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. No immobilizing dressing was used, for motion was desired and encouraged immediately after the operation. Result.—Active motion was so painful at first that not much was attempted until seven or eight days had passed. The patient reported occasionally after the operation. Within six weeks a definite rounded band, which rolled under the skin, could be felt. When flexion of the phalanx was attempted this band became more prominent, leaving the surface of the bone. When the band was held against the bone a greater degree of flexion could be obtained. Finally the middle phalanx could Fig. 3.—Cross-section of the tendon. Tho well be flexed to about 80 As the was about to fascia, preserved degrees. patient and appearing like normal fascia, forms a sheath for the tendon leave institutional work to enter private practice, he wished which has developed. There is no evidence that the fasciai tube the removed for cosmetic the plays an active part in the formation of the new tendon. It forms, finger reasons; crippled finger, merely a canal along· which the tenoblasts of the divided tendons; moreover, interfered somewhat with his work, notwithstanding proliferate. A, section through transplanted fascia. B, section that considerable improvement in function had followed the through new tendon. insertion of the fasciai transplant. Oct. 9, 1913, the finger was removed under novocain anesthesia, the amputation being employed and this case has been reported to show the made through the head of the metacarpal bone. When the functional and anatomic possibilities. was dissected a tendon was found. specimen well-formed This As Rehn2 has recently shown, some loss of motion from a normal tendon in the lack differed of luster only. In occurs in traneplanting flexor tendons into the all other respects it resembled closely a normal tendon. When fingers, the tendon, which was about 3% inches in length, was divided 1. Kornew, P.: Ueber die freie Fascien transplantation, Beitr. z. klin. transversely, the original fasciai tube could be seen. It con-' Chir., 1913, lxxxv, 144. 2. Rehn, E. : Klinischer Beitrag zur freien Sehnenverpflanzung, tained tendinous tissue. Both the sublimis and profundus Arch. f. klin. Chir., 1913, cii.

Downloaded From: http://jama.jamanetwork.com/ by a University of British Columbia Library User on 06/19/2015 because the transverse aponeurotic bands are lost. The neither stand nor walk. She lay on her back and could sit loss of these bands the tendon to leave the bone up only with great difficulty. Both lower extremities were permits flexed and when the muscle is contracted, in some loss of extremely spastic. resulting Examination,—Double Babinski, Oppenheim, Mendel and motion. This wae indicated in the caee for a reported, Bechterew were with double ankle-clonus. Both knee- of flexion of the could be present greater degree phalanx jerks were lively. The lower abdominal reflexes were absent. obtained by holding the tendon against the bone. In The various reflexes of upper extremities were normal. Pupils one of Rehn's cases a ring was worn to accomplish this reacted consensually to light, accommodation and pain. Gross purpose. motor power of the lower extremities was greatly diminished Fasciai tube of tendons offers much in plastic and the movements were carried out sluggishly and pain¬ repair out because operations on the extensor tendons of the fingere. There fully. Passive movements were difficult to carry of The showed no deformities, be some limitation of motion after of the the enormous spasticity. spine may repair the flexor tendons because of destruction of the transverse but there was a marked hypersensibility to pressure at tenth, eleventh and twelfth dorsal spines. There was a slight bands. Besides the flexor tendons are closely grouped hyperextension of the interphalangeal joints of the fingers. The in the and there is a finer mechanical palm adjustment cranial nerves were negative, save for a slight asymmetry of than there is in the common extensors. passive innervation of the face, the right being stronger; this difference, however, disappeared on active or emotional inner¬ vation. The lower extremities were covered with pigmented a millet-seed to a THE DIAGNOSIS OF SPINAL CORD TUMORS copper-colored scars varying in size from large pea. Over the middle of the outer aspect of the left leg WITH REPORT OF TWO CASES there was a scar of an old ulcération. The feet were cold and HYMAN CLIMENKO, M.D. Adjunct Visiting Neurologist to the Montefiore Home, Associate Visiting Neurologist, Neurological Hospital I.« fs AND DAVID FELBERBAUM, M.D. Pathologist to the Montefiore Home and Hospital NEW YORK J Through the wonderful advance in modern surgery, the spinal cord as well as the brain has become readily "ft H accessible, hence an early and accurate diagnosis of spinal cord tumors is of the utmost importance. The only hope for permanent relief lies in the earliest pos- sible removal of a new growth, before irreparable injury has taken ( to the cord place. — c The two following cases, which occurred in the ser- '-- ¿ vices of Dr. I. Abrahamson, to whom we wish to express our indebtedness for the courtesy of observing and reporting them, are of great interest from this point of view. The first illustrates how syphilis not of the cen- tral nervous system may mislead one, while the second is peculiar in its onset and course. Case 1.\p=m-\Mrs.H. S., aged 55, born in Austria, entered Montefiore Home Nov. 17, 1911, complaining of pains and loss of power in lower extremities, loss of control of bladder and sensation and in lower extremities and rectum, girdle tingling Fig. 1.—Chart of sensory disturbances areas found in Case 1. right hand. a, hyperalgesia ; b, anesthesia ; c, analgesia ; d, thermanalgesìa. was that the Rectangle in lower dorsal region shows location of extramedullary History.—The family history negative except tumor. patient's mother had a wasting disease of many years' stand¬ was of constitution and ing. The patient always a delicate cyanotic. Decubiti were over both buttocks. A sensory test had convulsions in early childhood. Her menstrual history taken in January, 1912, showed a loss of all three sensations had nine chil¬ was negative. She married at 21 and healthy from the level of the mammae, down anteriorly and posteriorly. dren, no miscarriages. At 25 she had a cystitis following The sensory disturbances found in May, 1912, are best seen childbirth. Ten years before admission she suffered from a by the accompanying chart ( Fig. 1 ). Vibration sense was chronic ulcération of the legs. Fifteen months before admis¬ absent in the lower extremities. Stereognostie sense was sion her present illness began and was insidious but pro¬ present. gressive in its course. She first complained of tingling and The heart was normal; pulse 78; blood-pressure 150 mm. pulling sensations which began in the soles of both feet and systolic and 120 mm. diastolic. Blood-serum, tested for the gradually ascended to the hips. A little later more or less Wassermann reaction by Dr. D. M. Kaplan and Dr. D. constant pains developed about the middle of the spine, shoot¬ Felberbaum independently, gave a strong positive reaction. ing downward into both legs, and later, stiffness and weakness The cerebrospinal fluid by Wassermann test at the same time, of both legs appeared. The weakness was immediately pre¬ however, was negative. The spinal fluid registered 30 cm. ceded by a girdle sensation in the lower part of the abdomen. by Nonne's apparatus, and was clear. Globulin reaction was Three months after the commencement of her illness she could positive. Albumin in excess and 25 cells were present in 1 cm. to she lost of fluid. On these was no longer walk. Two months previous admission laboratory findings the patient given control of bladder and rectum. A few weeks before admis¬ two full doses of salvarsan intravenously, followed by many sion she noticed a tingling sensation of the little finger of intramuscular injections of mercuric bichlorid. The condition right hand. No diplopia, headaches, vomiting or convulsions apparently improved a little, the level of the sensory dis¬ of motion. were present at any time. When admitted the patient could turbance became lower and there was some increase

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