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EDITOR'S NOTE -- We should like to see a satisfactory answer to Dr. Freiberg's question from an economic point of view. We believe the time must come when society will arrange that every person suffering from the after effects of poliomyelitis will be systematically placed in some occupation which will make the maximum use of his abilities compatible with the maximum of recovery. Two ends would be served -- society would gain by the human energy reclaimed; the recovery of the individual would be hastened rather than curtailed by the fully useful activity.

So much has been said and written concerning Poliomyelitis, or Infantile Paralysis, during the past two decades that the reading layman is pretty well informed regarding its general characteristics. He knows quite well that it is regarded as an acute infectious disease, that there is still doubt as to the manner of its transmission and contagiousness. Many persons know that the disease is one which produces its permanent disabling effects by reason of damage to the spinal cord but many are still unclear on this point; they look to the paralyzed limb as the seat of the disease and, therefore, they hope for miraculous and impossible help from treatment directed to the limb. Those who are well informed know that the true seat of the damage is in the spinal cord and that after the acute and often prostrating phase of the illness is past there is a period during which nature is able to bring about much repair at the site of the disease in the spinal cord, in the great majority of cases at least. However, not a few of even this group do not realize that medical science has thus far not enabled us either to limit the extent of the damage in the cord, or to definitely influence the degree to which repair in the spinal cord is to proceed. We do know that after a certain period, whose outside limit is assumed to be two years, no further repair in the cord may be expected. During the period of repair certain muscles are receiving no nerve impulses to make them act. Being unable to resist by contracting, as a normal muscle would do, they are subject to damage by various influences such as overstretching, unless we protect them. Unless they are so protected, when nerve impulses again come to them because of the repair which has taken place in the nerve centers in the spinal cord, the muscles will have so deteriorated that they can not respond by action. This deterioration may be so great as to be beyond recovery; most often it is not, if the proper things are done.

We may liken the situation to that of a system of electric bells which are worked by a central battery. If the battery is out of order, they will not ring. If, pending the repair or replacement of the battery, we permit the bells themselves to be damaged, when the battery is again in order the bells will fail to operate until they have been looked after. In this simile, the battery represents the spinal cord nerve centers, the wires are like the nerves which bring nerve impulses (or electric current) to the bells which we have likened to the muscles. Every intelligent person knows to what extent the muscles of an otherwise normal person deteriorate and weaken by lack of use, or exercise. But we also know that if the individual be otherwise normal, these weak muscles can be made again strong by well directed exercise. We also know that if such a weakened muscle, or set of muscles, be over-worked it becomes degenerated. It becomes not stronger, but weaker and our purpose is defeated. On the other hand, it is well understood that by means of judiciously controlled exercise, which we speak of commonly as "training" or gymnastics, muscles may be brought to a degree of strength which is much greater than usual. We have here only to think of the bulging muscles of the trained athlete; not, indeed, that such bulges are to be desired but rather as an example of the extent to which strength and even volume of muscle may be cultivated.

It is easy to imagine how important all of these considerations become when we have to deal with muscles which are weakened by paralysis in any conceivable degree; the muscle may have 90% of its proper strength or it may have 20%. But whatever it has should be conserved and carefully built up to the maximum which is possible. Here lies the virtue of exercise under warm water. The buoyancy of the water makes it possible for a trained person to control the exercise to a marvelous extent and to apportion it alike for the weakest muscle as well as the one which has perceptibly grown strong. It greatly facilitates the task of working quite weak muscles in combination with such as are much stronger, as no other method can approximate. If, at the same time that such suitable method of "physiotherapy" is being employed the weakened muscles are protected from becoming overstretched by means of suitable splints or braces and by regulating the patient activities, we may hope to bring him towards maximum degree of recovery.

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It is common knowledge that after the lapse of two years and in patients who have attained certain age, operations upon tendons and joints are often desirable in order to rid them of the need for braces, to make their brace needs simpler, or to correct deformities which have been permitted to develop. Patients sometimes present themselves at such time and under such conditions and who are now being submitted to expert care for the first time in their experience. The temptation is strong, under these circumstances, to proceed with planning for such operations under the impression that nothing else will help. Experience has shown that this is unwise in many cases, to say the least. Unless one is convinced that the patient has had the benefit of truly efficient physiotherapy under skilled supervision, it is not possible to be sure that muscles may not be salvaged by such treatment until an effort has been made to do so. It must be sufficiently long continued to be convincing and it must be supplemented by such aid of mechanical character as to assure the expert orthopaedic surgeon of the ultimate possibilities in the way of muscle development. Only when this has been done is it tenable to proceed with a plan for help by operative procedures. I have formed this opinion after long experience and after having seen the results of operations which were shown to be either needless or unwisely planned. On the other hand, operations which have been done after such a course of preparation, in this class of cases, have quite uniformly proved to be most satisfactory both to patient and surgeon, but above all, to the patient a great and lasting benefit. Whereas some patients resist the proposal of operation when it has been advanced with wisdom and conservatism, there are some who seek it looking for a cure-all. The surgeon needs occasionally to combat this attitude with quite as much firmness as is required to convince him who opposes an operation which has been proposed with utmost wisdom.