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 {UNITED STATES OF AMElUCA.il 
 

INFANTILE PARALYSIS, 
 
 AND ITS 
 
 | 
 
 ATTENDANT DEFORMITIES. 
 
 BY 
 
 CHARLES FAYETTE TAYLOR, M.D., 
 
 RESIDENT SURGEON NEW YORK ORTHOPAEDIC DISPENSARY ; AUTHOR OF " ME- 
 CHANICAL TREATMENT OF ANGULAR CURVATURE OF THE SPINE ;" 
 "SPINAL IRRITATION, OR CAUSES OF BACK- ACHE AMONG 
 AMERICAN WOMEN;" "THEORY AND PRACTICE 
 OF THE MOVEMENT-CURE," ETC. 
 
 PHILADELPHIA: 
 
 J. B. LIPPHNTCOTT & CO. 
 
 1867. 
 
Entered, according to Act op Congress, in the Year 1866, by 
 
 CHARLES FAYETTE TAYLOR, 
 
 In the Clerk's Office of the District Court of the United States 
 for the Southern District of New York. 
 
 Davies & Kent, 
 
 Electrotypers and Stereotype)^ 
 
 183 William St., N. Y. 
 
PREFACE. 
 
 Notwithstanding the very great progress made of 
 late years in medicine and surgery, there are still 
 many forms of disease which have not yet received the 
 careful study they require, and about which there is 
 so little to be found in medical literature that the 
 majority of physicians are practically excluded from 
 profiting by the experience of others. 
 
 A hundred cases of Infantile Paralysis occurring in 
 the practice of as many different physicians, in different 
 localities, without knowledge of each other, and per- 
 haps each the only case of a lifetime practice, afford 
 very imperfect opportunity for that careful, compar- 
 ative observation which positive science requires, 
 Hence the meagreness of the literature on this subject. 
 Only when some enthusiastic "specialist" calls them 
 from their hiding-places — few in a given locality, but 
 many in community — is there afforded sufficient oppor- 
 tunity for that consecutive and multiplied observation 
 necessary for establishing facts and making deductions. 
 As to the facts set forth in this book, there is scarcely 
 chance for mistake ; if the deductions are erroneous, 
 
IV PREFACE. 
 
 some keener mind will detect the error ; but, believing 
 them to be true, the profession have a right to them. 
 I only claim a faithful use of opportunity, and a 
 careful, honest observation of facts. 
 
 I wish to express my indebtedness to F. O. Earle 
 M.D., of Chicago, 111., lately assistant in this Institution 
 for the accurate drawings illustrating the text. 
 
 If these pages are true, there should be, ten years 
 hence, a smaller proportion of cripples than now dis- 
 tress our sight ; and that such may be the case is the 
 fervent hope of 
 
 The Author. 
 
 N. Y. Orthopedic Institution, 
 1303 Broadway, Sept., 1866 
 
 DN,) 
 
 • ) 
 
INFANTILE PARALYSIS 
 
 ATTENDANT DEFORMITIES. 
 
 STATEMENT. 
 
 Paralysis in early life is either the direct 
 or remote cause of a large proportion of the 
 distortions of the upper and lower extremities 
 which afflict a certain number in every com- 
 munity. 
 
 Perhaps it is not always sufficiently realized 
 that children of a tender age are as much 
 more liable to loss of muscular power than 
 persons of mature age, as they are to any 
 other form of sickness. The young of every 
 kind are always most susceptible and possess 
 least power of endurance, and when not well 
 guarded, suffer most from adverse influences. 
 And this is especially true with regard to 
 
t> INFANTILE PARALYSIS, AND 
 
 affections of the nervous system. Hence there 
 is sufficient reason for the fact, that paralysis 
 is of common occurrence in early life. 
 
 DEFINITION. 
 
 By the term ''Infantile Paralysis" I do 
 not mean simply a paralysis occurring in 
 infancy or childhood ; but I desire to restrict 
 the use of the term — and it is so used in this 
 paper — to indicate that form of paralysis 
 which occurs only in infancy. Or if the 
 same form of paralysis be found to occur after 
 maturity, then the term should indicate that 
 which occurs principally and characteristically 
 in children. In fact, as will be hereafter more 
 fully understood, I use the term to express a 
 paralysis peculiar to the growing period. Per- 
 haps, more correctly, it might be called the 
 paralysis of nutrition and development. 
 
 FREQUENCY. 
 
 There seems to be no doubt that this disease 
 is much more frequent now, and in this coun- 
 
 
 
 
ITS ATTENDANT DEFORMITIES. 7 
 
 try, than > formerly, and is rapidly increasing. 
 Nor is it difficult to account for this state of 
 tilings. 
 
 PROBABLE CAUSE. 
 
 Modern, and especially American, civiliza- 
 tion is characterized by peculiar activity of 
 the brain, and this is often carried to great 
 excess. 
 
 The motive-force of American progress is 
 brain-power. It is the ceaseless activity of 
 directing mind that, in two centuries, has 
 subdued the wilderness and peopled the 
 continent ; that has built vast cities whose 
 commerce reaches the remotest regions of the 
 globe ; and that has proved itself capable of 
 solving the most difficult political problems. 
 The creative energy of the distinctively Ameri- 
 can intellect is recognized everywhere. But 
 such vast results of this creative intelligence 
 have not been accomplished without some 
 sacrifices. It has diminished our physical 
 endurance. As a people, we are dyspeptic, 
 and weak in bodily vigor in the inverse ratio 
 
8 INFANTILE PAEALYSIS, AND 
 
 of over-activity of brain. Our laborers have 
 to be imported. We are predisposed to 
 nervous derangements. As a people, we are 
 over-worked. The nervous system becomes 
 exhausted, and a constitution less strong than 
 our own, but more excitable and impressible, 
 is transmitted to our children. 
 
 WHY VIGOROUS PARENTS PRODUCE SICKLY 
 OFFSPRING. 
 
 It is often asked, M How is it that, when 
 both parents are well and vigorous, the chil- 
 dren are often puny and nervous Y 3 The re- 
 ply must be, that the offspring partake of the 
 parents' condition at the time they were hegotten. 
 A man who is thoroughly engrossed in busi- 
 ness calculations and cares, or even in the 
 pleasures of society, will beget children with 
 physical powers correspondingly subordinated 
 to the nervous. To insure a perfect plant, it 
 is not only requisite that the seed be pro- 
 duced by a strong and vigorous tree, but 
 no drought must have absorbed its sap or 
 
ITS ATTENDANT DEFORMITIES. 9 
 
 untimely frosts have chilled it while the seed 
 was maturing. We have imperfect grapes 
 if an accidental cut lets the juice of the vine 
 leak out. 
 
 How, then, can even naturally vigorous 
 persons expect to bear children of equal vigor 
 if begotten while they themselves are ex- 
 hausted with intense mental labors and excite- 
 ments? It is a physiological impossibility. 
 Hence our children are born with a surprising 
 degree of nervous irritability ; just the temper- 
 ament for the production of infantile paralysis 
 when favorable circumstances combine to 
 produce it. 
 
 MOST COMMON AMONG THE RICH. 
 
 And, as may be supposed, this disease 
 occurs most frequently in the families of 
 active business men. Indeed, while strumous 
 diseases abound in the lower classes, I have 
 seen but very few cases of infantile paralysis 
 among them. My whole experience has led 
 me to regard infantile paralysis as being 
 
10 INFANTILE PARALYSIS, AND 
 
 almost confined to the families of active, in- 
 telligent men, as above indicated. 
 
 ITS PATHOLOGY. 
 
 The definite pathology of infantile paralysis 
 is not well understood. I have no theory to 
 offer, and will only assume to present the facts 
 connected with these cases which a pretty 
 extensive, close, and prolonged observation 
 of them may justify me in giving, with a con- 
 siderable degree of explicitness. 
 
 SYMPTOMATOLOGY. 
 
 In many cases the paralysis is ushered in 
 with symptoms apparently, in all respects, re- 
 sembling inflammation of the membranes of 
 the spinal cord. There may be every justifi- 
 cation in applying the term spinal or cerebro- 
 spinal meningitis to those cases. But there 
 are many even among these severer cases, 
 where the disturbance follows, rather than 
 precedes, the paralysis, in such a relation as to 
 suggest the inquiry, if the disturbance might 
 
ITS ATTENDANT DEFORMITIES. 11 
 
 not possibly have been the effect, rather than 
 the cause of it? So great a shock as the 
 paralyzing of a portion of the body might well 
 be expected to produce a profound impression 
 and serious disturbance. 
 
 CONSTITUTIONAL SYMPTOMS SOMETIMES TRIFLING. 
 
 There are other cases, however, in which 
 the constitutional symptoms are so trifling, as 
 to tax our minds to account for them in 
 connection with so serious and dangerous a 
 disease as inflammation of the spinal cord or 
 its membranes. Is it possible for distinctive 
 inflammation to be going on in the brain or 
 spinal cord, and the patient exhibit no 
 symptoms which might point to it? And 
 yet there are many cases of infantile paralysis 
 in which there is no noticeable variation 
 from ordinary health, the only symptom to 
 be noticed at the very time, being the 
 paralysis itself. 
 
 CaseI. — K. G., at eleven months old, had 
 learned to walk. Suddenly it was observed 
 
12 INFANTILE PARALYSIS, AND 
 
 that she was unable longer to do so, and 
 it was six or eight months later before 
 she regained imperfect locomotive power. 
 The right leg was partially paralyzed ; but 
 there was no sickness or other indication of 
 the cause, or even the time of its occurrence. 
 At thirteen I operated on her for partial 
 club-foot. 
 
 Case 2. — M. D., though a delicate, nervous 
 child, had no special sickness before or after 
 the paralysis. One day, when two years old, 
 she started to walk across the floor, but 
 became paralyzed when she got to the middle 
 of the room. The paralysis is in the right 
 leg — not complete, though attended with 
 partial arrest of development. 
 
 Several other cases of paralysis without 
 constitutional symptoms have come under 
 my observation, though they embrace but a 
 small proportion of the whole. But cases in 
 which the symptoms are very mild are quite 
 common. 
 
 In some instances the child is put to 
 
ITS ATTENDANT DEFORMITIES. 13 
 
 bed apparently well, and is found paralyzed 
 in the morning, but without any indication 
 of the time in the night when the paralysis 
 happened, nor was the paralysis followed by 
 any unusual bodily disturbance. 
 
 GENERAL HISTORY. 
 
 The majority of those cases, however, have 
 about this history : the child is getting its 
 first molar teeth — for the greatest number of 
 cases occur when the child is from fourteen to 
 twenty months old. Sometimes there has 
 been a diarrhea, or other drain upon the 
 S} 7 stem, or cause of irritation, accompanied 
 with slight fever, though not often enough to 
 keep the child abed. In a few days these 
 symptoms abate and the child appears better ; 
 but on making efforts to walk or use his 
 limbs, it is found that he has lost the power 
 to do so. In most cases, the exact time 
 when the paralysis happened is never ascer- 
 tained. - 
 
H INFANTILE PARALYSIS, AND 
 
 SELDOM UNCONSCIOUS. 
 
 It is seldom that the accession of this form 
 of paralysis is accompanied with unconscious- 
 ness. In one case, the child, in apparently 
 perfect health, was sleeping quietly in its 
 cradle, watched fondly by its father. It awoke 
 with a scream, and was found to be completely 
 paralyzed in its entire body. But neither 
 then, nor at any subsequent time, was there 
 any unconsciousness. It is true that there 
 are occasional cases of convulsions followed 
 by infantile paralysis,* but there are more 
 cases of convulsions which are not followed 
 by paralysis, and a careful study, when they 
 do exist together, has failed to establish 
 to my mind any direct connection between 
 them. Any sufficient irritation may produce 
 infantile convulsions ; but they do not seem 
 to be caused by or to cause the paralysis, 
 though the paralysis may happen at about the 
 
 ° Infantile apoplexy, with convulsions and paralysis, is quite 
 different from that which we are now considering. 
 
ITS ATTENDANT DEFORMITIES. 15 
 
 same time. As a general rule, this paralysis 
 in young children is accompanied with much 
 less severe symptoms (though this is not 
 always the case) than when the patient is 
 older. With increase of years, the accom- 
 panying symptoms in general become more 
 pronounced, and are neither so sudden in their 
 accession, nor do they pass so speedily away. 
 A child from ten to fourteen years old may 
 be sick for several months with a more 
 gradual and less uniform accession of paralysis. 
 This is often accompanied with severe symp- 
 toms of what is generally called spinal or 
 cerebro-spinal meningitis. 
 
 PECULIARITY OF INFANTILE PARALYSIS. 
 
 But the form, rather than the origin, of 
 this paralysis is to engage our study. 
 
 I wish to call attention to the idea before 
 alluded to, viz., that there is a form of paral- 
 ysis peculiar to the growing period; that it is 
 most likely to occur at the times of greatest 
 organic or vegetative activity; and that it 
 
16 INFANTILE PARALYSIS, AND 
 
 ceases to act after the organs have attained 
 complete maturity. The periods of life dur- 
 ing which it is most liable to occur are from 
 six months to four years of age, and again 
 from ten to fourteen. This form of child- 
 hood-paralysis has peculiarities not found in 
 other forms, whether these other forms occur 
 in children or adults. Children as w^ell as 
 adults may have apoplexy, softening, inflam- 
 mations, blows on the head, etc. ; but the 
 resulting paralysis is always essentially differ- 
 ent from that which we are now discussing. 
 
 NO EVIDENCE OF CENTRAL LESION. 
 
 One essential feature of infantile paralysis 
 is. that there is uniformly perfect recovery, so 
 far as we can discover, of whatever disease of 
 the nervous center — if it is ever really caused 
 by a local lesion — which may have caused it. 
 
 THE DISEASE PERIPHERIC. 
 
 Another essential characteristic of this pa- 
 ralysis is the entire absence of reflex irritability 
 
ITS ATTENDANT DEFORMITIES. 17 
 
 of the muscles, accompanied with a remark- 
 able diminution of capillary circulation in the 
 affected parts, and a correspondingly diminish- 
 ed muscular power. These, and the arrested 
 growth of certain parts, are the only remain- 
 ing evidence of previous disease. If we can 
 conceive of a general constringing of the capil- 
 lary vessels, and a shutting off of the capillary 
 circulation, with such a physical condition as 
 would result if the limb had for a long time 
 been tightly bandaged, we should gain a very 
 good idea of the actual condition in infantile 
 paralysis. In fact, my own belief is that the 
 disease is essentially peripheric, and that the 
 great nervous centers are only indirectly and 
 secondarily implicated. On no other hypoth- 
 esis can I account for all the phenomena 
 of these cases. But whether this suggestion 
 be the true solution or not, the essential con- 
 dition in infantile paralysis is a cutting off of 
 the capillary circulation and a corresponding- 
 loss of muscular irritability ; the latter to a 
 great extent, if not wholly, due to this depri- 
 
18 INFANTILE PARALYSIS, AND 
 
 vation of blood in the small vessels. And the 
 limb withers as does a plant when the chan- 
 nels to its irrigation are dried up. It is a 
 well-known physiological fact, that the func- 
 tion of any organ is diminished or destroyed 
 by cutting off its supply of blood, and a muscle 
 can no more act without its supply of blood 
 than it can act without the nervous stimulus. 
 In other words, you may paralyze a muscle 
 as completely by stopping its circulation as 
 by dividing its nerve. And it appears to me 
 that the only satisfactory explanation of all 
 the facts in these cases, is to suppose that 
 the paralysis is nearly, if not wholly, due to 
 the diminished capillary circulation rather 
 than, as in other forms of paralysis, to the 
 direct influence of a lesion in the brain or 
 spinal cord. By what precise pathological 
 condition this withdrawing of a large part of 
 the sanguineous fluid is brought about, I 
 have no theory to suggest. There is no 
 doubt as to the fact, however. 
 
ITS ATTENDANT DEFORMITIES. 19 
 
 TENDENCY TO RECOVERY. 
 
 There is another fact of immense import- 
 ance, and that is, that these cases all tend 
 toward recovery. Very few cases are to be 
 met with where some portions of the origin- 
 ally paralyzed members have not entirely 
 recovered. Of course, there are cases so bad 
 that the sufferer must always remain without 
 hope of essential improvement. Still, the 
 large majority of all the cases I have seen 
 had more than twice the paralysis when it 
 occurred, or when it was first discovered, 
 than they had at the end of the first year. 
 One arm or leg may be paralyzed, but 
 no other portion of the body affected. But 
 more frequently the patient who comes to 
 you a year after the attack, w r ith a single 
 paralyzed arm or leg, was at first paralyzed 
 in both legs or over the whole trunk and 
 extremities, but has recovered except as 
 to some single member. If the recovery is 
 complete, it generally takes place within a 
 few weeks, or at furthest a few months. And 
 
20 INFANTILE PARALYSIS, AND 
 
 it is a curious circumstance, that this spon- 
 taneous recovery of a portion of the original 
 paralysis is as much more complete in certain 
 members as it is more imperfect in the re- 
 maining ones. That is, in cases of paraplegia 
 for instance, if there is very great improve- 
 ment or complete recovery in one leg, the 
 other will improve but very little ; while, if 
 both legs improve alike, the result will be 
 more general power than in the worse leg, and 
 less power than in the better leg in the first 
 case ; as though nature possessed only reserve 
 force enough for the complete recovery of one 
 member, or a less relative improvement if this 
 force be divided between the two. But na- 
 ture, immediately after such a shock, is seldom 
 capable of repairing the whole damage which 
 has been inflicted. She does with comparative 
 rapidity what she can, and would often do 
 much more if permitted. Many a theory has 
 been triumphantly established by happening 
 to be tried at a time when nature is sure to 
 be using her reserve force to repair damages, 
 
ITS ATTENDANT DEFORMITIES. 21 
 
 and always with more or less success. If 
 the apostles of "electricity," "movements," 
 11 strychnia," the "ice bag," etc., have no 
 better data than partial recovery in a few 
 cases within the period of first recuperative 
 effort, their claims rest on a very unsatisfac- 
 tory basis. I have said in substance, that 
 there is a period of reaction during which time 
 recuperative effort is carried forward with 
 complete, or at least partial success. The 
 partial recovery may be either as to the 
 amount in all affected members, or com- 
 plete in a portion, while recuperation has 
 but slightly advanced in others apparently 
 no worse originally than the restored por- 
 tions. But why does the reparative pro- 
 cess stop half way ? Evidently because na- 
 ture may have exhausted her reserve force. 
 But why should this reparative effort stop so 
 entirely ? Why should we not expect, in ac- 
 cordance with the analogy of all recupera- 
 tive processes, a continuous, though retarded 
 improvement ? While the fact is, that after a 
 
22 INFANTILE PARALYSIS, AND 
 
 certain time improvement is very feebly mani- 
 fested and very slight in nearly all cases, while 
 in many the condition of the remaining 
 paralyzed limbs actually grows worse as time 
 passes ; averaging perhaps one case with 
 another, a total cessation of improvement 
 after the first few months. But I think it 
 can be very clearly established, that when 
 patients do not continue to improve beyond 
 a certain point, or when the improvement is 
 so feeble as only to be recognized from year 
 to year, as well as when there is no longer 
 any improvement to be seen, that it is not 
 always because nature has wholly exhausted 
 herself, but because accidental circumstances 
 have come in to interfere with her work, 
 which would otherwise have gone on much 
 further. 
 
 " CONTRACTIONS." 
 
 It is noticed that what are called " contrac- 
 tions" of various muscles, accompanied with 
 Mieir inevitable results, distortions of joints — 
 
ITS ATTENDANT DEFORMITIES. 23 
 
 begin to appear early in the history of the 
 case. And these so-called contractions go on 
 till the distortions become permanent de- 
 formities. When the contractions have pro- 
 ceeded to a certain extent, all increase of 
 muscular power ceases, and the case is gener- 
 ally considered fit only for the orthopaedic 
 surgeon. The question arises, " What is the 
 cause of these contractions ?" They occur 
 with a preponderance of certain forms ; that 
 is, talapes varus is more common than talapes 
 valgus, and contraction of the hamstring 
 muscles are more common than relaxation of 
 the same ; but there is the absence of all 
 uniformity or law in reference to it. Certain 
 contractions are most frequent simply because 
 circumstances more frequently favor them 
 than others, and not at all because the disease 
 itself predisposes particular muscles to con- 
 tract. I have used, and shall continue to use, 
 the word " contractions" in the ordinary way, 
 because the term sufficiently conveys the idea 
 of shortened muscles ; but I do not by its 
 
24 INFANTILE PARALYSIS, AND 
 
 use intend to accept the common idea of 
 active contractions of the muscles, in which 
 sense it is generally used. 
 
 NO REFLEX CONTRACTION. 
 
 It is just here where this form of paralysis 
 differs so radically from all others — from those 
 forms where there is a known lesion in the 
 nerve- center. When there is a rupture and clot 
 in, or inflammation of, the brain or spinal cord 
 or their meninges, the paralysis is always ac- 
 companied by reflex movements of the muscles, 
 rigidity, spasm, clonic spasm, pain, numbness, 
 and other indications of disturbance of in- 
 nervation. But in the form of paralysis under 
 consideration — except, possibly, during its in- 
 cipiency — there is a total absence of the least 
 variation of innervation ; no difference in the 
 quality or amount of muscular force is ever to 
 be noticed from one day to another, or varying 
 with physical or physiological disturbances. 
 In a word, Infantile Paralysis is peculiar, in 
 that it is characterized by unvarying want of 
 
ITS ATTENDANT DEFORMITIES. 25 
 
 irritability , and this want of irritability is prob- 
 ably the cause of, as well as the extent of, the 
 paralysis. What it is that has deprived the 
 muscles of their irritability, or has deprived the 
 nerves of their power of imparting their stimu- 
 lus to the muscles ; whether the origin was in 
 the nervous centers or in the nervous periphery 
 where the only evidence exists of anything 
 wrong — are questions regarding which I am not 
 prepared to express an opinion. My only 
 object at present is to direct attention to the 
 fact of the unvarying absence of irritability in 
 the muscles themselves, and the want of the 
 ordinary evidence of local disease anywhere 
 in the brain or spinal cord, as the essential 
 characteristic features of this form of paralysis. 
 
 SHORTENING OF CERTAIN MUSCLES. 
 
 11 What, then, causes the muscular contrac- 
 tions, and consequent deformities, which so 
 regularly follow as a seeming necessary con- 
 sequence of infantile paralysis ?" I reply, 
 without hesitation, that contractions and dis- 
 
26 INFANTILE PARALYSIS, AND 
 
 tortions are not necessary consequences of this 
 paralysis ; and, moreover, that these unhappy 
 results are always and entirely preventable. 
 Indeed, what seem to be contractions of 
 certain muscles — generally the flexors — are 
 not contractions at all, but simply a me- 
 chanical shortening of muscles when their 
 attachments are for a length of time brought 
 nearer together. Furthermore, this tendency 
 of muscles to adapt their length to the position 
 in which they are for a time placed, is found 
 to be much less in these cases than where 
 there has been no paralysis at all. And, as 
 might be supposed, the greater the paralysis, 
 the less the shortening of flexor and other 
 habitually relaxed muscles ; and, on the other 
 hand, the less the paralysis, the more readily 
 do these muscles assume a permanently 
 shortened condition when the limb is kept for 
 a time in such an attitude that the ends of 
 the muscles approach each other ; and when 
 muscles are not paralyzed, they become short- 
 ened or elongated according to the accidental 
 
ITS ATTENDANT DEFORMITIES. 27 
 
 position of the limb much more readily than 
 when paralyzed. In case of hip-joint disease, 
 for instance, a very short time will often 
 suffice to cause certain muscles to become so 
 much shortened as to require tenotomy. But 
 in infantile paralysis, the shortening of certain 
 muscles is not the first or principal damage 
 done by improper and careless positions of 
 the paralyzed limbs. 
 
 LENGTHENING OF MUSCLES. 
 
 The shortening, though the most noticeable, 
 is not the first or worst complication which 
 arises to arrest the progress of improvement 
 and to set in train a series of conditions 
 favoring the formation of distortions and 
 deformities. Any position of a limb which 
 allows the extensor muscles to become short- 
 ened must inflict a worse damage on the flexors 
 by keeping them extended till they lose their 
 remaining irritability and become degenerated. 
 Now, we have another fact connected with 
 these cases when they have arrived at the 
 
28 INFANTILE PARALYSIS, AND 
 
 stage of deformity, viz., this: the difficulty of 
 treatment consists much less in relaxing the 
 shortened muscles than in giving tone and 
 strength to their antagonists — the lengthened 
 and weakened ones. Indeed, it is this, in the 
 destruction of all remaining muscular irrita- 
 bility, and in many instances the destruction 
 and entire loss of the substance itself of the 
 expanded muscle, which constitutes the prin- 
 cipal anxiety in treating this class of de- 
 formities. As this important consideration 
 has been many times neglected, if not entirely 
 lost sight of, let us consider the effect of 
 simple extension upon the power and func- 
 tions of muscular tissue in its healthy state. 
 
 PROPOSITIONS. 
 
 In reference to this, the following are 
 believed to be true, viz. : 
 
 1st. To retain a healthy muscle in an 
 expanded state for a certain length of time is 
 to diminish or destroy its irritability and con- 
 tractile force. 
 
ITS ATTEMDANT DEFORMITIES. 29 
 
 2d. To extend a muscle while in the act 
 of contracting, that is, to overcome it, is to, 
 at once, destroy its irritability and force. 
 
 A moment's reflection will call up ample ^ 
 illustrations of the correctness of the foregoing ' 
 statements. 
 
 1. — A few months ago, Dr. Wm. H. Van 
 Buren read a paper before the New York 
 Academy of Medicine, on the successful treat- 
 ment of spasm of the sphincter ani, by means 
 of this principle of overcoming muscular 
 action. His treatment for this most distress- 
 ing disease is as efficacious as it is simple and 
 speedy. By inserting the thumbs within the 
 sphincter and placing the fingers on each 
 haunch as fulcrums, by a powerful effort he 
 stretches the hypertrophied muscle to the 
 fullest extent between the ischii. The irrita- 
 bility and hypertonicity of the sphincter is de- 
 stroyed and the cure is thus effected. I have 
 seen several cases of relaxed muscles, and one 
 case of real club-foot, which had been caused 
 by a violent extension of muscles while in the 
 
30 INFANTILE PARALYSIS, AND 
 
 act of contracting, which had from that moment 
 caused paralysis of those muscles. 
 
 THE " INDIA-RUBBER MAN." 
 
 * " There is a curious illustration of the 
 effect of extension on the ligaments and mus- 
 cles now in this city. At one of the minor 
 theaters there is exhibiting what is called the 
 "india-rubber man" — an individual whose 
 business it is to contort himself in the most 
 unheard-of and inconceivable manner — dislo- 
 cating his joints, laying his leg up along the 
 spinal column, and otherwise defying ordinary 
 anatomical laws. How did he attain this re- 
 markable flexibility of joints and relaxation of 
 muscles ? Muscles and ligaments are for the 
 purpose of holding the frame together, rather 
 than of facilitating its separation. I have 
 been informed that every day this man 
 subjects himself to a process of continuous 
 
 * From my paper on " Tenotomy," in the N. Y. State Medical 
 Society's Transactions for 1865. • 
 
.ITS ATTENDANT DEFORMITIES.. 31 
 
 stretching of the muscles. A heavy weight 
 is tied to the foot, which he holds pendent, 
 slowly swinging in the air. The same is done 
 to the arms and the whole body. The result 
 is an almost complete destruction of the 
 tonicity of the muscles and a corresponding 
 relaxation of all the tissues. The muscular 
 power is so overcome, and he is so nearly 
 paralyzed, that he can hardly walk ; he is 
 wholly incapable of a firm embrace ; the 
 spinal column can be made to reverse the 
 natural curves, and, altogether, he is an illus- 
 tration on a large scale of what must and 
 does occur in a single muscle or group of 
 muscles when subjected to continued or 
 violent traction or extension. The only 
 possible results, loss of irritability and de- 
 generation, are sure to follow. It might be 
 inferred, and such is the fact, that the effect 
 of extension is greater in the paralyzed 
 muscle than in the healthy tissue, and that a 
 slight degree of continuous or comparatively 
 feeble sudden extension, which might be harm- 
 
32 INFANTILE PARALYSIS, AND 
 
 less in healthy muscles, may be capable of 
 destroying altogether the feeble irritability 
 and power of a recently paralyzed muscle. 
 
 1 ' The fact that continuous extension has 
 the power of diminishing, and ultimately 
 destroying, the contractility of muscles, may 
 be explained without supposing rupture of 
 the fiber-cells, when we remember that 
 the course of the muscular fibrillae is not 
 straight but zigzag, and that in contraction, 
 this eccentricity is increased, the fibers being 
 thrown up into irregular zigzags. In pro- 
 longed extension, these eccentrics may be 
 destroyed and the spaces closed up by the 
 presence and pressure of other straightened- 
 out fibers. Instead of a wavy mass, the fibers 
 may approximate straight lines with a loss 
 of some of the most essential features of 
 muscular tissue and a corresponding loss of 
 contractility. 
 
 "It is no doubt already correctly inferred, 
 that I place much more importance on the 
 loss of power in certain muscles as explained 
 
ITS ATTENDANT DEFORMITIES. 33 
 
 above (a relative loss of power beyond the 
 primary effect of the original paralysis), than 
 on the shortened condition of certain other 
 muscles — their antagonists — which is usually 
 referred to as the cause of these deformities." 
 
 DIFFERENT DEGREES OF PARALYSIS IN DIFFERENT 
 MUSCLES. 
 
 Nothing is more noticeable than the vary- 
 ing degrees of paralysis in different extrem- 
 ities of the same individual, and indeed in the 
 same limb. It is true of these cases, that 
 there may be complete loss of contractility in 
 muscles receiving their nervous supply from 
 the same nerves, and even in contact with 
 other muscles evincing considerable muscular 
 power. There is no other explanation of this 
 apparent defiance of all known physiological 
 laws than the one I have given. But as a 
 matter of fact, these variations — this relative 
 losing or gaining of force — correspond exactly 
 in all cases with the position of the muscles, 
 
 whether they have been kept in extension or 
 
 2* 
 
34 INFANTILE PARALYSIS, AND 
 
 relaxation ; for muscles allowed to relax — all 
 other things being equal — gain as much as 
 the extended ones lose. The muscles kept 
 in a shortened position, recover irritability 
 more readily than if kept extended to their 
 natural length ; but having no extension, 
 become in time inelastic and tendonous ; 
 while those kept unnaturally extended, lose 
 their irritability and become thin and de- 
 generated. 
 
 And having thus destroyed the harmonious 
 action of the muscles, as well as their length 
 and mechanical adaptation, we have the first 
 elements of a deformity. 
 
 POSITION THE SOLE CAUSE OF SHORTENING AND 
 RELAXATION OF MUSCLES. 
 
 Having shown that position of the limbs 
 alone is sufficient to cause deformity even in 
 the healthy subject, it only remains to inquire, 
 "Is this actually the case in infantile pa- 
 ralysis ?" The reply must be affirmative. 
 
 The particular steps toward the production 
 
ITS ATTENDANT DEFORMITIES. 35 
 
 of deformity subsequent to an attack of 
 infantile paralysis are simple enough. Sup- 
 pose there is an attack of infantile paralysis 
 during the period of extreme loss of mus- 
 cular power ; the mere weight of the feet 
 is more than the flexors can resist, and 
 they are therefore drawn out. If the patient 
 be abed, the position of the feet is that of 
 extension — the toes droop by their own 
 weight. This dropping down of the foot 
 is aided — if not anticipated and provided 
 against, as it ought to be — by the ordinary 
 handling of the child ; the lifting and the 
 friction of the heel against the mattress as 
 the child is placed in bed under the covers ; 
 and thus it is kept up till talipes equinus is 
 actually produced. 
 
 Fig. 1 represents talipes equinus after the 
 foot has been used in locomotion. And 
 when recovery begins to take place, the first 
 feeble return of contractile power in the 
 flexors is resisted and overcome, while the 
 extensors, already in a shortened position, 
 
36 INFANTILE PARALYSIS, AND 
 
 finding no resistance, assume permanently a 
 shortened position. Now, what is the result 
 from this beginning? 
 
 Fig. 1. — Talipes Eqtjinus. 
 FORMATION OF VARIOUS DEFORMITIES. 
 
 The position of the other muscles up to this 
 time may not have been sufficiently unnatural 
 to cause much variation of force in them. 
 But when the patient has regained sufficient 
 strength above the feet to begin to use the 
 legs, he can not use them, because he has no 
 
ITS ATTENDANT DEFORMITIES. 37 
 
 perfect feet to stand on. The destroyed 
 flexors of the feet let the toes drop to the 
 floor, and the shortened extensors hold them 
 there. He is thus forced to sit, unable to 
 make use of the power he has up to this time 
 recovered in the legs above the ankles, 
 because of the deformity of the feet oc- 
 casioned from want of care, to prevent the 
 relaxation of the gastrocnemii muscles. Not 
 till after the patient begins to sit, do we usually 
 find shortening of the flexors of the legs and 
 thighs. And thus sitting inevitably sets agoing 
 renewed conditions favoring, and if persisted 
 in, compelling, lengthening of the extensors 
 and shortening of the flexors of the legs and 
 thighs. There are seldom other deformities 
 than the simple, equal extension of the 
 flexors of the foot, and shortening of the 
 flexors of the legs and thighs, while the 
 patient remains in bed or only sits. But if 
 he progresses still further, and begins to 
 stand and walk, either the paralysis is so 
 slight that the attitude of standing forces out 
 
38 INFANTILE PARALYSIS, AND 
 
 and lengthens the shortened muscles ; and, 
 relaxing the extended ones, allows them to 
 regain their lost power, and the patient 
 recovers more or less perfectly ; or, as often 
 happens, the tendo-Achillis will not yield, 
 the patient is thrown off the balance in efforts 
 to sustain himself ; the foot is twisted and con- 
 torted," and we get variations from talipes equi- 
 nus, which has existed up to this time. The 
 lateral muscles of the foot, already partially 
 overcome by their position, are forced out, as 
 the ankle twists to one side or the other ; 
 and we have talipes varus, valgus, and other 
 complications. If but one leg is paralyzed, it 
 is most frequently talipes varus ; but if both 
 legs are affected, it is generally talipes varus 
 on the side where the extensors of the knee 
 are weaker, and valgus on the side of the 
 stronger leg. The limping to relieve the 
 weaker leg throws an increased weight on 
 the originally better leg in such a way as to 
 overcome what were and would have re- 
 mained the stronger muscles, and we have 
 
ITS ATTENDANT DEFORMITIES. 
 
 39 
 
 as a result talipes valgus (see fig. 4), and 
 weakening of the hamstring muscles — results 
 opposite from the first tendency. Fig. 2 
 very well illustrates this idea. This peculi- 
 
 Fig. 2. 
 
 arity of locomotion often actually converts 
 what was, and should have remained, the 
 stronger foot and leg into the more deformed 
 
40 INFANTILE PARALYSIS, AND 
 
 and weaker. For talipes valgus, though not 
 so unsightly, is not so readily cured as talipes 
 varus. 
 
 The same general cause may also produce 
 the knock-knee (either alone or in connection 
 with the other deformities), and other com- 
 plications. So that to cure a talipes varus 
 of one foot, will often go far toward relieving 
 talipes valgus of the other foot. Of course, 
 we may have the same form of talipes of 
 each foot, but then it is usually varus. 
 In general, it may be said that all talipes, 
 except equinus, are produced after the patient 
 begins to bear weight upon his feet, and are 
 caused by the impossibility, in most cases, of 
 standing with shortened tendo-Achillis and 
 talipes equinus. The ankle bends down in 
 the direction of least resistance, which is 
 most frequently outward — overcoming and 
 elongating the tibialis- anticus and posticus 
 muscles. In other words, talipes varus is the 
 first effort of attempting to stand ; while 
 talipes valgus is generally brought on later 
 
ITS ATTENDANT DEFORMITIES. 
 
 41 
 
 by walking. But in some cases, placing the 
 child too early on its feet may at once 
 destroy all contractility of the extensors of 
 
 Fig. 3.— Talipes Varus. 
 
 the foot, and talipes valgus, or at a later 
 period talipes calcaneus, may be the result. 
 
 The last mentioned deformities — talipes 
 valgus and calcaneus — most frequently occur, 
 for the reasons above given, on the least 
 affected leg in paraplegia ; or if but one leg 
 
42 INFANTILE PARALYSIS, AND 
 
 is affected, and either of these deformities 
 follows, there is generally less paralysis, 
 except as to the foot, than when followed by 
 equinus or varus. In a word, the limb is 
 strong enough above the ankle to have more 
 weight thrown upon it to support. Fig. 4 
 represents talipes valgus, and fig. 5 talipes 
 calcaneus. 
 
 Fig. 4. — Talipes Valgus. Fig. 5. — Talipes Calcaneus. 
 
 It is thus seen that these several deform- 
 ities of the foot — which are often the direct 
 cause of other deformities at a distance from 
 
ITS ATTENDANT DEFORMITIES. 43 
 
 the extremities — are entirely accidental in 
 their origin, the worst form of talipes even 
 occurring on the least paralyzed leg ; the 
 paralysis being the occasion, but not the 
 direct cause, of these deformities. I have 
 dwelt on the manner in which club-foot 
 is produced in these cases, because it is the 
 first to appear, and is the most conspicuous. 
 The other distortions of the limbs come on 
 later, because the conditions favoring their 
 production are less constant and are generally 
 entirely wanting for a long time after the 
 accession of the paralysis ; being deferred 
 often till after the deformities of the foot have 
 become a fact largely influencing the forma- 
 tion of the other distortions. As the patient 
 recovers, if he can not walk, or walks with 
 great effort and imperfectly, he must sit a 
 great part of the time. Hence, after a while, 
 shortening of the flexors of the thigh and leg 
 begins to be manifest, with the inevitable 
 relative diminution of irritability and strength, 
 and finally degeneration of the quadriceps 
 
44: INFANTILE PARALYSIS, AND 
 
 extensor of the leg and even the glutei. It 
 does not take but a slight flexion at the 
 several joints to cause a deviation from the 
 equilibrium and the throwing of the osseous 
 framework off its balance, when the whole 
 weight is thrown on the muscles and liga- 
 ments. These give way in various directions, 
 producing a sad catalogue of deformities. 
 
 THESE DEFORMITIES ARE ALWAYS PREVENTABLE. 
 
 If I have stated nothing but the facts — anc 
 I have simply told my experience, begin 
 with no theory and anticipating no conclu- 
 sions — it follows as an inevitable corollar} 
 that the deformities ordinarily attending infantile 
 paralysis are entirely preventable! I do not 
 say that the paralysis itself is always curable ; 
 but, that the distortions generally following 
 it are not a necessary consequence of the 
 paralysis, and need not exist with it; and 
 they will' not exist if seasonable and proper 
 precautions are taken to avoid the secondary 
 injuries to which the peculiar condition of 
 
ITS ATTENDANT DEFORMITIES. 45 
 
 the muscles renders them liable. In these 
 cases no muscles contract ; they only become 
 shortened after having been kept relaxed for 
 a considerable time. The improvement, be it 
 more or less, would be uniform if the flexors 
 of the foot and extensors of the leg and thigh 
 were not kept in an extended position till 
 they had lost their irritability and force. If 
 the feeble muscles and ligaments of the joints 
 were not subjected to overwhelming strain, 
 by bearing too early an injudicious weight, 
 they would not give way under the first 
 attempt at exercise, instead of being strength- 
 ened by it — which they might be, if proper 
 precaution were observed, 
 
 TREATMENT OF THE PARALYSIS. 
 
 The treatment of infantile paralysis in the 
 early stages consists, for the most part, in non- 
 interference with the recuperative efforts of 
 nature. While the nervous system is com- 
 pletely overwhelmed by a recent shock, no 
 treatment (for the paralysis) is good treat- 
 
46 INFANTILE PABALYSIS, AND 
 
 ment. The general indications of the case 
 should first be attended to, of course. For 
 many months, and till interrupted by the 
 causes heretofore named, the tendency is 
 toward recovery ; though this recovery is, or 
 seldom would be, complete without appropri- 
 ate aid, and not often even then. Still, as I 
 have said, the natural tendency is toward 
 recovery ; and let no one fancy that his pet 
 remedy administered at this stage has effected 
 the change for the better. He may deceive 
 himself, but not those who have had experi- 
 ence in these cases. 
 
 We are to remember how little it may take 
 to injure the enfeebled muscular tissue, and 
 diligently guard the patient from possible 
 harm — knowing the direction from which 
 injury is most likely to come. To this end, 
 first of all, the patient should have the feet 
 protected from extension by their own weight. 
 This can be effectually done by placing them 
 on a kind of sandal or shoe, as shown in fig. 
 6, for keeping the foot at a right-angle with 
 
ITS ATTENDANT DEFORMITIES. 
 
 47 
 
 Cie leg. A careful decumbency is sufficient for 
 other muscles while the patient remains in 
 bed. After a time, the reaction from the first 
 prostration begins to take place, the febrile 
 
 Fig. 6. 
 
 symptoms subside, and all the bodily functions 
 resume their usually healthful course, except 
 the power of motion in certain extremities. 
 Even here, there is generally some decided 
 improvement. If one extremity continue 
 paralyzed, others, which at first seemed to be 
 equally affected, rapidly regain their usual 
 strength. But in certain members, the pro- 
 gress of amelioration is slow, and, may-be. 
 not sufficient to be noticed under ordinary 
 circumstances. 
 
48 INFANTILE PARALYSIS, AND 
 
 RECUPERATIVE PERIOD. 
 
 And here we arrive at a very critical 
 period. A certain amount of recuperation 
 has taken place with a corresponding amount 
 of improvement in some, at least, of the 
 muscles. How shall we keep up this re- 
 cuperative process ? Every organ is strength- 
 ened by the proper exercise of its function. 
 Whatever power there may be in a muscle 
 after a certain time, needs to be used in order 
 to develop more. But there may not be 
 enough for the purposes of locomotion or 
 actual bodily use ; and to let what has accu- 
 mulated remain inactive, is to enfeeble what 
 force there is for want of use. On the one 
 hand, there is the danger of breaking down 
 the inadequate muscles by placing the whole 
 weight of the body on them in premature 
 efforts to walk ; a^d on the other hand, 
 without effort the muscular strength will not 
 continue to increase. 
 
ITS ATTENDANT DEFORMITIES. 49 
 
 LEGITIMATE MUSCULAR ACTION. 
 
 Evidently, then, we must contrive to afford 
 the muscles opportunity to act within their 
 capacity — alike avoiding inactivity or over- 
 action — until their development has reached 
 the point where they are capable of being 
 made available in sustaining the weight of the 
 body, and in locomotion. The muscles of a 
 leg, for instance, may be capable of sustaining 
 thirty pounds' weight, not only without injury, 
 but with actual benefit ; when sixty pounds 
 — the weight of the patient, perhaps — would 
 cause it to break down. There is evidently, 
 then, but one thing to do in such a case. We 
 must furnish the muscle an exercise that shall 
 not exceed its capacity. If thirty pounds be 
 the extent of its force, thirty pounds must be 
 the extent of its exercise. And not until the 
 powers of the muscles have been developed, 
 till they are equal to sustaining the weight of 
 the body, should they be required to sustain 
 it. There is no physiological principle more 
 clear or simple. The leg of a paralyzed child 
 
50 INFANTILE PARALYSIS, AND 
 
 in relation to its body may be compared to 
 those of an infant called upon to support the 
 trunk of a man ; they can not do it, and 
 should not be allowed to attempt it till they 
 Iiave grown equal to their load. - But every 
 particle of latent force calls for use ; action is 
 its life and growth ; and under these unusual 
 circumstances we are called upon to furnish 
 the opportunity for whatever force there is/ 
 to act. 
 
 MUSCULAR DYNAMOMETERS. 
 
 This involves contrivances for the display 
 and use of small amounts of muscular force ; 
 to specimens of which the attention is now 
 invited. These muscular dynamometers — for 
 such they properly are — embrace the prin- 
 ciple of local exercise, which is equivalent to 
 a great saving of force, in having it under 
 control and direction — as well as the one 
 more particularly under consideration, viz. : 
 the ability to detect and use minute — and 
 without such facilities inappreciable — quan- 
 
ITS ATTENDANT DEFORMITIES. 
 
 51 
 
 tities of muscular power. Fig. 7, for exercis- 
 ing the flexors and extensors of the feet, is 
 contrived on the principle of a balance ; when 
 
 Fig. 7. 
 
 the weight, W, is moved to one side or the 
 other of the center, in the slightest degree, 
 the force is opposed to the flexors or exten- 
 sors of the foot ; and instead of supporting 
 the whole weight of the body above, only a 
 few ounces may oppose the muscles. 
 
52 
 
 INFANTILE PARALYSIS, AND 
 
 Figs. 8 and 9 represent contrivances on the 
 same principle, but adapted to attain the 
 same purposes with reference to the flexors 
 and extensors of the leg. They all are 
 reversible and unlimitedly adjustable. As 
 the mechanical action of the different parts 
 
 Fig. 8. 
 
 of our locomotive apparatus varies at each 
 joint, each contrivance must be adapted to 
 its special needs. But the principle of making 
 them all measures of force, and the means for 
 using and developing the same, must remain 
 the same throughout all. In the apparatus 
 represented in fig. 10 the whole leg is used 
 
ITS ATTENDANT DEFORMITIES. 
 
 53 
 
 as in the very act of walking, but with any 
 
 desired amount of force, from a few ounces' 
 
 I 
 up to more than the weight of the human 
 
 Fig. 9. 
 
 form ; and the contrivance is so arranged that 
 as the limb is flexed the resistance is less, 
 which increases as the limb is extended and 
 stronger, so as to secure a steady, equal 
 
5i 
 
 INFANTILE PARALYSIS, AND 
 
 amount of effort in all positions ; the resist- 
 ance being more when the leg is extended 
 and stronger, and less when the leg is flexed 
 and weaker. And so every apparatus for 
 
 Fig. 10. 
 
 giving exercise to a part must be adapted to 
 the special mechanical arrangement of the 
 member. If the patient has been carefully 
 attended, so that no damage has been done 
 by faulty positions while in a state of mus- 
 cular atony, there will be no difference in the 
 rate of recovery, nor will there be shortening 
 or lengthening of different muscles, and the 
 patient can begin to stand and walk at a 
 
ITS ATTENDANT DEFORMITIES. 55 
 
 much earlier stage, and with much less 
 strength, than when a very small amount of 
 shortening of muscles has been allowed to 
 take place. The reason for this is, that the 
 least contraction of the flexor muscles will at 
 once throw the patient out of his natural 
 erect position, and the weight of the body 
 must be held entirely by force of the muscles 
 instead of resting on the bony framework, 
 with only sufficient muscular aid to keep it 
 erect. In other words, every joint will be 
 slightly flexed with an impossibility of com- 
 plete extension. If these " contractions" 
 have already begun, the first attention must 
 be paid to removing them ; and when they 
 are recent and slight, extension of all the 
 joints may be made, and the patient assisted 
 to keep in the standing position by an 
 apparatus represented in fig. 11. The move- 
 able handles, C C, with the pad against the 
 knees at A, controlled either by the patient 
 or another, makes forcible or allows mus- 
 cular extension at will. The position itself — 
 
56 
 
 INFANTILE PAEALYSIS, AND 
 
 when not obtained by too much effort — is of 
 considerable value in aiding development. 
 The simple, upright position, even when main- 
 
 Fig. 11. 
 tained without the aid of the muscles, seems 
 to determine a certain amount of blood into 
 the lower extremities — perhaps by gravity — to 
 their decided benefit. And this leads us, by 
 
ITS ATTENDANT DEFORMITIES. 57 
 
 a natural step, to consider here the import- 
 ance of securing as complete a circulation in 
 the paralyzed members as can possibly be 
 obtained. It was observed in the first part 
 of this paper, that the special peculiarity of 
 infantile paralysis was that it was character- 
 ized by a greatly diminished capillary circula- 
 tion, making the loss of function due, at least 
 to a certain degree, to thie cause. 
 
 THERAPEUTIC VALUE OF WARMTH. 
 
 All those who have had experience in these 
 
 cases have recommended the warm or hot 
 
 local bath as of great value. My experience 
 
 is, that the value of local heat in these cases 
 
 can not be over-estimated. It is a constant 
 
 experience, that a limb which shows no sign 
 
 of motion before, will generally give good 
 
 evidence of awakened vitality after it has 
 
 been immersed in a hot bath. It is an almost 
 
 daily occurrence, that muscles which have 
 
 remained for years, apparently, without power 
 
 of motion, will evince contractile effort after 
 
 8* 
 
58 INFANTILE PARALYSIS, AND 
 
 the blood has been called into the inter- 
 muscular capillaries by a high degree of heat. 
 My plan is to apply the heat daily before 
 beginning their exercises ; and in the first 
 stages of the disease, the affected limbs should 
 be kept not merely warm but actually hot, 
 by means of heated bricks, bottles of hot 
 water, etc. But a dry heat is very much 
 better than the moist heat of a water bath. 
 Moisture not only can not be borne at so high 
 a temperature as dry heat, but it soaks the 
 epidermis, making the skin sensitive, and 
 preventing frequent repetitions ; once a day 
 is all it can usually be administered. And, 
 also, a large portion of the heat imparted by 
 the water bath is carried off again in the 
 subsequent evaporation from the surface and 
 epidermis into which it has been absorbed. 
 But a dry heat can be continued for hours 
 and repeated at short intervals, besides being 
 carried to a much higher degree. Parents 
 are directed to prepare a screen large enough 
 to protect the whole body of the child. This 
 
ITS ATTENDANT DEFORMITIES. 59 
 
 is put before the fire, and the patient is 
 placed behind it. Its legs are thrust through 
 and placed on a bench very near the fire, 
 where they are kept for hours at a time. 
 The heat should be kept from the child's head 
 and trunk, as we want not only positively 
 but relatively high heat. A still more effect- 
 ive plan is to place a gas-stove in a wooden 
 box, one side of which is curtained with a piece 
 of cloth having holes, through which the feet 
 and legs are thrust into the box, where they 
 are subjected to any degree of temperature 
 desired. Nothing can be more easily regu- 
 lated or more simple in its operation. 
 
 NECESSITY FOR EARLY AND CAREFUL MANAGE- 
 MENT. 
 
 It is believed that if infantile paralysis 
 were managed in its first stages on the plan 
 above indicated, having in view the physiol- 
 ogical indications and aiming at ultimate good 
 results, there would be a much larger per- 
 centage of recoveries than at present. My 
 
60 INFANTILE PARALYSIS, AND 
 
 own cases — those in which I have had the 
 good fortune to see them soon after the 
 attack — have uniformly disappointed every 
 one in the amount of their recovery. 
 
 Case 3. — A single case will illustrate the 
 principle. C. H. C, of Indiana, a lad ten 
 years old, was brought to me in June, 1862, 
 with paralysis of both lower extremities. 
 The attack had only been five weeks previ- 
 ously, and though it was a severe case, it 
 gave me another desirable opportunity of 
 conducting a case from very near the first 
 according to my own ideas of treatment. The 
 lad was large, active, intelligent — a usual 
 characteristic in these cases — particularly 
 precocious, with a rather slender physical 
 organization. About five weeks before, on 
 occasion of what was supposed to have 
 been slight over-exertion, he was taken with 
 symptoms usual with this kind of paralysis. 
 There were a few days of febrile disturbance, 
 which at first it was difficult to account for, but 
 when the paralysis was discovered, was called 
 
ITS ATTENDANT DEFORMITIES. 61 
 
 spinal meningitis. But whatever the cause, 
 his bodily health was perfect when I saw him, 
 and he had been brought a thousand miles to 
 me without the least inconvenience. There 
 was slight motion in the lower extremities, 
 but utter inability to walk or stand ; the legs 
 were diminished in size and lower in temper- 
 ature than natural ; all the other functions 
 were perfectly performed ; almost better, his 
 parents thought, so far as appetite, digestion, 
 and flow of animal spirits were concerned, 
 than before the attack. His treatment was 
 conducted on the principles and substantially 
 after the plan set forth in the preceding 
 pages. As he could not walk, he used to 
 slide himself along upon his haunches by his 
 hands, and it was fully two years before he 
 could walk alone. But he did walk at last ; 
 and for the past two years there has not been 
 found a more active and enduring young 
 person of his age and constitution in his 
 native city (Richmond, Ind.) There is no 
 dropping of the foot, twisting of the ankle, 
 
G2 INFANTILE PARALYSIS, AND 
 
 weakness of the knees, or halt or limp to 
 show that for two years and over he was 
 paralyzed and not able to take a step ! But 
 the point I wish to make in bringing this 
 case forward is, that during all these two 
 years of paralysis there were no so-called 
 "contractions" with their attendant distor- 
 tions and deformities of the paralyzed lower 
 extremities ! If deformities are a necessary 
 consequence of this form of paralysis, why 
 did they not occur in this case ? They were 
 not removed — had they been, the recovery 
 would never have been perfect ; but they 
 were prevented, by not allowing the condi- 
 tions to occur which cause shortening of the 
 muscles. Then why not prevent them in all 
 cases ? I do not hesitate to say that I believe 
 they might be thus prevented in all cases ; 
 though I do not pretend that even to prevent 
 deformity would in all cases be followed by 
 complete recovery from the paralysis, though 
 it would certainly increase the number of 
 recoveries. 
 
ITS ATTENDANT DEFORMITIES. 63 
 
 INJURY FROM DELAY. 
 
 But it unfortunately happens that in the 
 greater number of instances the orthopaedic 
 surgeon does not see the case in the early 
 stage of the disease, when he might advise a 
 course calculated to prevent deformity and 
 give the greatest chance of ultimate recovery ; 
 but the patient is brought to him with not 
 only paralysis, but paralysis accompanied 
 with different forms of distortions of the 
 affected limbs. He is not permitted to cure 
 the case now, even if a cure at first had been 
 possible ; but he must address himself to the 
 removing, so far as possible, of the two-fold 
 damage. It is now too late to think of 
 radical cure ; hereafter he must labor long 
 and anxiously to imperfectly repair what 
 might have been much more easily prevented. 
 But the slightest improvement in a child or 
 young person who is to enjoy such improve- 
 ment for a lifetime is to be diligently sought 
 and gratefully acknowledged. 
 
64 INFANTILE PARALYSIS, AND 
 
 TREATMENT OF THE DEFORMITIES. 
 
 We come now to the means for removing 
 the deformities allowed to be attendant on 
 infantile paralysis. And even here the de- 
 formity itself is not that which is the chief 
 thought ; for although there is something 
 very tangible in a club-foot, our surgery 
 should come in to divide the shortened 
 tendon for an ulterior object, the relieving 
 and restoration of the flexor muscles. Our 
 tenotomy should have quite as much reference 
 to the lengthened as to the shortened muscles. 
 And this is the secret — which should be no 
 secret — of the frequent failure of tenotomy 
 to effect that permanent benefit which it at 
 first promised and seemed to afford. When 
 no attention is given to the development of 
 the antagonists of the shortened muscles, 
 there is always danger of a recurrence of the 
 same condition. It must occur again if the 
 same causes continue to exist after, as before, 
 the operations. Where there is but partial 
 paralysis, and the shortening not extreme— 
 
ITS ATTENDANT DEFORMITIES. 65 
 
 implying retention of a certain amount of 
 force in their antagonist muscles — there may 
 be spontaneous development of these weak- 
 ened but not wholly exhausted muscles oc- 
 curring too soon after tenotomy to allow of 
 ultimately losing what is gained. But here, 
 as in all cases, the tenotomy was but the first 
 step — the loosening of the cords which pre- 
 vented motion, and the development — which 
 is the real cure — followed as a natural conse- 
 quence. So that while our art of surgery or 
 mechanics is applied directly to the tendons 
 and muscles which resist the movements and 
 bind up the parts in a distorted position, the 
 real result — which does not make, but permits 
 the cure — is the releasing the drawn out and 
 weakened muscles. There are indeed in- 
 stances when we are content to accept much 
 less ; where, if the limb be straightened, that 
 is all we hope to do. In such a case, the 
 lower part of the leg is used by active muscles 
 higher up, for purposes of locomotion, the 
 same as a wooden leg would be, and it has 
 
G6 INFANTILE PARALYSIS, AND 
 
 precisely the same use ; it is the bony frame, 
 not the muscles, which is used. 
 
 Observing that patients with paraplegia 
 differed exceedingly in the apparent use of 
 their legs — some with what seemed much 
 greater paralysis appearing to surpass in 
 powers of locomotion those retaining consid- 
 erable muscular force — I was for a long time 
 at a loss to account for this singular state of 
 things. But it seems to be the fact, that 
 where the paralysis is very complete, little or 
 no shortening of the muscles takes place — as 
 from the nature of the case we might on 
 reflection see must be the fact — and the whole 
 limb, or that part of it below the knee, is 
 moved by the muscles attached to the trunk, 
 which always retain much greater force — as an 
 artificial limb would be. And if the leg and 
 thigh are in the same perpendicular line, the 
 weight of the body is easily borne on the 
 osseous framework without the help of the 
 muscles ; and, unless the toe is hit, or some 
 cause should throw the knee forward, the 
 
ITS ATTENDANT DEFORMITIES G7 
 
 patient can progress without much trouble. 
 The foot is thrown far forward with a peculiar 
 swing— especially peculiar when both legs 
 are in this condition — and brought slightly 
 back, and the knee pressed backward by 
 leaning forward the trunk, so as to be sure 
 that the knee-joint is fully extended. In 
 general, the person has so often pressed the 
 knee backward with the hand on rising from 
 a chair and in other situations when he did 
 not feel secure on his feet, that the posterior 
 ligaments have been stretched till the leg no 
 longer forms a perpendicular line, but curves 
 backward. This enables him to make very 
 good locomotion ; but it effectually prevents 
 the slightest improvement in the power of the 
 muscles after the moment the knee passes 
 back of the perpendicular line of the leg. 
 
 NECESSITY FOR CARE AND JUDGMENT IN THE 
 USE OF MECHANICAL FORCE. 
 
 The flexor muscles are extended and 
 weakened by extreme extension, and the 
 
68 INFANTILE PARALYSIS, AND 
 
 extensors are never excited to action — the 
 motion at the knee, in such a case, being a 
 mechanical one, effected by flexors of the 
 thigh ; and hence they become degenerated 
 for want of use. The same cause produces 
 precisely the same result in the non-paralyzed 
 muscles, as the following case will illustrate : 
 
 Case 4. — A young girl had been treated for 
 morbus coxarius by counter-extension. The 
 treatment had been successful so far as to 
 arrest the diseased action in the hip-joint ; 
 but when she attempted to walk, it was found 
 that she had almost no strength in the knee, 
 and in that condition I first saw her. I 
 found, on examination, both extensors and 
 flexors of the leg with nearly complete 
 paralysis, and so great relaxation of the 
 posterior ligament and flexor muscles of the 
 knee, that on extension the knee would be 
 pressed some three inches back of the natural 
 position. Hence the injury by severe exten- 
 sion of the flexors and degeneration and 
 atrophy from non-use of the extensors of the 
 
ITS ATTENDANT DEFORMITIES. 69 
 
 leg, precisely as so often happens in infantile 
 paralysis. It was ascertained, on inquiry, 
 that, in effecting the counter-extension for 
 relieving the hip-joint, the adhesive straps 
 had been applied to the leg entirely below the 
 knee, the attending physician apparently not 
 suspecting that a force which could overcome 
 the powerful muscles about the hip-joint 
 would be liable to draw asunder the weaker 
 muscles of the knee. This case did not, and 
 could not, recover without aid, while the leg 
 was used, because it was, from the nature of 
 the case, self-continuing. It was cured by the 
 same means employed for the same condition 
 when preceded by infantile paralysis. This 
 treatment consists simply in applying an 
 apparatus with a stop-joint at the knee, which 
 will entirely prevent excessive extension, or, 
 indeed, will not allow the extension to be 
 quite as complete as natural. If the ap- 
 paratus is so adjusted that in standing the 
 knee can not quite reach the perpendicular, 
 that situation greatly stimulates the extensor 
 
70 INFANTILE PARALYSIS, AND 
 
 muscles, which soon recover when there 
 has been no paralysis ; and more slowly, of 
 course, if the muscles have been previously 
 paralyzed. The flexors also, kept continu- 
 ously relaxed, soon begin to shorten accord- 
 ing to the general law in such cases. 
 
 INFLUENCE OF DIVERSE CAUSES. 
 
 But this deformity (that produced by ex- 
 tension) is less frequent than permanent 
 flexion at the knee ; and when it does 
 happen, it can nearly always be traced to the 
 effects of oft-recurring over-straining, rather 
 than to constant position. For instance, the 
 talipes varus and flexion at the knee of one 
 leg, which is originally the leg the more 
 paralyzed, may cause talipes valgus and 
 extreme extension at the knee on the other 
 leg, which was originally but slightly affected, 
 and would have entirely recovered but for 
 these accidents. I say accidents, because it is 
 owing to the crippled condition of the one leg 
 that the weight of the body is constantly 
 
ITS ATTENDANT DEFORMITIES. 71 
 
 thrown over upon the better leg in such 
 a manner as to overcome the recovering, 
 though still enfeebled muscles of the other. 
 Thus we have produced talipes valgus by the 
 extension of the peronei and gastrocnemius 
 muscles. At the same time we may have 
 knock-knee, or extreme extension of knee by 
 relaxation of internal or posterior ligaments, 
 as shown in fig. 2. 
 
 This explains why we so generally find 
 such strange disproportions in the location and 
 degrees of weakness in different groups of 
 muscles. There - is no deformity, however 
 anomalous it may seem, that can not be 
 accounted for in the operation of wholly 
 preventable causes. 
 
 We find on the side of weaker gluteii the 
 stronger flexors ; and as we examine each set 
 of muscles which acts in concert with others to 
 produce a certain motion, there is never the 
 same condition in the corresponding group of 
 muscles in the two legs, nor in those co-oper- 
 ating to produce combined movements in the 
 
72 
 
 INFANTILE PARALYSIS, AND 
 
 same leg ; this result having been produced by 
 the purely accidental causes just explained. 
 
 EXTENSION TENOTOMY. 
 
 i In case there is flexion at the knee (fig. 
 12), even when it is only slight, if the 
 
 Fig. 12. 
 
 strength of the muscles has been so weak- 
 ened, either by the -previous paralysis or by 
 subsequent persistent extension of the ex- 
 
ITS ATTENDANT DEFORMITIES. 73 
 
 tensor muscles as to be unable to support the 
 body, no attempt at developing these muscles 
 will be at all availing until they have been 
 liberated from their unnaturally drawn out 
 position. This may be done either by divid- 
 ing the tendons of the shortened flexor 
 muscles or by extending them by mechanical 
 means, when that is possible. In either case, 
 and in all such cases, the object is to liberate 
 the confined joint and allow of motion, in order 
 that development, which has been stopped, 
 may go on. In many cases it will not be 
 found necessary to use the knife. But when 
 tenotomy is resorted to, some contrivance for 
 keeping up extension will be found absolutely 
 necessary, in order to sustain the limb in the 
 extended position until all the parts have 
 become adapted to their changed position. 
 Experience had taught me this. I noticed, 
 as previously remarked, that persons with 
 the knee bending slightly backward could 
 walk, bearing their weight upon the leg, 
 though there was little or no muscular 
 
74: INFANTILE PARALYSIS, AND 
 
 power ; while a very slight flexion at the 
 knee was always attended with utter useless- 
 ness of the leg in spite of considerable power 
 in the muscles. After vain efforts to develop 
 sufficient force in the extensor muscles to 
 sustain the body, I proposed to convert the 
 forward into a backward bending at the knee, 
 and adopted an apparatus (fig. 12) for that 
 purpose. The difficulty of carrying the plan 
 into successful execution did not depend so 
 much on the resistance of the muscles as on 
 the altered form of the knee-joint itself. 
 After the posterior portions of the articula- 
 tions have been in contact for a number of 
 years, they become so altered that when 
 weight is placed on the leg, the knee springs 
 forward from the mere shape of the joint 
 itself. This caused the necessity for a pro- 
 longed use of the apparatus with the idea of 
 continuing the contact of the anterior por- 
 tions of the joint until time and use had 
 so modified them that this difficulty should 
 be removed. As the ultimate object was to 
 
ITS ATTENDANT DEFORMITIES. 75 
 
 force extension so far that the knee should 
 
 pass back of the perpendicular, the action of 
 
 the apparatus was kept up in several cases 
 
 for six months, and in a few cases even longer 
 
 than that. The patients, rejoicing in the 
 
 ability to use the leg — which they could on 
 
 wearing the apparatus — and dispense with 
 
 crutches, were careful to secure adequate 
 
 « 
 support by keeping up extension. 
 
 RELAXATION OF EXTENDED MUSCLES CAUSES A 
 RESTORATION OF IRRITABILITY. 
 
 What was my astonishment and delight to 
 find, in all cases, after a lapse of a few months, 
 that the same extensor muscle which had 
 before exhibited no power, had regained con- 
 siderable contractility from having been kept 
 a long time in merely a relaxed position ! 
 However, this corresponds with other related 
 facts in connection with these cases. But this 
 fact alone, viz., the ability to restore, partially 
 at least, an enfeebled muscle by persistently 
 relaxing it, is of great consequence in the 
 
76 INFANTILE PARALYSIS, AND 
 
 treatment and prognosis of these unfortunate 
 cases. 
 
 This history would not be complete with- 
 out this concluding experience. 
 
 Case 5. — One patient — a boy — had pro- 
 gressed so far that he began to show consider- 
 able power of extension at the knee, and could 
 even take a few steps without the aid of his 
 apparatus or crutch, when one of my asso- 
 ciates, during my absence, made him an in- 
 strument, like many used, allowing "a little 
 motion" at the knee, with the not unnatural 
 idea of " exercising the muscles." At each 
 step there was a slight flexion at the knee ? 
 and downward movement of the whole body, 
 as its weight would overcome the muscles. 
 The result was, much to his chagrin, that less 
 than two months of this kind of " develop- 
 ment" sufficed to destroy every vestige of 
 power which the quadriceps extensor had 
 previously acquired ! A return to the former 
 treatment again restored the muscle to its 
 former condition, and a continuance of the 
 
ITS ATTENDANT DEFORMITIES. 77 
 
 treatment secured a continuance of improve- 
 ment. The corollary to such experience is, 
 that any " motion" which allows a muscle to be 
 overcome is injurious to its contractile power.' 
 A muscle knows no other "motion" than that 
 which allows it to contract ! 
 
 APPLIANCES CONSTRUCTED ON FALSE PRIN- 
 CIPLES. 
 
 It follows, then, that all those appliances 
 with elastic straps, ostensibly to give ex- 
 ercise to the muscles, but really allowing 
 them to be overcome with a part, instead of 
 the whole weight of the body — a difference 
 which the muscles, so long as they are still 
 overcome, must fail to appreciate — must be 
 wrong in principle. If the springs are stiff 
 enough to sustain the weight, then there 
 might as well be no springs at all. Adjust- 
 able stop-joints are better. The apparatus 
 for extension at the knee is simply a stop- 
 joint with a screw and knee-cap, as shown in 
 the cut (fig. 12). But the extension must be 
 
78 INFANTILE PARALYSIS, AND 
 
 unvaryingly persisted in till the ultimate 
 object is reached. 
 
 UNEQUAL ATROPHY OF DIFFERENT MUSCLES 
 NOT CAUSED BY THE PARALYSIS. 
 
 It must be seen that the variations in the 
 relative strength, as well as the length of 
 different muscles, do not depend on causes 
 existing in the muscles themselves, or even 
 on any peculiar condition of the nervous 
 s} r stem or the nervous centers. As another 
 illustration of the manner in which muscles 
 may be injured by remote causes, take the 
 following, which embraces a large class. Cases 
 often occur like this : a child is attacked 
 with infantile paralysis, and recovers, or is 
 supposed to have recovered. But in a few 
 years it is noticed that there is a peculiarity 
 about the gait ; the child walks well enough 
 on level ground, but is apt to stumble in 
 rough places, and finally it is perceived that 
 the leg is growing small above the knee / 
 
ITS ATTENDANT DEFORMITIES. 79 
 
 INFLUENCE OF DISTANT CONTRACTIONS ON THE 
 PHYSICAL MECHANISM. 
 
 Examination reveals a slight shortening of 
 the tendo-A chillis ; the heel does not quite t 
 touch the floor in walking, and there is 
 complete paralysis and atrophy of the quadri- 
 ceps extensor of the leg. The fact is, that 
 while the original paralysis lasted, a slight 
 shortening of the extensor muscles of the foot 
 had taken place — just enough to cause the 
 ball of the foot to touch the ground before 
 the heel — and a very little talipes equinus 
 was the result. Acting as a lever, of which 
 the ball of the foot forms one arm, the leg 
 has been extended by the weight upon it 
 without the aid of the quadriceps extensor. 
 At every step the toes reached the ground 
 first, and the knee is literally drawn back- 
 ward by the tendo-Achillis, while the extensors 
 of the leg are not allowed to act at all. The 
 result is, that in process of time these exten- 
 sor muscles become completely powerless and 
 degenerated from want of use. Those muscles 
 
80 INFANTILE PARALYSIS, AND 
 
 are much worse than if the paralysis had. 
 been somewhat greater ; for, in that case, the 
 talipes equinus would have been severe, or 
 have been converted into a talipes varus, and 
 in either case, by weakening the ankle, the 
 backward action of the tendo-Achillis is lost, 
 and the extensors of the leg would be obliged 
 to act. As these cases — which are not rare 
 — can walk well on ordinary ground, and only 
 fail in certain situations ; and as the slight 
 elongation of the foot just about compensates 
 for the shortening in other locations, it is 
 sometimes difficult to make the parents 
 understand that the case can be cured only 
 by making it temporarily appear worse. 
 
 EQUALIZING MUSCULAR AND MECHANICAL POWER. 
 
 For the first step is to lengthen — which is 
 to weaken — the tendo-Achillis ; but this at 
 once deprives the leg of its power of me- 
 chanical extension at the knee until those 
 extensors shall be increased in power suffi- 
 cient to perform their legitimate functions. 
 
ITS ATTENDANT DEFORMITIES. £1 
 
 The heel is let down — the leg is thus slightly 
 shortened — so that, altogether, for several 
 months there will be exhibited increased 
 weakness and halting. But it is the only 
 road to restoration, for if not counteracted 
 there is danger of gradual increase of mal- 
 positions and ultimate permanent lameness. 
 
 To treat a case of this kind, if it be severe, 
 the tendon may be divided ; but generally, if 
 the shortening is not great, it can be over- 
 come by an apparatus for producing exten- 
 sion of the tendo-Achillis, worn at night only, 
 but persisted in for months, and made to act 
 very efficiently. (See fig. 11.) Of course, in 
 connection with shortening of the tendo- 
 Achillis there is always more or less feeble- 
 ness of the flexors of the foot. I remember 
 several cases when, after consultation, the 
 parties were sent home w r ith no other advice 
 than to keep up nightly extension with the 
 simple apparatus with which they were pro- 
 vided, when they returned after a number 
 
 of months with very tolerable restoration of 
 
 4* 
 
82 INFANTILE PARALYSIS, AND 
 
 power in both extensors of the knee and 
 flexors of the foot. But they must have the 
 plan of treatment fully explained to them, 
 and must also be of the most intelligent class, 
 as it will be found difficult to make them 
 pursue a treatment which, at first, causes the 
 patient to be more lame and to appear worse 
 from clay to day. But it will be found that 
 as the vicarious extension decreases, the 
 legitimate action of the true extensors of the 
 leg will be stimulated, and in most cases the 
 best result attained. 
 
 I should say that it must be a very mild 
 and simple case where extension during the 
 night alone will suffice to lengthen the 
 shortened muscles or allow the elongated 
 flexors to contract. In most cases, an appa- 
 ratus with a flexion screw, as shown at the 
 ankle in fig. 12, is worn during the day ; and 
 if the case is very bad, the same may be used 
 at night also. Whatever the means, they 
 must be made efficient. 
 
ITS ATTENDANT DEFORMITIES. 83 
 
 TREATMENT OF TALIPES. 
 
 With regard to the treatment of the differ- 
 ent forms of club-foot which so generally are 
 allowed to follow infantile paralysis, the same 
 principle of treatment should be adopted 
 as in distortions of other joints ; we extend 
 or divide the shortened tendons in order to 
 relieve extended and weakened muscles ; and 
 we liberate the confined joints in order that 
 motion and development may take place. 
 The only difference between these deformities 
 of the feet and those occurring in other locali- 
 ties consists in their more complex nature, 
 and consequently in the greater difficulty of 
 adapting apparatus to the accomplishment of 
 several different and distinct ends at the same 
 time. But this task need not be so difficult 
 as it is often made. 
 
 When it is once understood that talipes 
 equinus is the first, and simplest, and most 
 natural sequence of the paralysis — the weight 
 of the foot being all that is necessary to 
 produce it — and that no other form of talipes 
 
84 INFANTILE PABALYSES, AND 
 
 is likely to occur while the patient lies in 
 bed ; and, moreover, that the bending of the 
 ankle outward (varus) is the result of weight 
 on a foot with a shortened tendo-Achillis ; 
 and that bending inward (valgus) of the ankle 
 is the result of weight partially overcoming 
 the gastrocnemius, soleus, etc. ; and talipes 
 calcaneus of weight entirely overcoming those 
 muscles, it will be found that the nature and 
 treatment of these deformities are capable of 
 great simplification. (See figs. 1, 3, 4, and 5.) 
 I have not alluded to the adductors and 
 abductors of the foot — the tibiales anticus 
 and posticus, and the peronei, because I 
 believe their influence so exceedingly small 
 in the formation of talipes that they need not 
 necessarily be taken into account ; though 
 once formed they exert a minor influence in 
 maintaining the deformity. In talipes equi- 
 nus and varus (figs. 1 and 3), the tendo-Achillis 
 is shortened ; in talipes valgus and calcaneus 
 (figs. 4 and 5), the tendo-Achillis is length- 
 ened. On the other hand, the flexor muscles 
 
ITS ATTENDANT DEFORMITIES. 85 
 
 of the foot are extended and powerless in 
 talipes equinus and varus, and are shortened 
 and active in talipes valgus and calcaneus. 
 The production of the valgus and varus, 
 though overcoming the internal or external 
 lateral ligaments of the ankle and the peronei 
 or tibiales muscles, as the case may be, must 
 have either extension or shortening of the 
 tendo-Achillis as a condition precedent. The 
 extreme distortion of the^ foot itself, with 
 the great alteration in form of the tarsal 
 bones in some cases, are all secondary and 
 subordinate matters, and disappear gradually 
 when the causes producing them are reversed 
 in time. The one essential fact which pre- 
 ponderates in considering the principle to be 
 kept in view in adapting apparatus to over- 
 come these distortions — for every apparatus 
 should be the exponent of an idea — is that the 
 os calcis is the point which determines and hence 
 controls talipes! Without a shortening or 
 lengthening of the tendo-Achillis there could 
 scarcely be a club-foot. And while we have 
 
8G INFANTILE PARALYSIS, AND 
 
 to provide for all the sequences of these 
 primary conditions, yet it should never be 
 lost sight of, that the cause must be re- 
 moved before the cure can be considered 
 complete. 
 
 APPARATUS FOR TALIPES. 
 
 The apparatus which I have used for 
 several years with great satisfaction, consists 
 of a "night" shoe and a "day" shoe. The 
 former is also worn during the day when the 
 patient can not walk, and the latter is often 
 worn at night instead of the night shoe. The 
 first consists simply of two pieces of thin 
 board — one for the sole of the foot, and the 
 other and longer piece to pass up the back 
 of the leg nearly to the knee. The rest 
 consists of the various straps and the way 
 in which they are adjusted. Much of the 
 inefficiency of many of the shoes for club-foot 
 arises from the defective manner of applying 
 the straps. For instance, how can a strap 
 which passes over the instep be expected to 
 
ITS ATTENDANT DEFORMITIES. 87 
 
 resist the strength of the gastrocnemius, soleus, 
 etc. ? Even after tenotomy, the pressure on 
 the top of the foot is often unbearable, 
 besides impeding the circulation. A better 
 way is to pass the strap entirely around the 
 
 Fig. 13. 
 
 ankle (fig. 13), fastening it on the same side 
 from which it started. Thus, in fig. 13, the 
 straps, B B, start at the heel and pass above 
 the os calcis around the ankle, just under* 
 the malleolus, and fasten on the* same side 
 
88 INFANTILE PARALYSIS, AND 
 
 and about three inches from the point they 
 started from. The straps pass around the 
 ankle in opposite directions. It will be seen 
 that these straps, instead of pressing on a 
 surface of only an inch or two in front of the 
 foot, have their pressure distributed over 
 more than the entire distance around the 
 ankle. They also pass above the heel ; and 
 besides firmly holding the ankle, they make 
 direct traction on the tendo-Achillis by their 
 downward action on the os calcis. By tight- 
 ening the straps, C C, the extensor muscles 
 are effectually antagonized. The strap A 
 simply holds the top of the apparatus in place. 
 This apparatus is just as effectual in 
 either of the other forms of club-foot as in 
 the variety just mentioned, all necessary 
 variation of action being secured by a slight 
 variation in the application of the straps. 
 For instance, by placing the foot piece in 
 contact with the sole of the foot, and allowing 
 the leg piece to pass under the leg, as shown 
 in the cuts, figs. 14 and 15, one strap, B B, is 
 
ITS ATTENDANT DEFORMITIES. 
 
 89 
 
 passed around the ankle, which is turned out 
 as before, while the other, A A, is passed 
 around the os calcis to act in the opposite 
 direction ; while a third, C, holds the meta- 
 tarsis in the same direction that the strap 
 A A holds the os calcis. Now, if we draw 
 
 Fig. 14. 
 
 the strap D, the leg piece is drawn under the 
 leg, and we have secured a most effectual 
 and complete lateral action without the use 
 of a spring or joint. If we now tighten the 
 
90 
 
 INFANTILE PARALYSIS, AND 
 
 strap E (fig. 15), as in talipes equinus, we 
 have effectually antagonized both the lateral 
 and posterior muscles, and have also the 
 quality and degree of action entirely within 
 our control. It is obvious that the same 
 
 Fig. 15. 
 
 apparatus will apply equally well to talipes 
 valgus or varus, by simply reversing the 
 action of the straps. For talipes calcaneus 
 it is only necessary to supply the posterior 
 strap, C (fig. 16), to make it a complete 
 
ITS ATTENDANT DEFORMITIES. 
 
 91 
 
 relief to the extensors of the foot and an 
 antagonizer of the flexors. 
 
 When these cases are taken at or near 
 their early stages, especially before the tarsal 
 bones have been subjected to the weight 
 
 
 Fig. 16. 
 
 consequent to walking, it only requires per- 
 severance to accomplish a restoration of the 
 equipoise between the different sets of mus- 
 cles ; and this can generally be done without 
 dividing them. But in long-standing cases 
 
92 INFANTILE PARALYSIS, AND 
 
 we meet with great difficulty in the altera- 
 tions and misplacements of the tarsal bones. 
 In all such cases we are obliged to keep up 
 the support, not only till relaxation of some, 
 and retraction of other muscles, has restored 
 a harmony of action, but also till the osseous 
 structures have been brought back, by con- 
 stant pressure in the right direction, to a 
 natural shape and position. In this case the 
 appliances just described, as they act prin- 
 cipally on the muscles, would not be sufficient. 
 We must use the same weight which was 
 instrumental in forcing the osseous structures 
 out of shape and position to bring them back 
 again. The patient must walk ; and while 
 walking he must have such appliances as shall 
 not merely allow him to progress, but shall 
 also convert what formerly was the means 
 of forcing the tarsal bones out of shape, into 
 the means of forcing them back to their proper 
 position. No apparatus without a lateral 
 action can do this. With a lateral deformity 
 in talipes varus and valgus, it is necessary to 
 
ITS ATTENDANT DEFORMITIES. 
 
 93 
 
 meet, check, and reverse this tendency by 
 lateral antagonism. The ankle brace repre- 
 sented in fig. 17 is calculated to meet the 
 indications in such cases. It consists of a T- 
 shaped piece of steel, C, with the lower end 
 
 Fig. 17. 
 
 bent at right angles and passing under the 
 sole of the shoe to which it is fastened. The 
 cross piece is just below the malleolus, and 
 from each end a strap, D D, passes around 
 
94 INFANTILE PARALYSIS, AND 
 
 the ankle. Around the heel, but acting in 
 the opposite direction, is the strap A, one 
 end of which is fastened into the sole of the 
 shoe, and the other, after passing around the 
 heel, goes through the back of the shoe and is 
 received by the slit, B, in the end of the 
 curved steel piece, which is a continuation 
 of C. At Gr is a joint allowing flexion and 
 extension, and at H is a stop-joint regulated 
 by a screw, I, which completely controls the 
 lateral action of the joint. It will be seen 
 that, as the straps D D and B B act in 
 opposite directions, either by drawing these 
 straps, or by the screw, I, we have the power 
 of turning the ankle outward or inward at 
 pleasure, and can convert the tendency to a 
 talipes varus into that for talipes valgus, or 
 the reverse, at once. As a practical matter, 
 it takes much time and perseverance, careful 
 attention, and a nice adjustment to keep the 
 apparatus constantly in order till the form 
 of the foot has been changed. The whole 
 weight of the body resting on the apparatus, 
 
ITS ATTENDANT DEFORMITIES. 95 
 
 and the distortion being resisted by it, it must 
 be made exceedingly strong. It is never 
 best to sacrifice efficiency to lightness. 
 
 THE OS CALCIS. 
 
 It will be seen that in all these appliances 
 the os calcis may almost be considered as the 
 helm by which the position of the foot is 
 controlled. And when the correct position 
 of this bone is secured and maintained a 
 sufficient length of time, the other distortions 
 of the tarsus will sooner or later disappear. 
 
 CONDITION REQUISITE IN APPARATUS. 
 
 Thus far I have spoken only of the me- 
 chanical appliances which seem best to answer 
 indications in the support of feeble joints; 
 to counteract the effect of shortened mus- 
 cles, and to relieve those whose position was 
 destructive to their irritability and force. 
 The main idea in these contrivances was to 
 have them accurately meet the indications 
 — whether of extension, relief, or support 
 
96 INFANTILE PARALYSIS, AND 
 
 — and to see that they interfered with no 
 other functions than those they were intended 
 to aid or resist. Adjustability and efficiency 
 must always be the grand object in the use 
 of mechanical agencies. There must always 
 be a principle of treatment which should be as 
 closely followed in the use of mechanical, as 
 in the use of any other therapeutic means. 
 
 DEVELOPMENT, THE PRINCIPAL OBJECT. 
 
 But even in these severe cases, when paral- 
 ysis, time, and neglect of suitable preventive 
 means have done their worst, we should still 
 be actuated by the same idea in the hope of 
 securing the largest amount of muscular de- 
 velopment of which the case is capable. Al- 
 though the mechanical treatment does secure 
 advantages of its own, it arises from the fact 
 that, by removing obstructions and protecting 
 the distorted members from injury w T hile using 
 them, there is a certain amount of spontane- 
 ous development. This spontaneous develop- 
 ment often, and in mild cases generally, 
 
ITS ATTENDANT DEFORMITIES. 97 
 
 amounts to sufficient to complete the cure. 
 But even in these cases the use of apparatus 
 only prepares the way, by removing obstruc- 
 tions, to the natural position of the parts, and 
 allowing a natural action of the muscles. 
 Development or increase of muscular power 
 is the only source of lasting improvement 
 after all. For, no matter how much or 
 how often these distortions are overcome, 
 either by surgical or mechanical means, 
 they are sure to recur unless the con- 
 ditions of paralysis and improper positions 
 are removed. 
 
 WHY DEFORMITIES RE€UE. 
 
 No matter how often the deformity may 
 have been cured, if the paralysis still exists, 
 there will be a tendency to a recurrence of 
 the same shortening of certain muscles, with 
 the same distortions as before, unless the 
 positions are constantly secured by mechani- 
 cal means. While the paralysis itself does 
 not directly produce the unequal distribution 
 
98 INFANTILE PARALYSIS, AND 
 
 of force, its existence renders the patient 
 liable, from slight and accidental causes, 
 to all those changes in the condition of the 
 muscles which were discussed in the first part 
 of this essay. In short, whatever may be the 
 apparent hopelessness of the paralysis, the 
 only object in treatment should be to remove 
 it as far as possible, and in the carrying out 
 of this idea the mechanical appliances can ac- 
 complish but the first step. 
 
 SPECIAL MEANS OF DEVELOPMENT. 
 
 The next thing to be attended to should be 
 those means which directly tend to increase 
 the nervous and muscular power of the 
 affected member. And here we come back 
 to the same remedies which are applicable in 
 the first stages of the disease. We have 
 labored long and patiently to imperfectly 
 mend what, by proper management, might 
 have been easily prevented, and now we 
 begin our actual treatment. Our object is to 
 increase the muscular power, and after the 
 
ITS ATTENDANT DEFORMITIES. 99 
 
 great and, to a certain extent, irreparable 
 loss in time, we should be prepared to 
 be satisfied with moderate amelioration, when 
 if the means had been applied in time 
 they might have gone far toward securing 
 complete restoration. Still, the stimulating 
 effect of heat and the gentle use of the 
 muscles without over-taxing them seem to be 
 the true physiological means for increasing 
 their irritability and power. 
 
 And it is truly wonderful to what an extent 
 the development may often be carried even 
 in the worst cases. Indeed, there are few 
 forms of distortion following infantile paral- 
 ysis which are so bad that they can not be 
 improved so as to afford the patient a service- 
 able limb. But it takes time and patience. 
 
 PARALYSIS OF UPPER EXTREMITIES. 
 
 Paralysis of the upper extremities is of 
 frequent occurrence ; and, incomprehensible 
 as it would appear, on the theory that this 
 form of paralysis arises from a lesion of the 
 
100 INFANTILE PARALYSIS, AND 
 
 brain or spinal cord, in the larger number of 
 cases, it is not accompanied by any paralysis 
 of the lower portion of the body. There are 
 cases of paralysis of the whole body and all 
 extremities, or of one upper and one lower 
 extremity. I have even seen a paralysis of 
 the arm on one side accompanied with paral- 
 3^sis of the opposite leg! Yet in the majority 
 of cases the paralysis affects only one upper 
 extremity. The paralysis of an upper extrem- 
 ity is characterized by the same phenomena in 
 all respects as when the disease affects a lower 
 extremity. Wherever there is extension of 
 a muscle, there we find the greatest weakness ; 
 and, on the other hand, wherever the muscles 
 have been relaxed, then they have "con- 
 tracted" or become shortened. From the 
 nature of the case, the deltoid is apt to 
 especially suffer. The weight of the whole 
 arm makes continuous traction upon the 
 deltoid, and we consequently find that muscle 
 almost invariably extended and atrophied to 
 the last degree — fig. 18. At the same time, 
 
ITS ATTENDANT DEFORMITIES. 
 
 101 
 
 we are seldom troubled with serious muscular 
 shortening, for the simple reason that the arm 
 hangs in such a manner that no muscles are 
 habitually relaxed ; but all the muscles, both 
 
 Fig. 18. 
 
 flexors and extensors, are weakened by con- 
 tinuous stretching. For this reason, the 
 paralysis of the arm, all other things being 
 
102 INFANTILE PAEALYSIS, AND 
 
 the same, is relatively worse than of the 
 lower extremities. There is seldom the same 
 amount of paralysis in flexors and extensors, 
 but the difference is generally that of different 
 degrees of weakness, according as they have 
 been subjected to different degrees of stretch- 
 ing. The obliteration of the deltoid and the 
 stretching of the ligaments and separation of 
 the head of the humerus from the glenoid 
 cavity is well shown in the cut. 
 
 The treatment for paralysis of the arm 
 must be the same in principle as for paralysis 
 in the lower extremities, with modifications 
 corresponding to the form of injury to which 
 it has been subjected since the paralysis 
 occurred. As the arm has not become dis- 
 torted by being bent down by the weight 
 above it, we have comparatively few deform- 
 ities, and these are not characterized by the 
 same degree of alteration in the osseous forms 
 as in the joints of the legs and feet. But we 
 have other difficulties equally formidable. 
 All the joints are partially drawn asunder, 
 
ITS ATTENDANT DEFORMITIES. 103 
 
 the articulating surfaces are smooth and 
 rounded, and the muscles and ligaments are 
 relaxed in many cases to the last degree. 
 
 THE MUSCLES MUST BE RELIEVED OF TRACTION. 
 
 There is one simple course to pursue. We 
 must sustain the arm, and by thus relaxing 
 the muscles, allow them to contract and regain 
 somewhat of their impaired contractility. I 
 have used with excellent effect a kind of sling 
 that partially flexes the elbow, and sustains 
 the whole arm so completely that the shoul- 
 der-joint is closed and the deltoid completely 
 relaxed. To this can be attached suitable 
 appliances for any deformities of the hand and 
 fingers which may exist. 
 
 DEFORMITY OF HAND. 
 
 The principal or most common difficulty of 
 the hand arises from atrophy of the adductor 
 muscles of the thumb. By the atrophy of 
 these muscles the thumb is drawn back into 
 the same plane as the fingers, and the ability 
 
104 
 
 INFANTILE PARALYSIS, AND 
 
 to adduct, flex, and oppose the other fingers 
 and to grasp is entirely lost. The apparatus 
 shown in fig. 19 is calculated to meet the 
 difficulty. It is made of covered tin or zinc — 
 gutta-percha will do — with the projection (a) 
 to adduct and hold down the thumb ; the 
 
 Fig. 19. 
 
 strap (i) keeps it in position. With the 
 thumb thus held opposite the fingers, the 
 patient at once begins to make the hand useful 
 in grasping and holding objects. This new 
 power also hastens the muscular development. 
 
ITS ATTENDANT DEFORMITIES. 105 
 
 The position of the thumb after atrophy of 
 its adductors is well shown in fig. 18. 
 
 The sustaining of the arm in the sling must 
 be continued uninterruptedly for a very long 
 time — it will be of no use unless kept up 
 without intermission — and should be com- 
 bined with suitable exercise of the muscles as 
 fast as they begin to recover contractile 
 power. But six months 7 suspension in the 
 sling alone before the exercises were com- 
 menced would, in many cases, be good treat- 
 ment. 
 
 The exercises should never consist of 
 hanging or holding heavy substances ; on the 
 contrary, gentle and light exercises should be 
 adapted to the feeble muscles. 
 
 HOW TO DETECT AND USE LATENT FORCE. 
 
 Fig. 20 shows an admirable apparatus for 
 exercising the deltoid muscle. So long as 
 the weight of the arm exceeds by the smallest 
 fraction the strength of the muscle, it will 
 continue to be overpowered and utterly in- 
 
106 
 
 INFANTILE PARALYSIS, AND 
 
 capable of causing the slightest movement of 
 the arm. And yet there may be within it 
 a latent strength, only needing opportunity to 
 
 Fig. 20. 
 
 be shown and developed till it might be- 
 come adequate to effect ordinary movements. 
 Suppose the arm weighs ten pounds, and the 
 deltoid could lift but five pounds — how is this 
 latent force to be made available ? Simply 
 by reducing the resistance to the muscle — 
 that is, reducing the weight of the arm — to 
 
ITS ATTENDANT DEFORMITIES. 107 
 
 three or four pounds, or to any amount less 
 than the capacity of the muscle, when we 
 should immediately witness a movement of 
 the arm by action of this muscle. The weight, 
 W, in the accompanying illustration, is moved 
 to a point where it will just balance and 
 neutralize so much of the weight of the arm 
 as shall reduce the resistance to the capacity 
 of the muscle. From this point we begin our 
 development. As the strength of the muscle 
 increases, less and less of the arm is balanced, 
 till, by-and-by, the muscle becomes capable of 
 raising the whole arm, and more. After that 
 time the power in the muscle continues more 
 than sufficient to accomplish motion. Other 
 exercises, adapted to the action of the arm, 
 forearm, wrist and fingers, must be employed, 
 if we would have the development uniform. 
 So of all actions of the various bodily mem- 
 bers ; apparatus must be contrived with such 
 complete adaptability, that the natural action 
 of the joint may be secured together with 
 most delicate measure of muscular force. 
 
108 
 
 INFANTILE PARALYSIS, AND 
 
 Fig. 21. 
 
 Fig. 21 (like fig. 17, for the ankle) illustrates a lateral action at 
 the knee. A rivet joint at A allows flexion and extension ; the 
 lateral motion at B is secured by the key C, lengthening or 
 shortening the side of the apparatus. In knock-knee, bow-leg, 
 and other deformities of the lower extremitie , lateral action is 
 indispensable. 
 
ITS ATTENDANT DEFORMITIES. 109 
 
 Iii what has been said, I have aimed to 
 illustrate principles, and hence have shown 
 the most simple adaptation of apparatus. 
 And as regarding deformities, I have avoided 
 extreme cases, and have confined my observa- 
 tions to such as, by following a consistent 
 plan of treatment, may always reward our 
 efforts with either cure or amelioration. 
 
 CONCLUSION. 
 
 The facts and arguments contained in the 
 preceding pages may be summed up in the 
 following propositions, viz. : 
 
 1. Infantile Paralysis is an arrest of vegeta- 
 tive development from some unknown cause. 
 
 2. The characteristics of this form of paral- 
 ysis suggest a peripheric blight rather than a 
 loss of central nerve-power. 
 
 3. With diminished nutrition, temperature 
 and muscular power there is also diminished 
 muscular irritability ; and there is no such 
 thing as involuntary or reflex contraction in 
 infantile paralysis. 
 
110 INFANTILE PARALYSIS, AND 
 
 4. The shortening of certain muscles is not 
 a necessary consequence of infantile paral- 
 ysis ; and when it does occur, it is simply 
 the adaptation of their length to the position 
 they happen to be in. 
 
 5. It is entirely accidental which muscles 
 become shortened, whether flexors or ex- 
 
 ' tensors. 
 
 6. Hence, deformities are not a necessary 
 consequence of infantile paralysis, and when 
 they are allowed to occur, the process of 
 recovery is arrested. 
 
 7. When deformities have already formed, 
 they should be treated for an ultimate end — ■ 
 viz., to bring the patient back to the place 
 from which he should not have been allowed 
 to diverge, where the treatment for his paral- 
 ysis should begin. 
 
 8. Hence, tenotomy and mechanical appli- 
 ances are only means to an end — the first 
 steps of a course of treatment having in view 
 the restoration of the muscular power. 
 
 9. The most natural means for this purpose 
 
ITS ATTENDANT DEFORMITIES. Ill 
 
 is the supply of local heat — involving in- 
 creased local circulation — together with local 
 exercise corresponding with the position and 
 ability of the part exercised. 
 
 10. The element of time must also be taken 
 into consideration. 
 
 The following cases will still further eluci- 
 date the foregoing views : 
 
 Case 6. — T. T., aged two years and a half, 
 was paralyzed while teething. Had had 
 several attacks of sickness, but no diarrhoea ; 
 was nervous and feverish. After lying altern- 
 ately in his crib and in his mother's arms for 
 three days, he seemed convalescing, when, 
 one day, on attempting to make him stand, it 
 was discovered that the right leg was paral- 
 yzed. The next day his left arm was found 
 to be also paralyzed. He at once began to 
 improve, and in three weeks was able to push 
 a chair about the room. In April, 1862, 
 seven months afterward, I saw him. He was 
 then a very active, nervous boy, but plump, 
 ruddy, and rather precocious. At that time 
 
112 INFANTILE PARALYSIS, AND 
 
 the hand was useless, and he walked badly. 
 After six weeks 7 treatment the use of the arm 
 and hand was fully restored. The leg and 
 foot improved equally with the hand and arm. 
 He had regained the use of the muscles, and 
 could control all his motions ; but he left 
 before he had regained enough strength in 
 the ankle to support his weight, and there 
 was some shortening of the tendo-Achillis 
 with diminished action of the flexors — not 
 enough power to lift the foot. He wore no 
 apparatus at that time, for I had not then 
 learned to anticipate and provide for the 
 effects of the weakened flexors. Two years 
 afterward he returned with a fully formed 
 talipes varus, and complete loss of power in 
 the flexors of the foot. Efforts to extend the 
 muscle proving unavailing, the tendo-Achillis 
 was divided, in the fall of 1863. Returning 
 home after the operation, I did not see him 
 for several months, and when he came back, 
 I found that extension of the muscle had 
 been carried too far; the tendo-Achillis had 
 
ITS ATTENDANT DEFORMITIES. 11<3 
 
 been too much elongated. The result was, 
 that the flexors of the foot had become in 
 turn shortened and restored to active strength. 
 Since then the chief treatment has been to 
 reverse the effects of the too great lengthen- 
 ing of the tendo-Achillis — that is, to overcome 
 the flexors and increase the strength of the 
 gastrocnemius ! 
 
 The points of special interest in this case 
 are the paralysis of one arm and leg on 
 opposite sides; the arrest of cure and the 
 formation of talipes after recovery had gone 
 on so far ; and the transferring of the seat of 
 shortened muscles from the posterior to the 
 anterior side of the leg ! 
 
 Case 7. — J. G., aged twelve years and five 
 months. In March, 1865, had slight indis- 
 position and loss of appetite, some fever, 
 and headache occurring evening and morning, 
 the latter increasing in severity as her 
 strength diminished. Complained also of pain 
 in the left leg. By the middle of April was 
 much reduced, and had an attack of diptheria, 
 
114: INFANTILE PARALYSIS, AND 
 
 from which she recovered in a few da3~s 
 without any apparent change in the other 
 symptoms. But from that time her previous 
 unpleasant symptoms gradually lessened. She 
 complained of pain in her back and legs, but 
 gained in strength. About the first of June 
 she began to try to walk ; but there was found 
 to be considerable shortening of the tendo- 
 Achillis of the left heel. She tried crutches 
 without avail, and finally could only creep a 
 little upon her knees. I first saw her on 
 the 20th of November following the attack. 
 At that time there was paralysis of both 
 legs, nearly complete loss of power in the left, 
 and shortening of the flexors of the thighs 
 and legs and of the extensors of the feet ; the 
 left foot particularly being extended nearly 
 to a line with the leg. The extensors of the 
 thighs and legs and the flexors of the feet 
 were wholly powerless. All improvement 
 which could have been of practical value had 
 ceased, and she was apparently crippled for 
 life. Believing that if the extended muscles 
 
ITS ATTENDANT DEFORMITIES. 115 
 
 could be speedily relieved, there would be a 
 further effort of Nature to resume the repar- 
 ative process (unfortunately interrupted by 
 the progress of the deformities), my attention 
 was at first directed to extending the short- 
 ened muscles. This was done by appropriate 
 apparatus, and at the same time the muscles 
 were brought into gentle use as fast as their 
 action was made possible through liberating 
 the motions. She at once began to improve, 
 and in May following I had the satisfaction 
 of seeing her walk erect and with the function 
 of every muscle restored to her. The res- 
 toration is quite complete. 
 
 This case is related to illustrate the gradual 
 and relatively prolonged course in the acces- 
 sion of the disease, as often happens in older 
 patients, and also to show the fact, that even 
 in a patient of her age it was not known at 
 w r hat time the paralysis occurred ; the arrest 
 of the recuperative process after the muscles 
 were allowed to lose their dynamic relations ; 
 and the immediate resumption of recuperation 
 
116 INFANTILE PARALYSIS, AND 
 
 when apparatus had restored them to their 
 natural positions. 
 
 Case 8. — This case is only interesting in 
 consideration of the wide extent and com- 
 pleteness of the paralysis in connection with 
 the mild character of her symptoms ; and 
 also, that even in so grave a case improve- 
 ment is still steadily going on, though at a 
 very slow rate. 
 
 S. W., aged seven years, complained of 
 some slight indisposition for two or three 
 days ; she had some fever, and headache. A 
 physician was called, who pronounced the 
 symptoms of a typhoid character, and in a 
 day or two she was found to be completely 
 paralyzed from head to foot. This was in 
 August, 1864. I saw her in May, 1865. At 
 that time she had regained tolerable use of 
 one hand ; but could neither stand nor sit, 
 and the so-called contractions existed wher- 
 ever circumstances had favored their occur- 
 rence. Of course the power of their antago- 
 nists was entirely gone. By proper apparatus 
 
ITS ATTENDANT DEFORMITIES. 117 
 
 the deformities were reduced, the contractions 
 overcome, and, as before stated, she has from 
 that day steadily continued to gain. Although 
 she can not yet walk, no deformity has 
 occurred, nor can occur so long as the same 
 principles of treatment are carried out. 
 
 Case 9. — The interesting feature in the 
 following case is the good degree of improve- 
 ment in the muscular power as a direct result 
 of the simple extension of the contracted 
 muscles. The development of muscle would 
 without doubt have been much greater if 
 her treatment had also embraced the local 
 exercises ; but in that case it would not have 
 so well illustrated the views so often insisted 
 on in these pages, that improvement is 
 arrested long before it has reached its 
 ultimate limit by positions which allow of a 
 shortening of muscles ; and also, that some- 
 times, as in this case, the process of recovery 
 may be resumed and carried forward to a 
 considerable extent years afterward, if the 
 injured muscles are relieved by extending the 
 
118 INFANTILE PARALYSIS, AND 
 
 shortened ones. In this case there was no 
 power in the flexors of the foot and extensors 
 of the leg during eight years; but they im- 
 mediately regained a considerable degree of 
 strength when the cause of the suspension 
 of improvement was removed. Apparatus, 
 shown in figs. 12 and 13, were furnished, 
 with appropriate directions. As I had never 
 seen the case but twice, and it had received 
 no other treatment, I wrote to the father for 
 the facts, which may as well be given in his 
 own words : 
 
 " My daughter Josie, who was placed tinder your 
 care in May and November, 1865, and has at home 
 followed your directions in wearing more or less 
 apparatus adjusted to her partially paralyzed leg, 
 first manifested to us that her leg was debilitated 
 when about eighteen months of age. She walked 
 when about a year old, then gave up walking. We 
 attributed the fact to debility from teething. When 
 she resumed walking, at about eighteen months of age, 
 the weakness in one leg was discovered. We flattered 
 ourselves she would outgrow it, having no suspicion 
 of the real trouble. Her condition when you saw her 
 in May, 1865, you can describe better than I can. 
 
ITS ATTENDANT DEFORMITIES. 119 
 
 She was then nine years and nine months old. I can 
 describe no symptoms except weakness in the leg; 
 wasting of the flesh, reducing it to from one to one 
 and a half inches in circumference below the size of the 
 other; a constant liability to fall upon that knee, so 
 much so that a pad was kept on it to prevent bruising ; 
 an entire inability to go either up or down stairs by 
 placing the weak foot or leg before the other. She also 
 uniformly bore her weight on the other leg, and thus 
 distorted her form. When she went to you, she could, 
 bear her weight on that leg alone, but was powerless 
 in the effort to kick with it, or to throw her foot in 
 front without throwing out the whole limb, and could 
 not approach toward a hop upon it. 
 
 " She has since that time shown much improvement, 
 sufficient to afford me much encouragement. She can 
 hop on it feebly, raising herself by a hop on that foot 
 about three inches perpendicularly without difficulty ; 
 can throw out her foot in front, but not with much 
 energy. Her lameness is still quite perceptible in 
 walking, and still more so when running. She falls 
 but seldom; her limb shows more hardness of muscle 
 and fullness. The apparent projection of the knee-pan 
 has to some extent diminished. 
 
 "Yours, J. M." 
 
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