Transactions New York Surgical Society

TRANSACTIONS OF THE NEW YORK SURGICAL SOCIETY Regular Meeting held February 9, 192I DR. \VILLIAM A. DOWNES, President, in the Chair BIRTH PALSY DR. A. S. TAYLOR presented a child three years of age, who was first seen by him when an infant of five and one-half months. She was a vertex. Labor was difficult and instrumental. She weighed ten pounds. There was a swelling in the right side of the neck which disappeared in two weeks. On the second day it was noticed that the right arm did not move. On the tenth day the fingers began to move and there has been some further improvement since. She was healthy and normal except for the right upper extremity, which was in characteristic position by the side, elbow extended, humerus rotated inward, forearm fully pronated, wrist flexed forty-five degrees and ulna adducted. The digits could be moved with fair freedom. The wrist could be very slightly extended. No supination was possible. No flexion of the elbow was possible. There was no power of abduction or external rotation at the shoulder. The shoulder was dislocated posteriorly. The pectoralis major was rigidly contracted. The extremity as a whole could be moved forward about thirty-five degrees. It was smaller than the left extremity, and the muscles softer. A cicatrix is felt in the right plexus. Operation (April ii, i9i8).-C. V., VI. and VII. were found badly torn and the ends united by a solid cicatrix about 1.5 cm. long. This was resected and end-to-end suture of the freshened stumps made with chromic gut. She made an uninterrupted recovery. One year after operation she could abduct the shoulder through the full range to nearly vertical, could rotate the humerus outward almost to the normal limit. The subluxation of the shoulder was almost gone spontaneously. She could flex elbow completely, could supinate about 75 per cent. of normal, moves the digits and wrist freely and with strength. She can put her palm to her mouth, on the top and on the back of her head. To a question as to how early he liked to operate on these cases Doctor Taylor replied that in cases in which there was no question as to the necessity for operation three months was the optimum time if the arm was held in proper position up to that time. The great difficulty was that these cases were likely to go without proper support to the arm and developed secondary deformities as the result of the nerve paralysis. He would say that three months was about the optimum time for operation. 773 NEW YORK SURGICAL SOCIETY CASE I. Neurofibronle.-Dr. A. S. Taylor presented a woman, aged thirty-six years, who, in November, I9I3, felt stiffness in the neck on awakening. In January, I914, developed pain between scapule: usually appearing at night: relieved by get- ting up and walking. If she rested during the day the pain would appear. In June, I914, the pain spread to the shoulders and down the arms to elbows. The pain was sometimes sharp and stinging and sometimes a dull ache. Sometimes the arms felt heavy and sometimes felt pinched. In September, I915, she first noticed troluble in climbing stairs, especially with right leg. Any jolt or jar caused sharp pain between the scapule. In October, I9I5, the feet became numb and this numbness crept steadily upward. In December, 1915, she lost power in the right upper extremity which also became numb. Soon the left upper extremity was also involved. In early January, I9I6, she became bedridden with loss of sphincteric control. She was a medium-sized woman, well nourished and of fair color. The upper level of anaesthesia to all types of stimuli ran across the chest just below the first ribs and down the ulnar half of the arm, forearm and hand on each side. There was marked loss of power in the upper extremities and complete loss in the lower extremities. The sphincters were paralyzed. The K. J.'s and A. J.'s were exaggerated. Babinski and Oppen- heim reactions were present on both sides. Blood and spinal fluid Wassermann's were negative. Spinal fluid culture was negative. Diagnosis.-Spinal cord tumor abouit the level of D. I. Operation (January 3I, I9I6, at the New York Hospital).-A right unilateral laminectomy involving C. VI., VII. and D. I. and II. was done. A tumor was felt beneath the exposed dura, which was then split longitudinally. A soft, friable, lobulated, vascular tumor about 3>2 by 1.5 by i cm. at its thickest portion extended from C. VII, to D. II., lay beneath the arachnoid, lay chiefly on the right side of the cord running forward laterally, and also extending a little to the left of the median line dorsally. It peeled out readily, having no adhesion to the cord substance proper. The posterior veins of the cord were intensely engorged and the cord was somewhat flattened postero-laterally. The dura was closed by fine catgut, and the superficial structures by layer sutures. On the sixth day she recovered bladder control. On the thirty- fifth day she recovered bowel control. On the fortieth day she took a few steps. She made rapid progress to complete recovery. The healing was perfect, the spinous processes are present and give an absolutely normal appearance to the spine. A number of surgeons emphasize the statement that this procedure ought never to be used. CASE II. Endothelioma of the Dura.-Dr. A. S. Taylor presented a second case, a woman, aged thirty years, who in December, 19I7, had pain in left lower dorsal region. Jolting increased this pain. Six months later the pain had spread to the right side and was more severe and persistent. In October, I9I8, there was a left drop-foot 774 TUMORS OF THE SPINAL CORD and spasms of muscles in right leg. In January, I919, left leg was paralyzed, and the feet felt numb. The right leg soon began to lose power. In April, I919, there was partial loss of sphincteric control. There was constant pain about the waist. She was a tall, slender, pale woman. Left lower extremity was paralyzed. Right showed slight muscular power. Sensory dis- turbance extended up to the level of D. IX. on the right side and D. VIII. on the left side with a zone of hyperaesthesia one segment above on each side. There were some irregular areas on the right leg and foot where touch or pin prick or both were appreciated. She could not tell the position of any of her toes. The abdominal reflexes were absent. K. J.'s and A. J.'s exaggerated on both sides L. 7 R. Left ankle clonus is almost inexhaustible. Right ankle clonus is about one-half as persistent. Babinski and Oppenheim present on both sides. Blood and spinal fluid Wassermann negative. Spinal fluid normal. Tenderness over the spines of D. VI. and D. IX. Operation (May 7, I9I9, at the New York Hospital).-Left unilateral laminectomy, involving D. IV, V., VI., and VII. Beneath exposed dura a circumscribed tumor was felt extending from D. V. to D. VII. The dura was split and a soft, purple, capsulated tumor about 4 by i by i cm. was exposed. It was adherent to the dura just below and behind the root of left D. V. This small piece of dura was excised and the tumor lifted out with it. The tumor showed two constrictions which made an upper large lobule and two smaller lower ones. The tumor was entirely left postero-lateral and had caused two shallow compression areas in the cord. The wound was closed by layer sutures without drainage. Recovery rapid and unevent- ful. On the thirteenth day she walked twenty-two steps and was taken home where she made a complete recovery. Pathological Report: Endothelioma of the Dura (Psammoma). Here again the unilateral laminectomy gave a perfectly satisfactory exposure and working field. DR. HAROLD NEUHOF stated that in regard to the hemilaminectomy, Doctor Taylor had inferred that it was indicated in some cases. It had proved unsatisfactory in his hands. It was his impression that the exposure obtained by a unilateral laminectomy was not adequate for a general exploratory investigation. If the localization of the lesion was clear as in Doctor Taylor's case in which the tumor lay on the right side, then a hemilaminectomy might be satisfactory and might fit that situation well, but the operation was one having strict limitations. The basic principle is not whether one approaches the cord by a hemilaminectomy or by a total laminectomy, but that the exposure shall be such that the cord shall be exposed to the minimum manipulation, and mani- festly the minimum of manipulation of the delicate structures was secured with a total laminectomy. Doctor Taylor had spoken of preserving the spinal processes for the sake of preserving the external contour. 775 NEW YORK SURGICAL SOCIETY He did not think that was a particular advantage, as the space occupied by the spinal processes removed by the total laminectomy is filled in with muscle and fascia, so that a normal external appearance is preserved. DOCTOR TAYLOR said he had seen a number of bilateral laminectomies in the neck where the ligamentum nuchae had been damaged. Being deprived of their elastic support these patients complained of more or less neckache because their muscle had to substitute for it. In the cervi- cal region hemilaminectomy gave ample opportunity to do any operation.

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