President, LOUIS H. BEHRENS, 374? Olive Street Vice-Pres., WALTER C. G. KIRCHNER, City Hospital

Executive, A. Ravold, Century Building Entertainment, Frank Hinchey, 4041 Delmar Ave.

OFFICIAL

Publication, W. E. Sauer, Humboldt Building
Public Health, R. B. H. Gradwohl, 522 Washington Ave.

A NEW PROCEDURE IN TENDON AND MUSCLE TRANSPLANTATION APPLIED IN A CASE OF INFANTILE CEREBRAL PALSY.

DRS. PHIL HOFFMANN AND SIDNEY I. SCHWAB.

ST. LOUIS.

Read before the Medical Society of City Hospital Alumni, St. Louis, February 1, 1906.

DR. HOFFMANN.-In presenting this case I shall limit my remarks to its orthopedic aspect, leaving the neurologic side to Dr. Schwab, with whom I have been associated in its care. The patient, a boy of seventeen, was afflicted with a left hemiplegia of cerebral origin, dating from a few days after birth. He had entire loss of power in the flexors of the hand and wrist, and barely enough in the extensors to extend the fingers, but not the wrist. The little extensor power present offered no possible chance of success from the ordinary method of tendon transplantation, i.e., attaching the tendons of the paralyzed muscles to contiguous healthy ones in the same segment of the limb. The extensor muscles were so weak that it was useless to try to divide their power with the flexors. There was, however, fair power in the flexors and extensors of the elbow. The boy had never used his hand, and there was no possibility of injuring its function by any procedure, as the hand could not have been worse functionally. The thought occurred that possibly we might draw upon the intact upper arm for power with which to supply the paralyzed segment below. The first thought was to cut away the biceps from its insertion into the radius and insert it directly into the central ends of the deep and superficial flexors of the fingers. This idea was abandoned because the great bulk of the muscle bellies of the finger flexors would afford but a poor medium through which the biceps could exert a pull upon the fingers, and because the dissection necessary to detach the origins of the superficial and deep flexors from the humerus, radius and ulna would result in such extensive scar formation as to probably altogether prevent transmission of the biceps' pull. A

method offering better assurance of success was finally devised. This was to interpose the palmaris longus and flexor carpi radialis between the source of power and the point of its application. These muscles are superficial, and being long and slender, approximating a tendon in shape, offered a good medium through which to transmit the biceps' pull. They being paralyzed, were used simply as passive structures to connect the tendon of the biceps, where it crossed the elbow, with the tendons of the finger flexors, where they crossed the wrist. After the biceps tendon had been detached from its insertion at the radius, it was sewed into a longitudinal slit in the bellies of the flexor carpi radialis and palmaris longus, which had been previously detached from their common origin at the inner condyle of the humerus. Next, the tendons of the flexor carpi radialis and palmaris longus were out from their insertions at the wrist and sewed, en masse, to the tendons of the deep and superficial finger flexors, including the long thumb flexor. Now, the biceps in contracting pulls primarily on the flexor carpi radialis and palmaris longus, and secondarily, through them, on the tendons of the flexors sublimis and profundus digitorum and flexor longus pollicis. The operation was performed at the Jewish Hospital, September 1,1905, and the splint removed November 10. No sign of flexor function was observed until November 26. Since then there has been

In

gradual improvement. He is now able to grasp a fork or spoon and carry it to his mouth; and can lift a five-pound flat-iron and hold it for thirty or forty seconds. order to prevent the biceps from also flexing the elbow when it is flexing the fingers, he must synchronously contract his triceps. None of the fingers have independent movement but all, including the thumb, are flexed together. Having no power in his wrist extensors, and the finger extensors being too weak to extend the wrist by a continuance of their action, he must wear a splint to hold the wrist in the [extended position, so that his new finger flexors can act to good advantage. He will later be relieved of the necessity of wearing the splint by an oper

ation to anchy lose the wrist in the extended position, a so-called arthrodesis.

Dr. Hoffmann then exhibited the patient.

DR. SCHWAB.-My interest in this case is chiefly concerned with the pleasure I have had in working with the orthopedist. There are several points in connection with this case that are of importance. It is one of infantile cerebral palsy in which the mentality is almost normal. In the greater number of these cases there is some mental involvement, but in a certain small percentage there is no apparent mental defect. In such cases the presence of a physical deformity will necessarily tend to interfere with the patient's success in life, and we are, therefore, moved to greater efforts to aid in the removal or betterment of this deformity. Therapeutic measures in the usual acceptance of the term, such as strychnine, electricity, etc., are of no avail, and dependence upon them alone is nothing short of a therapeutic crime. If this patient, some years ago, had been placed under the care of an orthopedist who under stood fully the mechanics of the arm and had been willing to make use of that knowledge, the results might have been much more gratifying than is the case now. The sad feature of the case is that the boy has been allowed to reach nineteen years of age without the attempt being made to afford him any logical sort of relief. The boy is sufficiently bright, but any position that he may apply for he will have to overcome a prejudice created by his deformity. He is able to write fairly well and has received a good enough education, but in spite of this any chance of advancement is practically denied to him. An attempt should be made in this class of cases first to correct deformity and then to restore function. If by any chance the two together can be obtained a most gratifying result will follow. The results in tendon work which Dr. Hoffmann has done in cases we have seen together have been on the whole encouraging, and we have felt that even in this apparently hopeless case an attempt was justified. The great trouble that we have found is that cases hopeful in the beginning for surgical interference are kept under treatment for years and years until the plastic period of youth or childhood is passed, and then it is frequently too late to obtain the best results. An example of this sort of therapy is the common custom of treating spastic types of paralysis with electricity, attempting apparently to increase the muscle tone in an already hypertonic muscle. There is one thing that can be positively asserted, and that is, that when such a condition exists, as in the present case, there is only one logi.

cal method of treatment, and that is surgicalorthopedic interference. The sooner this is understood the better the results are bound to be. In this case the result does not appear to be unusually brilliant. The patient still has his deformity and the restoration of function has been slight, comparatively speaking. The grasp of the hand has been in a measure restored. This case, however, may be taken as an example of the way we should go and the method of attacking the problem. The thing is to get these cases early before joint changes have taken place and before the atrophy and succeeding contractures of the muscles have produced a deformity too exaggerated for easy correction. In a case of anterior poliomyelitis, if in a year a full restoration of function is not obtained, then it is the duty of the physician to call an orthopedist to consider the advisability of surgical interference. In the very old cases it is uphill work to get good results. Spiller, Frazier and Taylor have in this country worked out the nervous-surgical aspects of these cases, and they and others have obtained good results by tendon-muscle nerve transplantation and suture. Dr. Schwab, in closing, insisted that great care be taken in making the differential diagnosis. Oppen

heim last year had called attention to cases of progressive muscular atrophy which had been operated upon with the idea that anterior poliomyelitis was present, of course no improvement had taken place. It was absolutely necessary in all these cases that a differential diagnosis be made, and in some cases this might be a hard task and at times impossible.

DISCUSSION.

Dr. Norvelle Wallace Sharpe thought the results were quite encouraging, for the boy was, certainly, a great gainer by what had been done. It was, as Dr. Schwab had said, an object lesson for all of us. The profession was derelict in this class of cases; as an example he mentioned a colleague who had himself had a congenital deformity. Some years ago Dr. Sharpe had tried to induce this gentleman to have something done by tendon or nerve transplantation, but found that he was strongly opposed to such treatment, at least for his individual case; and Dr. Sharpe believed that this man's view-point was the. result of his training in college years ago and the additional fact that the profession as a whole, fails to realize the actual possibilities, for this unfortunate class, by an intelligent intervention. It seemed, too, almost a crime to fill these patients with the conventional therapeutics of the neurologist. He wondered if something might not be done in

Dr. A. E. Taussig said that the comparative weakness of the fingers might be due to the weakness of the biceps, the young man not having been trained to use the biceps, if so, an increased finger function might be expected as a result of education of that muscle.

Dr. Francis Reder mentioned an experience of his which had occurred some ten years ago. A patient was brought to him, a lad of some fifteen years, who stumbled frequently while walking. The boy was found to have suffered from infantile paralysis when three years old, the muscles affected being the an terior set of muscles of the leg. It occurred to him that some good might result by slicing off a piece of the tendo Achilles and attaching it to the tendon of the tibialis anticus. Inexperienced as he was at that time in this work the result was reasonably satisfactory, and in six months the boy was able to walk without falling. The result was most gratifying to those interested in the boy. He wished to know what experience Dr. Hoffman had had with the extensor muscles of the leg, and would he not feel more encouraged as to a successful outcome to perform a tendon transplantation upon the leg than upon one of the upper extremities?

Dr. Hoffmann, in closing, said that operations upon the lower extremity were as a rule more successful, because in the upper extremity there was required a finer adjustment of the muscle balance. In the lower extremity, when one supplied the ability to lift the foot, a great deal was accomplished, as the main functions of the lower extremity were to bear the weight and clear the ground in a satisfactory manner. In the upper extremity the function required much more intricate muscle co-ordination. Replying to Dr. Taussig's remarks, Dr. Hoffman said that in the biceps in his case, the power was perThis was haps 50 per cent of the normal. enough, if it could be transmitted without any interference at all, to give a good grasp. But it also required training, and this would probably accomplish a good deal. The patient had already learned to use a fork and could bring it to his mouth. He could exert quite a pull temporarily, but not for a long time, so it appeared that training ought to do much for the boy. As to tendon transplantation, there was danger of it falling into disrepute because in many cases it had not been a success on account of the operation being done without due consideration of what power remained in the limb, and how best to redistribute it. In order to obtain success it

mained, and how that power could best be transferred to the point desired. In this case, the boy had the main function of the hand, the power to grasp. In the operation the pronator radii teres and the pronator quadratus were divided because they were short and held the forearm in strong pronation.

Dr. Schwab, in closing, insisted upon the care to be taken in a differential diagnosis. Oppenheim last year had called attention to cases of muscular atrophy operated upon by orthopedists. Of course no improvement had taken place. If the cases of anterior poliomyelitis were seen by the orthopedist early enough there was room for all sorts of manipulative interference. From the standpoint of the neurologist it was absolutely necessary that he be able to exclude progressive muscular atrophy, and this, from the neurologist's standpoint, was sometimes a very difficult thing to do. But in all cases the diagnosis between the spinal and the cerebral types of paralysis must be made.

Dr. Hoffmann said that this was undoubtedly a case of the cerebral type and had at one time been spastic, but the condition of the boy when they got hold of him was such that there was no spasticity of the flexors, which had degenerated and were flaccid.

stake, and no time should be lost in execu

Rupture of the Uterus.

EDITORIAL

WE print in this issue a paper on the above subject in which two cases are reported by the author as occurring in his own obstetrical experience of less than 600 cases. The fact that any practitioner, wherever located, may have such experiences leads us to call attention to it. In 1875 Bandl called attention to the fact that rupture was usually due to two principal causes: First, there is some malposition of the child, which interferes with its descent and at the same time furnishes angular parts of the child against the uterine wall. Second, in such cases the lower segment of the uterus becomes overdistended in Nature's effort to overcome the obstacle, and the wall becomes correspondingly thinner until the wall is ruptured by the angular prominence.

A second, and much rarer cause of this accident, is the presence of projecting promienences from the pelvio bones which tear the uterine wall as the descent of the child forces it out against them or pelvic tumors which obstruct the passage and lead to overdistension of the lower segment by undue uterine contractions. Ruptures rarely occur above the "contraction ring," because that part of the uterus is in active contraction, and is much thicker than the lower segment. There is great difference of opinion among authorities as to the frequency of this accident. Some place the ratio as low as 1 in 1200 cases, while others say 1 in 5000 cases. so infrequent that it makes little difference to the average practitioner. He is likely to only meet one or two, at most, in a lifetime practice.

It is

The treatment of such an accident requires the greatest care and expedition on the part of those in attendance. Two lives are at

The measures selected will depend upon the cause, location and extent of the laceration. Such ruptures are said to be "complete" or "incomplete," that is, whether they pass eritirely through the uterine wall, including the peritoneum, or whether the peritoneum is only stripped up and not lacerated. Also they may be classified as to whether or not any or all parts of the child are entruded into the peritoneal cavity. The object of treatment must be the immediate delivery of the child. This will usually be accomplished by forceps, by version, by embryotomy or laparotomy. In only about 10 per cent of the cases is the child saved. In complete ruptures the life of the mother is saved in only one-fifth of the cases, which go without treatment and in less than fifty per cent of the cases which receive the most prompt aud efficient treatment. In incomplete ruptures the prognosis is more favorable, athough even in these the mortality is high. C.E.B.

THE UROLOGICAL SOCIETY.-At a meeting held at the Blue Grass Hotel, St. Louis, on Friday evening, March 16, a society to be known as the St. Louis Urological Society was formed. The first contribution was a paper by Dr. Bransford Lewis, which was followed by an interesting discussion participated in by all members. Dr. Bransford Lewis was elected president, and Dr. E. A. Scharff secretary-treasurer, by the following named gentlemen, who constitute the charter members: Drs. J. L. Boehm, C. E. Burford, T. A. Hopkins, H. Jacobson, Bransford Lewis, G. M. Phillips, A. R. Ravold, Wm. Robertson, E. A. Scharff, H.J. Scherck, O. L. Suggett, A. S. Wolf.

IODINE AS AN ANTISEPTIC.-Nicholas Senn, professor of surgery in Rush Medical College, Chicago, concludes a scholarly study of iodine in surgery, with special reference to its use as an antisentic, with the following summary: 1. Iodine is the safest and most potent of all known antiseptics. 2. Iodine in proper dilution to serve its purposes as an antiseptic does not damage the tissues; on the contrary, it acts the part of a useful tissue stimulant, producing an active phagocytosis, a process so desirable in the treatment of acute and chronic inflammatory affections. 3. In the treatment of simple hyperplastic goiter actinomycosis and blastomycosis, the local use of iodine is made more effective by cataphoresis.-Ex.

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Vol. IV. A

THE DOCTOR'S RECREATION SERIES. Book About Doctors. By John Cordy Jeaffreson, Author of The Real Lord Byron." "The Real Schelly," "A Book About Lawyers." etc.,etc. Fourth of series of twelve volumes compiled for the amusement, rest and relaxation of medical men. Akron, Ohio: The Saalfield Publishing Co. (Price, Silk-Cloth, per vol. 82,50, Half-Morocco, per vol. $4.00. By Subscription Only.)

It is indeed fortunate that this interesting and valuable contribution to the literature embracing history and tradition has been incorporated in this series and placed at the command of American readers. Mr. Jeaffreson's Book About Doctors, beyond any other of his numerous works, made his reputation in literature in Britain, it was his greatest success. American readers will find it of intense interest from cover to cover. Though largely historical, dealing principally with characters of the seventeenth and eighteenth centuries, it seems to picture present conditions and characteristics and depict them immutable of the medical person, even though the armamentarium is vastly enlarged and changed with the years. The book is quite the equal in point of literary worth and vital interest of its fellows in the very attractive series.

"INDIVIDUALISM VERSUS SOCIALISM."-Any expectation of sensationalism in William Jennings Bryan's discussion of "Individualism versus Socialism" in the April Century is likely to be unfulfilled. The paper, it is said, is a succinct presentation of the claims and objects of individualism and socialism, which Mr. Bryan defines as tendencies rather than concrete systems. Mr. Bryan also urges that there should be no unfriendliness between the honest individualist and the honest socialist, since both are seeking that which they believe to be best for society; and he points out how the one may greatly aid the other in the common aim of both, the harmonious development of the human race, physically, mentally and morally. But he holds that the socialist is inclined to support monopoly, believing that it leads to governinent ownership of monopolistic industry; whereas individualists contend against consolidation of industries and "stand for a morality and for a system of ethics which they are willing to measure against the ethics and morality of socialism."

INFLUENZAL VERTIGO.-Stewart directs to keep patient recumbent, and give tonics and nutrients with moderate doses of alcohol during the later stages.

SURGERY.

JOHN MCHALE DEAN, M. D.

Common Duct Cholelithiasis.-In Journal of Surgery, Gynecology and Obstetrics, W. Mayo Robson discusses the subject of common duct cholelithiasis. Many new and interesting points are brought out by the author. The author finds the occurrence of stone in the common duct in 40 per cent of his cases. The symptoms of common duct stone are repeated "spasms" and jaundice. The jaundice is not as deep as we find in cancer of the pancreas or common duct, and is more intermitting. This changeable jaundice is caused by the movable stone in the duct acting on the principle of a ball valve. The author claims all cases of cholelithiasis are accompanied by more or less inflammation, and we frequently find as a result adhesions.

The obstruction of the duct is seldom complete, and in consequence distension of the gall bladder is not always present, as we would suppose from backward pressure of bile. The muscular coat of the gall bladder contracts in an effort to expel the stones. This contraction continues until atrophy of the gall bladder ensues. The author claims that the differential diagnosis of common duct stone and cancer of the head of pancreas is not always an easy task. By some elaborate chemical examination of the urine brought out by Dr. Cammidge certain acicular, sharp edged crystals arranged in rosettes are found. If these dissolve in dilute sulphuric acid in 30 to 40 seconds impacted stone or pancreatitis diagnosis is made. If these crystals are thick and rounded and dissolve in sulphuric acid in 1 to 5 min. utes cancer of the pancreas is the diagnosis. It is lamentable that the author did not in his valuable article describe this elaborate chemical process to enable others in using it in making a diagnosis. The author mentions . twenty-eight different conditions that may threaten the life of a patient suffering with common duct stone. The operation is rendered easier if with a longitudinal incision the liver is turned upwards and outwards. In this rotation of the liver we bring into view the common duct and the duodenum and an otherwise difficult and deep operation is rendered more superficial and easier in execution. Drainage of the common duct by a rubber tube fastened by catgut suture in situ is used by the author, together with drainage of the kidney pouch.