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Spastic Paralyses

muscles, nerve, sensitive, median, forster, radial, roots and shown

SPASTIC PARALYSES The spastic contractions of the muscles which we call spastic pareses are observed either as parts of cerebral processes (birth injury, encepha litis), or more rarely from spinal or meningitis diseases. In reality the affected muscles are in a state of hypertonus.

The investigations of Forster have brought new light to this sub ject. The higher centres in the cortex which act in regulating and inhibiting muscular action are almost always affected. They are either damaged by inflammatory or degenerative processes in the brain, or their nerve current interrupted by cross losions. The muscles are in a continuous state of reflex irritability which comes from the sensitive surface, and in this we will find the atavistic older functions to prevail considerably. The flexors of the hip and knee, of the leg, the muscles of the tendo Achillis, the pronators and flexors of the arm, the grasping muscles of the hand, all these are in almost continuous permanent tonic contraction which offers a rigid elastic resistance to active as well as passive action of their antagonists (Fig. 1S4).

Forster has shown that in spastic patients the long-continued pos ture alone will produce permanent contractions in that muscle which is shortened by the position (approaching of the points of insertion), so that the phylogenetie preponderance of tome of the muscles may be increased by the position of the child in utero.

To remove these permanent contractions Forster advises a treat ment which consists in the resection of the sensitive part of the reflex arc. Anatomical investigation shows that total sensitive paralysis of a segment of the body arises only when three consecutive spinal seg ments are deprived of their sensitive roots. Forster has formulated the law, "to make a choice of the sensitive roots of a limb in such a manner that never more than two neighboring ones, and of two neighboring ones preferably only one should be resected." Thus he rescets in Little's dis ease the second, third, and fifth lumbar and the second sacral root. By cutting through single posterior roots of the lumbar nerves, before they join the anterior ones, he prevents the occurrence of sensi tive irritation and thus stops the reflex spasm.

Though this is a major opera tion owing to the opening of the spinal canal, yet it is indicated in severe spastic cases and gives excellent results. In less severe cases, especially of the lower limbs, by weakening the stronger groups of muscles, lengthening the tendons by tenotomies (tondo Achillis, gastrocnemic), and les sening the adduetors by myoto mies, we can succeed in restoring muscular equilibrium. Posture

in overcorrectiou will give the muscles which had been dam aged by hyperextension a chance to contract. Gymnastic exer cises will teach these muscles their proper amount of work, which is now possible after their antagonists have been weakened.

In the lower extremities these simple operations will suffice. In the upper extremities we will get good results from neuroplasties, especially in those cases in which we have to deal not so much with a general weakening of the motor strength, as with the prevalence of certain groups of muscles.

The most annoying symptom is the continuous pronation of the hand—the so-ealled obstetrician's hand (flexion of hand and fingers, adduction of thumb) (Fig. 186). This is shown by neurological analysis to be the overaction of the muscles supplied by the median nerve over those supplied by the radial nerve, and that this condition is only less clear owing to the action of some of the muscles innervated by the ulnar nerve. Plastic operations on the median nerve and the radial nerve (Spitzy) will generally succeed in restoring the function.

We split off a central part of the median nerve from above the branch going to the pronator teres muscle, using this branch as a land mark; this we implant into the radial nerve, thus weakening the hyper activity of the median nerve and at the same time strengthening the conduction to the radial nerve. This will be shown by the muscular equilibrium in the motions after regeneration has occurred, i.e., after three or four months. Some spastic muscles which are innervated by the ulnar nerve—as, for instance, the adductor pollicis—can be weakened or shortened by myotomies (Figs. 1S5b, With these operative measures, which are assisted by bandages and apparatus, we will be able to overcome all the spastic affections, parapareses and hemipareses, though all these therapeutic measures will only succeed provided the intellectual faculties of the child are undisturbed.

Should the psychic centres and their branches be also affected, then no kind of operation or apparatus will produce any results of any account, because the gymnastic treatment, which is always important and neces sary, cannot be instituted.