soft parts, to their normal form. It ought to be possible to cure even a severe scoliosis in this way.