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Editor's Note
The applications of orthopedic surgery are many, but one that should be made unnecessary is in the correction of deformity allowed to develop from infantile paralysis. We are glad to note that Dr. Campbell agrees with the main thesis of the Georgia Warm Springs Foundation exhibit at the Century of Progress, "These gross architectural changes in the skeleton can be prevented by careful, protective attention."

When paralysis has occurred the question uppermost in the minds of the patient, his family and his physician is whether or not this condition will be permanent. The return of activity following an attack of acute anterior poliomyelitis depends upon the extent and distribution of nerve cell destruction in the spinal cord. A muscle whose cell control has been entirely destroyed will never function, but in those muscles whose controlling cells are only temporarily or partially impaired, there may be gradual restoration to excellent or even normal power. In the early stages of the disease, there is, unfortunately, no method of clinical examination or laboratory test by which the ultimate prognosis may be determined. In all cases, however, muscle power is regained spontaneously. The recovery is rapid during the first six months, and more slow thereafter, the condition becoming stationary, as a rule, in about eighteen months, although definite improvement may occur even after that time as the result of treatment. For example, it is often observed that a muscle is without power when overstretched. When the heel cord is contracted the anterior group of muscles may be feeble or apparently paralyzed until, by severance of the posterior structures, the foot is placed at a right angle to the leg. Muscle power is there after regained in the anterior group and dorisflextion of the foot in walking is possible.

The orthopedic treatment begins so soon as the paralysis is observed and consists of the prevention of deformity with suitable apparatus. Support of the extremity with the muscles in a state of relaxation not only prevents deformity but also affords the weakened muscles a better chance to recover. Activity should not be permitted too early. Parents often encourage paralytic children to walk because of the erroneous idea that functional exercise alone will cause improvement in strength in the affected muscles. On the contrary, paralyzed muscles should be maintained in a state of relaxation as over-fatigue tends to delay recovery and cause further deterioration. When the muscular soreness and other acute symptoms have subsided, massage, electrical stimulation, muscle training and underwater exercises are indicated in addition to apparatus for the prevention of deformity. Braces may be useful on the lower extremities and are indicated frequently until sufficient muscle tone returns to enable the patient to walk. Braces should conform to the limb and should regulate the range of motion in the joints. Unless braces are intelligently constructed, they may be so much weight added to an already defective member.

When the residual stage of paralysis is reached, no further increase in function is apparent regardless of continued physiotherapy or other conservative treatments. In the stage of residual paralysis, however, much may be accomplished by surgical procedures; in fact, there is rarely observed any case which cannot be materially improved by the institution of efficient and appropriate measures. In any program for the reconstruction of a paralyzed extremity, due consideration must be given to the planning of operative treatment along correct mechanical lines. The nerve and muscle mechanism of the patient's entire body must be considered and operations applicable to the individual case employed that will permit utilization of the remaining muscle power to the fullest degree. The purpose of an operation or a series of operations in anterior poliomyelitis may be three-fold: (1) to correct deformity; (2) to restore muscle balance; and (3) to stabilize loose and relaxed joints. The operations for the correction of deformity consist of forcible manipulation, lengthening of contracted soft structures, and division of bone for the correction of osseous deformities. Redistribution of muscle power is accomplished by tendon transplantation. The tendon of an active muscle is transferred to the point of insertion of a paralyzed muscle. The transplanted muscle must be of sufficient power to perform the function of the muscle whose action it assumes and must be so placed that there is no mechanical interference, if it is to be capable of performing the function of the replaced muscle. While brilliant results have been obtained by this method, many failures have also occurred, probably due to the lack of correct technic. Operations for stabilization consist of surgical arthrodesis or fusion of joints in a position that is most useful for function. Such methods are employed in the foot to secure a fixed and rigid support, resulting in improvement of gait and enabling the patient to discard braces and other apparatus.