July, 1952 P H Y S I O T H E R A P Y Page Five

THE SCOPE OF SYMPATHETIC DENERVATION 
IN POLIOMYELITIS

I. J. Zadikoff, Surgeon, Johannesburg

Poliomyelitis is a general infection caused by a 

filterable virus with its most marked effects on the 
nervous system. Pericellular and perivascular 

lymphocytic. infiltration leads to destruction of nerve 

cells not only in the ■ Central Nervous System but 

also in the Autonomic Nervous System. The effects 

on the Sympathetic Ganglia are always present to 

a greater or lesser extent, but these are often 

neglected in the storm of the general infection and 

motor nerve pathology.

The Sympathetic ganglia, like the anterior horn 

cells, are irregularly involved in this disease and 

thus the resultant vasospastic systemic symptoms in 

the acute stage of the disease are aggravated or 

lessened. Vasoconstrictor sequelae such as cold­

ness, discolouration, sweating, pain, muscle spasm 

and occasionally alternating flushing and pallor are 

commonly found. In  the late, heartbreaking stage 

of crippling paralysis, the affected limbs are com ­

monly cold, i/ioist and cyanotic. The diminished 

arterial supply in a paralytic limb, the bulk of which 

is poorly nourished fat, often produces, in cold 

weather, multiple reddish purple subcutaneous 

nodules (erythema induratum ) which may ulcerate 

as a result of fat necrosis.

Associated with the paralysis due' to the involve­

ment of the motor nerves, there is vasoconstriction 

in the muscles and thus diminished blood circulation.

'This aggravates the disuse atrophy due to the para­

lysis, pain, muscle spasm and in all probability, as 

Sister Kenny states, the atrophy resulting from 

muscle incoordination and mental disorientation. The 

aggravating factor of a “cold” muscle is commonly 

noticed by parents who state that the limb is much 
more useful on waking in th morning, better in 

summer than in winter and poorer after a swim in 

a cold swimming bath. A ll athletes are aware of the 

fact that warm muscles act more efficiently than cold 

ones.

In  time, bones too, particularly young growing 

ones, are affectcd as a result of the muscle in ­

activity and diminished blood .circulation in the 

limb. The younger the patient and hence the more 

the bones are yet to grow, the greater the in ­

activity of the muscles as a result of paralysis, and 
the more marked the vasospasm, the more marked 

will be the ultimate shortening of the limb. Im ­

provement o f the circulation will thus diminish the

detrimental effects of the muscle paralysis on the 

growth of bone.

Release of vasoconstriction is essential for the 

successful therapy in these cases. Vasospasm is not 

an unalterable pathological lesion but a physio­

logical and functional derangement of the sympa­

thetic nervous supply of the vessels, and is, fo r  the 

present, one of the few controllable factors in the 

progress of the disease; In  all stages of polio­

myelitis whether in the acute or chronic stages, it 

merits treatment pari passu with the other patho­

logical processes. A ll treatment for the lesion in 

the Autonomic Nervous System, whether conser­

vative or radical is based on the release of this 

vasoconstriction. Heat applied locally to the acutely 

affected limb can be in the form of hot packs, 
fomentations, lamps, or reflexly by heating other 

parts of the body. This has to be repeated at 

frequent intervals. In  the chronic stages, the wear­
ing of long woollen stockings and gloves, and if 

possible living in a warm  climate, particularly in 
winter, helps the cold limb.

Drugs, m ainly acting by virtue of temporarily 

blocking the sympathetic ganglia have been found to 

be very useful particularly in the actue stage. 

Etam on, Priscol, Tolaz-oline and Cyclospasmol to 

mention only a few, have all been used with a 

varying amount of success in the acute stages but, 

unfortunately to a much lesser extent, in my experi­

ence, in the convalescent and chronic stages of the 

disease. Direct injection of the sympathetic ganglia 
with local anaesthetics, has a temporary effect and 

rarely breaks the cycle permanently. It is painful, 

not entirely free from danger and unnecessary in the 

establishment of the diagnosis of vasospasm in this 

condition.

Radical treatment consists of operative pre­

ganglionic interruption of the sympathetic nerves to 

the affected limb. There is no associated arterial or 
venous disease other than the vasospasm and thus 

the post-operative release is immediate, maximal and 

usually permanent. Post-operatively the limb as a 

whole becomes more comfortable, skin lesions heal 

and in young patients bone growth improves. Sub­

sequent orthopedic procedures, too, are commonly 

less extensive, necessary orthopedic splints are worn 

more comfortably, and the muscles become more re­

sponsive to the ministrations of the physiotherapist.

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