MILITARY MEDICAL MANUALS
' '•_ • 1 I - _—	GENERAL EDITOR: SURGEON-GEN. SIR ALFRED KEOGH G,C,B,,M.D., r%R,C.P. !«| S THE TREATMENT i° AND REPAIR OF r NERVE LESIONS =co 1 A, BEN I STY	I 2
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MILITARY MEDICAL MANUALS

GENERAL EDITOR : SIR ALFRED KEOGH, G.C.B., M.D., F.R.C.P.

TREATMENT AND REPAIR OF NERVE LESIONS

TREATMENT & REPAIR OF NERVE LESIONS

BY

MME ATHANASSIO-BENISTY

HOUSE PHYSICIAN TO LA SALPETRIERE

PREFACE BY

PROFESSOR PIERRE MARIE

MEMBER OF THE ACADEMY OF MEDICINE

EDITED WITH A PREFACE BY

E. FARQUHAR BUZZARD, M.D., F.R.C.P.

CAPTAIN R.A.M.C. (T.)

WITH 62 ILLUSTRATIONS AND 4 FULL-PAGE PLATES

UNIVERSITY OF LONDON PRESS LTD. 18 WARWICK SQUARE, LONDON, E.G. 4

PARIS: MASSON ET C IE, 120 BOULEVARD SAINT-GERMAIN

1918

GENERAL INTRODUCTION

THE infinite variety of injuries which any war pre- sents to the surgeon gives to military surgery a special interest and importance. The special interest and importance, in a surgical sense, of the great Euro- pean War lies not so much in the fact that examples of every form of gross lesion of organs and limbs have been seen, for if we read the older writers we find little in the moderns that is new in this respect but is to be found in the enormous mass of clinical material which has been presented to us and in the production of evidence sufficient to eliminate sources of error in determining important conclusions. For the first time also in any campaign the labours of the surgeon and the physician have had the aid of the bacteriologist, the pathologist, the physiologist, and indeed of every form of scientific assistance, in the solution of their respective problems. The clinician entered upon the great war armed with all the resources which the advances of fifty years had made available. If the surgical problems of modern war can be said not to differ sensibly from the cam- paigns of the past, the form in which they have been presented is certainly as different as are the methods of their solution. The achievements in the field of discovery of the chemist, the physicist and the biologist have given the military surgeon an advan- tage in diagnosis and treatment which was denied to his predecessors, and we are able to measure the effects of these advantages when we come to appraise the results which have been attained.

But although we may admit the general truth of these statements, it would be wrong to assume that modern scientific knowledge was, on the outbreak

vi GENERAL INTRODUCTION

of the war, immediately useful to those to whom the wounded were to be confided. Fixed principles existed in aD the sciences auxiliary to the work of the surgeon, but our scientific resources were not immediately available at the outset of the great campaign ; scientific work bearing on wound prob- lems had not been arranged in a manner adapted to the requirements — indeed, the requirements were not fully foreseen ; the workers in the various fields were isolated, or isolated themselves, pursuing new researches rather than concentrating their powerful forces upon the one great quest.

However brilliant the triumphs of surgery may be — and that they have been of surpassing splendour no one will be found to deny — experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research.

The series of manuals, which it is my pleasant duty to introduce to English readers, consists of transla- tions of the principal volumes of the " Horizon " Collection, which has been appropriately named after the uniform of the French soldier.

The authors, who are all well-known specialists in the subjects which they represent, have given a concise but eminently readable account of the recent ac- quisitions to the medicine and surgery of war which had hitherto been disseminated in periodical literature.

No higher praise can be given to the Editors than to say that the clearness of exposition characteristic of the French original has not been lost in the render- ing into English.

MEDICAL SERIES

The medical volumes which have been translated for this series may be divided into two main groups, the first dealing with certain epidemic diseases, in- cluding syphilis, which are most liable to attack soldiers, and the second with various aspects of the

GENERAL INTRODUCTION vii

neurology of war. The last word on Typhoid Fever, hitherto " the greatest scourge of armies in time of war," as it has been truly called, will be found in the monograph by MM. Vincent and Muratet, which contains a full account of recent progress in bacteri- ology and epidemiology as well as the clinical features of typhoid and paratyphoid fevers. The writers combat a belief in the comparatively harmless nature of paratyphoid and state that in the present war haemorrhage and perforation have been as frequent in paratyphoid, as in typhoid fever. In their chapter on diagnosis they show that the serum test is of no value in the case of those who have undergone anti- typhoid or anti-paratyphoid vaccination, and that precise information can be gained by blood cultures only. The relative advantages of a restricted and liberal diet are discussed in the chapter on treatment, which also contains a description of serum-therapy and vaccine-therapy and the general management of the patient.

Considerable space is devoted to the important question of the carrier of infection. A special chapter is devoted to the prophylaxis of typhoid fever in the army. The work concludes with a chapter on pre- ventive inoculation, in which its value is conclusively proved by the statistics of all countries in which it has been employed.

MM. Vincent and Muratet have also contributed to the series a work on Dysentery, Cholera and Typhus which will be of special interest to those whose duties take them to the Eastern Mediterranean or Mesopotamia. The carrier problem in relation to dysentery and cholera is fully discussed, and special stress is laid on the epidemiological import- ance of mild or abortive cases of these two diseases.

In their monograph on The Abnormal Forms of Tetanus, MM. Courtois-Suffit and Giroux treat of those varieties of the disease in which the spasm is confined to a limited group of muscles, e.g. those of the head, or one or more limbs, or of the abdomino-

b

viii GMNMKAL INTRODUCTION

thoracic muscles. The constitutional symptoms are less severe than in the generalized form of the disease, and the prognosis is more favourable.

The volume by Dr G. Thibierge on Syphilis in the Army is intended as a vade mecum for medical officers in the army.

Turning now to the works of neurological interest, we have two volumes dealing with lesions of the peri- pheral nerves by Mme. Athanassio-Benisty, who has been for several years assistant to Professor Pierre Marie at La Salpetriere. The first volume contains an account of the anatomy and physiology of the peripheral nerves, together with the symptomatology of their lesions. The second volume is devoted to the prognosis and treatment of nerve lesions.

The monograph of MM. Babinski and Froment on Hysteria or Pithiatism and Nervous Disorders of a Reflex Character next claims attention. In the first part the old conception of hysteria, especially as it was built up by Charcot, is set forth, and is followed by a description of the modern conception of hysteria due to Babinski, who has suggested the substitution of the term " Pithiatism," i.e. a state curable by persuasion, for the old name hysteria. The second part deals with nervous disorders of a reflex char- acter, consisting of contractures or paralysis follow- ing traumatism, which are frequently found in the neurology of war, and a variety of minor symptoms, such as muscular atrophy, exaggeration of the tendon reflexes, vasomotor, thermal and secretory changes, etc. An important section discusses the future of such men, especially as regards their dis- posal by medical boards.

An instructive companion volume to the above is to be found in the monograph of MM. Roussy and Lhermitte, which embodies a description of the psychoneuroses met with in war, starting with ele- mentary motor disorders and concluding with the most complex represented by pure psychoses.

GENERAL INTRODUCTION ix

SURGICAL SERIES

When the present war began, surgeons, under the influence of the immortal work of Lister, had for more than a quarter of a century concerned them- selves almost exclusively with elaborations of tech- nique designed to shorten the time occupied in or to improve the results obtained by the many complex operations that the genius of Lister had rendered possible. The good behaviour of the wound was taken for granted whenever it was made, as it nearly always was, through unbroken skin, and hence the study of the treatment of wounds had become largely restricted to the study of the aseptic variety. Septic wounds were rarely seen, and antiseptic surgery had been almost forgotten. Very few of those who were called upon to treat the wounded in the early autumn of 1914 were familiar with the treatment of grossly septic compound fractures and wounded joints, and none had any wide experience. To these men the conditions of the wounds came as a sinister and dis- heartening revelation. They were suddenly con- fronted with a state of affairs, as far as the physical conditions in the wounds were concerned, for which it was necessary to go back a hundred years or more to find a parallel.

Hence the early period of the war was one of earnest search after the correct principles that should be applied to the removal of the unusual difficulties with which surgeons and physicians were faced. It was necessary to discover where and why the treat- ment that sufficed for affections among the civil population failed when it was applied to military casualties, and then to originate adequate measures for the relief of the latter. For many reasons this was a slow and laborious process, in spite of the multitude of workers and the wealth of scientific resources at their disposal. The ruthlessness of war must necessarily hamper the work of the medical scientist in almost every direction except in that of

x GENERAL INTRODUCTION

providing him with an abundance of material upon which to work. It limits the opportunity for de- liberate critical observation and comparison that is so essential to the formation of an accurate estima- tion of values ; it often compels work to be done under such high pressure and such unfavourable conditions that it becomes of little value for educa- tive purposes. In all the armies, and on all the fronts, the pressure caused by the unprecedented number of casualties has necessitated rapid evacua- tion from the front along lines of communication, often of enormous length, and this means the transfer of cases through many hands, with its consequent division of responsibility, loss of continuity of treat- ment, and absence of prolonged observation by any one individual.

In addition to all this, it must be remembered that in this war the early conditions at the front were so uncertain that it was impossible to establish there the completely equipped scientific institutions for the treatment of the wounded that are now available under more assured circumstances, and that progress was thereby much hampered until definitive treat- ment could be undertaken at the early stage that is now possible.

But order has been steadily evolved out of chaos, and many things are now being done at the front that would have been deemed impossible not many months ago. As general principles of treatment are established it is found practicable to give effect to them to their full logical extent, and though there are still many obscure points to be elucidated and many methods in use that still call for improvements, it is now safe to say that the position of the art of military medicine and surgery stands upon a sound foundation, and that its future may be regarded with confidence and sanguine expectation.

The views of great authorities who derive their knowledge from extensive first-hand practical ex- perience gained in the field cannot fail to serve as a

GENERAL INTRODUCTION xi

most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and its predominating note is the ex- haustive, practical and up-to-date manner in which it is handled. It is marked throughout not only by a wealth of detail, but by clearness of view and logical sequence of thought. Its study will convince the reader that, great as have been the advances in all departments in the services during this war, the progress made in the medical branch may fairly challenge comparison with that in any other, and that not the least among the services rendered by our great ally, France, to the common cause is this brilliant contribution to our professional knowledge.

A glance at the list of surgical works in the series will show how completely the ground has been covered. Appropriately enough, the series opens with the volume on The Treatment of Infected Wounds, by A. Carrel and G. Dehelly. This is a direct pro- duct of the war which, in the opinion of many, bids fair to become epoch-making in the treatment of septic wounds. It is peculiar to the war and derived directly from it, and the work upon which it is based is as fine an example of correlated work on the part of the chemist, the bacteriologist and the clinician as could well be wished for. This volume will show many for the first time what a precise and scientific method the " Carrel treatment " really is.

The two volumes by Professor Leriche on Fractures contain the practical application of the views of the great Lyons school of surgeons with regard to the treatment of injuries of bones and joints. Sup- ported as they are by an appeal to an abundant clinical experience, they cannot fail to interest English surgeons, and to prove of the greatest value. It is only necessary to say the Wounds of the Abdomen are dealt with by Dr Abadie, Wounds of the Vessels by Professor Sencert, Wounds of the Skull

xii GENERAL INTRODUCTION

and Brain by MM. Chatelin and De Martel, and Localisation and Extraction of Projectiles by Pro- fessor Ombredanne and R. Ledoux-Lebard, to prove that the subjects have been allotted to very able and experienced exponents.

ALFRED KEOGH.

PREFACE BY ENGLISH EDITOR

IN no department of medical science has more valuable work been performed by our French colleagues since the commencement of the War than in the stud}^ of nerve injuries. The establishment of neurological centres throughout France has resulted in the addition of a number of interesting contributions to this subject, which testify to the zeal and industry shown by our allies in this as in other fields of activity.

Madame Athanassio-Benisty, who has been assisting Professor Pierre Marie for several years, has incorpor- ated all recent acquisitions to our knowledge of nerve lesions, including several important contributions of her own, in the two volumes which are here presented to English readers. They form a comprehensive treatise on the subject, and should be of service not only to the neurologist, but to the medical practitioner who has had no special training in the study of nervous diseases.

The value of this work has been much enhanced by the generous provision of new illustrations and diagrams, and special attention may be drawn to the author's study of the vascular and vasomotor phenomena complicating the results of traumata inflicted on peripheral nerves, and to the detailed examination of nerve trunks in regard to the position of the various bundles of nerve fibres contained in

xiv TREATMENT AND REPAIR OF NERVE LESIONS

them. How far the surgeon will be able to adapt this additional knowledge to his purpose remains to be seen, and it is still too early, in spite of the long duration of the War, to compile any final statistics on the results of nerve suturing.

E. FARQUHAR BUZZARD.

PREFACE

THE first book published by Mme. Athanassio-Benisty in the " Horizon Series " dealt with the Clinical Forms of Nerve Lesions. It described the methods of ex- amination, and the signs by which affections of peri- pheral nerves can be differentiated.

I have already stated why it should be accepted as a reliable and practical guide to initiate medical men who are not specialists in the diagnosis of nerve lesions. This second volume is its necessary comple- ment. It describes the nature of the lesions, their method of repair, their prognosis, and especially their treatment, which constitutes the ultimate aim of all our researches.

The clinician, however careful an observer he may be, can never create a work of lasting and substantial value without the information which pathological anatomy alone can place at his disposal. But a clinic can hardly be described as " humane " which takes for its starting-point the purely objective findings of pathological anatomy. The former is elucidated and confirmed by the latter. The opposite method can only lead to artificial conceptions. Mme. Athanassio- Benisty has fully grasped this point by setting out to

xvi TREATMENT AND REPAIR OF NERVE LESIONS

study clinically the results of nerve lesions, and then by seeking to interpret them by the aid of pathological and anatomical findings.

Of these there has been a plentiful supply. Nerve injuries often necessitate surgical interference, during the course of which the naked-eye appearance of the injured nerve can be examined ; sometimes also, when resection has been considered necessary, a histological examination can in such a case be conducted under unusually favourable conditions.

These examinations, conducted in situ, together with microscopical researches made in my laboratory by my pupil, Ch. Foix, as well as the results obtained by other observers, justify the expression of a very definite opinion about the different varieties of in- juries to nerve-trunks and their process of repair. It has been possible to obtain from them useful indi- cations for operation.

From the very first we desired to know whether there existed a systematic distribution of fibres within the nerve-trunk similar to that of the collection of fibres constituting the spinal cord.

Direct electrical stimulation in the operation wound allowed us, in collaboration with H. Meige and Gosset, to prove definitely the existence of this systematic intra-truncular distribution, and even to determine the topography of certain nerves.

Mme. Athanassio-Benisty having taken an active part in all these researches, was well qualified to estab- lish their relation with the clinical observations which she had conducted. This has enabled her to bring

PREFACE xvii

forward a series of remarkably valuable data relat- ing to the evolution of wounds of the nerves, the most favourable time for operation, and the prognosis of early symptoms or late sequelae.

In the presence of the really surprising number of nerve injuries at the beginning of the war, operative interference at first became more frequent. It is not so long since it seemed to be the rule, and even }he duty, of the medical man in almost every case. Gradually, however, experience tempered this surgical ardour.

It was noticed that a number of operations which, if skilfully performed, had no bad effects, on the other hand did not appreciably hasten functional recovery. Except in certain conditions, which are daily becoming better understood, abstention from operation appears to be the wisest course. It was necessary, therefore, to have a clear idea of the clinical signs of severe lesions justifying operative interference. Mme. Athanassio- Benisty has devoted to these important questions several instructive chapters.

Even if nerve surgery has not completely fulfilled our first hopes, it must not be concluded that nothing can be done for the results of nerve injuries. Count- less improvements, and not a few recoveries, are due to the various resources of physiotherapy, e.g. electrical treatment, massage, mechanotherapy, and so forth.

But it is above all the employment of prosthetic appliances which constitute the principal therapeutical innovation for patients suffering from nerve wounds.

The majority of neurologists have expended much

xviii TREATMENT AND REPAIR OF NERVE LESIONS

time and trouble in devising and adapting appliances for the correction of loss of functional power and de- formities, whether transitory or permanent. In con- junction with Henry Meige, we were among the first to have constructed and to prescribe a series of appli- ances the benefits of which are constantly being appre- ciated by our patients both in their ordinary life and in the exercise of their occupations.

All these methods of treatment should be made widely known, and a large part of this book has been very properly reserved for their description.

I consider that the two volumes of Mme. Athanassio- Benisty will constitute an important contribution to neurology, and will allow our patients with wounds of the nerves to benefit by the experience gained in this war with regard to the prognosis, treatment, and diagnosis of nerve injuries.

PIERRE MARTE.

INTRODUCTION

IN the first volume we described the Clinical Forms of Nerve Lesions. The present volume is devoted to the study of the Treatment and Repair of these lesions.

In the first place we shall consider the method of nerve repair, as shown by experiments on animals.

The anatomical changes, both microscopical and macroscopical, caused by injuries to nerves will then be dealt with. Coincidentally we shall refer to the researches made on localisation in the nerve-trunks.

After having thus briefly recalled these essential anatomical and physiological facts, we shall be in a better position to describe, from a clinical and therapeutical aspect, the signs which enable a diag- nosis to be made of the severity, the seat, and the progress of repair up to cure of a given nerve injury.

Since the object of this work is essentially practical, a relatively large part of it will be devoted to the treatment of wounds of nerves.

Without entering into the details of various physio- therapeutic methods, such as electricity, massage, mechano-therapy, and radio-therapy, we shall indicate in what cases these procedures may be employed.

xx TEE A TMENT AND REPAIR OF NER VE LESIONS

Orthopaedic appliances for facilitating the return of the functional activity of the nerves or for remedying a defect in their functions (appliances for treatment, appliances for work) will be dealt with at greater length.

Surgical interference will be likewise considered, both from the point of view of indication and the results obtained, and the conclusions arrived at from our personal experience will be compared with the results obtained in the various military neurological and surgical centres.

Finally, side by side with organic nervous lesions, and quite distinct from hysterical conditions, there is a group of affections which require a special description, consisting of reflex paralyses and contractures, joint affections, " congealed hands," and muscular dys- trophies. The frequent occurrence, and the difficulties in the diagnosis of such cases, as well as the treatment most suitable to each, amply justify the space allotted to them in this work.

CONTENTS

CHAPTER PAGE

GENERAL INTRODUCTION v

PREFACE BY ENGLISH EDITOR . . xiii

PREFACE BY PROF. PIERRE MARIE . . xv

INTRODUCTION . . . . . xix

I. MACROSCOPICAL AND MICROSCOPICAL

LESIONS OF INJURED NERVES . . 1

II. RECOVERY OF SENSIBILITY . . .21

III. MODES OF RECOVERY OF ELECTRICAL

EXCITABILITY IN THE COURSE OF NERVE INJURIES . . . .35

IV. RECOVERY OF VOLUNTARY MOTILITY . 49 V. SIGNS OF SEVERE LESIONS OF THE NERVES 53

VI. SURGICAL TREATMENT OF INJURIES TO

NERVES ...... 72

VII. PHYSIOTHERAPEUTIC TREATMENT OF

INJURIES TO NERVES . . . . - 92

VIII. ORTHOPEDIC APPLIANCES ... 98

IX. INTRANERVOUS LOCALISATION . 120

xxii TREATMENT AND REPAIR OF NERVE LESIONS

CHAPTER PAGE

X. PHYSIOPATHIC AFFECTIONS . . .130

A. Symptomatology . . . .130

B. Pathogeny . ... .139 G. Treatment 151

XI. PARALYSES AT A DISTANCE. MUSCULAR

DYSTROPHIES . . . . .154

XII. JOINT AFFECTIONS ACCOMPANYING NERVE

LESIONS 101

INDEX 174

Treatment and Repair of Nerve Lesions

CHAPTER I

MACROSCOPICAL AND MICROSCOPICAL LESIONS OF INJURED NERVES

BEFORE considering the naked-eye and microscopical changes which nerves undergo as a result of war wounds, a brief description must be given of the current views as to the structure of nerves, the mode of their degeneration when subjected to various forms of traumatism (crushing, compression, and section), and the course of their cicatrisation and repair. The following description is based on the interesting re- searches of Nageotte1 and the article by Prof. Pitres.2

A nerve consists of nerve fibres, which constitute the active element of this organ, and of connective tissue. Within the nerve these fibres become grouped in bundles. Each bundle is enclosed in a connective- tissue sheath, the lamellar sheath ; the nerve-trunk itself is formed by the aggregation of these bundles, and is encased in a sheath consisting of connective tissue called the neurilemma.

1 J. Nageotte, Comptes Eendus de la Societe de Biologic, vol. Ixxxiii., and Revue Neurologique, July 1915.

2 A. Pitres, " Sur les processus histologiques qui president a la cicatri- sation et a la restauration fonctionnelle des nerfs traumatises," Journal de Midecine de Bordeaux, December 1915.

2 TREATMENT AND REPAIR OF NERVE LESIONS

The nerve fibre of the cerebro-spinal nerves is formed by three distinct elements : the axis-cylinder, the medullary sheath, and the sheath of Schwann.

The axis-cylinder or axone is a ribbon-like, glistening tract made up of contiguous fibrillse, which give it the appearance of longitudinal striation. Silver nitrate causes a black deposit on its surface.

The medullary sheath encloses the axis-cylinder, forming a sort of sleeve, interrupted at intervals corresponding to the annular constrictions. Myelin reduces osmic acid, and takes on a black colour. Finally, outside the medullary sheath is the sheath of Schwann, which is a delicate, transparent membrane bearing on its inner surface nuclei surrounded by a thin layer of protoplasm.

At the level of each annular constriction the nerve fibre consists solely of the axis-cylinder and the sheath of Schwann.

The blood-vessels and lymphatics of the nerve circulate between the lamellar sheaths.

SECTION OF A NERVE IN THE ANIMAL

In the first instance we shall consider the case of a nerve divided under aseptic precautions and whose proximal and distal ends have remained in close proximity to each other. Immediately after division there is an effusion of blood containing debris from the surrounding tissues.

Provided suppuration does not occur, in a few days a more or less exuberant mass of fibro-cicatricial tissue is formed, the size of which depends upon the dis- tance between the two severed ends of the nerve.1

During this time the nerve tissue proper of both the central and peripheral ends undergoes changes.

All the nerve fibres situated below the point of section — i.e. the whole of the lower segment of the nerve — undergo a series of histological modifications, known under the term of Waller ian degeneration,

1 A. Pitres, loc. cit.

LESIONS OF INJURED NERVES 3

from the name of the physiologist Waller, who de- scribed this condition.

Before the end of the first day the axis-cylinders of the nerve fibres begin to swell. At first this swelling is limited to the immediate neighbourhood of the wound, but subsequently it gradually travels down to the terminal filaments of the nerve. At the same time the fibrils constituting the axis-cylinder undergo changes, and grow sinuous and varicose.

From the second day onwards the nuclei of the sheath of Schwann tend to hypertrophy, their protoplasm increases in size and attacks the myelin, which becomes broken up into irregular, brilliant globular masses arranged around the axone.

Towards the fourth day the nuclei of the inter- annular segments start on a phase of active prolifera- tion, while the myelin becomes more and more broken up, until, by about the fifteenth day, it disappears completely.

Wallerian degeneration ends with the loss of ex- citability of the nerve fibres, which occurs three or four days after division of the nerve. This loss of nervous excitability seems to affect all methods of stimulation (electrical, chemical, and mechanical). The muscles do not become irresponsive to stimuli until much later, several weeks or even months after the nerves have grown inexcitable (Pitres).

Synchronously with the development of this process of degeneration a process of regeneration starts.

The lower segment, by undergoing the changes described above, prepares to receive the newly formed axis-cylinders about to be sent out from the end of the upper segment.

This process of regeneration progresses very slowly, and is only complete when the motor function of the nerve has been restored. We shall therefore have to describe this transformation in several phases.

From the first few hours after division of the nerve a number of slender fibrillse — the future axis-cylinders in the central extremity of the nerve — are seen to

4 TREATMENT AND REPAIR OF NERVE LESIONS

separate themselves from the lateral walls of the in- jured axis-cylinders immediately above the level of section. This is the initial phase of regeneration, and is termed Perroncito's phenomenon.

These fibrillse grow actively, and penetrate the fibro- cicatricial tissue which intervenes between the cut ends of the nerve. They are attracted by a sort of positive chemiotaxis towards the inferior extremity of the divided nerve. They increase in length and

FIG. 1. — Experimental neuroma in a rabbit (upper end).

Section and attrition. Cap of loose tissue on the end of the nerve ; this cap has not been colonised by the fibres, a, afferent end ; ft, neuromatous part ; c, cap of loose tissue. (After Pierre Marie and Foix.)

thickness, and their terminal extremity has a club- shaped swelling.

It should be noted that they do not penetrate the fibro-cicatricial tissue directly, but by spreading out in the form of an interlacing network (fig. 1).

It will be readily understood that when the inter- vening mass of fibro-cicatricial tissue is very exuber- ant and rich in fibres (such as occurs as a sequel to inflammations and protracted suppuration) the axis- cylinders of the central segment have great difficulty in getting through to reach the peripheral segment.

On the other hand, when the inflammation has been slight, the two cut ends being separated only by a short interval, cicatrisation by first intention may be perfect, and after regeneration the nerve may appear

Treatment and Repair of Nerve Lesions.]

{To face p. 4.

/

r- '

P PLATE I

Excessively sclerotic pseudo -neuroma. (After Pierre Marie and Foix.) ipture of the lamellar sheath. Spreading and dislocation of the fibres in the part of the nerve that has suffered most injury. Their structure is relatively preserved as well as their direction towards the lower end.

LESIONS OF INJURED NERVES 5

hardly thicker or more vascular at the site of the injury than elsewhere.

If the two segments are separated by more than 15 or 20 millimetres, a fibro-cicatricial bridge, or tract adherent to the neighbouring tissues, is formed connecting the two swollen ends of the nerve with each other.

The swelling of the central end, which is always the larger, represents a neuroma, formed by the prolifera- tion of the sheaths of Schwann and the young axones or neurites (Nageotte).

The peripheral segment, which shows a smaller swelling, is, on the other hand, made up solely of the exuberant proliferation of the nuclei of the sheath of Schwann, which terminates in a network of sheaths into which the young neurites penetrate.

Nageotte calls this swelling a glioma, since it is formed solely from the sheath of Schwann, which constitutes the neuroglia of the nerve.

This glioma grows rapidly, and presses straight on towards the central end.

In short, the regeneration of a divided nerve is due on the one hand to the proliferation of the axis- cylinders of the central end, and, on the other hand, to the proliferation of the nuclei and the protoplasm of the sheath of Schwann, which ends in the formation of new sheaths ready to receive the young neurites (axis-cylinder processes) both at the central end and in the whole of the peripheral segment.

" The neuroglia (sheath of Schwann) builds up the nerve, and the axis-cylinders proceed to lodge there" (Nageotte).

What happens when the wound has caused con- siderable destruction of the nerve and the two ends are completely separated from each other ?

The central bud divides and spreads out, the young axis-cylinders are folded back and rolled up, grow out at the sides or even turn round and grow in the opposite direction (fig. 2).

In the peripheral segment the sheaths remain

6 TREATMENT AND REPAIR OF NERVE LESIONS

empty, and wither sooner or later. Occasionally, however, despite the intervention of dense fibro- cicatricial tissue, a few axis-cylinders reach the in- ferior segment by devious paths and neurotise, i.e. regenerate it by penetrating into the prepared sheaths awaiting them there. This phenomenon was discovered by Ranvier.

As soon as these neuro-fibrillae reach the sheaths they grow rapidly, become coated with myelin, and gradually progress up to the terminal motor or sensory extremities of the nerves.

It is only then that any restoration of function

a FIG. 2. — Section and attrition in the rabbit.

a, cap of connective tissue and muscle ; 6, nerve in course of degenera- tion. The cap of connective tissue and muscle is mainly formed by the proliferation of Schwann's sheaths, but inflammatory scleroses and muscular adhesions play an important part in the injured nerves. (After Pierre Marie and Foix.)

appears in the nerve. The phase that requires most time is therefore the journey through the mass of fibro-cicatricial tissue, which presents the most for- midable obstacle to the regeneration of the lower end in the first place, and later to the functional recovery of the whole nerve.

The experiments of Van Lair have shown that a nerve divided under aseptic precautions in an animal, both cut ends remaining in contact, unites by first intention, and recovers its power to conduct impulses at the end of eight to eleven months. If the space between the cut ends is about 1 centimetre repair takes longer, and is not complete until about the end of fourteen months, but it may be delayed up to thirty months if the space between the cut ends is 2 centi-

LESIONS OF INJURED NERVES 7

metres. No recovery takes place when the interval is 4 centimetres (Pitres).

From Nageotte's researches1 it appears that in addition the following practical conclusions can be deduced ; although logically justified a priori, an operation is harmful which attempts to assist the junction of the two ends of the nerve and to canalise the growth of neuroglia on the end of the lower segment, for instance, by ingrafting a vein. In such cases the lower sprout is more delicate, and a large number of axones of the upper end do not reach it, but spread out in all directions in spite of the canalisation.

Nageotte also considers that a tight suture is less favourable than a loose one, allowing the growth of a fibro-cicatricial mass which will be well honeycombed by inter-anastomosing fibres of regeneration, thus ensuring a more perfect neurotisation of the inferior segment.

The above is a short resume of the facts known about the degeneration and regeneration of nerves in animals after experimental division or crushing.

INJURIES OF NERVES BY WAR WOUNDS

How do nerve injuries progress which are due to wounds received in war, and what is the naked eye and microscopical appearance of the injured nerve ?

Our knowledge of this remains incomplete in spite of elaborate investigations, since it is difficult to control all the various phases of this process.

On the other hand, it may be said that every time a nerve is injured by a war traumatism the reaction is peculiar to that case, since the conditions of the wound and the inflammation of the surrounding tissues are different on each occasion. In spite of a superficial resemblance in appearance and structure the cicatrix

1 J. Nageotte, "Le processus de la cicatrisation des nerfs," Revue Neurologique, July 1915.

8 TREATMENT AND REPAIR OF NERVE LESIONS

of a nerve which has been sutured, resected, or freed does not always take the same clinical course.

Nevertheless, two years of observation and research have established certain facts of an anatomical and pathological nature. We propose to describe them by giving a resume of the work of Pierre Marie and Foix,1 Claude, Vigouroux and R. Dumas,2 Mme. Dejerine and J. Mouzon,3 and Jourdan and Sicard.4

Following Pierre Marie and Foix, x'-"*'' "^v we shall distinguish three main ( - ^-6 types of lesions :—

1. Complete section.

2. Pseudo-neuroma of attrition.

3. Lateral notch.

Among these three main forms of lesions, the pseudo-neuroma of attrition is the one most frequently seen. The lateral notch occurs the fibres. B, Lower fairiy often Complete section, on

neuroma; c, region ,, J . 5j- i

of the degenerated the contrary, is relatively rare, and of only occurs, according to Claude, tissue Vigouroux and R. Dumas, in about 22 out of every 100 cases. We shall then proceed to describe four types of accessory lesions :—

4. Complete section with pseudo -continuity.

1 Pierre Marie and Foix, "Indications operatoires fournies par Fexamen histologique des nerfs leses par plaies de guerre," Presse medicale, Jan. 31, 1916.

2 Claude, Vigouroux and R. Dumas, " ^tude anatomique de cent cas de lesions traumatiques des nerfs des membres," Presse medicale, March 4,

FIG. 3. Complete section.

A, Upper neuroma; turning back of

fibres; &, cap connective

Foix.

3 M. and Mme. Dejerine and M. J. Mouzon, *'Les lesions des gros troncs nerveux par projectiles de guerre. Les differents syndromes cliniques et les indications operatoires," Presse medicale, May 10, July 8, August 30, 1915.

* Jourdan and Sicard, "]£tude macroscopique et microscopique des 16sions des nerfs par blessure de guerre," Presse medicale, July 29, 1915.

Treatment and Repair of Nerve Lesions.]

[To face p. 8.

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PLATE II

Pseudo -neuroma of attrition. (After Pierre Marie and Foix.)

At the lower part of the pseudo -neuroma there is a partial absence of myelin, but the arrangement of the fibres is preserved.

LESIONS OF INJURED NERVES

5. Lateral pseudo - neu- roma with or without a lateral notch.

6. Partial neuroma (in- tra- or juxta-nervous).

7. Simple nerve indura- tion.

l. Complete Section. — As soon as the surgeon finds the nerve- trunk in the operation wound either above or below the prob- able seat of the lesion, according to the course of the projectile, he will see by following it up that in the majority of cases where complete section has oc- curred it plunges " sud- denly and at an angle " into the wound (Pierre Marie and Foix). An ap- pearance such as this is strongly in favour of com- plete nerve division. In fact, by following and freeing the nerve it will be found to be severed, with both ends separated, swollen, and more or less adherent to the surrounding fibro- sclerotic tissue (fig. 3).

Histologically. the upper swelling, or " neuroma," when the injury has oc- curred sometime previously, is composed of adult me- dullary sheaths possessing relatively normal axis-cylin- ders (P. Marie and Foix).

Fio. 4.

Complete section. Old-stand- ing upper neuroma. (Mag- nification, 7-5 diameters.)

The neuroma is wholly com- posed of myelinated fibres. In its uppermost part (a) the fibres are parallel, in the middle part (&) they spread and diverge, in the lower part (c) they run in all directions. This part is, therefore, not suitable for suture. (After Pierre Marie and Foix.)

10 TREATMENT AND REPAIR OF NERVE LESIONS

This neuroma is encapsuled and surrounded by a coat of connective tissue, against which the young nerve fibres impinge and are obliged to retrace their steps (%. 4).

Thus the regenerated nerve fibres follow a longi- tudinal and parallel course in the upper part of the neuroma, and then diverge and scatter in all directions, a large number of them taking an upward course.

Pierre Marie and Charles Foix have been able to reproduce this pheno- menon in animals by dividing a nerve which had been previously com- pressed by forceps, contusion being a necessary factor to produce the inflammatory condition which is always very intense in war wounds.

The lower peripheral extremity of the cut nerve is also enlarged, but usually less so than the upper seg- ment. This lower pseudo-neuroma, or " glioma," to use the term em- ployed by Nageotte, consists in war wounds of a shell of fibro-connective tissue, very frequently containing muscular fibres, and covering a nerve in complete Wallerian de- generation.

Pierre Marie and Foix, as well as M. and Mme. Dejerine and J. Mouzon, have drawn attention to the phenomena of ascending degeneration of the myelin sheaths and of the axis-cylinders of the central end. This fact should be remembered, as it may help to explain some cases of complete division, in which nerve suture, carried out under the most promis- ing conditions, followed by complete healing of the wound, nevertheless ended only in failure.

2. Pseudo - neuroma of Attrition. — This lesion, which occurs in the majority of nerve wounds caused by projectiles, has the naked-eye appearance of a

FIG. 5.

Pseudo -neuroma of attrition.

a, region of healthy fibres ; &, region of degenerated fibres. (After Pierre Marie and Foix.)

LESIONS OF INJURED NERVES

11

nodule or cicatricial swelling, more or less olive- shaped and of regular outline, situated in the course of a nerve which has maintained its continuity (fig. 5).

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I I '

FIG. 6. — Pseudo -neuroma of attrition. (Magnification, 7-5

diameters.)

The increase in size is due to the over-production of interstitial tissue. Myelinated strands which have kept their direction are still easily recognisable, a, region grazed by the bullet ; 6, myelinated fibres in definitely grouped fasciculi ; c, small blood- vessel affected by endarteritis. (After Pierre Marie and Foix.)

This is what Sicard and Jourdan call the " trans- lesional nodule," Claude, Vigouroux and Dumas " incomplete section," M. and Mme. Dejerine and J. Mouzon " cheloid of the axis-cylinder." These last observers consider that this lesion is equivalent to

12 TREATMENT AND REPAIR OF NERVE LESIONS

total section when the clinical signs are severe, since their histological investigations have demonstrated to them that this "cheloid" was of such a fibrous and tough nature, that it had not yet been pierced by the axis-cylinders of the central end 113 days after the original injury, and that the peripheral end was in complete Wallerian degeneration. Resection followed by suture, according to them, is the only logical operative treatment suitable in such cases.

We know, however, nowadays that this kind of anatomical lesion is found in the great majority of

Flo. 7. — Experimental pseudo -neuroma of attrition in the rabbit.

a, afferent end ; 6, swollen pseudo -neuromatous end ; c, efferent end. (After Pierre Marie and Foix.)

nerve injuries, that nerve recovery is an exceedingly slow process when the injury has attained a certain degree of severity, as two years of observation have proved, and that, finally, the vast majority of nerve injuries recover without surgical interference, or after simply freeing the nerve. For all these reasons we incline to the opinion of Pierre Marie and Foix, whose histological arguments agree in all points with clinical observations and the results of operative interference to show that the existence of a pseudo-neuroma in the course of a nerve is not equivalent to a com- plete section of the nerve.

" Histologically, the pseudo-neuroma is mainly com- posed of fibrous tissue separating the bundles of nerve fibres, and thus causing the increase in size (fig. 6).

" There is no multiplication of nervous tissue, and this formation does not deserve the name of neuroma. It is a kind of small fibroma, which readily heals.

LESIONS OF INJURED NERVES

13

" With regard to the lesions, three zones can be dis- tinguished : an upper zone, in which the fibres descend by spreading, separated by the proliferation of con- nective tissue ; an intermediate zone, where the lesion is at its maximum, and from which point onwards the fibres degenerate ; and a lower zone, where the fibres exhibit more or less complete secondary degenera- tion.

" When the lesion is at its height two things may happen : either the fasciculi persist, the medullary fibres growing scarcer or disappearing com- pletely ; or the lamellar sheath is torn, and the sheaths of Schwann are then found freed, spread out, and partly dislocated.

" Regeneration appears to us to be very probable in those cases where the nerve fasciculi traverse the in- jured part, even when they are com- pletely degenerated, without being spread out.

" When spreading out takes place the prognosis, although less satis- factory, still remains relatively favourable. Considered from the point of view of the number of sheaths preserved intact the nerve is amply sufficient, for beside the full medullated sheaths, there are empty sheaths whose structure can easily be made out, and which will regenerate in their turn.

" As regards their direction and their chances of meeting the bundles of the lower end, it may be said that it is relatively preserved. Even if there are several fibres tending to run a very oblique course, or even some few here and there which incline backwards, it may be said that the vast majority has kept to the longitudinal direction, and that most of them show

FIG. 8. Lateral notch.

a, upper lip of the notch with the fibres turning back; 6, notch ; c, lower lip of notch. The region shown in white consists of sclerotic tissue. (After Pierre Marie and Foix.)

14 TREATMENT AND REPAIR OF NERVE LESIONS

a sufficient degree of continuity to enable them to recover their original form.

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FIG. 9. — Lateral notch. (Magnification, 7-5 diameters. ) E, notch, n, the nerve fibres are interrupted on the upper lip of the notch, where they form a small neuroma, ra, showing nerve bundles travelling from end to end, myelinated in their upper part, and almost completely demyelinated in their lower part, which, however, is continuous. (After Pierre Marie and Foix.)

" In short, in the case of the pseudo-neuroma of

LESIONS OF INJURED NERVES

15

attrition even with a small lateral cicatrix, we think that the nerve should not be interfered with, no matter what the clinical syndrome may be."

The fairly frequent occurrence of a small lateral notch on one of the sides of the pseudo-neuroma should be noted (Pierre Marie and Charles Foix).1

3. Lateral Notch.— The cicatricial nodule often shows on one of its sides a notch which occasionally corresponds to an incomplete sec- tion ; it can easily be seen at the part where the nerve is swollen (fig. 8).

When the notch is plainly visible to the naked eye the nerve often has two swellings, one above and one below the notch (P. Marie and Foix).

This is the lesion which Sicard and Jour dan have described under the name of nodules above and below the lesion.

From an histological point of view, the condition is the same as that described in the case of com- plete section ; the wall of the notch ff> Upper end ; &, ir-

itself is Composed of Very dense regular interme-

fibrous tissue.

With regard to the substance which joins the two swollen extremities of the nerve in the neighbourhood of the cicatrix, this is formed of fibrous tissue, which we have already mentioned, and in the more distant parts it shows the same histological characteristics as those seen in the pseudo-neuroma of attrition (fig. 9).

On the strength of these anatomical and patho- logical considerations, Pierre Marie and Foix advise that the surgeon should carefully preserve this bridge

1 Loc. cit.

FIG. 10.

Section with

pseudo -continuity.

diate segment ; c, lower end. (After Pierre Marie and Foix.)

16 TREATMENT AND REPAIR OF NERVE LESIONS

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of nerve tissue, and should pare down the ends of the two swellings and the wall of the notch, and then

suture end-to-end the

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the nerve.

4. Accessory Types.— Among the lesions less frequently met with we will mention in the first place that of pseudo- continuity. Complete division of a nerve is an unusual occurrence, as we have already pointed out (from 20 to 25 percent.) ; still more rare is the clean-cut section, with both ends far apart and out of line, which we mentioned in the first instance.

Anatomical section of a nerve occurs much oftener, in our opinion, in the form of pseudo- continuity (fig. 10).

Pierre Marie and Foix describe this lesion as follows : " The nerve shows two swellings at some distance from each other, of which the upper one is by far the larger. Between the two an apparent con- tinuity is established

by an irregular bridge, isolated by the dissection of the very dense fibrous tissue which filled up the space. " Careful microscopical examination then reveals : — " 1. That the section is complete or almost complete.

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LESIONS OF INJURED NERVES

17

" 2. That the intervening bridge is too thin, long, and ragged, and has hardly any value from the point of view of regeneration.

" This bridge is always exclusively made up of fibrous tissue, to which is added a quantity of muscular tissue elements " (fig. 11).

This type of lesion, which is fre- quently met with in lesions of the musculo-spiral when the nerve is lost in the callosity of a fracture of the humerus, requires, from a surgical point of view, the wide re- section of the fibrous bridge and the freshening up of the two ends of the nerve.

Lateral pseudo-neuroma, with or without a slight lateral notch. — This is the lateral nodule of Sicard and Jourdan, and the eccentric or lateral cheloid of M. and Mme. Dejerine. The swelling is irregular, and more in evidence on one side of the nerve (fig. 12).

Histologically, at the site of the lesion some nerve fibres are to be seen pushed back by the fibrous tissue, and others which had strayed from their useful direction (fig. 13).

Finally, there is a kind of lesion far less frequently met with than any of the preceding, the small enucleable neuromata, of an intra- or juxta-nervous character, i.e. either encapsuled within the nerve or jut- ting out on one of its sides (fig. 14).

These fibromata are of two kinds : the one are pure neuromata, formed of nervous fibres, and the others have a fibrous core. The first kind are situated in the interior of the nerve ; they have a soft consistence, and should be left alone (fig. 15).

2

FIG. 12.

Lateral pseudo -neu- roma with small lateral notch.

The pseudo-neuro- ma, which is more salient on the right side, shows at this level asmall lateral notch. Of the fibres Which were on their way to the upper lip, some turn back, thus forming a small neuroma, others curl in, pushed aside by the scle- rotic tissue, and eventually join the lower end. (After Pierre Marie and Foix.)

18 TREATMENT AND REPAIR OF NERVE LESIONS

The second type form hard swellings on the surface of the nerve.

According to P. Marie and Foix, the best plan is to leave them alone, since the cicatricial tissue which replaces them when they have been excised is equally

*

" -;

FIG. 13. — Lateral pseudo -neuroma with small lateral notch.

a, nerve fasciculus crossing the injured region ; 6, sclerotic mass enclos- ing and thickening the nerve ; c, small notch which has determined the lateralisation of the pseudo-neuroma. (After Pierre Marie and Foix.)

hard, and occasionally presents an even greater obstacle to the passage of nerve fibres.

Simple induration of the nerve. — This lesion corre- sponds clinically in the vast majority of cases to those painful affections chiefly found in the median and sciatic, which M. and Mme. Dejerine and J. Mouzon call the " syndromes of irritation."

The nerve shows an induration which often can only be felt but occasionally can be seen, in which case the nerve is slightly swollen, and has a greyish tint,

LESIONS OF INJURED NERVES

19

or, on the contrary, may be congested and soft if the lesion is of recent occurrence.

Pierre Marie and Charles Foix have drawn attention to various inflammatory changes in their researches on the anatomical lesions of nerves, viz. interstitial neuritis with isolated areas of inflammation, parenchy- matous neuritis, descending and retrograde changes in the axis-cylinders, the myelin sheaths and the struc- tures of Schwann, gross vascular lesions, with very marked endarteritis of the medium- sized and small vessels, etc.

The existence of these lesions throws an interesting light on what must occur from an histological point of view in the case of simple induration of nerves, with painful symptoms of a causalgic character, trophic manifestations, and irrita- tion of the motor fibres, etc.

Besides these lesions of the nerves proper we must note the existence of injuries to the tissues surrounding the nerve, to which Henri Claude, Vigouroux and R. Dumas have justly ascribed import- ance.

The fibro - sclerotic reaction is always very marked along the course of the projectile through the tissues, and in- creases when protracted suppuration has occurred in the wound, or when the injury to the nerve is serious, and is most marked when, in addition, a blood-vessel is wounded.

The exuberant lardaceous cicatricial tissue literally stifles what remains of the nerve cords and the blood- vessels.

Frequently the nerve becomes adherent to the blood-vessels and the muscles.

In addition, therefore, to the essential obstacles within the nerve itself which oppose its regenera-

FIG. 14.

Small neuroma with fibrous core.

c/, afferent fibres ; b, other fibres ; ^de- generated efferent fibres. (After Pierre Marie and Foix.)

20 TREATMENT AND REPAIR OF NERVE LESIONS

tion, we must bear in mind that there are lesser im- pediments, but not the less real, engendered by the injuries to the surrounding tissues.

FIG. 15. — Small intra-nervous microscopic neuroma. (Camera lucida, obj. 4, oc. 1.)

The medullated fibres spread out in bundles, to join up again further on leaving the small neuroma. Some intra-nervous neuromata of larger size have the same structure, a, afferent end ; 6, neuro- matous swelling ; c, efferent end. (After Pierre Marie and Foix.)

CHAPTEK II RECOVERY OF SENSIBILITY

THE English neurologist, Henry Head, performed a most interesting experiment in 1903. He caused his radial nerve to be divided and immediately sutured (the anterior branch and external cutaneous division in the neighbourhood of the elbow). In conjunction with W. H. Rivers he studied the nature and dura- tion of the alteration of sensation as well as all the various stages during the recovery of sensation.1

Our observations, which were made on a large number of wounded, have shown us that in the large majority of cases the various stages in the restoration of sensation are identical with those described by Henry Head.

We shall therefore briefly state the findings of this neurologist, drawing attention in places to any instance in which we have encountered a different condition of things, and noting any special characteristic in the sensory disorders of other nerves than the radial.

In the first few days after the operation Head noticed the following facts, which we have been able to confirm in several cases of recent injury to the radial nerve:—

1. Deep sensibility in the radial area in the hand and forearm was perfectly preserved. Any moderate pressure in this region was well felt and localised. Passive movements of the muscles were fully appre-

1 W. H. Rivera and H. Head, "A Human Experiment in Nerve Division," Brain, part iii., 1908.

21

22 TREATMENT AND REPAIR OF NERVE LESIONS

elated, as also was any movement of the joints ; vibratory sensation was unimpaired.

2. Superficial sensibility was, on the contrary, very much impaired :• — -

(a) Touches with cotton-wool, or deformations of the skin produced by pulling the hairs, and even vigorous pinching of the skin, gave rise to no sensa- tion in the area corresponding to the physiological sensory field of the radial nerve.

(6) Within the area- of insensibility to superficial touch there was another zone totally insensitive to painful stimuli. On the border separating these two zones pricking was normally painful.

(c) Insensibility to heat and cold was absolute, even for temperatures above 50° C. and chilling produced by ethyl chloride spray.

The thermal changes occupied a zone which was generally more extensive than the area of analgesia, without however exceeding the zone of insensibility to very light touch.

(d) Although deep sensibility was preserved, tactile discrimination (circles of Weber) was greatly affected ; the two points of a pair of compasses had to be sepa- rated by more than 8 centimetres in order to be recog- nised as two separate objects.

In the same way all appreciation of the size, shape, and dimension of objects was lost.

What was the subsequent course of this lesion, and what were the various stages in the course of sensory recovery ?

About fifty days after suture the extent of the analgesic area began to shrink, in addition cold was felt in certain parts of the zone still insensitive to cotton-wool.

At the end of four months sensibility to pricking and cold had still further improved, though heat was still not felt, except in the case of high temperature (50° C.), which caused a sensation of burning.

It was only after six months that even partial sensibility to superficial touch returned, due to pro-

RECOVERY OF SENSIBILITY 23

gressive restoration of the sensitiveness of the hair ; at the same time temperatures of about 45° C. were appreciated.

With the gradual return of sensibility to pain, cold and heat, was noticed a tendency of the sensation to be widely diffused, to radiate to a remote part, and to become localised at a distance from the point of stimulation.

These characteristics were especially well marked in the case of pricking and heat. When the skin was pricked in a part previously anaesthetic, sensation was delayed as compared to the normal side ; at the same time the prick was more painful, although dull, ill defined, excessively unpleasant, and diffused, the painful sensation developing slowly, lasting for a long time, and unlike that felt normally as the result of a prick. Often the localisation of the pain was indefi- nite, and the subject described the point of pain at a considerable distance from the point actually stimulated.

At this stage of recovery sensibility is vague and incomplete. Head gives it the name of protopathic

About eight months after suture gentle stroking with a pledget of cotton-wool aroused a diffuse ting- ling sensation, ill localised, persistent, and often adiating.

This partial return of superficial tactile sensibility due to the hairs, which became sensitive about

iree months after the operation. If the hairs were jhaved, superficial sensibility was again abolished.

Within this area the interrupted electric current roused no sensation.

Sensibility to cold returned earlier. Head attri- butes this fact to the existence of a greater number of " cold spots," i.e. of places in the skin specially sensitive to stimulation by cold. The " heat spots " must, according to Head, be fewer and more scattered.

It is only towards the four hundred and seventh

1 W. H. Rivers and Henry Head, loc. cit.

24 TREATMENT AND REPAIR OF NERVE LESIONS

day (fourteen months after section followed by suture) that a return of sensation was noticed for medium temperatures of about 37° C., accompanied by true appreciation of heat, which was then well localised.

From then onwards and for the next few months there was a gradual return both of superficial tactile sensibility (even after shaving the parts) and of sensi- bility to medium temperatures.

At the same time the tactile painful or thermal sensations lost their tendency to become diffuse, to radiate, to persist, or to manifest themselves in a disagreeable manner.

It was only very much later — two and a half to three years afterwards — that the skin regained its normal response even when shaved to quite superficial stimuli, and that the two points of Weber's compasses were clearly felt separately, and that the size and shape of objects were appreciated as well as tempera- tures between 26° and 37° C.

These secondary elements of sensory recovery con- stitute Head's epicritic sensibility, which eventually completes the protopathic sensibility.

These are the main points which the English neurologist brought out in his own case, in which the nerve had been divided and sutured under aseptic precautions.

In the course of recovery of sensation in nerve lesions due to war wounds we consider the earliest sign of recovery to be pain when the skin is pinched within the sensory area of the injured nerve.

This sign has been noted and described by Andre Thomas1 and Belenki,2 who considers it important, enabling one to recognise that the injured nerve is

1 Andr6 Thomas, " La sensibilite douloureuse de la peau a la piqure et au pincement dans la p^riode de restauration des nerfs sectionnes apres suture ou greffe," Soc. de Neur., Feb. 3, 1916. Revue Neurologique, Feb. 1916, p. 311.

2 Belenki, "Les symptdmes sensitifs dans les sections anatomiques et physiologiques des nerfs peripheriqnes," Presse medicale, Feb. 17, 1916.

.

^

;

RECOVERY OF SENSIBILITY 25

ill connected with the sensory centres. A. Thomas ightly draws attention to the fact that this sign long recedes the appearance of areas which are par-

thetic on pricking.

Pain on pressure of the nerve-trunk below the site f injury and the " formication of recovery " are ,ter manifestations.

This ill-localised, unpleasant, and persistent pain produced by pinching the skin appears to be localised in small circumscribed spots, just as the paraesthetic zones are later on for pricking and heat (A. Thomas).

It appeared to us that these areas occupied mainly

e middle third of the posterior aspect of the fore- arm in the case of injury to the musculo-spiral, and the lower third of the outer aspect of the leg in the case of injury to the great sciatic, and more especially to the external popliteal.

In the case of lesions of the ulnar, the seat of election is the inner aspect of the hypothenar emi- nence. These zones soon spread and coalesce, finally involving the whole of the sensory area of the nerve in question. They are at that time insensitive to pricking and to high temperature (45°).

This phenomenon is explained by Thomas in the ollowing way : —

" Between the time when the sensory fibre reaches he dermis and that at which it spreads out into the terminal organs or the epidermis, the return of sensibility undergoes a delay comparable to that of motor fibres in the interval which separates their ntrance into the muscle and their adaptation to the

otor end-plates.

It is not surprising that pinching should be felt before pricking. When the manipulation includes the whole skin and the subcutaneous cellular tissue, it affects the nerves themselves and the subdermic organs ; when it involves the skin only, it affects the terminal organs and a certain number of fibres which may not have yet crossed the deepest layers of the epidermis ; it thus reaches fibres which the more

26 TREATMENT AND REPAIR OF NERVE LESIONS

superficial pricks cannot affect, and it reaches a greater number of them." x

This sign appeared to us to precede the appearance of formication, noted by Letievent and recently in- vestigated and described by Tinel.2

Formication, which the patients compare to the sensation of an electric current, or more or less dis- agreeable tinglings, occurs in a large number of wounded, during convalescence, after a severe lesion or nerve section with subsequent suture. It makes its appearance several days after nerve sutures when the division of the nerve is of recent date.

The patients state that a slight tap with the finger on the cicatrix of the wound, especially over the probable seat of the nerve lesion, elicits a kind of electric vibration, coursing throughout the whole limb, but radiating mainly in a certain part or over the whole of the sensory area of the nerve.

To appreciate the value of this sign, frequently repeated examinations at close intervals of the char- acter of this formication are necessary, as urged by Tinel and Andre Thomas.

We have just seen that the first appearance of formi- cation is noticed very soon after nerve suture ; never- theless, so long as formication is only elicited by pressure or percussion of the nerve at the cicatrix, it does not indicate that the axis-cylinders of the central end have reached the peripheral end, but rather suggests that a certain number of nerve fibres, if not all, have encountered an obstacle, and that they have been rolled up inside a neuroma of such a size that frequently it can be definitely palpated. A few of these fibres have strayed into the neighbour- ing tissues ; any irritation of the cutaneous cicatrix, such as pricking or stroking with a brush, is felt not only at the actual place of stimulation, but also at the periphery of the limb, in the area supplied by the

1 Revue Neurologique, Feb. 1916, pp. 312-313.

2 Tinel, "Le signe du ' fourmillement ' dans les lesions des nerfs," Presse medicate, Oct. 7, 1915.

RECOVERY OF SENSIBILITY 27

branching out of the sensory fibres of the nerve (cicatricial topoparaesthesia).1

If repeated and successive examinations continu- ally confirm the existence of this neuroma, or swelling, in the course of the nerve, which is painful on palpa- tion, and pressure on which is accompanied by radiat- ing sensations of a more or less disagreeable nature referred to the periphery of the nerve, this sign must not be interpreted as the initiation of recovery, but should rather be taken to suggest the interposition of an obstacle to regeneration of a part or the whole of the sensory fibres of the nerve.

If, on the contrary, palpation and pressure on the nerve below the site of the wound give rise to formica- tion, and if, in addition, this pressure is painful, there is every reason to assume that neurotisation is taking place in the lower end.

In fact, while the sensation of formication thus descends along the course of the nerve, pain on pal- pation of the nerve-trunk itself appears, and this pain increases as the site of the lesion is approached. During this time the pain felt on pinching the skin becomes more intense, and its radiation towards the extremity of the limb increases.

A short time after the appearance of these signs the wounded complain of pain becoming more and more defined, mainly during the time they are mas- saged, in the muscles whose nerve-supply is given off highest from the injured nerve ; such is the character of the pain felt in the supinator longus in the neigh- bourhood of its upper insertion, or in the gastro- cnemius and soleus near the popliteal space.

This pain, which is at times very intense, similar to that noticed in certain painful affection of the nerves, has a complex pathogeny. It may be due to the sensory fibres having been directed to the muscles " by a sort of pointsman's error " (A. Thomas), or to the irritation of the nerve-trunk itself and of its

1 Andre Thomas, Societe de Neurologic, April 6, 1916. Revue Neuro- togique.

28 TREATMENT AND REPAIR OF NERVE LESIONS

sensory filaments, an irritation which often develops during the process of recovery.

With regard to the pathogeny of formication, Tinel attributes it to the advance of the regenerated axis- cylinders into the peripheral end of the nerve.

The signs which we have just described constitute the first manifestations of sensory recovery.

They invariably precede the return of electrical con- tractility, muscular tonus, and voluntary movement.

Henceforward recovery progresses along the lines described by H. Head.

First of all, sensibility to a prick reappears in the zone immediately adjoining the areas which in the first instance were quite irresponsive to any stimula- tion. This sensibility is at the start defective, or, to use Head's term, " protopathic."

Pricking is felt some time after contact over a wide area, and is interpreted as a vague, diffuse, per- sisting pain, radiating to remote parts, nearly always in the same directions. Thus in one of our patients, with a wound of the great sciatic, a prick at a point 10 centimetres above the tip of the external malleolus radiated, after several seconds' delay, into the heel and sole of the foot ; a prick over the external malleolus itself radiated to the external border and dorsum of the foot. These facts are ingeniously explained by Thomas as errors in the switching of the sensory fibres.

While this return of sensibility to pricking is develop- ing and becoming more definite, thermal sensibility is beginning to reappear. Ice and very hot water are appreciated, with great delay at the borders of the area which was primarily anaesthetic. But the sensa- tions are still vague, and often the patient is in error in his replies as to the temperature.

Medium temperatures (between 15° and 37° C.) are only distinguished very much later, towards the end of recovery, when all forms of sensibility have returned.

Moderate cold is felt earlier, and is more correctly interpreted, than tepid heat, which, at any rate in certain circumscribed areas, is always misjudged,

RECOVERY OF SENSIBILITY 29

even when motor, sensory, and electrical recovery is complete.

Along with the appearance of islands of parsesthesia to pricking and heat we see the return of sensibility to a superficial touch. This form of sensibility returns late, but once it has returned it recuperates more rapidly and more completely than the sensation for pricking, which requires a long time to regain its normal activity without the accompaniment of diffuse and radiating pain.

Head noted that this superficial tactile sensibility, which returned several months after suture, dis- appeared again when the areas originally anaesthetic were shaved.

It is necessary to realise that, even in perfect health, all nervous lesions being excluded, superficial tactile sensibility diminishes in delicacy as soon as the parts are shaved. From this point of view Belenki rightly distinguishes between the hair sensi- bility and cutaneous sensibility proper, and insists on the importance of eliciting this latter by a piece of paper or cotton- wool, since superficial tactile sensi- bility is far less acute in the parts naturally bald than in those normally covered with hair.

Deep sensibility (deep pressure, vibrating sensation, and recognition of position) once abolished, as in lesions of the ulnar, median, and the great sciatic nerves, reappears much later. It is as a rule regenerated by the time superficial " epicritic " sensation has returned, i.e. the return of tactile discrimination (compass points of Weber), recognition of medium temperatures, and precise identification of objects (stereognostic sense).

During the first period of recovery of deep sensi-

bility, possibly on account of the defective superficial sensibility,1 patients feel as if their limbs, or parts

1 The return of hair sensibility (traction of hair) in the first place, and later the perception of superficial touch, are accompanied at first, as has been noted by Head, by indefinite and diffuse tingling, which persists and radiates to a distance.

It is only at the time of the return of epicritic sensibility that very superficial and light tactile sensations are correctly appreciated.

30 TREATMENT AND REPAIR OF NERVE LESIONS

of their limbs which were previously anaesthetic, were inclosed in a vice. This is the case with patients suffering from injuries to the sciatic, in whom in- vestigations of this kind are most interesting.

After these general considerations let us examine shortly each of the important nerves of the limbs in regard to the interesting peculiarities of their sensory disturbance and recovery.

Musculo-spiral Nerve. — We have on many occasions laid stress on the variability and the slight degree of sensory changes in lesions of the musculo-spiral nerve.

In several cases of recent complete division of the musculo-spiral one occasionally notices an anaesthetic zone embracing a wide expanse of the physiological sensory area of the radial in the hand, as in Head's experiment.

In other cases, comprising severe injuries or anato- mical section, complete division dating back several months (in many of our cases the division of the nerve had occurred about one year before), sensory dis- turbances are far less marked. In particular, anaes- thesia to superficial touch affects only certain circum- scribed areas on the dorsal aspect of the thumb, the skin over the metacarpo-phalangeal joints of the index and middle finger, and a small area in the first dorsal interosseous space quite close to the fold of skin uniting the thumb and index.

In the rest of the territory supplied by the musculo- spiral, touch is normally felt (especially is this the case in those parts provided with fine hair). The same applies to moderately deep pricking. More superficial pricking is often interpreted as a touch, but is usually well localised.

Heat and cold are, on the contrary, for a long time mistaken for tactile sensations. Cold is generally better appreciated than heat, but with delay ; high temperatures of 45° to 50° C. are felt with a certain delay, and as a burning pain.

Tactile discrimination (circles of Weber) is often

RECOVERY OF SENSIBILITY 31

defective ; the points of the compasses have to be separated from 6 to 7 centimetres to be felt sepa- rately, and generally it is only the upper point that is localised by the patient.

What are we to think of those cases where, despite complete division of the nerve, the sensory nervous manifestations are unimportant, and appear to dimi- nish gradually without there being on the other hand any definite signs of recovery ?

It is generally admitted l that a supplementary nerve-supply from anastomoses occurs in the first few days following the physiological interruption, but that eventually disturbance of sensation always occurs when there is no regeneration or neurotisation of the distal part of the nerve. This is one of the signs of the " syndrome of complete interruption " described by M. and Mme. Dejerine and J. Mouzon.

In practice it is probable that this supplementary nervous supply undertaken by the neighbouring nerves can establish itself for a fairly long period, or else one is forced to admit that in the majority of cases the sensory area of the hand supplied by the radial is very restricted, and that the musculo- cutaneous on the one hand and the median on the other takes its place not only as regards deep sensi- bility, but as regards superficial sensibility as well.

As for the sensory area of the radial in the forearm, the types of disturbances that may be found there are still more ephemeral and changing.

The greatest change is towards the perception of pricking, cold, and particularly heat.

At the commencement of the recovery of a severe injury to the musculo-spiral, if the skin is pinched up between finger and thumb in the region normally supplied with sensation by the nerve in the forearm, intense pain is elicited of a diffuse and burning char- acter which does not occur in the normal limb. This pain often increases in intensity when the distal extremity of the limb is approached.

1 M. and Mme. Dejerine and J. Mouzon, Presse medicak, May 10, 1015.

32 TREATMENT AND REPAIR OF NERVE LESIONS

In the region of the anterior branch to the hand the pain on pinching, although well felt when recovery is advanced, always seems less marked than when the forearm is pinched.

Formication must be elicited by deep palpation of the nerve in the musculo-spiral groove, and especially at the neck of the radius.

In the case of transmission of nervous currents, the sensation of the electric current radiates into the first dorsal interosseous space and on to the dorsum of the thumb.

Median Nerve. — In severe wounds of the median, anaesthesia, as already stated, affects the last two phalanges of the index and middle fingers. This anaesthesia is complete to all modes of sensation, both superficial and deep, since the median supplies both superficial and deep layers of this region.

To test superficial tactile sensibility a more powerful stimulus than that exerted by the wisp of cotton- wool will be necessary, for in the normal state the skin of the palm of the hand is insensitive to light stimula- tion by cotton- wool, just as it is less sensitive than the back of the hand to thermal stimulation.

It is well, therefore, not to conclude that there is tactile anaesthesia of the palmar surface of the thumb and thenar eminence because these regions are insen- sitive to very light touching by cotton- wool.

In the course of lesions of the median, sensory recovery generally antedates the return of volitional motor power, but it remains defective for a long time in a stage of paraesthesia and in a protopathic condition. The re-establishment of electrical con- tractility and the appearance of voluntary movements take place before tactile discrimination, stereognostic sense, and the appreciation of medium temperatures are sufficiently developed.

The median nerve, more than any other nerve in the arm, gives rise, during the time of its sensory recovery, to painful sensations, which are either spon- taneous or elicited by pressure on the nerve- trunk

RECOVERY OF SENSIBILITY

33

below the seat of the lesion (path of the nerve in the forearm, thenar eminence). These manifestations recall in a measure what occurs in certain painful wounds of this nerve.

Pain when the skin is pinched is easily investigated on the thenar eminence, the palmar aspect of the thumb, and of the basal pha- langes of the index and middle finger.

To elicit formication the nerve must be compressed below the lesion, on the inside of the arm, the middle of the bend of the elbow, or on a line drawn along the middle of the anterior surface of the forearm. This sensation radiates to the palm of the hand and to the extremity of the index and middle finger.

The Ulnar Nerve.— The ulnar nerve possesses like the median a sensory area of its own, which occupies the little finger and the innermost part of the hypothenar eminence. Anaes- thesia is complete in this region when the nerve is in- jured.

When the nerve is recover- ing, a fairly severe pain is felt if the skin of the hypothenar eminence is pinched. This pain radiates to the little finger and the forearm, and, together with the sensation of formication, may extend up to the extremity of the little finger, as well as pain on pressure of the hypothenar muscles (fig. 16).

Great Sciatic Nerve. — During the first stage of sensory recovery pain is noticed on pinching the skin in the region supplied by the peroneal nerve, a branch of the external popliteal, the skin on the outer part

3

FIG. 16. — Sensory changes after injury to the ulnar nerve in course of re- covery.

Black : anaesthetic area. Grey: hypaesthetic area. Dotted : area of paraes- thesia (diffused and per. sistent pain on pinching the skin and on deep pricking).

34 TREATMENT AND REPAIR OF NERVE LESIONS

of the leg, which is coarser, being very tender to pinching. Later on medium pricking and heat cause pain, which radiates into certain areas according to the points irritated (fig. 17).

At the same time formication produced by pressure upon the trunk of the external popliteal over the neck of the fibula and the musculo-cutaneous nerve becomes more accentuated, and radiates towards the dorsum of the foot.

Spontaneous aching in the muscles and pain on pressure of the gastrocnemii become pre- dominant signs.

In the foot, the appearance of the areas of parsesthesia is more delayed. It is the outer border of the foot (external saphenous) which first recovers some sensi- bility to deep pressure.

Deep sensibility in the foot as well as superficial sensibility re- quires a very long time to reappear (sole and toes). It is only starting at the time when a large number of muscles have regained their power of voluntary movement and electrical contractility.

External Popliteal. — In^the case of an isolated lesion of the external popliteal sensory disturbances are less marked, in particular the deep sensibility of the dorsum of the foot is little affected.

Its sensory recovery is more rapid, and progresses according to the order just laid down for the great sciatic. The external popliteal has from every point of view much resemblance with the musculo-spiral, whereas the internal popliteal behaves like the median.

FIG. 17. — Distribution of sensory changes in a lesion of the great sciatic in course of recovery.

Black : absolute anaes- thesia. Grey : hypses- thesia. Dotted: areas of parsesthesia (deep pricking and heat (45° C.) elicit diffuse and severe persistent pain, felt more definitely in the back and sole of the foot than at the points of stimulation).

CHAPTER III

[ODES OF RECOVERY OF ELECTRICAL EX- CITABILITY IN THE COURSE OF NERVE INJURIES

importance was attached at the beginning of ;he war to the study of the diagnostic and prognostic

ilue of electrical examination, although the large number of injuries to peripheral nerves offered a

st field for such researches.

At first electro -diagnosis roused much enthusiasm ,mong neurologists and surgeons, the latter hoping to replace all clinical examinations by a rapid electrical examination, which was at one and the same time to reveal which nerve was affected, and the situation, nature, and extent of the lesion (section, crushing, compression, or simple irritation).

Very soon came disillusionment ; complete division )f the nerves was found in cases in which electro- liagnosis indicated partial R. D., and in other cases in which the R. D. was well-marked there was occa- sionally found to be no solution of continuity of the nerve, or it appeared even to be intact.

Henceforwards electro-diagnosis was discredited, and declared to be suitable only for detecting para- lyses due to psychical, functional, or other causes.

Specialists took part in the discussion in order to define the true characteristics of the R. D. and its significance from a diagnostic and prognostic point of view. They rightly insisted that the R. D. syn--

35

36 TREATMENT AND REPAIR OF NERVE LESIONS

drome is always changing and provisional, and that it requires a correct interpretation.1

Electrological findings arrived at previous to the war remain in general perfectly correct.

We shall first give a short account of the prevalent views as to the occurrence, characteristics, and changes in R. D., and then describe some phenomena which have struck us in the course of the very numerous electrical examinations which we have had occasion to perform.

Let us first state that the method we used was of the simplest. We conducted the investigations with the electrical apparatus of the most elementary de- scription with which every clinician can provide himself, and it is with this that all our examinations were made.

Faradic investigations were made with an induction coil with two dry cells (Gaiffe's model). We have nearly always used the bipolar method of Duchenne (of Boulogne), and only occasionally the unipolar method. The electrodes consisted of either two egg- shaped bulbs or of the two round button-shaped pads familiar to every one ; we used the current supplied by the coil wound with fine wire, the maximum intensity being obtained by the two coils being wholly engaged.

For galvanic investigations we used a battery con- sisting of thirty-two cells, with the indifferent electrode applied between the shoulder blades or in the lumbar region, according to which limbs were being examined, and an active electrode consisting of a pad about 2J centimetres in thickness. We have not used the current discharged from a condenser nor any other method requiring complicated instruments. The cases we examined had received their wounds some time previous, at least six weeks beforehand.

Characteristics of the Reaction of Degeneration.— The reaction of degeneration, which is very frequently seen as soon as the nerve is sufficiently affected to

1 A. Zimmern, Elements d'filectrotherapie clinique, 1906. Published by Masson.

MODES OF RECOVERY 37

show any marked paralysis, is the rule in cases of total paralysis.

At first it consists in abolition of the faradic and galvanic excitability of the nerve-trunk. The paralysed muscles do not react to stimulation by the faradic current, and their reaction to stimulation by the galvanic current is lessened and altered in character (slow contraction, inversion, or equalisation of the polar formula). The most constant qualitative modification is the slowness of contraction, which is always sufficiently marked to >e appreciated by the naked eye : the other modi- Lcations are less regularly seen, such as polar reversal (increase of muscular contraction or more rapid re- ;tion to closure of the anode than to closure of the sathode) or polar equality (K.C.C. = A.C.C.) ; both :hese latter are nevertheless important characteristics

R. D.

An indispensable characteristic, and one to which e attach the greatest importance, is the longitudinal <-eaction, to which Huet has drawn attention.1

It is elicited by stimulating the lowest part of the muscle near its tendon, so that the current passes throughout the length of the muscle. In cases of nerve lesion with R. D. the longitudinal reaction, which, according to the text-books, is more marked than that obtained by stimulation of the points of election, is also accompanied by a slow contraction, "r on the longitudinal hyper excitability is only 3lative, and in order to demonstrate it fairly strong currents are necessary.

During R,. D. the longitudinal reaction is accom- >anied as a rule by a more marked cathodal than anodal contraction; much more rarely the contrac- tion predominates at the anode.

Such is the description of the reaction of degenera- tion according to the generally accepted view. We must now consider how it develops, increases, and dis- appears.

1 E. Huet, " Quelques considerations sur 1'electrodiagnostic," Bulletin de la Societe d'filectrotherapie et de Badiologie, April 1915.

38 TREATMENT AND REPAIR OF NERVE LESIONS

The generally accepted ideas, confirmed by specialists in the course of their observations on war wounds, are as follows : —

Appearance of R. D. — The initial phase of R. D. is characterised by l—

1. Progressive diminution of excitability of the nerve to both the faradic and galvanic current.

2. Progressive diminution of faradic excitability of the muscle.

3. Galvanic hyper excitability of the muscles. The period occupied by this phenomenon is often fairly short, at other times it may last several months.

4. A tendency to sluggishness in the contractile re- sponse of the muscle.

The changes in electrical contractility commence four to six days after the injury, as soon as degenera- tion of the lower end starts to assert itself.

This preliminary phase lasts about two weeks. R. D. is then established, and is manifested by the char- acteristics which we have described.

After several weeks, or even months, some of these characteristics change. A lowered excitability to the galvanic current succeeds the hyperexcitability seen at the outset, the other signs of R. D. persist, e.g. sluggish contraction, polar reversal, and liveliness of the longitudinal reaction, compared with the response elicited from the motor points. This stage may last for months, or even years, according to some observers.

Evolution of R. D. — If the lesion of the nerve is irreparable (complete section without regeneration), the hypo excitability of the muscles continues to become more pronounced, and ends, in the case of complete atrophy and degeneration of the muscles, in muscular inexcitability to stimulation, both at the motor points and in the tendons, but the longi- tudinal reaction is the last to be lost.

1 A. Zimmern, " Quels enseignements nous fournit la reaction de degenerescence dans les blessures des nerfs," Presse medicate, April 15, 1915.

MODES OF RECOVERY 39

On the other hand, when the lesion is undergoing repair, excitability of the nerves to both the faradic and galvanic current reappears, and subsequently the muscles in their turn respond to stimulation. The return of faradic excitability of the muscles does not occur, according to the generally accepted view, until a certain time after the nerves have recovered their excitability to stimulation.

Qualitative defects in galvanic excitability are modified in their turn, in that the contraction becomes less sluggish, the contraction of the muscles grows more and more active, and the excitability at the motor points becomes more marked than the longi- tudinal reaction. Polar reversal persists for a con- siderable time as a reminder of a previous lesion.

During this progress of R. D. towards the normal, voluntary motor power has become re-established. This re- establishment of voluntary motor power precedes )y some time, according to the classical opinion of Duchenne of Boulogne, the return of the faradic excita- bility of nerves and muscles.

Finally, when all qualitative changes caused by the R. D. have disappeared, there still persists a general condition of hypo excitability for faradic, and especi- ally galvanic, stimulation, more marked in general in the muscles than in the nerve-trunks.

Such, then, is the evolution of the complete R. D. following division or severe injury of a nerve with interruption of its physiological function.

When the lesion is less severe, complete R. D. is re- placed by a partial R. D., which consists in —

1. Diminution of faradic and galvanic excitability of the nerves.

2. Diminution of faradic excitability of the muscles.

3. Qualitative impairment of galvanic excitability (sluggish contraction, predominance of the longi- tudinal reaction, reversal or equalisation of the polar formula, or persistence of the normal formula (NF>PF).

In the light of the foregoing, the interpretation of

40 TREATMENT AND REPAIR OF NERVE LESIONS

the observations made on the wounded in this war will be possible.

Although anatomical division- of nerves is rare, in- terruptions of the physiological functions of the nerves, on the other hand, are of frequent occurrence. We have not had the opportunity of seeing a sufficient number of recently wounded men ; for this reason we are unable to say whether hyperexcitability of the muscles to galvanism is a constant sign, nor can we say at what point of time exactly it appears or wanes.

The following is a resume of the electro- diagnosis carried out on two cases which we were able to ex- amine a very short time after they were wounded :—

CASE I. — Jules L , wounded May 7, 1915, by a shrapnel

bullet high in the upper arm.

Total paralysis of the musculo-spiral, paresis of the biceps, and pain in the region supplied by the musculo-cutaneous in the forearm and hand.

Electrical examination for the first time May 12 (five days after being wounded).

Faradic Current. — Tnexcitability of the musculo-spiral nerve. Hypoexcitability of the paralysed muscles, with wave-like fascicular contractions. A very strong current was necessary to cause the tendons to rise.

Galvanic Current. — Musculo-spiral nerve inexcitable. Very marked hypoexcitability of the paralysed muscles without sluggish- ness of contraction, but with a tendency to equalisation of the polar formula.

Examination on May 15, 1915 (eight days after being wounded).

Faradic Current. — Inexcitability of the musculo-spiral nerve in the arm. Very marked hypoexcitability of the paralysed muscles.

Galvanic Current. — Inexcitability of the musculo-spiral nerve. Hypoexcitability and polar reversal for the biceps.

Very marked hypoexcitability of the musculo-spiral muscles, but without sluggish contraction.

Examination on May 17, 1915 (ten days after being wounded). Faradic hypoexcitability of the muscles supplied by the musculo- spiral and of the biceps ; galvanic Inexcitability of the same muscles.

In all subsequent examinations faradic excitability never quite disappeared.

The paralysis decreased as time went on, so that at ten months after the wound it can be considered as cured.

MODES OF RECOVERY 41

When examined on December 6, 1915, the faradic hypoexcitability of the muscles had diminished, the nerve was excitable by the interrupted current, and galvanic inexcitability bad been replaced by galvanic hypoexcitability coupled with polar reversal, but without any sluggishness of the contraction.

CASE II.— Captain C , wounded August 24, 1915. Lesion of

the right brachial plexus (muscles supplied by the musculo-spiral, flexors of the fingers, thenar and hypothenar muscles, and interossei) ind of the axillary artery.

First electrical examination September 13, 1915 (twenty days Eter receiving the wound).

Faradic Current. — Inexcitability of the musculo-spiral nerve.

Hypoexcitability of the ulnar and median nerves.

Hypoexcitability of the muscles supplied by the musculo-spiral

irve, and of the thenar and hypothenar muscles.

Galvanic Current. — Sluggish contractions in the same muscles.

cammed on September 21, 1915 (about one month after being

junded).

Faradic Current.- — Hypoexcitability marked in the triceps and thenar muscles, less marked in the other muscles supplied by the musculo-spiral, and in the flexors and hypothenar muscles.

Galvanic Current. — Excessive hypoexcitability and slight slug- gishness of the contraction in the musculo-spiral muscles, the thenar and hypothenar muscles, and interossei.

Paralysis has steadily diminished.

In March 1916 (seven months after being wounded) the extensors of the hand and wrist have in a great measure recovered, as also the flexors and the interossei. There is still marked paralysis of the triceps, abductor longus pollicis, and thenar muscles.

Thus in these two cases faradic excitability had not completely disappeared, and paralysis had diminished. The impairment to galvanic excitability was purely quantitative in the first case, but assumed the characteristics of R. D. in the second case. The mild nature of the first case well confirms the fact to which Huet has drawn attention — namely, that the return to volitional motility occurs far more promptly in those muscles showing very marked hypoexcitability than in other muscles exhibiting the usual char- acteristics of the R. D.

In serious lesions due to wounds the injured nerve and the muscles supplied by it are inexcitable on faradic stimulation.

There is galvanic inexcitability of the nerve, often coupled with considerable hypoexcitability of the muscles, sluggishness of contraction, polar reversal

42 TREATMENT AND REPAIR OF NERVE LESIONS

for certain muscles, and, on the contrary, equalisation or a normal polar formula for other muscles.

Longitudinal excitability from the first few weeks onwards after injury exceeds the reaction obtained at the motor points. We have never been able to find in patients who have been wounded at least six weeks previously any hyper excitability of the muscles with the galvanic current, either when there was total anatomical section, or in those cases where the inter- ruption was of a physiological nature of long standing.

In these cases we have always found faradic inex- citability of the paralysed muscles three months after the infliction of the wound.

Among those with wounds of the musculo-spiral or sciatic whom we were able to follow up systematically,1 some showed complete section or serious injuries, which necessitated suturing or resection ; others, who were not operated on, were so severely injured that they showed only slight signs of return of sensibility even after a lapse of six months.

Among the first lot (those operated on) we noted a return of faradic contractility from the third week to the fourth month after operation.

It was necessary to use a strong current, obtained by totally engaging the coil wound with fine wire, and the electrodes had often to be applied below the motor points.

The contraction was feeble, occasionally quite localised, but sometimes it was transmitted down to the tendon, and a corresponding movement was elicited. Positive results were chiefly obtained in those muscles which were easily accessible, such as the tibialis anticus, peronei, gastrocnemii, extensor longus digitorum, extensor proprius hallucis, radial muscles, supinator longus, extensor communis digi- torum, thenar and hypothenar muscles, and interossei.

1 In investigating the course of electrical reactions it is easier to study musculo-spiral paralysis or lesions of the great sciatic and external popliteal, since the phenomena of diffusion are easier to interpret in these cases.

MODES OF RECOVERY 43

I We reported eleven of these cases to the " Societe 3 Neurologic, "1 viz. : — (a) Two complete sections (sciatic and external popliteal) operated on two months after being wounded (end-to- end suture) ; sixty days after operation faradic contractility appeared.

(b) One resection (external popliteal) performed four months after being wounded ; twenty-two days after operation faradic contractility reappeared.

(c) One partial resection (external popliteal) per- formed six weeks after being wounded ; seventy-five days after operation faradic contractility reappeared.

(d) Three hersages (great sciatic severely injured) performed four and seven months after the wound ; sixty days and one hundred days after operation faradic contractility reappeared.

(e) Four freeings (one great sciatic, one external popliteal, and two musculo-spiral cases) ; faradic con- tractility reappeared in from two to three months after operation, and six to eight months after receipt of injury.

The cases progressed as follows :—

(a) One of the two complete sections in which suture was performed by M. Gosset under perfect conditions does not show any return of voluntary motor power twenty-one months after the injury (nineteen months after operation). There are some indications of re- covery of sensation. Certain muscles continue to react to faradic stimulation. In the second case of complete section there is return of voluntary motility in the tibialis anticus one year after operation and fourteen months after injury.

(6) Total resection has resulted at the end of six months in restoration of voluntary motility, which is still improving.

(c) Partial resection has had a similar course.

f

1 Pierre Marie and Mme. Ath.-Benisty, "Du retour dela contractilite aradique avant le retablissement de la' motilite volontaire dans les

muscles paralyses, a la suite des lesions des nerfs peripheriques," Sociele de Neuroloyie de Paris, April 15, 1915, and May 6, 1915. Revue Neurolo- gique, May-June 1915, p. 494, and July 1915, p. 557.

44 TREATMENT AND REPAIR OF NERVE LESIONS

(d) Of the three hersages of the great sciatic, two have been followed by progressive motor restoration, the third shows the same slight degree of faradic con- tractility without any appreciable return of voluntary motility one year after operation.

(e) Finally, the four freeings have resulted in three cures ; the fourth (great sciatic trunk in the region of the buttock) has not shown any improvement, and we have also lost sight of this patient.

From all this, it is justifiable to conclude that this partial return of faradic excitability should be inter- preted as a prognostically favourable sign.1

Of course in many cases of severe wounds (sections with suture or regeneration after resection) we wit- nessed the confirmation of the generally-accepted rule that voluntary motility was restored, at any rate to a considerable extent, even at a time when electrical contractility, and especially faradic excitability, still remained in abeyance.

But in a large number of cases we have seen faradic contractility reappear, partly at any rate, several weeks, or even months, before voluntary motility appeared. This often coincides with sensory recovery (formication, deep aching in the muscles, or parsesthesia).

What can we conclude from these facts ?

Every time there has not been section or resection of a nerve one should ask oneself if faradic excita- bility has ever totally disappeared. Nevertheless the electro-diagnosis of all our wounded has always been carried out in a most thorough manner, and repeated many times by specialists.

We have often found when examining nerve lesions in course of recovery that there is no suggestion of faradic excitability in the muscles, although they had reacted definitely two or three days previously, and did so again later. Occasionally the mere inversion of the poles was sufficient to determine a fresh contraction.

1 Since these two reports we have been able to find this early return of faradic contractility in a large number of cases. These signs have invariably been of good import.

MODES OF RECOVERY 45

The most surprising thing was to see this dis- appearance of faradic excitability coincide several times with a return of voluntary motor contraction. The current then diffused itself into the neighbouring healthy muscles.

Moreover, in several of these cases, not only did the faradic excitability disappear, but the galvanic as well. One could no longer obtain either the longitudinal reaction or the sluggish contraction which had existed throughout the whole period of the paralysis. Ex- cessive diffusion, even with a feeble current, occurred into the sound muscles. We have observed several instances of this sort in typical cases where voluntary motility reappeared before faradic contractility.1

We may also mention that we have not always seen the assertion confirmed that faradic excitability of the nerve re-establishes itself before faradic excitability of the muscle. In many of the cases where partial faradic excitability of the muscles took place, the nerve re- mained inexcitable by transdermic methods. The importance of this phenomenon might be denied by attributing it, and quite justifiably, to a certain diffi- culty in reaching the nerves through the superficial structures, to the resistance of the tissues, a sudden diminution in the intensity of the faradic current, which, though difficult to detect, is quite possible, or even to a polarisation of the electrodes.

Nevertheless, in a case of musculo-spiral paralysis of three months' standing, in which the muscles re- acted very satisfactorily to the faradic current, we found in the course of an operation (liberation of the nerve) that the nerve-trunk directly stimulated in the operation wound hardly reacted to a current of equal force. The electrodes, it is true, were different.2 »ut the same current applied to the paralysed muscles

1 All our investigations on faradic contractility of the paralysed rves were conducted by the bipolar method ; the unipolar method

and the tetanising current did not give any appreciable results.

2 The electrodes used in this instance were specially sterilisable ctrodes devised by H. Meige,

46 TREATMENT AND REPAIR OF NERVE LESIONS

which had been exposed produced fairly powerful con- tractions in accordance with the excitability tested by the percutaneous method.

In another case (paralysis of the musculo-cutaneous) direct faradic stimulation of the nerve was negative even when the muscle of the biceps was feebly ex- citable.

To change the subject, and to return to the two cases of complete section sutured under very satis- factory conditions, which we referred to previously, it may be asked why, without any return of voluntary motility in one case, or with partial or late return in the other, faradic excitability of the muscles still exists ? This excitability varies, it is true, from day to day ; it is only slight, but still it has persisted now for more than twenty months. One of two things has happened : either the suture of the nerve has been a failure, and fibrous tissue has been interposed between the two ends, impeding all advance of the axis-cylinders towards the lower end, and division persists for this reason. In that case it is not clear why the muscles have not also become completely degenerated.

The other explanation is, that the suture has helped in recovery, which is manifested by sensory symptoms and by a return to faradic excitability in the muscles.

In cases of anatomical section not repaired by suture, or of crushing or compression by callus, faradic and galvanic excitability of the muscles1 is generally found to disappear in from eight to ten months, de- veloping simultaneously very marked amyotrophic changes.

It would be surprising if in other severe cases, or in cases of complete section, this muscular excita- bility of the faradic current should last twenty months without any nervous impulse being able to reach the muscle.

With this accumulation of contradictory facts, all we can conclude is that in a large number of cases the

1 The maximum intensity of the galvanic current used was of 25-30 milliamperes.

MODES OF RECOVERY 47

faradic contractility can appear in the muscles before voluntary motility, and this applies both to sections of the nerves which have been immediately sutured, and to physiological interruption of the nerve by a severe lesion.

It may be that in these cases faradic excitability has never at any time completely disappeared, and this one can easily understand, since there are certain kinds of paralysis existing with partial R. D., and that it has been masked by infiltration of the super- ficial layers which develops during the first few months after the wound, and which very probably also changes the structure of the muscle.

This infiltration can easily be detected in paralysis of the sciatic nerve. It is present, though less marked, in muse ulo- spiral paralyses.

The return of faradic excitability begins to appear in muscles which are atrophied, but still retain, or have recovered, a certain consistence and a certain degree of tonicity on deep palpation.

This faradic recovery takes place very slowly, but it progresses in a methodical manner right up to the time that voluntary movement appears, and occasion- ally it diminishes or even disappears for a short time when voluntary motility is about to return. On the contrary, in many other cases, especially in complete sections which have been sutured, or after resections, voluntary motility returns before electric contractility, and during the first few weeks, occasionally during the first months, which follow the onset of motor recovery, it is possible to find faradic inexcitability, or even galvanic inexcitability, of muscular masses which have been previously affected by paralysis and complete R. D.1 The electric current is rapidly diffused into the normal muscles in the neighbourhood.

Clinical researches will still be necessary, with direct electrisation of the paralysed muscles exposed in the operation wound, in order to clear up these cases.

1 Babinski has recorded a case of this kind, Societe de Neurologic, May 6, 1915. Revue Neurologique, July 1915, p. 553.

48 TREATMENT AND REPAIR OF NERVE LESIONS

In any case, whenever there is a serious lesion of the nerve which has not been operated on, or in case of section followed by suture with complete paralysis of the muscles and complete R. D., we continue to con- sider as a promising sign the appearance of faradic ex- citability in some of the paralysed muscles, no matter how slight this reaction may be.

This return generally coincides with signs of sensory recovery and an arrest in the advance of the amyo- trophy. The subsequent history of a large number of cases has confirmed this.1

1 Chinay, G. Bourgnignon, and Dagnan-Bouveret, while investigating the conditions of recovery of galvanic contractility, explain the early return of normal reactions in certain nerve injuries by the presence in the paralysed muscles of " a certain number of young regenerated fibres " in insufficient quantity for their contractions to determine a voluntary movement, but which, when examined electrically, may respond by a sharp contraction without inversion (Paris Medical, September 1916).

CHAPTEK IV RECOVERY OF VOLUNTARY MOTILITY

IN studying the clinical forms of nerve lesions we have described the manner in which motor recovery takes place in each nerve-trunk of the limbs, and noted the order in which the muscles successively regain their functional activity ; we need not, therefore, refer to this subject again.

Before the appearance of movements sufficiently marked to result in the displacement of a limb into which the terminal tendon of the muscle is inserted, one can convince oneself by palpation of the swell- ing of the muscle under the voluntary efforts of the patient.

Generally speaking, with severe lesions of the nerves, especially in cases of section or crushing of long stand- ing followed by considerable atrophy of the muscles, a certain degree of muscular tonicity returns before any reappearance of voluntary motility.

This phenomenon is far less definite in those lesions in which atrophy has not led to marked emaciation of the muscles, but it can be made out even in those cases.

The appearance of this tonus does not necessarily in- volve an improvement in the defective attitude of the in- jured limb. Numerous causes can intervene to accen- tuate a paralytic position — e.g. articular ankylosis, laxity of the ligaments, and so forth.

Even when nervous impulses reach the muscle its movements remain at first awkward and uncertain,

49 4

50 TREATMENT AND REPAIR OF NERVE LESIONS

and do not take place every time when the patient orders the limb to move, nor do the impulses reach all the muscles which are recovering.

For example, when a patient suffering from an in- jury to his musculo-spiral wishes to extend his wrist, his supinator longus contracts powerfully, and often in excess of the radial muscles.

A. Thomas attributes this to " an error in the switch- ing " of the motor fibres which have not taken the right direction, and have not encountered each time the sheaths destined for their reception. Possibly it may also be due to a certain amount of inco-ordination and muscular weakness, or to forgetfulness of their previous function, and to the tendency to put into play too large a number of muscles when a fresh move- ment is to be executed.

Once the movement has been performed it is rapidly exhausted.

The patient does not, as a rule, acquire power, skill, and delicacy in isolated movements until after a long period of training.

We must remind the reader that in order to appre- ciate recovery of voluntary motility it is necessary to examine the case repeatedly and minutely, so as to detect the part played by auxiliary muscles, and to avoid being misled by the contraction of antagonistic muscles.

As Claude 1 has many times remarked, adduction movements of the thumb dependent on the ulnar nerve may simulate a movement of opposition. Ad- duction of the thumb, when the ulnar nerve is para- lysed, may be initiated and simulated by the extensor longus pollicis.

The energetic contraction of the radial muscles causes hyper extension of the wrist, and determines a sort of " hollowing out of the hand " (Claude), which simulates a movement of flexion of the fingers.

In cases of simultaneous lesions of the median and ulnar nerves, flexion of the wrist can be obtained by

1 H. Claude, Revue Neurologique, April-May 1916, p. 493.

RECOVERY OF VOLUNTARY MOTILITY 51

the combined action of the abductor longus and ex- tensor brevis pollicis.

The anomalies of innervation of the muscles of the thenar eminence make the interpretation of their motor recovery rather difficult.

Froment x has suggested several signs which allow one to estimate the isolated action of each of these muscles.

Thus in order to judge of the return of functional activity in the flexor brevis pollicis, the classical test of opposition to the extremity of the little finger can still be used, or the patient may be asked to grasp a small glass.

Duchenne (of Boulogne) recommends the following test of the functional activity of the abductor brevis pollicis : opposition to the extremity of the index finger, first phalanx bent, last phalanges extended (hand in the shape of a duck's bill).

The condition of this muscle can still better be esti- mated (Froment) when a big cylinder or a bottle or a tumbler of large size is grasped.

During the regeneration of the nerve, and while voluntary motility is becoming established, another phenomenon to which Andre Thomas 2 has drawn attention may be seen, viz. muscular hypertonus, which is not uncommon in paralyses which are im- proving, and especially in certain cases of lesions of the muse ulo- spiral.

Together with this phenomenon, which may be localised in some of the paralysed muscles, one may observe the presence of cutaneous sensations in the territory of the musculo-spiral nerve, which can be elicited by pressure on certain muscles, such as the extensor communis or the supinator longus.

1 J. Froment, Revue N euroloyique, April-May 1916, p. 508.

2 A. Thomas, " Hypertonie musculaire dans la paralysie radiale en voie d'amelioration. Sensations cutanees dans le domaine du nerf radial, provoquees par la pression de muscles qui regoivent leur innervation du meme nerf. figarement des cylindraxes regeneres, destines a la peau dans les nerfs musculaires," Societe de Neurologie, July 29, 1915. Bevue Neurologigue, August-September 1915.

52 TREATMENT AND REPAIR OF NERVE LESIONS

Thomas explains this fact by the diversion of the sensory axis-cylinders which were destined for the cutaneous area into sheaths belonging to muscular fibres.

The presence of sensory axis-cylinders in contact with muscular fibres would then give rise to cutaneous sensations, and possibly also to an irritation of the muscle, tending towards contracture.

CHAPTER V

SIGNS OF SEVERE LESIONS OF THE NERVES

THE main object of the physician when faced with a nerve wound is to try to appreciate 'the severity of the lesion from the very start in order to know what treatment to adopt.

If it were possible to be certain at once that there was complete section, immediate suture of the nerve could be performed, as an early operation is the best condition for its success ; but this certitude can only be acquired after observing the wound for several months, and after having noted the absence of any sign of recovery.

Neurologists and surgeons have made numerous attempts to discover any signs which would justify a more rapid diagnosis and furnish definite indications for operation from the very start.

These researches, we must admit, have not yet re- sulted in any definite conclusions.

The most important and complete work on this sub- ject has been that of Mme. Dejerine and J. Mouzon. In the course of a series of articles these authors have described the signs which they consider as justifying the diagnosis of an anatomical nerve lesion.1 They have distinguished several symptom-complexes, which they have termed syndromes of interruption, syndromes

1 M. and Mme. Dejerine and M. J. Mouzon, " Les lesions des gros troncs nerveux des membres par projectiles de guerre. Les differentes syn- dromes cliniques et les indications operatoires," Presse medicale, May 10, July 8, and August 30, 1915.

53

54 TREATMENT AND REPAIR OF NERVE LESIONS

of compression, syndromes of irritation, syndromes of dissociation, and syndromes of recovery.

A. The Syndrome of Interruption justifies the diagnosis of complete histological interruption which is present whenever " the lesion prevents any axis- cylinder of the upper segment from passing into the lower segment, whatever the macroscopic or naked- eye appearance may be." Once we have admitted the lesion to be of such a degree of severity, surgical interference is indicated. Even if it is found on operation that the nerve is not divided, but merely presents a swelling or a " nerve cheloid," M. Dejerine, Mme. Dejerine, and Mouzon advise resection of the nerve and suture. All that they require is that the syndrome of interruption should first have been found by clinical examination.

Let us first of all study the symptoms constitut- ing this clinical syndrome ; we will then mention the criticisms that have been made :—

1. Muscular Signs. — Three fundamental signs exist : —

(1) Complete paralysis of all muscles supplied by the nerve below the lesion.

(2) Complete absence of tonicity, evidenced by soft- ness and flaccidity of the muscles on palpation, and by the position of the limb in repose ; wrist-drop (musculo- spiral), very marked ape-hand (median), irreducible claw-hand (ulnar), excessive varus equinus (external popliteal), and foot-drop (great sciatic).

(3) Absence of any pain on pressure of the muscles supplied by the injured nerve. This muscular analgesia is stated to persist some time even after the regenera- tion of the nerve and the reappearance of tonicity and voluntary motility.

Further muscular symptoms of secondary importance are :—

(a) Abolition of corresponding reflexes (tendinous, periosteal, and cutaneous).

(b) Exaggerated excitability of the muscle to mechanical stimulus.

SIGNS OF SEVERE LESIONS OF THE NERVES 55

(c) Amyotrophy.

(d) Certain deformities, such as dorsal swelling of the carpus or tarsus.

(e) Complete reaction of degeneration in the paralysed muscles.

2. Sensory Signs. — These are characterised by :—

(a) Absence of any zone of hypercesthesia or parces- ihesia in the region supplied by the injured nerve.

(b) Absence of pain on pressure applied to the nerve- trunk below the lesion.

(c) Localisation of the changes in objective sensibility as well as their topographic distribution, which embraces the whole cutaneous, osseous, and articular region supplied by fibres of the injured nerve which have been given off below the seat of the lesion.

B. Syndrome of Irritation. — This comprises painful injuries of nerves, on which we have sufficiently dwelt in our first volume.

C. Syndromes of Dissociation relate to the numerous partial lesions of the nerves, and give rise to incom- plete paralysis.

D. The Syndrome of Compression, which indi- cates lesions surrounding the nerve rather than in its

Jtual substance, is characterised by the same pheno- tena as those described in the syndrome of inter- iption, but in a less degree. What distinguishes this condition from the last, according to observers, is }he presence of pain when the muscles and the nerve- trunks are subjected to pressure and the lesser degree )f impairment of objective sensibility which generally consists in hypaesthesia.

E. Finally, the Syndrome of Regeneration of the >rve, " which may follow any of the previous syn-

Lromes," comprises :—

1. Sensory symptoms, viz. spontaneous pain radiat- ing throughout the whole course of the affected nerve ;

lin on pressure of the nerve-trunks ; shrinkage of the mcesthetic areas and appearance of parcesthesia (proto- >athic sensibility of Head).

2. Muscular symptoms subsequent to the signs of

56 TREATMENT AND REPAIR OF NERVE LESIONS

sensory recovery, mainly characterised by the return of muscular tonus (gradual modification in the posi- tion of the limb).

Such in outline is the very interesting and elaborate theory worked out by M. and Mme. Dejerine and Mouzon.

We think that the conditions met with in actual practice rarely assume this schematic appearance, and that the clinical varieties which the doctor has to examine do not always correspond to this de- scription.

The only syndrome which we shall discuss is that of complete interruption, on account of its great prac- tical importance. If this syndrome was allowed absolute diagnostic value each time that it was en- countered, operation would be necessary, and even if the operation did not show actual section of the nerve, resection followed by suture would nevertheless be indicated.

In accordance with Prof. Pitres, we believe that it is impossible to make a definite diagnosis of anatomical or histological interruption of the nerve, but only one of physiological interruption. " For even if loss of conduction necessarily follows transverse section of the nerve, it can just as well be the result of injuries which have affected the nerve-fibres without dividing the neurilemma — such as contusions, compressions, constrictions, and possibly even mere commotion of the nerve-trunk."1

Resection among other dangers would then result in interrupting for a long time a regeneration which was tending to take place spontaneously.

The practical side of the question has been well brought out by Henry Meige. " A scientific dis- tinction between anatomical section and physio- logical section or interruption is a thoroughly judicious

1 A. Pitres, " La valeur des signes cliniques permettant de reconnaitre dans les blessures des nerfs peripheriques : A. La section complete du nerf ; B. La restauration fonctionnelle," Societe de Neurologic, April 6, 1916. Revue Neurologique, April-May 1916, p. 477.

SIGNS OF SEVERE LESIONS OF THE NERVES 57

one, but I fear that in practice it is not always very carefully interpreted. Is not one liable occasionally to confound impairment in the function with mutila- tion of the organ ? And is there not a possibility of recommending the same operation for nerves which have undergone physiological interruption as for those with anatomical section ? I foresee a very real danger to which attention should be drawn.

" Circumspection is all the more necessary since the signs by which we diagnose a section or physiological interruption are still under discussion — their symp- tomatological value varies according to different ob- servers— and moreover these signs are only temporary, and in fact do on occasion become modified or dis- appear spontaneously without intervention.

" Hence we must ask ourselves whether the presence of these signs is of sufficient value to justify the re- section of a nerve-trunk which is not completely severed." l

The originators of the syndrome of interruption expressly state that value can only be attached to the syndrome when all its constituent signs are present at the same time.

Any one of these signs taken separately is only of doubtful value.

Thus complete paralysis of all the muscles supplied by the nerve below the seat of the lesion is an ab- solutely essential sign for the diagnosis of a complete interruption of the nerve. No one would think of maintaining such a diagnosis if a few of the muscles supplied by the nerve preserved their motility. Nevertheless there are some nerves — and these are the very ones most frequently injured, such as the musculo-spiral or external popliteal — which react to injury in the majority of cases by a generalised and immediate paralysis of all the muscles without the lesion being necessarily very serious.

With regard to the absence of tonicity of the muscles,

1 Henry Meige, Societe de Neurologic de Paris, April 6, 1916. Cf. Revue Neurologique, April-May 1916, p. 499 and following.

58 TREATMENT AND REPAIR OF NERVE LESIONS

it should be recognised that flaccidity of the muscle on palpation varies in each subject.

" Muscular tonicity varies considerably in the normal state. Individuals may be constitutionally hyper- or hypotonic. Some have short, bulky, and hard muscles which never relax completely; while others have long, thin, soft muscles in which relaxa- tion is excessive. The same condition can be observed in the tendons, ligaments, and aponeuroses. . . .

" We have seen muscles in which hypotonus and flaccidity were excessive recover their contractility without operation. The flaccidity of the muscles may be masked by con- comitant lesions in the muscles, tendons, or apo- neuroses, or by an cede- matous infiltration, which is not uncommon, especially in the lower limbs. We FIG. 18. — Musculo -spiral paralysis have seen several cases

in course of recovery. Great where the flaccidity and hypotonus of extensor muscles -, £ .-, i -,

of wrist, despite fairly good atrophy of the muscles only motor and electrical recovery became apparent after the in these muscles. subsidence of long-standing

oedema; at the same time

appeared definite signs of sensory and electrical and then motor recovery" (Henry Meige).1

The attitude of the limb at rest is of still more de- batable diagnostic value. Hypotonus may be very marked in the course of reflex paralyses and func- tional.pareses (Babinski). It is sometimes very pro- nounced in severe injuries to nerves, which never- theless recover in a few months. We have often seen musculo-spiral paralyses with marked wrist-drop

1 Henry Meige, loc. cit.

SIGNS OF SEVERE LESIONS OF THE NERVES 59

(fig. 18) or paralyses of the external popliteal accom- panied by excessive equino-varus (due to ligamentous distension) recover, both from the motor and electrical point of view, without either the attitude of the hand or foot altering in any appreciable manner.

What we have said of the variability of ulnar claw- hand l allows us to state that the existence of a claw- hand depends upon too many factors for one to be able to regard it as a definite diagnostic sign.

The interpretation of the " ape-hand " seen in lesions of the median may be complicated by an anomalous nerve-supply.

The absence of any pain on pressure of the muscles is a sign which Henry Meige and Pitres have discredited. It is indeed a very uncertain phenomenon. The muscles often present the same painlessness on deep pressure as on the sound side. In other cases, as many observers have recorded, in which pressure on the muscles was painful, a subsequent operation has shown that the nerve was completely divided with both ends apart. This has occurred fairly fre- quently in the musculo-spiral and external popliteal. In many cases this pain, which is sometimes very intense, is due to concomitant injuries to adjacent bones, tendons, or aponeuroses, or to the involve- ment of sensory filaments belonging to other nerves which supply the skin over the paralysed muscles.

We shall not criticise the motor and sensory signs, which the authors themselves declare to be but of secondary importance and which we shall discuss later.

From the practical point of view, we will remind the reader that a large number of cases of complete paralysis showing all the severe signs described under the name of " syndrome of interruption " recovered without any operation, or after simply freeing and clearing the nerve. In other cases considered to be of a very severe nature, and of several months' dura- tion, in which operation had shown a large, hard

1 Mme. Athanassio-Benisty, Clinical Forms of Nerve Lesions.

60 TREATMENT AND REPAIR OF NERVE LESIONS

fibrous swelling, with or without a lateral notch, the pseu do -neuroma was excised and end-to-end suture performed. Histological examination of these ex- cised neuromata conducted by Pierre Marie and Foix showed that very often some of the axis -cylinders of the upper end had systematically invaded the cicatrix, arid were advancing, for the most part, towards the lower end, which some of them had even reached. Re- generation was, in fact, taking place spontaneously.

Is there then no sign, no symptom or combination of symptoms, which will allow one to state with certainty that a nerve has suffered anatomical section — a diagnosis which is of the utmost importance as regards surgical treatment ?

We regret that we are forced to reply in the negative and to repeat what Prof. Pitres says : " It is possible to diagnose physiological interruption of a nerve, but it is impossible to diagnose its anatomical section."

Physiological interruption is capable of spontaneous repair in a large number of cases. It is not, there- fore, justifiable to recommend resection of a nerve as a routine treatment.

It is necessary to wait several months before one can state with any certainty that a physiological in- terruption of a nerve is severe and that it corresponds to an histological interruption. During this period it is essential to make repeated and careful examina- tions ; and then, if there is no sign of regeneration, and if the original symptoms suggestive of a severe lesion have not undergone any change, and not till then, should an attempt be made to induce by resection followed by suture a regeneration which it appears cannot take place spontaneously.

What then are the signs of a severe lesion which should be noted from the first ?

SIGNS OF A SEVERE LESION In our opinion these signs are as follows : — 1. Total Paralysis of all the Muscles below the Lesion. —This symptom is of most value in wounds of the

SIGNS OF SEVERE LESIONS OF THE NERVES 61

median and ulnar, as these nerves so often show only incomplete or dissociated paralyses as the result of injuries received in warfare.

It is of less value in the lesions of the musculo- spiral and external popliteal nerves.

2. Complete Reaction of Degeneration, which can be found from an early date (six or seven weeks after injury), and in which the quantitative and qualitative alterations become more marked at each subsequent examination. In the case of a severe lesion the faradic excitability of the muscles rapidly disappears, galvanic hypoexcitability becomes pronounced, and the sluggishness of the contraction increases, being very frequently accompanied by polar reversal and dis- placement of the motor points, resulting eventually in the longitudinal reaction which finally predomi nates over excitability at the motor points and per- sists alone several months afterwards. At a certain moment, as we have said, electrical excitability both to the continuous and interrupted current disappears absolutely. This progressive disappearance is a grave sign.

3. Rapid and Extensive Atrophy of the Paralysed Muscles is easily detected in the posterior part of the forearm in the case of the musculo -spiral (with wrist - drop) ; in the epitrochlear muscles, in contrast to the prominence of the supinator longus, in the case of the median ; in the whole leg in the case of the sciatic ; and in the antero -external part of the leg in the case of the external popliteal (with marked equino- varus).

Atrophy of the interossei and of the hypothenar eminence in the case of the ulnar nerve does not possess the same importance, since it occurs even when the lesion is not very severe.

4. The Presence of Certain Thermal and Vasomotor Disturbances, in addition to the preceding signs, is of great assistance in diagnosis. They are as follows :—

Considerable lowering of the local temperature (in the absence of any vascular lesion) of the skin covering

62 TREATMENT AND REPAIR OF NERVE LESIONS

the atrophied muscles. This refrigeration is still more noticeable when the skin is supplied by the injured nerve.

Palpation reveals this sign : on the posterior surface of the forearm in the case of musculo-spiral para- lysis ; on the hypothenar eminence and over the little finger in the case of the ulnar ; in the index finger in the case of the median ; on the antero -external surface of the leg in the case of the external popliteal ; and over the whole calf in the case of the great sciatic. In the last case, if the foot is warm and dry and slightly succulent, this is another sign of gravity. Frequently there is also a slight cedematous infiltra- tion of the malleolar region and even of the calf.

5. Absence of Pain when the Trunk of the Nerve is subjected to Pressure below the Seat of the Lesion.1 — Nevertheless in the course of complete division of the musculo- spiral and in certain lesions of the great sciatic, or of the external popliteal, there may be painful sensibility on pressure of the nerve -trunk below the seat of the lesion.2

1 The following are the points of election for palpation of each nerve : — Musculo-spiral. — The groove of the humerus, neck of the radius, and

external border of the forearm.

Median. — Inner aspect of arm, course of the nerve in the forearm (middle of anterior aspect), and thenar eminence.

Ulnar. — Groove between internal condyle and olecranon, and course of the nerve in the forearm (inner border).

Great Sciatic. — Course of the internal popliteal (middle of the popliteal space), posterior tibial (middle of the calf), and external popliteal (neck of the fibula).

2 Claude has also noticed cases of this type, especially in the course of a complete section of the musculo-spiral. Revue Neurologique, April- May 1916, p. 493.

FIG. 19. — Distribution of sensory changes in severe lesions of the great sciatic.

Black : complete an- sesthesia for all stimuli. Grey: hypaesthesia.

SIGNS OF SEVERE LESIONS OF THE NERVES 63

6. Considerable Disturbances of Objective Sensi- bility.— In lesions of the great sciatic these disturb- ances, in order to have any value, must affect the whole foot, except its internal border and the internal malleolus. The loss of deep sensibility on pressure and pinching is absolute, as is also the abolition of vibratory sensibility in the bones and the complete

FIG. 20.— Palm of the hand.

FIG. 21. — Back of the hand.

Distribution of sensory changes in the course of severe lesions of the median.

Black : complete anaesthesia for all kinds of stimulation. Grey : hypsesthesia to pricking, anaesthesia to heat and cold. Dolled area : less marked hypsesthesia.

absence of the sense of position in the toes or even the instep. In the leg this anaesthesia extends to the a ntero -external surface of that segment and comes more or less close to the knee (fig. 19).

In the case of the median, anaesthesia is complete in the last two phalanges of the index and middle finger, with total loss of deep sensibility and the sense of position. If the anaesthesia extends to the thumb and the thenar eminence, this sign is of still greater importance (figs. 20 and 21).

64 TREATMENT AND REPAIR OF NERVE LESIONS

In the case of the ulnar, sensory disturbances are very frequent and marked. The most significant are the complete loss of sensibility of all kinds in the little finger and on the inner part of the hypothenar eminence (fig. 22).

In the case of lesions of the external popliteal, the anaesthesia occupies the middle region of the dorsal aspect of the foot and a narrow tract running up the

FIGS. 22 and 23. — Area showing sensory changes in severe lesions of the ulnar.

Black : complete anaesthesia for all kinds of stimulation. Grey : hypsesthesia to pricking, anaesthesia to cold and heat.

outer surface of the leg as high as the junction of the middle and upper third (fig. 24).

This typical distribution may not occur, and we have observed cases of complete anatomical section of the external popliteal in the popliteal space in which the anaesthetic area was confined to the zone of the anterior tibial. The supplementary nerve - supply was probably due in this case to the external saphenous.

We have seen how inconspicuous and inconstant

SIGNS OF SEVERE LESIONS OF THE NERVES 65

were the sensory symptoms in the course of lesions of the nrusculo -spiral. Nevertheless a patch of anaes- thesia situated over the first dorsal interosseous space possesses some value.

Such are the main signs which claim the practitioner's attention.

Other less important symptoms must be mentioned. Their existence may form a further argument in favour of a severe lesion or complete division of the nerve. Their absence, on the other hand, is of far less significance.

They are as follows : —

Loss of the osteo-periosteal tendon and cutaneous reflexes. — We have already alluded to their variability.

Exaggeration of the Mechanical Ex- lity of the Muscle. — This is far from

ving any satisfactory information as

the nature of the lesion. Slowness of idio-muscular contraction is a sign of the same import as the sluggishness of the contraction produced by the continuous current, but it is not so constant.

Vasomotor and trophic disturbances are always present in severe lesions of the nerve, but one must always remember the possibility of the presence of a vascular lesion, and bear in mind the character of the reactions peculiar to certain nerves uch as the median or the great sciatic.

The abolition of the secretion of sweat is of value when present, and is almost always found in severe injuries to the median, ulnar, and great sciatic.

The researches of Claude and Chauvet1 and of Rene Porak 2 have shown that the disappearance of sweating

1 Claude and Chauvet, Semiologie reelle des sections totales des nerfs mixtes peripheriques. Paris, published by Maloine, 1901.

2 R. Porak, Societf Medicale des Hopitaux, July 30, 1915.

FIG. 24.— The zone of sen- sory changes in lesions of the external popliteal nerve.

Black : anaes- thesia. Grey: hypsesthesia.

66 TREATMENT AND REPAIR OF NERVE LESIONS

is observed and localised in the region of a nerve which has undergone complete anatomical division.

Certain trophic changes must also be considered, although too much value must not be given them. They are as follows :—

The presence of ulceration without any vascular lesion being present (Leri).

Hypotrichosis, or the lessening in number and size of the hairs in the zone supplied by an injured nerve. Maurice Villaret x has drawn particular attention to this sign. Hypertrichosis, on the other hand, would rather suggest an irritation of the nerve.

The same may be said of changes in the finger-prints recently studied by Cestan, Paul Descomps, and Euziere.2 In cases of severe injury to the median and ulnar nerves a breaking-up and mazing of the outlines may be seen, and is said to have the same significance as real trophic disturbances.

Andre Thomas has drawn attention to a series of signs from his study of the cutaneous cicatrix and the region around this cicatrix.

Stimulation of this zone by a fine brush or a needle gives rise to sensations which are localised to the area stimulated and are also transmitted to the periphery of the nerve (synsesthesia).

" This cicatricial topo-parcesthesia shows that there is at any rate a partial division of the nerve, and that this division is absolute ; this is the most important point which must be insisted upon in the presence of a syndrome of complete paralysis " (Andre Thomas).

In addition to this sign, one can usually find by palpation a swelling in the course of the injured nerve.

Among all these signs which we have just described,

1 Maurice Villaret, " Contribution a 1'etude des troubles du systeme pileux et de la sudation spontanee des membres au cours des lesions traumatiques de guerre des nerfs peripheriques," Societe Medicale des Hopitaux, December 17, 1915, and Revue jVewroZog^'gwe, April-May 1916, p. 495.

2 Cestan, Paul Descomps, and J. Euziere, " Les alterations des em- preintes digitales dans les lesions des nerfs peripheriques du membre superieur," Societe Medicale des Hopitaux, May 5, 1916.

SIGNS OF SEVERE LESIONS OF THE NERVES 67

we would attach most importance to the rapid and progressive atrophy of the muscles and to the progress of their electrical degeneration.

The presence of this sign, six to eight weeks after injury (the time at which the patients usually reach the neurological centres) justifies the diagnosis of total and complete paralysis.

The subsequent course, accompanied by careful and repeated examinations showing the persistence or aggravation of these signs, indicates a severe injury.

The disappearance of these symptoms, on the con- trary, will lessen the probability of such an injury.

" In general, one should be guided less by an associa- tion of clinical signs than by the evolution of these igns. Thus the diagnosis of complete physiological iterruption of a nerve cannot be made from a single examination, however carefully conducted. Even if ;his examination enables one to find all the principal i,nd secondary signs of a complete interruption, it must be followed by many other examinations at sufficiently long intervals to enable one to detect any progressive aggravation, or obstinate stagnation which could justify an exploratory operation" (Henri Meige).

The period necessary for the regeneration of the nerve is therefore variable. It depends mainly on the anatomical condition of the nerve, though the factors which are favourable or otherwise to its re generation are unknown to us, and also on the nature of each nerve, .he clinical individuality of the nerves being shown by the rapidity and ease with which they regenerate.

The first signs of sensory recovery, if they occur, tay appear alone for a long time without being followed by a progressive and regular regeneration of the other functions of the nerve.

Under these conditions how long must we wait

)fore being able to form a strong presumption in favour of a severe anatomical lesion, and before advising an operation ?

Is there no danger, in waiting too long, of degenera- tion occurring in the nerve-trunk, the muscles and the

68 TREATMENT AND REPAIR OF NERVE LESIONS

terminal sensory and motor organs, thus rendering all regeneration impossible in future ?

From the cases which we have observed, and which we shall describe later, we think we are justified in stating that there is no danger in waiting four or five months after the infliction of the wound.

On the other hand, if no sign of regeneration appears, it is wise to operate towards the fifth month, since further delay may impair the ultimate success of the suture.

When the severe signs which we have detailed persist or increase towards the seventh or eighth month, one can assume a complete section with or without pseudo- continuity of the nerve. All the more so is this the case when one sees the wounded for the first time, nine, ten, or twelve months after the injury.

One may ask if when in doubt it would not be better to operate as soon as paralysis is considered to be com- plete, and to resect and suture every injured nerve, since we cannot know from the start the gravity of the nervous cicatrix caused by the projectile. Is it not logical to replace an irregular inflammatory cicatrix by a regular aseptic one suitable for the passage of the axis-cylinders to the peripheral end of the nerve ?

This question can best be answered as follows : a large number of sutures with freshening of the two ends of the nerves performed within six weeks to four months after the injury (in other words, fairly soon), and in which healing has occurred by first intention, have resulted in failures, or else progress has ceased at an early stage of regeneration.

The same applies to many cases of total or partial resection followed by sutures performed under favour- able conditions, and according to the most logical methods.

These facts are particularly true in the case of lesions of the median and great sciatic nerve.

If nerve suture, which should always be attempted in the case of complete division of the nerve with separation of both ends, is not always successful, have

SIGNS OF SEVERE LESIONS OF THE NERVES 69

we the right to resect a nerve whose anatomical con- tinuity is intact and in which naked-eye examina- tion does not show any severe crushing nor any appearance equivalent to complete section such as we have described previously ?

We do not think that there is any justification for ich procedure.

ORDER IN WHICH THE SIGNS OF REGENERATION APPEAR

Which are the earliest symptoms indicating the ^generation of a nerve, and what is their value ? As we have already described them, we will now in what order they appear :—

1. Signs of sensory regeneration appear first. The irliest in the order of their appearance are pain when

skin is pinched in the sensory area of the nerve, pain when the nerve is pressed below the lesion, formication produced by this pressure along the nerve below the probable seat of its injury, and spontaneous and provoked aching in certain muscles. This sign is particularly marked in wounds of the sciatic.

These symptoms, as we have said, are early ; they may develop in certain injuries of the nerves after three or four months, sometimes earlier, and occasion- ally later.

They precede by a long time the other signs of >nsory regeneration, and also of motor and electrical

jovery.

Occasionally nervous regeneration seems to halt at

tis first phase. We have seen a few cases which have lot been operated on and more numerous ones in which the nerve has been operated on under perfect conditions and sutured end to end, and others in which the nerve has simply been freed and in which after twelve to eighteen months nervous regeneration had stopped at this stage of initial sensory recovery.

2. The muscular signs, which should be looked for carefully and at frequent intervals, are the next to

70 TREATMENT AND REPAIR OF NERVE LESIONS

appear. The arrest of the atrophy, which does not result in the complete emaciation only produced by total and definite section, is of great importance.

A certain consistency and tonicity of the muscles on palpation, and, more important still, the reappearance of this consistency after a period of progressive atrophy, is a sign of good augury. This sign is difficult to detect in certain cases of wounds of the sciatic with infiltration of the skin.

The change in the attitude of the limb is a sign of less value. The foot-drop may persist in wounds of the great sciatic even when motor regeneration starts in some of the muscles, and a certain degree of tonus can be found when the muscles are palpated. The same thing applies to wrist- drop in wounds of the musculo -spiral.

The relaxed condition of the ligaments, articular lesions, and occasionally vasomotor disturbances often prevent correct appreciation of the change in the position of the limb which a priori should always result from the increase in muscular tonicity.

Nevertheless an improvement in the dangling attitude of the toes in some lesions of the sciatic, the modifications in the course of the ulnar claw-hand coincident with other signs of regeneration, are of good import and should claim our attention.

3. In some of the muscles which have preserved or recovered some of their tonicity, one can find, four or six months after injury, sometimes later, a slight 'degree of faradic contractility.

The contraction may be quite trifling, occasionally quite localised, sometimes only perceptible on palpa- tion, or, on the other hand, sufficiently marked to occa- sion a distinct elevation of the tendon of the muscle that is being stimulated.

As we have already described the various forms of electrical recovery, we need not return to this subject. We will simply mention that the persistence of faradic excitability, its progressive increase , and its spread to other paralysed muscles are of favourable prognostic

SIGNS OF SEVERE LESIONS OF THE NERVES 71

import, and allow us to hope for a return of voluntary motility in the near future. The muscle which has first recovered its faradic contractility will usually be the first to regain its motility.

Motor recovery is less certain in cases in which excitability by the induced current varies from day to day, and does not progress in a regular manner.

The disturbance of objective sensibility subsides and gradually goes through those stages which we have described previously, while the sensory signs of the early stage persist (formication and pain on pressure of the nerve and skin).

Muscular atrophy being arrested, the firmness of the muscles increases, and finally voluntary movements begin.

Muscular contraction is at first shown by a simple lifting of the muscle in the course of certain contrac- tions of antagonistic muscles, but it becomes stronger and finally reaches the tendon. The movement is uncertain and weak at first, but gradually improves.

How long does it take for regeneration of the nerve to occur, by which we mean the first sign of motor return in a part or the whole of the paralysed muscle supplied by the injured nerve ?

Nothing is more variable. The time required is never less than five months in slight cases, and it may be as much as eight or ten months in severe cases and after early nerve suture of certain nerves such as the musculo -spiral or external popliteal ; it may reach twelve, fourteen, or sixteen months in some very severe instances, and in late sutures of the nerves mentioned above, or in some early sutures of the ulnar, median, or great sciatic.

Possibly we may see eventual nerve regeneration after a longer period still even in those which we now consider lost, despite sutures, grafts, and freeings. There is nothing to prevent us hoping for appreciable improvement in certain severe and complete paralyses which have not been operated on, and in which we see signs of commencing sensory recovery.

CHAPTER VI

SURGICAL TREATMENT OF INJURIES TO NERVES

FROM the beginning of the war both neurologists and surgeons were surprised by the high incidence of wounds of the nerves (20 per cent, of all wounds), and anxiously sought for the best treatment to apply to these cases.

At first both neurologists and surgeons agreed to avoid the use of the knife, since the first operations did not give those results which pre-war neurological and surgical literature had led them to expect. These operations neither relieved pain nor hastened motor recovery.

The operative technique was found fault with, or the blame was laid on the suppuration of the tissues, or the peculiar nature of wounds of the nerves in war, which always tear the tissues extensively and are accompanied by excessive fibrous reaction.

It must also be confessed that the knowledge of nerve degeneration and regeneration had been somewhat forgotten.

There was therefore a period of indecision, after which the neurologists adopted the surgical principle of exploration, and henceforth for a time handed over most of their cases to the surgeon.

Both parties acted logically and wisely in allowing themselves to be guided by the data furnished by clinical examination and the anatomical appearance of the lesions. Several essential rules were decided upon,

72

SURGICAL TREATMENT OF INJURIES 73

e.g. the importance of not interfering before complete cessation of all suppuration, the advantage of cleaning up the area of the lesion, and the need of protecting the nerve against any return of suppuration followed by sclerosis.

Another important point was also established, viz. the delicate nature of nervous tissue and the necessity of taking the greatest care in manipulating it. The logical sequence of this was the axiom : a nerve-trunk in which there is no solution of continuity should not be divided or resected.

There were certainly a few daring attempts to resect exuberant nerve cicatrices in order to suture the nerve in healthy tissue and thus to ensure a more rapid and theoretically more certain regeneration. Delorme in particular proceeded in this manner with regard to lesions of the great sciatic. The Surgical Society riticised this method, and we do not know what was subsequent history of cases thus operated on.

The fact remains that a large number of surgeons soon discarded any operations on nerves, discouraged both by the slowness of nerve repair in general and sutures in particular. A few of them even went so far as to declare every nerve suture to be a mistake and destined to failure from the start.

On the other hand, the campaign conducted by M. and Mme. Dejerine, and their definite advice to resect every cicatrix of a nerve-trunk manifested clinically by the " syndrome of complete interruption," without any sign of regeneration three weeks after receipt of the wound, influenced other surgeons, who resumed resecting. There are as yet no definite statistics which would enable their results to be gauged.

We consider it advisable to report those cases which we have been able to follow up personally, and to compare them with other cases in the various neuro- logical and surgical centres.

During the last months of 1914, and at the beginning of 1915, Professor Pierre Marie had a large number of cases under his care at La Salpetriere suffering from

lesi crit the

74 TREATMENT AND REPAIR OF NERVE LESIONS

nerve wounds, operated on by Gosset and Pascalis for severe or painful lesions, and less severe lesions with incomplete paralyses and some evidence of regenera- tion. It was to be hoped that freeing and cleaning up of the nerve-trunk would assist in the recovery of its functions. On the other hand, it seemed indicated to suture the nerve in the case of division.

In some of the cases in which clinical examination showed the presence of a severe lesion the nerve was found to be crushed, or had a very hard and exuberant swelling ; recourse was then had to resection followed by end-to-end suture.

In dealing with an anatomical section of the nerve, Gosset freshened the two ends and performed end-to- end suture.

Only in a few cases in which the distance sepa- rating the two segments was too great did he use nerve-grafting, the graft being usually taken from the cutaneous branch of the musculo-cutaneous, one of the two terminal branches of the external popliteal.

When the continuity of the nerve was unimpaired, the nerve cicatrix being represented by a " pseudo- neuroma of attrition," of which we have spoken before, without any crushing of the nerve or solution of con- tinuity, Gosset, in accordance with Professor Pierre Marie, only freed the nerve or subjected it to "her- sage," i.e. made a few slight longitudinal incisions over the cicatricial swelling, each 2 to 3 centimetres long, according to the requirements of each case.

Lateral notches were freshened and sutured.

Neuromata situated within the nerve-trunk were enucleated whenever possible.

The general results of these operations were as follows : —

First, and this is of the utmost importance, no aggravation of any kind was recorded. Our statistics comprise about 150 cases operated on.1 We are able to state definitely that an exploratory incision in nerve wounds is quite harmless when the surgeon is

1 About one-fifth of these cases were operated on by Pascalis.

SURGICAL TREATMENT OF INJURIES 75

sure of his technique, and conducts the operation with prudence and dispatch, and ensures absolute asepsis.

These operations, except in very rare instances, were performed after suppuration had completely sub- sided. The post-operative history was normal, and cicatrisation took place by first intention.

Among more than fifty simple freeings we have to record twenty complete cures ; one failure (shrapnel fragment imbedded in the great sciatic in the region of the buttock ; no voluntary movement had re- appeared one year after operation). All the other cases were followed by improvement which was more or less rapid, but always progressive.

Hersage was performed when the anatomical lesion appeared of a more severe nature.

Out of about fifty to sixty, twenty-five were com- pletely cured. One failure was recorded (great sciatic nerve in the region of the buttock), and there was undoubted and sustained improvement in thirty cases.

Among eleven sutures, we had two complete recoveries (both musculo-spiral), three partial and pro- gressive recoveries (two ulnar and one external pop- liteal). The six other cases were distributed as follows : three musculo-spiral (sutured one year after receipt of wound), one ulnar, two median, one great sciatic. Nearly all these cases nevertheless show commencing sensory recovery, except the two median.

We were able to follow up five complete resections followed by sutures, of which two were almost com- pletely cured (both external popliteal), one showed signs of commencing recovery (musculo-spiral), and two resulted in failure (one musculo-spiral, one ulnar).

Four partial resections were followed by two very satisfactory recoveries (one musculo-spiral, one external popliteal) and two failures (one median and one great sciatic).

Two musculo-spiral paralyse swith section and wide separation of the two ends of the nerve were treated by suture by means of a nerve graft. In these cases the nerves had been wounded eight to twelve months

76 TREATMENT AND REPAIR OF NERVE LESIONS

previously. Twenty months after the operation we can find only vague signs of sensory recovery.

Prom these statistics several general conclusions can be drawn which have been confirmed by the work of other neurological centres : —

1. Exploratory incisions carefully performed under aseptic conditions are not harmful to the injured nerves.

2. Freeings do no harm and may favour recovery.

3. Hersage of neuromata do no harm.

It is a question, however, whether operations of this kind are essential. Thus, an injured nerve which has not suffered severe cicatricial damage and has maintained its continuity will probably be able to regenerate at the end of eight to twelve months without an operation of any kind.

4. Sutures for complete sections of nerves, and performed six to eight months after receipt of the wound, often result in cure in the case of the musculo- spiral and external popliteal.

5. Resection followed by suture in severe lesions of the same nerves gives equally good results when the operation has not been postponed for too long a period (eight months at the very utmost after the wound).

6. Sutures or resections followed by sutures of the ulnar nerve regenerate far less quickly, and are altogether less satisfactory ; those of the great sciatic and of the median also regenerate extremely slowly; frequently twelve to eighteen months after operation there is no return of nervous function, or only a slight degree of recovery.

Such is the list of the results of operation which have been observed in Professor Pierre Marie's service at La Salpetriere.

Comprehensive statistics are practically non-ex- istent. Isolated reports and communications to learned societies mention some cases of nerve suture followed by motor recovery. Generally they refer to section of the musculo-spiral nerve with early suture

SURGICAL TREATMENT OF INJURIES 77

(two to six months after injury), but J. Heitz, in a report to the Health Service (May 1916), mentions a case of suture of the musculo-spiral performed very late, more than one year after receipt of the wound, and followed a few months after the operation by motor recovery.

We have also seen a case of this sort in which the musculo-spiral had been sutured one year after injury and where the power of voluntary movement began to return ten months after suture. Cases of this kind are of considerable interest and should be remembered.

Researches should be conducted along these lines in order to establish if it is advisable to interfere in old- standing cases of paralysis due to a wound, in which for some reason no operation has been performed.

Successes have less frequently been noted after suture of the ulnar, median, or great sciatic. On the other hand regeneration of the nerve is not uncommon in suture of the external popliteal.

Rene Dumas brought before the Surgical Society some careful statistics1 in which he had collected hundreds of cases which had been operated on, and he was able to draw some interesting conclusions from his own experience.

Rene Dumas has had the opportunity of perform- ing a considerable number of sutures and a very great number of freeings. He found that the recovery of movement did not occur until very late, but the point which struck him most was that there was a definite individuality in the nerves from the point of view of the rapidity and completeness with which they re- gained their motor power.

The musculo-spiral regenerates remarkably readily, and the ulnar only slowly, while the great sciatic (especially the internal popliteal) and the median give the most disappointing results.

Henry Meige has also pointed out that the musculo-

1 Rene Dumas, " Liberation des nerfs et recuperation fonctionnelle," Societe de Ghirurgie, meeting held February 2, 191 6. Bulletins et Memoir es de la Societe de Chirurgie de Paris, February 8, 1916.

78 TREATMENT AND REPAIR OF NERVE LESIONS

spiral is at once the most delicate of all nerves and the one which regenerates most satisfactorily both spon- taneously or after surgical interference.

Tinel has compiled statistics of 108 cases of suture or of nerve grafts.1 He casts no doubt on the success of nerve suture, and in 108 cases he had barely 12 to 15 per cent, of failures. Twenty-two cases were almost completely cured, and all the others are on the high-road to more or less rapid recovery; but at present we have only a brief summary of the clinical and anatomical features of these 108 nerve sutures.

Gosset2 has reported 126 cases of nerve suture, of which 25 were performed by means of nerve grafting.

The results appear to him to be encouraging, and he ascribes the failure of suture " to the fact that nerve resections have been too restricted, and that the suture had involved sclerosed portions of the nerve, and for this reason was doomed to almost certain failure."

It is difficult therefore to formulate general and definite rules with regard to operation on nerves ; one can only state what are the indications for operation, the most favourable period for surgical interference, and the clinical and histological findings in those cases which have resulted in failure. In short, though some definite points have emerged from the experiences of surgeons and neurologists during the last two years, the problem of surgical treatment of nerve injury is not solved in all its details. Nothing would be less scientific or more risky in the present state of our knowledge than to lay down definite axioms, always a dangerous thing in clinical medicine. The chief concern of the surgeon should be to respect the continuity of the nerve, not to form resections too hastily, and always to bear in mind the delicacy of nerve tissue, and the difficulty of its repair.

On the other hand, there is no justification for

1 Tinel, Les Uessures des nerfs. Paris, Masson, 1916.

2 Societe de Chirurgie de Paris. Meeting held April 12, 1916. Bulletin et Memoire de la Societe de Chirurgie, April 8, 1916, p. 971.

SURGICAL TREATMENT OF INJURIES 79

regarding as incurable nerve lesions more than a year old which have been operated on properly, even if they do not yet show definite signs of regeneration. Time may bring about unexpected cures. Therefore, when a medical board has to make a decision, a certain caution should be exercised in prognosis. The condition should be said to be permanent only in the minority of cases. The only fair and wise procedure is to pro- pose an allowance which may be renewed after a long period (two years).

INDICATIONS FOR OPERATION. TECHNIQUE

Just as each nerve reacts to injury in a special

anner, so it seems to exhibit some peculiar process of regeneration. This individuality in the nerves from

e point of view of their regeneration is an undoubted t, but is as yet only imperfectly understood.

Exploratory Incision. — The first question is to know whether exploration is necessary, and how long after

e wound the exploratory incision should be made. When the surgeon is sure of his methods there is no arm in exploration, and besides, it is not necessary to perform it in all cases.

Experience has taught us that a very great number of nerve injuries (more than 50 per cent.) are cured spontaneously without any intervention. It is there- fore necessary first of all to find out by repeated and careful clinical examination whether the lesion is a

ight one, which will probably undergo spontaneous regeneration.

Clinical examinations will have to be made at frequent intervals in order to arrive at a conclusion with the least loss of time.

In complete paralysis of the musculo- spiral or of the external popliteal, if the clinical signs remain severe four or five months after injury, and if the nerve shows no sign of regeneration, it may be assumed that there is an indication to interfere and to examine the appear- ance of the anatomical lesion.

80 TREATMENT AND REPAIR OF NERVE LESIONS

If the nerve is found to be divided or completely crushed, suture performed directly after resection generally gives the best results.

With regard to injuries of the ulnar, the fifth month is also the maximum period of time to be allowed before exploratory incision should be made, when signs of a severe lesion are persistent.

This nerve is slow to regenerate after suture or re- section, and it is important not to allow too much time to elapse before operating.

The median and great sciatic regenerate unsatis- factorily, slowly, and in a variable manner. Spon- taneous regeneration never takes place in them in less than eight to ten months after the wound, but when these nerves are divided, crushed, or severely injured, their regeneration is particularly protracted. Thus, when clinical examination reveals persistence of the signs of a severe lesion,1 the fourth month should not be allowed to elapse before interfering.

Naked-eye Appearance of the Injured Nerve.2— Inspection of the nerve is an important source of information from the point of view of surgical treat- ment. As the result of their histological researches, Pierre Marie and Foix have shown the way in which the appearance of a nerve should be interpreted. " We think," say these authors, " that between the anatomical condition as revealed by the simple naked- eye examination performed by the surgeon, assisted by the neurologist, and the histological structure there exists a sufficient resemblance to enable one to compare one with the other, and to draw from them practical conclusions." 3

Complete Section, Suture, Grafting. — In the case of complete anatomical section, with separation of the two ends, the lower extremity of the upper neuroma will have to be pared away. This extremity is formed by fibrous tissue which opposes the advance of the

1 See chapter on " Signs of Severe Lesions," p. 53.

2 See chapter on " Macroscopical Lesions," p. 1.

3 Presse medicale, January 31, 1916, p. 41.

SURGICAL TREATMENT OF INJURIES 81

axis-cylinders. The resection must be sufficient and must go beyond the zone of indurated tissue without, however, going as far as the perfectly normal part of the nerve. Excessive shortening of the central end would necessitate pulling on the nerve to allow sutur- ing, or would require the use of a nerve graft, which is not to be recommended. Paring will be all the more necessary because the extremity of the central

FIG. 25.

torsion with hori- zontal direc- tion of the fibres.

(After Pierre Marie and Foix, Revue Neuro- logique, Jan. 1916.)

FIG. 26.— Different methods of end-to-end suture.

(After J. Sicard, Paris Medical, Feb. 19, 1916.)

segment often shows a kind of torsion with a horizontal arrangement of the fibres, which constitutes an im- penetrable obstacle to the regenerating axis -cylinders.

The upper part of the lower pseudo-neuroma (peri- pheral end) must also be resected, since it is formed of fibrous connective tissue.

Once these two extremities have been freshened, they must be sutured end to end (fig. 26). The following is the method used by Gosset : Approxi- mate the two extremities by catgut, then unite the neurilemmas by several fine silk sutures, taking care not to draw the two cut ends too tight, so as to

6

82 TREATMENT AND REPAIR OF NERVE LESIONS

_J

J

facilitate the advance in a straight line of the axis-

cylinders of the central end (Nageotte).

Any operation must be rejected as illogical which involves any doubling over of one or other of the nerve segments, also bayonet suture, and- especially the grafting of the central end on to a healthy neigh- bouring nerve, or the peri- pheral end on to a neigh- bouring mixed nerve (fig.

FIG. 27. — Several illogical and de- fective methods of nerve suture. (After J. Sicard.)

27). Grafting. -

In all those cases in which the interval between two extremities of the nerves is too wide to allow of direct suture, the two ends can be joined together by the inter- position or grafting of a segment of another nerve.

A small piece of a sensory nerve is taken and placed between the two ends of the cut nerve and sutured as before (fig. 28).

The results of nerve grafting which a priori appears to be a logical procedure, cannot yet be appreciated, since regenera- tion is beset with difficulties and takes place but slowly. What happens to this nerve segment deprived of all blood-supply and used as a scaffold ? J. Sicard has suggested neuro-vascular auto-grafting lay transplanting the segment of a neighbouring nerve while preserving a large pedicle of vascular and connective tissue.

FIG. 28.— Nerve graft. (After J. Sicard.)

This procedure would be applicable in all cases

SURGICAL TREATMENT OF INJURIES 83

where there was a healthy sensory nerve in the neigh- bourhood.

Lateral Notch. Preserve the Continuity. — The lateral notch should be treated according to Gosset's method. Preserve the bridge of nervous tissue, pare away slightly all the wall of the notch, and suture the two lips end to end (fig. 29).

Crushing, Pseudo-continuity, Resec- tion.— When the nerve is very com- minuted, much torn, crushed, adherent to the neighbouring fibrous tissue, or imprisoned within a callus (as very frequently occurs in lesions of the musculo-spiral nerve), it often appears at the site of lesion as a flattened fibrous band situated between two swellings on the nerve and of a greater length than the nerve -trunk itself should be.

These cases are nearly always ex- amples of complete section of the nerve with pseudo- continuity, the tissues between the two swellings consisting of fibrous and muscular tissue only. Under these conditions the only logical operation is resection of this bridge of tissue with freshening of the two extremities of the nerve and end-to-end suture.

But the naked-eye appearance of a crushed nerve is not always so characteristic, and does not allow us to conclude definitely in every case that the nerve is absolutely interrupted. This all goes to prove that repeated and careful clinical examinations are essential. It cannot be repeated too often that the neurologist and the surgeon must not forget that very frequently injured nerves regenerate spontaneously (about 70 per cent, according to certain statistics).

Resection must therefore only be performed when the cause of the condition is thoroughly understood — that is to say, when all the symptoms of a severe lesion are present, and when repeated clinical examinations

FIG. 29.— Lateral notch treated according to Gosset's method.

84 TREATMENT AND REPAIR OF NERVE LESIONS

have not shown any sign of sensory electrical or motor recovery. Pseudo-Neuroma of Attrition : Liberation : Hersage.—

In the case of a pseudo-neuroma of attrition, the most frequent lesion of all, the continuity of the nerve must not be interfered with ; it must only be freed, and when the surgeon is able to do so, he must attempt slight hersage of the neuroma in the line of the axis of the nerve by trying to incise the fibrous tissue between the nerve bundles without dividing them.

The process of freeing the nerve should always be carried out, whatever the nature of the operation per- formed on the nerve ; it is also necessary so as to enable the operator to see the state of affairs and to judge of the condition of the nerve-trunk.

It is a good plan, then, to place the nerve among healthy muscular or aponeurotic tissue in order to separate it from the layer of bone below and from the skin above.

Various methods have been successively recom- mended for isolating the nerve from the neighbouring blood-soaked tissues, e.g. by healthy muscular or fatty tissue, a leaflet of peritoneum, the wall of an artery or vein, winding a thread of catgut round the injured nerve, etc.

But none of these methods seem to have given very satisfactory results. The essential is to follow several rules which are both logical and efficacious, viz. care- ful haemostasis, washing the operation wound with normal saline in order to prevent desiccation of the nerve tissue during the operation, and to remove all the tissue debris, which would result in keeping up a subacute inflammation ending in the formation of a fresh fibrous cicatrix, and lastly, to place the nerve in a bed of healthy muscular or aponeurotic tissue.

The surgical treatment of lesions of the brachial plexus must be considered separately. We have drawn attention to the fact that lesions of the plexus tend to recover spontaneously. Nevertheless, when

SURGICAL TREATMENT OF INJURIES 85

at the end of a few months one or more of the nerve- trunks show signs of permanent physiological inter- ruption, the time has come for surgical interference.

After making an extremely careful clinical examina- tion and an exact localisation of the lesion, the surgeon should proceed to inspect the nerve-trunks and try to perform suture in those cases in which there is com- plete section.

Localisation on a diagram is absolutely necessary, not only for the incision of the superficial layers, but also to serve as a guide to the intricacies of the nerves constituting the plexus. Electrization will often be of great help during the course of the operation.

Operations without apparent Success. Causes of Failure. — We do not know if certain nervous lesions which have been judged incurable may not subse- quently end in recovery. But when a suture has not given the hoped-for results even after several months, what are the causes to which one can attribute this delay in the regeneration of the nerve ? Is the failure temporary or permanent ?

When the operation has been performed too late, one can lay the blame on an ascending lesion of the nerve fibres of the central end. Degeneration of the peripheral end and of the muscles may also be in- criminated.

In cases of sutures or resections performed early, and in which the post-operative history has followed the normal course, we must lay the blame on ascend- ing degenerative lesions of the central fibres,1 lesions

1 The following description of these lesions is given by Pierre Marie and Foix : " Lesions of interstitial neuritis With islands of inflammation, lesions of parenchymatous neuritis with pronounced degenerative changes and descending and retrograde alterations of the axis-cylinders, medullary sheaths and sheaths of Schwann, excessive vascular changes with very marked endarteritis of the medium and small- sized vessels, perineural adhesions which are often hsematomata secondarily organised by the sclerotic tissue, and neuro-muscular adhesions, which are fre- quently seen and important to recognise, since it emphasises the practical rule not to leave a nerve in contact with a bleeding muscular surface. All these changes are obviously in part responsible for the slow progress of functional repair," Presse medicale, No. 6, January 1916.

86 TREATMENT AND REPAIR OF NERVE LESIONS

which reach a far higher level in some cases than is shown by the naked-eye appearance of the induration to be felt in the swelling on the upper segment. The interval between the two extremities must also be borne in mind.

Sutures performed by pulling on the nerve or the interposition of a nerve graft have far less chance of producing regeneration than end-to-end suture of two segments in close contact from the first.

The subsequent process of cicatrisation varies ac- cording to the case. Subacute inflammation of the section may arise, resulting in a fresh fibrous encyst- ment of the central end, and possibly also of the peripheral end, thus creating a fresh obstacle to the advance of the axis-cylinders ; finally the individuality of nerves from the point of view of their regeneration must be determined by the quality of their fibres and their intra-truncular arrangement.

The observations of Pierre Marie and Meige, there- fore, possess an important practical bearing, and it will be very interesting to elaborate and complete them.

We have already seen that clinical examination of the median and sciatic nerves showed that they contained a very great number of sensory, vasomotor, secretory, and trophic fibres. Now if it is always preferable from the point of view of eventual motor recovery to bring into apposition the two ends of a cut nerve in such a manner that the motor fibres of the central end destined for a certain muscle should follow the sheaths of the lower end destined for this same muscle, all the more so is it necessary that motor fibres should not end in sensory areas, or vice versa.

The fibres constituting the posterior roots of nerves are more numerous than those coming from the an- terior roots. On the other hand, certain nerves, such as the median and the sciatic, appear to contain a very great number of sensory, vasomotor, or secretory filaments. This explains how easy and unfortunate

SURGICAL TREATMENT OF INJURIES 87

it is for motor fibres to stray into sensory sheaths (Foix).

Foix has suggested the following hypothesis in order to explain the ease with which the musculo- spiral nerve regenerates, and the frequent failure of sutures of the median and ulnar nerves. The musculo- spiral gives off most of its sensory fibres very high up. The median and ulnar, on the other hand, have a large sensory area situated lower down, and their sensory fibres remain right up to the end united with the motor fibres.

The result is that paradoxical regeneration of the motor fibres in sensory sheaths is much more likely to take place in them, and if the many obstacles to satisfactory progress after suture be borne in mind, it is easy to understand why motor regeneration, which is relatively frequent in the musculo-spiral after suture, appears to be rare in the case of the ulnar and median.1

If to all these causes of failure be added other indivi- dual factors opposing regeneration, such as age, certain dyscrasias, and especially alcoholism, it is clear that regeneration after suture is not without difficulty. There is an obvious danger in deliberately resecting when the continuity of the nerve is preserved, and there is a possibility of interrupting a process of regeneration. It is impossible to tell if the resection and suture are not going to impair the regeneration of the nerve and end in complete failure.

Before closing this paragraph we would like to draw attention to two points : What views should be held about immediate sutures ? Must we refrain from operation through fear of suppuration in the wound which always takes place at first ?

We have been able to follow several cases of nerves which had been sutured immediately (two to eight days after the wound). Regeneration occurred in- variably, and even more rapidly, it seemed to us, than

1 Foix, Societe de Neurologic, meeting held May 4, 1916. Revue Neurologique, June 1916, p. 904.

88 TREATMENT AND REPAIR OF NERVE LESIONS

in other cases (especially in wounds of the sciatic). Other authors, such as Mendelssohn,1 Braquehaye,2 and Carriere,3 have drawn attention to rapid re- generation after immediate suture.

It would be desirable for cases of this kind to be carefully studied. Surgeons at the front seem per- fectly right in suturing immediately if the nerve is obviously cut. " Nerve suture, if done immediately after receipt of the wound," says Prof. Pitres,4 " is a logical operation frequently of use, because by obviat- ing the separation of the lips of the wound and the exuberant production of more or less tough connective tissue it facilitates the passage of the young fibrils of the central end towards the peripheral end of the nerve. But however easily and thoroughly this operation is performed, it does not prevent degene- ration of the fibres of the peripheral segment.

"Latesuture seldom gives favourable results, because it cannot be performed without causing a profound disturbance in the growth of the fibres which takes place at the extremity of the central end. A fortiori, is resection of this central end contra-indicated ex- cept in rare cases. It is seldom of use and generally harmful, because it destroys the whole histological process which has taken place in the zone of growth of the new axones."

The last point to settle is as follows : " What views are to be held as to the immediate and rapid return of motor and sensory functions of a nerve after suture ? "

Personally we have never observed instances of this kind, and we do not know of any neurological communication describing such cases.

Pitres thinks that in view of the inevitable dege- neration of the lower segment, even when sutured

1 Societe de Neurologic, meeting held December 2, 1915. Eevue Neuro- logique, November-December 1915, p. 1285.

2 Braquehaye, " Section du nerf median droit. Suture immediat du nerf. Retour partiel des fonctions," Reunion medicate de la Vl« armee, November-December 1915.

8 Rapport mensuel du Service de Sante, May 1916. 4 Journal de Medecine de Bordeaux, December 1915.

SURGICAL TREATMENT OF INJURIES 89

immediately, " the opinion that occasionally im- mediate and ultra-rapid functional return of a divided nerve occurs is ill-founded, and rests on errors of interpretation. Among the observations which have been brought forward in its favour, there is not one which can bear searching criticism."1

Mme. Dejerine 2 thinks that " rapid recovery of motility occurring one or two days after suture of the nerve is absolutely incompatible with clinical, anatomical, and pathological experience. It has neither been observed after primary sutures per- formed immediately after injury, nor in secondary sutures performed at a later date. . . .

" After nerve section the peripheral end of the nerve always degenerates throughout its whole extent.

"If * rapid ' motor recovery does not exist from a histological point of view, how are we to interpret the so-called rapid recovery which has been clinically confirmed a day or two after nerve suture ? When these cases are critically investigated they are always found to be inaccurate and to lack clinical precision."

SURGICAL TREATMENT OF PAINFUL FORMS OF NERVE LESIONS

We have seen in studying the symptomatology of painful cases that there is often a development of ankylosis and retraction rendering the use of the limb absolutely impossible. Apart from the gloomy out- look of such a condition, the intensity of pain which is unrelieved by internal medication or external application suggests surgical intervention. Simple freeing of the nerve, which seems the only method to follow in these cases where the anatomical lesion is confined to a thickening or induration of the nerve, does not give satisfactory results.

1 Loc. cit.

2 Societe de Chirurgie, December 1915.

90 TREATMENT AND REPAIR OF NERVE LESIONS

Resection of the nerve followed by immediate suture above the wound has not always resulted in complete and permanent abolition of causalgia. On the other hand, section of a mixed nerve, which is apparently only slightly injured, is always a serious measure, since motor recovery may suffer through it.

Sicard conceived the idea of using the method of alcoholisation of the nerve-trunk, which he had already employed in trigeminal neuralgia. The results ob- tained by him seem to be promising.

His method is as follows : under general anaesthesia the injured nerve-trunk is exposed, freed from the surrounding cicatricial tissue, and then 1 cubic centimetre of sterilised alcohol at 60° is injected with a fine needle. The injection must be made 2-3 centi- metres above the lesion. When successful, a small cedematous swelling appears, and the nerve-trunk at once assumes a characteristic white appearance. The alcohol should be preserved in ampoules sterilised by tyndallisation in order to maintain its strength.

Pain vanishes instantaneously, and, on the other hand, the alcohol is said to interrupt motor conduc- tivity for only a relatively short time (six to ten months).

Alcoholisation of the nerve-trunk, which alleviates the pain, is also said to stop the progress of ankylosis, and prevents retractions and dystrophy of all the tissues of the affected limb.

We have elsewhere recorded a case of causalgia of the median nerve, operated on by Gosset, who per- formed hersage on the swelling of the nerve-trunk. This hersage, which doubtless acted by tearing apart the nerve filaments without dividing them, brought great and progressive relief from pain, so that in eight to ten days the patient hardly suffered at all.

Another form of treatment of these nerve injuries has been advocated by Leriche.1 It consists in ex- posing the brachial artery (for causalgia of the median) and excising all its sympathetic and connective -tissue

1 Presse medicate, April 20, 1916.

SURGICAL TREATMENT OF INJURIES 91

leath for about 12 centimetres. It is said that the ^suiting freedom from pain is considerable. Other investigators have tried the same method on ihe popliteal artery for causalgia of the sciatic nerve, [t is, however, better to wait before expressing an >pinion about the efficacy of these operations.

CHAPTER VII

PHYSIOTHERAPEUTIC TREATMENT OF INJURIES TO NERVES

PHYSIOTHERAPEUTIC methods hold the first place in the treatment of nerve lesions. Occasionally they are used as a complement to surgical treatment, and sometimes alone, in those numerous cases in which the nerve lesion tends to heal without operation.

Given the long period required by the evolution of a nerve lesion even in cases of physiological inter- ruption of moderate degree, it is essential to prevent degeneration of the paralysed muscles, to keep the circulation of the affected limb active, and to pre- vent rigidity of the joints and vicious attitudes.

Massage, movement, electrotherapy, and the wearing of suitable appliances help in attaining this end.

MASSAGE AND MOBILISATION

Hand massage and vibratory massage should be employed daily, and often for many months. The essential complement to this treatment is passive movement of the joints. Rapid muscular atrophy is thereby avoided, absorption from the infiltrated tissues is favoured, and rigidity of the articulations prevented. Passive movement can only be of short duration after the daily massage, and is not sufficient in cases of multiple ankylosis.

Frequent treatment by active mechanotherapy and gymnastics should be employed as well. The patient

92

PHYSIOTHERAPEUTIC TREATMENT 93

should also be strongly advised to move the different segments of the affected hand several times daily with his sound hand.

This unceasing collaboration of the patient and the ctor is the best of all methods of physiotherapy. In painful forms, with a tendency to articular igidity and deformity, we must have recourse to massage and movement as soon as the pain subsides a little. Since water is the favourite element with patients of this kind, they should get accustomed to use their flexor muscles by making them squeeze a wet sponge, and by having them massaged lightly under water (Meige).

tWe will not describe the various installations and ppliances used in.mechanotherapy, which are some- mes elaborate, sometimes simple, and mostly useful, rovided that they are thoroughly adapted for their purpose. It is very important that the physician should arrange about their application himself, and that he should supervise this part of the treatment.

When nerve regeneration has in a great measure taken place, or when, on the other hand, regeneration does not seem likely to occur, it is useless to pursue mechanical or electrical treatment any further, since it will be superfluous. It is very important, however, to massage and use the battery on an injured limb during the first few months after the wound, as re- generation of the nerves and muscle is assisted thereby. When clinical examination has shown the persistence of the signs of a severe lesion, such as complete paralysis, and when an operation has been performed, massage should be resumed, as it will then help in regeneration.

When signs of recovery begin to appear, it is often better to send a patient back to civil life for several months, by temporarily discharging him from the service. The patient who has to earn his living always hastens his recovery.

But it is absolutely necessary to discharge any soldiers who have suffered from nerve lesions from

94 TREATMENT AND REPAIR OF NERVE LESIONS

a year to eighteen months, and who have been operated on more than six months previously, and who have had an uninterrupted and appropriate physio- therapeutic treatment for more than one year.

If recovery is to appear at a later date, the exer- cise of a trade, we repeat, will be better for him than rest.

If the paralysis is permanent, and if regeneration appears out of the question, it would be wrong both to the individual and to society to prolong the illusory treatment.

ELECTROTHERAPY

The currents used in electrical treatment of para- lysis of the nerves are of two sorts : the constant or galvanic current, and the induction or faradic current.

1. The faradic current is produced by an apparatus similar in structure to the Ruhmkorff coil. The majority are composed of a primary coil enclosing a core of soft iron. The extremities of this coil are joined to the poles of a battery. (A portable appa- ratus contains two or three dry cells.) Over this coil another coil, called the secondary coil, is made to slide. By means of an interruptor variations are produced in the continuous current which flows through the primary coil. 'Each wave of closure or opening thus produced in the primary circuit develops an induced electromotive force in the secondary circuit. It is this induced current which is used in electro- therapy. The faradic or induced current is still graduated and measured in quite an empirical way by more or less sliding the movable coil over the primary coil.

2. The galvanic or continuous current is furnished by batteries composed of zinc chloride or, better still, of sulphate of mercury. The batteries in general use, consisting of thirty-two to forty cells, are sufficiently powerful.

PHYSIOTHERAPEUTIC TREATMENT 95

The galvanic or continuous current is graduated by means of collectors, and is measured by means of a small apparatus called milliamperemeter.

In order to introduce the current into the organ- ism, appliances called electrodes are used. The best electrodes are those of cotton- wool. They are made of tin plate of variable size, covered on one side with several layers of cotton. The whole is enclosed in a covering of tightly stretched gauze.

Before being applied the electrodes should be thoroughly soaked in slightly salt, tepid water.

Each sitting should last ten to fifteen minutes, and should be repeated every day or every second day.

"Painless Paralysis.1 — When electrical examina- tion has shown impairment of electrical contractility, appropriate treatment must be chosen for each par- ticular case.

" Paralysis accompanied by partial and slight R. D., and which is not painful, should be subjected to the action of the galvanic current, together with a faradic current with slow interruptions (galvano-faradisa- tion). Return of motility will thus be facilitated, and muscular atrophy prevented.

" Paralysis accompanied by well-marked partial R. D. or complete R. D. should be treated by the galvanic current.

" The rhythmical galvanic current should be used in painless paralyses, and those limited to a single nerve by localising the current on muscles supplied by this nerve ; movements which the patient cannot perform voluntarily will thus be easily elicited.

" But if too great diffusion of the current provokes movements in antagonistic muscles to the detri- ment of the injured muscles, rhythmical galvanisation should be replaced by the continuous current. What- ever may be the character of the continuous current, only the current from cells or accumulators should be

1 We are much indebted to Dr Grunspan for this note on the electrical treatment of painful and painless paralyses.

96 TREATMENT AND REPAIR OF NERVE LESIONS

used. The current supplied by the sector is a wave current, and therefore painful. Care must be taken to stuff the electrodes with several layers of cotton- wool soaked in hot water.

"Painful Paralysis. — The continuous current well applied is an excellent therapeutic agent ; it stimu- lates vasomotor activity in the region to which the electrode is applied, awakens the excitability of the nerves, and exercises at the same time a sedative influence ; it is therefore used with great success in painful paralysis.

" Under these conditions the negative electrode is placed on the point of emergence of the nerve, and the positive electrode on the hand if the patient is affected by painful paralysis of the upper limb, or on the foot if the paralysis is in the lower limb.

•" The current must be made to reach the point of maximum intensity desired by proceeding to increase it gradually ; it should seldom be below 50 milli- amperes, and the application should last at least fifteen minutes. The electrodes must be well applied, and fixed in order to distribute the current evenly and to prevent burns. Some painful paralyses resist the sedative action of the continuous current. In these stubborn cases excellent results are sometimes obtained by radiotherapy."

Electrical treatment, just like mechanical treat- ment (massage, gymnastics), must not be persisted in indefinitely.

If at the end of ten or twelve months there is no sign of recovery, it is best to send the patient back to civil life. If the injured nerve is going to regenerate, the muscular work which he will be obliged to perform in carrying on his trade and in his ordinary life will take the place of the benefit which he would derive from electrization for a few minutes at a time.

If the nerve is definitely lost, no physiotherapeutic- treatment will prevent the complete degeneration of the paralysed muscles.

PHYSIOTHERAPEUTIC TREATMENT 97

RADIOTHERAPY

Radiotherapy has been mainly used in painful lesions of the nerves, and especially in wounds of the median and sciatic.

Cestan and Paul Descomps l first systematically used this method and obtained satisfactory results.

The technique is as follows : "1 milliampere with a hard tube (the hardness of the tube being essential). Rays VIII-IX. Aluminium filter of 1 millimetre. Distance of the anti-cathode from the skin 20 centi- metres. One sitting per week lasting a quarter of an hour."

Mile. Grunspan uses the following method, which had previously been recommended by Babinski for stubborn neuralgias.2

The point of emergence of the nerves is irradiated once a week for three weeks. In particularly painful neuritis of the median two irradiations are per- formed a week, one on the cervical roots, the other on the brachial plexus. This treatment is continued for three weeks, followed by a period of three weeks' rest, after which a fresh series of six applications can be repeated.

Pain can also be satisfactorily alleviated by heat in every form, such as hot-air baths, light baths, and diathermy.

Diathermy has a great advantage over the other two methods, in that it penetrates throughout the entire thickness of the tissues.3 But this process demands expensive appliances, and necessitates skilled supervision throughout the whole application.

1 Cestan and Paul Descomps, " La radiotherapie dans le traitement de certaines lesions traumatiques du systeme nerveux," Presse medicale, November 25, 1915.

2 Babinski, " Spondylose et douleurs nevralgiques attenuees a la suite de pratiques radiotherapiques," Societe de Neurologic, May 5, 1908.

Babinski, Charpentier, and Delherm, " Radiotherapie dela sciatique," Sociele de Neurologie, April 6, 1911.

3 M. Grunspan, " Essais de mensuration de la temperature reelle des tissus au cours des traitements par 1'air chaud, la diathermic et 1'electro- coagulation," Revue de Chirurgie, 1912.

7

CHAPTER VIII ORTHOPAEDIC APPLIANCES

As soon as patients suffering from nerve injuries were admitted into the clinic of Prof. Pierre Marie, Henry Meige set about improving the functional disabilities and deformities produced by paralyses and contractures resulting from nerve lesions. With this end in view he proceeded to create a whole series of corrective appliances adapted to the peculiarities of each indi- vidual case, and frequently altered and improved them, his principal object being to simplify them and adapt them for daily use. In July 1915 he laid before the Neurological Society of Paris the essential con- ditions which these prosthetic appliances must fulfil.

"It is of the utmost importance," he said, " when a group of muscles is paralysed to oppose as soon as possible the ascendancy of the antagonistic muscles.

"Massage and movement have this end in view. This object should also be the initial aim of appliances ; they prevent and correct vicious positions, and at the same time favour motor recovery.

" First of all, they lessen the resistance which the weight of an extremity, too heavy for the regenerating muscles, opposes to their first tentative contractions.

" Over and above that, the antagonistic muscles as soon as they are immobilised lose a part of their contractile force ; they become accustomed to relaxa- tion, and the struggle becomes less unequal with the muscular group, which is beginning to have contrac- tions of its own." 1

1 Henry Meige, " II faut favoriser les restaurations mo trices a la suite des blessures des nerfs au moyen d'appareils appropries," Socieie de

»

ORTHOPEDIC APPLIANCES 99

These appliances "should be easy to make, cheap, and light ; they must not compress the tissues, and they should be as inconspicuous as possible."

" Each patient should have an appliance specially

constructed for him, on account of the great individual

variations in skeletal and muscular structure, the

localisation and intensity of the paralyses, and the

resence of complications in the bones, tendons, or

lood- vessels, pain, etc.

"It is necessary that these appliances should be made to measure, tried on many times, modified according to individual peculiarities, and re-made as often as necessary."

" At the same time it is very important to regulate

e time during which such an appliance is to be worn daily, since a certain period must elapse before the patient becomes accustomed to its use. At first it should be worn for a few hours only, the time being gradually increased until it is worn throughout he whole day.

" If the appliance causes any discomfort or pain, :ven if slight, it must be frequently altered until it is horoughly comfortable and satisfactory.

" Inversely, as motor recovery progresses, the time uring which the apparatus has to be worn is de- reased, or another may be substituted if it is better adapted for the new state of the patient.

" In all cases frequent inspection is necessary to

ntrol the progress and check any faulty move-

ents " (H. Meige).1

These appliances are specially useful in musculo- spiral paralysis and in lesions of the external popliteal

correct hand- or foot-drop.

All neurologists have exerted their ingenuity to

medy faulty positions of the limbs by more or less

Neurologie, meeting of July 29, 1915. Revue Neurologique, August- September 1915, p. 761.

Pierre Marie and Henry Meige, " Appareils pour * blesses nerveux,' " Academie de Medecine, meeting of August 10, 1915.

1 LOG. cit.

100 TREATMENT AND REPAIR OF NERVE LESIONS

simple means, and it may be said that to-day in every neurological centre similar appliances are used, and that all are capable of useful service.

We cannot enumerate, far less describe, all of them. We only mention those which we saw used, and which were appreciated by the patient, since the satisfaction which an appliance gives to the patient is the best criterion of its excellence.

The Neurological Society of Paris has appointed a commission consisting of Souques, Mme. Dejerine, Henry Meige, Jean Camus, and Froment " to formu- late the essential conditions which must be fulfilled by a prosthetic appliance for nerve injuries, and to state the indications for their use." The first two reports of this commission contain the following suggestions : —

" First of all, we think we ought to issue a warn- ing against a certain number of errors committed in the conception and application of prosthetic apparatus for nerve injuries.

" These errors may have the most regrettable con- sequences.

" Occasionally the appliance does exactly the opposite to what we desire to effect.

" Thus immobilisation appliances are used in cases where movement is indicated, while in other cases appliances are used which are heavy and tend to cause excessive compression, thus favouring muscular atrophy and preventing motor recovery. Or an appliance which has been successfully used to treat a definite form of paralysis is wrongly applied to another type of paralysis, in which its action is useless, or even harmful. Another error is that patients suffering from hysterical paralysis are not uncommonly seen wearing appliances intended for organic lesions. Here the prothesis not only con- firms an error of diagnosis, but, what is graver still, it tends to render chronic or even permanent dis- orders which by their very nature are essentially and rapidly curable."

I ORTHOPEDIC APPLIANCES 101

Principal recommendations :— 1. Carefully select the points of support in order to void compression of muscles, vessels, or nerves. 2. Avoid all excess in correcting deformities. 3. Favour the play of the affected muscles and their antagonists, without allowing predominance of the latter.

4. Graduate the mechanical effects of the apparatus methodically.

' Two types of apparatus are to be considered : — "1. Appliances for temporary incapacity: these should be light, practical, easy to alter as progress becomes apparent, and specially designed to favour this progress.

"2. Appliances for permanent incapacity: these are mainly intended to be of practical use, and should enable the individual to carry on his occupation. They must be strong, easy to put on and take off, and simple to clean."

APPLIANCES INTENDED TO CORRECT MUSCULO- SPIRAL PARALYSES

In musculo -spiral paralysis the most important aim of prosthetic appliances is to correct " an attitude of the hand which is not only ungraceful but impedes flexion of the fingers, which is generally well preserved. They also cause the swelling on the dorsal aspect of the carpus and the oedema of the metacarpus, which is so frequently seen, to disappear. In short, their effect is to oppose the tendency of the flexors to embody the whole motor activity and to retract " (H. Meige).

The simplest and the most practical appliances consist of a palmar support which prevents wrist-drop.

A simple aluminium splint bandaged to the fore- arm has been recommended by Tuffier.

We have found that the appliances made in the service of Prof. Pierre Marie at La Salpetriere accord- ing to the directions of Henry Meige have given most satisfactory results.

102 TREATMENT AND REPAIR OF NERVE LESIONS

The first model consists of an aluminium splint, which encloses the palmar aspect of the forearm/and is prolonged on to the palm of the hand by a sort of spoon-shaped continuation which is accurately adapted to its shape. This prolongation curves slightly back on the internal border of the metacarpus, and has a hook situated between the thumb and the index finger.

FIG. 30. — Applicance of Henry Meige (musculo-spiral paralysis). Leather cuff holding an aluminium trough, in which the hand rests horizontally, permitting flexion of the fingers. The thumb is supported by a ring of leather.

The appliance is surrounded by a sheath of leather, and is fixed to the forearm by a long cuff kept in position by a lace passing through eyes and hooks. The patient can easily put on or take off his appliance, which is also very inconspicuous (fig. 30).

The same apparatus can be modified in order to

FIG. 31. — Articulated supporting appliance, allowing angle of inclina- tion of hand on forearm to be varied (musculo-spiral paralysis, contracture of the flexors). (Henry Meige.)

correct stiffness of the wrist by adding a sort of joint between the forearm splint and the palmar spoon, whereby the inclination of the hand can be graduated and the hand can be maintained in the desired posi- tion (fig. 31).

ORTHOPEDIC APPLIANCES

103

Another type of appliance consists of an aluminium splint applied by means of a leathern cuff to the dorsal surface of the forearm. From the lower part of this splint four flat springs project, ending in rings, through which pass the first phalanges of the last four ringers.

The rigidity of the springs is sufficient to correct the wrist-drop, besides which it does not impede the action of the flexors of the hand and fingers, so that

FIG. 32. — Spring appliance of Henry Meige, keeping the fingers and the hand horizontal (paralysis of the extensors of the wrist and fingers). The thumb is abducted by a ring of leather fixed to a spring catch.

the patient is able to perform all the movements of prehension (fig. 32).

Henry Meige has designed a still more simple and practical apparatus with a palmar button (figs. 33 and 34).

It consists of a metal splint, which is fastened to the lower third of the forearm by a leathern cuff. At the carpal border of the splint is fixed a slightly bent iron wire ending in a padded button, which rests in the hollow of the hand.

The iron wire is rigid enough to support the weight of the hand and to correct its tendency to drop ; it even allows the patient to lift heavy weights without the hand giving way, which is so troublesome in ordinary movements. It also has the great advan- tage of allowing complete flexion of the fingers and adduction of the thumb.

It can be made as resistant as desired, and is then most valuable for workmen.

It is also the most convenient appliance to write

104 TREATMENT AND REPAIR OF NERVE LESIONS

with. Lastly, it is quite inconspicuous, and easily and cheaply manufactured.

The palmar button can be separated from the arm- piece, which enables the two pieces to be made in advance and to be fitted separately, according to the size and dimensions of the patient's hand and forearm.

FIGS. 33 and 34. — Appliance for musculo -spiral paralysis with palmar button. (Meige. )

To correct paralysis of the extensors and the ab- ductor longus pollicis these appliances can be fur- nished with a leather ring fixed to a spiral spring intended to separate the thumb.

Another model has been used by Souques, Megevand, and Donnet.1 It consists of a leather arm-piece lined with chamois leather, surrounding the lower end of the forearm and lacing up on its anterior aspect.

At each side of the arm-piece an iron rod is fixed, articulating with another bent iron rod which unites at the palm with that of the opposite side. The articula-

1 Societe de Neurologic, June 29, 1916. Revue Neurologique, July 1916, p. 119.

ORTHOPEDIC APPLIANCES 105

tion between the two rods takes place at the wrist, and is homologous to it in its action. Successive

FIG. 35. — Appliance for correction of musculo -spiral paralysis (appliance at rest). (A. Souques, M^gevand, and Donnet.)

movements of voluntary flexion and mechanical ex- tension can thus take place freely (figs. 35 and 36). The appliance of Froment and Muller (figs. 37 and

FIG. 36. — Appliance for correction of musculo -spiral paralysis (front view).

38) is of an analogous design, but can be locked, the hand remaining slightly hyperextended to allow heavy objects to be grasped; it is a good apparatus for working with.1

Other equally practical appliances are those of Privat and Belot (figs. 39 and 40), Leri and Dagnan- Bouveret (fig. 41), Mouchet and Anceau, Rieffel and Ripert.

The commission appointed by the Neurological

1 Revue Neurologique, July 1916, p. 123.

106 TREATMENT AND REPAIR OF NERVE LESIONS

Society to investigate prosthetic appliances for patients suffering from wounds of the nerves has directed its attention mainly to the requirements of working appliances in cases of musculo-spiral paralysis. The following are the principal remarks contained in their second report : —

" The dominant question is for the hand to find a

FIG. 37. — Appliance for permanent musculo-spiral paralysis seen from the upper surface. (Froment and Muller.)

fixed point in the apparatus which will oppose its tendency to drop, even during effort and when the object grasped is heavy.

" Can an extensor spring supply this desideratum ? To this we have to reply in the negative. . . . Thus

FIG. 38. — The same seen from the lower surface.

it has been found that some workmen take off their appliance to work.

" In distinct opposition to appliances designed with the object of re-educating the parts, we have here to supplement the spring by a catch ivhich arrests and maintains the hand in the most useful position. This position is in general that of slight extension analogous to that in which the hand is placed when making an energetic grasping effort. This catch is essential.

ORTHOPEDIC APPLIANCES 107

" The following types of catch have been suggested : " An elastic catch with a palmar button concealed in the hollow of the hand (Meige's model).

FIG. 39. — Prosthetic appliance for paralysis of the musculo -spiral and external popliteal nerves. (J. Privat and J. Belot.)

" A dorsal catch or extensor spring supplied with a catch (Camus's model).

" A catch hidden in the articulation on the sides of the wrist and leaving the palm of the hand quite free.

FIG. 40. — Appliance of Privat and Belot in position.

This catch may be fixed or adaptable to various positions (Froment and Muller, types A and B)."

" Other types of catch may be invented.

" The essential point is the presence of an efficient catch, and one which is concealed and leaves the hand free.

" In appliances intended for the use of working men and labourers, the aim is not so much lightness or concealment as strength, ease in putting on and

108 TREATMENT AND REPAIR OF NERVE LESIONS

taking off and in cleaning it. The method of attach- ment to the forearm should also receive careful attention. Although a short arm-piece is for many reasons desirable, it is better to distribute pressure over a wider area than to have a localised and powerful

FIG. 41. — Appliance of Leri and Dagnan-Bouveret for musculo- spiral paralysis.

constriction, for it is to this part that is transmitted the resistance to the movement of flexion which is arrested by the catch.

" For the business man, on the contrary, a light, inconspicuous, and convenient appliance is essential, one with which he can write and draw. Here the problem is simpler, and is partially solved by appli- ances already in use. It should be noted that the

ORTHOPEDIC APPLIANCES 109

metal pieces placed on the ulnar border of the hand are very inconvenient when writing."

All these appliances aim at correcting paralysis of the extensors of the wrist (radial muscles), but they do not compensate for paralysis of the extensors of the fingers.

Naturally attempts have been made to correct this

latter disability, and by the aid of flat or spiral springs,

>r elastic tractors with one end fixed to the wrist

id the other end to the phalanges, this has been fairly satisfactorily accomplished.

An appliance of this sort had originally been in- rented by Duchenne (of Boulogne). Mme. Dejerine las had one made in which the digital attachments ire very well thought out. Sollier, Cestan, Chiray, jtc., have devised other models which certainly give results. The latest type (that of David and Bateau), made at the Grand Palais, is remarkably

aptable.

Generally these appliances with digital adaptations fulfil their aim fairly well, which is to compensate Por the paralysis of the extensors of the fingers, but ;hey are more complicated and costly, and they are Iso more cumbrous. They are specially useful to >atients who have to perform delicate movements with their fingers.

In the majority of cases the simplest appliances should be preferred, such as Henry Meige's palmar button apparatus.

APPLIANCES FOR SCIATIC PARALYSES

Shoulder-belt Appliance of Henry Meige. — The prin- ciple of this apparatus is as follows : — The affected Foot is raised by traction starting from the shoulder >f the opposite side by means of a belt slung over the shoulder and prolonged downwards by an elastic suspender and fixed below to the sole of the boot of the paralysed foot (figs. 42 and 43).

If there is paralysis of all the leg muscles, the lower

110 TREATMENT AND REPAIR OF NERVE LESIONS

attachment is effected by two cords fixed to each side of the sole or by a stirrup. This apparatus has the advantage of ensuring the raising of the foot, since its

A B

FIGS. 42 and 43. — Appliances for foot-drop. (Henry Meige.)

Sling passing from the opposite shoulder to the affected foot and hold- ing up an elastic suspender fixed to the sole of the boot. A, by two attachments (paralysis of all the muscles raising the foot) : B, by one attachment to the external border (paralysis of the external popliteal).

drop is very inconvenient when walking, and of pre- venting a steppage gait.

In paralysis of the ant ero -external group of muscles a single attachment to the outer border of the boot is sufficient. As a rule, to enable the foot to be firmly

ORTHOPEDIC APPLIANCES 111

)lanted on the ground, it is advisable to raise the

FIG. 44. — Prosthetic appliance for paralysis of the sciatic nerve (appliance ready to be put on to foot). (Souques, Megevand, and V. Donnet.)

FIG. 45. — The same appliance fitted on.

external border of the boot by means of a layer of leather about 1 centimetre thick.

This raising of the sole is sometimes enough to

112 TREATMENT AND REPAIR OF NERVE LESIONS

correct the defect in gait when the foot-drop is not too marked. Its use is still required for some time even after discarding the other corrective appliances. Appliance of Souques, Me*gevand, and Donnet.1 — The two lateral springs which constitute the essential part of the apparatus communicate to the foot a move- ment of flexion when it leaves the ground. By flex- ing the foot on the leg, this appliance maintains it in

FIG. 46. — Appliance of Privat and Belot for paralysis of the external popliteal.

a good position without causing any false movements of rotation or distortion.

The half ring of the upper portion is simply applied to the calf and only exerts slight pressure (figs. 44 and 45).

Appliance of J. Privat and J. Belot.2 — The apparatus is of simple construction, and consists of a steel spring fixed underneath the sole, and of a leather strap which is tightened behind the calf in order to produce tension of the spring (figs. 46 and 47).

1 Revue Neurologique, November-December 1915, p. 1253.

2 Ibid., July 1916, p. 120.

ORTHOPEDIC APPLIANCES 113

Similar useful appliances have been thought out and made by A. Leri, Sollier, etc.

Of all these appliances preference must be given to that of Souques, Megevand, and Donnet, which corrects foot- drop remarkably well, and which is in addition strong, cheap, and inconspicuous ; all our patients fitted with it have been well satisfied.

The shoulder-belt appliance of Henry Meige is

FIG. 47. — Same appliance fitted on.

especially indicated in cases where there is extreme nderness or a painful wound of the calf.

APPLIANCES FOR PARALYSIS OF THE MEDIAN Appliances of this kind are far less

are lar less numerous.

This can be explained by the fact that paralysis of the median involves a far less noticeable deformity than does paralysis of the musculo -spiral, the lesion only becoming noticeable when the patient tries to perform movements of grasping.

8

1 14 TREATMENT AND REPAIR OF NERVE LESIONS

In order to remedy this inability to oppose the thumb to the fingers, J. Froment and Wehrlin 1 have

FIG. 48. — Appliance of Froment and Wehrlin. Semi-diagrammatic drawing. The position of the dorsal spring on the forearm has been slightly lowered for it to be visible in this position of the hand and give a view of the mechanism as a whole.

devised the following appliance, which fulfils its purpose well and is simple in construction.

It consists of a leather cuff round the wrist and of a

ring worn round the thumb. The ring is connected with the cuff by two springs, one of which is inserted on the outer border of the metacarpo-phalangeal joint of the thumb, and is directed towards the pisiform bone, being attached to the cuff at the inner border of the wrist. This spring is intended to replace the paralysed opposing muscle, and should be well on the stretch.

A second spring is attached to the ring on the dorsal aspect of the metacarpo-phalangeal joint and to the cuff on the dorsal aspect of the wrist in the neighbour- hood of the posterior border of the radius. This spring

1 Revue Neurologique, November-December 1915, p. 1233.

FIG. 49. — A new type of prosthetic appliance for paralysis of the median. (J. Froment.)

ORTHOPEDIC APPLIANCES 115

plays the part of antagonist, and should therefore not be much on the stretch (fig. 48).

Froment x has modified this appliance in such a manner that the springs, instead of being attached to the base of the first phalanx of the thumb, are inserted into its upper extremity (fig. 49).

This arrangement allows extension of the last phalanx of the thumb, and thereby effects a more perfect and efficacious opposition to the fingers.

APPLIANCES FOR ULNAR PARALYSIS

An appliance for ulnar paralysis has been invented by Cuneo and Holland with the object of " preventing or correcting vicious attitudes and secondary de- formities, which are often the cause of the poor results of operations for compression or division of nerves."

" I am able to state," says Cuneo, " that the use of corrective appliances for these deformities not only obviate additional operations, but also considerably hasten the return of voluntary motility." 2

Two kinds of cases may be met with : —

(a) Ulnar Paralysis with Claw-hand. — The appliance will consist of a forearm-splint keeping the hand in hyperextension. To this splint two arched supports are fixed. The first one is ventral and holds the series of elastic tractors intended to produce flexion of the fifth, fourth, and, if desired, third finger as well (first action of the interossei). A second series of tractors fixed to a second arched support will produce extension of the second and third phalanges (second action of the interossei).

(6) Complete Claw-hand due to section of the ulnar and median at the wrist. A similar appliance, but furnished with eight instead of six tractors, and having in addition a special tractor for the thumb, will supply all the movements needed.

In spite of all these interesting attempts, prosthetic

1 Revue N eurologique, July 1916, p. 125.

2 Bulletin de la Societe de Chirurgie de Paris, March 15, 1916 (No. 10).

116 TREATMENT AND REPAIR OF NERVE LESIONS

appliances for ulnar paralysis are at present very un- satisfactory, because in the majority of cases there are obstinate retractions of the tendons which frequently become irreducible.

APPLIANCES FOR PARALYSIS OF THE UPPER BRACHIAL PLEXUS

The lesions of the upper brachial plexus leave the motility of the hand practically unaffected, but the

FIG. 50. — Position of flexion allowing the patient to use his hand. The angle of flexion can be varied at will, the forearm preserving the position in which it has been placed. (J. Dagnan-Bouveret.)

hand is useless owing to permanent extension of the forearm on the arm.

It is in order to get a useful flexion of the elbow, which, on the other hand, must not be permanent, and can be varied at will, that Dagnan-Bouveret has invented an ingenious apparatus, which he describes as follows : —

" It consists of an arm-splint and a forearm-splint united at the elbow by a double lateral hinge joint.

ORTHOPEDIC APPLIANCES

117

>n the pivot of each of these hinge joints, and fixed its upper branch, there is a segment of a serrated rheel. The lower branch has a catch which bites on us wheel, and is kept in contact with it by a spiral spring. " On the other side of the spring the catch has

TIG. 51. — Position of disengagement. The catch lifted by hyper- extension of the hand becomes disengaged, and the forearm, being no more supported, falls automatically into extension on the arm. (Dagnan-Bouveret. )

ittached to it a steel wire (fig. 50) which passes along }he forearm-splint and, uniting with the wire from the )ther catch, is fixed to a small chain. This follows the >alm of the hand, and is fastened to a ring which the >atient wears on one of his fingers, preferably the index or the middle finger.

" When no traction is made on the chain, the catch )ites on the serrated wheel, and the angle formed by bhe two splints cannot be increased ; it can only vary in the direction of greater flexion. If, on the other , the chain which passes to the catch is pulled,

118 TREATMENT AND REPAIR OF NERVE LESIONS

the latter is raised and the angle formed by the two splints can be increased until they are eventually in a straight line with one another.

" The apparatus, which is worn on the shirt, is covered by the sleeve, so that the only part seen is the chain in the palm of the hand and the aluminium ring on one of the fingers.

" The working of the apparatus is very simple ; by means of the sound hand or with the paralysed one, which many of these patients are able to make climb up their clothes, using pockets and buttonholes to help, the forearm is brought to the degree of flexion desired,, and retains this position automatically.

" Then when the patient desires to extend his fore- arm he only has to hyperextend the hand, by which movement he pulls on the chain and disengages the catch, and the forearm falls down " 1 (fig. 50).

APPLIANCES SUITABLE FOR WORK IN PATIENTS SUFFERING FROM INJURIES TO NERVES

The course of paralysis following wounds is very slow ; moreover, many cases will remain wholly or partially disabled. It is therefore important, from the social standpoint, to find some means of mitigating their disability.

It is most important that all neurologists and surgeons should use appliances which are suitable both for the nervous injuries presented by the patients and for the particular occupation in which they are engaged.

Obviously, even the best appliances will only mitigate the patient's disabilities, and in most cases the professional re-education of the wounded becomes an important question.

This problem is beginning to be partially solved

1 Jean Dagnan-Bouveret, " Presentation d'un appareil de prothese fonctionnelle pour les paralysies du plexus brachial superieur," Societe de Neurologie, January 6, 1916. Revue Neurologique, January 1916, p. 181.

ORTHOPEDIC APPLIANCES 119

both by the State and by private enterprise, but the

^urologist must intervene in the choice of appliances intended to facilitate definite manual labour. A badly

lought-out apparatus is not only inconvenient, but may even retard the progress of motor recovery. The following recommendation made by the Commission of the Neurological Society of Paris should therefore receive our warm approval : —

"Patients suffering from nerve injuries, in whose case a prosthetic appliance is indicated, should first be subjected to a special neurological examination, in which the conditions to be fulfilled by the appliance to be supplied to him must be specified.

" As soon as the patient has been given the appliance,

le shall be examined again to make sure that it fulfils

11 the desired conditions."

CHAPTEE IX INTRANERVOUS LOCALISATION

THE researches undertaken by Pierre Marie and Henry Meige in collaboration with A. Gosset * have clearly shown that the nerve fibres which go to different muscles are systematically arranged in the interior of the nerve-trunk, where they form bundles, each of which has its individuality.

In order to demonstrate this, the investigators had recourse to direct electrisation of nerve-trunks in operation wounds by means of an electric stimulator, which could be thoroughly sterilised, and which had been invented by Henry Meige (fig. 52).

The investigations were made on injured nerves and neighbouring healthy nerves. The faradic current alone was used, its intensity varying in each case. For healthy nerves the coarse wire coil completely disengaged or even held at a distance from the primary coil gave a sufficient current to excite the nerve-trunks (in these cases it is even better to use a rheostat).

On the other hand, when the nerve was injured, a current furnished by the fine wire coil more or less engaged had to be used.

These investigations present many difficulties, which will necessitate subsequent researches in order to settle the question of some doubtful localisations.

First of all, if the nomenclature be used which is

1 Pierre Marie, Henry Meige, and A. Gosset, " Les localisations motrices dans les nerfs periph6riques," Academie de Medecine, December 28, 1915,

120

INTRANERVOUS LOCALISATION

121

W

employed by ana- tomists to designate the different aspects of a nerve-trunk, it will be found that nerve -trunks are nor- mally subjected to one or more torsions on their longitudinal axis, so that a certain amount of confusion may arise according to the level at which the nerve is examined. The difficulty is far greater in the case of an injured nerve incarcerated in a callus, or strangled by fibro-sclerotic pro- liferations. Its liberation, always an essential matter, occasionally necessitating chiselling the nerve out of the neighbouring cicatricial tissue, does not facilitate the investigation.

FIG. 52. — Henry Meige's electric stimulator. A, insulating apparatus, consisting of two glass tubes connected by two ligatures, LL'. Into each of these tubes a bent ferro -nickel wire, F F', is passed. E, stimulating points : two glass tubes entering the tubes of the insulator ; into each tube a bent iron or platinum wire is introduced. The exciting end, whether pointed or blunt, projects 1 millimetre beyond the drawn-out end of the glass tube. The other extremity of the wire passes into the insulator and comes in contact with the ferro -nickel wire, which in turn penetrates into the small tube of the stimulating point and comes in contact With the nickel Wire ; by this device contact is doubly assured, as Well as the rigidity of the apparatus. C, conducting wires : copper wires on which are strung fragments of glass tubes and an arrangement of inter- penetrating wires similar to that described above (Bulletin de VAcademie de Medecine).

122 TREATMENT AND REPAIR OF NERVE LESIONS

The following precautions in technique are necessary according to these writers in order to succeed in investigations of this kind. The nerve-trunk must be disengaged for a sufficient length (6 to 8 centimetres), so that it can be liberated from the neighbouring tissues.

After this freeing two sterilised and dried glass rods are slipped under the nerve -trunk, taking care not to allow the nerve to rotate, which would cause the guiding marks to be lost.

Care being taken to avoid injuring the nerve and changing its supports, the sterilised electrodes must be applied to that part of the nerve-trunk situated between the two glass rods, and then successively to all the points of its periphery.

The investigator must occupy himself exclusively with the exact localisation of the points to which he applies electrical stimulation.

Another observer records the resulting motor reaction.

A third observer varies the intensity of the electric current.

Each of them states his findings, which are noted for each fresh application of the electrodes.

At first a current of very feeble intensity should be used, which is progressively increased until a muscular response is definitely obtained.

If no movement occurs, one should make sure that the current is flowing well by applying the elec- trodes to another muscle in the wound which is not paralysed.

One must always be on one's guard against the phenomena of diffusion which occur when the current is too strong, or when the nerve has not been thoroughly isolated. Contraction will then be seen in the neigh- bourhood of the operation wound either in certain muscles which are innervated by other nerves than the one electrically stimulated, or in muscles supplied by the stimulated nerve, but innervated by filaments situated above the point of application of the electrodes.

INTRANERVOUS LOCALISATION 123

All these difficulties which Pierre Marie and Henry Meige rightly emphasise show the complicated nature of an investigation of motor localisation, and how essential it is to make numerous examinations in order to be able to obtain absolutely certain results.

These authors investigated sixty-four cases, with the following results :—

MEDIAN NERVE

The motor bundlesof this nerve appear to be arranged as follows in its course in the arm.

The fibres intended for the pronator muscles are situated in the antero-external region of the trunk of the median nerve.

The fibres for the thenar muscles are situated in the posterior region of the nerve.

With regard to the exact localisation of fibres in- tended for the flexors of the carpus and flexors of the fingers these investigations are less positive, since these muscles can be made to contract both by electriz- ing the internal as well as the external border of the nerve. Is this due to torsion caused by traumatism or surgical intervention, or is it due to individual peculiarities ?

However that may be, it can be taken that as a general rule the nerve fibres of the flexor muscles of the fingers predominate in the postero-internal region of the nerve.

When electrical stimulation is applied to the two heads of the nerve before their junction to form the V of the median a contraction of the pronators is obtained when .the outer head of the nerve is stimulated, whereas stimulation of the inner head causes contrac- tion of the flexors of the fingers and carpus.

ULNAE NERVE

The investigation of the localisation of the fibres in this nerve is a singularly laborious task, owing to its

124 TREATMENT AND REPAIR OF NERVE LESIONS

smaller size and the difficulty in preserving its relations and identifying its various surfaces.

It is probable, however, that the nerve fibres for the flexor carpi ulnaris tend to group themselves towards the inner side, and the fibres for the flexors of the fourth and fifth fingers in the postero-external region.

The localisation of the fibres intended for the inter- ossei, hypothenar, and adductor pollicis muscles is less definite.

According to clinical observations, however, it would appear that they occupy the anterior and internal aspect of the nerve.

MTJSCULO-SPIRAL NERVE

Electrization of the different surfaces of this nerve has demonstrated several localisations which appear to be constant. Especially is this the case with nerve fibres intended for the radial muscles which are situated in the internal part of the musculo-spiral in its course down the arm.

All the extensor muscles of the fingers appear to be under the control of fibres which occupy the postero- internal part of the nerve.

Lastly, the movement of supination is obtained by application of the current to the external region of the musculo-spiral.

SCIATIC NERVE

In the case of the internal popliteal, fibres intended for the gastrocnemius and soleus are definitely localised in the posterior region of the nerve.

Those destined for the tibialis posticus are localised in the antero-internal region, and those intended for the flexors of the toes are situated in the postero-internal region.

In the case of the external popliteal, the fibres for the peronei occupy the posterior region of the nerve, those for the tibialis anticus occupy the antero-internal region, those for the extensors of the toes the antero-

INTRANERVOUS LOCALISATION 125

external region, and those which are destined for the extensor proprius hallucis occupy mainly the external region.

These results should be compared, on the one hand, with those of M. and Mme. Dejerine1 (confirmation by operation of the findings obtained by clinical examination), and, on the other hand, with the results obtained by the previous investigations of Stoffel.

With regard to the musculo-spiral nerve, M. and Mme. Dejerine and Mouzon adopt the following intra- truncular arrangement :—

Externally, the anterior cutaneous branch in front, then the branch to the supinator longus, and lastly the branches to the radial muscles further back.

Internally, the branches to the extensor carpi ulnaris and the muscles of the thumb in front, and then those to the extensor communis and that to the supinator brevis behind.

In the ulnar nerve the fibres are arranged thus in the region of the arm : — internally, superficially the cutaneous branches, those to the hypothenar emi- nence, then those to the interossei (those to the most external are placed furthest out), at the back the nerves for the adductor pollicis and flexor brevis pollicis. Externally, the nerves to the flexor carpi ulnaris and the flexor profundus.

In the external popliteal in the lower part of the popliteal region, the motor fibres are situated as follows : — internally, the tibialis anticus, next the extensor proprius hallucis, then the extensor communis; and externally, the peroneus longus and brevis.

In the internal popliteal the nerve bundles are situated as follows : — internally, the fibres of the ex- ternal saphenous, then the plantar nerves, and the nerve to the inner head of the gastrocnemius ; towards the external part, on the contrary, the nerves to the tibialis posticus, the flexor longus digit orum, the calcaneal branches, and the superficial branch of the external plantar.

1 Presse medicale, No. 13, March 2, 1916.

126 TREATMENT AND REPAIR OF NERVE LESIONS

We will now give a short account of the results obtained by Stoffel.

The musculo-spiral nerve above the bend of the elbow.

Anterior aspect. — Sensory branch.

External border. — Supinator longus.

Internal border. — Supinator brevis.

Posterior aspect. — Internally, the motor fasciculi of the common and special extensors, the abductor longus pollicis, and extensor carpi ulnaris. Externally, the extensors of the carpus.

The median nerve in the middle third of the arm.

Anterior aspect. — Sensory bundle and fibres of the thenar muscles. (These two bundles together form three-fifths of the nerve according to Stoffel.)

External border. — Pronator muscles and flexors of the carpus.

Internal border. — Flexor sublimis digitorum.

Posterio-internal aspect. — The fibres of the flexor pro- fundus, flexor longus pollicis, and pronator quadratus.

The ulnar nerve in the lower third of the arm.

The anterior aspect and the external border of the nerve are taken up by the large sensory bundle.

Internal border. — Flexor carpi ulnaris in front, and the flexor profundus digitorum behind.

The interossei, the adductor pollicis, and the hypo- thenar muscles are right at the back.

The external popliteal nerve.

In the trunk of the nerve itself, in the popliteal space, it will be found that the anterior tibial nerve is external; while the musculo-cutaneous, on the con- trary, is postero -internal (see the internal popliteal).

The common trunk of the external saphenous nerve and the cutaneous peroneal branch is situated in the posterior and internal region of the nerve.

The internal popliteal nerve.

Anterior aspect. — Internally, the fibres for the flexor longus digitorum ; externally, those for the tibialis posticus.

External border. — Fasciculus for the flexor longus hallucis.

INTRANERVOUS LOCALISATION 127

Posterior aspect. — Fasciculus for the gastrocnemius and soleus.

Examination of the trunk of the internal popliteal in the upper part of the thigh, where it forms the inner half of the great sciatic, shows that the nerve fibres of the posterior muscles of the thigh (biceps, semi- tendinosus, semimembranosus, adductor magnus) occupy the inner border of the internal popliteal.

From all these facts emerge some unquestionable conclusions which the surgeon should bear in mind as far as possible when performing a nerve suture.

In the case of the musculo-spiral nerve two fasciculi seem to be definitely established from a topographical point of view ; the fibres for the supinator longus occupy the external border of the musculo-spiral nerve in the middle third of the arm, and those for the extensor communis digitorum occupy the postero-internal region of the nerve.

In the case of the median nerve during its course in the arm, the fibres for the pronator muscles occupy the ex- ternal border of the nerve, and those for the flexor sublimis digitorum occupy the internal border of the nerve.

Although little definite appears to be known as yet of the localisation of the fasciculi for the thenar muscles, we may remind the reader of the circum- stances mentioned above to which Stoffel attached great importance.

According to this writer, the fibres for the thenar muscles are mixed up with the sensory fasciculus of the median nerve, and this aggregation of sensory and thenar fibres takes up three- fifths of the nerve.

What we have said in dealing with surgical treat- ment concerning the numerous failures in sutures of the median and their determining causes shows the advantage in localising the different motor bundles so as to bring them to meet, as far as the exigencies of the operation allow, and to prevent the motor sheaths being invaded by the much more numerous sensory fibres.

Motor localisation is more uncertain in the ulnar

128 TREATMENT AND REPAIR OF NERVE LESIONS

nerve than in any of the large mixed nerve-trunks of the limbs.

Our clinical examinations have, however, revealed that localisation on the internal border of the nerve of the fibres for the interossei and the sensory fibrils of the nerve, noted by M. and Mme. Dejerine and Mouzon, is very nearly correct, and that the localisa- tion on the external border of the ulnar nerve of the branches for the deep flexors of the last two fingers, discovered by the method of Pierre Marie, Henry Meige, and Gosset, is correct and is confirmed by clinical experience.

In the external popliteal only one motor localisation appears to be constant, viz. that of the fibres for the tibialis anticus on the antero-internal side of the nerve,

Finally, in the case of the internal popliteal nerve the fibres destined for the gastrocnemius and soleus occupy the posterior aspect of this nerve-trunk, both in the region of the thigh and in the popliteal space, and the fibres for the flexor longus digitorum the inner border of the nerve-trunk.

An exact localisation of the motor fibres of the great sciatic and of its internal popliteal branch would be of great value for the same reasons we have detailed in the case of the median, as these reasons, in our opinion, partly explain the cause of failure in certain sutures of this nerve.

Systematically conducted investigations, thoroughly carried out on a large number of nerves, at different levels in their course, by different observers by means of the method of Pierre Marie, Henry Meige, and Gosset, may lead to definite conclusions.

These investigations should be made not only on injured nerves which are still excitable during an operation undertaken to free them, as is indicated in certain painful conditions, but also on healthy nerves, which can easily be exposed in operation wounds in the course of any of the operations which have to be performed for nervous, vascular, osseous, or muscular lesions.

INTRANERVOUS LOCALISATION

129

We hasten to add that no harm has ever resulted from those investigations which we have seen carried out with all the requisite aseptic precautions and avoidance of any injury to the nerve-trunks, but they require a rapid and extremely careful operator of considerable experience.

CHAPTER X

PHYSIOPATHIC AFFECTIONS

REFLEX DISORDERS, CONGEALED HANDS, ETC.

IN the present chapter we propose to deal with a series of affections in which the main symptom is at one time a certain rigidity, at another time, on the contrary, a paresis, and sometimes, and more often, an association of rigidity and paresis, which is " neither true paralysis nor true contracture, but which results in almost complete immobilisation " (Henry Meige). These symptoms differ both from those seen in definite nerve lesions and in merely neuropathic (pithiatic) disorders.

The circumstances under which these conditions make their appearance, the thermal, trophic, and vascular symptoms which accompany them, and the stubbornness with which they resist all treatment, necessitate their being placed in a category of their own for the present. Their pathogeny and the problems raised as to their nature and the best method to adopt in dealing with them, both from a purely medical and military aspect, have given rise to large numbers of studies, of which we will endeavour to give a short account.

A. SYMPTOMATOLOGY

These affections can be divided into three different categories, although this division is very schematic :—

1. Paralyses with contract ures — the most typical cases.

130

PHYSIOPATHIC AFFECTIONS 131

2. Contractures.

3. Flaccid paralysis with hy pot onus.

1. Paralysis with Contractures

Synonyms : — Congealed hand of Henry Meige, com- plete paralysis of the hand of Pitres, acromyotonus of Sicard, reflex paralysis of Babinski and Froment, para- tonic paresis of Pierre Marie and Foix, etc.

This type of affection is chiefly seen in the upper limb,Jrarely in the lower limb. It was in the year 1915 that the neurological centres first noted the appearance of cer- tain stubbornly maintained attitudes of the limbs, and especially of the hand. They were accompanied by nearly complete functional impo- tence, which resisted all the physiotherapeutic methods which ordinarily improve rigidities or Contractures re- sulting from osteo-articular or muscular lesions. Psycho-

therapy proved equally in- FlG- 53.—" Congealed hand."

effective.

At the Neurological Society of Paris, Henry Meige, Mile. G. Levy, and the present writer x drew attention to those disabilities following a wound of the forearm or of the hand, a wound which often left the nerves and bones intact, and which at times amounted merely to a simple contusion. H. Meige lays stress on the fact that the electrical reactions are but slightly affected, arterial pressure is equal to that of the sound side, and that frequently there is no impair- ment of the reflexes or sensibility, but that on the other

1 Henry Meige, Mme. Ath.-Benisty, and Mile. Levy, " Impotence de tous les mouvements de la main et des doigts, avec integrite des reactions electriques (main figee)," Societe de Neurologie, November 4, 1915. Revue Neurologique, November-December 1915, pp. 1273-1276.

132 TREATMENT AND REPAIR OF NERVE LESIONS

hand vasomotor and thermal disturbances are nearly always present. The various joints show a certain degree of rigidity, and after passive movement of the hand it returns to its congealed attitude, resembling the " accoucheur's hand " in its slightly dropped wrist, hollow palm, extended fingers, and in the thumb and little finger tending to approach the middle line below the three other fingers, which are themselves tightly applied to each other.

Babinski and Froment, who have devoted special attention to the study of this condition, have given a complete description of all the objective symptoms which differentiate it from known organic affections and from contractures or paralyses of an hysterical or pithiatic nature. The signs are as follows : 1—

(a) The presence of very marked vasomotor dis- turbances, generally with segmentary distribution, which does not correspond to a definite nerve area and predominates at the extremities.

The " congealed hand " or the paretic foot have generally a cyan otic or salmon-pink appearance. The

1 J. Babinski and J. Froment, " Les modifications des reflexes ten- dineux pendant le sommeil chloroformique et leur valeur en semiologie," Academic de Medecine, October 19, 1915.

J. Babinski and J. Froment, " Sur une forme de contracture organique d'origine peripherique et sans exageration des reflexes," Societe de Neurologic, November 4, 1915.

J. Babinski and J. Froment, " Contribution a 1'etude des troubles nerveux d'origine reflexe. Examen pendant 1'anesthesie chloroformique," Societe de Neurologic, November 4, 1915.

J. Babinski and J. Froment, " Paralysie et hypotonie reflexes avec surexcitabilite mecanique, voltaique et faradique des muscles," Academic de Medecine, January 11, 1916.

J. Babinski and J. Froment, " Contractures et paralysies traumatiques d'ordre reflexe," Presse medicale, February 24, 1916.

J. Babinski and J. Froment," Des troubles vasomoteurs et thermiques d'ordre reflexe," Societe de Neuroloique, March 2, 1916.

J. Babinski, Les caracteres des troubles moteurs dits " fonctionnels " et la conduite a tenir a leur eyard.

Rapport a la Societe de Neurologic, meeting of April 6-7, 1916. Revue Neurologique, April-May 1916.

J. Babinski, J. Froment, and Heitz, " Des troubles vasomoteurs et thermiques dans les paralysies et contractures d'ordre reflexe," Annales de Medecine, September-October 1916.

Treatment and Repair of Nerve Lesions.}

[To face p. 132.

PLATE III.

Two varieties of " congealed hand " compared with the sound hand.

PHYSIOPATHIC AFFECTIONS 133

slightest pressure on the skin causes a blanched area which does not disappear for some time.

(6) Local hypothermia is permanent and often pro- nounced. Measurements with a thermo-electric appa- ratus show that there may be differences of 4° to 5°, or even 8° C., between the affected and healthy side.

(c) The systolic pressure is equal on both sides, but the amplitude of the oscillations is always slighter on the affected side. After chilling the limbs, this differ- ence may become considerable. It grows less marked, disappears, or becomes inverted under the action of heat.

On the affected side Babinski found a diminution of haemoglobin and the red corpuscles on examination of the blood by the colorimetric method. By the spectro- scopic method the haemoglobin appeared less reduced on that side.

(d) Atrophy of all the tissues of the hand and ringers, with occasional increase in size of the joints, resembling those of patients affected with chronic rheumatism.

(e) Moisture and occasionally maceration of the skin. (/) Decalcificatiori of the skeleton of the affected

limb, clearly recognisable in the skiagram.

(g) Hypotonus, especially marked in the purely paralytic forms, but seen also in certain cases showing contractures. •

(h) Mechanical hyperexcitability of the muscles of the affected limb, especially noticeable in the paretic type, but also seen in the type accompanied by hypertonus.

This hyperexcitability of the muscles is most obvious in the small muscles of the hand or foot (thenar, hypothenar, interossei, extensor brevis digi- torum, and muscles of the sole of the foot). Even slight percussion of the muscles on the affected side elicits a slow movement of great amplitude.

(i) Modifications in electrical contractility. These are purely quantitative and are not accompanied by any signs of R. D.} and consist simply in faradic and

134 TREATMENT AND REPAIR OF NERVE LESIONS

voltaic hyper excitability, premature fusion of the con- tractions, and more rarely slight subexcitability.

This hyperexcitability to mechanical and electrical stimuli may also be seen in the nerve-trunks. But both in the nerves and in the muscles it varies with the temperature. If both limbs are artificially re- frigerated it becomes accentuated on the affected side, while if, on the contrary, the affected limb is heated, muscular superexcitability becomes less.

(j) The tendon reflexes are but slightly modified.

(k] If the patient is put under chloroform narcosis, one finds that the contracture often does not disappear until deep anaesthesia has been reached, and that it returns at the same time as the tendon reflexes, some- times before the reappearance of the conjunctival reflex. In addition during chloroform narcosis the reflexes of the affected limb become exaggerated, and for a very long time clonus of the injured side can be noticed when the reflexes of the healthy limbs are already abolished.

Pierre Marie and Foix 1 added several remarks to this symptomatological complex. According to them the " congealed hand " is kept flexed on the forearm by a contraction of the palmar muscles, which can be seen standing out under the skin.

The condition considered as a whole constitutes a paretic state, with weakness of all movements and apparent inability to execute some of them.

The movements which are most impaired according to Pierre Marie and Foix are those of abduction and extension of the thumb. During slight movements of the hand and in a state of repose one can recognise very clearly the hypertonus of some of the muscles (flexor carpi radialis, palmaris longus, interossei and adductor pollicis), and the hypotonus of the others (muscles of the lower area of the musculo-spiral). When the radial muscles contract there occurs at the

1 Pierre Marie and Foix, " Sur une forme specials de ' par6sie para- tonique des muscles moteurs de la main,' " Societe Medicale des Hdpitaux, February 4, 1916.

PHYSIOPATHIC AFFECTIONS 135

same time a contraction of the palmar muscles, which are in a state of hypertonus, and this contraction opposes the efficacy of the action of the radial muscles.

Muscular hyperexcitability to mechanical stimuli is said to predominate in the case of muscles supplied by the median and ulnar (thenar muscles,* flexors, interossei and hypothenar muscles).

Unipolar faradic stimulation of the back of the forearm causes flexion of the hand instead of the normal extension. This fact would indicate a weakness of the extensor muscles of the hand, as has been pointed out by Babinski.

The trophic disturbance finds expression in the diminution of size and flabbiness of the hand, the thinning of the skin, which becomes finer and often of a pink tinge, and in the occasional deformity and striation of the nails.

2. Contractures

There is not always a definite line of demarcation between the conditions just described and pure con- tractures ; generally a certain degree of paresis of some ' muscles is associated with contracture of others.

Contractures of the upper limb generally predominate in the hand and in the fingers ; the biceps is fairly frequently affected.

According to Andre Leri and Edouard Roger the most frequent varieties are extension contracture of the hand and fingers (fingers extended or hyper- extended either all together or in groups of two or three, and separated from one another). A more frequent variety is the classical attitude known as " accoucheur's hand," with the fingers extended and brought close together and pressed against each other.1

1 Andre Leri and Edouard Roger, " Sur quelques varietes de con- tractures post-traumatiques et surleur traitement," Societe Medicale des Hopitaux, October 22, 1915.

136 TREATMENT AND REPAIR OF NERVE LESIONS

According to Sicard j1 contractures of the hand and fingers adopt certain attitudes which can be schema- tically classified under the following five headings: —

(a) "Fist" appearance. All the fingers are power- fully bent into the palm of the hand. This is due, according to Sicard, to contracture of the flexors of the forearm (" median nerve hand").

(b) " Holy water basin hand." The palm of the hand is hollow, and is surrounded by the half -bent fingers, due to contracture of the interossei and the adductor pollicis (" ulnar nerve hand ").

(c) " Spindle hand," due to contracture of the extensors of the hand, fingers, and interossei ("musculo- spiral and ulnar nerve hand").

(d) " Swan-neck hand," or " median and ulnar nerve hand," flexed at an acute angle at the wrist with the fingers extended.

(e) " Sign-post hand " (flexion contracture of the last two fingers, and extension of the index).

All these contractures can easily be distinguished from fibro -tendinous retractions by applying Esmarch's rubber band to the root of the limb as far as possible away from the group of muscles which has undergone contracture (Sicard). Circulation in the limb is thus suppressed, and after several minutes the contracture vanishes. In retraction, on the other hand, the position of the limb does not alter. The efficacy of this method can be increased, according to Sicard, by injecting locally in the neighbourhood of the muscular tendons involved a few cubic centimetres of a 1 per cent, solution of stovaine and cocaine. As soon as the elastic band is relaxed, contracture of the parts reappears as pronounced as ever.

Sicard adds the following features which char- acterise the contractures with or without paresis, which he has denominated acromyotonus :—

1 J. A. Sicard and Imbert, " La bande de caoutchouc et 1'alcoolisation locale des nerfs dans le traitement des contractures par blessures de guerre," Societe Medicate des Hopitaux, April 16, 1915.

J. A. Sicard, " L'alcoolisation tronculaire au cours des acromyotonies rebelles du membre superieur," Paris Medical, June 3, 1916, No. 23.

Treatment and Repair of Nerve Lesions.]

A

[To face p. 136.

PLATE IV.

" Congealed hand." A, profile view. B, palmar view,

PHYSIOPATHIC AFFECTIONS 137

"Their appearance after wounds of connective tissue, muscle, or bone, quite independent as a rule of any direct injury to a nerve-trunk.

" Their extension to neighbouring muscular areas quite independent of the sphere of injury.

" Their frequent localisation in the extremities, and especially in the hand and fingers.

" Their painless character so long as the hyper- tonic position is not interfered with, and the parox- ysms of pain when any correction is attempted.

" Their aggravation by the local application of massage or electricity or by direct mobilisation.

" Their disappearance under general anaesthesia and a rubber band ; their immediate reappearance on the cessation of general anaesthesia or local ischaemia.

" Their partial and transitory improvement as the result of very gentle manipulations.

' The characteristic, persistent, and penetrating odour of maceration which is occasionally given off by the hand and fingers which have undergone con- tracture.

" Their resistance to ordinary treatment and even to prolonged extension in plaster apparatus " (Sicard).1

In some of these cases, according to Sicard, a marked exaggeration of the bone reflexes may also be found, as is shown, for example, by generalised flexion of the fingers and hand on percussion of the meta- carpal bones, etc.

Other types of contractures of the upper limb have been described by Babinski and Froment, e.g. the upper limb extended and tightly pressed against the body ; the upper limb folded on itself and describing a Z, with the forearm bent and the wrist dropped, etc.

Contractures of the Lower Limb. — These can affect the extremity of the limb just as in the case of the upper limb, but they frequently also involve the knee and the hip.

In the foot, the following attitudes may be seen : talipes varus and talipes equino-varus and extension

1 Paris Medical, June 3, 1916, pp. 510-511.

138 TREATMENT AND REPAIR OF NERVE LESIONS

contracture of the last four toes with flaccid paralysis of the big toe (Babinski and Froment).

The contractures of the leg may be either in flexion or extension.

In the last case they are often associated with talipes varus.

In the hip contractures of several of the muscles of the pelvic girdle may be observed, often involving external rotation of the lower limb. Frequently these contractures of the hip muscles are accompanied by paresis and sensory disturbances in the foot, and by the abolition of the plantar cutaneous reflex (Babinski and Froment). Artificial heating of the foot may cause this reflex to reappear.

Symptoms of paresis, as we have seen, are very often associated with the usual signs of contractures. Their objective characteristics are exactly the same as those found in affections of the first category, viz. vasomotor troubles, hypothermia; atrophy of the entire limb, decalcification of the skeleton, and hyper- excitability of the muscles to mechanical stimuli and faradic and galvanic currents.

It was among wounded men affected by contractures of the lower limbs that Babinski and Froment con- ducted their very interesting investigations on the modification of the tendon and osteoperiosteal re- flexes under the influence of chloroform narcosis.

While the tendon reflexes (knee-jerks, ankle-jerks) are in some cases definitely exaggerated when com- pared with the healthy side, in other cases they are hardly modified at all, but under general anaesthesia the difference between the healthy and the affected side is marked and indicates a hyperexcitability of the spinal centres (Babinski and Froment).

It is often possible in these cases to find patellar clonus on the affected side even when all the other reflexes are abolished. In like manner the knee- and ankle-jerks reappear first during the period of recovery from the anaesthetic, and are far more marked than those of the sound side.

PHYSIOPATHIC AFFECTIONS 139

The determining causes of contractures of the lower limb are also relatively slight, such as seton- like wounds of the soft parts of the leg or thigh, superficial wounds of the foot, and simple contusion of the hip or knee.

3. Flaccid Paralyses with Hypotonus

They are less frequently seen in a pure condition than the varieties just described, and are often associated with more or less marked contractures.

They are frequently situated in the upper limb, and affect by preference the hand which shows wrist- drop, together with a much more marked hypotonus of the extensors of the carpus and the hand than is seen in paralysis following a complete division of the musculo-spiral nerve.

Contracture of the biceps may coincide with the wrist -drop.

In all these affections the phenomena are con- stantly found to which Babinski and Froment have drawn attention, especially hypothermia and the hyperexcitability of muscles to mechanical stimuli.

B. PATHOGENY

The pathogeny of these affections has been very much discussed.

Babinski and Froment,1 Andre Leri and Edouard Roger,2 and Guillain and A. Barre 3 were the first to draw attention to the necessity of distinguishing these disorders from manifestations of pithiatism or simulation.

1 Babinski and Froment, " Les modifications des reflexes tendineux pendant le sommeil chloroformique et leur valeur en semiologie," Aca- demic de Medecine, October 19, 1915.

2 Andre Leri and Edouard Roger, " Sur quelques varietes de con- tractures post-traumatiques et sur leur traitement," Societe Medicale des Hopitaux, October 22, 1915.

3 Georges Guillain and A. Barre, " Les contractures dans la patho- logic nerveuse de guerre," Bulletin de la Societe Medicale des Hopitaux, January 21, 1916.

140 TREATMENT AND REPAIR OF NERVE LESIONS

The interpretation of the pathogeny differs, how- ever, with each writer.

Babinski and Froment regard these lesions as being of a reflex character analogous to the disorders noted by John Hunter in 1839, and studied under the name of reflex amyotrophies by Vulpian and Charcot. The last observer interpreted them as the manifestation of a condition either of stupor or of exaltation of the cells of the corresponding spinal centres.

Babinski and Froment consider the hypothesis of Charcot as possible, but incline to the idea that owing to the importance of the vasomotor and thermal disorders which influence the condition of the muscles, it might be possible to assign the sympathetic system an important share in the genesis of these conditions.

In point of fact, the mechanical hyperexcitability of muscles and nerves seems to be closely related to hypothermia.

Refrigeration increases muscular excitability on the affected side, especially in the small muscles of the extremities.

After immersion in hot water, on the other hand, muscular contraction becomes rapid and less intense.

Premature fusion of the contractions disappears also.

Under the influence of heat, the appearance of tremors and an appreciable exaggeration of the tendon reflexes may occasionally be observed.

Babinski and Froment suppose that these pheno- mena are due to a vaso-constrictor spasm produced by a reflex irritation originating in a peripheral lesion.

On physiological grounds, these writers hold that " side by side with the condition of anaemia and hypo- thermia a third factor inevitably comes into play, when the action of these two is prolonged, viz. the accumulation of physiological poisons, which deserves careful attention. The muscle then behaves as in the first stages of vera trine poisoning." J

1 J. Babinski and Froment, " Des troubles vasomoteurs et thermiques d'ordre reflexe," Societe de Neurologic, March 2, 1916. Revue Neuro- logique, March 1916, p. 410.

PHYSIOPATHIC AFFECTIONS 141

Babinski and Froment remark that the disorders in question are chiefly manifested by physiological anomalies, and have therefore suggested that they should be known under the name of physiopathic disorders, which is a non-committal term as regards their pathogeny, and enables them to be distin- guished from affections of which the organic origin is known.

Leri and Edouard Roger, while guarded as to the origin of some of these contractures, which they consider as purely functional and hysterical, draw attention to a number of genuine cases which give rise to these contractures.

The first category of muscular contractures is due to an irritation of the muscle by metal dust in the fleshy part of the muscle, as is shown by radiography. These writers are inclined to think that other foreign bodies may sometimes be incriminated, which are neither metals nor bones, and are invisible on the screen, but are nevertheless able to determine powerful con- tractures of the biceps or the flexor muscles of the leg, less by irritation of the motor filaments than by direct irritation of the muscle fibres themselves. On other occasions they regard this irritation of the muscle fibres as caused by a very adherent cicatrix, especially when suppuration has been prolonged or when the path of the projectile has been in the neighbourhood of a tendon.

In a second and rarer group, according to these authors, the irritation does not affect the muscle but the nerve itself. These contractures may be con- fined to a single muscle or a single group of muscles, which is logical, seeing the specialisation of nerve fibres in the interior of the nerve-trunks.

Finally, a third variety of organic contractures can occur in the muscles which are antagonistic to the paralysed muscles. Thus there are musculo -spiral paralyses, in which the wrist, instead of dropping, rises and becomes rigid owing to violent contracture of the flexors of the fingers and carpus.

142 TREATMENT AND REPAIR OF NERVE LESIONS

According to Georges Guillain and A. Barre, we must distinguish :—

1. Contractures due to compression, irritation of the nerve, a foreign body (bony or metallic), by cicatricial fibrous tissue, to incomplete wounds of a nerve with or without painful neuroma affecting by reflex action the adjacent spinal centres, the reaction of the nerve in this case being often manifested by contracture and not by paralysis.

2. Contractures due to irritation of the muscle by a foreign body (metal dust, callus, etc.).

3. Contractures caused by ischsemic constriction1 due to an appliance put on too tightly after injury. Besides this pure ischaemia we must also take into con- sideration compression of nerve-trunks and muscles.

In a subsequent study Guillain and Barre 2 record a certain number of Contractures with paresis due to an irradiating neuritis.

In support of this pathogeny they refer to the exaggeration and diffusibility of the reflexes, and the existence of pains arising both spontaneously and on pressure of the nerve-trunks situated above and below the wound.

The explanation of these objective modifications is to be found, according to Guillain, " in the role played by the nerves in the conduction of microbes and toxines and that of ascending neuritis, the latter being con- sidered rather from the physiological than from the anatomical standpoint." 3

The role of the sympathetic and the factors of im- mobilisation and constriction of the limb must also be taken into consideration.

* The many poisons — microbial and cellular — causing hsemolysis and cytolysis may cause the dis-

1 G. Guillain et A. Barre, " Les Contractures ischemiques," Reunion Medicate de la VI6 Armie, January 12, 1916.

2 Georges Guillain and A. Barre, " La nevrite irradiante," Societe, Medicale des Hopitaux, April 7, 1916.

3 G. Guillain, " Les nevrites irradiantes et les contractures et paralysies traumatiques d'ordre reflexe," Societe Medicale des Hopitaux, May 26, 1916.

PHYSIOPATHIC AFFECTIONS 143

tant secondary affections, of which we see the clinical manifestations, either by the lymphatic channels of the nerves or by the nerve-trunks themselves " (Guillain).

Some authors are inclined to think that all the unquestionably organic symptoms of these affections may be possibly due in the first place to prolonged im- mobilisation of the limb. This immobilisation is neces- sary at first for the treatment of the wound, and is then due to the employment of various appliances (splints, plaster of Paris, etc.) used for correcting the vicious position of the limb, and is continued subsequently by the patient consciously or uncon- sciously.

This hypothesis gave rise to a long and important discussion at the meeting of the Neurological Society of Paris on 6th and 7th April 1916.1

According to Henri Claude, these cases occur, as a rule, among wounded men who have been sent to units where their wound received the chief attention without any movement of their joints, from fear of causing them pain. ' They were put in splints for weeks or months ; when the dressings were removed, ill-advised suggestions made them think that the use of their limb was impaired, and the medical officer was afraid of causing them suffering by rectifying the vicious attitude of their limb, which became more and more exaggerated in consequence. . . .

" If the patient is left to himself and wrongly advised, or if he present that apathetic and indifferent frame of mind seen in so many patients for whom hospital life is almost a social condition, the abnormal attitude which primarily indicated a reaction of defence or a painful reflex is rendered permanent by a psychical process of an hysterical nature, or simply by habit. ...

" Whatever the mechanism of the fixation of the vicious attitude may be, it gets more and more exag- gerated as time goes on, and becomes less and less

1 Revue Neurologique, April-May 1916, pp. 524-572.

144 TREATMENT AND REPAIR OF NERVE LESIONS

reducible, owing to the articular and muscular lesions which are often present from the beginning of this affection, but become progressively aggravated in all cases " (Henri Claude).1

Jean Camus thinks that in a fairly large number of these affections " prolonged immobilisation of the limbs is the only explanation acceptable of these late symptoms.

" Immobilisation is due to many causes, such as too long application of a plaster apparatus, or large and irregular wounds with fistulous openings which have taken months to cicatrise ; in other cases im- mobilisation has either been the wish of the patient from the first, or, what is more frequent, has been adopted after immobilisation originally due to an apparatus or a dressing.

"In these cases a reflex does not give rise to the symptoms, but the cause resides in the wish of the patient to become immobilised or to persist in an im- mobilised condition which he did not create himself in the first place." 2

Andre Thomas is inclined to think that the thermal and circulatory disorders are the result of prolonged immobilisation and inertia.

" The wasting of the limb and decalcification of the bones may, in a very large proportion of cases, be the result of immobilisation or inertia, but it is not im- probable that in some cases the muscular atrophy may be due to the same cause as the so-called reflex muscular atrophies." 3

Henry Meige and A. Thomas have also emphasised the fact that reflex contractures and paralyses are very rare in severely wounded cases whose disabilities are incurable.

According to Tinel, the organic factor in these affections is nearly always a slight nervous lesion of the nature of neuritis, but this idea of neuritis does

1 Revue Neurologique, April-May 1916, pp. 532-536.

2 Jean Camus, Revue Neurologique, April-May 1916, pp. 540-542.

3 Revue Neurologique, April-May 1916, pp. 542-546.

PHYSIOPATHIC AFFECTIONS 145

not seem sufficient to him to explain the intensity of these contractures, their persistence, and their pro- gressive aggravation.

" An important functional factor must certainly be adduced in addition, undoubtedly more important as a rule than the actual neuritis, viz. muscular inaction, prolonged immobilisation, and moral inertia, which almost all these patients display.

" There is therefore a problem to solve : the symptoms found have exactly the appearance of organic troubles ; the circumstances of their appear- ance, on the other hand, have something perplexing, illogical, and paradoxical, which makes them more allied to functional and hysterical disorders " (Tinel).

Babinski and Froment x protest against the import- ance attributed to immobilisation. They think, on the contrary, that these disorders are likely to develop without there having been any immobilisation, properly speaking, at any time.2

For our part, we think that a critical examina- tion should be made of the facts which have been reported and variously interpreted.

First of all, one point should be noted ; that is, that war wounds can determine contractures and flaccid pareses with hypotonus.

Thus we had the opportunity of seeing a very marked and irreducible contracture of the biceps in the course of complete section of the musculo-spiral nerve in the middle third of the arm, without fracture of the humerus. This contracture came on immediately after the wound ; besides which the body of the muscle itself appeared of harder consistence than that of the opposite side, and there existed at this level an obvious hyperexcitability to mechanical and electrical stimu- lation when compared with the healthy side.

On many occasions we have been able to observe

1 Revue Neurologique, April-May 1916, pp. 546-549.

2 Babinski and Froment, " Troubles nerveux d'ordre reflexe ou syndrome d'immobilisation," Societe de Neurologic, May 4, 1916. Revue Neurologique, July 1916, p. 914.

10

146 TREATMENT AND REPAIR OF NERVE LESIONS

these contractures of the biceps, and eventually a certain degree of tendinous retraction supervened.

What is the determining cause of the contracture in these cases ?

Is it a lesion of the muscle itself due to metallic dust, a fibrous cicatrix or other foreign bodies invisible on radiography, as Leri affirms, or is there an irritation of certain motor or sensory nerve fibres constituting that ascending contracture of which Ducoste speaks,1 or should it be attributed to a lesion of the periosteum or of the articular fibrils of the neighbouring joint ?

We are unable to say. We will confine ourselves to reporting other similar cases.

A patient suffering from a wound of the lower jaw, with injury of the cervico-facial branch of the facial nerve, showed a very obvious contracture of the clavi- cular head of the sterno-cleido-mastoid. This con- tracture did not inconvenience him in any way, he did not complain about it, and it was only revealed by medical examination.

We had the opportunity of seeing other partial and transitory contractures in the course of lesions of the brachial plexus, accompanied by irritation of the spinal cord,2 contractures of the trapezius on the healthy side, or of the pectoralis major on the paralysed side, and of certain nuchal muscles. This last variety was characterised by pain and aching in the contractured muscle, which was hard and hyperexcitable on per- cussion with the hammer or by electric currents.

We also saw an example of flaccid paresis with marked hypotonus of the whole right upper limb.

The wound (a grazing of the muscles of the anterior aspect of the forearm) had not involved any import- ant nerve. The patient, however, showed a com- plete atrophy of the whole limb and the muscles of the shoulder girdle, with very marked flaccidity and

1 Maurice Ducoste, " Les contractures dans les lesions nerveuses peripheriques," Societe de Biologie, July 24, 1915.

2 Mme. Athanassio-Benisty, Formes cliniques des lesions des nerfs. Masson, 1916, pp. 158-159.

PHYSIOPATHIC AFFECTIONS 147

incomplete and feeble movements. Movements of the flexors were limited by a kind of stiffness of the fingers. There was slight hypo-excitability to electrical stimu- lation, but the strongest sign in favour of an organic lesion was the complete abolition of all the tendon and periosteal reflexes of the upper limb, including the scapular reflex.

The patient had been buried by the explosion of a mine, and the act of rescuing him had doubtless been the cause of pulling on the cervical roots, possibly giving rise to an ascending lesion, which had reached as far as the cells of the anterior group of the cord.

We may thus find in the traumatic neuropathology of war, contractures as well as flaccid paralyses even without direct injury to the nerve-trunk. A reflex mechanism can certainly be invoked to explain these phenomena. We confine ourselves for the present to reporting these facts, without suggesting an interpre- tation.

The affections described above, in which the symptomatology appears well established, but in which the pathogeny is still under discussion, can, in our opinion, be classified in four groups according to their determining causes : —

1. Painful neuritis.

2. Direct involvement of the muscles.

3. Involvement of the bones, fibrous tissue, and tendons.

These three groups must be carefully distinguished from a fourth group, which comprises another form of contractures and hypotonic conditions, viz. those in which the initial cause is only a slight wound (seton- like wound, contusion) and in which the subsequent symptoms mainly consist of a prolonged immobilisa- tion.

1st Group. — Painful neuritis. — We have here to deal with slight wounds of nerves, chiefly involving the median or ulnar in the forearm and wrist (more rarely in the arm), and constituting a painful form of neuritis, as is proved by a frequent history of definite causalgia,

148 TREATMENT AND REPAIR OF NERVE LESIONS

presence of pain on palpation of the nerve-trunk, articular rigidity, vasomotor and secretory disorders, generalised atrophy, and finally a more or less appreci- able degree of de calcification of the skeleton.

2nd Group. — Various muscular lesions — Constriction —Lesions of sensory nerve fibres, — This group com- prises contractures due to wounds of muscles or to constriction (plaster appliances). Possibly they may occasionally be due to an irritation of the peripheral sensory fibres determining, by a reflex mechanism in the spinal cord, an increased nervous influx to certain muscles according to a radicular or peripheral distri- bution.

In any case, the possibility of direct irritation of the muscular fibres must not be lost sight of ; thus we have seen a case of persistent contracture of the triceps due to the inclusion of a piece of a coat in a wound of the elbow. When this foreign body was removed the contracture disappeared.

3rd Group. — Lesions of the bones, muscles, and tendons. — In this group we have to deal with injuries to the muscles or tendons, involving the periosteum, or even fracture of the neighbouring bones, which have sup- purated for long periods, and necessitated the use of plaster apparatus, or at least prolonged immobilisation in a sling.

We shall see in a later chapter how prolonged sup- puration affects the joints of the extremities of a limb, especially the hand. These joints become inflamed, and the inflammation results in very obstinate rigidity of the affected joint.

Suppuration in bones also gives rise occasionally to considerable decalcification of the hand and fingers, a thinning of all the integuments, and a general wasting of the muscles similar to that seen when the intr a -nervous sympathetic fibres are subjected to irritation.

4th Group. — Congealed hand. — Finally, a fourth group comprises contractures of the nature of club- foot and that form of paralysis combined with hyper-

PHYSIOPATHIC AFFECTIONS 149

tonus of the hand, which is best expressed by the name of congealed hand.

In the first place, there may be only a simple con- tusion or trifling wound, or, on the other hand, seton- like wounds of the soft parts of the forearm, leg, or thigh, and more or less transfixion of the extremities, but with only slight injuries to bones or tendons.

It is principally in these cases that an important pathogenic role can be attributed to immobilisation.

The limb has first been immobilised on account of pain and suppuration. The resulting stiffness has not been treated by massage and other physiotherapeutic methods, and the part has been confined in plaster or in splints.

These means of restraint have increased the rigidity, and their pressure, which at times has been very marked, has caused atrophy, and then a paresis of certain muscles, especially of those supplied by the musculo- spiral, the tonus of which muscles is inferior to that of the flexors. A certain hypertonus, and contracture of some other normally very powerful muscles, such as the flexors of the carpus and the fingers, the adductor pollicis, the interossei, etc., then appear, and give rise to vicious positions.

After giving up these appliances, the patient con- tinues to immobilise the affected limb consciously or unconsciously.

The articular and muscular disorders may also be- come aggravated by the immobilisation and chilling which result from it, and by all the modifications which these different factors bring about in the structure of the muscles.

It is therefore not unlikely that immobilisation enters to a certain extent into the etiology of " con- gealed hand." This hypothesis does not in any way exclude that of the reflex mechanism suggested by Babinski and Froment.

In addition, it may also be advanced, as has already been done by the present writer in conjunction with Henry Meige, and as Babinski and Froment incline to

150 TREATMENT AND REPAIR OF NERVE LESIONS

believe, that in these reflex phenomena not only are the spinal nerve paths called into play, but the sympa- thetic as well. The thermal, vasomotor, and secretory disorders, which are rarely absent in these cases, support this view.

Whatever the pa.thogeny of this condition may be, the reality of these phenomena is incontestable, and we actually find ourselves in the presence of a group of clinical facts which it is essential to differentiate.

One more fact deserves to be mentioned, on which Henry Meige has laid special stress.

This is the peculiar mentality of the majority of these patients, especially those who have " congealed hands."

" A peculiar state of mind, consisting in torpor and inertia, combined with the constant obsession of their infirmity ; they keep their eyes fixed upon it, and protect it with the other hand ; they gloat upon it, so to speak, but yet they are in no pain. This solicitude, associated with their passive inertia, and the absence of all organic symptoms, and often even of any apparent wound, has not infrequently made one think that such cases are exaggerators or simulators " (Meige).1

" Solitary, anxious, and careworn, making no un- necessary gesture, and perpetually on the lookout, they show a perfect motor negativism for the affected limb.2

" It seems sometimes as if one were in the presence of one of those localised motor amnesias which give rise to a condition of aboulia for certain movements, and which are undoubtedly of psychopathic origin."

It is important to take into account this mental factor, which, even if it does not of itself constitute the whole affection, undoubtedly aggravates the motor disturbance.

In the lower limb this immobilisation and the re- tention of (vicious attitudes often result in contrac-

1 JRevue Neurologique, April-May 1916, pp. 550-551.

2 Ibid., November-December 1915, p. 1276.

PHYSIOPATHIC AFFECTIONS 151

tures and paresis, shown by various disturbances of gait.

Limping following commotion, contusions of the hip or knee, or superficial wounds is often justified at first by more or less severe articular or peri-articular lesions, but is persisted in as a bad habit.

Henry Meige, who has made a study of these forms of limping, sums up their clinical history in the follow- ing formula : " Habit creates the aptitude for the attitude." x

The majority of these contractures, which are limited to one group of muscles of the thigh, are not irreducible, as can be found by using the diplocinetic method advocated by H. Meige :

" Vigorous traction or pressure is simultaneously exerted on the different segments of both lower limbs whilst rapidly giving successive commands, such as ' straighten,' * bend,' ' pull,' ' push,' ' separate,' ' bring together,' etc., so quickly that the patient has not time to prepare his muscular answer, but obeys mechani- cally."

This method, well followed out, enables one to judge up to what point the rigidity or disappearance of voluntary motility is real or assumed.

C. TREATMENT

All authors agree that these affections are obstinate, and that treatment such as is usually prescribed generally ends in failure.

Psychotherapeutic measures, counter-suggestion in particular, do not affect the progress of this condi- tion, and, according to Babinski and Froment, this is the principal characteristic which distinguishes these disorders from pithiatic manifestations.

The physiotherapeutic measures which can be used are but few. Recourse must be had to very gentle

1 Henry Meige, " De certaines boiteries observees chez les ' blesses nerveux,' " Societe de Neurologie, October 7, 1915. Revue Neurologique, November-December 1915, pp. 939-947.

152 TREATMENT AND REPAIR OF NERVE LESIONS

manipulations in order not to cause pain and increase stiffness and contracture. The same applies to elec- trization, and especially to intense faradic currents.

Immobilisation in plaster is always bad, and only serves to increase the vicious attitude.

Diathermy sometimes gives good results according to Babinski.

A large number of writers nevertheless think that pyschotherapeutic measures are essential. Thus Grasset proposes semi-isolation of these patients in a special hospital, forbidding them to go into the town except on a Sunday with the special permis- sion of the medical offcer.

Professional and military re-education should not be neglected. In short, all that we have said pre- viously about the obscure pathogeny of these affections indicates that treatment must vary with each case.

In lesions due to injuries of the nerves, muscles, or bones, gentle but persevering mobilisation will prevent irreducible ankylosis.

In the case of " congealed hands," or contractures following slight wounds or contusions, early and energetic mobilisation, in combination with firm psychotherapeutic measures, employed in units at the front, will soon put an end to commencing rigi- dity. Sick leave must be refused, as it nearly always has a bad effect in these cases.

In obstinate forms in which treatment does not cause any obvious improvement it is better to dis- charge the patient temporarily or put him under medical supervision, since in the absence of such supervision the condition always tends to remain stationary.

It is for those stubborn contractures, causing complete loss of power in the hand and fingers, which cannot be improved by any of the usual treat- ments, that surgical interference has been suggested.

J. Sicard x has proposed alcohol injections into the

1 J. H. Sicard, " L'alcoolisation tronculaire au cours des acromyo- tonies rebelles du membre superieur," Paris Medical, June 3, 1916.

PHYSIOPATHIC AFFECTIONS 153

nerve supplying the muscles suffering contracture. By this process "relaxation of the contracture and disappearance of the pain for a certain time is obtained."

The technique is as follows : — First of all a skia- gram is taken of the limb to see if there is any foreign body present ; if there is, this must be extracted. After local anaesthesia the nerve-trunk is exposed and anaesthetised with 2 cubic centimetres of a 1 per cent, solution of cocaine, and about 1 cubic centimetre of alcohol at 20° is injected into the nerve-trunk.

" Almost immediately after the injection, some- times only after the lapse of several minutes, muscular relaxation occurs, and cutaneous anaesthesia appears in the injected territory, and at the same time a rise of temperature of several degrees is noted in the zone supplied by the nerve " (Sicard).

Immediately after the operation the fingers of the patient are separated from each other by thick layers of cotton-wool, the hand is put in a good position and wrapped up in a thick layer of cotton- wool on which a plaster bandage is applied.

The plaster should be kept on for two to three weeks, then the hand is massaged gently every day, and the fingers are fixed one day in flexion and the next day in extension. ,

A light and easily movable prosthetic apparatus can be used with advantage.

Daily supervision is essential ; healing takes several weeks or even months, and requires a lot of patience.

The paralysis resulting from alcoholisation of the nerve is only transitory, since, according to Sicard's researches, with a solution of alcohol at 20° reaction of degeneration is rare and transient, and regeneration of the nerve takes place rapidly.

CHAPTER XI

PARALYSES AT A DISTANCE. MUSCULAR DYSTROPHIES

HENRI CLAUDE, Vigoureux, and Lhermitte in October 19 15,1 under the name of muscular dystrophy of the myopathic type, described a form of paralysis with muscular amyotrophy limited to the trapezius and serratus magnus, sometimes on one side of the body and sometimes symmetrical and involving both shoulders.

The remarkable feature in the four cases recorded by these authors is, that they deal with paralysis at a great distance from the wound.

The projectiles (bullet or shell fragment) on their passage through the tissues did not affect the nerve fibres of the paralysed muscles. In one case, even where there was bilateral paralysis of the trapezius and serratus magnus, the original wound was in the lumbar region.

In the different cases related by these writers, amyotrophy, static deformity, and functional dis- ability were marked. One shoulder was lower than the other, and the scapula was rotated so that its axillary border had become horizontal and its spinal border receded from the line of the spinous processes.

Abduction of the arm was very defective, and its forward movement was accompanied by marked winging of the scapula.

1 Henri Claude, A. Vigouroux, and J. Lhermitte, " Sur certaines dystrophies musculaires du t}^pe myopathique consecutives aux trau- matismes de guerre," Presse medicale, October 11, 1915.

154

PARALYSES AT A DISTANCE 155

Electrical reactions were only quantitatively modified without any qualitative manifestation of R. D.

Taking all these symptoms into consideration, and especially the localisation of the loss of power in the muscles of the shoulder, particularly in the trapezius and serratus magnus, which are the favourite seat of primary myopathies, and in view of the normal state of sensation and of the reflexes as well as the absence of any reaction of degeneration, the writers reject any hypothesis of a neuritic process, and conclude that this condition must be due to a develop- ment under the influence of traumatism of an " im- pairment of nutrition . of certain muscles giving rise to atrophy and secondarily to paresis."

Subsequently Claude, Vigouroux, and Lhermitte 1 reported two other cases of paralysis of the trapezius and serratus magnus, one following a quite superficial wound of the deltoid region of the same side, and the other a fall while the patient was carrying a load. In the last case paralysis developed slowly, and was preceded by pain which was mistaken for rheumatism.

This paralysis assumed features which made it resemble muscular dystrophy.

Further, Claude arid Lhermitte 2 have had occasion to observe other kinds of paralyses at a distance which they consider to be of a different type, and which they have attributed to lesions of the peri- pheral nerves.

In one of these cases a soldier had been wounded in the internal aspect of the right thigh by fragments of a bomb, portions of which had reached the femur and caused protracted suppuration (nine months). When the patient was able to get up he was paralysed in both legs. The wound, which could only have

1 Henri Claude, Vigouroux, and J. Lhermitte, " Deux nouveaux cas de dystrophie musculaire a type myopathique consecutifs au trau- matisme/' Societe Medicale des Hdpitaux, February 11, 1916.

2 Henri Claude and Jean Lhermitte, " La nevrite motrice extenso- progressive dans les lesions traumatiques des nerfs peripheriques," Societe Medicale des Hdpitaux, July 7, 1916.

156 TREATMENT AND REPAIR OF NERVE LESIONS

involved the muscular and cutaneous branches of the right anterior crural and obturator nerves, had at the end of several months given rise to an atrophic paralysis with sensory and reflex disorders, and a reaction of degeneration in the whole territory of the right great sciatic, and also in the terminal branches (external and internal popliteal) of the great sciatic on the left side.

A second case was that of a soldier who, after a wound of the foot which had completely healed, had shown paralysis of the muscles supplied by the external popliteal nerve of the same side, with reaction of degeneration and loss of the ankle- jerk, but without any painful manifestations.

Though we do not pretend to offer a definite opinion as to the nervous or muscular pathogeny of these different affections, we are nevertheless inclined to believe that there exists a close connection be- tween these two types of lesions of which Claude, Vigouroux, and Lhermitte have recorded examples.

Perhaps some obscure affection of the nerves must be incriminated in each of these cases.

The personal cases of which we shall give a short account may serve as a connecting link with the extreme cases mentioned above, and clearly show that we have to deal with one and the same process which as yet is not fully understood.

We have seen three cases of unilateral paralysis of the trapezius and serratus magnus, the first follow- ing an attack of rheumatism of the shoulder (accord- ing to the diagnosis on the case sheet), the second from carrying a heavy burden fixed by a strap to the shoulder, and the third which had occurred after a wound in the scapular region.

The symptoms were identical with those described by Claude, Vigouroux, and Lhermitte. The following cases are less schematic : —

A soldier who was in perfect health was injured by a revolver bullet, which penetrated the posterior part of the inner wall of the left axilla at a level of

PARALYSES AT A DISTANCE 157

the inferior angle of the scapula ; passing under the superficial layers of the back the bullet came to a stop under the skin at the level of the spinal border of the right scapula. It was easily extracted two months afterwards, and there was hardly any sup- puration.

At the time of injury the patient did not fall, had no shock or contusion, and did not spit up any blood. Four or five days after the wound he started to have pain in his arm. On the left side the pain ran from the shoulder down to the thumb, and on the right from the shoulder down to the elbow. Fifteen days later he became hoarse and out of breath, and the left pleura was tapped several times, about 2 litres of a blood-stained fluid being removed.

Tt was only about four weeks after being wounded that his left arm began to become paralysed.

When we examined him two months after the first of the symptoms we found considerable atrophy of the left arm, with complete muse ulo -spiral paralysis, paresis of the biceps, and flexor longus pollicis and atrophy of the first interosseous space.

Clinical examination showed paralysis of the right serratus magnus and trapezius, with winging of the scapula and paralysis with atrophy of the triceps and supinator longus.

Electro-diagnosis revealed partial reaction of de- generation in all the muscles supplied by the left musculo-spiral and in the first dorsal interosseous.

On the right side there was hypo-excitability to the faradic current and sluggishness of the con- traction to the galvanic current in the supra- and infraspinatus muscle, rhomboideus, and lower bundles of the trapezius. The other paralysed muscles only showed quantitative modification in their electrical excitability.

The reflexes were affected as follows : — On the right percussion of the triceps tendon caused slight flexion of the forearm on the arm, and a brisk con- traction of the deltoid. The stylo-radial reflex pro-

158 TREATMENT AND REPAIR OF NERVE LESIONS

voked a contraction limited to the biceps, with slight supination of the forearm. All these reflexes were abolished on the left side.

There was no more pain, but on palpation the musculo-spiral nerve was found to be increased in size and rolling under the finger.

The pain at the first was situated in the course of this nerve.

The disturbance of objective sensibility was very slight, and occupied the territory of the musculo- spiral and musculo-cutaneous.

There was no sign of a spinal lesion.

One year after injury the paralysis, electrical dis- turbances, and amyotrophy had nearly all disappeared. The patient's voice had again become normal.

Here is another case recalling what A. Hesnard has described as symmetrical irradiation.1

P- was wounded on December 4, 1914, by a

projectile in the right deltoid region. Fracture of the humerus. Immediate paralysis of the right musculo-spiral.

Three or four days after the injury there was very severe pain in the right biceps, and a short time afterwards a left musculo-spiral paralysis appeared.

Examination fourteen months after the injury (for the report required before payment of the pension) the patient showed a fracture of the right humerus, which was united but still suppurating, and a musculo- spiral paralysis from which he had in great part re- covered, both from the point of view of voluntary motility and electrical contractility.

There is still, however, some stiffness of all the joints of the limb, and objective sensory disturbances in the first three fingers of the right hand. These disturbances are due to the existence of an arterio- venous aneurism, which clinical examination shows to be in the upper and internal region of the arm. On the left side he shows musculo-spiral paralysis,

1 A. Hesnard, " Les irradiations symetriques dans les lesions trau- matiques des plexus nerveux," Presse medicale, May 18, 1916.

PARALYSES AT A DISTANCE 159

with marked atrophy and loss of faradic and galvanic excitability of the paralysed muscles.

In a third patient we saw co-existing with left musculo-spiral paralysis (as a result of the fracture of the humerus by a projectile, which suppurated con- siderably and took a long time to consolidate) a paralysis with atrophy of the right deltoid and latissimus dor si.

The functional impairment resulting from this last paralysis was more inconvenient to the patient than the left musculo-spiral paralysis.

The fourth case was still more curious. It occurred in a man who had been repatriated from Germany, and who had suffered from a severe wound of the upper part of the left leg, with long-standing suppuration and ankylosis of the left knee, which was followed by paralysis and atrophy of the muscles supplied by the left ulnar nerve.

This paralysis had developed gradually without pain six months after the injury, and had gone on increasing. When we saw the patient fifteen months after being wounded he showed considerable atrophy and para- lysis of the interossei and hypothenar muscles, with paralysis of the deep flexors of the last two ringers and the flexor carpi ulnaris.

Reaction of degeneration and well-marked sensory disturbances were present.

In none of these cases had clinical examination shown any involvement of the spinal cord.

We consider that these different paralyses were the result of a neuritic process.

In three cases there had been prolonged suppuration of the original wound.

On two occasions paralysis had been preceded by pain.

Since cases of this kind are still very uncommon, we will confine ourselves to mention them without drawing any conclusion as to their pathogeny.

Treatment must consist, as in wounds of the nerve- trunks, in massage and electrization. With regard to

160 TREATMENT AND REPAIR OF NERVE LESIONS

the measures to be adopted from the administrative standpoint, we think that, according to the date of the wound, these patients should either receive a tem- porary discharge or a discharge under medical super- vision, with an allowance liable to be renewed. One of our patients had, in fact, almost completely re- covered one year after the onset of the symptoms, and another had considerably improved within a similar period.

CHAPTER XII

JOINT AFFECTIONS ACCOMPANYING NERVE LESIONS

IN this chapter we shall not discuss ankyloses due to fractures within or near the joints, but shall deal with joint affections encountered in the course of nerve injuries, and which are due to causes which are some- times difficult to determine.

Generally immobilisation of the limb is regarded as the primary cause of stiffness of the joint. This im- portant causal factor in ankylosis must of course be taken into account. But, as a matter of fact, joint affections only follow immobilisation under certain conditions, which vary with the nerve involved.

The main factors in causing articular rigidity appear to be :—

1. Fracture of a bone, even if it is situated at a great distance from the affected joint.

2. Prolonged suppuration of the wound, especially long-continued suppuration of the area of a fracture.

3. Prolonged immobilisation by an appliance or a sling, especially if the fracture has taken long to unite (a frequent cause of stiffness of the shoulder).

4. Contracture of the muscles acting as active liga- ments to the various articulations.

5. Contractures of the ischsemic type, resulting in retraction of muscular tendons (vascular lesions).

6. Various nervous lesions.

itii 11

162 TREATMENT AND REPAIR OF NERVE LESIONS THE FREQUENCY AND SEAT or JOINT AFFECTIONS

VARY ACCORDING TO THE NERVE INJURED

M usculo-spiral paralyses are very frequently accom- panied by ankylosis of the elbow. This ankylosis occurs with the joint in flexion. Extension is limited, and there is often limitation of supination, and some- times even of pronation. At other times it happens that supination alone is limited, other movements of the elbow being well performed.

During the course of musculo-spiral paralyses, rigidity of the wrist, with limitation of extension, may also be seen ; occasionally, but more rarely, lateral movements of the wrist are impaired.

Finally, stiffness of the fingers is also frequently met with in musculo-spiral paralysis. It is impossible to flex the phalanges passively and completely.

Careful examination of the cases with injury to the musculo-spiral nerve shows certain details, which should be remembered.

They are nearly always cases of fracture of the humerus in its middle third, which have necessitated prolonged immobilisation of the arm, and which have suppurated. Ankylosis becomes very gradually estab- lished.

More rarely ankylosis was immediate, the elbow having assumed a right angle directly after the wound, and in those cases it can be found on careful examination that the biceps is contractured, its tendon is prominent, and its body may even appear more excitable to mechanical and electrical stimulation.

It is not rare to see cases of injury to the musculo- spiral nerve with a fracture of the shoulder, which have suppurated for a long time, or resulted in pseud- arthroses, showing a certain degree of stiffness of the shoulder.

Wounds of the median nerve are only rarely accom- panied by ankylosis of the elbow. When this ankylosis exists it is slight, and mainly affects the

JOINT AFFECTIONS

163

FIG. 54. — Painful form of wound of the median. State of the hand twenty months after the wound. Numerous ankyloses and deformity of the terminal phalanges and of the nails.

movements of supination ; occasionally, but far less,

'__^ that of pronation.

Extension of the wrist may be limited ; at the same time difficulty in flexing the phalanges on each other is observed. We have just spoken of complete lesions of the median or of incom- plete painless lesions. For in causalgic forms of wounds of this nerve joint affections reach quite unexpected pro- portions. We have dis- cussed these conditions at length elsewhere.1

These manifestations affect the elbow joint (ankylosis

in flexion), wrist joint

(ankylosis in flexion), and

especially the finger joints.

The articulations most

affected are the metacarpo-

phalangeal and then the

interphalangeal. In the

attenuated painful forms

these last articulations are

the only ones involved (figs.

54 and 55).

In wounds of the ulnar we

must distinguish between

complete painless paralyses

and incomplete paralyses

which are more or less pain- ful. In the former, apart

from the retractions found

in ulnar claw-hand, joint affections are infrequent,

except where the wound has suppurated for a long

1 Clinical Forms of Nerve Lesions.

FIG. 55. — An appearance of the hand in the painful form of Wounds of the median nerve. Deformity of the fingers and nails. Ankylosis of the wrist in hyperflexion.

164 TREATMENT AND REPAIR OF NERVE LESIONS

period, or where the lower end of the humerus has been involved, with injury to the internal condyle.

On the contrary, in incomplete lesions of the nerve giving rise to painful symptoms it is not rare to see multiple articular rigidities arise in spite of early mobilisation of the limb.

These conditions affect the elbow and the wrist, but principally the metacarpo-phalangeal and the inter- phalangeal joints.

In the course of severe lesions of the great sciatic and of its external branch of bifurcation the external popliteal, ankylosis of the knee or ankle is hardly ever seen.

It is only the phalangeal joints of the toes which may be affected by a certain degree of stiffness.

But very marked joint affec- tions are caused by incomplete lesions of the trunk of the sciatic, especially those which involve and irritate the fibres of the internal popliteal.

Ankylosis of the knee is very frequent, and is occasionally very marked, but what is seen still more frequently is ankylosis in extension of the tibio-tarsal and meta- tarso-phalangeal joints, those of the big toe being the most affected.

The articulations of the tarsal bones with each other and with the metatarsals may also become involved, which explains the rolling up of the foot towards its internal border, and the rotation which the front of the foot seems to undergo on the back of the foot (fig. 56).

From this brief summary it appears that incomplete lesions of the median and sciatic nerves, the very lesions which give rise to the causalgic syndrome,

FIG. 56.— Claw-toe defor- mity following a lesion of the trunk of great sciatic. (Painful form.)

JOINT AFFECTIONS 165

have the most pernicious effect on the joints, and especially on those of the extremities.

Besides which, in fairly numerous cases, the joints of the fingers become thickened, and their swelling contrasts with the thinning of the inter-articular digital segments. Sometimes radiography shows not only decalcification of the bones of the hand or foot, but in addition a very slight 'increase in size of the bony extremities of the phalanges, and especially of the heads of the metacarpal bones. *

It is therefore obvious that the nature of the nervous lesion constitutes a highly important factor.

In many cases of this kind it is the only cause, and neither a fracture of the limb nor a prolonged sup- puration can be incriminated. Muscular contracture, ischsemic retraction, and vascular lesions may also be diagnosed.

Ankyloses of the elbow are chiefly met with in lesions of the musculo-spiral, even when the projectile has not fractured the humerus, and the arm has not been immobilised for a considerable period.

It must be remembered that the most frequent site of wounds involving the musculo-spiral nerve is the middle third of the arm, and at this level the nerve has already given off fibres for the triceps, and the majority of its articular fibres for the supply of the elbow.

The bony and muscular lesions, and the forma- tion of more or less developed sclerotic tissue, inflame and irritate the healthy nerves in this situation, hence the articulation which they supply is affected also.

If, as seems likely, these incomplete, painful, and irritative lesions of the nerve are of an inflammatory nature, Guillain's hypothesis, according to which microbial and cellular poisons follow the nerve fibres, and especially their lymphatics, would also, in our opinion, explain the frequent involvement of the articulations.

The synovia! sheath of the articulations supplied by

166 TREATMENT AND REPAIR OF NERVE LESIONS

the injured nerve then becomes the seat of a subacute inflammation. This inflammation is propagated to the bony surfaces with trophic impairment and impli- cation of the whole fibrous peri -articular capsule. We know little as yet about what may be the effect of the lesion of the nerve on ligaments and aponeuroses, which depend upon it for their nerve -supply.

With regard to aponeuroses, Henry Meige l has drawn attention to an affection peculiar to the knee in patients wounded in the anterior crural nerve, consisting in a loss of power due to a kind of relaxa- tion of the various aponeuroses of the knee, especially those in connection with the vasti muscles and the ligaments of the knee joint. This relaxation persists long after the nerve and the muscle have in great measure recovered.

Prolonged suppuration and immobilisation in the case of a fracture (e.g. a fracture of the humerus) affect the distant articulations of the wrist and fingers, the resistance of which have been lowered by the immobilisation of the hand, which the patient cannot move on account of the inconvenience and pain caused by the fractured arm.

These articular disturbances have a bad effect on the nutrition of all the neighbouring tissues ; not only do the bones become decalcified, but all the tissues become emaciated, so that the hand assumes an aspect similar to that seen in causalgic hands.

Deformities of the joints due to nervous causes, and especially to irritative traumatic lesions of the nerves, were described some time ago by Weir Mitchell. Professor Dejerine has recently reported two cases of this kind, which are of considerable interest.2 One of the articular lesions resulted from an irritative lesion of the median " exactly limited

1 Henry Meige, " De certairies boiteries observees chez les blesses nerveux," Revue, Neurologique, November-December 1915, p. 939.

2 J. Dejerine and E. Schwartz, " Deformations articulaires analogues a celles du rhumatisme chronique, avec troubles trophiques, cutanees et hyp&ridrose relevant d'une lesion irritative du nerf median," Societe de Neurologie, meeting of February 4, 1915. M. and Mme. Dejerine and

JOINT AFFECTIONS

167

to the area of this nerve." In the other case the joint lesions, which resembled those of chronic rheu- matism, were bilateral, and appeared to be the result of an elongation of the roots of the brachial plexus. This condition arose in the case of apatient suffering from quad- riplegia following a vertebral lesion of the lower cervical and upper dorsal region caused by a bullet.

We consider it ad- visable to end this chapter by a short account of the nerve - supply of the bones and joints of the upper and lower limbs, as a know- ledge of this subject may often explain the pathogeny of certain ankyloses.

The circumflex nerve furnishes two articular branches, one of which is given off not far from its origin, and supplies the anterior aspect

of the Capsule of the A, anterior aspect. B, posterior aspect.

shoulder joint.

The second is intended for the lower and internal part of the articulation, and is given off at the part where the circumflex winds round the neck of the

M. Mouzon, " Troubles trophiques articulaires analogues a ceux du rhumatisme subaigu et semblant consecutif a un tiraillement des racines des plexus brachiaux chez un soldat atteint de paraplegie traumatique," Societe de Neuroloy'ie, meeting of July 1, 1915.

FIGS. 57 and 58. — Nerve-supply of the bones and joints of the upper limb.

168 TREATMENT AND REPAIR OF NERVE LESIONS

humerus ; finally, deltoid branches furnish osseous fibres for the head of the humerus.

The musculo-cutaneous nerve gives off :—

(a) The nerve to the diaphysis of the humerus, a motor nerve containing also a few sensory fibres 1 for the periosteum and for the bony substance of the humerus. It accompanies the vessels of the diaphysis and enters the nutrient foramen of the bone. The filaments are lost in the compact tissue and in the marrow of the bone.

(6) The anterior articular nerve of the elbow, which arises separately or as one of the branches of the nerves to the biceps (Cruveilhier), passes down in the neighbourhood of the sheath of the vessels of the arm, and is distributed to the anterior ligaments of the elbow joint.

(c) A small vascular branch for the wrist joint. (It arises from the anterior and internal branch of the nerve.)

The median nerve supplies :—

(a) A small articular fibre for the elbow, which is given off about the middle third of the arm and travels down in the sheath of the brachial artery, which it accompanies up to the epitrochlea. There it subdivides into two filaments which supply the antero-internal part of the capsule of the elbow.

(6) Filaments from the upper branch to the pronator teres. which are very slender, are also closely applied to the brachial artery, and are distributed to the anterior surface of the elbow joint, or, more precisely, to the antero -external part of the capsule, where they anastomose with filaments of the musculo- spiral.

(c) From the anterior interosseous nerve arise : —

(1) A small filament for the articular ligaments of the elbow near the head of the radius.

(2) Filaments for the interosseous membrane and the periosteum of the anterior surface of the two bones of the forearm* (on the course of these nerves numerous Pacinian corpuscles are found).

1 Piorier and Charpy, Traite d'anatomie humaine, tome iii. fascicule 3.

JOINT AFFECTIONS 169

(3) Branches for the articulation of the wrist and for the first row of carpal bones.

According to Rauber, the anterior interosseous nerve also gives off nerves to the diaphysis of the two bones of the forearm.

(d) The palmar collateral nerves of the median and their dorsal branches supply bony and articular fila- ments. Throughout their course these collateral

A B

FIGS. 59 and 60. — Nerve-supply of the bones and joints of the hand. A, palmar aspect. B, dorsal aspect.

nerves show groups of Pacinian corpuscles near the articulations. The ulnar nerve furnishes :—

(a) An articular filament for the postero-internal part of the elbow joint. It is given off about the middle of the arm.

(b) Two articular branches, which are given off between the olecranon and internal condyle, and spread out on the articular capsule near the ole- cranon.

(c) Small branches for the dorsal ligaments of the articulations of the carpus. They are given off from the dorsal cutaneous branch of the hand.

(d) Digital nerves and palmar collateral nerves given off by the ulnar supply, like those of the median, fine

170 TREATMENT AND REPAIR OF NERVE LESIONS

fibres for the neighbouring articulations. Several Pacinian corpuscules are attached to these fibres.

(e) The deep branch of the ulnar gives off in its turn branches for the anterior ligaments of the carpus and for the metacarpo-phalangeal joints.

The musculo-spiral nerve gives off :—

(a) A recurrent branch for the shoulder joint coming from the branch to the long head of the triceps.

(b) Filaments given off by the branch to the inner head of the triceps and ending in the internal region of the elbow joint.

(c) Periosteal filaments for the shaft of the humerus.

(d) Articular filaments arising at the level of the elbow and distributed to the ante ro -external liga- ments of the elbow joint.

(e) The posterior interosseous nerve, a branch of the musculo-spiral, gives off filaments to the inter- osseous membrane and the posterior aspect of the periosteum of the two bones of the forearm, besides which it supplies all the articular nerves of the dorsum of the hand and the root of the fingers.

These nerves also supply the metacarpo-phalangeal joints, after having joined up with the perforating branches of the deep branch of the ulnar.

The nerve -supply of the joints of the upper limb is summarised in the appended table : 1—

1. Shoulder Joint.

Posterior region — Suprascapular nerve. Anterior ,, — Circumflex nerve.

2. Elbow Joint.

, (Upper part — Musculo-cutaneous. Antero-external M^Ue part— Musculo-spiral.

reSlon [Lower „ „ ,,

Antero-internal y Upper part — Median.

region t Lower ,, ,,

1 A. Soulie, Les nerfs. In Poirier, tome iii. fascicule 3, p. 946.

JOINT AFFECTIONS 171

Postero-external f Upper part — Musculo -spiral.

region (Lower part — Ulnar.

Postero -internal /Upper part — Ulnar.

region I Lower ,, ,,

3. Wrist Joint.

Anterior region — Median. Posterior „ — Musculo-spiral.

4. Carpal Joints.

Anterior region — Ulnar. Posterior „ —Musculo-spiral.

5. Finger Joints.

A. Metacarpo-phalangeal joints.

( Filaments of the palmar collateral

of the fingers. Anterior region , Branches Jf the deep branch of

the ulnar.

(Dorsal collateral filaments of the fingers. Dorsfl interosseous nerves of the radial.

B. Articulations of the first and second phalanges. Anterior region — Collateral palmar filaments. Posterior region **" ^"^ *"*

C. Articulations of the second and third phalanges.

Anterior region — Palmar collateral filaments.

I Dorsal branches of the palmar Posterior region collateral, except for the last

( two fingers.

The nerve- supply to the joints of the lower limb can be summarised as follows :— -

1. The hip joint is supplied by four nerves — the

172 TREATMENT AND REPAIR OF NERVE LESIONS

anterior crural, the obturator, the sciatic, and the

inferior gluteal.

The anterior crural nerve is distributed to the anterior and external part of the joint, and especially to the liga- ment of Bertin.

The obturator gives filaments to the lower and inner part of the joint.

The sciatic and the inferior gluteal supply the posterior region of the hip joint.

2. The knee joint re- ceives its nerves from the anterior crural for its anterior surface, and especially from the branch to the vastus externus, externally, and from the internal saphen- ous on its inner aspect.

The nerves for the posterior part of the capsule are supplied by the internal popliteal for the internal portion, and by the external popliteal for the external portion.

3. Tibio-tarsal joint. Three nerves supply this joint — anterior tibial, posterior tibial, and the external saphenous.

The anterior tibial supplies the anterior ligament of the joint, the external saphenous the

A B

FIGS. 61 and 62. — Nerve-supply of the bones and joints of the lower limb.

A, dorsal aspect. B, ventral aspect. Great sciatic in white.

JOINT AFFECTIONS 173

external and posterior part of the articulation, and the posterior tibial the postero -internal region.

4. The articulations of the foot. Those of the tarsus, like those of the' metatarsus, receive their nerve - supply on the dorsal aspect of the foot from a deep branch of the anterior tibial, and on the plantar side from the two plantar nerves, the internal on the inner side, and the external on the outer side.

EXPLANATION OF FIGURES 57 TO 60.

In figures 57 to 60 the muscular or cutaneous territory of each nerve is distinguished by special markings, as follows :—

Median and anterior crural : solid black.

Musculo -spiral : fine, close cross-hatching from risht to left.

Musculo -cutaneous of the arm and external popliteal : open cross-hatching from left to right.

0 Ulnar and internal popliteal : thick cross-hatching. Circumflex and gluteal nerves : black dots.

Obturator : dots separated by lines.

INDEX

Abductor brevis pollicis, tests of

functional activity, 51. " Accoucheur's hand," 132, 135. Acromyotonus, 131, 136. Adductor pollicis muscle, localisa- tion of fibres for, 124. Alcoholic injections, 152, 153. Alcoholisation of nerve-trunk,

Sicard's, 90. Anatomical section of nerves,

impossibility of diagnosis,

60.

Animals, section of nerve in, 2. Ankle-jerk, 138.

Ankylosis of the elbow, 162, 165. Annular constrictions, 2. An tero- external muscles, paralysis

of, orthopaedic appliance

for, 111.

" Ape-hand," 59. Aponeuroses, Meige's observations

on, 166. Arm, the, motor bundles of median

nerve in, 123. Articular rigidity, main factors

causing, 161. Articulations of the foot, 173.

of the phalanges, 171. Atrophy of muscles, 67.

as a sign of severe lesion, 61. Atrophy of tissues, 133. Attrition, pseudo -neuroma of, 8,

10. Pierre Marie and Charles Foix

on, 12. Axis-cylinder, the, 2.

descending and retrograde

changes in, 19. Axone. (See Axis-cylinder. )

Babinski's^use of radiotherapy in

neuralgia, 97.

Biceps, the, contracture of, 139. Bones, suppuration in, 148. Brachial plexus (upper), appliances

for paralysis of, 116.

Carpal joints, nerve-supply of, 171. Causalgia of median nerve, 74, 90. Cerebro- spinal nerves, nerve fibre

of, 2.

Cestan's use of radiotherapy, 97. Cheloid, eccentric or lateral, 17.

of the axis-cylinder, 11. Chloroform narcosis, 134. Cicatricial topo-paraesthesia, 27,

66. Circumflex nerve, the, functions

of, 167. Claw-hand, appliances for, 1 15.

signs of regeneration, 70. Club-foot, 148. Cold, insensibility to, 22.

sensibility to, 28. Complete section. (See Section.) Compression, syndromes of, 54, 55. " Congealed hand," 131, 132, 148. peculiar mentality of patients,

150.

Constriction, 142, 148. Continuous current, the, 94. Contractures, 135 et seq.

caused by ischsemic constriction,

142. with paresis due to irradiating

neuritis, 142.

Cutaneous cicatrix, the, 66. reflex, the, loss of, 65.

174

INDEX

175

Dagnan-Bouveret's apparatus for lesions of upper brachial plexus, 116.

Decalcification in paralysis with contractures, 133.

Degeneration, reaction of. (See

Reaction of degeneration.) Wallerian, 2.

process of regeneration, 3.

Deltoid branches, functions of, 168.

Descomps, Paul, satisfactory re- sults from use of radio- therapy, 97.

Diathermy, 152. advantage of, 97.

Diplocinetic method of Meige, 151.

Dissociation, syndromes of, 54, 55.

Dumas, Rene, statistics of opera- tions for nerve injuries, 77.

Eccentric cheloid, 17. Elbow, the, ankylosis of, 162, 165. anterior articular nerve of, 168. articular fibre for, 168. joint, nerve -supply of, 170. Electric stimulator, Meige's, 120. precautions in technique, 122. Electrical contractility, modifica- tions in, 133.

degeneration of muscles, 67. examination in nerve injuries,

35 et seq.

reactions, phenomena of, 42. Electrodes, 95. Electro-diagnosis of two cases

examined, 40, 41. Electrotherapy in paralysis of

nerves, 94. End-to-end sutures, 74, 81. (See

also Sutures.)

Epicritic sensibility, Head's, 24. Exploratory incisions, 76.

question of, 79. Extensor communis digitorum,

fibres for, 127. proprius hallucis, localisation of

fibres for, 125.

Extensors of the toes, localisation of fibres for, 124.

External popliteal nerve, lesions

of, 64, 165.

localisation of fibres for, 124. motor localisation of, 128. paralysis of, 79.

appliance of J. Privat and

J. Belot, 112. situation of fibres in, 125.

Faradic contractility, 42 et seq., 70. current, the, 94.

excitability as sign of regenera- tion, 70.

investigations, 36. Fasciculi in median nerve, 123. in musculo- spiral nerve, 127. in thenar muscles, 127. Finger joints, nerve -supply of, 171

prints, changes in, 66. Fingers, flexors of, localisation of

fibres, 123. stiffness of the, 162. " Fist " appearance of contrac- tures, 136. Flaccid paralyses with hypotonus,

139.

Flexor brevis pollicis, return of functional activity in the. 51.

carpi ulnaris, nerve fibres of, N 124, 125.

longus digitorum, fibres for, 128. sublimis digitorum, fibres for,

127.

Flexors, hyperexcitability in, 135. of fourth and fifth fingers, fibres

for, 124. of the carpus, localisation of

fibres in, 123.

Foot, the, articulations of, 173. contractures of, 137. sensibility in, 34.

Foot-drop, appliances for correc- tion of, 99, 109 et seq. " Formication of recovery," 25.

26.

Freeing the nerve, successful re- sults of, 75. (See also Liberation of nerve.) Froment and Wehrlin's appliance for paralysis of inedian, 1 14.

176 TREATMENT AND REPAIR OF NERVE LESIONS

Galvanic current, the, 94.

investigations, 36. Gastrocnemius muscles, fibres for,

124, 128.

Glioma, Nageotte's term, 5, 10. Gosset's method of end-to-end

suture, 81. method of treatment of lateral

notch, 83. report on sutures and nerve

grafts, 78. Great sciatic nerve, disturbances

of objective sensibility, 63. lesions of, 164.

Delorme's resections, 73. points of election for palpation,

62 (note). unsatisfactory regeneration of,

77, 80.

Grunspan, Dr, on electrical treat- ment of paralysis, 95. Mile., method of radiotherapy,

97.

Guillain's hypothesis, 165. Gymnastics, 92.

Hand, complete paralysis of the,

131.

massage, 92.

Hand-drop, appliances for correc- tion of, 99.

Hair sensibility, 29 (note). Head, Henry, " A Human Experi- ment in Nerve Division," 21. Heat, insensibility to, 22.

sensibility to, 28. Hersage, 85, 90.

definition of, 74. Hip joint, nerve-supply of, 171. the, muscular contractures of,

138.

" Holy water basin hand," 136. Humerus, fracture of the, 162.

nerve to diaphysis of, 168. Hypertonus, 134. Hypertrichosis, 66 Hypothenar muscles, hyperexcita-

bility in, 135. localisation of fibres for, 124,

125.

Hypothermia (local) in paralysis with contractures, 133.

Hypotonus in paralysis, 58, 133,

134. Hypotrichosis, 66.

Idio-muscular contraction, slow- ness of, 65. Immobilisation, 161.

(prolonged) of limb, 143 et seq.,

149.

Incisions, exploratory, 79. " Incomplete section," 11. Induration of the nerve (simple),

18.

Inertia (moral), 145.

Infiltration of superficial layers, 47.

Injured nerves, macroscopical and

microscopical lesions - of,

1 et seq. (See also Lesions.)

Internal popliteal nerves, fibres for,

128.

localisation of fibres of, 124. situation of nerve bundles in,

125.

Interossei, fibres for, 128. hyperexcitability in, 135. localisation of fibres for, 124,

125.

liiterosseous nerve (anterior), fila- ments from, 168. Interruption, syndromes of, 53, 54,

56.

muscular signs, 54. sensory signs, 55. Interstitial neuritis, 19. Intranervous localisation, 120 et seq.

neuroma, 17. Irradiating neuritis, 142. Irradiation of nerves, 97. Irritation, syndromes of, 54, 55.

Joint affections, accompanying

nerve lesions, 161 et seq. frequency and seat of, vary according to nerve injured, 162. Joints, the, deformities of, due to

nervous causes, 166. passive movement of, 92. Juxta-nervous neuroma, 17.

Knee-jerk, 138.

joint, nerve-supply of, 172.

INDEX

177

Lamellar sheath, the, 1. La Salpetriere, results of opera- tions for nerve injuries at,

73 et seq.

Lateral cheloid, 17. nodule, 17. notch, 15.

Cosset's method of treatment,

83.

pseudo-neuroma, 17. Leg, the, contractures of, 138. (See

also Lower limb. ) Lesions, accessory types, 8, 9, 16. complete section, 9. due to war wounds, earliest sign

of recovery of sensation,

24.

lateral notch method of treat- ment of, 15. of bones, muscles, and tendons,

148.

of central fibres, 85. of external popliteal nerve, 34,

164.

of great sciatic nerve, 33, 164. of injured nerves, macroscopical

and microscopical, 1 et seq. of interstitial neuritis, 85 (note). of median and ulnar nerves, 50. of musculo -spiral nerve : sensory

changes, 30. of nerves, 147.

radiotherapy in, 97. severe, signs of, 53 et seq. of parenchymatous neuritis, 85

(note).

of peripheral nerves, 155. of plexus, 84. of sciatic nerve : attitude of

toes, 70.

of sensory nerve fibres, 148. of the foot, 34. of ulnar nerve, 25, 33. of upper brachial plexus, 117. pseudo-neuroma, of attrition, 8,

10.

reflex, 140. section with pseudo-continuity,

16.

severe, signs of, 60 et seq. three main types of, 8. Liberation of nerve, 75, 89.

Limb, the, prolonged immobilisa-

of, 143 et seq., 149. Limbs, signs of regeneration in the,

70.

Longitudinal reaction, 37. Lower limb, contractures of, 137.

Macroscopical and .microscopical lesions of injured nerves, 1 et seq. Massage and mobilisation, 92.

under water, 93. Mechanotherapy, active, 92. " Median and ulnar nerve hand,"

136. Median nerve, appliances for

paralysis of, 113. disturbances of obiective sen- sibility, 63. fibres of, 86, 127. functions of, 168. intranervous localisation of,

123. points of election for palpation,

62 (note).

radiotherapy in, 97. sensory changes of lesions of,

32.

syndromes of irritation in, 18. unsatisfactory regeneration of,

77, 80, 87. wounds of, 162. Medullary sheath, the, 2. Meige's shoulder-belt appliance,

109 et seq.

Microscopical examination of pseudo • continuity lesions, 16.

Milliamperemeter, the, 95. Mobilisation, value of treatment,

152. Motility, rapid recovery of, 88.

Mme. Dejerine on. 89. (voluntary), recovery of, 49 et seq. Motor fibres, " an error in switch- ing of," 50.

power (voluntary), re-establish- ment of, 39. Muscles, the, absence of pain on

pressure, 59.

absence of tonicity of, 57. atrophy of, 67.

12

178 TREATMENT AND REPAIR OF NERVE LESIONS

Muscles, electrical degeneration of, 67.

exaggerated mechanical excit- ability of, 65.

faradic contractility in, 70.

fibres for, 123.

mechanical hyperexcitability of, 133.

of pelvic girdle, contractures of, 138.

(paralysed), atrophy of, 61. Muscular contractures antagonistic

to paralysed muscles, 141. due to irritation by metal dust, 141, 142.

dystrophies, 154 et seq.

hyperexcitability, 135.

hypertonus, 51.

inaction, 141, 145.

lesions, 148.

paralysis, a promising sign in, 48.

signs in syndrome of interrup- tion, 54. of regeneration, 69.

tonicity, 58.

Musculo-cutaneous nerve, the func- tions of, 168.

Musculo-spiral nerve, intra-trun- cular arrangement of, local- isation of Dejerine and Mouzon, 125.

localisation of fibres of, 124, 125, 127.

nerve-supply of, 170.

paralysis of, 79.

points of election for palpation, 62 (note).

ready regeneration of, 77, 78, 87.

sensory changes in lesions of, 30. Musculo-spiral paralysis, 47, 162.

prosthetic appliances for, 99, 101 et seq.

Nageotte's researches on nerve de- generation and regenera- tion, 1, 7.

Narcosis, chloroform, 134.

Nerve division, complete, 9.

fibres, section of, histologies! modifications, 2.

Nerve grafting, 74, 75, 82.

injuries, appliances suitable for work for patients suffering from, 118.

indications for operation, 79. Leriche's treatment of, 90. macroscopical appearance of,

80.

operative technique of, 72. physiotherapeutic treatment

of, 92 et seq.

recovery of electrical excit- ability, 35 et seq. results of operations, 74 et seq. spontaneous regeneration of.

79. surgical treatment of, 72 et seq.

(See also Nerve lesions. ) lesions, accessory, 8, 9, 16

et seq.

individual factors opposing re- generation, 87. joint affections accompanying,

161 et seq.

of inflammatory changes, 19. operations without apparent

success, 85. surgical treatment of painful

forms of, 89 et seq. with reaction of degeneration, 37. (See also Nerve injuries.) liberation of, 89. regeneration of, period necessary

for, 67.

section of, process of regenera- tion, 3.

simple induration of, 18. -supply of joints, summary of,

170 et seq. suture, illogical and defective

methods of, 82. -tissues, injuries of, 19. -trunk, alcoholisation of, 90. Nerves, crushed, treatment of, 83. injuries of, by war wounds, 7. (Cf. Nerve injuries and Nerve lesions.) liberation of, 84. points of election for palpation,

62 (note).

regeneration of, early symptoms, 69 et seq.

INDEX

179

Nerves, signs of severe lesions of,

53 et seq.

spontaneous regeneration of, 83. structure of, 1. Nervous tissue, delicate nature of,

73. Neuralgia. Babinski's method of

radiotherapy for, 97. trigeminal, Sicard's treatment

of, 90.

Neurilemma, 1. Neurites, 5.

Neuritis, interstitial, with in- flammation, 19. (painful), 147.

Neuroglia (sheath of Schwann), 5. Neuroma, enucleable, 17. (experimental) in rabbits, 4. hersage of, 75, 76. intra-nervous and juxta-nervous,

17.

meaning of, 5. Neuro-muscular adhesions, 85

(note). Neuro-vascular auto-grafting, 82.

Objective sensibility, disturbances

of, 71.

as sign of severe lesion, 63. Orthopaedic appliances, 98 et seq. Oscillations in paralysis with con-

tractures, 133. Osteo-periosteal reflex, loss of the,

65.

Pain, absence of, when trunk of nerve is subjected to pres- sure below seat of lesion, 62. Palmar collateral nerves of the

median, 169. Palpation of nerves, points of

election for, 62 (note}. Paralysed muscles, atrophy of,

61. Paralyses at a distance, 154 et seq.

treatment, 159. (flaccid) with hypotonus, 139. Paralysis, electrical treatment of :

note by Dr Grunspan, 95. of all muscles below a lesion, 60. of antero- external muscles, appli- ance for, 111.

Paralysis of median nerve, ap- pliances for, 113. of sciatic nerve, 47. of the nerves : electrotherapy

in, 94.

of upper brachial plexus, appli- ances for, 116. (painful), 96. (painless); 95. (total), a sure sign of, 67. ulnar, appliance for, 115. with contractures, 131.

signs of, 132 et seq. Paratonic paresis, 131. Parenchymatous neuritis, 19. Paresis associated with contrac- tures, 138.

Paretic foot, the, 132. Pathogeny of physiopathic affec- tions, 139 et seq. Perineural adhesions, 85 (note). Peronei muscles, localisation of

fibres for, 124.

Perroncito's phenomenon, 4. Phalanges, articulations of, 171. Physiological interruption, 56.

diagnosis, 60. Physiopathic affections, 130 et

seq.

due to prolonged immobilisa- tion, 142.

four groups of, 147. motor disturbances in, 150. pathogeny, 139. symptomatology, 130. treatment, 151.

Physiopathic "disorders," 141. Physiotherapeutic measures in physiopathic affections, 151. treatment of nerve injuries, 92

et seq. Pitres, Professor, on value of

immediate suture, 88. Plexus, the, lesions of : sponta- neous recovery, 84. Polar equality, 37.

reversal, 37.

Popliteal nerves, lesions of, 34. Pronator muscles, fibres for, 123,

127.

teres, filaments from upper branch to, 168.

180 TREATMENT AND REPAIR OF NERVE LESIONS

Prosthetic appliances, 99, 101 etseq.

Meige on, 98.

Protopathic sensibility, 23, 28. Pseudo-continuity of nerve, 16, 83. Pseudo -neuroma, lateral, 17. of attrition, 8, 10, 84.

Pierre Marie and Foix on, 12. Psychotherapeutic measures in physiopathic affections, 151, 152.

Radial muscles, contractions of, 50. nerve, injury to : sensibility

and, 21.

Radiotherapy, 97. Ranvier's phenomenon, 6. Reaction, by stimulation, 37. longitudinal, 37. of degeneration, appearance of,

38.

characteristics of, 36. (complete), as sign of severe

lesion, 61. evolution of, 38. qualitative defects, 39. Recovery, " formication of," 25,

26.

syndromes of, 54, 55. Reflex amyotrophies, 140. disorders, 130 et seq. paralysis, 131. Regeneration of nerves, order in

which signs appear, 69. spontaneous, 79. the syndrome of, 55. Resection of nerve -trunk, question

of, 73.

Resections, 75, 76, 83. Rivers, W. H., "A Human Ex- periment in Nerve Divi- sion," 21.

Schwann, sheath of, 2. Sciatic nerve, fibres of, 86.

intranervous localisation of, 124.

paralysis of, 47.

prosthetic appliance for, 111.

radiotherapy in, 97.

sensory changes of lesions of, 33.

syndromes of irritation in, 18. Sciatic paralyses, appliances for, 109 et seq.

Section and attrition in animals,

5, 6.

(complete), 9, 80. " incomplete," 11. Sensibility, deep, 29. epicritic, 24. protopathic, 23, 28. recovery of, 21 et seq. superficial, 22.

impairment of, 22. to a prick, 28. to touch, 29.

Sensory changes of lesions of ex- ternal popliteal nerve, 34. of great sciatic nerve, 33. of median nerve, 32. of musculo- spiral nerve, 30. of radial nerve, 21. of ulnar nerve, 33. Sensory fibres, errors in switching

of, 28.

fibrils of ulnar nerve, 128. nerve fibres, 148. recovery, first manifestations of,

28.

regeneration, signs of, 69. signs in syndrome of interrup- tion, 55. Shoulder-belt appliance (Meige's),

109 et seq., 113. Shoulder joint, nerve-supply of,

170.

" Sign-post hand," 136. Skin, the, moisture of, 133. Soleus, the, fibres for, 124, 128. Spinal centres, hyperexcitability of

the, 138.

•' Spindle hand," 136. Spontaneous regeneration of nerves,

83. Stoffel's investigations on nerves,

126. Supinator longus, fibres for,

127.

Surgical treatment of nerve in- juries, 72 et seq., 89 et seq. causes of failure, 85. Sutures, 81.

for complete sections of nerves,

75, 76.

immediate, 87. " Swan-neck hand," 136.

INDEX

181

Sweat, abolition of secretion of, 65. Symmetrical irradiation, 158. Symptomatology of physiopathic

affections, 130 et seq. Syndromes, 53 et seq. " Syndromes of irritation," 18. Systolic pressure, 133.

Tactile discrimination, 22.

sensibility, disappearance of,

29. Tendon reflexes, 138.

in paralysis with contractures,

134. Thenar eminence, innervation of

muscles of, 51. muscles, fibres for, 123.

hyperexcitability in, 135. Thermal disturbances as signs of

severe lesion, 61. Thomas, Andre, on recovery of

sensation, 25.

Thumb, the, adduction of, 50. Tibialis anticus muscle, localisation

of fibres for, 124. posticus muscle, localisation of

fibres in, 124. Tibio-tarsal joint, nerve-supply of,

172. Tinel's statistics of suture and

nerve grafts, 78. Toes, extensors of the, localisation

of fibres for, 124. the, signs of regeneration in,

70. Topo-parasthesia. cicatricial, 27,

66.

Translesional nodule, the, 11. Trigeminal neuralgia, Sicard's

treatment of, 90.

Traumatic neuropathology, con- tractures without direct in- jury .to nerve -trunk, 147. Trophic changes in severe lesions

of nerves, 65, 66.

Ulceration, 66. Ulnar claw-hand, 59.

signs of regeneration, 70. nerve, arrangement of fibres in,

125.

lesions of, 25, 33. localisation of fibres in, 123. nerve-supply of. 169. paralysis of : adduction of

thumb in, 50.

points of election for palpa- tion, 62 (note}. sensory disturbances, 64. slow regeneration of, 77, 87. time for exploratory incisions,

80.

uncertainty of motor localisa- tion in, 128. paralysis, appliance for, 115.

with claw-hand, 115. wounds of, 163. Unilateral paralysis of trapezius

and serratus magnus, 156. Upper limb, the, contractures of, 135.

Van Lair's experiments, 6. Vascular lesions, 19. Vasomotor disturbances, 65.

as sign of severe lesion, 61.

in paralysis with contractures,

132. Vibratory massage, 92.

Wallerian degeneration, 2.

War, percentage, of nerve injuries

in, 72.

Weber, circles of, 22. Wrist-drop, appliances for correc- tion of, 101 et seq. Wrist joint, nerve-supply of, 171.

vascular branch for, 168. the, branches for articulation

of, 169.

the, flexion of, 50. the, rigidity of, 162.

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MILITARY MEDICAL MANUALS

A Series of handy and profusely illustrated manuals translated from the French under the general Editorship of the DIRECTOR- GENERAL of the Army Medical Service,

SIR ALFRED KEOGH

G.C.B., LL.D., M.D,, Hon. F.R.C.S., &c.

Each translation has been made by a practised hand, and is edited by a specialist in the branch of surgery or medicine covered by the volume.

It was felt to be a matter of urgent necessity to place in the hands of the medical profession a record of the new work and new discoveries which the war has produced, and to provide for everyday use a series of brief and handy mono- graphs of a practical nature.

The present series is the result of this aim. Each mono- graph covers one of the many questions at present of surpassing interest to the medical world, written by a specialist who has himself been in close touch with the progress which he records in the medicine and surgery of the war.

Each volume of the series is complete in itself, while the whole will form a comprehensive picture of the medicine and surgery of the Great War.

LONDON :

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Extract from

the Introduction by the General Editor, Sir Alfred Keogh.

THE special interest and importance, in a surgical sense, of the great European War lies not so much in the fact that examples of every form of gross lesion of organs and limbs have been seen, but is to be found in the enormous mass of clinical material which has been presented to us and in the production of evidence sufficient to eliminate sources of error in determining important conclusions. For the first time also in any campaign the labours of the surgeon and the physician have had the aid of the bacteriologist, the pathologist, the physiologist and indeed of every form of scientific assistance in the solution of their respective problems.

The achievements in the field of discovery of the chemist, the physicist and the biologist have given the military surgeon an advantage in diagnosis and treat- ment which was denied to his predecessors, and we are able to measure the effects of these advantages when we come to appraise the results which have been attained.

But although we may admit the general truth of these statements it would be wrong to assume that modern scientific knowledge was, on the outbreak of the war, immediately useful to those to whom the wounded were to be confided. Fixed principles existed in all the sciences auxiliary to the work of the surgeon, but our scientific resources were not immediately avail- able at the outset of the great campaign ; scientific work bearing on wound problems had not been arranged in a manner adapted to the requirements,

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were not fully foreseen ; for the workers in the various fields were isolated or had isolated themselves pursuing new researches rather than concentrating their power- ful forces upon the one great quest.

However brilliant the triumphs of surgery may be, and that they have been of surpassing splendour no one will be found to deny, experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research.

The series of manuals, which it is my pleasant duty to introduce to English readers, consists of translations of the principal volumes of the "Horizon" Collection which has been appropriately named after the uniform of the French soldier.

The views of great authorities, who derive their knowledge from extensive first-hand practical experience gained in the field cannot fail to serve as a most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and - its predominating note is the exhaustive, practical and up-to-date manner in which it is handled. It is marked throughout not only by a wealth of detail, but by clearness of view and logical sequence of thought. Its study will convince the reader that, great as have been the advances in all departments in the services during this war, the pro- gress made in the medical branch may fairly chal- lenge comparison with that in any other, and that not the least among the services rendered by our great Ally, France, to the common cause, is this brilliant contribution to our professional knowledge.

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MILITARY MEDICAL MANUALS

THE TREATMENT OF INFECTED WOUNDS

By A. CARREL and G. DEHELLY. Trans- lated by HERBERT CHILD, Capt. R.A.M.C., with Introduction by Sir ANTHONY A. BOWLBY, K.C.M.G., K.C.V.O., F.R.C.S.,

Surgeon-General Army Medical Service. With 97 illustrations in the text and six plates. Price, 55. net. Postage 5 d. extra.

"Is as fine an example of correlated work on the part of the chemist, the bacteriologist, and the clinician as could well be wished for, and bids fair to become epoch-making in the treatment of septic wounds.

" I am glad to take the opportunity of expressing the ap- preciation of British Surgeons at the Front of the value of what is known to us as Carrel's method. The book itself will be found to convey in the clearest manner the knowledge of those details which have been so carefully elaborated by the patient work of two years' experience, but it is only by scrupulous attention to every detail that the best results will be obtained . . .

"The utility of Carrel's method is not confined to recent wounds, and in the following pages those surgeons who are treating the wounded in Great Britain will find all the necessary in- formation for the treatment of both healthy and suppurating wounds." — From Sir Anthony Bowlbfs Introduction.

This volume is included by arrangement with Messrs. Bailliere, Tindall and Cox.

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MILITARY MEDICAL MANUALS THE PSYCHONEUROSES OF WAR

By Dr. G. ROUSSY, Assistant Professor in the Faculty of Medicine, Paris, and J. LHERMITTE, sometime Laboratory Director in the Faculty of Medicine, Paris. Edited by Colonel WIL- LIAM ALDREN TURNER, C.B., M.D., and Consulting Neurologist to the Forces in Eng- land. Translated by WILFRED B. CHRIS- TOPHERSON. With 13 full-page plates. Price, 6s. net. Postage $d. extra.

The Psychoneuroses of War being a book which is addressed to the clinician, the authors have endeavoured, before all else, to present an exact semeiology, and to give their work a didactic character.

After describing the general idea of the psychoneuroses and the methods by which they are produced, the authors survey the various clinical disorders which have been observed dur- ing the War, beginning with elementary motor disturbances and passing on through sensory disorders and disorders of the special senses to disturbances of a purely psychical char- acter. Under the motor system, affections such as paraplegia, the tics and disturbances of locomotion are detailed ; under the sensory system, pains and anaesthesias are passed in re- view ; under disorders of the special senses, deafness and blindness are studied ; then follows a detailed account of the visceral symptoms and finally some types of nervous attacks and lastly the psychical disorders.

A special chapter is given to a consideration of cerebral concussion and a review of the symptoms following the ex- plosion of shells in close proximity to the soldier. The book ends with a survey of the general etiology of the psycho- neuroses of war, the methods of treatment adopted and used successfully by the authors, and finally the points bearing upon the invaliding of the soldier and his discharge from the Army.

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MILITARY MEDICAL MANUALS

THE CLINICAL FORMS OF NERVE LESIONS

By Mme. ATHANASSIO BENISTY, House Physician of the Hospitals of Paris (Salpetriere), with a Preface by Prof. PIERRE MARIE. Edited with a Preface by E. FARQUHAR BUZZARD, M.D., F.R.C.P., Captain R.A.M.C.T., etc. With 81 illustrations in the text, and 7 full-page plates. Price, 6s. net. Postage $d. extra.

In this volume will be found described some of the most recent acquisitions to our knowledge of the neurology of war. But its principal aim is to initiate the medical man who is not a specialist into the examination of nerve injuries. He will quickly learn how to recognise the nervous territory affected, and the development of the various clinical features ; he will be in a position to pronounce a precise diagnosis, and to foresee the consequences of this or that lesion. In this way his task as military physician will be facilitated.

With this end in view considerable space has been devoted to the illustrations, which are intended to remind the physician of the indispensable anatomical elements, and the most striking clinical pictures. Numerous diagrams in black and white enable him to effect the essential work of localisation. The diagnosis of nervous lesions is thus facilitated.

A second volume will be devoted to the study of the lesions themselves, together with their restoration, and all the methods of treatment which are applicable to such lesions. This will appear immediately.

Together these volumes will represent a complete epitome of one of the principal departments of " war neurology."

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THE TREATMENT AND REPAIR OF NERVE LESIONS

By Mme. ATHANASSIO BEN1STY, House Physician of the Hospitals of Paris, with a Preface by Professor PIERRE MARIE, Members of the French Academy of Medicine. Edited by E. FARQUHAR BUZZARD, M.D., F.R.C.P., Captain R.A.M.C.T., etc. With 62 illustrations in the text and 4 full-page plates. Price, 6s. net. Postage $d. extra.

The other book published by Mme. Athanassio Benisty, which was devoted to the Clinical Features of Injured Nerves, explained the method of examination, and the indications which enable one to differentiate the injuries of the peripheral nerves. It is a highly practical guide, which initiates in the diagnosis of nervous lesions those physicians who have not hitherto made a special study of these questions. —This second volume is the necessary complement of the first. It explains the nature of the lesions, their mode of repair, their prognosis, and above all their treatment. It provides a series of particularly useful data as to the evolution of nerve-wounds — the* opportunities of intervention — and the prognosis of immediate complications or late sequelae.

But it is especially the application of prosthesis which constitutes the principal therapeutical innovation by which our "nerve cases " have benefited. All these methods of treatment ought to be made commonly known, and a large space has been reserved for them in this volume, which will not only furnish an important contribution to the science of neurology, but will enable the medical profession to profit by the knowledge recently acquired in respect of the diagnosis, prognosis, and treatment of nerve-wounds.

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MILITARY MEDICAL MANUALS THE TREATMENT OF FRACTURES

By R. LERICHE, Assistant Professor of the Faculty of Medicine, Lyons. Edited by F. F. BURGHARD, G.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France.

Vol. I. FRACTURES INVOLVING JOINTS.

With 97 illustrations from original and specially prepared drawings. Price, 6s. net. Postage $d. extra.

The author's primary object has been to produce a handbook of surgical therapeutics. But surgical therapeutics does not mean merely the technique of operation. Technique is, and should be, only a part of surgery, especially at the present time. The purely operative surgeon is a very incomplete surgeon in time of peace ; " in time of war he becomes a public disaster ; for opera- tion is only the first act of the first dressing."

For this reason Prof. Leriche has cast this book in the form of a compendium of articular therapeutics, in which is indicated, for each joint, the manner of conducting the treatment in the different stages of the development of the wound. In order to emphasize their different periods he has described for each articulation :

i. The anatomical types of articular wounds and their clinical development. — 2. The indications for immediate treatment at the front. — 3. The technical indications necessary for a good functional result. — 4. Post-operative treatment. — 5. The con- ditions governing evacuation. — 6. The treatment of patients who come under observation at a late period.

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MILITARY MEDICAL MANUALS THE TREATMENT OF FRACTURES

By R. LERICHE, Assistant Professor in the Faculty of Medicine, Lyons. Edited by F. F. BURGHARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France.

Vol.11. FRACTURES OF THE SHAFT. With 156 illustrations from original and specially pre- pared drawings. Price, 6s. net. Postage 5^. extra.

Vol. I. of this work was devoted to Fractures involving Joints ; Vol. II. (which completes the work) treats of Fractures of the Shaft, and is conceived in the same spirit — that is, with a view to the production of a work on conservative surgical therapeutics.

The author strives on every page to develop the idea that anatomical conservation must not be confounded with func- tional conservation. The two things are not so closely allied as is supposed. There is no conservative surgery save where the function is conserved. The essential point of the treatment of diaphysial fractures consists in the early operative disin- fection, primary or secondary, by an extensive sub-periosteal removal of fragments, based on exact physiological knowledge, and in conformity with the general method of treating wounds by excision. When this operation has been carefully performed with the aid of the rugine, with the object of separating and retaining the periosteum of all that the surgeon considers should be removed, the fracture must be correctly reduced and the limb immobilized.

For each kind of fracture the author has given various methods of immobilization, and examines in succession : the anatomical peculiarities — the physiological peculiarities — the clinical course —the indications for early treatment— the technical steps of the operations — and the treatment of those who only come under observation at a late period.

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FRACTURES OF THE LOWER JAW

By L. IMBERT, National Correspondent of the Societe de Chirurgie, and PIERRE REAL, Dentist to the Hospitals of Paris. With a Preface by Medical Inspector-General FEVRIER. Edited by J. F. COLTER, F.R.C.S., L.R.C.P., L.D.S. With 97 illustrations in the text and 5 full- page plates. Price, 6s. net. Postage ^d. extra.

Previous to the present war no stomatologist or surgeon possessed any very extensive experience of this subject. Claude Martin, of Lyons, who 'perhaps gave more attention to it than anyone else, aimed particularly at the restoration of the occlusion of the teeth, even at the risk of obtaining only fibrous union of the jaw. The authors of the present volume take the contrary view, maintaining that consolidation of the fracture is above all the result to be attained. The authors give a clear account of the various displacements met with in gunshot injuries of the jaw and of the methods of treatment adopted, the latter being very fully illustrated.

In this volume the reader will find a hundred original illus- trations, which will enable him to follow, at a glance, the various techniques employed.

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MILITARY MEDICAL MANUALS

FRACTURES OF THE ORBIT AND INJURIES OF THE EYE IN WAR

By FELIX LAGRANGE, Professor in the Faculty of Medicine, Bordeaux. Translated by HERBERT CHILD, Captain R.A.M.C. Edited by J. HERBERT PARSONS, D.Sc., F.R.C.S.,

Temp. Captain R.A.M.C. With 77 illustrations in the text and 6 full-page plates. Price, 6s. net. Postage $d. extra.

Grounding his remarks on a considerable number of obser- vations, Professor Lagrange arrives at certain conclusions which at many points contradict or complete what we have hitherto believed concerning the fractures of the orbit : for instance, that traumatisms of the skull caused by fire-arms produce, on the vault of the orbit, neither fractures by irradia- tion nor independent fractures ; that serious lesions of the eye may often occur when the projectile has passed at some distance from it. There are, moreover, between the seat of these lesions (due to concussion or contact) on the one hand, and the course of the projectile on the other hand, constant relations which are veritable clinical laws, the exposition of which is a highly original feature in this volume.

The book is thus far more than a mere "document," or a collection of notes, though it may appear both ; it is, on the contrary, an essay in synthesis, a compendium in the true sense of the word.

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MILITARY MEDICAL MANUALS

HYSTERIA OR PITHIATISM, AND REFLEX NERVOUS DISORDERS

By J. ^ BABINSKI, Member of the French Academy of Medicine, and J. FROMENT, Assistant Professor and Physician to the Hospitals of Lyons. Edited with a Preface by E. FARQUHAR BUZZARD, M.D., F.R.C.P., Captain R.A.M.C.T., etc. With 37 illustra- tions in the text and 8 full-page plates. Price, 6j.net. Postage $d. extra.

The number of soldiers affected by hysterical disorders is great, and many of them have been immobilized for months in hospital, in the absence of a correct diagnosis and the application of a treatment appropriate to their case. A precise, thoroughly documented work on hysteria, based on the numerous cases observed during two years of war, was therefore a necessity under present conditions. Moreover, it was desirable, after the discussions and the polemics of which this question has been the subject, to inquire whether we ought to return to the old conception, or whether, on the Other hand, we might not finally adopt the modern conception which refers hysteria to pithiatism.

This book, then, brings to a focus questions which have been especially debated ; it does not appeal exclusively to the neurologist, but to all those who, confronted by paralysis or post-traumatic contractures, convulsive attacks, or deafness provoked by the bursting of shells, have to grapple with the difficulties of diagnosis and ask themselves what treatment should be instituted. In it will be found all the indications which are necessary to the military physician, summarized as concisely as is possible in a few pages and a few illustrations.

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MILITARY MEDICAL MANUALS

WOUNDS OF THE SKULL AND THE BRAIN. Clinical forms and medico-surgical treatment.

By C. CHATELIN, and T. De MARTEL.

With a Preface by Professor PIERRE MARIE. Edited by F. F. BURGHARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France. With 97 illustrations in the text, and 2 full-size plates. Price, 6s. net. Postage 6d. extra.

Of all the medical works which have appeared during the war, this is certainly one of the most original, both in form and in matter. It is, at all events, one of the most individual. The authors have preferred to give only the results of their own experience, and if their conclusions are not always in conformity with those generally accepted, this, as Professor Pierre Marie states in his Preface, is because important advances have been made during the last two years ; and of this the publication of this volume is the best evidence.

Thanks to the method of radi9graphing the convolutions after filling the furrows, which has become sufficiently exact to be of real service to the clinician, the authors have been able to work out a complete and novel cerebral pathology, which presented itself in lamentable abundance in the course of their duties, which enabled them to examine and give continued attention to many thousands of cases of head injuries. Physicians and surgeons will read these pages with profit. They are pages whose substance is quickly grasped, which are devoid of any display of erudition, and which are accompanied by numerous original illustrations.

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LOCALISATION AND EXTRACTION OF PROJECTILES

By Assistant-Professor OMBREDANNE, of the Faculty of Medicine, Paris, and M. LEDOUX- LEBARD, Director of the Laboratory of Radi- ology of the Hospitals of Paris. Edited by A. D. REID, C.M.G., M.R.C.S., L.R.C.P., Major (Temp.) R.A.M.C., with a Preface on Extraction of the Globe of the Eye, by Colonel W. T. LISTER, C.M.G. With 225 illustrations in the text and 30 full-page photographs. Price, IDS. 6d. net. Postage 6d. extra.

Though intentionally elementary in appearance, this com- pendium is in reality a complete treatise concerning the localisation and extraction of projectiles. It appeals to surgeons no less than to radiologists.

It is a summary and statement — and perhaps it is the only summary recently published in French medical literature — of all the progress effected by surgery during the last two and a half years.

MM. Ombredanne and Ledoux-Lebard have not, however, attempted to describe all the methods in use, whether old or new. They have rightly preferred to make a critical selection, and — after an exposition of all the indispensable principles of radiological physics — they examine, in detail, all those methods which are typical, convenient, exact, rapid, or interesting by reason of their originality : the technique of localisation, the compass, and various adjustments and forms of apparatus. A considerable space is devoted to the explanation of the method of extraction by means of intermittent control, in which the complete superiority of radio-surgical collaboration is demonstrated.

Special attention is drawn to the fact that the numerous illus- trations contained in this volume (225 illustrations in the text and 30 full-page photographs) are entirely original.

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WOUNDS OF THE ABDOMEN

By G. ABADIE (of Oran), National Corre- spondent of the Societe de Chirurgie. With a Preface by Dr. J. L. FAURE. Edited by Sir ARBUTHNOT LANE, Bart., C.B., M.S., Colonel (Temp.), Consulting Surgeon to the Forces in England. With 67 illustrations in the text and 4 full-page plates. Price, 6s. net. Postage $d. extra.

Dr. Abadie, who, thanks to his past surgical experience and various other circumstances, has been enabled, at all the stations of the army service departments, to weigh the value of methods and results, considers the following problems in this volume, dealing with them in the most vigorous manner :

1. How to decide what is the best treatment in the case of penetrating wounds of the abdomen.

2. How to instal the material organisation which permits of the application of this treatment ; and how to recognize those conditions which prevent its application.

3. How to decide exactly what to do in each special case ; whether one should perform a radical operation, or a palliative operation, or whether one should resort to medical treatment.

This volume, therefore, considers the penetrating wounds of the -abdomen encountered in our armies under the triple aspect of doctrine, organisation, and technique.

We may add that it contains nearly 70 illustrations, and the reproductions of sketches specially made by the author, or photographs taken by him.

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WOUNDS OF THE BLOOD- VESSELS

By L. SENCERT, Assistant Professor in the Faculty of Medicine, Nancy. Edited by F. F. BURGH ARD, C.B., M.S., F.R.C.S. Formerly Consulting Surgeon to the Forces in France. With 68 illustrations in the text and 2 full-page plates. Price, 6s. net. Postage 5^. extra.

Hospital practice had long familiarised us with the vascular wounds of civil practice, and the experiments of the Val-de- Grace School of Medicine had shewn us what the wounds of the blood-vessels caused by modern projectiles would be in the next war. But in 1914 these date lacked the ratification of extensive practice. Two years have elapsed, and we have henceforth solid foundations on which to establish our treat- ment. This manual gathers up the lessons of these two years, and erects them into a doctrine.

In a first part, Prof. Sencert examines the wounds of the great vessels in general ; in a second part he rapidly surveys the wounds of the vascular trunks in particular, insisting on the problems of operation to which they give rise. " I should like it to be clearly understood," he concludes, " that the surgery of the blood-vessels is only a particular case of the general surgery of wounds received in war. There is only one war surgery : the immediate operative surgery which we have been learning for the last two years.

" This rule is never more imperative than in the case of vascular wounds. Early operation alone prevents deferred and secondary haemorrhage ; early operation alone can prevent the complications which are so peculiarly liable to result from the effusion of blood in the tissues ; early operation alone can obviate subsequent complications. Here, as everywhere, the true and useful surgery is a surgery of prophylaxis."

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MILITARY MEDICAL MANUALS

THE AFTER-EFFECTS OF WOUNDS OF THE BONES AND JOINTS

By AUG. BROCA, Professor of Topographical Anatomy in the Faculty of Medicine, Paris. Translated by J. RENFREW WHITE, M.B., F.R.C.S.,Temp. Captain R.A.M.C.,and edited by R. C. ELMSLIE, M.S., F.R.C.S.; Orthopedic Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's Auxiliary Hospital, Roehampton; Major R.A.M.C.T. With 112 illustrations in the text. Price, 6s. net. Postage $d. extra.

This new work, like all books by the same author, is a vital and personal work, conceived with a didactic intention. At a time when all physicians are dealing, or will shortly have to deal, with the after-effects of wounds received in war, the question of sequelae presents itself, and will present itself more and more.

What has become— and what will become — of all those who, in the hospitals at the front or in the rear, have hastily re- ceived initial treatment, and what is to be done to complete a treatment often inaugurated under difficult circumstances?

This volume successively passes in review : vicious calluses — prolonged and traumatic osteo-myelitis (infected stumps) — articular and musculo-tendinous complications — and "dis- solving " calluses — terminating by considerations of a practical nature as to discharged cases.

Profusely illustrated under the immediate supervision of Pro- fessor Broca, this volume contains 112 figures, all executed by an original process.

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MILITARY MEDICAL MANUALS

ARTIFICIAL LIMBS

By A. BROCA, Professor in the Faculty of Medicine, Paris, and Dr. DUCROQUET, Surgeon at the Rothschild Hospital. Edited and translated by R. C. ELMSLIE, M.S., F.R.C.S., etc. ; Orthopaedic Surgeon to St. Bartholomew's Hospital, and Surgeon to Queen Mary's Auxi- liary Hospital, Roehampton ; Major R.A.M.C.T. With 210 illustrations. Price, 6s. Postage 5^. extra.

The authors of this book have sought not to describe this or that piece of apparatus — more or less " new-fangled " — but to explain the anatomical, physiological, practical and technical conditions which an artificial arm or leg should fulfil. It is, if we may so call it, a manual of applied mechanics written by physicians, who have constantly kept in mind the anatomical conditions and the professional requirements of the artificial limb.

Required, during the last two years, to examine and equip with appliances hundreds of mutilated soldiers, the authors have been inspired by this guiding idea, that the functional utilisation of an .appliance should take precedence of considerations of external form. To endeavour, for aesthetic reasons, to give all subjects the same leg or the same arm is to risk disappoint- ment. The mutilated soldier may have a "show hand" and an every-day hand-implement.

The manufacturer will derive no less profit than the surgeon or the mutilated soldier himself from acquaintance with this compendium, which is a substantial and abundantly illustrated volume. He will find in it a survey and a reasoned criticism of mechanisms which notably display the ingenuity of the makers — from the wooden " peg " of the poor man, together with his " best " leg and foot, to the artificial limb provided with the very latest improvements.

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TYPHOID FEVERS AND PARA- TYPHOID FEVERS (Symptomatology, Etiology, Prophylaxis)

By H. VINCENT, Medical Inspector of the Army, Member of the Academy of Medicine, and L. MURATET, Superintendent of the Labora- tories at the Faculty of Medicine of Bordeaux. Second Edition. Translated and Edited by J. D. ROLLESTON, M.D. With tables and tempera- ture charts. Price, 6s. net. Postage 5^. extra.

This volume is divided into two parts, the first dealing with the clinical features and the second with the epidemiology and prophylaxis of typhoid fever and paratyphoid fevers A & B. The relative advantages of a restricted and liberal diet are discussed in the chapter on treatment, which also contains a description of serum therapy and vaccine therapy, and general management of the patient.

A full account is to be found of recent progress in the bac- teriology and epidemiology of these diseases, considerable space being given to the important question of the carrier in the dissemination of infection.

The excessive frequency of typhoid fever in war time is demonstrated by a sketch of its history from the War of Secession of 1861-1866 down to the present day.

The concluding chapter is devoted to preventive inoculation, the value of which is proved by the statistics of all countries in which it has been adopted.

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MILITARY MEDICAL MANUALS

DYSENTERIES, CHOLERA, AND EXANTHEMATIC TYPHUS

By H. VINCENT, Medical Inspector of the Army, Member of the Academy of Medicine, and L. MURATET, Director of Studies in

»

the Faculty of Medicine, Bordeaux. With an Introduction by Lt. Col. ANDREW BALFOUR, C.M.G., M.D. Edited by GEORGE C. LOW, M.A., M.D., Temp. Captain I.M.S. Price, 6s. net. Postage $d. extra.

This, the second of the volumes which Professor Vincent and Dr. Muratet have written for this Series, was planned, like the first, in the laboratory of Val-de-Grace, and has profited both by the personal experience of the authors and by a mass of recorded data which the latter years of warfare have very greatly enriched. It will be all the more welcome as hitherto there has existed no comprehensive handbook treating these great epidemic diseases from a didactic point of view. The articles scattered through the reviews, or memoirs buried in the large treatises, did not respond to the need which was felt by the military physician, in France as well as in distant expeditions, of a work which should bring to, a common focus a number of questions which were, in general, very imperfectly understood.

The authors review, in succession, the Clinical details, the Epide- miology, and Prophylaxis of Dysenteries, Cholera, and Typhus. In the section dealing with Prophylaxis, in particular, will be found practical advice as to the special hygiene possible in the case of large collections of people placed in conditions favourable to the development of these diseases.

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MILITARY MEDICAL MANUALS

ABNORMAL FORMS OF TETANUS

By MM. COURTOIS-SUFFIT, Physician of the Hospitals of Paris, and R. GIROUX, Resident Professor. With a Preface by Professor F. WIDAL. Edited by Surgeon-General Sir DAVID BRUCE, C.B., F.R.S., LL.D., F.R.C.P., etc., and FREDERICK GOLLA, M.B. Price, 6s. net. Postage $d. extra.

Of all the infections which threaten our wounded men, tetanus is that which, thanks to serotherapy, we are best able to prevent. But serotherapy, when it is late and insufficient, may, on the other hand, tend to create a special type of attenuated and localised tetanus ; in this form the contractions are as a general rule confined to a single limb. This type, however, does not always remain strictly monoplegic ; and if examples of such cases are rare this is doubtless because physicians are not as yet very well aware of their existence.

We owe to MM. Courtois-Suffit and R. Giroux one of the first and most important observations of this new type ; so that no one was better qualified to define its characteristics. This they have done in a remarkable manner, supporting their remarks by all the documents hitherto published, first expounding the characteristics which individualise the other atypical and partial types of tetanus, which have long been recognized.

The preventive action of anti-tetanic serum should not cause us to disregard its curative action, the value of which is incontest- able. However, a specific remedy, even when a powerful specific, cannot act upon all the complex elements which constitute a disease ; and tetanus presents itself, in the first place, as an affection of the nervous system. To contend with it, therefore, a symptomatic medication should come to the aid of a pathogenic medication. — Professor WidaL

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MILITARY MEDICAL MANUALS

SYPHILIS AND THE ARMY

By G. THIBIERGE, Physician of the Hopital Saint-Louis. Edited by C. F. MARSHALL, F.R.C.S. Price, 6s. net. Postage $d. extra.

It seemed, with reason, to the editors of this series that room should be found in it for a work dealing with syphilis considered with reference to the army and the present war.

The frequency of this infection in the army, among the workers in munition factories, and in the midst of the civil population where this is in contact with soldiers and mobilized workers, makes it, at the present time, a true epidemic disease, and one of the most widespread of epidemic diseases.

Dr. Thibierge, whose previous labours guarantee his peculiar competence in these difficult and important questions, has, in writing this manual, very notably assisted in this work.

But the treatment of syphilis has, during the last six years, undergone considerable modifications ; the new methods are not yet very familiar to all physicians ; and certain details may no longer be present to their minds. It was therefore opportune to survey the different methods of treatment, to specify their indications, and their occasionally difficult technique, which is always important if complications are to be avoided. It was necessary before all to state precisely and to retrace, for all those who have been unable to follow the recent progress of the therapeutics of venereal diseases, the characters and the diagnostic elements of the manifestations of syphilis.

Of late years, moreover, new methods of examination have entered into syphilitic practice, and these were such as to merit exposition while the old elements of diagnosis were recalled to the memory.

In short, this little volume contains those essentials which will enable the physician to accomplish the entire medical portion of his anti-syphilitic labours ; it will also provide him with the elements of all the medical and extra-medical advice which he may have to give the civil and military authorities in order to arrive at an effective prophylaxis of this disease.

It is therefore a real practical guide, a vade-mecum of syphili- graphy for the use of civil or military physicians.

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MILITARY MEDICAL MANUALS

WAR OTITIS AND WAR DEAF- NESS* Diagnosis, Treatment, Medical Reports*

By Drs. H. BOURGEOIS, Oto-rhino-laryngolo- gist to the Paris hospitals, and SOURDILLE, former interne of the Paris hospitals. Edited by J. DUNDAS GRANT, M.D., F.R.C.S. (Eng.); Major, R.A.M.C., President, Special Aural Board (under Ministry of Pensions). With many illustrations in the text and full-page plates. Price, 6s. net. Postage $d. extra.

This work presents the special aspects of inflammatory affections of the ear and deafness, as they occur in active military service. The instructions as to diagnosis and treatment are intended primarily for the regimental medical officer. The sections dealing with medical reports (expertises) on the valuation of degrees of disablement and claims to discharge, gratuity or pension, will be found of the greatest value to the officers of invaliding boards.

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MILITARY MEDICAL MANUALS

MALARIA :

Clinical and Haematological Features*

Principles of Treatment*

By P. ARMAND-DELILLE, P. ABRAMI, G. PAISSEAU and HENRI LEMAIRE. Preface by Prof. LAVERAN, Member of the Institute. Edited by Sir RONALD ROSS, K.C.B., F.R.S., LL.D., D.Sc., Lieut.-Col. R.A.M.C. With illustrations and a coloured plate. 6s. net. Postage 5</. extra.

This work is based on the writers' observations on malaria in Macedonia during the present war in the French Army of the East. A special interest attaches to these observations, in that a considerable portion of their -patients had never had any previous attack. The disease proved to be one of exceptional gravity, owing to the exceptionally large numbers of the Anopheles mosquitoes and the malignant nature of the parasite (plasmodium falciparum). Fortunately an ample supply of quinine enabled the prophylactic and curative treatment to be better organised than in previous colonial campaigns, with the result that, though the incidence of malaria among the troops was high, the mortality was exceptionally low. Professor Laveran, who vouches for this book, states that it will be found to contain excellent clinical descriptions and judicious advice as to treatment. Chapters on parasitology and the laboratory diagnosis of malaria are included.

Further volumes for this series are under consideration, and future announcement will be made as soon as possible.

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DISEASES OF WOMEN

By THOMAS GEORGE STEVENS, M.D., B.S. (Lond.), F.R.C.S. (Eng.), M.R.C.P. (Lond.) ; Obstetric Surgeon, with charge of out-patients, St. Mary's Hospital, Paddington ; Surgeon (Gynaecological), the Hospital for Women, Soho Square ; Physician to in-patients, Queen Charlotte's Lying-in Hospital ; Examiner to the Central Midwives' Board. With 202 illustrations. Price, 155. net. Postage 6d. extra.

"... The whole book is a refreshingly good one ; there is no chapter in it that the student or practitioner can read without profit, and it is particularly strong in its pathology. The illustrations are good, and the plan Dr. Stevens has adopted of reproducing his large microphotographs by direct photography upon a plate exposed in the rays of the epidiascope is certainly a success. . . "—Lancet.

" May certainly claim to be regarded as a good textbook in

which the student and practitioner will find much valuable

information. . . .

"The manual presents a genuine attempt to deal with the

subject in an up-to-date manner. . . .

"The author has handled the subject rationally and the

treatment suggested is well considered. The language of

the book is concise, it is well printed, and the text interspersed

by numerous illustrations, which are not only interesting but

useful." — British Medical Journal .

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MENTAL DISEASES. A Text-book of Psychiatry for Medical Students and Practitioners*

By R. H. COLE, M.D. (Lond.), M.R.C.P. ; Physician for Mental Diseases to St. Mary's Hospital ; Examiner in Mental Diseases and Psychology, University of London. With 52 illustrations and x plates. Price, los. 6d. net. Postage 6d. extra.

" There is a breadth of view, a comprehensiveness of plan, and a surprising completeness of detail in little space, and its numerous illustrations and plates are decidedly good. ... A plain and very readable book, and of special service to the student and the busy practitioner." — -Journal of Mental Science.

"The details of general treatment and management of patients suffering from various forms of insanity are complete and practical . . . excellently illustrated." — British Medical Journal.

"It is not often one finds a book which one does not think could be improved. But we think in this instance such a book lies before us. Dr. Cole has treated 'his subject very fully. Apart from the mere classification of insanity its diagnosis, prognosis, and treatment, he gives us some inter- esting information concerning sanity, consciousness, sleep, memory, and so forth, which cannot fail to be of value. We can cordially recommend this book." — St. Bartholomew's Hospital Journal.

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THE MEDICAL DISEASES OF CHILDREN

By T. R. C. WHIPHAM, M.A., M.D. (Oxon), M.R.C.P. ; Physician to the Evelina Hospital for Sick Children ; Assistant Physician and Physician-in-charge of the Children's Department at the Prince of Wales's Hospital ; Lecturer on Diseases of Children at the North-East London Post-Graduate College. With 67 illustrations. Price, IQS. 6d. net. Postage 6d. extra.

" This new work on the Medical Diseases of Children is a plain, straightforward account of the common complaints to which infants and young children are subject. ... As a late Secretary, and always an active member of the Children^ section of the Royal Society of Medicine, the Author records his experiences in these associations on almost every page of his work. . . . Owing to its general accuracy and temperate views, this new work on the Medical Diseases of Children is a perfectly safe work to put into the hands of a student." — Lancet.

DISEASES OF THE EAR, NOSE, AND THROAT

By GEORGE NIXON BIGGS, M.B., B.S.

(Durh.), Consulting Aural Surgeon, Evelina Hos- pital for Sick Children ; Surgeon-in-charge, Ear and Throat Department, Royal Waterloo Hospital for Women and Children ; Assistant Surgeon, Ear and Throat Department, Seamen's Hospital (Dreadnought) Greenwich. With 108 illustrations. Price, ioj. 6d. net. Postage 6d. extra.

" Intending operators will hardly find a book with more lucid diagrams than those in this volume, while their frequency enables the steps of any procedure to be followed with a facility as nearly equal as possible to that of actual individual tuition."— Hospital.

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By WILLIAM TURNER, M.S., F.R.C.S., Lecturer on Clinical Surgery, London School of Clinical Medicine (Post-Graduate) ; Consulting Surgeon, Royal Hospital for Diseases of the Chest, etc. ; and E. ROCK CARLING, B.S., F.R.C.S., Senior Teacher of Operative Surgery, London School of Clinical Medicine (Post- Graduate) ; Surgeon (in charge- of out-patients), Westminster Hospital.

With A CHAPTER ON THE EYE

by L. V. CARGILL, F.R.C.S., Senior Oph- thalmic Surgeon and Lecturer in Ophthalmology, King's College Hospital ; Surgeon, Royal Eye Hospital. With illustrations and photographs. Price, IDS. 6d. net. Postage 6d. extra.

"... A very practical book which cannot but prove of the greatest value in the daily work of the practitioner. In this book he will find what he wants." — Lancet.

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MINOR SURGERY

By LEONARD A. BID WELL, F.R.C.S., Senior Surgeon to the West London Hospital, Dean of the Post-Graduate College, Consulting Surgeon to the Blackheath and Charlton Hospital and to the City Dispensary, and Author of " Handbook of Intestinal Surgery." Second Edition, revised and enlarged. With 129 illustrations. Price, \os.6d. net. Postage 6d. extra.

". . . . The second edition has been greatly enlarged and discreetly revised. . . . We may say at once that it is greatly improved. It is larger, but lighter, and its scope is wider. . . . The practitioner will find much pleasure in reading this book, and he will profit the more he studies it, for in it he will find guidance in the use of old methods, and many suggestions for efficient employment of the new." — British Medical Journal.

THE DISEASES OF THE SKIN

By WILLMOTT EVANS, M.D., B.S., B.Sc., F.R.C.S., Surgeon to the Royal Free Hospital, and Surgeon to the Skin Department, Royal Free Hospital ; Senior Surgeon to the Hospital for Diseases of the Skin, Blackfriars* With 32 illustrations. Price, los. 6d. net.

" Although he has written a comparatively short book, he has produced a very complete treatise, for practically every patho- logical condition of the skin receives its meed of attention . . . "The illustrations, which are almost all original, are suitable, good, and well produced . . ." — British Medical Journal.

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LONDON MEDICAL PUBLICATIONS DISEASES OF THE EYES

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"Cannot fail to be a boon to every student' and general practitioner into whose hands it falls. There are so many excellent manuals on ophthalmology written, in the English language that it seemed as though there could be no place for another, and yet, now that we have this book in our hands, we feel that it has given the student exactly what he requires. . . . Judging the book by the standard necessary for the student and the general practitioner we can give it the highest praise and can confidently recommend it." — British Medical Journal.

APPLIED PATHOLOGY. Being a Guide to the Application of Modern Patho- logical Methods to Diagnosis and Treatment

By JULIUS M. BURNFORD, M.B. (Lond.), D.P.H. (Camb.), M.R.C.P.; Assistant Physician (late Pathologist) to the West London Hospital ; Lecturer in Clinical Pathology to the Post- Graduate College ; Physician to the Putney Hospital and to the Royal Ear Hospital ; Lecturer in Bacteriology to the Westminster Hospital Medical School, etc. Illustrated with five coloured plates and 46 drawings. Price, los. 6d. net.

" The whole tone of the book is practical, and as a summary of up-to-date knowledge in this branch is thoroughly trust- worthy."— Lancet.

"The book is one which may be strongly commended as a guide to the newer applications of pathological methods to the elucidation of clinical problems." — British Medical Journal.

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ANESTHESIA AND ANALGESIA

By J. D. MORTIMER, M.B. (Lond.), F.R.C.S. (Eng.) ; Anaesthetist, Royal Waterloo Hospital ; Throat Hospital, Golden Square ; St. Peter's Hospital for Stone, etc. ; Instructor, Medical Graduates' College. Super Royal i6mo. Illus- trated. Price, 6s. net.

" Mr. Mortimer's description of the various methods of adminis- tration are admirably clear and practical. . . . The book has, we think, very well accomplished what its author set himself to achieve." — Lancet.

THE PRINCIPLES AND PRACTICE OF MEDICAL HYDROLOGY. Being the Science of Treatment by Waters and Baths

By R. FORTESCUE FOX, M.D. (Lond.), F.R.Met.Soc., late Hyde Lecturer on Hydro- logy, Royal Society of Medicine. Price, 6s. net.

" The whole science of treatment by waters and baths is dealt with in a thoroughly scientific spirit. . . . Dr. Fox's book is comprehensive. , . . The whole book may be commended as a most useful and trustworthy guide to the use of baths and waters, and it may be especially directed to the notice of medical men in charge of spa establishments." — British Medical Journal.

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THE UNIVERSITY OF LONDON PRESS has been founded in close relationship with the University of London with a view to its doing- for London, what has been done for the Universities of Oxford and Cambridge by their respective Presses.

London teaching has in the past exerted a profound in- fluence on medical thought and practice, and in presenting* the series of London Medical Publications to the Profession, the Directors of the Press think it well to state the principles by which they have been guided and the general aim of the works in question.

The writers have been exclusively selected from among those who are London teachers, graduates or physicians or • surgeons to hospitals, general or special, within the statu- | tory London area of the University. Each writer has special knowledge and experience in the subject on which he writes.

The books are intended to be essentially practical manuals for Practitioners, of sufficient length to omit no important feature, but as concise as is consistent with lucidity.

They are freely illustrated, many drawings and photo- graphs having been made specially for the purpose. Elaborate discussions of unproved theories and conflicting views have been carefully avoided, the authors in each case giving the result of their own experience and an account of the treatment they themselves adopt.

It is hoped by these means to present a fair view of the present London Medical thought and practice, and to pro- vide practitioners with a series of works, giving reliable and easily accessible information in the various departments of Medicine and Surgery.

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