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Chapter IV

Contents

CHAPTER IV

IN HOSPITALS CARING FOR ORTHOPEDIC AND NEUROSURGICAL CASES

Though special hospitals were not maintained solely for either orthopedic or neurosurgical cases, special services were organized for such cases in a number of general and base hospitals and officered by men with special training for the types of work concerned. However, prior to the early part of the year 1919 both orthopedic and neurosurgical cases had been distributed largely through the military hospitals of the country, and only gradually, after the bulk of the overseas cases had arrived in the United States,' were they concentrated in the hospitals having special services for their care.

The two classes of cases under consideration here are particularly noteworthy because their number was large, their hospitalization was prolonged and they furnished the most evident exhibitions of the value of reconstruction, particularly with respect to physiotherapy, curative exercises, and the curative workshops, though, of course, their prolonged stay in hospital enabled them to profit to the fullest extent from all instructional courses. The outstanding features, however, were that the two pathological conditions largely responsible for the existing disabilities-contracted soft tissues and paralyzed muscles-generally speaking, yielded readily to a combination of surgery and physiotherapy, and that the nature of the progress of improvement was such as to permit its mechanical measurement. The larger peripheral nerves lying deep in the soft tissues and often in close proximity to the bones, it followed that lesions involving these two structures were frequent.

ORTHOPEDIC CASES

The greater number of the orthopedic cases which were in the hospitals after the year 1918 consisted of amputations and gunshot fractures which were complicated by osteomyelitis. They were largely concentrated in the orthopedic services of the following hospitals by the summer of 1919: Walter Reed and Letterman General Hospitals, General Hospitals Nos. 2, 3, 6, 10, 24, 25, 26, 27, 28, 29, 30, 31, 36, 48, and 41, and the base hospitals at Fort Riley, Kans., and Fort Sam Houston, Tex.2

AMPUTATION CASES

As a class, the amputations called for much less physiotherapeutical treatment than the fractures, for the involved structures had been removed by the process of amputating. The physiotherapy measures required by the stumps consisted principally of the action of radiant heat and light and of massage to mobilize adherent scars and to prevent or remove edema and motion of the neighboring joints to prevent contractures. On the other hand, the amputations called for much more in the line of what might be called curative exercises, which took the form of instruction in the use of the artifi-


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cial limbs and were of extreme practical importance. Those for the upper extremity consisted of such instruction as would enable the wearer to obtain maximum results from the appliance by the motivating muscular action. Those for the lower extremity were more complicated and important, as the items of balance, proper joint action, aind weight bearing were concerned in the acquisition of correct locomotion.

With all stumps massage, heat, and compression bandages were used as indicated to obtain the proper condition of the soft parts in order to insure the best condition possible for the reception of the appliance. This frequently called for the mobilization of terminal adherent skin scars by heat, massage, and diathermy, and for the application of such stimulating agencies as the actinic ray and electric light to small granulating areas of an indolent nature. These measures assisted the weight-bearing exercises, end pressure against a firm cushion, in accustoming the stump to the reception of the body weight where such was intended. Following the receipt of the artificial leg, instruction was given in balancing and in the proper muscular action necessary to move it in a natural manner when walking. Figure 52 represents the type of such exercises.

OSTEOMYELITIC CASES

The osteomyelitic cases required a great amount of attention from the department of physiotherapy. The original injury, subsequent operations, chronic inflammatory conditions, and disuse caused massive bodies of scar tissue, atrophy of bone and soft tissue, contractures, and a condition of poor circulation, with its resulting edema, and sluggish granulations. The various physiotherapeutical measures available were of invaluable assistance to corrective surgery in removing these conditions. The whirlpool bath, the contrast bath, the paraffin bath, radiant heat and light, and massage largely were used for their pronounced qualities as local circulatory stimulants and to improve local nutrition. These changes in turn assisted in the absorption of scar tissue, and diathermy was thought to have a direct softening action which further aided in this absorption.a The same measures relieved contractures, and, together with active and passive motion, gradually restored function to stiffened joints when the limitation of motion was not due to bony involvement. Under such conditions, active motion of an involved joint is usually of greater benefit than passive motion, but is often limited by an exaggerated pain sensibility. Games of various sorts, particularly those requiring active exercise of a competitive nature, such as baseball, potato races, etc., were often used to overcome this more or less voluntary inhibition of the motion of a joint and the use of the motivating muscles. In the excitement of competition imaginary or slight pain was forgotten and joints were not only freely moved to the limit of available motion, but more or less tension was placed on the contracted structures which tended to lengthen them in a manner which was even more efficacious than gentle, continued force employed passively. The tendency to forget too completely under those conditions was so common that constant supervision was necessary to prevent a too ardent use, with a subsequent reaction which delayed progress.

a See subsequent pages under heading "Neurosurgical cases" for detailed account of the use of physiotherapeutic agencies.-Ed.


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FIG. 52.- Exercises teaching the use of artificial legs – learning the correct balance and step. Cane used as little as possible.


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The same idea applied to activities in the curative workshops, in that use of disabled members was more free when the attention of the individual was absorbed by an interesting occupation. Metal working, wood working, toy making, weaving, etc., were employed where tissues and small joints of the hand were involved; weaving on large looms, and drills and other machines run by means of a handle on the rim of a large wheel, were used to increase the range of motion of the larger joints of the arm.

NEUROSURGICAL CASES

The physical aspect of reconstruction in neurosurgical cases was most prominent in lesions of the peripheral nerves. Peripheral nerve cases were collected in special services in the following-named hospitals at about the same time as the orthopedic cases were: Walter Reed and Letterman General Hospitals, General Hospitals Nos. 1, 2, 3, 6, 10, 11, 26, 28, 29, and 41, and the base hospital at Fort Sam Houston, Tex. 3 The cases of this type which were in General Hospital No. 1 were soon transferred to General Hospital No. 41, and no cases in addition to those derived from its own service were sent to General Hospital No. 10. There were 2,347 of these cases actually present in hospital on May 1, 1919.3 Of these, 147 were lesions of the brachial plexus, 589 of the ulnar nerve, and 529 of the musculospiral, 433 of the median, 349 of the sciatic, and 283 of the external popliteal.

The conditions found with old peripheral nerve lesions were decidedly discouraging at first glance, as the atrophy, contractures, and circulatory disturbances superimposed upon the nerve lesion, and often with complicating and complicated orthopedic conditions, seemed to offer an almost hopeless field. But coincident with the necessary surgical procedures to remove infection and restore anatomical continuity to the bones and nerves, radiant heat and light, massage, baths, and diathermy aided greatly in the removal of local pathological conditions and in preventing further loss by atrophy, while the galvanic and sinusoidal currents were used to maintain the contractive ability of the paralyzed muscles and improve their general tone. The curative workshop employments furnished active exercise for muscles recovering from paralysis and aided greatly in the removal of the fibrosis of the small joints following interference with nerve function. The galvanic current was also of the greatest value in the definite diagnosis and prognosis of these cases, aiding in the location of the nerve lesion and in the differentiation as to the anatomical cause and its degree.

APPLICATION OF PHYSIOTHERAPY TO NERVE INJURIES b

The aftercare of cases of peripheral nerve injuries embraces three principal methods of treatment; namely, operative interference, corrective splinting, and the physical measures which are grouped under the term "physiotherapy."Accordingly, the Surgeon General, the late spring of 1918, placed physiotherapy upon its present basis, defining it as "physical measures such as are employed under physiotherapy, including hydro-electro- mechano-therapy, active exercises, indoor and outdoor games, and passive exercises in the form of massage." 4

b The following account of the application of physiotherapy is based on a report on "Application of Physiotherapy to Nerve Injuries," by Maj. J. B. Montgomery, Medical Corps, United States Army. On file, Historical Division, S.G.O.


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In the treatment of peripheral nerve injuries there are two phases which are especially unusual. First, the benefits derived from surgery-which, in given cases, is absolutely essential-are only a means to the functional result after months of tedious treatment. The brilliant, immediate results such as can usually be associated with surgical operations are not obtained by any other method. Secondly, there are no other groups of cases in which physiotherapy plays such a vital part in securing a maximal functional result. This applies not only to the cases of nerve injuries which are showing spontaneous recovery, but also to those which have had surgical intervention in the form of neurolysis, neurorrhaphy, and the like.

RECORDS

In the physiotherapy treatment of nerve injury cases it is essential that the director of physiotherapy make a clinical examination, together with a brief history. The following notations should be included on a suitable clinical record form: Cause and date of injury; date of healing of wound; time of appearance of paralysis in relation to injury; treatment up to present time, including surgical measures; muscle groups paralyzed; area of sensory impairment; degree of atrophy; extent of fibrosis; presence of trophic ulcers; vasomotor changes and neuromata; formication or the "D. T. P." (distal tingling on percussion); measurement of girth of affected limb as compared with the opposite or normal limb, and measurements with suitable protractors of any limitation of joint mobility, if such be present. The electrical reactions should be taken, following which the specific treatment should be outlined, with proper instructions to the aide to whom the case is referred. A report is then sent to the surgeon of the findings of the electrical reactions, stating in terms of pathology the condition of the nerve as interpreted from the reactions, and the outline of treatment which the patient will receive. A monthly progress note and report to the surgeon is in order, with special reference to any material changes in electrical reactions, return of sensory or motor functions, progressive advancement of the D. T. P. and the like. The practice of personal consultations with the surgeon who has charge of the patient can well be emphasized.

PATHOLOGY

In a limb with a paralyzed muscle group and associated sensory and trophic disturbances there occur many pathological processes. Primarily, a progressive muscular atrophy, with a fibro-fatty degeneration of the muscle fibers, takes place. A circulatory deficiency due to trophic disturbances and loss of muscular contractions is present. Function of one or more joints is interfered with. The antagonistic muscle groups are unopposed, with resulting overstretching of the paralyzed muscles, which may lead to contractures. Due to a loss of function of joint movements and fibrosis of the articular capsules, adhesions of the articulating surfaces and of the adjacent tendons may supervene, with limitation of motion ranging all the way from simple stiffness to complete ankylosis. Thus, without adequate treatment, deformities, much worse than the original paralysis may be present.


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HEAT

BATHS

WHIRLPOOL BATH

The whirlpool bath, an aerated hot-water bath, is suitable for arm or leg cases. The temperature of the water can be gradually increased to 110º or 115º F., and the duration of its application is established at 20 minutes. This bath was introduced during the World War and has proved to be the most curative of all physiotherapeutic agencies in the treatment of cases of peripheral nerve injuries. The increased vascularity and softening effect upon tissues results in a relaxation of the muscular elements, which become more supple and

FIG. 53.- Ischemic atrophy common after nerve injuries and one of the conditions most resistant to physiotherapy

elastic. Muscle spasm is relieved and increased mobility of the joints results.A most important feature of this treatment is that the subsequent massage is more efficiently administered and such treatment can be adequately given in much less time, as the aide starts her manipulations on a limb which is softened, relaxed, and in a state of active hyperemia. Further, any manipulations or stretching of joints and tendons is more easily accomplished, is less painful, and the patient's apprehension is less acute. The use of this bath is also an ideal preparation of the muscles for testing the electrical reactions. Occasionally cases of irritable nerve injuries will be made more irritable and the whirlpool bath can not be utilized. One case of hyperesthesia of the median nerve obtained relief from a bath, the temperature of which was maintained between 70º and 80º F.


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CONTRAST AND CABINET BATHS

Under this phase of physical measures two other baths should be mentioned, although their use in the treatment of nerve injuries is somewhat limited. The contrast bath is used where a circulatory stimulation is desired and has been aptly spoken of as "circulatory gymnastics." Immersion of the limb for a period of about two minutes alternately in a hot-water (100º to 110º F.) bath and then in in a cold water (60º F.) bath is the mode of application. As a result, the vessels of the part are alternately dilated and contracted. The cabinet bath and general hydrotherapy are used mainly in the treatment of the

FIG. 54.- Whirlpool bath

patient's general condition, as they have a marked tonic as well as eliminative effect. The cabinet bath is equipped with approximately 50 electric lamps (carbon filaments). The patient is seated on a stool with his head exposed. The temperature ranges from 120º to 160º F., and the exposure is from 4 to 10 minutes. This bath is followed by the "hydro" of tepid overhead and circular showers and the Scotch douche, the latter consisting of more or less rapidly alternating streams of jets of hot and cold water under a pressure vary ing from 10 to 30 pounds. The cabinet bath produces a profound physiological action. These effects are, briefly, a profuse diaphoresis with dilation of the superficial vessels, an increase in body temperature, pulse and respirations,


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and a marked increase in the excretion of the urinary solids. The follow-up hydrotherapy enables the relaxed vessels to regain their tonus, the temperature, pulse, and respiration become nearly normal, and the reaction, a feeling of general well-being, is attained.

PARAFFIN-WAX BATH

A modification of the whirlpool bath in the form of the paraffin-wax bath has been more recently introduced. A temperature of 150º F. is attained, and it is advocated that a more active hyperemia is produced, with a correspond-

FIG. 55.- Control table for Scotch douche

ing beneficial effect upon the tissues. There is some doubt whether this bath has any advantages over the ordinary whirlpool bath.

HOT-AIR BATH (RADIANT HEAT AND LIGHT)

The hot-air, steam, or vapor baths have been practically superseded by dry heat derived from radiant heat and light applicators. This is commonly, although improperly, spoken of as "baking." There are different styles and sizes of applicators, employing four, eight, or more electric incandescent lamps, preferably with carbon filaments. In addition to these ordinary forms of "bakers," which are portable and can readily be adjusted to the part to be treated, the large, nonportable, deep, phototherapy applicator, with a non-focusing 1,500-watt tungsten filament lamp, is of special value in the deeper


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FIG.56.- Radiant heat and light treatments of the extremities

FIG. 57.- Radiant beat and light treatment of the entire body


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penetration and higher temperature obtained. These applicators are built in various sizes. They are convenient and easily utilized, and hence have practically superseded other forms of dry heat. There is some, though very slight, chance of producing burns, especially over an anesthetic area, but with proper use an even distribution of heat is obtained over the entire exposed area and the risk of a burn is minimal. The claim that colored lamps have an increased therapeutic value has not been substantiated. Radiant heat and light is applicable in many cases where the whirlpool bath can not be used, viz, where there is an open wound which could not be subjected to the water bath, and in nerve injuries affecting the shoulder, back, buttock, or thigh.

A brief statement of the physics of the light as derived from the incandescent lamp is of interest. In the spectrum of the incandescent carbon lamp approximately 93 percent are infra-red rays. Hence the physiological effect of the use of incandescent lamps results from the heat or infrared rays. These rays have no pigmenting effect, but do penetrate into the tissues, causing an active hyperemia with an elevation of the skin temperature. With the increased vascularity, improved nutrition, d increased cellular activity, the rationality of this treatment as a preliminary to massage and passive and active exercise is readily understood.

FIG. 58.- Alpine lamp

MERCURY VAPOR LAMPS

The mercury vapor or quartz lamps, both the air-cooled and water-cooled types, also have a limited use. The actinic rays derived from these lamps are extremely stimulative, and an exposure to these radiations may result in erythemia of from a mild degree to bleb formation. Hence, it may be used as a form of counterirritation in neuralgia, neuritis, and like conditions. Trophic ulcers and skin lesions associated with trophic disturbances may likewise be treated with these stimulative radiations.


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MASSAGE AND PASSIVE MOVEMENTS

Of equal importance with heat in nerve injuries are massage and passive movements. In fact, one term should be devised for the combined application of heat, massage, and passive movements. In cases of nerve injuries this triad of physical measures should he started at the earliest possible time and should be continuous, and every paralyzed muscle group should receive this form of daily treatment.

Passive movements are carried out only upon the relaxed limb. These movements should be executed slowly with firm, steady pressure. Avoidance of sudden movements or jerking needs no comment. The particular joint

FIG. 59.- Massage of thigh muscles. Note separation of muscle groups by the thumbs

should be passively put through its entire range of movements. Certain cases of limited joint mobility require a certain steady pressure to effect maximum range of motion. The term "stretching" seems most appropriate.

Massage and passive movements, together with preliminary heat, are the most important treatments for paralysis. Their chief value consists of the maintenance of the nutrition of the affected muscles and the prevention or stretching of adhesions of joints, muscles, and tendons. The fibrosis and contraction of articular capsules, especially of the finger joints in cases of ulnar, median, and musculospiral paralysis, needs special mention. Stiff fingers or "griffes" readily result from paralysis of these nerves due to the loss of voluntary contractions. The attending loss of function--that of prehension--is very grave. With early passive motion treatment, which even the patient can often do, this single deformity is readily prevented. Another important benefit de-


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FIG. 60.- Massage of the calf muscles

FIG. 61.- Massage about a recently healed wound


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rived from massage is the nutritional improvement in the skin and subcutaneous tissues, thereby lessening the occurrence of trophic ulcers and eczematous conditions. Adherent scars can be loosened and freed from the underlying tissues to a greater or lesser extent. Deep massage is often of value when applied to the area of an old healed wound preliminary to an operation, in order to stir up any latent infection if it be present. Passive movements used in conjunction with massage are executed to increase the range of movements of stiffened joints, to stretch contracted scars, to prevent the formation of adhesions in regional joints, and to forestall contractures and adhesions in the paralyzed muscles and tendinous processes. With the administration of these manipulations the paralyzed muscles must be relaxed with the deformity overcorrected. For example, in a musculospiral paralysis the forearm and hand must be supported (usually

FIG. 62.- Massage to retain mobility in finger joints after nerve injury

on a small table with the wrist in moderate dorsiflexion. In an external popliteal nerve paralysis the foot should be supported in dorsiflexion. In certain paralyses the corrective splint may not necessarily be removed, as in a circumflex nerve injury with deltoid muscle paralysis. With the abduction or airplane splint all treatment can be given to the shoulder girdle musculature with the splint in situ. However, if the splint is removed, the patient should be lying flat on his back with the arm in abduction and the forearm supported, resting on the plinth or table. The question of the vigor to be used in massage depends upon the individual case. Gentleness in early nerve injuries and cases of hyperesthesia is imperative. Following surgical operations, massage should be avoided over the operated area. This alsoholds true relative to sites of injury in any case. In nerve sutures where extreme flexion or extension of the adjacent joint has been necessary to secure end-to-end anastomosis, due to loss of nerve substance,


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FIG. 63.- Massage to release adherent scar in amputation stump

FIG. 64.- Stretching a fibrosed ankle


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no movement should be permitted for a period of from one to two months. Massage to be effective must be given correctly. It is an art which practice alone can teach. The experienced patients know the difference between massage and mere “rubbing." For real massage a thorough and practical knowledge of anatomy is absolutely essential. If the operator is rough and too vigorous the possibility of doing harm is apparent.

ACTIVE EXERCISES

The value of active exercises in nerve injury cases can not be too strongly emphasized. These exercises can be given only after return of voluntary power,

FIG. 65.- Resistive exercise for strengthening thigh muscles in preparation for use of artificial leg

must be carefully adapted to the individual case, and usually should follow the regular treatment of heat, massage, and passive motion. Exact and purposeful movements should be carried out, but not to the point of extensive fatigue. In fact, the execution of these natural movements and the use of resistance must be guided solely by this factor of fatigue. Without proper supervision much harm may be done, the progress of regeneration halted, and recovery delayed accordingly. Active exercises are spoken of as reeducation, and such have been systematized and placed on a true. scientific basis in the larger medical clinics devoted to the treatment of cases of infantile paralysis. The value of active exercises is obvious. The patient himself is building up his weakened muscles and overcoming the functional inactivities attendant upon the long period of


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relative immobility. This contractility enhances the nutrition of the paralyzed muscles and mobilizes the articulations. It greatly assists in the formation of substitutional movements. With the progress of voluntary movements and endurance of the muscular contractions the patient can be assigned to specialized work in the curative workshops of the occupational therapy department. Here, with proper supervision, the coordination and strength of muscular contractions under the stimulation of the voluntary impulses will progress with perhaps more rapidity than in any other form of treatment. Associated with active exercises and voluntary functioning, mechanotherapy has a niche. The various forms of apparatus (Zander's and McKenzie's types) are useful in strengthen-

FIG. 66.- Testing muscle reaction with galvanic current

ing the muscular contractions, in causing the normal functioning in its proper direction, and in stretching shortened tendons or stiffened joints.

ELECTROTHERAPY

Much discussion has been raised as to the real value of electrical currents in the treatment of nerve injuries. There is no doubt but that some over-enthusiasts have made unsubstantial claims relative to its merits and that many who have confined themselves to a small specialized branch of electrotherapy have made exaggerated statements. However, it can not be denied that electrotherapy is a valuable adjunct to the primary triad-heat, massage, and passive movemients-in the treatment of nerve injuries.


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IN PARALYSIS

The treatment of nerve palsies with electricity is a matter of considerable discussion as to its true value. It is the usual statement that the muscles supplied by the affected nerves should have daily stimulations or contractions with an electrical current.

GALVANIC CURRENT

Since in a paralysis the nerve trunk is inexcitable, stimulation of the muscle itself is the only alternative to cause a contraction, and interrupted galvanism is the form of electricity which is usually advocated. From the writer's experience in physiotherapeutical treatment of a large number of peripheral

FIG. 67.- Interrupted galvanic current to muscles in case of injury to the external popliteal nerve, with foot drop

nerve injuries due to gunshot wounds, this has been a false procedure and no functional improvement could be attributed to this one therapeutic method. With the interrupted galvanic stimulation, only a short jerk is elicited for each contraction, and only a small portion of the muscle is affected, namely, that part adjacent to the active electrode. Again, too much stress has been laid on the value of this muscular contraction. It is difficult to conceive of any value in this localized spasmodic contraction or jerk as a means of increasing nutrition or preventing muscular atrophy. This treatment may cause considerable pain or discomfort. Small though slowly healing burns, especially over anesthetic areas, not infrequently result from the application of this current. Further to determine its efficiency from the clinical aspect, selected cases of peripheral nerve injuries received physiotherapy treatment, one group with


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and one group without interrupted galvanism. Again, the same cases were treated with interrupted galvanism for a period of several months and then received the same treatment, excepting that the galvanic contractions were omitted. No difference in the rapidity of progress could be noted in either group of cases. Accordingly this method of treatment was discontinued, although a sinusoidal current was used in selected cases in which an appreciable contraction of the paralyzed muscle groups could be obtained. The contraction from the sinusoidal current is rhythmical, smooth, prolonged, not at all painful, and perhaps is of material assistance in keeping the muscular elements in a better nutritional state.

FIG. 68.- Muscle treatment with sinusoidal current. The electrode was usually bound in place

FARADIC CURRENT

The faradic current is of little use unless a contraction is obtained. Recovering peripheral nerve cases have voluntary power for some time prior to any faradic irritability. These cases are then amenable to active exercise or reeducational movements and faradism has little place in their treatment, although at times it is a very useful procedure in conjunction with active movements for supplementing the voluntary contractions of affected muscles. However, there is one large group of cases, which, strictly speaking, is not included in peripheral nerve injuries yet are associated with them in physiotherapeutical practice, namely, the functional or hysterical paralyses, in which faradism plays an important part in the treatment. When the faradic current is applied to either the nerve trunk or motor points of the affected muscle groups in this type of case, a normal muscular response is obtained. This is indicative of an intact


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nerve trunk, and without exception is absolutely diagnostic that no organic lesion of the spino-muscular neurone is present. The muscular contractions which are obtained in this type of case with faradism are utilized as a form of suggestive treatment which has proved to be most valuable. The patient is placed so that he can voluntarily use the muscles of both the affected and the opposite limb, and with the active faradic electrode in place on the nerve trunk or motor points of the paralyzed muscle group he is asked to contract these muscles and those of the other limb, the faradic contraction then being brought about. This is only one of the procedures whereby faradism is used as a part of the suggestive treatment of these cases.

IN IRRITATIVE LESIONS

HYPERESTHESIA, CAUSALGIA, HYPERTONICITY

A large group of cases for which the galvanic current is applicable are those with irritative lesions-hyperesthesia, causalgia, and those with hypertonicity with a tendency toward contractures. The median and internal popliteal nerves are especially prone to such lesions. The writer has also treated one case of partial degeneration of the anterior crural (femoral) nerve with intense hyperesthesia of its sensory distribution. A sedative form of treatment is called for in these cases. The positive or anodal electrode has a pronounced soothing effect. Its application may be direct, the electrode being a relatively large pad applied directly to the affected area, or it may be used in the form of the anodal galvanic bath, the whole limb being immersed. This galvanic bath with a weak solution of quinine has more recently been advocated, but it seemed to have no special value over the ordinary galvanic bath in the two cases which received this treatment. However, in the painful condition of causalgia, where the relief at best may be only temporary, a tepid whirlpool bath is perhaps as soothing as any treatment. In fact, very little progress has been made in the treatment of this condition.

Facial nerve palsies which show an incomplete lesion seem to improve most rapidly, and in some cases this improvement is most striking with the application of negative galvanism. A large pad of the size and shape to roughly correspond to one side of the face is the cathodal or negative electrode, while the anodal or indifferent pole is placed on the back of the neck. A current as strong as the patient can reasonably bear (usually 8 to 15 ma.) is allowed to flow for a period of 20 minutes. This is given daily and is followed by massage of the affected facial muscles. This application of constant galvanism may be applied to any region of the body and has many beneficial effects. It undoubtedly helps to maintain the nutrition of the tissues. It may be given either with the simple electrodes in the form of pads or as a galvanic bath. When combined with faradism, the galvano-faradic method of treatment, we have a form of special nutritional and contractile effect that has many advocates.

Ionization cataphoresis is a form of galvanism whereby elements of certain salts are passed into the tissues for the purposes of lessening pain and "dissolving" fibrous tissues. Potassium iodide, sodium salicylate, sodium chloride, bisulphateof quinine, and cocaine are some of the solutions which are used. It seems, in the experience of the writer, that whatever effect is produced is due to the


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effect of the constant galvanic current rather than to the diffusion in the tissues of small amounts of drugs. Theoretical, experimental, and practical work seems to bear this out. It is quite probable that the beneficial effects of this form of ionic medication are due to the action of the electrical currents themselves--i. e., the passage of galvanic currents of low amperage through the tissues results in heat production in the deeper-lying tissues, effecting an increased blood

supply and an enhanced cellular activity with marked nutritional benefits. This constant galvanism seems to be of greatest value in tissues which are or have been the seat of a chronic inflammatory process. As previously stated, large pads, well moistened to overcome the resistance of the skin, or the water baths, together with a prolonged application of currents of relatively low amperage, are material factors in the efficiency of its application.

PARAPLEGIA

The treatment of paraplegia cases is fraught with many discouragements both to the patient and the surgeon. This discussion has been placed under this separate paragraph because the treatment of these cases is perhaps more distinctive than that of any peripheral nerve lesion. While the number of gunshot-wound cases with spinal cord injury who survive the initial injury is relatively small, yet each military hospital of the World War had a number of these unfortunate cases. These cases have been bedridden for months, with possibly developed contractures and the inevitable bedsores, so that the return of any voluntary power or sensation is truly a ray of hope to the patient. In those exhibiting signs of regeneration with some recovering function, both sensory and motor, physiotherapy has a very wide and useful field of application. If they are up in a wheel chair so that they may be brought to the physiotherapy clinic, it has been found that a hot tub bath of hypertonic salt solution is of marked benefit. The salt seems to have a very beneficial effect upon the trophically involved skin and serves to keep the ulcers, if present, clean as well as stimulated. Many of these ulcers are very deep and sluggish and are prone to be quite septic. This bath also serves as the ideal preliminary to massage and passive movements, and the hyperemia is more complete than can be obtained from radiant heat and light. If the progress of regeneration continues so that the patient can walk with braces and crutches, special coordinating exercises, walking exercises, and the like produce more beneficial results than any other form of treatment which is available.

HIGH-FREQUENCY CURRENT

The high-frequency current is still another form of electrotherapy which is used in the treatment of nerve injuries. This form of current can be applied directly to the part with vacuum or nonvacuum electrodes-improperly called the violet ray. Heat, surface stimulation, and counter irritation derived therefrom can be used for cases of trophic ulcers, facial palsies,-functional paralyses, and disorders of sensation, such as paresthesias, anesthesias, hyperesthesias, and the hysterical types of sensory disturbances. Another form in which this current has a valuable usage is diathermy or thermopenetration. This heat, as the name implies, affects the deeper-lying tissues. Therefore its chief utility lies in the treatment


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FIG. 69.- Static treatments

FIG. 70.- Bergonie chair for giving general electric treatments for the psychological effect


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of certain types of neuritis, the nonsuppurative inflammations, and in the irritative nerve lesions, as previously mentioned. In the treatment of stiff joints and contracted tendons this deep heat renders the part more amenable to stretching manipulations and like methods. It is of special value in ischemia, in which the increased circulatory exchange will tend to minimize the associated fibrosis.

FIG. 71.- Thermolite

FIG. 72.- Apparatus for applying radiant light and heat to limbs (Burdick, type L4)

STATIC CURRENT

Static currents produced by the static machine have a limited application in the treatment of peripheral nerve injuries. Its currents are of some utility in cases of neuralgic pains;, the myalgias, stiff joints, and especially in the psychoneurotic states and fuctional paralyses.

LOSS OF MUSCLE MEMORY

Some patients with peripheral nerve injuries who have had a group of muscles paralyzed for many months seem to lose the power to transmit the normal motor impulse to the muscles, or the muscles have lost the ability to receive

FIG. 73.-Vibrator, with flexible shaft (Victor)

FIG. 74.- Galvanic apparatus, with meter and rheostat (Victor)

it, as manifested by an inability to cause more than a very weak contraction, at best, after the power of faradic contraction has returned. Such cases require the same reeducating exercises as do muscles paralyzed following cerebral injuries.

PARALYSIS FOLLOWING HEAD INJURIES C

In the treatment of the neurological complications of head injuries at Walter Reed General Hospital, the first requirement was a thorough study by a.

c Based upon: The Late Treatment of Gunshot Wounds of the Head, by Lieut. Col. H. H. Kerr, M.C., Surgery, Gynecology, and Obstetrics, Chicago, 1920, XXX, 550-554.


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competent neurologist; on the basis of his diagnosis the treatment was prescribed. In the cases of gross spastic paralysis daily massage and splinting were instituted at first, the masseuse being instructed to stretch gradually each contracted muscle. The overstretched extensors were treated by massage and deep transverse percussion. The massage was accomplished by passive exercises, with special attention to extension to overcome the continued flexion. The massage and passive exercises were employed to make possible the voluntary use of the extensors in simple movement. In certain cases voluntary movement could not be obtained for some weeks, but in all cases such movements eventually were brought out. At a very early date the patients were gotten out of bed and urged to walk. During this early period a right-angle-stop splint had to be worn on the ankles to permit locomotion. Crutches and, later, canes were necessary, but their use was soon discouraged and the patient made to walk by himself, no matter how awkwardly or slowly he did it.

FIG. 75.- Faradic and galvanic apparatus with meter and rheostate (Wappler)

Under such a regime, the bedridden paralytics were soon up and around the wards. The cases were then given reeducative exercises of a competitive nature or in game form. Each movement was considered in the light of its three components-its extent, its force, and its time. The exercises aimed to produce, first, extent of motion; later, force; and finally, rapidity. When all three had been brought to normal, an accurate motion had been produced. Stepping over a string standard, kicking a basket ball at a target, and dropping a tennis ball into a basket are types of the exercises employed.

FIG. 76.- Interrupted galvanic apparatus, with mter and rheostat (Victor)

The game idea and the sense of com petition were made an integral part of the reeducation. To this end, scores were kept of the different exercises and games in which the patients took part. For instance, a man's ability to stretch his arm up the wall, or to release a tennis ball into a basket a certain number of times in a given time, was measured from day to day and compared with his fellow patients. A game of baseball was played every day by all the patients together. It was most interesting to watch one of these games. No matter

FIG. 77.- Galvanic and slow sinusoidal apparatus, day and compared to like efforts of his with meter and rheostat (Wappler)


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FIG. 78.- High frequency apparatus (Victor)

FIG. 79.- Electrodes


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FIG. 80.- Galvanic and sinusoidal apparatus, mounted with motor generator (Victor)

FIG. 81.- Apparatus, polysine, for galvanic and sinusoidal currents (McIntosh)


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how awkwardly a motion might be performed, under the stimulus of the game they somehow seemed to be able to make hits and score runs, apparently forgetting their disability in the effort.

In addition to the scores of their exercises, each patient was measured as to his extent, strength, and speed of movement at least once a fortnight. The results of these measurements were charted graphically and tacked to the wall, where each patient could see not only his own progress but also the progress of his fellow patients. In addition to the moral stimulus that these charts gave the patient himself, they were an invaluable guide to the therapy. Thus particular attention was paid to that movement which showed the least improvement. In this way one group of muscles was brought back toward normal as soon as another, and substitution of movement did not occur. With improvement, exercises which educated, the time and the accuracy of each movement were instituted. When the patient could grasp a pencil he was made to practice drawing a circle, then a square, and thus gradually was taught to write again.

Cases with gross defects and destruction of the motor cortex gradually acquired all the movements which they had lost. An experience with a large number of cases of cerebral paralysis most strikingly demonstrates that much more can be done for these cases than is commonly supposed. With proper appreciation of this fact, we should be able to reeducate each case of traumatic cortical injury to a degree of practically no permanent disability.

REFERENCES

(1) Annual Report of the Surgeon General, United States Army, 1919, ii 1095, 1105.

(2) Ibid, 1164, 1166.

(3) Ibid, 1096.

(4) Memorandum, Office of the Surgeon General, Washington, June 3, 191S. Subject: Physical reconstruction of invalided and disabled soldiers. On file, Record Room, S. G. O., Miscellaneous.

(5) Miramond de Laroquette: Actions des bains de lumiere naturelle et artificielle. Archives d'électricité medicale expérimentales et cliniques, Bordeaux, 1912, xxi, 82-97.