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Mouth (17) Should Be Closed Preferably by a Cotton Tubes Has Not Been Resorted to Frequently in Man, the Plug upper end or mouth (17) of the funnel is normally long defects in tendons may be bridged by tubes of open for the reception of protein and blood-serum to be fascia; and that tendon, which cannot be differentiated used for the test, introduced into and through the fun¬ from the tendon which has been destroyed, develops to nel (15) to the attached thimble (19) af 18, which repair the defect. should have an outside diameter of 11/16 inches. The The repair of defects in tendons by means of fasciai mouth (17) should be closed preferably by a cotton tubes has not been resorted to frequently in man, the plug. Because of the definite connection between the direct transplantation of tendon having been attempted funnel and container mouth, the thimble will be main¬ offener. The following case is reported because an tained at the proper level, and in a centered position opportunity was offered later to examine the tendon with respect to the inner wall of the container and out which had formed within the fasciai tube, and also to of contact, therefore, with it. study the fate of the transplanted fascia. The container is provided with a lateral opening (20) with the tubular extension 1 inch below the History.—Dr. W. K., aged 32, was admitted to the Presby¬ (21) terian Hospital, Jan. 26, 1913. Fourteen months before a shoulder for the dual of the atmos¬ purpose equalizing patient had bitten the ring finger of his right hand. Soon a pheric pressure, and also of providing a means for intro¬ severe infection developed which necessitated removal of the ducing into the chamber (12) liquids at any time dur¬ terminal and a part of the middle phalanx of the ring finger ing the progress of the test without having to remove thirteen days after the injury was received. Finally both the the funnel-stopper with attached thimble. The form of apparatus shown in Figure 2 includes a container 101 of a simpler form than that above described. Instead, however, of providing ground con¬ nections immediately between the filling-funnel and the mouth of the container, a rubber gasket (22) serves the pjurpose of making a substantially air-tight seal for the chamber (12), and at the same time serves the purpose of maintaining the thimble (19) in spaced relation to the walls of the container and at a proper level in the solution contained therein. All the other features of the apparatus are identical with the description of Figure 1. When the container has been filled with the required amount of distilled water and the parts assembled it is ready for sterilization with live steam, after which there is no part of the technic that requires or allows of the exposure of the outer surface of the dialyzing thimble, a feature readily recognized as a safeguard in performing the Abderhalden sérodiagnostic examination. The neces¬ sary chloroform and toluol may readily be added to the sterile distilled water through tube 21 or hole 20 by means of sterile pipets. The top of 21 should be closed with a cotton plug in Figure 1. In Figure 2, hole 20 may be closed with a strip of adhesive plaster, which serves the added purpose of making a good place for necessary notations. Otherwise the technic of the test is the same as previously described by various writers. Fig. 1.—Diagrammatic sketch to show tube made from fascia lata which surrounds the proximal ends of the tendons and Is attached distally to the periosteum. If the tendons are to be REPAIR OF TENDONS BY FASCIAL attached separately two fasciai tubes are used. TRANSPLANTATION sublimis and profundus tendons were removed, the incisions D. AND DAVIS, M.D. DEAN LEWIS, M.D., CARL B. continuing to discharge for two months after the first CHICAGO operation. The free of tendons to defects Examination.—The terminal phalanx of the ring finger is transplantation repair absent. The end of the middle phalanx has also been removed, in other tendons from trauma or infection has resulting the bone lying close to the skin which seems, however, to be become a well-recognized surgical procedure. The ten- well nourished. On both the volar and dorsal surfaces of the don of the palmaris longus has been used in most of the finger are longitudinal scars which extend to the middle of cases in which free transplantation has been attempted, the hand. The scar on the volar surface is somewhat hyper- for it can be removed without interfering with the func- trophic. There is no flexion of the middle phalanx. The proxi¬ tion of the wrist or hand. When a number of tendons mal phalanx can be flexed by the lumbricales and interossei. The skin on the volar surface is somewhat adherent at the site are to be \p=m-\for example, when the common repaired of the but it can be moved well over extensor tendons of the are to be or longitudinal scar, fairly fingers repaired tissue on either side of it. In of when defects exist in the material the subjacent the middle the long tendons\p=m-\enough of the hand, at about the transverse there is some be the tendons palm fold, may not supplied by palmaris longus slight enlargement and resistance, which probably indicates and another source of supply for material for trans- the position of the retracted and attached ends of the flexor plantation must be looked for. sublimis and profundus tendons. Experimentally, it has been demonstrated that fascia Operation.—Jan. 27, 1913, an attempt was made to repair behaves much like tendon when transplanted, and that the tendons and prolong them to the end of the middle pha- Downloaded From: http://jama.jamanetwork.com/ by a University of British Columbia Library User on 06/19/2015 lanx, part of which, as stated above, had been removed. An tendons had proliferated into the tube, for each tendon could incision was made at the side of the finger and a volar flap be seen separated by a delicate fibrous septum. The newly was raised. Considerable scar tissue was found, but enough formed tendon is represented in Figure 2. tissue could be carried up with the flap not to interfere with Histologically the fascia is well preserved. The nuclei stain its integrity. The incision was carried through the interdigital well and the bands of fibrous tissue are very similar to those fold into the palm, for the ends of the tendons were so adher¬ found in normal fascia. Fascia when transplanted usually ent that considerable dissection was required to free the ten¬ becomes somewhat edematous and infiltrated with leukocytes. dons in order that a fasciai transplant might be inserted, so These changes, however, occur early and after twenty-four that when they contracted their action would be transmitted days the transplanted can hardly be differentiated from nor¬ to the transplant and not expended on tissues adjacent to it. mal fascia. The thin layer of subcutaneous fat transplanted After the tendons were dissected free an incision was made into with the fascia has disappeared and the newly formed tendon which has formed as the result of the proliferation of the tendons inserted into the fasciai tube, is closely adherent to the transplanted fascia. The tissue filling the tube is tendin¬ ous in structure, well-developed bundles of fibrous tissue being separated by delicate connective-tissue septa. There is no histologie evidence that this tissue has developed from the fasciai transplant. The transplant has apparently merely acted as a tube which has directed the growth of the prolifer¬ ating tendons. These findings are not in accord with those of Kornew,1 which are based on experimental work on rabbits and dogs. He believes that, when a fasciai tube is inserted between the cut ends of tendons, the fascia proliferates to form the tendon and very little of the new tendon is formed by proliferation from the ends of the divided one. The in the case which we Fig. 2.—Tendon which formed following the operation· The findings finger was amputated 255 days after the fasciai tube was inserted. have descrined would indicate that the fasciai tube plays The a for fascia remains intact, forming sheath the tendon which a the has developed from the proximal ends of the flexor sublimis and passive rôle in the development of new tendon. profundus terdon. The two tendons, separated by a thin connec¬ Experimental work has already demonstrated the value tive-tissue septum, can be distinguished in the tube. of fasciai tubes in the repair and reconstruction of tendons. This method has not as been the thigh and the fascia lata was exposed. A strip of fascia yet extensively measuring about 3% inches in length and % inch in width was then removed, a thin layer of subcutaneous fat being left attached to the transplant. The fasciai transplant was then placed back of the tendon, one end of the transplant was sewed around the tendons, and the other end was attached to the periosteum at the end of the middle phalanx. The surface covered with fat was placed so that it would form the inner lining of the fasciai tube. This was done with the idea of furnishing to the tendon, which we hoped would develop, a layer of tissue which would permit of its sliding within the fasciai tube. We hoped to reproduce much the same con¬ ditions that are found in the osteo-aponeurotic canals and synovial sheaths normally. After the fasciai tube had been completed by a layer of fine chromic catgut sutures, which united the edges of the transplant anteriorly, the skin flap was sutured back into position with fine beeswaxed silk and a dry dressing was applied.
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