It was better to make two or more incisions and tunnel between these for passage of tendons rather than extensive subcutaneous dissection. The sheath of the tendon should be divided longitudinally and at the conclusion of the transference closed again with fine catgut.

Primary union was essential. It was safer to avoid touching the tendons for purpose of examination or section. Fine needles with silk were passed through the ends of tendons and then covered with sterilized gauze until ready for transplantation. The pinching of tendons with artery clamps, thumb forceps, or other instruments was to be avoided.

A very important detail of technique was a thorough anatomical knowledge of the tendons, their points of insertion, their relations one to another, and their action.

Statistics did not yet show which was better, grafting or transplantation of one tendon into another tendon, or into bone or periosteum. It is never desirable to transplant a lifeless tendon into a live one, but the live tendon should be transplanted into the point of attachment of the lifeless one. Suturing of tendons together is not always sufficient; where possible, end of tendon should be passed through button hole of another, end spread out, and quilt suture employed.

After tendons had been transferred, after the lengthened tendons had been shortened by looping or suturing or by sectioning and overlapping, test of position of foot should be made. He had discarded kangaroo tendon for tendon suturing, owing to size, and employed silk. He found it unnecessary to employ drainage save when extensive dissections were made, when he employed small drain for forty-eight hours. The hand or foot was put in a position of overcorrection and fixed with plaster of Paris bandage; parts not disturbed for two weeks, and even if healing was per priam position was maintained for some weeks; apparatus subsequently used for many months.

Of the operations, twenty-four for equino-valgus, thirteen for calcaneo-valgus, five for valgus, nineteen for equino-varus, twelve for equinus, three for calcaneus, ten for hemiplegic drop-wrist, five for dangle-leg, and one for congenital deformity of the thumb. With so many operators at all times exercising the greatest liberty, combinations of tendons would suggest themselves. The aim, however, had been to correct deformity and to place tendons where deformity could not easily occur and where best functional results might be expected.

The operations for correcting drop-foot and valgus had varied-a very common one was to make an incision one and a half inch in

length along the dorsum of the foot, beginning at tibio-tarsal joint and extending downward. Separate the skin beyond the extremity of the incision down to the tibialis anticus, divide the tendon, separate carefully from the underlying parts, pass it through a button-hole about the middle of the extensor proprius hallucis, and let it terminate among the divisions of the longus digitorum. The operation was often supplemented by subcutaneous division of the tendon Achillis. When one was desirous of raising the outer border of the foot, either the whole or part of the tendon of the tibialis anticus was extended to the peroneus tertius and brevis.

The following operation was frequently done when marked valgus existed and when the tibialis anticus was completely palsied: a part of the extensor proprius hallucis was passed through the tendon of the tibialis anticus and sutured into the posterior tibial at its insertion. Through same incision the tendons of the extensor longus digitorum might be shortened by overlapping and suturing.

Two cases presented feet with muscles so much paralyzed that through the anterior vertical incision tendons along the front of the foot were shortened and sewn firmly to the annular ligament so as to limit motion. The result in one at end of one and a half years was fair, that is, the patient could make voluntary flexion to ninety degrees without abducting the foot. In the other case the result was negative; by negative, he meant a condition ir statu quo ante.

The technique of the operation for relief of drop-wrist was yet incomplete. The procedures thus far employed were lateral incisions, one over the radial border and one over the ulnar border, with detachment of the flexor tendons and the insertion of the same into the extensor tendons. Again, the anterior and posterior incision about the middle and lower third of the forearm, then dissection through the interosseous space so that the flexor tendons could be transmitted to the extensor tendons. There had been five cases, with one good result, two fair, and two negative. In the earlier operations there was cicatrization in the interosseous space between the tissues in this locality and the tendons passed through. In two instances he attempted to meet this difficulty by implanting a scroll of celluloid in the interosseous space, removing it at end of four weeks to find tissues growing into the ends of the scroll. In one case he had used a solid cylindrical piece of celluloid in the interosseous space, removed same at end of three weeks and found a patulous opening, through which he passed the proximal

ends of the flexors and sutured them into the extensor communis digitorum with good results.

Of the ninety-two cases operated upon, he had succeeded in tracing and getting final results in sixty-nine. Good results were obtained in thirty-two per cent, fair in forty-four per cent, negative in twenty-four per cent.

Dr. Gibney further described the technique of a case of calcaneovalgus with complete paralysis of all the posterior muscles, and the operation for dangle-leg, with report of five cases.

Dr. Gibney presented nine patients, showing the results of various operations for tendon transplantation and arthrodesis performed by Drs. Townsend, Whitman, and himself. The technique and results in these cases has been covered in the above abstract.

Dr. Joseph Collins read a paper entitled "Some Neurological Questions Involved in Tendon Transplantation," in which was pointed out: 1. The necessity for the more careful and persistent treatment of cases of anterior poliomyelitis, principally by the hypodermatic use of strychnine and by massage, in order that the natural irritability of the muscle fibre be continued as long as possible. 2. The necessity of differentiation as to causation and morbid dependency of the different forms of cerebral palsies, in order that appropriate cases for tendon transplantation or other operative procedure might not be allowed to go unaided; and 3, the neuro-mechanisms of tendon transplantation. These, as well as the psychological questions involved, were explained by word and diagram. In conclusion, Dr. Collins urged that the operation of tendon transplantation for function transference be given a wide scope of usefulness through more frequent employment of it, especially in cases of cerebral palsies.

Dr. R. H. Sayre said that the patients and the papers produced had presented the matter very clearly, and that there was little to add to either the theoretical or practical sides of the subject. In his own experience he had some very satisfactory results and others that were poor. In some instances more power had been gained than was anticipated, and in others there had been a stretching of tissues so that there was a partial return of the original disability.

Dr. B. Sachs considered the view taken by the readers of the papers very encouraging; many of the cases usually deemed hopeless were in reality capable of improvement; the operation was rational, and he thought operative procedure applicable to cerebral spastic cases

as well as to infantile spinal cases. He said the difficulty in operation lay in determining exactly which muscles were overacting and which were underacting, and the failures in determining this accounted for a great many of the negative and poor results.

Dr. Jacob Teschner remarked that he was pleased to hear that a more favorable prognosis should be given poliomyelitis, according to Dr. Collins. His aim in treating long standing poliomyelitis (three to twenty years' duration) had been first to build up the muscles to their highest possible capacity and then to determine whether or not operation would improve matters. In many cases he had found operative treatment unnecessary after such treatment. He agreed with Dr. Whitman in that no operation should be undertaken until at least two years after onset of the paralysis. As to the treatment referred to, he quoted from a paper of his in the Annals of Surgery (November, 1899), his views not having changed.

Dr. Henry Ling Taylor said it was to be remembered that tendon transplantation was still in the experimental stage, and that final conclusions could not yet be given. The idea that any paralytic foot or hand could be improved by tendon grafting and that apparatus could be eliminated was not founded on experience; in properly selected cases the procedure was of undoubted value. A very fair and conservative presentation of the subject had been given.

Dr. Russell A. Hibbs read a report of tendon transplantation operations performed at the New York Orthopedic Hospital. While the ultimate results had not been so good as the immediate ones, the operation seemed justifiable, for it made apparatus more effective. He thought the operation would probably prove to be an adjunct only to mechanical treatment.

Dr. T. Halstead Myers said the results recorded at the meeting were unusually good and encouraging; he considered it interesting to note that there had been no bad results. He believed the upper extremity offered a field for better results than the lower. He asked if, in transplanting flexors or other tendons, any valuable motion had been lost in these cases. He thought the removal of deforming contractions of equal importance with the increase of power.

Dr. Townsend replied that the original action of the tendons was destroyed.

"NEC TENUI PENNÂ.”

VOL. 33.

JUNE 1, 1902.

No. 11.

H. A. COTTELL, M. D., M. F. COOMES, A. M., M. D., Editors. A Journal of Medicine and Surgery, published on the first and fifteenth of each month. Price, $2 per year, postage paid.

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THE FORTY-SEVENTH ANNUAL MEETING OF THE KENTUCKY STATE MEDICAL SOCIETY.

The forty-seventh annual meeting of the Kentucky State Medical Society will be historical in at least one respect, and that is that it adopted the amalgamated constitution and by-laws unanimously. Now who says that doctors never agree? In this they acted wisely, and the readiness with which the new constitution was adopted was due almost entirely to the unceasing efforts of the committee to which the work of revising the old constitution was entrusted. Especially is Dr. J. N. McCormack to be credited with a large part of this work. His position and his knowledge of the wants of the profession rendered him especially fitted for the great work. He had educated the profession of the State up to the point of understanding the necessity for the change, and in that way there was no difficulty in securing its unanimous adoption.

The amount of scientific work done at the meeting was not up to the average, either in quantity or quality. Why this was so it is difficult to understand. The attendance was not large. This was possibly due to the fact that the place of meeting was so remote from many members. The Society will meet in Louisville next year, and we are of the opinion that Louisville should be the permanent place of meeting. It is centrally located and many doctors want to visit the city, and would attend the meetings when they would not otherwise do so.