(3) When the disease is epidemic, urotropin should be recommended as a prophylactic.

(4) The establishment of an isolation sufficiently long to cover the infective period of the disease, at least six weeks.

(5) The prompt disinfection (total destruction if possible) of any materials or fomites that may have become infected by contact with the nose or mouth of one suffering from the disease, and—

(6) The recommendation that careful attention be paid to the cleanliness and hygiene of the nasopharynx.

THE TREATMENT Of the diSABILITIEs followING

ANTERIOR POLIOMYELITIS.

FREDERICK C. KIDNER, M. D.
DETROIT, MICHIGAN.

THE treatment of the disabilities which follow anterior poliomyelitis, has been forced of late years on the attention of the whole medical profession. The old feeling of hopelessness engendered by lack of accurate prognosis, and the apathy of parents, has been replaced by enthusiasm engendered by the splendid researches into the causes of the disease, and the good results obtained from persistent treatment.

The disappearance of a large proportion of our cripples depends henceforth on the early recognition of the disease and on the untiring efforts of physician and friends. There is no disease which requires more devotion and courage in its treatment-none which better rewards persistence. The ability of a sufferer from the effects of infantile paralysis to take his place among his fellow men as an active citizen, depends on two factors: First, the prevention of deformity; second, the fullest possible development of the muscles which are not absolutely disabled.

Realization of these two requirements can be reached only by constant watchfulness, and the systematic employment of many distinct methods of treatment. Consideration of all is here impossible. Therefore, I shall attempt merely to outline the measures and procedures which seem to me the most important and valuable.

Mechanical treatment is necessary from the moment a diagnosis is made through the appearance of weakened muscles. This may be at any time from one to ten days after the onset of the disease. It is the signal for immediate measures to protect the weakened muscle groups, which must be put in positions of complete relaxation and rest. This can often be accomplished with the aid of sand bags and pillows. Splints, however, may be necessary. These are easily improvised from heavy iron wire, with the aid of a wrench and vice (Figures I and II.) For instance, suppose a child shows weakness in the anterior muscles of the thigh and in the front of the leg. A posterior splint bent at thirty degrees at the knee, and to a right angle at the foot, will hold the quadriceps relaxed, and prevent stretching of the tibials. Recumbency alone will not do these things. Such a splint must be loosely applied by bandages giving equal pressure, and not constricting at any one point.

Protective treatment alone should be used while pain and tenderness are prominent. As soon as the pain and tenderness begin to subside, gentle massage should begin. It should be carried out with the greatest precautions to prevent even a single stretching of the affected muscles. Each day during this period, careful search should be made for newly affected regions, and as such appear, they too, should receive attention. In many cases a plaster jacket by fixing the spine, seems to limit the spread of the disease, and certainly limits pain.

By such measures, the comfort of the patient is greatly increased, every fiber which may retain its contractility is saved from stretching, and its full power preserved for future use.

To my mind the care with which these details are carried out in the first few days, largely determines the length of the period of convalescence and has a strong influence on the amount of the ultimate paralysis.

Ordinarily, by the end of the second week, the patient is beginning to recover from the prostration of the acute disease and the full extent of the damage done is to be determined. The case now enters the period which may be called that of spontaneous recovery. This period continues for at least two years. No acknowledgment of permanent paralysis should be made until this time has elapsed. A recent case demonstrates this fact. A small boy, who was paralysed fourteen months ago, came to the hospital two months ago. He had no apparent control of either leg. Under careful treatment for the last six weeks, he has gained the ability to go through all the motions necessary for walking, although he is unable to bear much weight.

It is during this period that the physician's ingenuity and persuasive powers are most severely taxed. He must be constantly hopeful and instill into the family of the patient a spirit of thorough persistence.

As soon as the patient shows a desire to walk, ambulatory apparatus which completely protects all the weakened muscles becomes necessary. Its object is to prevent contracture and to replace weakened muscles. It must be light, durable, and free from all constricting bands.

At the same time active measures are to be adopted for the restoration of function. Electricity is difficult of application, and to my mind of very doubtful value. Massage, as generally used, is inefficient. To be useful it must consist of deep muscle kneading with percussion with heavy vibration, but without roughness sufficient to cause pain. It has a strong influence on the blood supply and prevents atrophy. I say this advisedly, in spite of the recently expressed opinions of Sachs and Taylor, of New York, who consider the time spent on massage merely wasted. Heat is extremely valuable in its effect on the vasomotor system. It can be easily applied by the incandescent electric light enclosed in a tin shield. It overcomes the stasis in the vessels, and the cold, stiff feeling in the part. Thorough baking for twenty minutes each day will keep a limb warm for hours and often wholly overcome its cold clammy condition.

As soon as soreness and pain have completely disappeared, muscle training, the most important factor in restoration of function, must begin. It must be skillfully and carefully applied in order to prevent overstretch

ing of the weak muscles. It is best begun by simple passive motion, carried on by the person in charge of the case. As the patient's confidence is won he must be encouraged to make an effort to reproduce these passive motions, the actual work being done by the attendent. For example, if the tibial muscles are paralyzed, the attendant should dorsiflex the foot slowly and rhythmically, meanwhile explaining to the child what he is attempting to accomplish. Little by little, if there is any contractility left in the dorsiflexors, they will begin to take up their function. As their strength increases, less and less of the actual motion will have to be carried out by the attendant, while more and more of the work will be done by the patient's own efforts. At last a stage will be reached where

A

The arm splint is made of flexible metal, and can be placed at any angle for the gradual correction of hand deformity.

FIGURE II.-Leg and Foot Splint.

The leg splint is very cheap, and can be bent as needed to hold all leg muscles

at rest.

the patient may be allowed to perform the motions without assistance. The same careful conservative method must be carried out with each group of affected muscles. At no time should the protecting apparatus be omitted, except during the actual treatments, until the affected muscles have so far recovered that all danger of contracture has disappeared. Only after. weeks of education should the parents be allowed to undertake these methods of muscle training. It is better that limbs be held in good position by apparatus, without other treatment, than that muscles should be

overstrained by too much enthusiasm. Massage, in protected positions, may always be allowed and encouraged at home, and is, in fact, absolutely necessary to prevent atrophy.

In cases treated from the first by such a course, we shall know at the end of two years what our final results are to be, and we shall have all the structures of the body in the best possible condition for reconstructive

surgery.

At the end of two years it is usually safe to say that no further spontaneous improvement will occur. We then reach the time for permanent measures. The worst cases to handle are those in which there is more or less paralysis of the spinal groups of muscles. Scoliosis, the result of unequal pulls on the vertebræ, is most intractable and very often means the permanent use of rigid jackets. Attempts at cure depend on decreasingly complete support, with education of the muscles. It seems to me that Professor Lange's metal bars fastened to the spinous processes, may be applicable to these cases. He has successfully used steel wire bars plated with tin, and fastened to the spinous processes with silk, in a number of cases of spinal caries. The balance of the spinal column is so sensitive and the leverage so great that no artificial ligaments or transplanted muscles can hold.

In the treatment of the limbs, however, there are a number of procedures which enable us to improve function. Most prominent of these is tendon and muscle transplantion. It is applicable in many cases where small groups of muscles are paralyzed. For instance, strong peroneals may be brought from the back of the foot, and made to serve the purposes of weakened tibials. Strong hamstrings or a strong sartorius may do excellent service when implanted into a patella tendon. Slips from a trapezius may do good work when implanted into a deltoid. The technic of these operations, is always more or less difficult and their adaption to any given case calls for great ingenuity. The range of application of any given muscle to a new situation, is greatly increased by the use of silk strands to lengthen the tendon used. My feeling in regard to this procedure is that it has great usefulness, but that excessive enthusiasm in its use is apt to do more harm than good by decreasing the total efficiency of a given limb.

Another extremely useful operation is that of inserting artificial ligaments. Its object is to replace paralyzed tendons by firm, strong bands of foreign material, which shall oppose active muscles. An excellent opportunity for the insertion of these ligaments, which was introduced by Professor Lange, is afforded in the very common cases of toe-drop, following the paralysis of the tibial muscles. The technic of the operation is not difficult, but it requires extreme attention to the details. The most satisfactory material is the silk prepared, as is this which I shall pass around. It is a corrosive silk impregnated with paraffin to overcome its irritating qualities.

If toe-drop exists, incisions are made over the tibia and fibula at the junction of the middle and lower thirds, and over the inner surface of the scaphoid and the outer surface of the cuboid. With a strong needle,

silk is first fastened through the periosteum of the tibia and fibula. A long blunt instrument is then passed from each of the lower incisions beneath the skin and fibers of the anterior ligament, if possible, to the corresponding incision above. The long ends of silk are then drawn back to the lower incisions and there again made fast, with tension just sufficient to hold the foot in very slight dorsiflexion. The wound is closed and the foot put in plaster for from one to three months. Protected motion is then allowed for three months more. Finally, apparatus can be entirely discarded. A foot so treated will present a flat firm base and allow some

FIGURE III. This splint with simple "step" joint preventing toe drop, at ankle, but no joint at knee, can be made roughly but serviceably for from six to eight dollars. It is moderate in weight, and wholly prevents stretching of the quadriceps or anterior leg muscles. The joint at the ankle springs open, allowing removal of shoe and foot piece from rest of splint. This makes it much easier to put shoe on a weak, flabby foot.

use of the gastrocnemius. I have had no experience with Meisenbach's rubber muscles.

When the paralysis of the limb is so complete that these measures are out of the question, arthrodesis or fixation of joints is our chief reliance. To my mind, it is best to rely on apparatus with massage and other measures to promote growth, until the child is well grown, twelve years or more. Nothing is more unsatisfactory than a limb which has grown crooked after erasion of joint cartilage. I am well aware that very frequently, destruction of joint surfaces does not always interfere with growth. Still, I feel that we ought not to take away any chances of