of Rhodes. Spurious works Andronicus.

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The improvement had been so very little and there seemed to be
no encouragement to oflFer and the child strived so hard to use
her limbs. Now he believed she had ceased to improve. He
concurred in the diagnosis made, but he could see no future for
the child.

Dr. Sayre said that in a good many of these spastic cases,
improvement would follow stretching the legs and keeping them
stretched for a good part of the twenty-four hours, so as to
overstretch the contracted muscles in order that the anterior
shin group, and the extensors of the thigh could act without
undue opposition. These patients should also receive systematic
instruction in coordination of their muscles, and in making
voluntary eflForts. He had seen many patients who were enabled
to walk, and acquire the ability to get around without assistance,
through the employment of these methods. In many cases
which he had sent to Mrs. Seguin, of Orange, where there were
mental and muscular deficiencies, the improvement had at times
been marvelous. In the case under consideration, the calf
muscles were so contracted that the patient could not put the
heel to the floor. Dr. Sayre thought that by stretching these
muscles the heel could be placed upon the floor and the patient
thus enabled to balance better than she now did. In the
present case tenotomy probably would not be necessary. The
co-ordination of movements was to be taught by exercises very
similar to those used by Fraenkel in cases of locomotor ataxia.

EXTENSIVE PARALYSIS DUE TO ANTERIOR POLIOMYELITIS.

Dr. Oscar M. Schloss presented this patient for Dr. Roland
G. Freeman. This was a case of anterior poliomyelitis with
extensive paralysis which involved the thoracic respiratory
muscles. Previous to the onset of the disease the child was
perfectly well, could hold its head erect, and was able to support
its weight. The onset nine weeks ago was sudden with fever,
convulsions, vomiting, diarrhea, and these acute symptoms
lasted three days. At the end of this time the mother noticed
that the child could not hold its head up, and that all four
extremities were powerless and that the respirations were more
rapid than normal. The child was admitted to Dr. Long's
clinic at the New York University and Bellevue Medical College.
At this time it was noted that all four extremities were partiafiy
paralyzed. The child was able to move the hands and feet, but
otherwise the extremities were powerless. The respirations were
entirely diaphragmatic and the anterior neck muscles were



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NEW YORK ACADEMY OF MEDICINE. 167

f

paralyzed. An ankle reflex was present, there was no per-
ceptible knee-jerk, but a slight contraction of the quadriceps
could be felt. None of the reflexes could be obtained in the arms.
Sensation seemed to be intact. During the three weeks the
child had been under observation there had been a noticeable
improvement. The right arm could be moved and the shoulder
muscles alone seemed paralyzed. The left leg could be flexed
and extended at the knee-joint, but movement at the hip was
still very defective. The leift arm and right leg were still power-
less and the respirations were entirely diaphragmatic.

PARALYSIS OP ABDOMINAL MUSCLES.

Dr. Marshall Carleton Pease presented these cases for
Dr. Henry Dwight Chapin.

The first child developed anterior poliomyelitis about five
weeks ago; some four weeks later it developed a pneumonia,
and with this pneumonia appeared the paralysis of the abdominal
muscles which seemed to include the external rectus, possibly the
internal rectus, particularly of the left side.

The second child developed whooping-cough last July, and
there still were signs in the right chest.

The third child had what appeared to be a recrudescence of
the anterior poliomyelitis. This patient had been operated
upon for mastoiditis.

discussion.

Dr. William P. Northup, speaking of complete paralysis of
the thoracic muscles, the work of respiration being done by the
diaphragm, said that he had seen probably four or five such
cases in his life. The first case presented by Dr. Schloss for
Dr. Chapin came to his clinic at the Bellevue Medical College,
and he asked those present to examine it carefully. He recalled
a case seen last week in the accident ward of the Presbyterian
Hospital. A man was brought in on the ambulance. He
overheard the remark that there was something queer about the
case. The patient was a laborer and he had fallen from a scaf-
fold and received a scalp wound, and nothing else could be
found. However, both his legs were paralyzed; they had no
power in them whatever. The arms, however, were all right.
It was then noted that the thoracic muscles were not working,
while the diaphragm was working well. This man grew worse.
He was turned over to see if there was any back injury, but
none was found. The next day Dr. Northrup inquired how the
patient got along. The coroner found the sixth cervical vertebra
had been driven in, mashing the spinal cord to a pulp.

Dr. Northrup presented some photographs of three cases of
paralysis of the abdominal wall due to poliomyelitis.

Dr. Henry W. Frauenthal presented several photographs of
children with hernia or bulging through the abdominal wall,
similar to the two cases shown by t)r. Wm. P. Northrup.



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168 TRANSACTIONS OF THE

He presented a case similar to the one of Dr. Henry D. Chapin's
with paralysis and atrophy of the thoracic muscles which, when
he was presented at the Hospital for Deformities and Joint
Diseases, in August, 1907, had all the muscles of the extremities
and trunk involved, also the diaphragm was still involved. He
was referred to this hospital by Dr. Henry Koplik, hoping that
in the event of death from pneumonia, due to the involvement of
the diaphragm, an autopsy would be performed.

Under massage, high frequency and sinusoidal electricity he
finally regained the perfect use of his legs and left arm, the
right arm being still involved, but the pectoralis major and
minor together with the other muscles of respiration have not
as yet responded.

This case with others was reported in the Amer. Jour. Obst.
of April.

THE NEW TREATMENT OF SPASTIC PARALYSIS BY RESECTION OP
POSTERIOR SPINAL NERVE ROOTS.

Dr. L. Pierce Clark presented this communication. There
was a twofold motor disturbance in the extremities as a result of
damage or destruction of the superior pyramidal tracts, namely,
contraction and weakness of various muscles. The character
and completeness of the injury of the pyramidal tracts gave the
peculiar type of contraction and paresis of the different muscles
in the several types of spasticities. Complete hemiplegia as the
result of total destruction of all the pyramidal tract of the oppo-
site side was rare. As a rule, hemiplegia underwent some degree
of spontaneous cure, but whole series of movements could be
performed only with incompleteness and difficulty. When the
pathway of excitability of muscles from the cortex by way of the
pyramidal tracts was destroyed or severely damaged, the irri-
tability of the muscles from the periphery, as the result of
sensory impressions was not only preserved, but was more or less
heightened. The pyramidal path also inhibited the lower spinal
reflex and in the lessened control permitted an insubordinate
activity of the lower spinal centers. The objective evidence of
the enhanced reflex irritability in the lower arc was shown in
the spastic syndrome of increased knee-jerk, ankle clonus,
Babinski reflex, etc. As a rule, the greater the absence of volun-
tary motion, the greater the reflex activity. Aside from the
involuntary associated movements in the diplegics, they had a
more or less late, but permanent, spastic muscular contracture
which did not disappear on ether narcosis. These contractures
prevented motor functions by offering more or less resistance to
extension. The inhibiting function of the pyramidal tracts was
independent throughout of the function producing spasticity.
When the seat of entry of the posterior or sensory roots were
diseased, as in tabes, the reflexes were abolished. Many sur-
gical procedures had been undertaken to restore the normal
balance in the spinal reflex afc in diplegics. In a review of the



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NEW YORK ACADEMY OF MEDICINE. 169

dififerent plans of surgical relief for these motor defects one was
struck at once with the almost unanimous point of attack to
which surgeons had heretofore addressed themselves; they had
endeavored to reduce the excess of motor pull on the spastic
muscles by reducing some part of the motor apparatus. It
was frequently admitted that the degree of muscle tone in an
extremity was determined by the sensory impression from the
parts and especially from the muscles. Tonic spasm might
therefore be regarded as an augmented degree of this state due to
various causes. The motor part of the reflex arc was obviously
beyond attack, for while the contraction would be temporarily
relieved, a complete palsy of the muscles involved would result.
Neurectomy in the peripheral nerves proper could not be em-
ployed as these consist ^ike of sensory and motor nerves. The
posterior sensory roots were the points of attack if one sought
the sensory side of the arc. Just what part and how much of the
sensory stimuli might be removed to gain the desired end, flaccidity
was even yet not clear. The best point of attack on these sensory
nerves was in the spinal canal, dorsal to their ganglion. Dr.
Taylor, therefore, operated at this point. The work of Forster
and Tietze and Gottstein was then briefly summarized.

The first case presented was a boy eleven years old whose
history was negative except a cerebral diplegia secondary to
meningoencephalitis induced by a very severe attack of malig-
nant scarlet fever at eleven months of age. The boy's para-
plegic syndrome was typical. With this spastic handicap the
boy was able to walk by very short steps without assistance,
but with arms extended. Various orthopedic measures failed
to materially help him. Inasmuch as they had at that time no
positive guide regarding the amount of resection necessary the
dorsal roots of but one side, the left, were resected. They were
the last dorsal and five lumbar. The operation was performed
August 23, 1909, by Dr. Taylor. On the fifth day after the
operation the patient was entirely free from pain*. One week
after examination there was a greatly reduced spasticity in
the whole left leg, there was a great reduction in the reflexes,
there was absence of ankle clonus and an imperfect production of
the Babinski. The crossed leg progression was succeeded by
quite a straddling-skating gait. The patient now stood and
walked alone. Later further operation would be undertaken.

The second case was an eighteen-year-old boy who had suffered
from left hemiplegia from birth. The typical infantile hemi-
plegic syndrome developed, the arm and leg were moderately
undeveloped, the left forearm was contracted on the arm at an
acute angle, and the hand was flexed at more than a right angle
at the wrist. The fingers were in extension and could just be
moved. The whole extremity was in a "birdwing" contracture
and spastic. The patient was feeble minded. Three days ago
Dr. Taylor resected the dorsal nerve roots from the fourth
•cervical to the second dorsal inclusive. A rough examination of



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170 TRANSACTIONS OF THE

the patient two days after operation showed anesthesia in the
lower two-thirds of the whole length of the arm. The arm was
entirely free from spasticity. Tenotomy, physical training and
orthopedic appliances will be employed. ^

DISCUSSION.

The Surgical Technic. — Dr. Alfred S. Taylor stated that the
technic in resection of the posterior spinal nerve roots differed
somewhat from that of an ordinary laminectomy; in the latter
they removed the spinous processes and more or less of the
laminse of both sides. Tietze had complained that there was
great difficulty after doing a laminectomy in exposing the pos-
terior roots of the spinal nerves. In doing an ordinary laminec-
tomy the portions removed were near the median line. It
occurred to Dr. Taylor that if he could get sufficient room through
a unilateral exposure, he would not only come directly down
upon the nerve roots but would leave the spines intact, and this
would be a very efficient operative procedure.

The operation consisted in making a longitudinal incision
just to one side of spinous processes; the muscles were separated
from the spinous processes and were retracted from the laminse
themselves outward to the articular processes of the vertebrae.
Then by means of a Doyen saw, he sawed through the lamina at
the base of the spinous process and also near the articular
process. One might get from one-quarter to one-half an inch of
room by cutting outward toward the articular processes. After
making a double line of sections, the parts could be lifted and
removed by means of bone forceps. To get under the remaining
laminae he used the rongeur forceps, leaving a clean-cut entrance
between the bones, thus coming down upon the dura. Then
the highly vascular layer of fat was divided, and whatever
hemorrhage occurred here was readily controlled by pressure.
The dura was exposed and slit longitudinally, fully exposing the
spinal cord.

Dr. Taylor had made many dissections. He showed pictures
of spines in which laminectomy was performed, showing well the
exposure he obtained. One picture showed the conditions
before, the other after opening the dura mater. One-half the
lumbar enlargement as well as one-half the cauda equina was
clearly visible. The lower cord itself could be readily turned
90 degrees without injury to the lumbar enlargement.

It seemed to Dr. Taylor that this method was adaptable for
exposing tumors of the spinal cord. After an ordinary laminec-
tomy there resulted a marked deformity of the back, and a part
of the cord was not protected by bone.

DEMONSTRATION OF A CASE AFTER LIMITED RESECTION.

Dr. Alfred S. Taylor presented this patient. In operating
upon this boy he worked through a groove about three-eighths
of an inch wide. There was at present no loss of function in the
spine. The spine was flexible laterally and antero-posteriorly.



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NEW YORK ACADEMY OF MEDICINE. 171

Dr. Taylor also presented two cases upon whom he intended
to operate, one being a case of infantile cerebral diplegia and an
epileptic as well.

Dr. Charles Ogilvy had previously seen the patient pre-
sented by Dr. Taylor when he had been unable to walk without
a shuffling gait; he then had great difflculty in raising the feet
from the floor. The spasticity was then decidedly more marked
than it is at present. It was very difficult to describe in so
many words the improvement in a case of this kind, as it was
more of an improvement of the conditions than a cure of them.
Dr. Ogilvy intended to have had the patient walk with braces
and crutches; in fact he had been measured for braces.

The second case reported by Drs. Clarke and Taylor presented
very marked contractures; these are still present after the
operation, but without doubt these contractures can be readily
corrected.

The exposure made of the cord by Dr. Taylor was certainly
beautiful, and the hemorrhage was much less than one had in
doing an ordinary bilateral laminectomy. The patients did
remarkably well. Both patients had done spendidly. The
second case was practically well the day following the operation.

DISCUSSION.

Dr. Joseph Fraenkel said that in order to understand the
rationale of this mode of treatment of spastic paralyses, it would
be necessary to say a few words about the diagnostic and prog-
nostic interpretations of the reflexes. Ten years ago Dr.
Fraenkel made a study of the relationship of the tonus of the
tendons to the reflex phenomena by means of an apparatus
devised by Moskens of Utrecht {New York Medical Record,
December 12, 1903). Among the conclusions reached in this
study, the one having particular reference to the subject in
question read: **That disease of the pyramidal tracts causes
hypertonia and increase of reflexes. The tendon jerks under
such conditions are increased unless additional disease of the
ascending tracts, anterior horns or some part of the peripheral
neurons neutralizes this influence." The loss of motor function
in spastic conditions was in direct proportion to the reflex
spasticity. It appeared then rational to add sensory disease
wherever the loss of motor function was considerable. From
this theoretical consideration he hesitated to take the practical
step because there was uncertainty as to the outcome and
difficulty in finding a quantitative gauge. Dr. Beer, at Dr.
Fraenkel's suggestion, tried the influence of stovain injections
into the nerve or cerebrospinal fluid. The immediate results
obtained were quite convincing in the shape of marked return
of motion, disappearance of spasms, ankle clonus and Babinski
signs. These beneficial results lasted of course as long as the
influence of the stovainisation and with the disappearance of
the anesthesia thus produced, the spastic phenomena became



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172 TRANSACTIONS OF THE

reestablished. He said he was glad to hear that the experiments
on the living, and the work done by Foerster, gave further
corroboration of the correctness of this therapeutic measure.
It would be necessary, however, to be very careful in the selection
of cases adapted for this mode of interference. First of all, it
appeared that cases of extreme spastic contractures would derive
benefit from posterior nerve cutting by having their inordinately
stiff, useless extremities changed into more or less flaccid ones.
The other cases, cases with subcortical sensory implication,
should be excluded on account of the irritative motor phenomena
(chorea, athetosis, etc.) arising from such lesions and the liability
of their becoming aggravated by additional sensory disease.
Concerning the operative technic he emphasized the fact,
that the severance had to be made so that the intervertebral
ganglion was left in connection with the peripheral stump, in
order to avoid distrophic consequences.

Dr. Virgil P. Gibney said that so far as the operation itself
was concerned, they were waiting to see results which promised
at present to be favorable. He had never seen a case of spas-
ticity overcome, although he had seen improvement in some
cases. He had divided the hamstring muscles, the tendo
achillis, the adductors of the thighs, and had even removed
en masse the tensor vagina femoris to get rid of the spasticity;
the correction lasted for months, sometimes even for years, and
he hoped the spasticity was overcome; but it would creep back
on him and at last he became skeptical about ever being able to
finally abolish it.

Dr. Edward D. Fisher said that the operation was one that
was likely to produce a temporary paralysis, but even that might
be better than the spasticity, especially in the more severe cases.
The operation cut off the sensory impulses passing to the brain.
There was a proper physiological basis for this operation. Two
things had been accomplished; muscular flaccidity and the re-
moval of irritating impulses to the brain. The contractions, or
contractures taking place in the arms or legs were caused by
sensory impulses passing to the brain and then passing down the
cord as motor impulses; and again being caused primarily by
impulses from the brain itself.

Therefore the value of the operation was a double one; it
had a double value. It first reduced the spasticity, and might
also improve the cortical condition, not by regenerating the cells,
but by removing the source of irritation and giving them a rest.
It might thus have an influence in reducing the tendency to
epileptic seizures. Dr. Fisher believed that it was well worth
while to go on with this work, and have it fully demonstrated
by many cases, and see what the later results would be.

In observing the boy Dr. Taylor presented, he noticed the
reflexes were returning. It was possible aU the sensory fibers
did not decussate in the spinal cord.

The question of the removal of sensory irritation had been



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NEW YORK ACADEMY OF MEDICINE. 173

taken up by other methods and with the same results. It made
no difference whether it was by cutting the posterior spinal nerve
roots, or by destroying the nerve itself, or impairing its function.

In these cases he thought the operation a justifiable one and
that there were hopes for it in the future. The selection of
appropriate cases was very important. Those in which there
was the least mental impairment would prove the most suc-
cesrful.

Dr. T. Halsted Myers said that these cases divided them-
selves into classes according to degree and some cases could be
improved by educational • methods of treatment and training.
In the severer contractures one must decide whether there was
a permanent structural muscular change, or whether the deformity
was due to the spastic condition itself. If there were structural
changes in the muscles, he thought operation was indicated and
should be the first step taken, making full division of the tendons
and muscles. If sufficient improvement did not result, he
thought, then, from a description of the operation, that it might
help. He would look for results.

Dr. Samuel Lloyd was very much interested in the work
previously done along the line of section of the posterior nerve
roots. In this work there was to be considered the question of
regeneration, and just how much that would bring back the
^ spastic condition of the patient at a later date. The operation
' might give a cortical rest and, in that way, it might cause an
improvement in the spasticity. We must, however, wait and
learn what the conditions are. The question of regeneration of
the posterior spinal nerve roots and destruction of the cord,
which many had in mind, was a very interesting one. It had
been suggested by Dr. Dana and Dr. Abbey and ot}iers, in fact
the hope had been made, that by using the posterior spinal nerve
roots impulses might be carried to the destroyed segment of
the cord, and in that way get impulses into the lower cord. In
the cases experimented on, they got no such results.

With regard to the operation. Dr. Lloyd disagreed with Dr.
Taylor with regard to the difficulty or results of removing the
lamina. A single incision was made; then a section of the spinous
process was made at its base; it should then be lifted with the
attached muscles at the side, and incised. This would leave the
spinal processes intact. The laminae then can be removed by
means of an osteotome or a Gigli saw, as one chose. In this way
he thought they would get a better approach.

There was a tremendous amount of difference among different
patients with regard to the amount of hemorrhage. In one
patient it may be a very small affair; whereas, in another patient,
with dilated veins, one met with a greal deal of hemorrhage. But
it was seldom that they met with hemorrhage that was at all
sensational.

Removing a full lamina gave a field of approach to the spinal
cord and enabled one at once to get at the posterior spinal nerve



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174 BRIEF OF CURRENT LITERATURE.

roots without rotating the cord 90 degrees; in the upper part of
the spinal cord it was not so movable as in the lower portion.

Dr. Lloyd was impressed with the slight deformity which
followed the operation. The spinous processes did not fall
in and they did not get a weakened spine. The laminae filled
up afterward; there was a bony regeneration.

Dr. Clarke in closing said that one must remember that the
resection of the dorsal nerve roots was done dorsal to the sensory
nerve ganglion and that this point of resection insured absolutely
no regeneration of the nerve or return of the former spastic
element. Furthermore, the ganglion being left on the peripheral
portion equally insured against the supervention of trophic
changes in the peripheral structures. The work was to continue
on a large series of cases and scientific reports would be issued
from time to time.

Dr. Taylor, in closing, wished again to call attention to
the fact that Tietge had complained of the unsatisfactory
approach to the posterior roots by means of the usual bilateral
laminectomy, whereas his own (Taylor's) method brought the
operator directly down upon the roots sought, and the roots of
the opposite side could be divided, if necessary, through the same



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 18 of 109)