Un articolo storico di Speranski pubblicato in American Review of Soviet Medicine, Oct. 1946, Vol IV. #1 POSTTRAUMATIC CONTRACTURES A. D. SPERANSKI Studies were undertaken on the nature of posttraumatic contractures. The neural or reflex origin of contractures has been taken for granted since the reflex character of posttraumatic contractures has been proved by careful clinical experiments of Molotkov, Novotelnov, Leriche, and Shamov. The source of the pathologic reflex contracture may lie in the sympathetic or spinal nerves. An analysis of the available literature suggests that both points of view are probably correct. Some posttraumatic contractures are not the result of scars, and finally, others occur after superficial soft tissue wounds without injury to large nerves. These are called hysterical contractures. They may also occur after protracted immobilization, especially in plaster casts. In the first case, deep irritation is apparently absent; in the second, the local disturbances follow pressure and irritation from interrupted circulation in tendons, muscles, and joints. Work was carried on for several years on dystrophic processes in the nervous system produced by various methods. New facts have been gathered by S. I. Frankshtein in the prewar period. The study was based on the Sherrington pattern of decerebrate rigidity. The cat was used because decerebrate rigidity is pronounced in this animal. The animal was anesthetized, skull trephined, carotids ligated, and blunt separation of the brain done in the region of the tentoriurn. Such interference produces contracture of an extensor type due to disturbance of normal tonicity. This may last hours and days. The whole phenomenon is attributed to irritation of the red nucleus (Sherrington, Magnus), or its removal (Beritov). Both central and peripheral irritation was investigated in order to ascertain in what manner extensor rigidity was intensified after external influences. It was noted that the side on which the animal lies is always under greater tension than the opposite. We investigated other forms of peripheral irritation likewise related to the proprioceptor but of a more specialized character. A local inflammatory process might be such an irritation. Experimental procedure: 1-2 drops of turpentine was injected subcutaneously on the posterior surface of one paw. An abscess developed and within 3-5 days the cat favored the injured paw and walked on three legs. The abscess sometimes reached considerable size and ulcerated. After decerebration, the body and extremities were affected with extensor rigidity with the exception of the injured part. The affected paw either remained soft and pliable in all its joints or developed flexor rigidity. Prolonged observation revealed an intermittent relaxation of spasticity, not only in the affected paw but in the homolateral one. This can be explained only by the fact that the irritation spreading through the nervous system is of a reciprocal character. A peripheral inflammatory process, therefore, involves the neural segments. This involvement occurs also in decerebration when a conscious protective reflex is nonexistent. The unconscious protective reflex as seen in a decapitated frog was studied in the following experiment. Cats were given subcutaneous turpentine injections in the front or hind paws. Decerebration was postponed until the abscess healed and the functions of the extremity restored. After decerebration, rigidity developed in all parts of the body with the exception of the paw that had recently been inflamed. The following case is characteristic. Decerebration was performed on a normal cat but for some unexplained reason, decerebrate rigidity did not affect one of the hind legs. It remained flaccid during the whole experiment. When the cat died postmortem examination revealed an old healed fracture of the corresponding hip. It may be assumed that peripheral trauma or inflammation produces irritation of the nervous system which in turn acts as a source of further irritation. This source of nervous irritability is always manifest in the intact animal because the unusual mobility of the nervous system favors rapid compensation for any functional disturbance. In other words, the animal becomes functionally compensated sooner than the complete healing of the injury. This concept was demonstrated experimentally many years ago but met with strong objections. Surgeons pointed out that in operations on various parts of the body and for various injuries they had not observed focal disturbances in the nervous system. It seems that were it not for the compensating capacity which a complex organism possesses, thanks to its nervous system, contemporary surgery would hardly be possible. In other experiments, mechanical pressure was produced by a plaster of paris bandage, applied for 3-8 days. After removal of the plaster cast the cat was decerebrated. The results were the same as in the first series of experiments. Extensor decerebrate rigidity occurred in the body and extremities but not in the one that had been immobilized by the plaster. A modification of the experiments consisted in applying the plaster to a flexed or extended leg. The bandage was removed in 8-5 days. The cat quickly began to walk and ran normally making equal use of all legs. Decerebration at this point produced rigidity similar to the pattern following inflammation. It appears that brief plaster immobilization involves not only local tissue disturbance but a permanent change in the corresponding parts of the nervous system. A protective reaction was not formed because the animal had recovered its functions before the experiment. It is only possible to assume an after effect of irritation and to speak of the changes in the nervous system as a result of inadequate proprioceptive irritation. The experiments show that there was a change in the nervous system, developing progressively from the periphery. The effect on the nervous system is either dissipated with varying rapidity or persists depending on the duration and degree of intensity of the irritation. Similar experiments were then done on dogs. This was undertaken to analyze the capacity of the nervous system for compensatory activity as worked out by Anokhin and Asratyan. Inflammation was produced by 2-3 drops of turpentine injected under the skin of the front or hind paw posteriorly. In a very short time the dog drew in the paw and moved about on three legs. When another injury was inflicted on the animal in the same region of the opposite paw, the animal almost immediately began to use all four extremities freely, without limping. This occurred in several cases where repeated symmetrical irritation produced less effect than the previous unilateral injury. It appears that the so-called protective reaction does not play any role. Corroboration was obtained by the following experiments. A plaster of paris bandage was applied to a cat in an extended position, not only on one, but on both front legs. After five days the bandage was removed and the animal was decerebrated. Decerebrate rigidity was uniform but extensor rigidity of the front legs alternated with flexor rigidity. Similar clinical and experimental observations were known but no explanation offered. Trendelenburg noted that motor disorders in dogs after decortication disappeared rapidly if a bilateral operation were done on the brain. P. K. Anolchin noted the same phenomenon after bilateral section of the posterior radicles. A. Kharitonov observed a more rapid recovery of functions in animals when total rather than partial removal of the cerebellum was done. Finally, Gubich observed that motor functions are restored more readily in a dog when bilateral cutting of the sciatic nerves was performed instead of unilateral. These facts become clear when it is realized that neural processes are interwoven and interacting and occur to a marked degree in the same or neighboring segments. Conclusions and suggestions: Incipient reflex contractures or other affections such as causalgia lacking clearly defined organic changes should be counterirritation in a symmetrical part of the body. This stimulation may be the quartz lamp, roentgen rays, mustard poultice, cantharidin or, as recommended by Davidenkov, novocaine. Probably different combinations are called for in various cases. This treatment does not hold any danger for the patient. Voprosy neirokhirurgii 1944, Vol. 8, No. 3, pp. 3-7
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