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PARALYTIC POLIOMYELITISBy A. GRAHAm APLEY, F.R.C.S.

Consultant Orthopaedic Surgeon, Rowley Bristow Orthopaedic Hospital;Assistant to the Department of Orthopaedics, St. Thomas's Hospital, London

Introduction-The Stages of PoliomyelitisThe terms used to describe the successive stages

of poliomyelitis vary widely. For the purpose ofthis article the disease will be considered to passthrough five stages (Ritchie Russell, I949), whichmay be briefly summarized as follows:

I. Prodromal (Invasion) StageInvasion probably occurs via the pharynx. A

'minor illness' results with fever, malaise, sorethroat and gastro-intestinal upset. This stage lastsonly 24 to 48 hours and is usually so trivial as to berecognised only in retrospect. The only feasibletreatment is prophylaxis by preventive inoculationand precautionary isolation.

2. Pre-paralytic (Meningitic) StageThe virus has by now penetrated the central

nervous system, and is there multiplying. Clinic-ally there may be a' major illness,' usually abruptin onset, with fever, headache, vomiting, stiffnessof neck and back, and pain in the trunk and limbs.The patient is in a critical phase, hovering forsome days between complete recovery and whatmay be disastrous paralysis. He must be restedimmediately, and the rest enforced and complete,because fatigue may precipitate paralysis and un-doubtedly increases its severity. (Ritchie Russell,1947, Horstmann, I950).

3. Paralytic (Acute) StageThe virus attacks and destroys anterior horn

cells. Soon after the major illness paralysisappears and is quickly maximal in extent. Thereis, in addition, spasm and tenderness of muscles.The essentials of treatment are rest, assisted res-piration if necessary, and the relief of discomfort.

4. Convalescent (Recovery) StageThe virus is dead, but has destroyed a variable

number of nerve cells. The patient is no longerill in himself, and paralysis to some extent recovers.The patient's recovery of function is assisted byphysical treatment and by training, while inter-mittent splintage is often required.

5. Definitive (Chronic) StageThere is permanent residual paralysis with

deformity, flailness and trophic changes.As a rule, only the last three of these five stages

concern the surgeon, and these will now bedescribed.

The Paralytic or Acute StagePathology. Predominantly, the virus of polio-

myelitis attacks the anterior horn cells. It islikely that 'fatigued' cells fall the most readyvictims. The attacked cells undergo chroma-tolysis, and the disintegrating nuclear fragmentsare rapidly phagocytosed, so that the cell virtuallydisappears in a few days. Many cells, however,undergo chromatolysis but escape phagocytosis(Bodian, 1948) and these cells regain a normalmicroscopic appearance within a remarkably shortspace of time, usually four to five weeks (Edds,1950o). Cells which recover were presumably lessfatigued, less virulently attacked, or merelydamaged by oedema.

Virus and oedema may damage not only cells inthe anterior horn, but also antero-lateral horn cells,and the so-called inter-nuncial cells concerned withshort linkages within the cord.

Clinical Features. The paralytic stage is arbi-trarily defined as lasting from the onset of definitemuscle paralysis (usually one to five days after the'major illness') until all pain and spasm havedisappeared. It is not to be supposed'that paralysisis common, even after the' major illness,' and themodern view (W.H.O. Report, 1954) is thatparalysis, whether bulbar or spinal, is an infrequentcomplication of a common disease. Occasionally,on the other hand, the pre-paralytic stages havepassed unnoticed, and paralysis is one of the firstpresenting features.

Paralysis varies enormously in extent and dis-tribution, but is always flaccid in type. Spinalinvolvement may paralyse limb muscles, theparalysis being characteristically asymmetrical indistribution, with the lower limbs more often in-volved than the upper; more immediately impor-tant is paralysis of the diaphragm, intercostal

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muscles and accessory muscles of respiration,leading to dyspnoea and, rarely, to death.

In the spinal type of paralytic poliomyelitis thepatient's mind remains unclouded, even though heis irritable and apprehensive; the sudden develop-ment of flaccid paralysis in an alert patient is strongpresumptive evidence of poliomyelitis. Some ofthe spinal muscles are painful, tender, and resentfulof rough handling and of stretching. Thesemuscles are often said to be in ' spasm,' a much-abused word in the vocabulary of poliomyelitis.Almost certainly the spasm is simply a reflexguarding, to prevent nerve roots from beingstretched (Mitchell, I954). Spasm and pain aredistressing symptoms, and often associated withsweating and hyperaesthesia. Sometimes there isa temporary retention of urine.The bulbar type of disease, which appears to be

increasingly frequent, may attack various cranialnerves, of which the most vital are those supplyingthe laryngeal and pharyngeal muscles. If theseare damaged, a rattling noise develops in the throatof the distressed patient who is unable to coughaway excess mucus, and speaks in a feeble whisper;dysphagia and dyspnoea are.also common. Bulbarpalsy is a sinister condition; it demands urgentdiagnosis and Urgent treatment.

TreatmentThe patient must be kept alone (isolated), alive

(by artificial respiration if necessary), and aerated(with a clear airway); he should be relieved (ofpain) rested (by intermittent splintage) and relaxed(by reducing 'spasm'). These points requireseparate consideration.

Poliomyelitis is an infectious disease, not onlyduring the pre-paralytic, but also during the earlyweeks of the paralytic stage. Droplet infectionshould be prevented, and the faeces, which alsocontain the virus, disposed of as in enteric fever;in fact the patient is barrier-nursed. Quarantineof contacts is a rarely attainable ideal, but childrenwho have been intimate contacts should certainlybe kept at home, and they should avoid over-exertion, though how this latter can be achieved inan active child I have never understood.

If respiratory muscles are weak the patient mustbe helped to breathe. Until recently this objectwas achieved by means of an 'iron lung.' Thepatient's body, but not his head, was enclosed inan air-tight coffin-like box, and the air pressurewithin the box alternately raised and lowered bymeans of a pump. The apparatus is cumbersomeand makes nursing difficult; moreover, if there isalso bulbar paralysis, the forced inspiration is liableto suck mucus into the bronchi. A simpler wayto assist breathing is to perform tracheotomy,connecting the tracheal tube to a breathing appara-

tus (like a Boyle's anaesthetic machine), and tocontrol this apparatus by a pump.To mantain a clear airway is of special impor-

tance in bulbar palsy. The patient's positionshould be frequently (but gently) changed, so thatgravity assists the drainage of mucus; intermittentsuction is also useful (Lassen, 1950). If there isbilateral paralysis of the laryngeal abductors atracheotomy is essential.The patient is apprehensive, alert, and in pain,

so that analgesics and sedatives must not be with-held. He should be rested on a flat bed withfracture boards covered by a rubber mattress.One pillow is usually sufficient, and no elaboratesplints should be used. If the arms are paralysedthey may be rested on pillows or suspended inGuthrie Smith slings. The wrists can be supportedin a cock-up splint, and the thumb held opposedby an elastic garter. The patient lies flat with thehips extended, and a small pad or pillow preventsthe knees from hyper-extending. A board for thefeet to rest on is usually sufficient to prevent footdrop. The emphasis is on rest in a natural posi-tion, and on the avoidance of cumbersome splints.To discourage the development of contractures,not only is the posture changed at frequent intervals(nurses as well as physiotherapists should betrained to do this) but affected limbs are twice aday moved passively through their full painlessrange. Such movements should not be forcedand must never hurt the patient.

It has for long been realised that passive move-ment of affected limbs is often painful, evoking'spasm ' and cramps. How may these be avoided?Some American workers (Ranschoff, 1948) haveemployed curare-like relaxants, but they do notabolish pain and are not advised. Probably thebest method is that of Sister Kenny and herdisciples; the affected limbs are wrapped in hotmoist packs, which are comforting and usuallypermit increased passive movement (Bingham,1943). Sister Kenny's methods and, indeed, hervery name, engender fierce controversy, probablybecause although she was unqualified, she treatedpatients better than did most doctors. Hermethods were based upon quite unsound pathology,but they worked. Their success was largely dueto the abandonment of elaborate splintage, therelief of pain and spasm, and the regular employ-ment of gentle passive painless movements; allthese in addition to her boundless enthusiasm.

The Convalescent or Recovery StagePathology. The dead cells, in which chroma-

tolysis was succeeded by phagocytosis, are nowconverted into scar tissue; their axons undergoWallerian degeneration and the mnuscle fibres whichthese axons supply are paralysed completely and

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without possibility of recovery. Cells which weredamaged but not destroyed recover fully andspeedily, so that the muscles they supplied arecapable of functioning again within a few weeks.The contrast between irrevocable destruction andrapid return to potential normality is marked; andyet the clinical process of improvement takes placegradually over a period of many months. Suchslow improvement is due to hypertrophy of sur-viving nerve cells and muscle fibres, a processwhich is assisted and hastened by training. Fora limb to be paralysed severely and permanently,about two-thirds of the I2,ooo anterior horn cellssupplying it must have been killed (Bodian, 1948).

Clinical Features. The disease is said to be in theconvalescent stage when the muscles are no longerpainful or tender, which occurs at about six totwelve weeks from the onset of paralysis, thoughoccasionally it lasts much longer. Quite arbitrarilythe stage is held to last two years.The patient is not ill. Headache, malaise and

pain are absent; and so is muscle spasm, in spiteof Sister Kenny's assertions to the contrary.Permanent paralysis of any muscle group leads, ofcourse, to weakness; but this weakness is usuallymanifested in one of two ways. First, if the musclescontrolling a joint are all paralysed, a conditionconveniently called balanced paralysis, the jointbecomes flail. Second, unbalanced paralysis, inwhich one muscle group is more severely involvedthan its opponent, results in deformity at the joint;stronger muscles overcome weaker and with thepassage of time may lose their extensibility, so thatthe deformity becomes fixed. Some authoritiesbelieve that deformity may also result from con-tracture in skin and in subcutaneous fibro-elastictissues, or from the persistence of untreated spasmin muscles; proof for these views is lacking, butit is not possible to explain all deformities simplyon the grounds of unopposed or unbalanced muscleaction.

In addition to weakness, wasting, and deformityor flailness, trophic changes appear, the limb be-coming cold and blue. These trophic changes areusually thought to result from venous pooling, asequel to the paralysis, and probably this is thetrue explanation; but sometimes the trophicchanges are disproportionately greater than theparalysis, possibly because of paralysis of the actualblood vessel walls due to damaged antero-lateralhorn cells.

TreatmentTreatment in the convalescent stage is most

simply considered under four headings:I. The patient is fit and should be got up. He

should be got up and about as soon as possible, ifnecessary with splints, if necessary with crutches,

if necessary in a wheel chair, but up at all costs.Only two factors should be allowed to stand in theway; first, if respiration still needs assistance,when the process of weaning the patient fromassisted breathing may have to be slow; andsecond, if there is unbalanced trunk paralysis, forthis carries a high risk of scoliosis which mayquickly become severe. If scoliosis threatens, thepatient should be kept recumbent until hyper-trophy has occurred, or until a back support con-trols the potential deformity.

2. Some muscle groups remain paralysed, andsplintage is often required. Paralysis does not byany means always demand splintage. Unbalancedparalysis, however, may need splintage to preventthe surviving muscles from shortening and pro-ducing fixed deformity; and balanced paralysismay require splintage to provide stability. Anysplints employed should be removed at least twicea day while the affected joints are moved passivelythrough their full range.

3. Some muscle groups are 'recovering' andrequire exercise. Gradual 'recovery' is due tohypertrophy, a process which should be encouragedwith all speed and energy. It is pointless toexercise muscles which have already recoveredfully, and it is futile to attempt to train muscleswhich are paralysed completely. Treatment mustconcentrate upon muscles which are weak enoughto need training, yet active enough to benefit fromit. Training should begin early, and shouldquickly become strenuous (Mead, 1950). It isonly during the earlier, still active stages of thedisease that exertion is dangerous and rest essential.Once the convalescent stage is reached the attitudeof doctor, physiotherapist and patient shouldundergo a complete volte-face. Rest is noweschewed; the patient is coaxed, cajoled, persuadedand, if necessary, bullied into increasing activityand power, as if he were a boxer training for afight. It is during this training programme thatcharts of muscle power are helpful, the strength ofeach group being recorded thus:

o .... no activity.I .... a flicker.2 .... contraction, not powerful enough to act

against gravity.3 .... sufficient power to act against gravity.4 .... sufficient power to act eves against

resistance.5 .... full strength.

Once it is apparent that a particular group willnever achieve useful power (thr'ee or better), thephysiotherapist may permit and even encouragethe development of trick movements, teachingmuscles to assume unfamiliar functions.

4. The limb is trophic and requires 'coddling.'It is difficult or impossible to prevent trophic

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changes from developing, but their effects must beminimized if training is to achieve its effect. Theessential is never to allow the limb to become cold.Keep the bed warm, the room warm and well-ventilated, and the limb itself warm; woollenstockings, or two pairs, are helpful. Exercises ina warm swimming pool, sometimes dignified by thename of hydrotherapy, are also useful: the watermakes the patient feel light in body and light inspirit.

The Definitive or Chronic StagePathology. The dead nerve cells have been

replaced by scar tissue. Paralysed muscles arewasted, and if a limb is severely involved the bonesbecome slender and decalcified. Moreover, thelimb does not grow normally, so that paralysisduring childhood leads to relative shortening.

Clinical Features. The patient is completelyfit except for his paralysis. Paralysis is lower-motor-neurone in type, the muscles being flaccidand tendon reflexes diminished. The affectedlimb (or limbs) may look blue, is wasted and oftenshort and deformed. There are frequently exten-sive chilblains and the skin is cold to the touch.When a badly paralysed limb is picked up,.it hasa peculiar ' floppy' feel which, in the presence ofnormal skin sensation, is almost characteristic ofpoliomyelitis.As far as the actual paralysis is concerned, the

patient may be affected in three ways: first, asisolated weakness, in which there is inability toperform an individual action; second, there maybe unbalanced paralysis of the muscles controllinga joint, in which case there is not only weakness,but possibly also fixed deformity; and, third, theremay be complete or balanced paralysis resulting ina flail joint. Most joints have two main move-ments, one assisted by, and one' opposed to,gravity. Paralysis of the anti-gravity muscles isthe more disabling and more liable to lead to fixeddeformrnity.

Treatment-PrinciplesFurther true recovery is, by definition, im-

possible. Attention must now be concentrated onminimizing the functional effects of the paralysis,largely by apparatus or by surgery. The mainprinciples are:

i. First, to consider the patient as a whole. Itis pointless to embark upon an extensive programmeof reconstructive surgery in a limb if the patient'sparalysis is so severe and widespread that he willbe unable to take advantage of any localizedimprovement.

2. Next, to consider the limb as a whole. Nosplint or operation should be employed to improvethe function of a portion of a limb unless the use-

fulness of the limb as a whole is also thereby in-creased. For example, reconstructive surgery tothe hand may be a pointless luxury if the patientis unable to put his hand to its task. Again, it maybe foolish to operate upon a foot, apparently im-proving its function, if that function cannot beutilized because the patient has still to wear acaliper in order to control his knee. While con-sidering the limb as a whole, the problems oftrophic changes and shortening may requireattention. These problems are mnore frequentand important in the lower than in the upper limb.

3. Finally, to consider the individual parts.Balanced paralysis results in a flail joint. In thelower limb stability is essential, and the flailnessmust be dealt with by splintage or by arthrodesis.Unbalanced paralysis leads to deformity, and ifthis proves disabling it may be practicable todivide the strong deforming muscle through itstendon and to re-attach the tendon more usefully;not only is deformity overcome, but balance maybe restored. The re-routing of muscles may alsobe used in treating weakness of individual actions,particularly in the upper limb where such actionsare often more important than stability. Trans-planted tendons should, if possible, be anchoredto bone. It is easier to learn to use the trans-planted tendon and muscle if it is a synergist ofthe paralysed muscle.

Survey of Treatment in the Definitive StageTrunk

Unbalanced paralysis, in which one side of theback or belly muscles is stronger than the other,leads to scoliosis. The scoliosis is liable to becomesevere, because gravity assists the stronger group,and the weaker group becomes stretched and stillweaker. Spinal jackets and supports are of somehelp in minimizing deformity, but severe im-balance is rarely controlled satisfactorily, and it issometimes wise to fuse a portion of the spine aftercorrecting the curve.

Balanced paralysis leads to a floppy trunk, butnot to a fixed deformity. External supports canprovide reasonable stability; they are of greaterbenefit than with unbalanced paralysis, for in thelatter it is difficult to oppose a constant unilateralforce.

ShouiderUnbalanced paralysis. Weak adductors .matter

little, for once the limb has been abducted, gravitycan bring it down again; therefore no deformityand little disability result. Weak abductors, how-ever, render the limb almost useless. Moreover,the strong unopposed adductors, aided by gravity,lead to fixed adduction deformity which may

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64 POSTGRADUATE MEDICAL JOURNAL February 1955

require operative correction. Loss of ability toabduct may be overcome as described below.

Balanced paralysis. Abductor action can berestored to the limb by arthrodesing the shoulder-providing that the scapular muscles are power-ful. If the trapezius, rhomboids and serratusmagnus are strong, they can act on the ' scapulo-humerus' enabling the limb to be placed andstably maintained in useful positions. The jointshould be arthrodesed in 700 of abduction and 300forward of the coronal plane. The operation is auseful one for abductor paralysis, whether balancedor unbalanced; it should, however, only be per-formed if the hand is sufficiently useful to takeadvantage of the improvement.

ElbowUnbalanced paralysis matters as a rule only if

the forearm flexors are paralysed, for gravity canreplace the extensors. The exception is in thepatient who has to use crutches, for elbow extensorsare then necessary. Normally, however, if onlythe extensors are powerful, it is reasonable tore-attach them so that they will act as flexors;even though the resulting power is unlikely topermit weight to be lifted, it may be sufficient tolift the hand to useful positions.

Balancedparalysis leads to a flail elbow. Again itis flexion that matters most. An intact pectoralismajor can be dis-inserted and attached to thebiceps. Failing this, it is sometimes possible toadvance the origin of the wrist flexors higher upthe humerus. Even if there are no muscles tostabilize the joint it is better for the patient to weara moulded splint, which holds the elbow bent at auseful angle, rather than to have the joint arthro-desed. Modern polythene splints are light, clean,and comfortable.

Wrist and HandUnbalanced paralysis of wrist flexors is not much

of a handicap, for gravity opposes the extensors.But paralysed extensors in the presence of strongflexors leads to fixation of the wrist in the flexedposition, a poor position for function. Thedeformity can, to some extent, be prevented bysplintage but once deformity has occurred the wristflexors should be re-routed to act as extensors.

Balanced paralysis of flexors and extensors givesa flail wrist; but the wrist is not totally flailunlessthe long finger muscles are also paralysed. Aflail wrist may be stabilized by a cock-up splint orby an arthrodesis. Operation, however, is notoften indicated, for it should only be performed ifthe fingers function well enough to take advantageof the stability, and if the fingers do function wellthe wrist usually has sufficient stability already.

Paralysis of the thumb and fingers are sometimes

benefited by surgery. The hand as a whole worksas a vice and as pincers; each of these functionsshould be considered. For the vice action fingerflexors are required, preferably aided by wristextensors. It is sometimes advisable to arthrodesethe wrist and utilize any acting wrist muscles tore-inforce finger flexion. It should be noted thatthe arthrodesis serves two purposes; it stabilizesthe wrist, and it also' liberates' muscles which canbe given more important tasks. The pincer actionof the hand demands a strong opponens pollicis;if this muscle is paralysed a substitute can be pro-vided by detaching the flexor sublimis from onefinger, winding the tendon round that of flexorcarpi ulnaris (which acts as a pulley) and insertingthe sublimis into the radial side of the thumb.Excellent opposition is obtained in this way.

HipUnbalanced paralysis is chiefly of importance

when it affects the glutei and the tensor fascia lata.If, during the paralytic stage, the patient has beentreated sitting up instead of lying flat, fixed flexionand adduction are liable to develop at the hip.Once present this deformity is difficult to overcome,and its correction may require stretching andplaster, or even surgical division of the flexors.Occasionally, unbalanced paralysis of the adductorsand extensores leads to dislocation of the hip,which makes the inevitable Trendelenburg limpeven worse. Hip dislocation in poliomyelitis isvery difficult to deal with and arthrodesis isoccasionally worth consideration.

Balanced paralysis of the hip muscles leads toflailness. Flexion can be achieved by thrustingthe trunk forwards in walking, so that gravity helpsthe lower limb forwards into a flexed position; butextension and abduction cannot be mimicked, andwhen weight is taken on the limb a severe Tren-delenburg dip occurs. No satisfactory treatmentis known. A method sometimes used is to fit acaliper attached by a hinged bar to a pelvic band;and to incorporate an adduction lock in the bar.The apparatus is cumbersome and not veryefficient. Arthrodesis of the hip does at leastprovide stability, but is technically difficult toachieve, and a stiff hip is a great nuisance if theknee muscles are also paralysed.

KneeUnbalanced paralysis of the knee flexors is not

often disabling, for the straight leg can be lifted byflexing the hip while the quadriceps contracts, andgravity flexes the knee as soon as the quadriceps isallowed to relax. Only rarely does a genu recurva-tum develop and necessitate a caliper with a Jones'sknee brace.

Unbalanced extensor paralysis is more disabling

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and may result in fixed flexion deformity at theknee. It is a little unfashionable to transpose thehamstrings to the quadriceps, but the operation iswell worth while; not only are the deformingmuscles divided, but sometimes the reinforcedquadriceps muscle is strong enough to stabilizethe knee without a caliper.

Balanced paralysis of the knee flexors and exten-sors is common and results in flailness. The simplesttreatment is to provide a caliper, which shouldbe hinged at the knee to prevent the straight legfrom being a nuisance in buses; the hinge musthave a simple locking device to prevent the caliperfrom buckling when the patient stands. Womensometimes prefer to dispense with the caliper andhave the knee arthrodesed; the individual mustweigh the inconvenience of a permanently stiff legagainst the elegance of a well-stockinged one.Arthrodesis is probably best performed with theknee at i 80o°, but there is a modern trend towardsarthrodesis in 20° or so of flexion, providing thatthe disease has not shortened the limb. Theflexion makes the leg less of an obstruction toother people, and allows it to swing through inwalking.

It is by no means always necessary to treatquadriceps paralysis with either splint or operation;for if the ankle is in fixed equinus, when the patienttakes weight the equinus foot forces the knee intoslight hyperextension, and in this position the kneeis often stable enough to permit safe walking.

AnkleFoot paralyses tend to be combined in a wide

variety of ways; moreover the long muscles of thetoes act also on the ankle and sub-taloid joints.Despite these complicating factors it is simplestto consider the foot as three separate joints: ankle,sub-taloid, and metatarso-phalangeal (the termsub-taloid is used to mean the sub-taloid and mid-tarsal complex).

Unbalanced paralysis at the ankle joint is chieflyof importance when the dorsiflexors are weak.A toe-raising spring or back-stop attached to a legiron can prevent foot-drop; but if the plantar flexorsare strong enough and unopposed, they pull thefoot into fixed equinus which requires correctionby stretching and plaster, or by division of thedeforming tendon. It should be a rule that whenany tendon is divided to overcome fixed deformityin poliomyelitis that tendon should be insertedusefully elsewhere.

Strong ankle dorsiflexors with weak plantar-flexors is less often disabling or deforming, becausegravity assists plantarfiexion. If, however, im-balance is gross, fixed calcaneus deformity (usuallyassociated with cavus) develops, and requiressurgical correction. Elmslie's operation (I934) is

satisfactory for this purpose. It consists of a two-stage sub-taloid fusion, the second stage being bya posterior approach and combined with tendontransplantation.

Balanced paralysis of ankle muscles, especiallyif combined with weak toe muscles, leads to flail-ness. Stability is readily provided by a below-kneecaliper with a toe-raising spring attached to theshoe. It is often possible, however, to dispensewith apparatus by performing Lambrinudi's opera-tion (Lambrinudi, 1927); the sub-taloid and mid-tarsal joints are arthrodesed and a segment cut offthe talus so that with the talus in gross equinus thefoot fits on to it in only slight equinus. In itsfully equinus position the talus locks into the anklemortice and cannot plantarfiex further. Theslight equinus of the foot helps to compensate forany associated quadriceps paralysis (see above).The idea behind Lambrinudi's procedure is abrilliant one, and the operation finds wide applica-tion in foot paralysis, permitting deformity to beovercome and stability to be achieved. It isimportant to note that arthrodesis of the anklejoint is not required in poliomyelitis.

Sub-taloid JointUnbalanced paralysis may affect the invertor

muscles so that when the foot is dorsiflexed it pullsup into valgus (eversion), and in time develops afixed valgus deformity. It is important to balancethe foot, and to balance it as early in the diseaseas possible-even during the convalescent stage.The strong evertors should be re-inserted into sucha position that they pull the foot up straight. Butif weak invertors are combined with weak ankledorsiflexors, as is commonly the case, a Lam-brinudi's operation is often the best procedure.

Similarly, unbalanced evertor paralysis resultsin the foot being pulled up into varus (inversion)and may lead to fixed varus deformity. Balancemay be achieved by a toe-raising spring attachedto the outer side of the shoe, or by a tendon trans-plant. Frequently the associated paralyses aresuch that Lambrinudi's operation is required. Itshould be noted, however, that any sub-taloidfusion is likely to fail if a strong but unbalancedmuscle is left intact. Such a muscle (or itstendon) should be divided and, as usual, employedusefully elsewhere.

Balancedparalysis of the sub-taloid joint leads,not to a fixed deformity, but to a floppy unstablefoot. To some extent the flailness can be con-trolled by a below-knee caliper, but arthrodesis ofthe sub-taloid mid-tarsal joint is the most satis-factory procedure. Dunn's triple arthrodesisprovides excellent sub-taloid stability, but oftenLambrinudi's operation is more suitable becauseof associated foot drop.

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Toe JointsUnbalanced paralysis of the muscles controlling

the toes is of importance only when the longmuscles overpower the short. The result is abunching-up of the whole foot into claw foot andclaw toes-deformities which soon become fixed.The metatarsalgia which inevitably results may behelped by suitable padding, supports and footwear,designed to distribute pressure evenly. Lam-brinudi advised arthrodesing all the inter-phalan-geal joints in the straight position, and re-insertingthe long extensor tendons into the metatarsal necks,an operation which is laborious but has goodresults.

Balanced paralysis of toe muscles is of littleimportance except for its frequent association withother foot weaknesses. It is of interest that weakleg and foot muscles rapidly result in gross flatfoot, but only if the external rotators of the hip arealso paralysed; for these rotators are partiallyinserted into the tibia (via the ilio-tibial tract) and,when they act while the foot is anchored by bodyweight to the ground, they twist the tibia outwardsand so lift the inner border of the foot.

Trophic Changes and Shortening.In the upper limb trophic changes usually

occur only with gross paralysis, and shortening isof no account. In the lower limb, however, a cold,blue limb with extensive chilblains, is distressi'nglyfrequent, and shortening may be both severe anddisabling. The trophic changes are impossible toprevent and difficult to treat. Two pairs of socksor stockings and fur-lined boots are helpful, butonce chilblains develop they are liable to ulcerateand only to heal temporarily in the summer. It isimportant, not so much to warm cold feet, as neverto allow them to become cold-a counsel oferfection in England. Lumbar sympathectomy

has intermittently evoked staunch advocacy butthere is a widespread feeling that the operation ishelpful only for two or three years, after which

the trophic changes recur. The combination ofskin-grafting with sympathectomy certainly allowsan otherwise intractable trophic ulcer to be satis-factorily healed, and the operation could perhapsbe employed more often than it is at present.

Shortening can be compensated for by a raisedshoe, and this is often the best method. Actuallengthening may be achieved by oblique divisionof the femur, or of the tibia and fibula, and treatingthe osteotomy with traction so that union occursin an elongated position. The procedure isdangerous, since it is liable to many complications,and is rarely performed. An alternative procedureis to shorten the longer leg, which may be achievedbefore growth is completed by fixing metal staplesor blocks of bone across the growth discs. Theoperation is simple and free from complications,but there is a reasonable reluctance to interferewith a patient's remaining sound leg. It may bethat in future a simple and safe method of lengthen-ing a bone will be achieved, for it has been shown(Trueta, 1953) that if the portion of the bonemedulla which includes the nutrient artery isblocked (by disease, injury or experiment), thejuxta-epiphyseal arteries hypertrophy and the bonesubsequently grows longer.

BIBLIOGRAPHYBINGHAM, R., J. Bone Jt. Surg., 25, (3), 647.BODIAN, D. (1948), 'Pathological Anatomy in Poliomyelitis,'

Lipincott, Philadelphia.EDDS, M. V. (I950), J. Comp. Anat., 93, 259.ELMSLIE, R. C. (I934), ' In Modern Operative Surgery,' Cassell

& Co. Ltd., London, (quoted by Cholmeley, J. A., J. Bone Yet.Surg., 35b, (I), 46).

LAMBRINUDI, C. (I927), Brit. J. Surg., i5, 193.LASSEN, H. C. A., (i953), Lancet, 37.MEAD, S. (1950), J. Amer. Med. Ass., 144, 458.MIITCHELL, G. P. (1954), Lancet, x8.RANSOHOFF, N. S. (1950), Med. Clinics of N. America, 34, 562.RITCHIE RUSSELL, W. (947), Brit.-Med. J., IoI9.RITCHIE RUSSELL, W. (I949), Brit, Med. Y., 465.RITCHIE RUSSELL, W. (I952), 'Poliomyelitis,' Edward Arnold

& Co., London.TRUETA, J., Bull. Hosp. Jt. Dis., New York, 14, 2, I47.WORLD HEALTH ORGANISATION (x954), Technical Report

on Poliomnyelitis, 8i.

RUTHIIN CASTLE NORTHWA~IIV~iLES-.A Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctorsi technicians and nurses.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is, less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Castle, Ruthin. Telephone: Ruthin 66

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