316



1XFAXT1L1-: PARALYSIS.




Fig. 88. Xnrmal standing position, showing deflection of spine
before mental and muscle effort for correction. (X. Y. Hospital for
Deformities and Joint Diseases.)



EXERCISES PERFORMED BEFORE A MIRROR. 317




Pig 89 Deflection corrected. Maximum muscle effort at point of pencil.
(X. Y. Hospital for Deformities and Joint Diseases.)



318 INFANTILE PARALYSIS.

producing growth and development in the conducting
nerve-trunk to its most distant filament. It was demon-
strated by Anderson, of Yale, and others that when a
person is securely placed on a body balance, and concen-
trates his mind on one extremity, the balance tips in the




Fig. 90. Plumb-line test to demonstrate muscle contraction. (N. V
Hospital for Deformities and Joint Diseases.)

direction of this limb, showing that a hyperemia, a true
determination of blood to the part, had been secured.

It has been found, in post-mortem examinations of the
human brain, that when motion of an extremity is guided
by mental concentration the convolutions of the gray
matter of the brain presiding over this motor area are in-
creased; the reverse of this process has been frequently



EXERCISES PERFORMED BEFORE A MIRROR. 319

demonstrated: post-mortem examination of the cerebral
cortex of an individual minus an extremity from intra-
uterine amputation demonstrates lack of development of
the cortical center for that area.

Other conditions being equalized, that is, the securing




Fig. 91. Plumb-line test to demonstrate muscle control. Xote
approximation of waist to plumb line and increased bulk of left
erector spina?. (X. Y. Hospital for Deformities and Joint Diseases.)

<f ample nourishment and the absence of undue fatigue,
the stimulus transmitted from the brain to the periphery
depends on the calibration of the conducting nerves, as the
diameter of copper wire regulates the volume of electric
current.

Normal and equalized conditions are not, however,
found in the nerve-trunks after invasion bv an attack of



320



INFANTILE PARALYSIS.



poliomyelitis. "The anterior roots at the (affected) level
are decreased in size. A similar condition exists in the
motor nerves" i Vulpius). The trophic function has been
seriously impaired, and there is a constant condition of
hyperexcitability which produces undue fatigue. In addi-




Fig. 92. Muscle effort and muscle balance (erector spi:
acquired by corrective exercises for lateral curvature. Three-year
student at leading school of physical culture. Unaware of lateral
curvature ; subsequently absolutely corrected by Frauenthal method.
(X. V. Hospital for Deformities and Joint Diseases.)*

tion some filaments have suffered degeneration and atrophy
subsequent to the destruction of their peripheral neuron.
the motor cell.

The problem of the mirror work to be described is,
then, not the simple problem of securing a certain number



EXERCISES PERFORMED BEFORE A MIRROR.



321
To



of contractions daily of an unused and paretic muscle,
achieve a good end-result we must produce:

1. Muscular contractions to (a) prevent the atrophy
of disuse; ( b ) promote regeneration.

2. Determination of blood for nourishment to secure
trophic repair and growth for (a) impaired nerve-trunks;




Fig. 93. Therapeutic exercise before a mirror. Individual instruction.
(X. V. Hospital for Deformities and Joint Diseases.)

( b) paretic muscles: (c) inhibited structural growth,
cartilage, and bone.

3. Re-establishment of sensory and motor impulse to
i a ) directly increase calibration of nerve; (b) co-ordinate
nerve impulse now wasted.

4. New anastomotic association paths for impulses
whose motor tract or level has been seriously invaded or
destroyed.



21



322 INFANTILE PARALYSIS.

The effectiveness of the following method outlined has
been abundantly demonstrated by the results we have
shown from time to time with cases of poliomyelitis and
locomotor ataxia in various clinics held during the past
t\vem\ vears:

METHOD OF MIRROR TREATMENT.

Treatment should be given before a large and well-
lighted mirror, so that the patient may see all parts of his
body clearly. There should be no clothing in use which
hampers movement or obscures the view. The patient
should be in stockingfeet, or soft moccasins. \Ye do not
sufficiently appreciate what a foot can do when un-
trammeled.

In corrections of the torso, particularly lateral curva-
tures, a compound mirror is needed, and should be so
arranged that the patient can constantly and without effort
observe the erection of the spinal and other muscles of the
back.

The mirror should extend to the floor ; in all foot work,
and most of the leg work, and also in the stretching and
rising for lateral curvature, the child's vision would be at
once obscured by a mirror hung above the floor line.
\Yhile some of this work can be done on an absolutely
steady table drawn close to the mirror, a rug thrown on
the floor provides a base of operations for the patient whose
stability is assured, and one factor of distracted attention
is thus eliminated.

The most important factor in the treatment is the in-
structor. A trained instructor with a high grade of
intelligence is needed for this, work. The graduate in
physical culture needs a postgraduate training of at least
one year to become proficient, a good knowledge of anat-
omy, tact, patience, and the personality which insures



EXERCISES PERFORMED BEFORE A MIRROR.



323



obedience. The graduate in physical culture who has
acquired muscle control by persistent training is the be>t
instructor.

There should be nothing in the range of vision to
distract the attention of the patient from the work in
hand. In private practice at office or home, no one should




Fig. 94. Therapeutic exercise before a mirror. Individual instruction.
(X. V. Hospital for Deformities and Joint Diseases.)

be present in the room besides the instructor and the pa-
tient. Individual treatment is desirable, for by this means
we have obtained the best results. However, in institu-
tional work, children over 3 years of age are given in-
struction in groups of 6 or more. \Ye have such daily
classes at the Hospital for Deformities and Joint Dis-
eases. The classes have been visited by the leading
neurologists and pediatricians of New York City, and the



324 INFANTILE PARALYSIS.

visitors unite in wondering and favorably comment on the
ability of the children for concentrated work, which is
continued with total unconsciousness of the presence of
strangers.

Concentration, directed by an able instructor, is the
keynote of this treatment, to which the mirror forms a
most valuable aid. The patient's whole attention must be
centered on the part under treatment, and when possible
on the particular muscles involved. \\'hen the child ob-
serves the desired action taking place in the mirror, and
realizes that his effort is bearing fruit after a few days
of work, it is surprising the excellent effort he will put
forth.

In the beginning, light massage or beating of the
muscle will aid its action. This is also attained by approxi-
mating the origin and insertion of the muscle, which in-
creases the belly bulk, with a corresponding increase in
contractile force. The instructor must make clear to the
patient the muscles to be brought into use. The c< mtraction
should be made slowly for maximum effort and effect.

When the contractile force is not sufficient to move the
limb, the instructor aids in the desired motion, at the same
time compelling the patient to make all mental effort toward
its attainment. As the muscle becomes stronger, the
needed assistance is lessened. The muscle is allowed to
take up more of the work, run the. whole of the exercise,
and receive the maximum amount of work possible in its
weakened condition. The exercise must always stop short
of the fatigue point. Fatigue, if encountered, will be both
mental and physical' and partake of the nature of neuras-
thenia. One must be guided by judgment and experience
as to the amount of exercise to be used, particularly during
the first instruction with seriously impaired muscles. It is
here again that the services of a competent instructor are



EXERCISES PERFORMED HERWK A MIRROR.



325



invaluable for the welfare of the patient and the results
the physician desires to attain.

The muscles most frequently involved in infantile paral-
ysis are those making up the perineal group. Placing the
child on a chair in a comfortable position before the mirror,




Fig. 95. Suspension correction for lateral curvature. (N. Y.
Hospital for Deformities and Joint Diseases.)

the instructor approximates the origin and insertion of the
muscles composing the group by bringing the foot up to a
right angle with the leg; he then urges the child to aid
in bringing up the small toes at the side of the foot through
an arc of about 30 degrees. If the child cannot do this
alone, the instructor places one hand on the knee to keep
the leg in position, and the other hand under the foot ; this
greatly aids the child's effort to make the required con-



326 I XI- AX TILE PARALYSIS.

traction. This should be repeated several times, but never
to the fatigue point. Each set of muscles should be con-
tracted in a similar manner. If the motion cannot be
brought about, still the mental effort should be made for
this attainment. As a result of using this method I have
been able to show at medical clinics 43 ambulant patients
who were formerly unable to walk for a period of from
nine months to four years. Many of these cases had been
referred to the institution by Drs. Kerley, Koplik. Mandl,
and other men of standing.

In the treatment of lateral curvature due to infamil'-
paralysis (and this is the primary cause of a majority of
mild as well as very deforming cases of curvature) we are
handling paretic or paralyzed muscles on one side of the
spine and unopposed, overcontracted, healthy muscles on
the opposite side. Securing a permanent result is de-
pendent on the success in equalizing this muscle force, or
in re-establishing in the weaker muscles a strength equiva-
lent to that on the opposite side. The correction effected
by Abbott's overcorrection method is promptly lost on
removal of the jacket unless this muscle re-education and
actual renewal is attained. Abbott himself now follows
up the overcorrection with muscle education.

I have seen so many cases of return of function to
paralyzed extremities by the persistent use of this line of
treatment that I would advise the discouraged to renew
effort, expecting to meet with such agreeable surprise as
I have at the results accomplished by the work.

Arthur H. after initial attack received four months' treatment
at one clinic, eight months' treatment at another clinic, and on goin.n
to the third clinic an operation for fixing the foot and ankle \va>
suggested, as apparently there was extensive atrophy and no func-
tion.

At that time she (Mrs. H.) met the mother of a patient who
had had her child for treatment at the second institution for three



EXERCISES PERFORMED BEFORE A MIRROR



327



years, with no ability to stand or walk, and Mrs. H. was informed
by her that under treatment at the 1 lospital for Deformities and
Joint Diseases for five months the child was able to walk without
braces. Mrs". H., regarding this as an absurdity, made a special




Fig. 96. Able to walk with almost normal gait after one year's treatment.
(X. V. Hospital for Deformities and Joint Diseases.)

visit to the child's home, and, seeing what she regarded as a miracle,
brought her child.

This child was under treatment for seven months before he
gained any promise of bearing his weight on his right leg, and after
one year he is able to walk with almost normal gait.



328 INFANTILE PARALYSIS.

BREATHING EXERCISES.

The alarming increase in the respiration rate during
the acute stage of poliomyelitis is evidence that practical!}
every case suffers from some involvement of the respiration
center. The fatal cases are usually if not always termi-
nated by paralysis of the respiratory tract. Kvery case of
upper-extremity involvement presents some atrophy of the
serrati; the serrati are involved in all cases of postparalytic
scoliosis. The majority of these children, whether left with
a lesion of upper or lower extremity, present a very indif-
ferent chest expansion; this is so noticeable as to suggest
that the so-called phthisical chest is the inheritance not
from a tuberculous ancestor, but from one who had had an
inhibiting attack of poliomyelitis.

To overcome this serious defect, as well as to provide
oxygenation for all the body tissues, breathing exercise -
should be made a constant accompaniment to any and all
physical therapy undertaken.

Resistance movements and muscle training are of most
value in treatment. The earlier they can be begun after
the subsidence of all irritation, the better the outcome.

It has been the attention of this kind that has yielded
results after operation: where the work of exercise has
produced most of the improvement and not the operation.

AYe have found that there is invariably some regression
of the original paralysis, and the best results therefore
naturally seem to be obtained from the treatment of cases
referred early in the course of the disease. \Ye believe
that the best results of treatment do result from treatment
instituted as early as possible and judiciously given: we
have, however, had complete restoration of function in
cases referred to us as hopeless and with complete loss of
function as late as eight months after the acute stage.



EXERCISES PERFORMED BEFORK A MIRROR. 329

In several cases between u and 18 years of age in
which the patient could not hold any article in the grasp
of the affected hand, and no improvement had been noted
for periods of time extending to >ix years, by a careful
system of training and development of the muscles the
hand was enabled to grasp and use a knife or fork, and
finer movements were gradually acquired until the patient
could write with the affected hand.

In this treatment, time should not be considered a
factor, either in a hopeless prognosis or in the discourage-
ment which causes the parent to stop treatments. Failure
is usually the result of neglect; it may be due to faulty
methods of the use of electricity in its many manifestations,
to overmassage or injudicious exercise.

The apathetic and a\\kward child will develop enthu-
siasm in the hands of a skillful and tactful instructor, fresh
association paths for muscle impulse will develop, co-ordi-
nation between action and impulse will be gradually re-
stored, while at the same time deformities arising from the
overaction of unopposed muscles must be recognized and
inhibited.

It has been said that association fibers in the decussa-
tion tract of the brain are able to take on the function of
fibers whose cortical relations have been impaired. If this
is true of the higher centers, we are justified in expecting
a similar adjustment of transmission of impulse in the
various levels of the cord. Observation demonstrates that
such renewal of association paths occurs.



CHAPTER XVI.

Mechanotherapy.

MECHANICAL apparatus was first devised for the bed-
fast paralytic with muscles atrophied from the waist down,
to enable him to walk. The iliopsoas muscle, a great




Fig. 97. Xight support for foot and instep. Aluminum. Weight, 3 l /> drains
(X. Y. Hospital for Deformities and Joint Diseases.)

levator of the thigh, takes its origin and innervation in
part from the dorsal spine; it is therefore found, in
numerous cases of paraplegia, that the iliopsoas is wholly
unaffected, and may be utilized in locomotion, once the
flaccid limbs are stiffened and properly supported. Heine-
constructed a primitive brace in 1840, which stiffened the
legs of a paralytic, and took its support from a metal belt
encircling the rim of the pelvis ; this brace was successful
and a drawing of it was published. The clever mechanism
stimulated the production of apparatus with more delicate
(330)



MECHAXOTHERAPY.



331



Fisr. 98.



fie. 99.





Figs. 98 and 99. Private patient at the hospital with infantile
paralysis involving muscles of both legs and spine. Able to get
about by proper-fitting braces. Fig. 99 shows anterior view. (X. Y.
Hospital for Deformities and Joint Diseases.)



332



IXFAXTILIi PARALYSIS.



adjustment and adaptation, until today in England and
Germany it is possible to secure a glove-fitting support of
molded leather with a feather-weight framework of hollow
steel.

It has been found that splints and braces, when used
understandingly, are of value in the treatment of infantile




Fig. 100. Same as Fig. 98, posterior view.

paralysis from the time of onset. Their abuse in the hands
of the unskillful and negligent is very detrimental to the
patient.

I wish to state with emphasis that any type of apparatus
that is bandaged to the limb, or is attached with straps and
buckles, is detrimental to the paralyzed muscles. An
atrophy of muscle is produced, either throughout the
muscle length or locally. \Yhere the collar of the brace



MECHAXOTHKRAPV



333



Figf 102.





Figs. 101 and 102. Neglected case of paralysis of both lower
extremities with involvement of muscles of eye (abducens and left
oblique"). Boy had not walked until splints were applied. He is now
improving under treatment with electrotherapy, massage, and muscle
training. Fig. 102 shows brace ; motion confined to one axis.



I - -

and an indentation of the muscle substance.
doe t CSSHR 'phy. which can be plainly palpated.
Another prevailing evil is the encasing" of these para-
. 1 muse", s f-Paris or starch bandages, thus

:finement r. I >sure atrophy to the already




Fig. 103. Hyperextension of knees. (X. Y.
Deformities and Joint Disea-

damaged musculatore. when every effort should be made
to retain the tone of the muscle until it again comes under
the control of the will and renews its function. More
damage can be done with this type of confinement than can
be regained by the muscles in a year's treatment and with
our best endeavor.



:,'-_ ~ .TH.-.- - - -



Another grave objection to braces k that

'-rr. : r :"-.- ^.- -_.-. :



appluiirr -hooW be used dot is not rupiui





:

-. - - .-



-



daihr to permit the UrJimrrt uutliucd in Ac

- "v



\\ ith this liiiMt^tMM ifisJinrilii

:\r. : r.:e:~ - : - :-T^:T::7": ?-.-



The orthopedic splint or brace- is used ia infndfe for




336



INFANTILE .PARALYSIS.



ysis as a (i) prophylactic, (2) supportive, and (3) cor-
rective measure.

i. In the early stage during onset and regression of
paralysis, as a prophylactic support and protection from
dragging of the bed-coverings or faulty posture.




Fig. 106. Paraplegia, with slight spontaneous improvement of muscles of
left leg. (N. Y. Hospital for Deformities and Joint Diseases.)

2. During the first months of convalescence to maintain
function and nutrition, to inhibit contractures, to lessen
muscular tension, to maintain muscular balance, to main-
tain the integrity of ligaments, muscle tendons, and joint
capsules.

3. In the later periods of the disease, mechanisms are



MECHAXOTHEKAPV.



337



used for the fixation and limitation of mobility of flail joints
and flaccid extremities, for muscle substitution, and to cor-
rect paralytic deformity.

Splints. As the acute constitutional symptoms of the



Fig. 107.



Fig. 108.





Figs. 107 and 108. Same as Fig. 106 after three months' treatment.

attack subside a lingering neuritis will force the patient to
assume the most comfortable position, and one which
favors the unopposed action of the unaffected muscles.
Such posture, by favoring contractures, conduces to the de-
velopment of contractures and deformity. This is par-
ticularly true of the child or youth still in the developmental



23



338



INFANTILE PARALYSIS.



period, whose tissues and bones may be considered malle-
able. Thus, a girl of 1 5 years of age, in the fourth week
of an attack of acute poliomyelitis (previously diagnosed
and treated as rheumatic fever), was found with marked




Fig. 109.- -Old operation and brace treatment. Uncured. Note
pressure atrophy from brace. Paralysis of both lower extremities.
Overtreated to inhibition. Final recovery on moderate treatment.

contracture of leg on thigh, and a footdrop, both of which
conditions might have been lessened or prevented by ligh 1
splinting.

The pressure of bed-clothes on the paretic foot and
ankle is obviated by the use of a light aluminum splint
applied to the heel and plantar surface of the foot, and



MECHAXOTHERAPY.



339



projecting an inch or more beyond the great toe. The use
of a bed-cradle is directed in the chapter on treatment.

All mechanisms which are need in the early stage of
the disease to inhibit contractures and deformity should




Fig. 110. P. S., scoliosis following acute poliomyelitis, erect. (N. Y.
Hospital for Deformities and Joint Diseases.)

be devised to interfere as little as possible with circulation
or nutrition. Plaster-of-Paris bandages encircling the
trunk or extremities and splints tightly secured by a band-
age are not to be used.

Supportive . Ipparatus. Mechanisms which aid loco-
motion and activity are of much importance. When no



340



1XFAXT1 LI-: PARALYSIS.



deformity exist 1 -; the loss of function from paralyzed
muscles can he supplemented by mechanical contrivances
which make the hones and the apparatus unite in support-
ing- the body weight. The exercise thus obtainable develops




Fig. 111. Same as Fig. 110, stooping.

the weakened and paretic muscles, resulting in a restora-
tion of the motor function.

The simplest mechanism is a walking chair.

In many of these cases, by a proper application of
therapeutic and mechanical agencies, we can circumvent
subsequent deformity. The brace, however, must not be
too heavy, and the adjustment must be carefully regulated.



Fig. 112. X-ray of spine of P. S.



MECHANOTHERAPY.



341



Jones, of Liverpool, stales that "nothing has tended more
to the discredit of the practice of orthopedics than the
lumbersome and complicated machinery with which sur-
geons have loaded their unfortunate patients." It f re-




Fig. 113. M. K., scoliosis following acute poliomyelitis, erect. (N. Y.
Hospital for Deformities and Joint Diseases.)

quently happens that parents realize this and discard
braces, which not infrequently are found to weigh from
one-twelfth to one-eighth of the weight of the child. J
have a large scrap-heap of such useless splints.

Tn the chronic stage of poliomyelitis apparatus is used
to fix the flail joint and limit its motion to one axis only,



342 1XFAXT1LE PARALYSIS.

to control the degree of motion in that axis, to replace
paralyzed muscles, and to correct deformities.

The cheapest form of splint is the malleable-iron rod
bent to fit the part, and attached to the body with leather




Fig. 114. Same as Fig. 113, stooping.

and steel bands. The more intricate modification of this
apparatus, made of steel, is provided with movable lock
joints, which may be fixed or released at will, which are
further controlled with a front and back stop, the joint
being uniaxial, or a gimbal joint which permits lateral
movement; this apparatus also takes its fixed position from






Fig. 115. X-ray of spine of M. K.



MECHAXOTHERAPV.



343



straps and bands which encircle the body and extremity.
When the use of apparatus is to be temporary only, and
for one of the working class, these braces are sufficient.



Fig. 116.



Fig. 117.











Figs. 116 and 117. Extreme kyphosis following acute poliomyelitis.
(X. Y. Hospital for Deformities and Joint Diseases.)

Made of the lightest construction the material admits,
readjusted at frequent intervals, removed daily for the
treatment necessary to offset pressure atrophy and the
interference with circulation, they are indispensable for



344



1 X 1- A X T I LE PARALYS1 S.



some otherwise helpless cases. The pressure of the en-
circling band has been avoided in an apparatus constructed
by skilled artisans in England and Germany in which the
pressure is evenly distributed over the limb or torso by







Fig. 118. Same as Fig. 116.



Fig. 119. Same as Fig. 116.



the use of molded leather sheaths. (These are known by
the name of the first manufacturer as braces. Messing.)