Whitman also states that: "The sensation of the paralyzed part is not affected except in extreme cases. The temperature is lower from the first. In many instances the limb is not only cold, but it is congested and blue. These circulatory disturbances are caused primarily by the interference with the vasomotor system, but they are confirmed later by the atrophy of the muscles and by the permanent contraction of the blood vessels." In general it can be said that the amount of impairment of circulation as well as the retardation of growth corresponds to the degree of the paralysis.

The treatment of the acute stage of anterior poliomyelitis is symptomatic combined with rest in bed and measures to relieve the congestion of the spinal cord. Some authorities advocate keeping the patient in bed six weeks and more.

As the acute symptoms subside, attention is directed to the paralyzed area and measures are taken to maintain the nutrition of the muscles and prevent deformity. The nutrition of the muscles is maintained by massage. Muscle beating, hot air baths, electricity in various forms, etc.: each method or combination of methods having its more or less enthusiastic supporters. Deformity should be prevented at this time by daily passive movements of the joints to their physiological limits in all directions, later when the patients attempt to use their limbs deformities must be prevented by mechanical treatment.

Whitman sums up the principles of mechanical treatment as follows: "To prevent deformity due to weakness and to utilize the muscular power that remains so that the disabled member may carry out its function."

When, through the use of mechanical support, a disabled member is capable of functioning a great advance has been made; but treatment should not stop at this point. Only too often the fitting of the patient with braces ends the attempts at treatment when in reality mechanical support should be only an adjunct to or preliminary to muscle training.

When a patient begins to use his limbs he naturally makes the motions which are the easiest for him. The action of the stronger muscles predominate and the muscles with only a small amount of power remaining are not only not used but are constantly stretched and strained. As a result the weakened muscles tend to atrophy and degenerate still more and in a short time awkward and vicious habits of action are formed.

The object of muscle training is to develop and increase the efficiency of the partially paralyzed muscles thereby increasing the efficiency of the limb as a whole and at the same time preventing or improving the awkward and vicious habits of action.

There is nothing new in the use of muscle training in cases of anterior poliomyelitis. Probably Miss Colby at the Children's Hospital in Boston has done as much to show the importance of this line of work as anyone in this country. The object of this paper is to call attention to the value of muscle training and to illustrate the method of its application.

One of the first essentials in work of this character is to get the confidence and cooperation of the patient. The patients, most of whom are children, may be sensitive. They may be humiliated by their awkward attempts to use the limbs and they do not trust their own powers; on the other hand they may be apathetic and not care to exert themselves. At the same time the parents or friends of the patient may be apathetic and fail to encourage and instruct the patients as they should. The long course of the disease has made them discouraged and they lose hope that the patients will ever be any better.

The best results can undoubtedly be obtained in cases where treatment can be started early, i. e., before mechanical treatment has been attempted, but surprisingly good results can sometimes be obtained in cases of long standing that had previously been considered as beyond further improvement.

It is an established fact that voluntary movements, be they ever so slight, are of much more benefit in maintaining and building up nutrition in a muscle than is passive motion, electricity or even massage. Electricity is probably more widely used in the treatment of anterior poliomyelitis than any other therapeutic agent. It is of undoubted great value in maintaining the nutrition in muscles that are temporarily paralyzed, but as soon as a muscle regains any of its voluntary activity there can be no question as to the greater efficacy of voluntary movements in maintaining and developing nutrition. Light massage, gentle manipulation and light percussion are very stimulating to the growth of muscle and are usually much more agreeable to the patient than the use of electricity. Heavy massage, manipulation or percussion, however, are detrimental and cause the weakened muscles to atrophy still more.

In the treatment of our cases we use light massage, gentle manipulation and light percussion to improve the circulation and

muscle tone but especial stress is laid upon training the patient to make voluntary movements.

Sometimes it is found that the muscle power necessary to a certain movement is present but the patient is unable to make the movement because he does not know how. For example: power of voluntary movement may be present in the extensor muscles of the leg and some little contractile power may be present in the flexor muscle, but the patient, by disuse, has lost voluntary control. When the patient is instructed to flex the leg the nervous impulse generated causes instead an extension of the leg. In such a case the patient has to be assisted in the movement and after a time the association path in the brain will be re-established. Resisted movements are sometimes found to bring out more voluntary contro! by the patient and are always excellent strength builders. Sometimes when a certain voluntary movement is absent in one limb but is present in the opposite limb it can be developed by instructing the patient to try and make the movement with both limbs. In such a case the nervous impulse seems to extend over into the paralyzed limb and cause the movement which would be impossible if the effect was made with the weakened limb alone.

The muscle training must be of such a nature as to secure the interest and cooperation of the patient. Most of the patients are small children and the exercises are given in the form of gymnastic play; the legs may be called little horses, the arms, birds' wings, etc. Angular movements are given the preference because of the usually relaxed condition of the joints. The children are trained to do the various exercises carefully and correctly and with the limbs held in as correct a position as possible.

The variety of exercises and the ways of interesting the children are almost infinite, but the accompanying photographs of a case of anterior poliomyelitis in which both legs are involved serves to illustrate some of the ways in which the exercises may be given and the interest of the child aroused.

In giving the exercises of muscle training it is very important not to overtire the small patients. Twenty minutes to half an hour every day or three times a week is time enough to spend with any child. The instructor should plan to stop each day's work when a small gain has been made so that the child will get the idea he is improving and not get discouraged by fatigue and failure. It is sometimes surprising how sensitive the little patients are to failure and how quickly they get a desire to improve.

Clinical and Patbological Notes

A Lithopedion Thirty-five Years Old Reported by JAMES N. VANDER VEER, M. D. and CHARLES P. MCCABE, M. D.

Mrs. M. G. R., aged sixty-five years, died on September 30, 1909, following an organic heart lesion, and had given a history as follows:

She became pregnant in August, 1874, and the day of her expected confinement was May or June of 1875. Within the week that her expected confinement was to take place she suffered from labor pains in a perfectly normal manner, and summoned her family physician at that time. He came and attended her the whole night through while the pains continued. But there was no presentation of any part, and so far as could be learned from the patient, the physician could not make out that the cervix was enlarging as it should. The following morning the pains ceased and since that time she had not suffered in any appreciable manner, until her later years, from what she supposed to be a false labor. No child was born. The patient had had one living child three years prior to this pregnancy and three years after this pregnancy she became pregnant once more and, within the normal period, was delivered of a living child, a girl now thirty-two years old.

In the interim, to 1909, she suffered no inconvenience whatsoever, except occasionally a bunch would present itself in her abdomen, which could be moved from side to side, but which, by choice, seemed to lie on the left side.

In June, 1907, she had an attack of grippe and pneumonia while in a nearby town, at which time Dr. McCabe attended her, and since that time she suffered from an organic heart lesion due to the grippe, followed by nephritis, and eventually an anasarca and an ascites developed, requiring tapping of her abdomen in the summer of 1908. Shortly after this her legs became markedly edematous, with large ulcerations of the calves of both legs, and general debility rapidly came on. For the last eight months prior to September, 1909, she had been unable to lie in bed, by reason of the kidney complication, and was compelled to sit in a chair during the entire twenty-four hours in order to obtain sufficient breath.