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ALTHOUGH the place of physiological rest in the treatment of poliomyelitis is now pretty well understood by most orthopaedic surgeons and others in the medical profession, there are still many to whom its importance has not become apparent.

Physiological rest is not simply rest in bed, but the maintenance of the body and its extremities in such positions that all forces, both internal and external, are unable to operate to the disadvantage of affected muscle groups.

The pull of gravity, the weight of the bed-clothes and the action of strong muscles opposing weak ones are all influences which are detrimental and if uncontrolled lead to the production of deformities.

Myalgia, or muscle pain, is one of the earliest symptoms to appear in the acute stage of this disease, due to neuritis and irritation in the spinal cord from the inflammatory process going on within it.

It is evidenced by pain, soreness and aching, with spasm or drawing up and tightening of the muscles of back, legs and arms. The muscles corresponding to and served by the spinal centers involved in the pathological process begin to show loss of function and atrophy very early.

Sir Robert Jones pointed out many years ago that if the joints are allowed to flex out of their neutral position, the muscles would draw up one side of the joint and their opponents on the opposite side would be stretched. For instance, when a patient, to relieve pain or soreness, lies with the knees drawn up and foot dropping down during the early phases of an attack, the hamstring muscles on the back of the thigh and the calf muscles become shortened and the quadriceps (the large muscle group on the front of the thigh) become elongated or stretched.

In the lower leg the foot would drop because the heel would be pulled up by the taut calf muscles, assisted by the weight of the foot pulled down by gravity. The combination of these forces would produce a stretch palsy which is superimposed on the paralytic weakening.

There is still another factor, called atrophy of disuse, which occurs in muscles that are idle and not functioning normally, which occurs also in such cases.

We have, then, these three factors to contend with: namely, atrophy from disuse, stretch palsy, (the paresis from over tension) and the actual paralysis from the disease.

These conditions should be borne in mind early in the course of the disease and their effects counteracted.

It can readily be seen that ordinary rest may not be sufficient to control them. Some form of mechanical support of the various joints, in neutral positions, in order to establish complete physiological rest, is the means usually employed.

This splintage can be accomplished by putting the affected members in plaster casts, then splitting the casts in halves. When these plaster shells are made as light as possible they are very comfortable and are form fitting. The posterior portion can be used when the patient is recumbent and the front half when he is on his face. Cabot wire splints are very light and quite suitable for control during the acute stage. Wire mesh or aluminum splints are also suitable but not so readily obtained. As the pain in the muscles is increased by joint motion, the prevention of it by splinting soon brings the pain under control and does away with muscle spasm. This breaking up of the vicious circle of movement-pain-spasm, constantly being repeated, is one of the most important aspects of the early treatment, and is probably next in importance to the immediate use of convalescent serum. Fewer sedatives are required to quiet the patient and much injury to the affected muscles is prevented.

The positions found to be best are, feet at right angles to the leg -- and they should be so placed even when there is little or no evidence of their involvement- - ; knees just off the position of full extension, say five to eight degrees of flexion; hips extended slightly, and abducted until it is determined whether abductors or adductors are unequally affected, and in a neutral (knee forward) position as to rotation.

The back should be supported so that the lumbar curve in the "small of the back" does not sag down and flatten, and in case there is too great pain the legs may be raised, moderately flexing at the hip joints to slacken the pull on the large hip flexors that fasten to the front of the spinal column.

The shoulders are the most commonly neglected of any part, as the presence of paralytic involvement of the shoulder girdle or scapular muscles is often slight, and not noted when the patient can apparently move his arms and use his hands.

The weight of the body on the shoulder blades holds them more or less fixed so that the upper arm muscles have a point of leverage to work from and no apparent loss of function is evident. If there is any doubt, whatever, the arms should be held in abduction and outward rotation. This guards against the shortening of the powerful pectoral muscles on the chest and the adductors of the shoulder joint, both of which are favored by gravity, and eases off the stretch on the shoulder cap or deltoid muscles.

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The elbows should be kept extended if the triceps is involved and semiflexed if not; the forearm in supination or palm up until the balance between the pronators and supinators is determined and then the weaker should be favored. The wrists should be bent back, or extended, to about 45; the fingers kept in a neutral position of semiflexion.

The thumb is often neglected and serious malformation is invited. It should be abducted from the index finger and carried forward toward the palm. The palmar aspect of the splint should rest only on the ulnar side of the palm and never on the fatty part or eminence of the metacarpal part of the thumb, which would tend to make a flat hand.

The light papier mache hand splints described and recommended by Dr. Jean McNamara in a recent number of the "Physiotherapy Review" are admirable for the purpose. At the Orthopaedic Hospital, in Los Angeles, we have used a light frame of wire covered with light canvas, in the form of aeroplane wings placed crosswise of the bed under the mattress of a Bradford frame, bent forward slightly, (the hands and elbows being controlled by small splints) for cases of shoulder girdle and arm involvement.

These positions must be maintained at all times and when the patient is turned there should never be any alteration in them.

All through the period of convalescence the weakened sets must never be stretched and in muscle training we believe that the joints should never be carried beyond the point of placing the affected muscles on a slight tension to give them a starting point. Even in flail parts these precautions should be maintained.

The same protective care is carried over into the functioning or walking stage of convalescence. When braces take the place of splints these same physiological precautions must be taken. No deformity should ever be allowed to occur, and it will not occur if such physiological rest treatment is instituted early and continued throughout all the stages of treatment.

When deformity has already occurred in later stages, it should at once be corrected and a return to positions of physiological rest may allow the regaining of power lost by atrophy from disuse and the stretch paresis caused by deformity.

Very often there is not so much actual residual paralysis as one had supposed at first glance. It should be stressed to all and sundry, that the occurrence of deformity is a direct index to the kind of care the patient has had and usually means that some one has neglected to properly apply the principles of physiological rest positions for a long enough period.