SPASTIC HEMIPLEGIA TREATED BY OPEN 
TENOTOMY OR MYOTOMY IN THE 
FOREARM AND HAND. 
BY 
AUGUSTUS THORNDIKE, M.D., 
BOSTON, MASS. 
REPRINTED EROM THE 
TRANSACTIONS OE THE AMERICAN ORTHOPEDIC ASSOCIATION, 
Vol. V., 1892. THREE CASES OF SPASTIC HEMIPLEGIA TREATED 
BY OPEN TENOTOMY OR MYOTOMY IN 
THE FOREARM AND HAND. 
By AUGUSTUS THORNDIKE, M.D., 
BOSTON. 
Although neurologists have not as yet expressed their approba- 
tion of tenotomies for the amelioration of the gait in cerebral spastic 
paraplegia of children (Little's disease), yet the published experience 
of many, like Rupprecht1 in Germany, Adams2 in England, Brad- 
ford3 and Bullard, Scudder,4 Willard5 and others in this country, 
has led orthopedists to regard spastic paralysis of the lower limb 
as a condition usually remediable under surgical treatment with or 
without the use of apparatus. The present attitude of many nervous 
specialists is shown by the following quotation from Gowers's Dis- 
eases of the Nervous System, vol. i. p. 453, edition of 1892: 
" The tendo Achillis is sometimes divided for contracture of the 
calf-muscles, but the operation is useless and ought never to be per- 
formed." Nevertheless, I venture to say that there are few ortho- 
pedic surgeons in this country who have not seen good, nay, even 
brilliant, results from this very operation. 
In the upper extremity, however, the task of restoring the im- 
paired function presents difficulties which do not occur in the leg 
and foot; instead of merely improving locomotion, the operation 
aims to restore the power of grasping and lifting with the hand, 
and to obtain, if possible, precise and delicate motions with the 
fingers, and comparatively few have attempted it. It follows as a 
matter of course that very few such operations have been published, 
1 Volkmann's klin. Vortrage, p. 172. 
2 Adams: Lancet, September 27, 1891. 
3 Trans. American Orthopedic Association, vol. iii. p. 7. 
4 Ibid., vol. iv. p. 366. 5 Ibid., p. 391. 2 
TREATMENT OF SPASTIC HEMIPLEGIA. 
and I shall therefore confine myself to a report of three cases-one 
of Dr. Bradford's, one of Dr. Burrell's, and one of my own-all 
hitherto unpublished, and in all of them the condition of the hand 
is known more than one year after operation. 
No claim is made to a permanent and absolute cure; for although 
many of the results obtained in the foot have been brilliantly suc- 
cessful, it does not seem possible that dividing with the knife the 
bellies or tendons of the affected muscles can cure the central 
nervous lesion on which the condition depends. All that is claimed 
here is that in these few cases of tenotomy or myotomy in the fore- 
arm and hand-cases where the operator felt that he was invading 
the dangerous ground of experimental surgery and was taking great 
risks in a locality where septic infection would be disastrous in the 
extreme-in all three of these cases there has been some improve- 
ment of function. 
It was not my intention to refer to trephining and the older 
operation of nerve-stretching for the relief of spastic hemiplegia; 
but I believe that the results here reported show greater improve- 
ment in the utility of the hand than any recorded cases where the 
lesion has been localized and attacked at its focal centre. 
Case I.-Miss X. was a private patient of Dr. Bradford's, who 
has kindly given me the following notes: At eighteen months she 
presented herself with spastic hemiplegia of the right hand and 
foot. The foot was in a position of moderate equinus; the knee 
was not affected; the adductors and other thigh muscles not in- 
volved ; ankle clonus was present. The arm hung with the elbow 
semiflexed, the hand in extreme pronation, the wrist slightly flexed, 
the fingers and thumb not bent, but the thumb carried in on to the 
palm of hand. After the tenotomy of the tendo Achillis the child 
soon learned to walk, and the arm was at first treated by massage 
only. This was five years ago. No apparatus was used after re- 
moving the plaster bandage on the foot. As the child grew older 
she learned to use her hand a little, but the mother insisted on 
having the same operation performed on the hand as on the foot, 
and two years after the tenotomy of the tendo Achillis, Dr. Bradford 
divided all the flexor group of muscles in the forearm by an oblique 
incision starting two fingers' breadth below the bend of the elbow AUGUSTUS THORNDIKE. 
3 
at the inner border of the supinator longus muscle, and extending 
obliquely inward and downward to the inner surface of the fore- 
arm, taking care in deepening the incision to avoid the median 
nerve and ulnar artery, which were found and isolated by the ana- 
tomical rules usually employed. The operation was done under 
ether, and was rendered bloodless by the Esmarch method. After 
all the muscles of the forearm arising from the internal condyle of 
the humerus had been divided, the resulting dead space was left to 
heal by blood-clot; the skin was sutured over it, baked dressings 
applied, and a plaster bandage held the wrist and elbow straight 
with the hand in extreme supination. Several weeks later the 
plaster was removed, the wound was all healed, and massage was 
employed as before. It is now three years since the operation, and 
the patient still comes in occasionally for observation. She can do 
many things with her hand and fingers, but as the biceps was not 
divided there still remains a little flexion at the elbow. The im- 
provement in this case was very great, and the hand is a very 
useful one. 
Case II.-E. W., a colored girl, first brought to the Children's 
Hospital as an out-patient in March, 1883. She was a year and a 
half old. She presented a right-sided hemiplegia, which had been 
noticed for about one year. The arm was flaccid, and the leg had 
been stiff for about six months. She did not return after her first 
visit until she was ten years old, when she was admitted by Dr. 
Burrell to the hospital for operation. At that time (September 9, 
1890) the arm hung by the side, and the thumb was flexed stiffly on 
the palm, and all attempts to extend it beyond a certain point caused 
great pain. The hand at the wrist was drawn over to the ulnar 
side and somewhat flexed, and the elbow was also a trifle bent. 
Under ether the Esmarch bandage and tourniquet were applied, and 
three incisions were made by Dr. Burrell as follows: first incision, 
along the web between the thumb and forefinger, dividing the tendons 
of the flexor brevis pollicis; second incision, three-quarters of an 
inch long, made in the palm at the base of the thenar eminence and 
dividing the palmar fascia, which was tense; the third incision was 
a small one over the flexor carpi ulnaris tendon just above the bend 
of the wrist, dividing that tendon and several adjacent ones which 
felt tightly stretched. The wounds were closed by continuous catgut 4 
TREATMENT OF SPASTIC HEMIPLEGIA. 
sutures in the skin; a baked dressing was applied, the deformity 
reduced, and the hand bandaged to a straight palmar splint with the 
thumb abducted. The incisions healed without mishap; she con- 
tinued to wear the splint for about two months. When last seen in 
January, 1891, four months after the operation, she was gaining in 
power in using her thumb. I have since heard, through Dr. Bullard, 
from the child's mother. She came to see him, and in reply to his 
questions said that the thumb still remains extended, with very little 
grasping power. The hand is still a little drawn over. She goes 
to school, but is backward mentally. She still holds her elbow 
somewhat bent, although she can extend and use it. In this patient 
the improvement was not very great; but it is possible that had she 
not been mentally deficient she might have learned to use her hand 
to better advantage; for there is no doubt that much of the improve- 
ment in my own case, which follows, came from the after-treatment 
-electricity and training the muscles by mild exercises. 
Case III.-M. C., aged fourteen years, was referred from the 
Children's Hospital to the House of the Good Samaritan, on account 
of her age. She entered on March 3, 1891, and the following 
history was obtained. She was a well child until two years ago, 
when after vaccination she had a copious eruption of boils, during 
which she was suddenly seized with convulsions lasting over an 
hour, and on coming out she was found to be paralyzed over the 
right side of her body. In a few weeks power began to return, 
first in the hip and shoulder, then in the elbow and knee, but she 
has never gained much in her foot or wrist. The stiffness has been 
there almost all this time. She was a large, well-nourished girl, 
not especially bright, but not much below the average of her age in 
school attainments, and certainly not mentally deficient. There 
was no facial paralysis. The habitual position of the arm, hand, 
and leg may best be seen by referring to the accompanying photo- 
graphs. Both leg and arm were extensively atrophied, and the 
hand was held flexed at right angles with the wrist; the thumb was 
folded on the palm and usually the fingers closed over it. On 
attempting to open the fingers or bend the wrist, resistance was 
encountered unless the force was applied very gradually and gently, 
when all resistance immediately vanished. All deep and superficial 
reflexes on the right side were increased. The fingers were neither AUGUSTUS THORNDIKE. 
5 
blue nor cold; the right shoulder was a little the higher, and there 
was a slight lateral deviation of the spine. In the leg the knee- 
jerk was much increased, and the ankle clonus was very troublesome, 
as it came on at every step. There was half an inch of absolute 
Fig. 1. 
Fig. 2. 
Shows the position. 
Shows the atrophy. 
shortening in the leg and a still greater difference in the arms. The 
atrophy is shown by the following measurements : 
Measurement around the upper arms: right, 8| inches; left, 9| 
inches. 
Measurement around the forearm: right, 7 inches; left, 8f inches. 
Measurement around the thigh: right, 16| inches; left, 18f inches. 
Measurement around the calf: right, 11J inches; left, 13| 
inches. 6 
TREATMENT OF SPASTIC HEMIPLEGIA. 
The right humerus measured 10| inches, the left 11 inches. 
The right ulna measured 8f inches, the left 9| inches. 
A large amount of shortening for the arm, considering the com- 
paratively brief duration of the affection-two years. 
The foot was first corrected by a subcutaneous tenotomy of the 
tendo Achillis and plantar fascia. Plaster-of-Paris bandages were 
immediately applied and kept on for three weeks, after which a 
Taylor club-foot shoe was worn. She now wears a light outside 
steel shoe with a right-angled catch at the ankle, and a high sole on 
her boot compensates for the shortening, so that she now walks 
without limping. 
After correcting the foot, a second operation was performed, one 
month after the first, on the arm, following the same incision which 
Dr. Bradford had used in Case I. of this series. The median and 
ulnar nerves were found by dissecting for them, and the line of 
incision was carried straight down to the interosseous membrane so 
as to divide all the muscles of the flexor-pronator group, leaving the 
two nerves stretching across the space between the divided ends of 
muscle-a dead space of about an inch and a quarter, which was 
left to fill in and heal by blood-clot. The ulnar artery was not to 
be found; the radial was large and was drawn aside with the belly 
of the supinator longus muscle. The skin was united by catgut 
sutures, and a baked dressing and plaster-of-Paris bandage applied 
from the finger-tips to just below the shoulder-the arm bent at a 
right angle and the hand in the position of extreme supination. 
There was no pain to speak of, the temperature remained normal, 
and the wound wras found solidly healed on removing the plaster 
bandage three weeks later. After this a millboard splint was worn, 
and the child encouraged to use her hand without the splint for an 
hour or two daily, gradually lengthening the periods of exercise 
until the splint was wholly discarded. The arm was at first very 
weak, but a little voluntary flexion of some of the fingers was pos- 
sible, and there was no stiffness. In a few days, however, there 
appeared a tendency for the hand to return to the old position of 
pronation and for the fingers to flex, and this tendency progressively 
increased in a most discouraging fashion. The extensor group of 
muscles was weak, and what was at first paretic wrist-drop gradually 
became stiff and contracted as before, only not to so great an extent. 
Under electricity and careful teaching she nevertheless learned to AUGUSTUS THORNDIKE. 
7 
use her hand a little, and could even hold a crochet-needle and do 
simple crochet-work before leaving the hospital. 
Since then she has been to the Out-patient Department for 
Nervous Diseases at the Children's Hospital, where Dr. Bullard and 
Dr. Burr have continued the electrical treatment begun at the House 
of the Good Samaritan. I sawr the patient twice in April of this 
year-one year after the second operation. Her mother had died 
meanwhile, and the young girl had taken her place, doing all the 
housework and cooking for her father and the two younger children. 
She had improved a great deal in using her hand, could feed herself, 
sweep the floor, stir the saucepans, and make the fire, using her 
right hand to a certain limited degree; but she could not lift more 
than one or two pounds with her right arm. This case also, like 
Dr. Bradford's, shows a great gain in the utility of the hand. 
In conclusion, let me call to your attention that in the first case, 
Dr. Bradford's, where the best result was obtained, the patient was 
younger, only three and a half years old, instead of ten and four- 
teen, the ages of the other two respectively. Massage had also 
been carefully tried for two years, with very little success prior to 
the operation, and the exercises and massage have been carefully 
followed out ever since. In Dr. Burrell's patient, however, the 
final gain was very slight, according to the mother's staterpent to 
Dr. Bullard. This child was certainly gaining at the time she 
eeased to attend the Children's Hospital clinic; but owing to her 
mental deficiencies she had been unwilling to persevere in following 
out the exercises, and when left to her own devices she omitted them 
entirely, and her hand speedily relapsed very nearly into its former 
state. My own case also emphasizes strongly the necessity for care 
and perseverance in the after-treatment, for there is no doubt in my 
mind but that she would have followed in the footsteps of Dr. Bur- 
rell's patient had she not been a bright and willing girl, ready to 
persevere and work in exercising her fingers and to come regularly 
for her electrical treatment. 
These cases are too few to draw conclusions from, nevertheless 
they do appear to show that improvement may be obtained after 
tenotomy or myotomy of muscles of the forearm. Also that much 
of the success should be attributed to careful training of the divided 
muscles for months after the operation.