Should the substance of muscle or nerve he lost, then we can only replace it by that which is still intact. A defect will always remain. We must therefore attempt to simplify conditions so as to be able to get along with what is left (Lange).
From this we will see that we must make use of intact material m supplanting the paralyzed nerves as well as temlomi.
The secondary deformities (positions from contractions) must be removed or even over-corrected before each operation (Iloffa) by weak ening the antagonists (lengthening of the tendon), by shortening the overstretched tendons and ligaments, so that the newly-awakened function should find conditions of tension as nearly normal as possible.
Types of Paralyses.—We will now describe some types which lead to certain distinct deformities, without, however, expecting to be able even to mention most of the very large number of varieties.
If the focus of paralysis should be located in the root of the fifth or sixth cervical nerve, paralysis of those muscles would follow which are supplied by the upper branches of the brachial plexus. Paralysis of the deltoid muscle would be most noticeable (this lifts the arm up to the horizontal and presses the head into the socket). The arm hangs down flabbily, its weight stretching the capsule so that the head of the humerus is often several centimetres from the glenoid cavity (paralytic flaccid joint).
Should the sixth cervical nerve also be affected, we would find the muscles of the upper arm (biceps and triceps) paralyzed as well, and the elbow-joint could not be moved voluntarily.
In rarer cases we find isolated affections of part of the muscles of the forearm, e.g., only those dependent upon the radial nerve, while the region of the median nerve remains intact.
Since, however, the single nerve trunks intermingle in the brachial plexus and take fibres for their muscles from the different segments, we can understand why paralyses in the hand are not found arranged according to the distribution of the nerves but according to segments. A grafting would have to he done high in the plexus in order to provide real new nerve conduction.
Should the disease have affected all the cervical segments we would then observe a complete paralysis of the arm.
A similar affection of the lumbar segments will make the leg hang down flabbily, the flaccid joints permitting every kind of motion ("are polichinelle"). When the pendulous leg is used to step, the gluteal
muscles, being paralyzed, will permit the head to slip easily out of the acetabulum (paralytic dislocation of the hip).
As the knee, when its extensors are paralyzed, can only give seine support by locking itself by maximal tension of the posterior ligaments every time it has to carry the weight of the body, a genu recurvatumn (an over-extended knee) will easily develop.
The foot hangs down in equinus position and is slung down upon the ground so that. it turns over inward quite easily (talipes equinovarus paralyticus).
All these deformities are the more pronounced in partial paral ysis when the stronger antagonists contract in the direction of the clef ormit v.
If only the, psoas muscles should be intact, we would then observe a contraction of the hip in flexion; should the quadriceps he paralyzed and the flexors be intact, then the knee could not be actively extended (contraction in flexion in the knee). If only the muscles of the peroneal nerve should be paralyzed, then a paralytic talipes equinovarus would easily develop, from contraction of the muscles served by the tibial nerve. The opposite condition, the paralytic talipes he served in paralysis of the supinators, also the parklytictalipes calcaneus after paralysis of the muscles of the tendo Treatment with Apparatas.—Orthorudits have worked for sonic decades to produce apparatus to correct all these possible deformities. We attempt to restore the necessary firmness and motility to the limbs by enveloping them in supports which we join with splints, and hinges and elastic traction, so as to keep the weight off the paralyzed limb (see Apparatus for coxitis). In policlinical practice the celluloid steel-wire splints are very serviceable Lange); they are made similar to the flat-foot braces (q. v.) and are cheap and light, and can be made without the aid of the mechanic (see celluloid casts for fractures of the femur, Fig. 174b).
Only recently have we attempted by operations to free these un fortunates from their apparatus, which were unattainable for the poor owing to their original cost and the cost of repairs, and which were to the wealthy a constant source of worry and anxiety.