limb by the manipulator, at the same time that they are strenuously
resisted by the patient. From the nature of this method, and its aim
in stimulating the voluntary innervation of the muscles, it {1158} is
admirably adapted to hysterical paralysis. Theoretically, it is
difficult to perceive the applicability of this method in organic
atrophic paralysis, especially in young children, whose voluntary
efforts cannot be commanded. There are, however, several real
indications for passive gymnastics in the treatment of infantile
paralysis. Surface friction and deep massage have some influence in
dilating the blood-vessels and causing an afflux of blood to the cold
and wasting muscles. A probably more important effect may be produced
upon the contraction caused by malposition and adapted atrophy of
certain groups of muscles. It is these contractions which formerly
constituted the special objection of the orthopædist, and were treated
almost universally by tenotomy. They are in any case the proximate
cause of deformities; and, generally existing on the side of the joint
opposite to the most severely paralyzed muscles, they keep these
over-stretched and prevent them from receiving the benefit of the
electrical treatment. Muscles which will not contract to the faradic
current while thus stretched will often begin at once to do so when
the rigidity of their antagonists has been overcome.
Persevering stretching by the hands will often overcome this rigidity
as completely, and even more permanently, than will the
tenotomy-knife. It is in this part of the treatment that entirely
ignorant and even charlatan manipulations do, not unfrequently,
achieve remarkable results.[172]
[Footnote 172: Of course many of those on record, and to some of which
I have been a witness, relate to hysterical contractions, hysterical
scoliosis, etc.]
It is the retracted tendo Achillis and plantar fascia which most
frequently require this manipulation. In the paralytic club-foot of
young children all authorities agree in the value of repeated
manipulations and restorations of the foot as nearly as possible to a
position where it may be retained by simple bandaging. While turning
the foot out it becomes perfectly white, but on releasing hold of it
the circulation is restored, after which the manœuvre may be repeated
(Sayre).
This principle of intermittent stretching by seizure of the segments
of the limb above and below the joint applies to all forms of
paralytic contraction. In the trunk the pelvis should be held by the
mother, while the manipulator, seizing the thorax of the child between
both hands, moves it gently but forcibly to and fro in the required
direction. Great care is required in these manipulations—not merely to
avoid exhausting the muscles, but even to avoid fracturing atrophied
bones.
It may be laid down as a positive rule that tenotomy should never be
performed in the contractions of spinal paralysis until the resources
of manipulation have been exhausted. It is to be remembered that the
rigidity depends on no active contraction of the muscle, but on its
elastic retraction. The manœuvre of stretching does not appeal to the
force of contractility, which may have been lost, but to the force of
elasticity, which remains and can be made to act in a reverse
direction. Finally, in the cases where the retracted muscles have not
been originally paralyzed, but have lost the power of contracting
during the process of shortening, this power may be restored if the
muscle regain its normal length.
The operation of tenotomy, apparently a far more heroic measure, is
often a less efficacious means of arriving at the results. Unless
followed by the application of apparatus which permits motion in the
joint, section of contracted tendons is only of brief utility.
{1159} Though the edges of the cut tendon have been kept apart until
the intervening space is filled by new tissue, union is finally
effected by the latter, and retraction through elasticity is again
imminent. Often, therefore, the deformity is repeated in spite of
repeated operations; when it is not, the happy issue is due to the
fact that, with increased freedom of locomotion immediately after the
tenotomy, the patient has been enabled to bring the influence of
weight to bear in such a manner as to fix the limb in a new and more
convenient position. Thus, after section of the tendo Achillis for pes
equinus, if the patient begins at once to walk on the paralyzed foot,
the weight of the body, pressing down the heel, may keep the tendon
stretched. So walking immediately after section of the hamstring
muscles will have a tendency to produce genu-recurvation by the same
mechanism which produces it in total paralysis, and the original
deformity will not recur.
Besides the tendo Achillis, the parts which may be occasionally
submitted to tenotomy are the plantar fascia, the peroneal muscles,
very rarely the anterior tibial and extensors, the hamstrings, the
thigh adductors. Section of the external rotators of the thigh or of
the tensors of the fascia lata could hardly ever be required, and
among these operations Hueter[173] rejects that on the plantar
aponeurosis as inadequate. The excavation in the foot it is designed
to remedy depends upon alteration in the form of the tarsal bones, and
can only be cured by means of forcible pressure exerted on their
dorsal surface. Section of the peroneal muscles, often recommended by
Sayre, is considered by Hueter to be superfluous after section of the
tendon achilleis. Paralytic contraction of the hamstrings or of the
hip flexors is rarely sufficiently severe to demand tenotomy.
[Footnote 173: _Loc. cit._, p. 416.]
From what has preceded it is evident that maintenance of locomotion is
of great importance, in order to avoid the deformities which are
threatened by prolonged repose. Locomotion, however, can only be
safely permitted with the assistance of apparatus capable of
restraining the movements liable to be produced by the weight of the
body. The supporting instrument which restrains movement in certain
directions must, however, facilitate it in others: immovable
apparatus, such as is not infrequently applied after tenotomy, is
always injurious.
In young children unable to walk, the development of pes equinus may
often be prevented by drawing down the foot to a sole splint made of
thin wood, gutta-percha, or felt, and fastening it with a flannel
bandage. The point of the foot may be drawn up toward the tibia by a
strip of diachylon plaster. If the equinus has already developed, a
splint of gutta-percha or of felt (Sayre) may be modelled to the leg
and foot while the latter is held forcibly in dorsal flexion. The
splint is attached by means of strips of adhesive plaster. It should
extend as far as the knee, and be suitably padded (Seeligmüller).
In children able to walk a sole splint of thin metal, to which the
foot had been previously attached by a flannel band, should be
inserted in a stout leather boot. On the outer side of this boot
should run a metallic splint, jointed at the ankle and extending to a
leather band surrounding the leg just below the knee. A broad leather
band, attached to the outer edge of the sole anterior to the
talo-tarsal articulation, also passes up on {1160} the outside of the
foot, gradually narrowing until, opposite the ankle, it passes through
a slit in the side of the shoe, to be attached to the leg-splint. This
band tends to draw the point of the foot outward, and thus correct the
varus (Volkmann). Sayre[174] has improved on this shoe by dividing the
sole at the medio-tarsal articulation, in which lateral deviation
takes place, and uniting the anterior and posterior parts by a
ball-and-socket joint, permitting movement in every direction.
[Footnote 174: _Loc. cit._, p. 88.]
The orthopædic boot for the treatment of calcaneo-valgus is
constructed on the same principle. But the splint runs up the inner
side of the leg, and the leather strap passing to it from the edge of
the sole draws the point of the foot inward and raises its depressed
inner border (Volkmann). Essential to the treatment of this deformity,
however, is the elevation of the heel. This is effected by means of a
gutta-percha strap which is attached below to a spur projecting from
the heel of the shoe, and above to a band encircling the leg. If, by
rare exception, a paralytic calcaneus exists in a child unable to
walk, a simple substitute may be found for the shoe in a board
sole-splint projecting behind the heel, attached to the foot by a
strip of adhesive plaster, which finally passes from the posterior
extremity of the board up the back of the leg, and is there secured by
a roller bandage.
The device of the gutta-percha elastic band to replace the
gastrocnemius muscle illustrates a principle of wide application in
orthopædic apparatus. The suggestion to replace paralyzed muscles by
artificial ones was first made by Delacroix[175] in an apparatus
designed for the hand. The suggestion was repeated by Gerdy;[176] and
in 1840, Rigal de Gaillac proposed to exchange the metallic springs
hitherto used for India-rubber straps. Duchenne elaborated the
suggestion in a remarkable manner,[177] using delicate spiral springs
as a substitute for the lost muscles, and taking the greatest pains to
make the insertion-points of these to exactly correspond with the
insertions of the natural muscles. This was effected by means of
sheaths, imitating natural tendinous sheaths, sewed to a glove or
gaiter in which the hand or foot was encased.
[Footnote 175: Article “Orthopédie,” _Dict. des Sciences médicales_,
quoted by Duchenne.]
[Footnote 176: _Traité des Bandages_, 2d ed., Paris, 1837, quoted by
Duchenne.]
[Footnote 177: See chapter on “Prothetic Apparatus” in his treatise
_De l'Électrisation localisée_.]
At the present day the prothetic apparatus the most employed is that
contrived by Barwell.[178] The principle is the same as Duchenne's,
but the artificial muscles are made of India-rubber, to which a small
metallic chain is adjusted, and they are attached to the limb by means
of specially-devised bands of adhesive plaster and pieces of tin
bearing loops for the insertion of the muscle. In this apparatus the
artificial muscles do not attempt to imitate the situation of the
natural muscles with the precision which Duchenne claimed for his.
Barwell's own dressing for talipes valgus consists of two rubber
muscles which pass from the inner border of the foot, one to the
inner, the other to the anterior, part of a band which encircles the
leg just below the knee. For talipes calcaneus another band is
required behind the leg, passing to the heel, as in Volkmann's
apparatus, already mentioned. For talipes varus a rubber band {1161}
should pass on the outside of the foot; for equinus, one or more from
the anterior part of the leg to the sides of the anterior part of the
foot.
[Footnote 178: A tolerably minute account of the Barwell dressing is
given by Sayre, _loc. cit._, p. 84.]
Sayre endorses Barwell's dressing as entirely adequate for the
treatment of any form of club-foot, but modifies it by substituting a
ball-and-socket shoe for the adhesive plaster which should encircle
the foot. The artificial muscles are then passed from the sides of the
shoe to a padded leather girdle encircling the leg. A straight splint,
jointed opposite the ankle, runs up from each side of the foot to this
girdle, and from it two lateral upright bars, jointed at the ankle,
pass to the heel of the shoe; and from below the joint passes forward
on each side a horizontal bar reaching the point of origin of the
artificial muscles and giving attachment to them.
In equinus it is necessary to bind the heel of the foot down firmly in
the heel of the shoe; and this is accomplished by means of two
chamois-leather flaps which are attached to the inside walls of the
shoe and lace firmly across the foot.[179]
[Footnote 179: “The aim of the dressing or instrument is simply to
imitate the action of the surgeon's hand; accordingly, any apparatus
combining elastic force is far superior to any fixed appliance; and,
moreover, that is to be preferred which is the most readily removable.
Shoes, therefore, are better than bandages or splints. A proper shoe
must have joints opposite the ankle and the medio-tarsal articulation;
it must permit the ready application of elastic power; and it must not
so girdle the limb as to interfere with the circulation” (Sayre, _loc.
cit._, p. 91).]
Sayre places so much confidence in the power of this elastic tension
to overcome contractions that he rarely resorts to tenotomy in the
treatment of paralytic talipes. Hueter, however,[180] considers
tenotomy much the speediest, and therefore the most desirable, way of
removing contractions.[181]
[Footnote 180: _Loc. cit._]
[Footnote 181: _Loc. cit._]
Seeligmüller quotes with approval Böttger's method for the treatment
of deformities, where the weight of the body is utilized to stretch
the retracted tendons. Thus, for talipes equino-varus an
over-reduction is effected under ether, and the foot forced into a
position of moderate calcaneo-valgus. In this position it is retained
by the immediate application of a plaster or silica bandage. After
this has hardened the child should be encouraged to walk in the mould,
with the addition of felt shoes having a slanting sole that is
thickened like a wedge at the inner side of the foot and strapped on
like a skate. Then, during the act of walking the body tends to
constantly force down the heel and thus stretch the retracted tendo
Achillis, while the bandage and felt sole (acting like a splint)
prevent the inner side of the foot from slipping up.
For talipes valgus the method is analogous, but the foot is forced
into an equino-varus position, so that the tendo Achillis is
artificially shortened, and ultimately becomes a rigid band, capable,
in spite of the sural paralysis, of sustaining the heel.
A cause of relapse in talipes not unfrequently overlooked is the
presence of even slight contractions of the hip- and knee-joints.
These by shortening the limb tend to the production of equinus, since
the foot points itself in order to reach the ground. These
contractions, whose rigidity is far inferior to that induced by
chronic arthritis, may be overcome by forced extension under ether or
gradually by manipulations, or by the weight-and-pulley apparatus,
applied in the recumbent position, as in morbus {1162} coxarius. The
obvious objection to the latter method is the confinement in bed which
it necessitates in a child enjoying at the time perhaps robust general
health.
The contraction once overcome, the limb must be placed in apparatus
which shall both maintain suitable extension and assist in supporting
the trunk during station and locomotion. The latter purpose is
effected, as in apparatus for chronic joint diseases, by transferring
the weight of the body to steel splints running up each side of the
limb, the outer one as far as a girdle which encircles the hips; the
inner to a band surrounding the upper part of the thigh. Thus is
extended the support which in paralysis limited to the leg-muscles is
given by the steel splints inserted in the side of the club-foot
shoes.
In the simplest form of apparatus locomotion is expected to be
accomplished by the action of muscles inserted above the seat of the
paralysis. Thus, when the muscles passing over the ankle-joint are
paralyzed, the foot is moved as a dead weight by means of the
quadriceps extensor, popliteus, and hamstring muscles inserted at the
upper extremity of the leg. If the quadriceps cruris is paralyzed, the
rotators of the thigh, ilio-psoas, sartorius, and adductor muscles,
passing from the pelvis to the thigh, and which are so frequently
intact in atrophic paralysis, are enabled to move the limb if the
weight of the body is borne by steel splints, if these be light and
properly jointed at the hip, knees, and ankle.[182]
[Footnote 182: Or the joint of the knee may be kept locked while the
patient walks, when extension of the limb is mainly required, during
both the active and passive movements of locomotion, the necessary
flexion being supplied at the hip and ankle. By means of a key the
knee-joint can be flexed during the sitting positions.]
But an important aid to locomotion may be obtained from the artificial
muscles, whose elastic tension is of such value in overcoming
contractions. The quadriceps extensor, the most frequently paralyzed,
may be supplemented by an India-rubber band and chain passing down the
front of the thigh from a point on the pelvic girdle corresponding to
the anterior iliac spine to a point on a leg-band, imitating the
tibial insertion of the quadriceps tendon. Analogous bands stretched
on the posterior aspect of the thigh simulate the hamstring muscles.
When the external rotators are paralyzed, the artificial muscle must
stretch from the pelvic girdle to a band encircling the upper part of
the thigh.
The action of these muscles, apart from their elastic tension of
repose, is thus explained by Duchenne: When any effort is made to move
a paralyzed limb, the intact antagonists to the paralyzed muscles
contract; thus, the flexors of the leg. But this contraction, being
constantly opposed by the elastic tension of the artificial
quadriceps, is restrained and gradual, instead of being brusque,
jerking, and excessive, as it otherwise would be. This is the first
result obtained. In the second place, contraction of the antagonist
having ceased, the artificial muscle which has been stretched returns
upon itself in virtue of its elasticity, and restores the limb to the
position of normal equilibrium.
For the act of walking, however, the artificial quadriceps would
require to be made tense enough to resist flexion, and thus keep the
limb in extension. An artificial anterior tibial muscle, however,
would require to yield to the intact gastrocnemius while the heel was
being raised from the floor; then its elastic force should be
sufficient to retract the point of {1163} the foot in dorsal flexion
during the pendulum movement which passively swings the leg forward.
The tension of the artificial muscle should therefore be so adjusted
that it can only be overcome by the active contraction of the
gastrocnemius, and at the moment of greatest tension, immediately
after stretching, it should be able to quite overcome the
gastrocnemius, then relatively[183] relaxed.
[Footnote 183: We say relatively, believing that the simultaneous
contraction of antagonist muscles has been well established as a
constant normal phenomenon.]
The anterior tibial, gastrocnemius, and many other of the artificial
muscles devised by Duchenne are still in use in the modified form
given to them by Barwell. On the other hand, the action of the long
peroneus in pronating the foot, and which Duchenne imitated by an
elaborate artificial tendon following the exact course of the natural
one, is to-day generally supplemented by the jointed shoe and laced
bandage.
In paralysis of all the muscles surrounding a joint, when the limb is
placid and no retractions by adapted atrophy have taken place, the
artificial muscles can only serve to oppose the malpositions which are
threatened from mechanical influences.
In the upper extremities prothetic apparatus has been principally used
for progressive muscular atrophy. Paralysis of the wrist extensors is
perhaps the only case in which the artificial muscle is required in
anterior poliomyelitis. A string may be necessary to support the arm
in paralysis of the deltoid, to avert luxation of the humerus.
Duchenne's ingenuity did not shrink from the difficult task of
supplementing the muscles of the trunk. This he did by inserting the
elastic spirals in corsets in a direction following that of the
muscles paralyzed. Thus, a unilateral paralysis of the sacro-lumbalis
may be met by a spiral splint running up one side of the spine; below,
to the lateral posterior portion of a pelvic girdle. In bilateral
paralysis two springs are used to antagonize the action of the
abdominal muscles.
In Barwell's apparatus for the trunk[184] India-rubber bands are again
substituted for spiral springs. No attempt is made to imitate the
direction of muscles, but the force is applied in any direction
required to antagonize the pressure producing the deformity.[185]
[Footnote 184: Especially designed for habitual scoliosis, but
applicable also to the paralytic deformity.]
[Footnote 185: Volkmann (_loc. cit._, p. 778) thinks that the force of
Barwell's India-rubber straps, whether for scoliosis or club-foot
apparatus, is inadequate, and much inferior to metallic springs.]
It is always important to remember the rarity of scoliosis caused by
spinal paralysis of the trunk-muscles, and the much greater frequency
with which this deformity occurs as a consequence of the paralytic
shortening of a leg. A high shoe, equalizing the length of the lower
extremities, is then the simple and efficient remedy.
In cases of long standing, even when the scoliosis is due to this
cause, certain muscles on the concave side of the curve may become so
retracted and rigid as to require tenotomy. Before this operation it
is necessary to put the rigid muscles on the stretch as much as
possible; and this may be done, if necessary, by means of Sayre's
hanging apparatus. After this operation the spine may be straightened
out with ease—an important distinction from advanced habitual
scoliosis, where the alteration in the shape of the vertebræ defeats
all attempts at rectification. The position {1164} may be maintained
by elastic straps or corsets and by removing the condition which has
led to the deformity.
Seeligmüller criticises too unfavorably the entire system of elastic
tension in the prophylaxis and treatment of paralytic deformities. He
quotes Duchenne's admission, that in certain cases traction upon
rigidly-retracted tissues becomes insupportably painful, and must be
abandoned. It is in these cases that tenotomy becomes an indispensable
preliminary to the use of apparatus. Sayre insists that the necessity
for tenotomy is indicated when pressure on the rigid muscle is
followed by instantaneous spasmodic contraction in the affected or
neighboring muscles. He declares that such contractions indicate
reflex irritations, show that the muscle has undergone structural
change, and that any attempt to stretch or lengthen it would be
followed by an excess of irritation and pain.
This explanation can hardly be accepted, since muscles, whether
imperfectly or not at all paralyzed, which from position and adapted
atrophy have become retracted, have necessarily undergone structural
changes. The greater these changes, the greater the diminution of
reflex excitability; and in any muscle completely paralyzed and
degenerated this is entirely lost. If, however, the afferent nerves
retain enough vitality, if the muscle be slightly paralyzed or
altogether intact, then irritation of its tendon by stretching may
serve to excite contractions in the belly of the muscle. The
possibility of such spinal reflexes is demonstrated by the now
familiar phenomenon of the tendon reflex in various spinal
diseases.[186] The contractions must be painful from the impediments
offered to the progress of the contracting nerve, and from the
exaggeratedly vicious position into which they tend to force the limb.
Under these circumstances prothetic apparatus must be deferred until
section of the tendons has been made.
[Footnote 186: “Passive muscular tension excites tonic contraction in
a muscle, and this action may, in abnormal conditions, be excessive,
as in the myelitic contractions (so-called tendon reflexes).... The
afferent nerves commence in the fibrous tissues of the muscle, and
seem to be especially stimulated by extension” (Gowers, _On Epilepsy_,
1881, p. 97).]
{1165}
DISEASE OF ONE LATERAL HALF OF THE SPINAL CORD.
BY H. D. SCHMIDT, M.D.
SYNONYMS.—Unilateral lesion of the spinal cord; Spinal hemiplegia and
hemiparaplegia; Unilateral spinal paralysis.