nerves in the same individual repair more readily than others. Better results may be obtained, for instance, after suture of the musculo-spiral nerve than after suture of the median or ulnar.

As illustrating the simple suture and the satisfactory result that may be obtained under favorable conditions, the following case is reported in which apparently perfect repair took place in a remarkably short space of time:

Mr. A. B., white, aged thirty years, blacksmith, was kindly referred by Dr. C. A. Blanton, of Richmond, Va. Patient was in good health with no history of previous disease bearing upon the injury. He was industrious and not dissipated. August 3rd, 1908, while forging, a piece of steel broke loose from his hammer and penetrated the lower part of the right arm completely severing the musculo-spiral nerve at this point. Symptoms: complete paralysis of all extensor muscles on back of forearm supplied by posterior interosseous nerve, giving typical wrist-drop, and abolition of sensation in the skin over the area supplied by the radial nerve.

Operation at Memorial Hospital, August 4, 1908. Under ether, an incision was made in the groove between the brachialis anticus and supinator longus muscles and was continued upward and backward for about four inches. The musculo-spiral nerve was found completely divided. The piece of steel was removed from muscle tissue near the musculo-spiral. The ends of the nerve were cut across with a sharp knife and sutured with chromic cat-gut in the manner indicated above. A piece of muscle was then sutured over the nerve and the wound closed. The arm was put in flexion in a plaster cast. The wound healed primarily. Improvement was gradual, but apparently complete. Six months after operation extension of the right hand was complete and forcible and the area of anesthesia had practically disappeared.

Nerve grafting or implantation may be employed in cases in which so much of the trunk of one nerve has been injured that its ends cannot be approximated. This method is more satisfactory than either the flap operation or attempts to bridge the ends by inserting foreign substances.

The following is a brief abstract of a case which has previously been reported in Journal of the A. M. A. of March 3, 1906: H. J., aged twenty-one, negro, previous health good. In August, 1903, he was thrown some distance by explosion of a boiler and suffered several injuries. He was unconscious for several hours, but on recovering found his right hand and forearm paralyzed. On November 17, 1903, he was referred to me. There was complete paralysis of both motion and sensation in all of the right forearm and hand except in those muscles and that portion of the skin supplied by the ulnar nerve and a small portion of the skin supplied by the musculo-cutaneous nerve. There was marked atrophy. The first operation was performed November 17, 1903. The median was found crushed and destroyed. It was cut across and implanted into a nick in the ulnar nerve. In January, 1905, the patient returned to the hospital and great improvement was noted. A second operation was performed on January 17, 1905. The musculo-spiral was exposed at the outer side of the elbow and cut across. With a closed hemostat an opening was burrowed beneath the biceps from the lower angle of the incision and the distal end of the musculo-spiral was implanted into a slight nick in the median nerve. The following report was kindly made for me by Dr. Call, Professor of Medicine in the Medical College of Virginia, and is the result of his examination of this patient November 16 and 17, 1905:

"Extension of forearm good. Flexion of forearm excellent, with slight degree of pronation. With forearm extended, pronation and supination are good. Flexion and extension of wrist are both present, extension being the stronger, but both are of good force.

"Phalanges.-Flexion of little and ring fingers good, of middle finger less strong. Index finger has less strength than the middle, but all these fingers flex with considerable strength. All the phlanages flex except the first phalanx of the index finger, which has scarcely perceptible motion. Extension of all the phalanges occurs, that of the middle and index fingers being weaker than that of the little and ring.

"Thumb. Slight flexion of terminal phalanx, less marked flexion in the first phalanx. Abduction and adduction both present to slight extent. Very little backward movement. Rotation can not be accomplished. With the hand at rest the thumb is slightly adducted.

"Nerves. Galvanic stimulation of nerves gives the following result: Ulnar, below the point of implantation, gives marked contraction, stimulation of the median gives marked contraction, but weaker than results from stimulation of the ulnar, especially weak in the thumb muscles supplied by the median. Musculo-spiral could not be located at the radial point, though the corresponding nerve on the uninjured side showed marked contraction. Stimulation of area just over the region of posterior interosseous nerve gives marked response in muscles supplied by that nerve, though the contraction of some of these muscles was due to unavoidable direct stimulation of the muscles themselves.

"Stimulation of the ulnar nerve above the implantation of the median gave ulnar and median response, the ulnar group being markedly stronger.

"No anesthesia or paresthesia. Partial cutaneous analgesia was marked on dorsal surface of middle finger. There is marked atrophy in the muscles of right arm, forearm and hand, as compared with the well developed muscular left side.

"The nails on the index and middle fingers show evidence of past trophic disturbances."

When last heard from, patient was doing his regular manual work on a farm, making good use of his right hand and forearm.

Unfortunately, we do not obtain such good results in all cases as in these two that have just been reported. Of three cases of suturing of the brachial plexus or some of its immediate terminal branches, an entirely satisfactory result has only been attained in one instance; in the other two cases, slight extension in the area of sensation and a hardly preceptible increase in motion would scarcely justify the term "improvement." În both of these cases, however, conditions were most unsatisfactory, as one patient developed syphilis shortly after the second operation, and the other had extensive scar tissue from an old suppuration in the region around the injured nerve.

Nerves may be sutured successfully several years after they have been injured, but the longer reparative surgery is postponed in such cases, the more imperfect is regeneration and the less likelihood of attaining satisfactory results. Consequently, these cases should not be neglected, but should be operated upon as soon as possible after injury, though, where from circumstances, prompt suturing has not been possible, the patient should be given the benefit of an operation, even if the injury has existed for several years.

DISCUSSION.

DR. STUART MICHAUX, Richmond: I would like very much to ask Dr. Horsley what results have been obtained in the transplantation of nerves in cases of hemiplegia. I read a series of articles some years ago, in which experiments had been made in hemiplegia. These experiments, I think, dealt with transplanting large trunks from the cervical plexus across the base of the neck, and also transplantation had been made by splitting the sciatic nerve and carrying it across the buttocks. I have not seen anything in the literature about these experiments, and would like very much if Dr. Horsley could tell us something about them.

DR. J. SHELTON HORSLEY, Richmond: I have nothing further to add, except in reply to Dr. Michaux's inquiry. I have had no personal experience along this line, and I have not seen any results from such operations. I know that such things have been attempted, but the nearest thing to it is what the orthopedic men have had considerable experience with-transplantation of nerves in cases in which there has been acute anterior poliomyelitis limited to one particular muscle or group of muscles. For instance, one of the tibial or peroneal nerves may be transplanted into the popliteal or some other nerve, and the_results reported have occasionally been satisfactory, though not brilliant. In such cases, when the lesion is a comparatively local one in the spinal cord, if we cannot obtain uniformly satisfactory results, I should hardly think, when the brain itself is out of commission, we could hope for very good results. The movements would probably be irregular, and hardly of very much service to the patient.

PYLOROPLASTY.

By HUGH H. TROUT, M. D., Roanoke, Va.

As far as we know, the first step toward the modern operation of pyloroplasty was the digital dilation of the pylorus, as originated by Loreta, in 1883.

1

Very naturally, however, this operation was soon found to be impractical and was replaced by the operation of Heineke and Mikulicz, who performed it independently in 1886 and 1887; thereby replacing a reckless divulsion by a definite plastic operation. In May, 1902, Finney first described the operation with which this paper has to deal. It is largely based on a report of eight cases operated upon by the author.

The operation is hard to describe in words, but once seen, is definite and clear and, therefore, the nearest approach one can have to the actual operation is the illustrations, which briefly explain themselves.

Before advising an operation of any description, I believe one should conscientiously Lave medical methods tried to the fullest extent, but not wait until the strength of the patient is so wasted that surgical interference is indeed a forlorn hope.

The following cases will be very briefly reported, only the important features being mentioned:

Case No. 1.-Age, forty years. Male. History of vomiting of bright red blood at periods covering a space of about ten years. Some temporary relief and benefit from forced rest and milk diet, etc. Patient had recovered from one of these attacks about one month previous to operation. On operation, an ulcer found just to the gastric side of the pylorus and being about 2cm in diameter. The ulcer was removed by an extension of the horse-shoe incision around the same.

Cases 2, 3 and 4.-Were very similar to each other in having adhesions around the pylorus, which made the operation somewhat difficult in obtaining the mobilization of the duodenum. All showed old partially healed ulcers on the stomach side of the pylorus and all gave the usual history of pyloric obstruction, pain, etc.

Case No. 3. The patient had been on liquid diet for over four years and the pylorus was found too small to admit the point of a pair of curved scissors usually employed to make the incision through the pylorus.

These four cases have all been operated upon for over three years, and each reports no present gastric disturbance or inconvenience and a gain in weight varying from twenty to sixty pounds, with a relative increase in strength and general health.

Case No. 5.-Mr. K.; September 2, 1908, 28 years. With this case, we enter into a series of cases of too recent a date to draw any final conclusion, but each presents some points of interest. The patient had suffered with pain in the right hypochondriac region for a period of over eight years, and the most distinctive feature of the pain was the almost immediate relief obtained by the taking of solid food but no relief by taking water. During the five months before admission, he had lost in the neighborhood of thirty pounds. As might be expected, in this case, a duodenal ulcer was found, excised and pyloroplasty performed. When seen last week, he reports a gain in weight of sixtysix pounds since leaving the hospital, this being about thirty. pounds above his normal weight; and a complete cessation of all pain.

Case No. 6.-Miss D.; age 43 years, February 1909. The duration of pain, four years. On liquid diet most of the time and for the past year has been taking morphia. On admission, was taking about five grains daily. Pronounced history of intense vomiting. Operation, large number of dense adhesions around the pylorus and a saddle-shaped ulcer which was about the size of a silver quarter of a dollar. The operation was done in fifty minutes in spite of the adhesions, and there was no history of leakage or trouble with stitches. The patient was heard from four days ago and has gained about forty pounds; no pain, and has ceased the use of morphia. On first examining the pylorus, there was some question as to whether it was an early carcinoma. Microscopical examination proved it to be ulcer.

I am sure this diagnosis could never have been made without an incision into the pylorus, which, of course would not have been done with a gastro-enterostomy. Case No. 7.-K.; age 41 years. Presents no feature further than a greatly constricted pylorus, due to an old healed ulcer.

Case No. 8.-Mrs. D.; age 41. Patient had been vomiting for over three months and apparently nothing could stop the same. Certainly the best efforts of over six

physicians did no good; and to all it was apparent she was dying. An exploratory laparotomy was done on April 5, 1909. Operation revealed a thoracic and abdominal aneurysm, and it was thought if she were able to retain her food her life might be prolonged; so a pyloroplasty was hurriedly performed. She ceased her vomiting and did not die until she had demonstrated the fact that the pyloroplasty allowed her to retain solid food, which she had not done for over four months.

A partial post mortem showed the stitches holding perfectly, no leakage and no adhesions. The largest diameter of the aneurysm was three inches.

If there be one point more prominent than any other about this report of cases, it must be the absence of post-operative nausea and other complications; such as the much dreaded "vicious circle," both of which are so often obtained in gastro-jejunostomy.

3

We realize fully that there are many advocates of gastro-enterostomy, and from the writings of many, we may indeed wonder with Doctor Portis, that we are not born with a gastro-jejunostomy.

We are too apt to forget the part taken by the stomach and duodenum in digestion and absorption, and think too little of ulcer and other intestinal disturbances to be expected after short circuiting.

When one considers the mortality of gastro-enterostomy, one must recall the number of such operations done without any definite pathological basis. It has not been long since I saw a prominent surgeon of this country do three gastro-enterostomies for duodenal ulcers, all of the "microscopical variety," and at the same time, remove an adherent appendix. Many of us have seen gastric and duodenal symptoms disappear after appendectomies, and do not doubt but that these patients were benefited by the operation, but whether by the appendectomy or the gastro-enterostomy, no one will ever be able to state.

In performing a gastro-enterostomy it is usually impossible to examine an ulcer, for they are more frequently located close to the pylorus, and in most cases in which the operation is demanded, the pylorus is abnormally high. This being true, one can readily see it is practically impossible to remove an ulcer located near the pylorus through the opening of a gastro-enterostomy; and where there is hemorrhage, the operator is forced to rely on drainage for the control of the same. This is always not safe, for a number of severe hemorrhages have been reported following such procedure, and Korte cites two cases of fatal hemorrhage from ulcers eight and twelve days after operation. The possibility of this occurrence should certainly lead one to excise an accessible ulcer rather than trust to gastro-enterostomy to stop hemorrhage.

The question of ulcer of the jejunem near the anastomotic opening following gastrojejunostomy is not as slight as some surgeons would have us believe, for without much trouble I have been able to collect sixty such cases from literature and this, in spite of the fact that most men are not prone to report their failures. Lenander' has advanced the theory that pain is absent in the early stages of ulcer because there are no pain perceiving nerves in the intestine and therefore, ulceration is painless until it invades the peritoneum. If this be true, we have an explanation of the long interval between the operation, and the symptoms being so pronounced as to allow a diagnosis of ulcer. Why this condition is not more frequent, I do not understand, for apart from having food not sufficiently churned in the stomach and allowed to empty itself before is it in liquid form, thereby causing mechanical injury, we have in most cases an increase in hydrochloric acid or certainly a normal amount, and this is allowed to escape into the portion of the intestine accustomed to receiving foods in a neutral or alkaline condition. Apart from this, Parlow has shown that hydrochloric acid is a specific excitant of the pancreatic gland, but has no effect if retained in the stomach or allowed to escape into the jejunum.

It is interesting to note in passing that the mortality of perforated jejunal ulcer is about seventy-two per cent, and the majority are perforated before diagnosis is made. Examination of the stools after gastro-enterostomy shows that fats and albumins are, at the best, only partially digested. This condition of the stools is not found after pyloroplasty. Another post operative feature occasionally following gastro-enterostomy and not pyloroplasty is the severe diarrhoea caused by the imperfect digestion due to this presence of acidity interfering with the bowel ferments.

Friedenwald has demonstrated a return to normal of the stomach acidity, etc., after a number of Finney's pyloroplasties.

8

Cannon, Murphy,' Leggett and Maury, have all demonstrated that in an uncertain proportion of cases the anastomosis of a gastro-enterostomy will close and the old condition of pyloric stenosis remains. The latter two have also demonstrated by their

experimental work on dogs that in about one-half of the cases of gastro-enterostomy food passes through the pylorus in spite of a more dependent anastomosis of a gastroenterostomy. And Schostak makes the suggestion that in most of such reported cases, the obliteration has been due to peptic ulceration. Paterson10 reports nineteen cases of closure of the anastomosis.

I do not want to be misunderstood to advocate this operation to the exclusion of gastro-enterostomy, but believe pyloroplasty will become more and more popular as it is better understood.

It is the object of most surgery to attempt as near as possible the return to normal, and it is certain pyloroplasty fulfills this requirement closer than any other operation now known for pyloric obstruction.

1. Loreta, Lancet, August 18, 1883.

BIBLIOGRAPHY

2. Finney, Bulletin Johns Hopkins Hospital, May, 1902.

3. Portis, Annals of Surgery, Vol. XLIV, page 901.

4. Korte, Verhandl der Deutch Gessellsch, f. Chir. 1900, 1, page 137.

5. Lenander, Certrale, f. Chir. 1901, page 209.

6. Parlow, The Work of the Digestive Glands.

7. Leggett and Maury, Annals of Surgery, October, 1907, Vol. XLVI, No. 4, page 549.

8. Leggett and Maury, Annals of Surgery, Vol. XLVI, No. 4.

9. Schostak, Beitrage zur klin. Chir. Bd. LVI, 1907, Hect. 2.

10. Paterson, Annals of Surgery, August, 1909, Vol. I, No. 2.

DR. R. L. PAYNE, JR., Norfolk: Dr. Trout's paper was an exceedingly interesting paper to me, for I have been particularly interested in gastric surgery for the last two years. As he said, the first men who did a pyloroplasty were Heinecke and Mikulicz, in 1886, and they were followed by Duranty and Segal with their type of operation. In 1904, Narath reported a type of operation, which was a decided copy of the original Heinecke-Mikulicz operation, making a larger flap, but with results almost similar to the Finney pyloroplasty.

As Dr. Trout told you, Finney first reported his operation in 1902, and called it pyloroplasty; while as a matter of fact, the term is rather indefinite. It is an operation not only on the stomach and duodenum, but on the pylorus, and correctly the term should be gastro-pyloro-duodenostomy. A little later, following the report of Finney's operation, Gould modified it by the use of the clamp, and this procedure has been more or less universally accepted, but obviously it is a wrong procedure, because the clamps preclude the possibility of examination of the duodenum or stomach; and for that reason, in spite of the more excessive hemorrhage by the Finney method, it should be used, I believe, in all cases.

Now, the vital question at issue is the choice of a pyloroplasty versus a gastroenterostomy, and Dr. Trout has well treated the salient points in the discussion. The claims for gastro-enterostomy against pyloroplasty are principally, in the minds of the average surgeon, that the pyloroplasty does not produce an opening at the lowest point of gravity in the stomach, the difficulty in freeing the stomach and pylorus, and that we are unable to deal with a perforating ulcer or a freshly bleeding ulcer. Now, these objections, to the men who are doing pyloroplasty frequently, are more or less of a phantom nature. It is easy to free the stomach or pylorus, if we are familiar with the anatomy and especially if we follow the teachings of Kocher in his article of 1903, in which he advocated immobilization of the duodenum, which simplifies the operation considerably. Whereas, for gastro-pyloro-duodenostomy, we never have a vicious circle and we avoid a peptic ulcer of the jejunum, or contracture or closure of the opening, such as frequently and commonly is seen in gastro-enterostomy.

The life of pyloroplasty is so short that the limitations of the operation are more or less indefinite. Still its greatest field lies in benign stenosis of the pylorus. However, there are a great many men who have reported a large series of cases, Finney among others, reporting fifty in which he has operated for acute and bleeding ulcers of the stomach and duodenum, and I believe that pyloroplasty after Finney's method will probably be the operation of choice in the future as against gastro-enterostomy; and as Dr. Trout has told you, if you will review the literature, the mortality is slightly in favor of pyloroplasty.

DR. H. H. TROUT, Roanoke, (concluding the discussion): I wish to thank Dr. Payne for his kind discussion of my paper. As regards the name pyloroplasty, if we had to use the name as it really is, no one would do the operation, I believe. It is too much