Abnormal Psychology 18th Edition Jill

M Hooley
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transversely, the vessels of the lumbar region are compelled to describe a
somewhat prolonged vertical course before reaching their point of
distribution. From these circumstances, even transitory congestions in the
circulation of the cord are easily followed by irreparable injury of its
delicate elements.
133 Loc. cit., Path. Trans., 1884.

Finally, in all discussions on pathogeny must not be forgotten the doctrine

of Leyden134 that infantile paralysis, also progressive muscular atrophy, is
a disease which may begin at the periphery and extend to the centres, as
well as the reverse. It must also be remembered that, as yet, only very
scanty evidence exists to support this, in itself, plausible theory.
134 See loc. cit., ut supra.

COURSE OF INFANTILE PARALYSIS.—The most ordinary course of infantile

paralysis is that already described as typical—namely, extremely rapid
development to a maximum degree of intensity, then apparent
convalescence, retrocession of paralysis, atrophy, and ultimate
deformities in limbs in which paralysis persists.

Several variations from this typical course are observed. Complete

recovery may take place, as in the so-called temporary paralysis of
Kennedy135 and of Frey.136 These cases are very rare. But their possibility
seriously complicates the estimate we may make of the efficacy of
therapeutic measures.137
135 Dublin Quarterly Journal, 1840.

136 Berlin. Klin. Wochensch., 1874. I have described one such temporary case in the article
already quoted. These cases seem about as frequent in adults. (See Frey, loc. cit.; also case
of Miles, etc. etc.)

137 As of the case of complete recovery, the only one the author had seen, related by Dally,
Journal de Thérap., 1880, 1, vii.

On the other hand, there may be a complete absence of regression; and

this is observed sometimes in cases where the paralysis is originally
limited; sometimes where it is extremely extensive, involving nearly all the
muscles of the trunk or limbs;138 or muscles or limbs originally spared may
become involved in a fresh attack. Laborde relates cases of this kind. In
Roger's first case paraplegia occurred under the influence of scarlatina
two months after paralysis of one arm.
138 Thus in Eulenburg's case, quoted ut supra.

The form of anterior poliomyelitis most frequent in adults is the subacute,

and after that the chronic. Both are extremely rare in children, the latter
excessively so. Seeligmüller and Seguin139 both admit the possibility of a
chronic form in children, and the latter has kindly communicated to me
one case from his private practice:

Miss N. D——, æt. 15, paresis in both legs, first at age of nine, increased
at age of twelve, when weakness of vision first noted. At fourteen both
feet in rigid pes equinus, and both tendons achilleis cut, without benefit.
Hands became tremulous, without paresis. On examination at age of
fifteen found moderate atrophy of muscles of both legs. Tendo Achillis
united on both sides, and equinus persists. Voluntary movement exists,
both in anterior tibial and in gastrocnemius muscles, but diminished in
anterior tibial. Faradic contractility diminished in both sets of muscles;
examination difficult from extreme sensibility of patient. In both hands
interossei, muscles of thumb, and little finger show tremors and fibrillary
contractions. Thenar eminences small, abductor pollicis nearly absent,
not reacting to faradic current. Optic nerves slightly atrophied. Mind
enfeebled, memory poor; articulation not affected. Five years later the
motor paralysis and mental enfeeblement had still further progressed, but
no exact notes exist of this period.
139 Loc. cit. (ed. 1877).

Erb140 relates a case that he considers unique at the time in a girl of six.
The paralysis began insidiously in the right foot in July; a fortnight later
had extended to the left foot; complete motor paralysis existed in August,
without any lesion of sensibility: after electrical treatment, then instituted,
first return to motility to peroneal muscles in November; by January child
able to walk again and electrical reactions nearly normal.141
140 Brain, 1883.

141 In the same number of Brain, A. Hughes Bennett quotes cases of so-called chronic
paralysis in very young children which are evidently cases of general paresis from congenital
 cerebral atrophy. The children were defective in intelligence, could not sit up nor hold up the
head; the electrical reactions were preserved. I have seen a great many such cases: they
are indeed not at all uncommon. Much more so is Bennett's diagnosis.

COMPLICATION WITH PROGRESSIVE MUSCULAR ATROPHY.—Raymond142 and

Seeligmüller describe some rare cases where progressive muscular
atrophy declared itself in persons previously affected with infantile
paralysis in other limbs. Both observers infer a gradual and chronic
extension along the cord of the originally acute anterior poliomyelitis.143
Similar cases have much more recently (1884) been quoted by Ballet as
tending to modify the prognosis which has usually been pronounced
favorable quoad life and further spinal accidents. (See infra.)
142 Gaz. méd., 1875. No. 17.

143 It seems to me that Seguin's case, above quoted, might be an example of such
complication(?). But I have not seen the patient myself, and describe the case according to
the views of the author.

PROGNOSIS.—The prognosis of atrophic paralysis, quoad vitam, is, as is

well known, extremely good. The prospect of recovery from the paralysis
is variable. It cannot be estimated either by the extent of the initial
paralysis or by the severity of the fever or attendant nervous symptoms.
The electrical reactions alone are of value in the prognosis, and their
value is very great. Duchenne first formulated their law: “All the cases of
infantile paralysis which I have seen where the faradic contractility was
diminished but not lost, and which could be treated by faradic electricity
within two years after the onset of the paralysis, have completely
recovered.”144 This encouraging statement must be read as applying
rather to individual muscles than to cases as a whole. Few complete
recoveries of patients are claimed even by so enthusiastic an electrician
as Duchenne; who nevertheless affirms his not unfrequent success in re-
creating entire muscles out of a few fibres saved from degeneration.
144 Loc. cit.

The persistence of galvanic irritability in muscles which fail to contract to

the faradic current has been shown by Erb to belong to the degenerative
reactions. Hammond, however, without alluding to the qualitative changes
in the galvanic contractions, sees in them the elements of a relatively
favorable prognosis, even when faradic contractility is lost. Thus, out of
87 cases, in 39 of which the paralyzed muscles contracted to the galvanic
but not the faradic current, 14 were entirely cured, 28 greatly improved,
30 slightly improved, 15 discontinued treatment very early.145
145 Loc. cit., p. 482.

Examination of fragments of living muscle obtained by Duchenne's

harpoon, though useful, should not be allowed to exaggerate an
unfavorable prognosis. Much fat may be found in such fragments when
the muscle is as yet by no means completely degenerated and can be
made to contract to one or the other current. Erb, however, admits that
the results of treatment have not, in his hands, been brilliant; but adds
that he has had no opportunity to treat any cases which were not of long
standing.146
146 Loc. cit.

Volkmann147 considers the paralysis entirely hopeless, and advises the

concentration of all effort upon the prevention or palliation of deformities.
147 Loc. cit.

It seems probable that at the present moment sufficient data do not exist
for formulating a fair prognosis; nor will they until a much larger number of
cases than hitherto have been submitted to all the resources of a complex
and persevering system of therapeutics from the earliest period of the
disease.

SPECIAL PARALYSES.—Among the paralyses, some exercise a more

unfavorable influence on locomotion than others. Thus, paralysis of the
muscles of the trunk is more difficult to palliate, either by apparatus or by
the efforts of the patient, than any paralysis of the limbs. Similarly,
paralysis of the upper segments of a limb is more crippling than when
confined to the lower. Partial paralysis of the muscles surrounding a joint
is often (but not always) more liable to lead to deformity than total
paralysis.

Influence of Neglect.—Apart from the influence of treatment in curing the

paralysis, must be estimated in the prognosis the effect of care and
watchfulness in limiting the disease and in averting many consequences,
even of those which are incurable. The rescue of muscles only partially
degenerated may often serve to compensate the inaction of those which
are irretrievably ruined.

Ballet148 has recently called attention to the fact that in certain cases
persons who had been attacked with an anterior poliomyelitis in childhood
became predisposed to different forms of spinal disease. Four have been
observed: (1) transitory congestion of the cord, causing paralysis of a day
or two's duration; (2) an acute spinal paralysis of the form usually seen in
adults; (3) subacute spinal paralysis; (4) progressive muscular atrophy.
The author relates cases under each of these heads, and further quotes
one related by Dejerine in 1882.149 The patient, a carpenter aged fifty-five
and with an atrophic deformity of the foot, became suddenly paralyzed in
the four limbs, trunk, and abdomen. The paralysis was complete in a
month, was stationary for three months, then began to improve, and at
the end of six months from the onset of the disease recovery was
complete.
148 Revue de Médecine, 1884.

149 Revue de Médecine, 1882.

The observations of progressive muscular atrophy in persons bearing the

stigmata of an infantile paralysis are quite numerous.150
150 Charcot, Soc. Biol., 1875, and Gaz. méd.; Seeligmüller (4 cases), in Gerhardt's
Handbuch, 1880; Hayem, Bull. Soc. de Biol., 1879; Vulpian, Clinique méd. de la Charité,
1879; Pitres, new observation, quoted by Ballet in 1884.

The prognosis cannot be the same for cases where everything is done to
avert malpositions and for those where all precautions are neglected.
Thus, prolonged rest in bed favors pes equinus; the use of crutches
necessitates flexion of the thigh and forced extension of the foot;
locomotion without support tends to displace articulations by
superincumbent weight, causing pes calcaneus, genu-recurvatum. Finally,
compensatory deformities must be averted from sound parts, as scoliosis
from shortening of the atrophied leg, equinus from passive shortening of
the gastrocnemii through flexion of the leg, etc.

ETIOLOGY.—Concerning the etiology proper of infantile paralysis little

definite is known. It is probable, as has been already noticed, that
traumatisms have a much more decided influence than is generally
assigned to them. Leyden particularly insists on this influence, and on the
facility with which a traumatism relatively severe for a young child may be
overlooked, because it would not be recognized as such for an adult. It
must be noticed, however, that children are much more liable to have the
arms wrenched and pulled violently than the lower extremities; yet in a
great majority of cases the lesion is situated in the lumbar cord.

It has been shown that the myelitis, though so limited transversely, is

often far more diffused in the longitudinal axis of the cord than might be
supposed from the permanent paralyses. This fact corresponds to the
initial generalization of the motor disturbance. It seems possible that the
traumatic irritation, starting from the central extremity of the insulted
nerve, diffuses itself through the cord until it meets with its point of least
resistance, and here excites a focal myelitis. That this point should most
frequently be found in the lumbar cord would be explained by its relatively
less elaborate development, corresponding to the imperfect growth and
function of the lower extremities.

A second cause of anterior poliomyelitis is, almost certainly, the presence

of some poison circulating in the blood. The frequent occurrence of the
accident in the course of one of the exanthemata is one indication of this;
other indications are found in such cases as that related by Simon, where
three children in one family were suddenly attacked—two on one day,
one, twenty-four hours later.151 The same author relates a case of motor
paralysis in an adult, followed by atrophy of left lower extremity, and which
occurred during a fit of indigestion caused by eating mussels.152 The
acute ascending paralysis of Landry, with its absence of visible lesion,
has been said to strikingly resemble the effects of poison. Hydrophobia
and tetanus are again examples of the predilection exhibited by certain
poisons for the motor regions of the cord.
151 Journal de Thérap., 7, vii., 1880, p. 16. These children belonged to an American family,
but were seen by several distinguished French physicians.

152 P. 357.

The evidence that infectious diseases may constitute the immediate

(apparent) causal antecedent of acute poliomyelitis has led, not
unnaturally, to the theory that all cases of acute infantile paralysis are due
to a specific infecting agent, some as yet unknown member of the great
class of pathogenic bacteria. It may be noticed, however, that the
occurrence of the spinal accidents after the ordinary infectious diseases,
as scarlatina and measles, should as well indicate that a specific agent
proper to itself was at least not essential to its development.153
153 Perhaps the occurrence of diphtheria in the course of scarlatina and typhoid should
indicate a similar lack of real specificity in the morbid agent of the former disease.

The influence of exposure to cold, which seems to have been sometimes

demonstrated, must probably be interpreted, as in the case of
rheumatism and pneumonia, as effective by means of some poison
generated in the organism when cutaneous secretion, exhalation, or
circulation has been suddenly checked.

DIAGNOSIS.—The diagnosis of the acute anterior poliomyelitis of childhood

is usually easy, but unexpected difficulties occasionally arise.

Typical cases are markedly different from typical cases of cerebral

paralysis, but in exceptional cases these differences disappear. This is
shown in the following table:

SPINAL PARALYSIS. CEREBRAL PARALYSIS.

Hemiplegic, (rule). Monoplegic as residuum of
Paraplegic or monoplegic (rule). hemiplegia or as consequence of solitary tubercle
(exception).
Hemiplegic as residuum from paraplegia, or
original and involving facial nerve (very
exceptional).
Intelligence free (rule). Intelligence depressed (rule).
Intelligence depressed (when spinal paralysis Intelligence free (exception, especially with solitary
has affected imbecile children). tubercle).
Disposition lively. Disposition apathetic or cross.
Initial convulsion unique; general symptoms Convulsions repeated; pyrexia prolonged several
of a few hours' duration (rule). days or weeks (rule).
Convulsion repeated during two to three
weeks before paralysis; fever a month (rare
exceptions).
Sensibility intact (rule). Sensibility intact after initial period.
Occasional hyperæsthesia (exception).
Reflexes cutaneous, and tenderness lowered
Reflexes intact.
or lost (rule).
Reflexes preserved when only single
muscles in groups paralyzed.
Associated movements of hand absent Associated movements frequently observed in
(Seeligmüller). hand.
Extensive and rigid contractions of upper extremity
No rigid contractions of upper extremity.
very frequent.
Atrophy of paralyzed muscles and arrested
Atrophy very slight.
development of limb, very marked.
Faradic contractility diminished or lost;
Electrical reactions normal.
degenerative galvanic reaction.

Rather singularly, the diagnosis from transverse myelitis is less liable to

error than that from cerebral paralysis:

ANTERIOR
TRANSVERSE MYELITIS.
POLIOMYELITIS.
Fever brief or absent. Persistent fever.
Sensibility intact. Hyperæsthesia, then anæsthesia.
Decubitus absent. Presence decubitus.
Reflexes lost. Reflexes increased.
Atrophy of muscles. Atrophy of muscles sometimes as intense.
Electrical muscular Loss of electrical contractility, but not proportioned to sensory and motor
contractility lost. disturbance; less rapidly completed.

The diagnosis from hæmatomyelitis is almost impossible, and practically

useless. For if the hemorrhage be severe, the child dies at once, as in
Clifford Albutt's case. If less severe, it excites a myelitis, and the history
becomes identical with that of the disease we are considering; or if the
clot beyond the anterior cornua, it is identified with a vulgar myelitis of
traumatic origin.

Progressive muscular atrophy is extremely rare in childhood, but is

occasionally seen under hereditary influence (Friedreich's disease). In
adult cases confusion is not only easy to make, but often difficult to avoid,
especially with the rare, chronic form of poliomyelitis. The basis of
distinction is as follows:
 ANTERIOR POLIOMYELITIS. PROGRESSIVE MUSCULAR ATROPHY.
Onset sudden; maximum of paralysis at the March very gradual; maximum of disease
beginning. not attained for years.
Faradic contractility not lost until atrophy
Faradic contractility lost almost at once.
complete.
Shortening of limbs and atrophy of limbs (in
No arrest of development of limbs.
infantile cases).
Functionally associated muscles frequently Capricious selection of muscles, but frequent
associated in paralysis: hand rarely affected. wasting of these at eminences.

Paralysis from lesion of a peripheric nerve closely imitates anterior spinal

paralysis.154 It is distinguished by closely following the distribution of the
injured nerve, and, usually, by concomitant lesions of the sensibility and of
cutaneous nutrition.
154 The importance of this fact has been shown in the section on Pathogeny. (See also
quotations from Leyden and remarks on lesions of peripheric nerves.)

The pseudo-paralysis sometimes observed in syphilitic children as a

consequence of a gummatous infiltration of the bones at the junction of
the epiphysis and diaphysis155 might easily be mistaken for a spinal
paralysis. But it is an affection peculiar to the new-born; the electrical
reactions of the paralyzed muscles are intact; careful examination will
show that the movements of the muscles are not impossible, but
restrained by pain; often other syphilitic affections are present.
155 Parrot, Wagner.

The diagnosis from diphtheritic paralysis is embarrassed, from the fact

that true anterior poliomyelitis may develop in the course of diphtheria as
of other infectious diseases. The paralysis of the soft palate, preservation
of faradic reaction, absence of atrophy, and the usually rapid recovery
must establish the differentiation.

In spinal paralysis there is loss of the reflexes,156 and also of faradic

contractility, both of which are preserved in hysteria. In hysterical
paralysis, also, there is no wasting of the affected muscles.
156 See Gowers's monograph on “Spinal-Cord Diseases” for an excellent summary of the
spinal reflexes.
Various diseases of the bony skeleton or articulations may simulate spinal
paralysis. Congenital club-foot, caused by unequal development of the
bones and cuticular surfaces, is to be distinguished from the paralytic
variety by the date of its appearance,157 by the deformity of the tarsal
bones, and by the extreme difficulty of reduction.
157 Though in some cases paralysis of the muscles of the foot seems to take place during
fœtal life, and a club-foot result which is both congenital and paralytic.

Caries of the calcaneum, leading the child to walk on the anterior part of
the foot to avoid pressure on the heel, may leave after recovery such a
retraction of the plantar fascia as to cause a degree of equinus and varus,
with apparent paralysis of the peroneal muscles. I have seen one such
case.

Congenital luxation of the hip may simulate paralysis; indeed, by Verneuil,

it has been attributed to an intra-uterine spinal paralysis. There is,
however, no change in the electrical reactions of the muscles surrounding
the joint.

In coxitis, however, Newton Shaffer158 has demonstrated a moderate

diminution of faradic contractility in such muscles, and a corresponding
degree of atrophy; and this fact might complicate the diagnosis of
paralysis from arthritis of the hip-joint. Gibney159 has called attention to
the facility with which this confusion may arise, and Sayre160 relates cases
of infantile paralysis mistaken for coxitis.
158 Archives of Medicine.

159 Am. Journ. Med. Sci., Oct., 1878.

160 Orthopædic Surgery.

In a case observed by myself, which had been previously diagnosed as

coxitis, the mistake was all the more interesting as the paralysis which
really existed seemed to have been caused by a meningitis rather than
primary myelitis of the cornua.161 It thus corresponded to the meningo-
myelitic case related by Leyden.
161 The details of this case are as follows: C. P——, aged 11, ten months previous to
consultation suffered from febrile attack, accompanied by retraction of head, severe pains
 diffused through body and intense at nape of neck; unconsciousness for thirty-six hours;
vomiting; no convulsions. Case diagnosed as cerebro-spinal meningitis by attendant
physician. Convalescence in a week, but with pain in lumbar region of back, predominating
on right side, so aggravated by standing or walking that both acts impossible. Coincidently,
pain in right calf; exquisite tenderness to pressure even from stocking. No complaint in
recumbent position. Child could not get from floor to bed, nor raise right leg from ground. As
pain subsided walking became possible, but right leg dragged. Chronic twitchings on left
side, face, arm, leg. These symptoms lasted ten or twelve weeks, but at end of nine weeks
patient could walk up stairs. In ten months power of walking almost recovered, but there
remained a certain amount of lordosis and oscillation of pelvis, which is jarred on the left
side while the right leg is swung forward. Recumbent, all movements executed equally well
on both sides and passive motion of the hip-joint perfectly free. Circumference of right thigh
and leg diminished from one-half to one inch as compared with the left. Faradic contractility
diminished on the right side in the gluteal muscles, vastus externus, and rectus, and in the
gastrocnemii. The sacro-lumbalis muscle was, unfortunately, not examined, but from the
lordosis was probably affected. The remaining muscles were intact. Pain on pressure
persisted over right side of second, third, and fourth lumbar vertebræ. Diagnosis was made
of a limited meningeal exudation, with compression of anterior part of cord or of a portion of
the lumbar and of the sacral plexus.

Scoliosis, which may be caused by the relatively rare unilateral paralysis

of some of the muscles of the trunk, may also be simulated by paralysis
with shortening of one lower extremity. To compensate the shortening, the
trunk is bent over on the paralyzed side; hence a lateral curvature, easily
reducible, but easily leading into error.

It would seem easy to distinguish traumatic cases of subluxation of the

humerus from those due to paralysis of the deltoid. Yet sometimes only
the history will serve to establish, and that somewhat doubtfully, the
diagnosis.162
162 A child of four was brought to me with a stiffness and rigidity of the shoulder-joint which
could only very partially be overcome by passive motion, and not at all by voluntary effort.
The mother stated that several months previously the child had, without apparent cause,
become suddenly unable to move the arm. After two months' delay it was taken to a
dispensary, and told that the arm was out of joint, and had it reset under ether. From this
date the stiffness had gradually developed. The deltoid was atrophied, with marked
diminution of the faradic contractility. Question: Were these signs merely symptomatic of an
arthritis consequent on a dislocation, or was the latter the result of a spinal paralysis of the
deltoid?
THERAPEUTICS.—The treatment of anterior poliomyelitis embraces two
stages. In the first it is directed against inflammation of the spinal cord
and the paralysis of the muscles; in the second period the spinal lesion
has run its course and the paralysis is considered incurable. Treatment is
then directed to the prevention or palliation of deformities or toward
facilitating the functions of the limb in spite of them.

These two periods are not, however, rigidly separated from each other in
chronological order. From the very outset it is important to take certain
precautions to prevent deformities, and while palliating these with
orthopædic apparatus it is important for years to continue treatment of the
paralyzed muscles in the hope that at least a remnant of them may be
saved. To abandon the case to the orthopædic instrument-maker, or to
neglect the problem of dynamic mechanics while applying electricity and
studying the progress of fatty degeneration, are errors greatly to be
condemned.

The treatment of the initial stage is necessarily purely symptomatic for the
fever and convulsions, since the diagnosis cannot be made out until these
have subsided.

As soon as the diagnosis is clear, however, certain measures should be

adopted to diminish the hyperæmia of the spinal cord. Dally163
recommends the ventral decubitus; almost all modern authorities advise
ice to the spine and ergot internally or subcutaneously. Thus, Althaus164
makes hypodermic injections of ergotin in doses of one-fourth of a grain
for a child between one and two years old; one-third of a grain between
three and five; and one half grain from five to ten; and these doses
repeated once or twice daily. The only objection to this treatment is the
degree of local irritation it can hardly fail to occasion. Hammond, who
“affirms ergot to be of great service, the only medicine capable of cutting
short the disease or of limiting its lesions,” recommends the internal
administration of the fluid extract—ten drops three times a day for infants
of six months, half a drachm for children between one and two years.165
163 Journ. Thérap., t. viii., 1880.

164 On Infantile Paralysis.

 165 I have elsewhere quoted one case of early recovery under the use of ice and ergot; or
was this a case of temporary paralysis?

The belladonna treatment, at one time so warmly praised by Brown-

Séquard, retains to-day few adherents.

Simon advises cutaneous revulsives to divert the circulation to the

surface; thus, hot-air baths, mustard powder sprinkled on cotton
enveloping the limbs. Ross advises mercurial inunction along the spine,
followed by iodine and blisters. At the same time, iodide of potassium
should be given internally in large doses. The action of this drug upon
inflammations of the nerve-centres seems, within certain limits, to be
indisputable, but its mode of action is certainly very obscure. Where the
lesion can be attributed to a meningo-myelitis,166 the iodide may be
expected to facilitate the absorption of the exudation. In these cases it
should be continued for a long time.167
166 As in Leyden's first case, and my own.

167 Binz explains the local action of iodine by an exudation of leucocytes which follows the
dilatation of blood-vessels. These elements break down the exudation into which they are
poured, and thus facilitate its absorption.

Electrical treatment may be begun by the end of the first week after the
paralysis. At this stage Erb recommends central galvanization as an
antiphlogistic remedy for the myelitis. For this purpose a large anode
must be placed over the spine at the presumed seat of the lesion, while
the cathode is applied over the abdomen. By a slight modification of the
method the cathode is placed over the paralyzed muscles. The
application is stabile, and, according to Erb, should last from three to ten
minutes; according to Bouchut, several hours daily. Erb's method is
intended exclusively as a sedative to the local inflammation. When the
cathode is placed on the muscles it is hoped that the descending current,
replacing the lost nervous impulses, may avert the threatening
degeneration of the muscle and nerve.

Faradization cannot modify the inflammatory lesions of the cord. As a

means of averting degeneration in completely paralyzed muscles it is
inferior to galvanism, and should not therefore be used in those muscles
which refuse to contract under its stimulus. Its immense utility, however, is
as a stimulus to muscles imperfectly paralyzed, but liable to degenerate
from inaction and to be overborne by their antagonists. The excitation of
contractions in such muscles is a powerful local gymnastic, helping to
maintain nutrition by artificially-excited function.

For the same purpose, muscles inexcitable to the faradic current should
be, when this is possible, made to contract by the interrupted galvanic
current. After this treatment has been prolonged during several months,
the faradic contractility often returns, and the current then should be
changed (Seguin).

The value of electrical treatment has been very differently estimated. Erb
remarks that “its results are not precisely brilliant.” Roth, whose testimony
perhaps is not above suspicion, since evidently prejudiced, insists that
numerous cases fall into his hands which have submitted for months to
electrical treatment without the slightest benefit. On the other hand,
Duchenne, as is well known, has expressed almost unbounded
confidence in the therapeutic efficacy of faradization, declaring that it was
capable of “creating entire muscles out of a few fibres.”

The sensitiveness of children to the electrical current, and their terror at

its application, seriously interfere with its persistent use; as, if the
patience of the physician is maintained, that of the parents is very likely to
fail in the presence of the cries and resistance of the child.

It is very probable that some of the failures of electrical treatment are due
to the attempt to rely upon it exclusively, instead of suitably combining
both electrical methods with each other and with other remedial
measures. With our present knowledge it is safe to assert the desirability
of persistent electrical treatment during at least the first two years
following the paralysis. The currents must never be too strong—the
faradic, at least, never applied for longer than ten minutes at a time. The
muscles should be relaxed by the position of the limbs (Sayre). If the
muscles continue to waste, and especially if they become fatty, the
electrical response will grow less and less, and finally cease altogether.168
In the contrary case the galvanic contraction will become normal in
quality, and the faradic contractility will return and increase, while the
atrophy is arrested and the muscle regains its bulk and voluntary powers.
Sometimes, as already stated, the latter is regained, while faradic
contractility remains greatly diminished.169
 168 Passing through three stages: faradic contractility diminished, galvanic contraction
increased; faradic response lost, galvanic degenerative; absence of contraction to either
current.

169 Sayre (loc. cit.) has noticed cases in which the muscle would contract several times
under faradism, then refuse to do so for a day or two. This observation, if valid and not due
to unequal working of the battery, is a most curious one.

A succedaneum to electricity that is highly prized by some authorities is

strychnia, especially when subcutaneously administered. Pelione170
relates the cure of two cases in children of four and five years, after three
and four years' duration of the paralysis, by strychnia—one-half
milligramme daily. None should be given to children under six months, but
over that age one-ninety-sixth of a grain may be given (Hammond). It
should not be given subcutaneously more than two or three times a week
(Seeligmüller).171
170 L'Union médicale, 1883.

171 Duchenne relates a case of a paralysis general at the outset and remaining so for six
months. It was then treated by strychnine for five or six months, and at the end of that time
had become limited to the lower extremities (Elect. local., ed. 1861, p. 278).

The incidental action of electricity in attracting blood to the paralyzed

muscles may be sustained by several other methods.

Among these the external application of heat, either dry or in the form of
hot douches, alternating with cold, is an adjuvant remedy of real
importance. Beard has suggested tubing, malleable to the limbs, for the
conduction of hot water. It is desirable to employ massage immediately
after cessation of the hot applications.

On the value of massage and passive gymnastics opinion is even more

variable than in regard to electricity. Roth, a specialist in orthopædics,
places it at the head of all remedial measures, and denounces electricity
in comparison. Many professional manipulators, ignorant of medical
science, continually claim wonderful triumphs over regular physicians
obtained by means of systematized massage. Volkmann, on the other
hand, dismisses the pretensions of the Heilgymnastik with considerable
contempt, declaring that faradization is the only method which can really
secure exercise to paralyzed muscles.
The Swedish movement cure consists in passive movements imparted to
a 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 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
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.

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 Hueter173
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.
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 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). Sayre174 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.
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 Delacroix175 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.
175 Article “Orthopédie,” Dict. des Sciences médicales, quoted by Duchenne.

176 Traité des Bandages, 2d ed., Paris, 1837, quoted by Duchenne.

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 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.
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
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).