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Associate in Neurology. Columbia University, 
Assistant Surgeon, New York Neurological Institute, 
Professor of Neurosurgery, New YorL Posi-Graduaic Medical School and Hospital 

With a Chapter on 




Professor of Anatomy and Director of Anatomical LabomtorieSa University of Michigan 




1»i THE MtMMl 



No surgical treatment of peripheral nerves can be intelligently undertakne 
without an eye on their anatomical and physiological connections with the 
central nervous system. Nerves cannot be considered as independent peri- 
pheral structures, as are muscles and tendons, but rather as peripheral parts of 
the central nervous system, in close association and intimate relation with the 
latter. The surgical treatment of peripheral nerves is closely allied to the 
surgery of the brain and spinal cord and forms the third division of the surgery 
of the nervous system. While the brain and spinal cord have received great 
attention the peripheral nerves have been singularly neglected and surgical 
practices have been evolved ill adapted to nerves, their special histology and 
special manner of repair. An attempt has been made to examine critically 
and make use of researches and investigations in the anatomy and physiology 
of peripheral nerves which have a direct bearing on their treatment and should 
form a basis for it. In the first number of the Archives of Surgery Dr. William 
Mayo has aptly said that "The philosophy of surgery has lagged and opera- 
tions based on unsupported opinions as to their wisdom or necessity are too 
frequently advocated." If this be true for general surgery it is more particu- 
larly true for peripheral nerve surgery where methods have been employed 
without sufficient regard for the embryology, anatomy, physiology or clinical 

The aim of this book has been to give principles and methods whose 
foundations are laid in embryology, anatomy, and physiology as well as in 
experimental work, and in clinical practice, and to advocate the use only of 
such procedures as have been shown by such criteria to be of value. It is not 
sufficient to be familiar with the gross anatomy alone, for the microscopic 
anatomy must also be pictured. In peripheral nerve surgery it is, perhaps, this 
particular phase which is especially needed and has been too often wanting. 
The technic of nerve surgery is the more successful the nearer it approaches 
what might be termed histological surgery. Considerable attention has been 
given to the fallacies of certain practices in nerve surgery and it is hoped that 
these have been shown sufficiently to indicate their futility and to warrant the 
author's contention that they be discarded. Stress at times has been placed on 

understanding of 

the comparative anatomy and embryology, for only by an understanding o 
these can a broad conception of peripheral nerves and their surgery be gained. 
The more general neurological aspects of peripheral nerves, including the 
various syndromes, motor, electrical and sensory have been so admirably treated 
by Tinel and Anasthasio-Benisty that no attempt has been made to parallel 
these excellent works; but rather to present the surgical and mechanical phases 
of peripheral nerves, barely treated by these authors. The motor changes in 
nerve injuries which underlie the various deformities are dealt with so that intel- 
ligent mechanical treatment may be undertaken. The importance of measures 
other than surgery has been emphasized for they are felt to be essential for a 
successful outcome of any purely surgical measure. Most of these principles 
the author was privileged to learn while temporary assistant during 1915-1016 
to Sir Robert Jones, whose teachings it is agreed are so fundamentally sound. 
Nerve crossing in anterior poliomyelitis has not been dealt with since the 
author does not advocate its use. 

I feel particularly honored to have the chapter on "Nerve Degeneration 
and Regeneration" written by Dr. G. Carl Huber Professor of Anatomy, Uni- 
versity of Michigan, whose brilliant researches in peripheral nerves in 1895 
and since have been epoch making. It was a distinct pleasure to have had the 
opportunity to work with him during part of his latter experimental work and to 

I am glad to thank Miss Salome Slingluff for her cooperation and skill 
in interpretation in making the illustrations, and Miss Etta R. Schamberg for 
her willingness and painstaking work with the manuscript, and the publishers 
Messrs. Saunders Company for their interest and valuable cooperation in many 

Byron Stookey. 




Anatomy I7 

Formation of Ventral and Dorsal Roots — Ventral and Dorsal Primary Divisions — Com- 
parative Anatomy — Motor and Sensory Components Distinct — Formation of Mixed 
Nerve — Early Intermingling of Nerve Fibers — Histology: — Neuraxis — Medullated and 
Non-medullated Fibers — Nerve Trunk: — Development — Formation of Ganglionic Crest — 
Cellular Changes in Ganglionic Crest — Formation of Primitive Dorsal Root — Segmentation 
of Ganglionic Crest — Formation of Ventral Root — Migration of Sheath Cells — Origin of 
the Neuraxis — Migration of the Sympathetic Cells — Formation of the Gray and White 
Rami Communicantes — Theoretical Importance of Funicular Anatomy — Evidence not 
in Support of Stoffel's View — Definite Funicular Arrangement Only in Restricted Portions 
of the Nerve Trunk — Results of Dissection of Macerated Specimens — Funicular Identifica- 
tion by Bi-polar Stimulation — Limitations of Bi-polar Stimulation — Internal Nerve Plexuses 
— Axial Rotation. 


Nerve Degeneration and Regeneration 4I 

Historical — Modern Methods — Experimental Embryology — Modern Staining Methods — 
Monogenetic and Autogenetic Theories of Regeneration — Experimental Evidence Supports 
Monogenetic Theory — Degeneration of Medullated Nerve Fibers — Degeneration of Non- 
medullated Fibers — Degeneration of Nerve Endings in Muscle — Changes at the Point of 
Injury — Abortive Regeneration — Behavior and Fate of the Neurolemma Sheath — Regenera- 
tion of a Peripheral Nerve — Secondary Hole of the Sheath Cell — Doubtful Chemo tactic 
Influence — Selectivity of Motor or Sensory Regenerating Fibers not Found — Formation of 
the Medullary Sheaths and Neurolemma — Nerve Transplantation — Fresh Transplants — 
Preserved Transplants — Heterotransplants. 


Methods of Nerve Repair 8o 

Standardization of Terms— Use of Specific Terms Recommended — Methods to be Dis- 
carded — Nerve Flap, Technical Considerations, Experimental Results — Suture a Distance, 
Histological Basis of Method — Nerve Implantation, Critic of the Method, Its Value — 
Methods Available: — End-to-end Suture, Funicular Suture — The Ideal Suture — Nerve 
Crossing, Correspondence in Function Essential, Dissociation of Associated Movements 
Desirable — Nerve Transplantation, Clinical Results, Experimental Results, Failure Possibly 
Due to Technical Faults in Suture, Re-exploration of Graft Indicated — Preserved Grafts — 
Methods to Diminish Nerve Gaps: — Mobilization of Nerve Ends — Importance of Wide 
Exposure — Nerve Stretching, Limitations and Dangers — Two Stage Operation — Trans- 
position, Advantages and Uses — Resection of Bone. 


Direct Nerve Implantation and Direct Muscular Implantation II2 

Direct Nerve Implantation in Human Surgery — Experimental Evidence in Support of 
Method — Hyperneurotization — Direct Muscle Implantation in Human Surgery — Experi- 
mental Evidence in Support of Method — Further Experimental and Clinical Studies 





Tubular Sulur^ (Men a Single Large Path tor Downgrowing NWuscs-Tubuiimum | 
Mean* of Nwve Illation -Decalcified Bone Tubes, Disadvantages-Hardened Artei 
[eapoftMCJ i,f Blank Uyer— Technk of Arterial Tubulization— The Use of Fresh Bl 
Vcwcl, Implantation into Veins In Situ- Magnesium Tubes-Gelatine Tubes-Gala 
Tuba A|W lube -Rubber Tubes -Objection to Certain Met hods- Facial Tubul 
tion, UfldUtblMi DtUfttfr-CMgile Membranc-Huber's Alcoholized Cargilc Membra. 



Inhibition ..I Nerve Conductivity Without Destruction of Nerve Fiber— Sources of Nei 
I'ri'Miirr Nrrve Coniiiasion -Flcclnc Examination of Nerve Trunk— Injection of S 
Solution us ■ Muni <•! Internal Liberation -Nerve Liberation w Nerve Suture— Techi 
D | Nerve Liberation Results. 


■ u\ \\u\i Si rrai 

I'oiltlon nf the Pallet) I Suture Materials Inslrumenls— Anesthetic— Genera! Operali 
In hnli Special Incisions The Skin Incision— Nerve Stretching — Level of Suture 
IVi I I Km I in l'iuI Suture Technic of Nerve Crossing —Partial Nerve Crossing 

Value i'l t'niopli'tr lli-1i>r\ Local Examination Importance of Data Obtained by Foe 
Kxantlnallmi Senaor) Kxamfnation Discussion ol Terms — Technic of Examinatia 
Limitations KeturnlnM Senaaikin Relation of N'on-medultated Fibers to Pain an 
IViniiciiiiiiie Mot. ii l-viiinouitn'ii IniiMrtnnce ol Individual Muscle Action— Elcctr 
I v.iiiiih.umi, 1 ithKiludtn&l Reaction Polar Equality— Reaction of Complete Dcgcner; 
ii.iii liii|,v hi I l.vuic l\;tmiti;iimri Diagnostic Value Signs of Rcgcneration- 
NeoMllr-lh mid Paleokinetic MKi- m Peripheral Xetvcs— Functional Differences ( 
Sarw|Ai«m ami Sarvoalvtcs Unci's Sijtn, lis Limitations o ol Regeneration Folio* 

Inn sunn, Intermitted RcimWra I and Rro|icrMion Criteria ror Estimating Result 

■ ■i Nerve Suture, I'tow ol tV"l<«w RoicncMiion Without Oj-.- rati on— Early Mere 
1 v|-l,ii,,M,.i> Value ol know in* ViMlnniieal '■ ■ ns ©f Xerve Esptomtion- 

Ws W „i i ,,,i\ IliM-niliou Factors Interferine aitli Successful Repencratbn- 

i ...'il'i.-l >iiti\v Impulse* Miwi i K 

linri'i k in - . [1 - M«dawW TreMment- 

( .^mDcnerv 

^ , lM iment-Ut. 

>■.. , _ :. .. :. Operation— Asao 




Facial Nerve 197 

Importance of Facial Musculature — Experimental Facial Nerve Crossing — Spinofacial 
Crossing — Hypoglossofacial Crossing — Advantages of Hypoglossofacial Suture — Ana- 
tomical and Physiological Considerations — Embryological Development of the Hypo- 
glossal Xcrve and the Descendens Hypoglossi — Operative Indications — Traumatic Injuries 
— Bell's Palsy — Congenital Mal-dcvelopment of Facial Nerve — Operative Technique — 
Exposure of Facial Nerve — Exposure of Spinal Accessory Nerve — Hypoglossofacial Suture 
— Exposure of Hypoglossal Nerve — Technic of Implantation — Mechanical Treatment. 


Brachial Plexus 220 

Relation of the Brachial Plexus to the Development of the Upper Extremity — Embryology 
of the Brachial Plexus — Anatomical Consideration of the Brachial Plexus — Motor Root 
Supply to the Muscles of the Upper Extremity — Post-fixed and Pre-fixed Types of Plexus — 
Anatomical Types of Brachial Plexus Injuries — Mechanism of Shoulder Girdle Move- 
ments — Upper Radicular, Duchennc-Erb Type of Injury, Deformity, Mechanical Treat- 
ment — Middle Radicular Injury — Lower Radicular or Duchenne-Aran Type, Mechanical 
Treatment — Obstetrical Paralysis — Etiology — Secondary Injury of the Spinal Cord — 
Pathology — Mechanical Treatment — Deformity — Duration of Treatment — Late Mechani- 
cal Treatment — Reeducation — Exercises — Time of Operation — Operative Technic — 
Surgical Treatment in Neglected Cases — Brachial Plexus Injuries in Adults, Pathology, 
Treatment — Cervical Rib — Probable Cause of Late Appearance of Symptoms — Deformity 
— Cause of Vascular Disturbances — Sensory Changes — Mechanical Treatment — Surgical 


Musculospiral and Circumflex Nerves 265 

Anatomy — Course — Variations in Course — Branches — Terminal Branches — Nerve Plexuses 
Anomalies in Distribution — Deformity in Complete Injuries of Dorsal Cord, Mechanical 
Treatment — Deformity in Musculospiral Nerve Injuries, Mechanical Treatment — Disso- 
ciated Paralysis of the Musculospiral Nerve — Exposure — Position of the Arm — Incision — 
Exposure in the Arm — Special Incisions — Perpendicular Course of the Nerve — Exposure 
of the Posterior Interosseous Nerve — Transposition of the Musculospiral Nerve — Comment 
— Circumflex Nerve — Course — Branches — Exposure in the Axilla — Exposure at the 
Surgical Neck — Deformity — Mechanical Treatment. 


Musculocutaneous Nerve 302 

Anatomy — Course — Branches — Anomalies of the Musculocutaneous and Median Nerves — 
Varieties of Communications — Deformity, Mechanical Treatment — Exposure in the Axilla 
— Exposure of Secondary Cords of the Brachial Plexus — Exposure of the Musculocutaneous 
in the Arm — Comment. 


Median Nerve 316 

Anatomy — Course — Variations in Formation and Course — Branches— Motor Branches, 
Lower Part of the Arm, Forearm, Wrist — Anomalies of the Median and Ulnar Nerves — 
Varieties of Communications — Clinical Evidence of Communications— Deformity, Mechani- 
cal Treatment — Exposure of the Median Nerve — Position of the Arm — Incision — 
Exposure at the Elbow — Exposure at the Wrist — Comment. 


Ulnar Nerve 

Anatomy — Course — Branches — Funicular Anatomy— Deformity, Mechanical Treatment- 
Exposure of the Ulnar Nerve in the Arm — Position of the Patient— Incision — Exposure f 
the Elbow— Incision— Exposure in the Forearm— Exposure at the Wrist— Injuries Asst 
dated with Fracture of Medial Condyle — Comment. 



Embryologies I Development — Relation to Development of Lower Limb— Torsion c 
Lower Limb— Variations in Segmental Distribution — Prefixed and Post-fixed Varieties- 
Injury to IhcLumbo-sacral Plexus. 


Scutii; Nerve 

Anatomy — Course — Branches— Funicular Anatomy of the Peroneal Division — Funicula 
Anatomy of the Tibial Division — Exposure of the Sciatic Nerve— Position of the Patient- 
Exposure of the Upper Third— Exposure in the Thigh — Exposure in the Popliteal Space— 
Exposure of the Tibial Nerve — Exposure of the Internal and External Plantar Nerves— 
Eijiosure of the Peroneal Nerve — Transposition of Peroneal Xervr— Deformity in Sciath 
Nerve Injuries — Mechanical Treatment— Comment. 


Nihvis lNikrui l:ntly Injured 

Recurrent Laryngeal Nerve: —Suture — Direct Implant .11 ii-n lit illogical Factors ir 
Recurrent Laryngeal Paralysis - Spinal \civ*»nry Nerve.— Syndrome of the Foramer 
Lacerum— Anatomy— Course — Variations — Deformity Mechanical Treatment— Expo 
sure l.'irii: Tlioraeic Nerve \n atomy 1 ktormity Mechanical Treatment — Exposure — 
Supra scapular Nerve: — Anatomy -Deformity- -Mechanical Treatment— Exposure — 
Anterior Crural Nerve:— Surgical Treatment — Deformity— Mechanical Treatment — 
Obturator Nerve: -Exposure 1 leformity— Superior and Inferior Gluteal Nerves:— 


Xervb Ti-Moas. 

Xeuroma Fibroma Location (Vie Relation to Neuroses — Treatment — Plexiform 
Neurofibroma Malicnanl Defeneration Frequent; - Differentiation Between Primary 

. Primary \\-uro-.jtiom:i - — Treatment — 


■ ! ■ VK-.ihol in Faeial XerA-e— Selective Action on Sensory Fibers Use of Alcohol 

S S; Causa f ■ ■■ ilar Sympathetectomji — 

■ - - m; 1 igatuie oj .. Nerve, in Causalgia. 





A typical peripheral nerve is made up of neuraxes from nerve cells either 
within the brain stem and spinal cord, or from cells of the spinal, cranial and 
sympathetic ganglia. If a nerve contains processes only from motor cells of the 
brain stem or cord it is known as an efferent or motor nerve, and if processes 
only from sensory cells, an afferent or sensory nerve. Rarely can this absolute 
distinction be made; even in so-called pure motor nerves some afferent proprio- 
ceptive fibers may be present as well as sympathetic postganglionic fibers to 
glands, etc. Mixed nerves, which constitute the great majority of peripheral 
nerves, contain axones of motor cells of the brain stem or spinal cord as well as 
processes of the cranial or spinal, and sympathetic ganglia. 

From the distal part of the spinal ganglia fibers are seen to pass laterally 
and are joined very shortly by fibers from nerve cells in the basal or ventral 
part of the spinal cord. These two bands unite to form a typical spinal nerve. 
The fibers which pass central from the ganglia form the dorsal root and those 
from the basal, or ventral part of the spinal cord, the ventral root. 

Almost immediately after the union of the dorsal and ventral roots, which 
usually takes place within the intervertebral foramina, the spinal nerve divides 
into ventral and dorsal primary divisions. The dorsal primary division passes 
backward to supply the dorsal axial musculature, the skin over these muscles 
and it extends also to the skin in the region of the skull and onto the axio- 
appendicular junctions of the upper and lower extremities. The ventral 
primary division, after contributing fibers to the sympathetic through the 
white ramus communicans, passes lateroventrad to supply, by means of lateral 
and ventral branches, the lateral and ventral axial musculature and the skin 
over them. (See Fig. i.) By rearrangement of the ventral primary divisions 


correspond to the lateral branch of a typical spinal nerve and the secondary 
ventral to the ventral branch. 

Fig. r. — Schematic drawing of a typical spinal nerve. The fibers which form the peripheral 
part of the nerve are indicated but are not carried throughout the nerve. These fibers are the 
axones of motor cells situated in the ventral gray, ■); Peripheral processes of sensory ceils in the 
dorsal ganglion, 6; and sympathetic fibers, through the gray ramus communienns, c. The primary 
ventral division, colored green, is (hat part of the typical spinal nerve which enters into the forma- 
tion of ihe limb plexuses. The lateral brain h Imiirnci the dorsal division of the plexus and the 
ventral Ihe ventral division. 


The motor and sensory components of the spinal nerves in some of thelower 
forms, as the Amphioxusand Petromyzon, remain as separate motor and sensory 
nerves throughout their course and have no connections with each other. 
Each nerve arises from the spinal cord at different segmental levels for each 
coi responding nerve— the motor opposite each muscle plate and the sensory at 
the intermuscular septum. (See Fig. 2.) 

The sensorv libers are collected into two branches, ventral and dorsal, which 


ganglion cells are scattered throughout both the ventral and dorsal sensory- 
branches and in the dorsa) root, thus recalling the diffuse arrangement of the 
sensory cells found in some of the invertebrates. (See Fig. 3.) According to 
Allen's (1917) studies of the adult Pohstotrema the ventral sensory and the 




: % nils. 

jS _ 

1 nvs. 


} ^CJ 




Fig. 2. — Graphic reconstruction of two spinal nerve 
the motor and sensory components are widely separated and that the ganglion cells a 
through the sensory rami and the dorsal root. The light area immediately outside the 
bordered by a dotted line, is taken to he fibrous connective lissin.'. X 50. ( Allen, Joi 
Neur., 1917). V.R., Ventral root (radix posterior); R.D. It., ramus dorsalis or poster 
R.D.S., ramus dorsalis or posterior (sensory); D.R., dorsal root; N.C., nerve cell; R. Y.T. 
trails or anterior (sensory); Sp.Cd., spinal cord; tt.V.Af., ramus ventralis or anterior" (motor) 
Xc, notocord. 

of Comp. 
■ (motor); 

Fig. 3. ^-Transverse section passing through the dorsal root and ramus ventralis from an adult 
Amphioxus. Note the ganglion cells scattered through the dorsal root, ramus ventralis and dorso- 
lateral portion of the spinal cord. X so. (Allen, Jour, or Comp. Neur., 1917.) NC, nerve cell; 
ifyo., myotomes; R.V.S., ramus ventralis or anterior sensory; D R., dorsal root (radix posterior); 
Sp.Cd., spinal cord. 

ventral motor branches are united, forming a mixed nerve, the first to appear 
in the vertebrate series, whereas the dorsal sensory and the dorsal motor 
nerves still remain as separate and distinct nerves having no connection with 
each other. In the most caudal sensory nerves — -the caudal series being always 


are scattered along the course of the sensory nerves in both the ventral and 
dorsal branches, thus repeating the conditions found in the Amphioxus and 

Each of the ventral roots of the motor nerves of the Polistotrema arises by a 
series of small rootlets arranged in two groups, cephalic and caudal, having 
separate foramina of exit. The cephalic group gives rise, in the main, to the 
ventral motor division, and the caudal, to the dorsal motor division. 

In the embryological development of Polistotrema the same primitive condi- 
tions as found in Amphioxus and Petromyzon are repeated, in that the ventral 
and dorsal motor branches are separate throughout their entire course. The 
more cephalic motor root appears earlier than the caudal, and since the 
cephalic group of motor rootlets contributes mainly to the ventral branch 
and the caudal group to the dorsal, it might be, as Allen has suggested, that 
the ventral branch phylogenetically is older than the dorsal. This view receives 
additional support from the fact that the ventral branches of the motor and 
sensory nerves unite to form a mixed nerve — a more advanced condition — while 
the dorsal motor and dorsal sensory nerves remain separate. (See Fig. 4.) 

In the adult shark the spinal nerves, while having some differences in their 
segmental arrangement from the above, are mixed sensory and motor nerves 
both in the dorsal and ventral divisions, whereas in the early stages of the shark 
embryo the sensory and motor nerves are separate. In some of the later 
embryonic stages they remain separate in part of their course; the sensory and 
motor parts of the dorsal divisions are still separate, while the sensory motor and 
parts of the ventral division have united to form a single mixed nerve, thus 
showing the later development of both the dorsal sensory and dorsal motor 
nerves. At first the motor and sensory fibers do not mingle to form a true mixed 
nerve. The afferent and efferent neuraxes merely run in two adjacent bundles, 
separated by a layer of neurolemma cells, and only in their more distant por- 

and since all of these bundles possess nerve cells they all probably contain sensory or receptive fibers. 
(5) These cells are sufficiently numerous in the ventral bundle to form an elongated ganglion about a 
segment long, and any section through it would reveal from one or two to fourteen cells. (6) All of 
the fibers to the (esophagus, both sensory and motor, come from this ventral bundle. X 11. (Allen, 
Jour, of Comp. Neur., 1917.) D.Myo., dorsal border of myotomes; D.R., dorsal root (radix posterior); 
M.C.P. (1), posterior division of the M. constrictor pharyngis; AY., notochord; A\C\, nerve 
cell; Oes.j oesophagus or pharynx; R.D..\f., ramus dorsalis or posterior (motor); R.D.S., ramus dor- 
salis or posterior (sensory); R. M.C.P. (1), vagus branches to posterior division of the M. constrictor 
pharyngis. R.Oes., vagus branches to (esophagus or pharynx; R.V., ramus ventralis or anterior; 
R.V.M., ramus ventralis or anterior (motor); R.V.S.. ramus ventralis or anterior (sensory); Sp.Cd., 
spinal cord; Sp.G., spinal ganglion; V.Afyo., ventral border of myotomes; V.R. (1), cephalic ventral 
or anterior root; V.R. (2), caudal ventral or anterior root; A'., vagus nerve. 


tions are these fibers intermingled forming a mixed motor and sensory nerve. 
This point is noteworthy in its relation to the early development and first 
appearance of what has been called the funicular anatomy or internal top- 

Collateral branch. 

led nerve-fiber. 



termination, though it may give off numerous collaterals in its course. (See 
Fig. 5.) It consists of neurofibrils imbedded in a semifluid neuroplasm and 
surrounded by a very delicate membrane, the axolemma. The fibers are 
described as of two types, medullated and nonmedullated, 
depending upon the presence or absence of a sheath known 
as a medullary or myelin sheath. The medullary sheath 
contains myelin— a chemical substance made up largely 
of lecithin, and supported by a framework of neurokeratin. 
Outside of the myelin is a delicate nucleated sheath known 
as the sheath of Schwann orneurolemma. Thenonmedul- 
ated or nonmyelinated are also known as the fibers of 
Remak. They have a nucleated sheath similar in char- 
acter to the sheath of Schwann. According to Ranson 
(1912), the number of such nonmyelinated fibers is much 
larger than formerly was thought. The nonmedullated 
fibers of the peripheral nerves arise from the cells of the 
sympathetic and spinal ganglia. 

The medullated fibers arc surrounded by a strand of 
sheath cells forming the sheath of Schwann orneurolemma. 
Each cell joins with the adjacent cell, at which point 
there is a slight constriction of the sheath forming a 
node of Ranvier. A single sheath cell and its nucleus, 
which lies upon the inner surface of the sheath, is found 
between each node. (See Fig. 6). The collaterals of the 
n euraxes are given off only at the nodes of Ranvier. The 
neurolemma extends from just below the origin of the 
neuraxis from the ganglion cell or spinal cord to its peri- 
pheral termination. Within the myelin, and extending Ranvier, cement suh- 
from the neurolemma, is a delicate framework constituting y Toml l na !j axdemma* 
the neurokeratin. e, myelin;/, Schmidt's 

As has been said, the nonmedullated fibers differ from ^rtlf"^) ■ e '"perinu- 
the medullated by the absence of the medullary sheath, clear protoplasm; h, 

™,- ~, . i 1 - .1 . ,- 1 nucleus <ifi].'i;i-' .It- 111111:1; 

1 his nerve hber is enclosed in a very thin, line membrane. ( - neura:( ; s (Caial 

Fid. 6. — Schematic 
drawing ui myelinated 
nerve liber. A segment 
between nodes of Ran- 
vier. a, Sheath of 
Schwann; b, node of 



Both medullated and nonmcdullatcd fibers are assembled in nerve bundles 
called funiculi, and the funiculi in turn are joined together into a larger group 
by a surrounding sheath of connective tissue called epineurium, thus forming 
a peripheral nerve. The individual fibers of the funiculi are separated by a 
small amount of connective tissue called endoncnrium and the funiculi are sur- 
rounded by a lamcllated layer of fibrous tissue which encircles the funiculi, 
called by Key and Retzius (1S73) perineurium. (See Fig. 7.) Between the 

layers of the perineurium small spaces are found which communicate with the 
lymph clefts between the nerve libers, and in which lie the majority of the blood 

Formation of Ganglionic Crest. Schulte and Tilney (1815) have shown 
that the ganglionic crest, which extends as two lateral folds along the neural 
tube, is formed by a process of evagination from the neural tube with subse- 
quent delamination which takes place cephalocaudad along the dorsal portion 
of the neura! folds. These authors found an evagination and massing of cells 
on the ental surface of the neural folds close to the neurosomatic junction, but 

Fir.. 7. — Drawing of a cms? -ci (inn of .1 typical nerve. Mai lory conutilne tiss 
nective tissue blue. Blood vessels red. Epraeurium — connective tissue sheath s 
nerve as a whole. Perineurium— connective sheath between the funiculi and sur 
Endoneurium — the supportinc. connective tissue within the funiculi. 

Note the large number of blood vessels throughout the section in the epineuriu 
and cndoitfitrium. 


a solid anlage may replace a hollow one " Most of the cells which 

form the ganglionic crest separate from the neural tube and extend latero- 
ventrad between the neural tube and the ectoderm until they may lose 
temporarily their connection though some of the cells remain permanently 
within the tube. From the ganglionic crest the capsule and afferent ganglionic 
cells and their processes arise, as well as the sheath cells and the sympathetic 

Areas TCTtebT»li» ! "f"" 1 * P™***"" 

FlG. a. — Diagrammatic transverse section through a thoracic segment of a 17 mm. human 
embryo (Huber collection, No. 14), showing a typical thoracic nerve. Enlarged 15:1, (From 
Keibel and Mall, "Human Embryology.") 

Changes in Ganglionic Crest. — The cells of the ganglionic crest pro- 
liferate and undergo further differentiation forming slender central processes 
which re-unite secondarily with the spinal cord. These processes constitute 
the axones of the ganglion cells and make up the dorsal root of the spinal 
nerve. Slender processes also appear later at the opposite poles of the cells, the 
cells at this stage being bipolar. By gradual shifting of the cell body, the two 
processes are united, forming the unipolar cells of the higher vertebrates, while 
in the lower forms (amphioxus, cyclostomes) and in the acoustic ganglia of 
all, bipolar cells are found. In the spinal region of the embryo the crest 
becomes segmented along its ventral margin forming neuromeres, which corrc- 


spond in number to the muscle segments (myotomes), and eventually each of 
these segmented masses of ganglion cells becomes a ganglion of the dorsal root 
of the spinal nerves. The ganglionic crest contains also supporting cells, from 
which the capsule and sheath (neurolemma) cells arise, as well as ganglion cells 
which give origin to the afferent (sensory) nerve fibers, the central processes 
making up the dorsal roots and the peripheral, the afferent fibers of the peri- 
pheral nerves. (See Figs. S-9.) 

Formation of the Ventral Root.— While the ganglionic crest is undergoing 
proliferation and segmentation, the cells within the neural tube are proliferating, 
and further differentiation occurs. Two types of cells are distinguishable, the 
spongioblasts and the neuroblasts, the former having branches and processes 
connecting with each other, the latter moie or less pear-shaped and arranged 
in clusters, having a small central protoplasmic process growing out from one 
pole— the axone. The axones tend to group themselves into protoplasmic 
strands and may extend either into other parts of the neural tube, forming 
association paths within the central nervous system, or the strands may pene- 
trate the neural wall and grow out into the mesoderm, thus forming the 
primitive ventral motor root. (See Figs. 8-9.) Later when the motor root has 
further advanced, a few cells begin to migrate from the neural canal along the 
neuraxes. These are sheath cells. All the sheath cells thus have their origin 
from the neural tube or ganglionic crest; a point which proves their close relation 
to the neuroglia. Allen has shown in the shark embryo that the motor or 
effector fibers of the spinal nerve develop considerably in advance of the sensory; 
but the cells destined to become neurolemma migrate from the ventral lateral 
surface of the spinal cord at a later date than those from the dorsal root. 

Origin of Sheath Cells. — The capsule and sheath cells arise principally 
from the ganglionic crest, and only after the nerve is more advanced in its 
development do they extend along the ventral root from the neural tube. 
The sheath cells in their migration along the nerve fibers at first enclose only 
Unro tw»<4T«H lint laipr. hv niultinlicntinn rht>se ™11= ,.™„i,„i„ i, n i„,„„ *;,„ 


Experimental Evidence to Show Origin of Neuraxes and Sheath Cells.— 

Two main theories have been offered concerning the origin of the neuraxes, one 
the outgrowth theory of His (1S90) and the other the celt chain theory of Bethe 


Fie. 10. — Semi diagram ma lie view of the nerves of the abdominal walls of the frog larva (nor- 
mal specimen). Abd.M., abdominal muscle; I1L., rudiment of hind leg; Mat.N., motor branch of 
segmental nerve running in inscriptio tendinea of the primary abdominal muscle; Mat. Sue, motor 
nucleus (ventral born cells) in spinal cord; Stgjf., segmental (spinal) nerve; Sen.IT., sensory branch 
of spina! nerve running to integument outside of muscle; Sp.C., spinal cord; S/i.G., spinal ganglion. 
(Harrison, Amer. Jour, of Anat.) 

(1903) and others. A still older theory is that of Hensen, according to which 
there always are protoplasmic intercellular bridges in the developing embryo 
and out of certain of these bridges the nerve fiber is differentiated. Held 
(1909) has supported a modification of this theory; according to him the nerve 
fibers differentiate from the nerve cell bodies along these protoplasmic bridges. 
Likewise two main views have been held concerning the origin of the sheath 


and from the surrounding mesodermal tissues invaded the nerve fibers and 
surrounded them. The more recent view on the other hand has been that the 
sheath cells were closely related to the neuroglia and were of ectodermal origin. 
Both of these important questions, heretofore unsettled, have been con- 
clusively answered by the experimental work of Harrison (1007). By excising 

Fir., it. — Semidiajtrammalk view of the nerves of tin ;iln.l<iniin;il walls of a frog larva from 
which the ganglion crest had been removed. Only motor nervea are present and hese consist of 
axis cylinders without shealh cells. .Harrison, Amer. Jour, of Anal, i 

the ganglionic crest of frog larva this investigator has shown that afferent nerve 
fibers do not develop and that only efferent fibers from the undisturbed ventral 


nerve cells may be observed in an artificial medium such as coagulated blood, 
thus offering direct proof of the outgrowth theory of the nerve fiber. 

Thus the important deductions of these ingenious experiments apply not only 
to the development of nerve fibers, but are of equal value in throwing light upon 
nerve regeneration, the great importance of the nerve cell, the relative unim- 
portance of the sheath cell for regeneration, and the secondary role these cells 
play in the formation of the nerve. 

Migration of the Sympathetic Cells. — During proliferation of the gang- 
lionic crest and its gradual shifting lateroventrad a strand of both ganglion 
and sheath cells gradually migrates from the ventral border of the crest to the 
region of the aorta. (See Fig. 8.) Some of these cells remain here and form 
cell clusters — the primitive prevertebral sympathetic ganglia — while others 
continue to migrate and form the more peripheral sympathetic ganglia. 
This strand from the ganglionic crest is the primitive ramus communicans. 
Later, the cells of the dorsal ganglia and the nerve cells within the basal part 
of the neural tube send fibers to the sympathetic ganglia; those from the neural 
tube (efferent and preganglionic) terminate within the sympathetic ganglia, 
while those from the dorsal ganglia (afferent) continue uninterrupted through 
the ganglia to their ultimate termination in the sensory end organs. These 
fibers, which become medullated, form the white rami communicantes. From 
the sympathetic ganglia small postganglionic fibers pass to the spinal nerve as 
axones of sympathetic cells. The fibers of these cells are nonmedullated, grey- 
ish in color, and hence are called the grey rami communicantes. 


Theoretical Importance of Funicular Anatomy. — A finer anatomy of the 
peripheral nerves suggests possibilities of exact methods of nerve repair, which 
should lead to marked improvement in the end results of peripheral nerve 
surgery. As more exact histological studies of nerve regeneration have led to 
more precise technic in the mechanics of nerve suture, so more exact knowl- 
edge of the finer morphological structure of the nerve trunk should also lead 
to greater nicety in the union of nerve ends and eventually, perhaps, to funic- 
ular suture as well as truncular. If there exists within the nerve trunk 
definite funiculi or nerve paths destined to serve certain muscles, or sensory 


Evidence not in Support of Stoffel's View. — However, there is some con- 
troversy concerning the existence of separate and definite paths over any great 
length within the nerve trunk. Stoffel and his followers claim that a definite 
internal topography with a definite nerve pattern exists throughout the nerve 
trunk, with definite paths destined to definite muscles and muscle groups. 
Such a conception has been vigorously denied by Heinmann (1916), Borchardt 
and Wjasmenski (1917) , Langley and Hashimoto (1917), Compton (1917), 
Dustin (191S), Kunzel (191S) and others. Heinmann holds that the method of 
funicular nerve suture insisted upon by Stoffel has materially discouraged 
nerve suture and also that the theoretical basis of Stoffel's views on internal 
topography are erroneous. 

Heinmann studied the internal structure of the musculospiral, ulnar, 
median and sciatic nerves in macerated dissections and found many internal 
nerve plexuses, which he believed disproved Stoffel's theory of the existence of 
definite nerve paths from the large nerve plexuses to the periphery. Such 
definite nerve paths Heinmann found only in a few places and over a 
very short course; for example, the nerve path for the gastrocnemii ran 
as a separate bundle only for a short distance and then joined one of the plexuses 
in the nerve and no longer existed as a definite and distinct bundle. Hence, 
only in such restricted portions of the nerve trunks could Stoffel's operative 
method be used. In addition to these dissections, Heinmann imbedded two 
nerves side by side and made a series of cross sections, staining them by the 
Weigert method. The appearance of the cross sections varied greatly and no 
constant appearance in either nerve was found when sections were made at 
corresponding levels even with such complete exposure as could not be dupli- 
cated in any operative wound. He believes that the task of learning the 
anatomical appearance of such cross sections, with the exception of a few 
areas which are constant in certain nerves, would be as futile as it would be 

In speaking of these internal plexuses, Compton (1917) states that ' proxi- 
mal to the plexus, these bundles, although superficially continuous with the 
nerves below, have partly lost their identity, through interchange of fibers," 
and that, "one of the functions of the plexuses in the nerve trunks is to supply 
each muscle several routes by which impulses may reach it." Thus, in case 
one path is blocked, several others are still available. Dustin (191S) has also 
shown that morphologically the funicular arrangement varies at each level 


— Macerated dissection of the left uln 
a between these nerves. The bundles < 
separated. D, short communication; E, long c< 
trinsic muscles of the hand), m, Branch to pronator t. 
part of muscle; 20, branch to superior belly, flex 

i nerves showing two types of com- 
ervc have been dissected free and 
i the deep branch of the ulnar (in- 
mcrul head, upper pari, and lower 
nis; ;'>, brands to |i;ilm:ir!sl(inj;iiH; 
li In flexor digitoram 

3, branch to flexor digitorum sublimis, 3d. 41I1 and slh fingers; 411, brain 
profundus, 3d, 4th and 5th fingers; 4b, branch to flexor pollicis longus; 4c, anterior interussous 
nerve; s, branch to deep belly of flexor indicia sublimis; da and 6/1, branch to flexor carpi ulnarb.; 
7. dorsal cutaneous branch of (he ulnar nerve, 8, palmar cutaneous branch of the ulnar nerve; i), 
deep muscular branch of the ulnar nerve; io, superficial branch; ir, palmar cutaneous branch of 
the median nerve. (After Borcliardt and Wjafnieuski.) 


Median N. right 

1 ... iiUiittmtMus nerves, macerated dissect ion. Bundle i, la, lb, ic 

r» .i', 1 i roMO to the radial above. The bundle to the pronator teres 

A**** iW «Mwt lui.l ..I the nwdiin and the bundle lo the flexor carpi radialis 

.V. It* ulnar «,lp ,.{ the bundle i, ro, ii>, w, lies the bundle tor the 

. - bWRdlfl Mid the bundle to the flexor difiilorum sublimis 

' hh««fc thf Innar head. The cross section appearance of various 



Median N. left 

3 c m.Higtwr 


3 cm.hi$k«c 


2 cm higher 

the same individual even though the sections are made at 3 cm. intervals. 
Considerable variance is found in the corresponding nerves in the same 
individual and in different individuals. Dustin believes that "it is possible 
to establish as a principle, that the identical arrangement is never found at 
the same level in two different individuals . . . and 
that it is impossible to conceive of a functional sys- 
tematization of a nerve having funiculi as its anatomi- 
cal basis. 79 

Dissection of Macerated Nerve Trunks. — In 
studying peripheral nerves by means of macerated 
dissections so as to bring out finer funicular connec- 
tions Borchardt and W jasmenski found in more than 
fifty cadavers that throughout the entire nerve 
course there were numerous internal plexuses, with 
frequent interchange of fibers from the different 
funiculi. In the median nerve, one or two paths 
were found to have a definite course from the for- 
mation of the median nerve to their ultimate dis- 
tribution. However, even these received numerous 
communications and their position within the nerve 
trunk varied. Figures 12 and 13 illustrate the 
great complexity and intermingling of the nerve 
fibers which takes place before the path finally 
makes its exit from the nerve trunk. As a result 
of this elaborate study, these authors' conclusions 
differ greatly from those of StoffePs school — ''ac- 
cording to our findings, the motor paths lie more 
or less constant only a short distance from the point 
at which they leave the nerve stem. ,, The con- 
clusion is reached that "it is impossible to rely 
alone upon the anatomical relations . . . without 
electrical stimulation (of the separate funiculi). 
Exact knowledge of the individual paths is difficult 
or almost impossible." Morphologically, the nerve 

trunk varies greatly with each cross section, so that if 2 , 4 or 6 cm. separate the two 
nerve ends, which frequently is the case clinically, identification of the corre- 

4 cm higher 


2cm. higher 
than A 

intomal condyle 

border border 

Fig. 14. — Cross section of 
human median nerve (left). 
The marked differences in the 
cross section appearance of the 
median nerve at various levels 
are seen. To unite identical 
bundles in the presence of large 
nerve defects is impossible. 
(Horchardt and Wjasmcnski.) 


sponding nerve paths within the distal and central stumps becomes impossible. 
(See Fig. 14-) 

Funicular Identification by Bipolar Stimulation. —By means of bipolar 

stimulation on the surface of various nerves exposed at operation, Marie, Gosset 
and Meige (1915) have somewhat strengthened the view of StoiTel (1913) that 
there exist definite nerve paths from the large plexuses to the periphery. By 
comparing the results of such stimulation on different nerves, and certain 
definite surface points, presumably constant, in different nerves, they have been 
able to map out to some extent a surface topography which seems to indicate a 
definite funicular arrangement within the nerve trunk. By this means, Putti 
(1916), Kraus and Ingham (1930) have come to similar conclusions. 

Surface topography of the funicular arrangement in peripheral nerves as 
studied by means of the bipolar electrode offers numerous obstacles to accurate 
funicular determination. Not only is variance found in a given nerve at 
similar levels in the same individual, but also in corresponding nerves in other 
individuals. A further obstacle exists in the fact that it is rarely possible for 
the examiner to say with assurance that any given point in one nerve cor- 
responds with a similar point in another nerve, especially when the operations 
are done at different times with the extremities in positions, although similar, 
yet probably not identical. Marie, Gosset and Meige, in describing the technic 
used in their localization tests, speak of the nerve to be examined as "free over 
an area of 6 to 8 cm." and that "two glass rods were passed beneath the nerve."' 
By such displacement of the nerve some variation in the position of the nerve 
trunk may occur, though every precaution be taken to avoid such displacement. 
The variability in length of the extremities, the variability in the position of the 
extremity in different operations, as well as the variability in relative position 
at which branches arise from a given nerve, make precise comparison of corre- 
sponding points on a nerve too doubtful to be scientifically accurate. Another 
point is the fact that in most nerves of the extremities a variable degree of tor- 
sion in their longitudinal axis normally lakes place which makes precision in 
comparative surface localization difficult. Still another variant to be con- 


complete severance and generally at a time when, due to degeneration, the 
distal segment no longer responds to electrical stimulation. Consequently, 
electrical stimulation of the individual funiculi in the cross area, the only 
precise means of accurately determining funicular arrangement, is not clinically 
possible. Topographical localization by means of the electrode can be accurate 
only when the separate funiculi are stimulated in freshly made cross sections; 
and each stimulation checked by serial section of the nerve in question. 

Internal Nerve Plexuses. — The existence of intercommunicating funiculi 
within the nerve trunk has long been recognized. However, it is only lately 
that the significance of such plexuses in relation to nerve surgery has been 
appreciated. In the rabbit, cat, dog and human Langley and Hashimoto 
(1917) found that the sciatic nerve was made up of bundles or bundle groups, 
which, with few exceptions, rarely ran a separate and distinct course over any 
great distance and which usually formed internal nerve plexuses, particularly 
in regions near which branches arise. (See Fig. 15.) 

Between these internal nerve plexuses regions are found in which the 
funiculi are more or less distinct, though they still show some intermingling and 
communications, yet not so marked as in the plexuses. These areas are called 
intermediate regions (Langley and Hashimoto) or zone nodale (Dustin). 
Such a region is especially likely to exist where there is considerable distance 
between the origins of branches from the nerve. The greater the distance 
between branches, generally speaking, the greater the length of the inter- 
mediate region. Langley and Hashimoto say that, "in the peroneal portion 
of the sciatic nerve there is no part longer than 1 or 2 cm. in w T hich there are 
no plexuses." Similar plexus arrangement is found in the nerves of the upper 
extremity. Dustin found that plexuses were especially seen near levels at 
which nerve branches were about to be given off, and that, conversely, the 
intermediate regions were found in those parts of the nerve trunk where 
branches were not given off. In the corresponding nerves of different individ- 
uals, the intermediate zones may be markedly diminished or nearly absent, 
and the entire nerve trunk be made up of numerous small funiculi or areas in 
which the funiculi are collected into one or two or three larger funiculi. Thus 
there is considerable variance in the longitudinal extent and in the amount of 
intermingling of the fibers. These communications serve "to collect together 
the afferent and efferent fibers of different nerve roots for the area supplied by 
the peripheral nerves' ' (Langley and Hashimoto). Hence, the rearrangements 
generally take place both immediately above the level at which branches are 





to be given off, and again immediately below in preparation for the rearrange- 
ment of the branches to be given off still lower. Compton and also Langley 
and Hashimoto conclude that "the complexity of the lower plexuses in the 
sciatic of the larger mammals makes it certain that so far as dissection goes, no 
bundle above the plexuses can be said to correspond even approximately with 
any bundle below it." Speaking for the nerves of the upper extremity, Dustin 
found that " the funicular topography of the same nerve is continuously modi- 
fied by the exchange between different funiculi through numerous anastomoses." 
Compton, Langley and Hashimoto, and Dustin further conclude that separate 
suture of the individual bundles, so as to attain accurate apposition, seems 
hardly feasible, for even the slightest rotation would suffice to distort the nerve 
pattern. Furthermore, such separate suture is hardly to be expected either 
above or within a nerve plexus, whereas suture of the funiculi below the level 
of the plexuses from which the funiculi have arisen would serve to prevent 
distortion of the pattern and poor shunting of the neuraxes. 

In the branches immediately below the plexuses, the funicular arrangement 
is fixed, and any distortion resulting from suture cannot readjust itself within 
the nerve trunk, hence can be overcome only by re-education through central 
readjustment. Hence, in the areas where the funiculi are fixed, particular 
attention must be paid to funicular union. The objections suggested by 
Langley and Hashimoto to the prolonged time, essential to such suture, needs 
hardly to be considered, and the amount of scar tissue resulting which these 
authors think also objectionable can be minimized by scrupulous care in the 
technic and the avoidance of trauma such as is gained by using a constant 
stream of salt solution, in place of sponging the nerve ends, etc. 

In most instances, when a multiple graft is done experimentally, it has not 
been possible to observe the normal funicular arrangement. Yet, in spite of 
this disregard of the internal arrangement of the nerve paths, these animals 

respective peroneal and tibial divisions. In the peroneal, P, marks a stretch of the upper plexus in 
which the plexus was less than above and below it; /, marks a stretch in which the characters of the 
intermediate region were less developed and the plexus greater than below. In the tibial, P marks 
a portion of the intermediate region, in which rather more than a third of the nerve hud scarcely any 
plexus, the rest had a moderately developed plexus. The upper half of the lower plexus of the tibial 
consisted of a varying number of bundle groups running at different points an isolated course for 
2-3 centimeters. In the external popliteal the beginning of the plexus formed by the three bundle 
groups is shown. The nerves, the bundles /;,, hi and some bundles connected with lu are pulled 
away from the trunk; H, hamstring nerves; B, nerve for femoral head of biceps; T.S., tibial saphe- 
nous; P.5., peroneal saphena; P. C\, lateral cutaneous; G, nerve to gastrocnemius; A, probably articular 
branch. b\a, Bundle arising from the upper plexus and running a long separate course, most of the 
fibers of /I, came from it. b«a, Long separate bundle arising from the intermediate region. (J. X. 
Langley and M. Hashimoto, Journal of Physiology, 191 7.) 


show return of function, with formation of motor end plates within the muscles 
and contraction of the muscles on stimulation of the nerve trunk, both above 
and below the graft. 

By the passage of neuraxcs through multiple grafts, it would seem that 
whatever funicular arrangement had previously existed was thereby greatly 
dispersed, and yet functionally excellent motor re-cstablishment takes place. 
Kennedy (iooi) has reported that after nerve crossing, in which a flexor nerve 
was sutured to an extensor, re-establishment of function occurred almost as 
early as when the same nerve was cut and resutured. 

Prevention of Even Minimal Axial Rotation Difficult. — From a practical 
standpoint, in end to end suture without loss of substance, even under favorable 
conditions, slight axial rotation of the nerve ends of only a few millimeters is not 
only most probable, but almost certain to occur. Such slight rotation might 
suffice in many instances to prevent apposition of corresponding funiculi. Dis- 
tortion is perhaps still more apt to occur, even with the least rotation, in those 
nerves in which the funiculi are small and numerous, such as the median in 
certain locations, and the ulnar nerve. This fact may account, in part at least, 
for the relatively poor functional return in the latter nerve. Funicular apposi- 
tion is also unlikely at certain levels in all nerves in which the funicular arrange- 
ment is fixed. These technical difficulties, together with the variations of size 
and arrangement in cross sections of the same nerve at different levels, make 
accurate funicular apposition most difficult, particularly when loss of substance 
has occurred. In nerve surgery, the best which can be done is to try to prevent 
axial rotation of the nerve trunk by stay sutures. When this is impossible due 
to loss of anatomical continuity, one can only approximate the nerve ends, 
paying careful attention both to the position of the nerve trunk within its 
bed above and below the line of suture as well as to the appearance of the cross 
sections. At best, under such circumstances, exact funicular apposition is 

In some nerves at certain levels a distinct funicular arrangement can be 
recognized, even though there is loss of substance. This is particularly true for 
instance of the musculospiral nerve in the lower third, the peroneal near the 
head ofjhe fibula,' the median near the bend of the elbow and the ulnar at the 
bend of the elbow. These positions correspond in each nerve to levels at which 
branches are about to be given oil. and consequently the funiculi to form each 



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The numerous contributions dealing with the question of degeneration and 
regeneration of severed or injured peripheral nerves, and the correlated question 
of the development of peripheral nerves, evidence the importance of the subject 
and the interest taken therein. Laboratory experimentors and clinicians have 
contributed to this extensive literature, and there is perhaps no field in medicine 
in which the interdependence of experimental and clinical work is so clearly 

Attention was drawn to this subject as early as the latter part of the 18th 
century, when Arnemann (1787) recognized the fact that the peripheral part 
of a divided nerve lost its conductivity and normal, glistening appearance while 
the central stump retained its irritability and glistening appearance, and 
Cruikshank (1795) an d Haighton (1795) reported on ingenious experiments 
bearing on loss of function and its repair in a divided peripheral nerve. The 
experiments recorded by these two observers were similar and were reported 
about the same time and independently. Both observers found that on cutting 
the vagosympathetic trunk in the neck of a dog on both sides, death followed 
within a few days, while if this nerve was severed only on one side and the 
animal allowed to recover, the second nerve could be cut some weeks later 
without death of the animal; showing a recovery of function of the first nerve 
cut. A histological study of a peripheral nerve with loss of conductivity 
after injury was not undertaken until nearly fifty years later, when Nasse 
(1839) recognized and first described a fragmentation of the medullary sheath 
in the peripheral portion of a nerve after section and noted the ultimate dis- 
appearance of the medullary layer and the neuraxis of the peripheral, injured 
nerve fiber; though it was not until 1852 that Waller clearly demonstrated 
that when continuity is severed in a peripheral nerve, the portion separated 
from the "ganglion cell" undergoes secondary degeneration, in recognition of 
which we have spoken of this phenomenon as Wallerian degeneration. Waller 
regarded the central cell as the nutritive center and believed that the part 
degenerated was replaced by outgrowth from the center, on regeneration of the 
peripheral portion. Some years later Ranvier (1871-78) and still later Vanlair 


(1882-85) in a series of contributions extended our knowledge concerning this 
subject, more particularly as concerns the down growth of the central fibers 
in the process of nerve regeneration. However, the views of Waller were 
not universally accepted. Philipeaux and Vulpian (1859-60) after extended 
resection of a peripheral nerve in young animals, found the peripheral segment 
regenerated after a period of several months, and this without apparent union 
with the central stump, and believed to have demonstrated the possibility of 
autoregeneration — regeneration of the peripheral stump in and of itself. There 
were other observers (Schiff, Erb, Wolberg) who maintained that the neuraxes 
of the nerves of the peripheral stump did not undergo degeneration, but re- 
mained intact. 

Thus, just prior to about 1890, three main views were current in literature 
as concerns the question of degeneration and regeneration of a severed peri- 
pheral nerve: (1) The view of Waller, that after secondary degeneration of the 
peripheral stump, new neuraxes grew out from the central end; (2) that after 
secondary degeneration, the new neuraxes developed in the peripheral stump 
and were secondarily united to the neuraxes of the central end; (3) that the 
neuraxes of the peripheral stump did not degenerate, or only incompletely so, 
and might in time unite again with those of the central end. In the years 
following 1890 there appeared a series of monographic contributions dealing 
with de- and regeneration of peripheral nerves, each based on extensive experi- 
mentation, controlled by careful histological studies. These contributions 
embrace those of Biinger (1891), Howell and Huber (1892), Stroebe (1893), 
Huber (1895); they may be said to mark the beginning of the modern work 
on nerve degeneration and regeneration. Biinger (1891) in his communication 
pointed out that the proliferation of the sheath cells in the early stages of 
degeneration took place by means of mitotic cell division. He also defined 
much more clearly than previous workers the nucleated protoplasmic strands, 
the "bandfasern" which develop within the old sheaths of degenerating nerves 
during the second and third week after injury, and interpreted them as embry- 
onic nerve fibers, built up from a chain of ectodermal sheath cells. Within the 
protoplasmic bands a delicate longitudinal striation was observed and re- 
garded as indicating development of neuraxes, the whole evidencing auto- 
regeneration in the peripheral nerve stump. The studies made by Stroebe 
(1893) were based on observations made on tissues stained after his specific 
neuraxis stain, and by use of his method he believed to be able to demonstrate 
down growth of the neuraxis from the central stump. Huber (1895), using 


Stroebe's method in an experimental study on the bridging of nerve defects, 
was able to demonstrate down growth of neuraxes from the central uninjured 
portion of the nerve, division of central neuraxes, bulbous ends on down growing 
fibers and down growth of nerve fibers of central origin through tissues and 
substances not nerve fibers. These studies were followed by a series of con- 
tributions which again favored the possibility of autoregeneration of the 
peripheral degenerated nerve, Galeoti and Levi (1895), Kennedy (1897), 
Wieting (1898). In summarizing the work of this decade it may be stated 
that there prevailed two distinct views as to the mode of degeneration and 
especially of regeneration of severed or injured peripheral nerves; (1) A mono- 
genetic conception, according to which regeneration of the peripheral degen- 
rated portion of a nerve is obtained through down growth of neuraxes derived 
as processes of central neuraxes at all times connected with central nerve cells, 
and (2) a polygenetic conception, according to which regeneration is obtained 
through the mediation of cells derived from both the central and peripheral 
stump, which cells become linked to form a continuous nerve fiber. These 
opposed views existed because with the technical methods at the disposal of 
workers final solution could not be reached owing to the fact that the tissue 
elements involved could not be differentially stained, and this applied more 
particularly to the staining of the early stages of growing neuraxes. 

Recognizing this lack of adequate technical methods, Bethe (1903) 
attempted to bring solution to this problem by the use of specially devised 
experiments in which he attempted to separate completely portions of a periph- 
eral nerve from central connections, which peripheral portions were weeks 
and months later used for histological study. In these experiments the sciatics 
of very young dogs were used, and these were either grasped at the sacrosciatic 
foramen, torn out with roots and ganglia and cut in the middle of the thigh, or 
extensively resected in the middle of the thigh and the central end turned into 
muscle and there sutured. Carefully conducted physiological tests and autopsy 
studies seemed to exclude down growth of nerve fibers from the central to the 
peripheral stump. Studies of the peripheral stump, supposedly completely 
separated from central connection, revealed the presence of medullated nerve 
fibers, evidencing, it was thought, autoregeneration in the peripheral end of the 
resected nerve. The experiments of Bethe appeared convincing and excited 
much interest; however, they have not received confirmation and have in the 
main been refuted by careful experimental observations of Langley and Ander- 
on (1904), Lugaro (1905) and others. 


Two lines of work have been instrumental in bringing solution to this 
problem: (i) Studies on the histogenesis of the nervous system and peripheral 
nerves and especially certain studies in experimental embryology; and (2) the 
development of modern silver methods for the differential staining of neuraxes 
of nerve fibers and especially young and growing neuraxes. 

The histogenesis of neurones has been a subject much discussed, particu- 
larly as relates to the development of peripheral nerves and their constituent 
parts. Of the current interpretations of the mode of development of peripheral 
nerve libers the one more commonly accepted is the out growth theory of His 
(1890). According to this theory, the nerve fiber, more particularly the 
neuraxis. is regarded as an out growth of a single cell. This cannot be demon- 
strated in adult tissue, but admits of near demonstration in early embryonic 
stages. During the past two decades the wide application and development 
of special, differential neuraxis staining methods, applicable more especially to 
embryonic tissue and extensively used by Cajal and others, have gone far 
to demonstrate and establish the out growth theory of the developing nerve 
fiber. This theory was further very substantially confirmed through the 
experimental observations of Harrison ( 1007). who was able to observe isolated 
ganglion cells, taken from the spinal cord of amphibian embryos and cultured in 
coagulated lymph, send forth neuraxis processes, these showing end tips and 
bulbs, and division much as observed in the developing embryos. Developing 
neuraxes. as observed in sections of suitable stages, are from the beginning 
found accompanied and closely associated with cellular elements, regarded by 
earlier observers as of mesodermal origin, by more recent observers quite 
clearly shown to be ectodermal derivations, and variously thought of as differ- 
entiating to form sheath cells or participating in the formation of the neuraxis 
itself. The presence of these cells led to the formulation of the so-called "chain 
theory" of the development of peripheral nerves with which, among others, 
the names of Balfour (1S75), Dohrn (1901). and later Bethe (1903) are asso- 
ciated. According to this theory each nerve is thought to be the product of a 
chain of cells, extending from the nerve center to the peripheral end organ. 
The study of sections alone did not seem sufficient to enable final solution of 
thi* '" its solution, experimental embryology was called to aid by 

iserver was able to ablate the dorsal portion of the 
•jeural crest in very young amphibian embryos, 
the dorsal spinal ganglia, without injuring the 


motor fibers. In due time certain ventral root fibers were found to develop, 
but were found to be devoid of sheath cells. There were further experiments 
on amphibian embryos in which developing limb buds were transplanted, which 
later gave evidence of neurotization, indicating, it was thought, that there does 
not of necessity exist a primary connection between central nerve cell and 
peripheral end organ as is postulated in other hypotheses concerning the 
development of peripheral nerve fibers, Held (1909). The results of these 
experimental embryologic observations of Harrison and others have been 
summarized as follows (Streeter, 191 2): "It was shown that no peripheral 
nerve fibers would develop in an embryo from which the nerve centers had been 
removed, thus establishng the fact that the ganglion cells are an essential 
element of the nerve fibers. It was shown that the sheath cells of Schwann, 
upon the influence of which in the formation of the fibers many of the his- 
tologists had placed much emphasis, were not essential to the growth of the 
nerve fiber, and that the axis cylinders will develop and extend out in the 
surrounding tissues in the normal way and reach their normal length in speci- 
mens where the sheath cells have been eliminated. It was shown, by modify- 
ing the environment of the developing nerve, that fibers will form in surroundings 
entirely different from their natural path and establish completely foreign 

These histogenitic and experimental embryonic observations have con- 
tributed much to bring clarity to the problem of nerve de- and regeneration 
and to weaken the position of the advocates of the polygenetic theory of 
nerve regeneration. The marked improvement in technical methods in rela- 
tively recent years has assisted greatly in furthering our knowledge of de- 
and regenerating peripheral nerve fibers. The silver methods of Cajal, of 
Bielschowski and of Ranson, permit of sharp differential staining of neuraxes, 
especially young and growing neuraxes, and have thus enabled a more precise 
study of the fate of the neuraxis of a degenerating nerve and of the reappearance 
and growth of the neuraxis in a regenerating nerve. In experimental observa- 
tions controlled by careful histological studies, using differential neuraxis 
staining with modern silver methods, it has been possible to follow step for step 
the neurotization of the degenerating or degenerated peripheral stump through 
down growth of centrally derived neuraxes. Quite an extensive literature, 
based on observations made with the aid of differential neuraxis staining 
methods, is already at hand. This literature includes contributions by Per- 
roncito (1907), Poscharissky (1907), Cajal (1908), Ranson (191 2), Boeke 

, I»*fcrigl«» '*yi*.< *»d #ther» Practically all the 
•hfcwrver* vtw Juve «w4 !he wsfere dhrer method* of staining the neuraxes 
ifcfr? f*t0M* etpownU of the nuaogCMtic theory of nerve regeneration. 
hi MKll rifver pfrj«f«tio»i« th*re are pretest no appearances which would 
mtiutr*t ttmtfiiUm «t*ge» in the development of neuraxes from the nucleated 
' mu "' ! - 1' -itIv taught by Bungex and stated by other 

■ '" ..r - 1.. | .. i . gj ,., i.. theory erf nerve regeneration; on the other hand 

' fine neuraxe* may often be observed in the proximal end d 

Duel before Ibe nucleated protoplasmic bands law 
hat) ■!■ ■ ■ i-i|ir .). J| | he approximation of the ends of a divided nerve has bat 
r ...rl | !.<- growing, bulbou* end* of the new neuraxes in a regenerating 
directed toward lh< periphery, in the distal part of a divided 
1 low ird Ihe wound a* might be expected in autoregeneration o( 
i Further, [1 has been observed that there is a great over- 
'" ■ M ( "■ Hi Mi tlui i" i in fact that a number of branches may ai 
Ural tti unxu and i>Ii) sheaths of peripheral degenerated 
Often round to contain a nutnl>et of newly formed neuraxes, difficult to 
cm tht theory ol autoregeneration These silver methods have enabled * 
onnicdulUted fibers in degeneration and regeneratior 
itudy not possible with .iher staining methods. 
Slu4ie> in histogenesis o( peripheral nerves, in experimental en 
nenl of peripheral nerves, and the morerece 



matic injury, varying somewhat in width with the character of the injury, but 
usually not found wider than about J^ cm. The structural changes observed 
differ in medullated and nonmedullated nerve 
fibers and need thus to be considered separately. 


Soon after injury to a peripheral nerve and for a 
period varying from one to several days, the med- 
ullated nerve fibers distal to the line of injury 
(except in the immediate vicinity of the wound) 
present no demonstrable structural change and re- 
spond to mechanical and electrical stimulation. 
The ensuing structural changes are first demon- 
strable in the neurofibrils of the neuraxes, which 
present varicosities, and this is soon followed by a 
granular breaking down of the neurofibrils, Mon- 
ckeberg and Bethe (1899). In pyridine silver 
preparations an irregularity of the contour of 
the neuraxes is observed and an inequality of 
staining, Ranson (1912). Changes in the myelin 
sheath are observed in certain of the medullated 
fibers, beginning with the fourth day after injury 
(dog, and probably man; second or third day in 
rabbit and guinea-pig). These changes in the 
myelin are first recognized as irregularly spaced 

FtG. 16. — Nerve fibers Irom the 

peripheral stump of the sciatic of 

rabbit, 5 days after ! 

enlargements and constrictions, giving to the fiber Silver preparation. The medul- 

, „,,.,„ , , lary sheath is found in segments 

a vancosed appearance. This is followed by seg- varying m length . fl , r^ng seg . 
mentation or fragmentation of the myelin sheath ment of m y elin containing b, por- 

, ,. ., . ... . ,, tion of neuraxis in granular 

and soon after the neuraxis, resultmg in the for- degeneratiori; d, sheath or neuro- 
mation of segments of unequal length, found within ltmM ee,ls in processof prolifera- 

., , , ,, , , ,. tion; e, connective tissue cell;/, 

the neurolemma sheath and known as myelin short neuraxis fragmerit . < Ca j a i, 

ellipsoids. Such myelin ellipsoids usually present Trabajos del lab. de Investiga- 

rounded ends with the layer of myelin extending C " meS W '' ' 

around the ends. Within such segments fragments of the neuraxis are readily 

stained in silver preparations, and the neurokeratin net is well preserved 

and readily stainable in the myelin layer surrounding the myelin ellipsoids. 

Hand in hand with the fragmentation of the myelin sheath and neuraxis, of 



the degenerating medullated nerve fibers, there is observed a hypertrophy of 
the protoplasm of the sheath or neurolemma cells. These in their growth in 
size are first seen to press on and constrict the myelin and neuraxis, and as 
these fragment and the pieces draw apart, to fill the en- 
tire sheath. Both the protoplasm and the nuclei of the 
11 I sheath cells stain more deeply and nuclei present a rich 

\ /*'* £4 chromatin content. (See Fig. 16.) In the succeeding 

few days there is observed a progressive fragmentation 
of myelin ellipsoids, resulting in the formation of short 
segments of myelin, or oval or spherical masses, in which 
small masses of the neuraxis may still be demonstrated 
with silver staining; accompanying this there is to be 
noted a marked increase in the protoplasm of the sheath 
cells and a proliferation of their nuclei, in part at least 
by means of mitotic cell division, Btinger (i8gi), Huber 
(1892). The hypertrophied protoplasm of the sheath 
cells encloses and surrounds the myelin and the neur- 
axis remains. By the end of the first week after injury 
to a peripheral nerve, nearly all of the nerve fibers of 
the distal stump present evidence of secondary degen- 
eration, though not all to the same degree, and there 
■J I are a certain per cent of medullated fibers, especially 

in the periphery of the funiculi, in which the fragmenta- 
tion of the myelin and neuraxis hasnotbegun; such fiber s 
persist as apparently unaltered fibers into the second 
week after injury to the nerve. During the second 
Fie. 17— Degenerating week alter injury to the nerve there is observed a pro- 
nerve fibers of the peripheral g ress ; ve fragmentation of myelin and neuraxis remains, 

stump of the sciatic of a 

rabbit , 10 days after section, and an increase in the sheath cell protoplasm with nuclear 

Silver preparation, o sheath pro iifer a tion. (See Fig. 17.) The myelin is now found 

or neurolemma cells, in- 
creased in number through in the form of larger and smaller globules, surrounded 
proliferation; b, myelin glo- by sneatn ce n pro t plasm which exerts a phagocytic ac- 
d, connective tissue cell, tion on these myelin remains. Toward the end of the 
{Cajal, Trabajos del lab. de seC ond week and during the third week after injury to 
Invcstigadones Biol., 1906.) 

the nerve, the myelin globules become less numerous 
and the protoplasm, and nuclei of the sheath cells form a syncytical, nucleated 
strand of protoplasm found within the old neurolemma sheaths, and containing 


here and there larger or smaller globular remains of myelin. These nucleated 
protoplasmic bands of protoplasm were first fully described by Biinger (1891), 
and in literature have been known as the " Bandfasern"oi Biinger. They were 
observed and described quite independently by Howell and Huber (1892) and 
designated as embryonic fibers. These syncytial, nucleated protoplasmic 
bands, the product of the hyperplasia of the protoplasm of the sheath or neuro- 
lemma cells and proliferation of their nuclei found within the old neurolemma 
sheaths, in both medullated and nonmedullated nerve fibers, constitute a stage 
in the degeneration of the nerve fibers of the peripheral stump of an injured 
nerve that persists without material alteration for weeks and months. Since 
the sheath cells are of ectodermic origin, these nucleated protoplasmic bands 
must be regarded as ectodermal derivatives, as a syncytial nucleated protoplasm, 
reverted to an undifferentiated, embryonic state. Some time after their forma- 
tion there may be observed a delicate longitudinal striation of their protoplasm. 
This was regarded by Biinger (1891) and Bethe (1903) and later adherents of 
the polygenetic school of nerve regeneration, as indicating neuraxis develop- 
ment and leading to autoregeneration of the peripheral nerve. Even in silver 
preparations, a faint longitudinal striation of the protoplasm is now and again 
observed, but no observer working with modern, differential neuraxis staining 
methods has been able to find transition stages between the syncytial, nucleated 
protoplasm bands and neuraxes. 

The removal of the myelin and neuraxes in a degenerating peripheral fiber 
has been the subject of much study and discussion. The fixed and wandering 
cellular elements of a peripheral nerve trunk have been related to this process 
in one way and another. This subject has received extensive consideration by 
Doinikow (1911), using various differential staining methods in his study. 
According to this observer, in the rabbit, beginning with the fragmentation of 
the myelin the second day after injury to the nerve, there may be found fat 
droplets in the protoplasm of the sheath cells, which are thought to pass to 
the tissue lymph spaces of the endoneurium, probably in colloidal solution. 
With the fourth day after injury of the nerve, minute fat droplets arc demon- 
strable in the mesodermal cellular elements of the endoneurium, and by the 
end of the first week in the cellular elements of the perineurium. In the period 
from 30 to 60 days after injury there may be noted a progressive process of 
removal. The ectodermal elements of the liber gradually become free of the 
products of degeneration, while the number of the fat droplets and other prod- 
ucts of degeneration in the " Bandfasem" become fewer, they increase in the 


mesodermal elements, especially lipoid substances stainable in Sudan and 
Scharlach R. 

The account here given of the mode of degeneration of the nonmedullated 
nerve fibers of a peripheral nerve stump after injury is taken from Ranson 
(1912) who gave us the first accurate description, in preparations based on 
pyridine silver staining. Two types of nonmedullated fibers are recognized 
depending on the rate of degeneration : those degenerating during the first week, 
which are thought to be afferent, nonmedullated libers, the peripheral processes 
of small ganglion cells of the spinal ganglia, and those which degenerate during 
the second and third week, looked upon as efferent nonmedullated fibers, the 
neuraxes of sympathetic neurones. In the former type the neuraxes begin to 
degenerate within 24 hours after injury to the nerve. They first become gran- 
ular and then, after two or three days, become broken into segments of darker 
and lighter staining. The darker segments are thought to represent fragments 
of the neuraxis. the lighter segments, perhaps fluid exudate. By the fourth day 
the darker segements begin to disintegrate and to disappear about the end of 
the first week. During the second week the fibers are difficult to see, but pro- 
liferation of the sheath nuclei takes place, so that with the third week after 
injury, fine nucleated bands of protoplasm develop, usually seen grouped in 
rather compact small bundles, found between the nucleated protoplasmic 
bands developed from the medullated fibers. The more slowly degenerating, 
elferent nonmedullated libers may show uniform coloration fourteen days after 
injury to the nerve. These resistant nonmedullated nerves, in some of the 
pyridine silver preparations, stand out quite clearly after the medullated 
and less resistant nonmedullated fibers have undergone degeneration. Their 
mode of degeneration is the same as that of the more rapidly degenerating 
nonmedullated fibers. "We have, therefore, as the terminal stage of the 
degeneration of the nonmedullated libers, nucleated protoplasmic bands which 
differ from the similar bands formed from the medullated fibers only in size and 


found that changes are observable in the neurofibrillar net of the end plate 
during the first day in that these fibrils stain very lightly. This stage lasts 
only a short time and is followed by one in which the fibrils hypertrophy, here 
and there agglutinate and stain deeply. This hypertrophy and agglutination 
of the neurofibrils proceeds, in the course of the next day or two, until darkly 
staining irregular strands, thicker than the normal divisions of the nerve 
branches of the ending, are found. These clump and appear to run together 
and then fragment to form irregularly formed stainable masses which ultimately 
disappear. The periterminal net of the motor ending degenerates a short 
time after the neurofibrillar portion. The telolemma nuclei are said to dis- 
appear and there is noted a proliferation of the sole plate nuclei, probably by 
amitotic cell division. An enlargement of the sole plate, due to hypertrophy 
of the sarcoplasm of the sole plate is noted. 

The degeneration of nerve terminations in the neuromuscular and neuror 
tendinous end organs awaits special study with the aid of differential neuraxis 
staining methods. It can now be stated that the ncuraxes disappear completely 
in these endings. 

In the immediate vicinity of the wound, approximately within 5 mm. of the 
cut surface, in the distal stump certain changes are observed which differ from 
those described for secondary degeneration both for medullated and non- 
medullated nerve fibers. In sections of tissue including that portion of the 
distal nerve stump adjacent to the wound in the nerve, and fixed in chromacetic- 
osmic acid mixture, about 24 hours after injury, the myelin sheaths of the 
medullated nerves, for a variable distance, do not color black in the osmic 
acid as do normal medullated nerves, but present a granular appearance. 
This is regarded as due directly to the traumatic injury inflicted. The neuro- 
lemma sheaths often appear distended. Polymorphonuclear leucocytes appear 
in appreciable numbers between the nerve fibers, and now and then may be 
seen within the neurolemma sheaths, even in experiments in which a sharp 
knife and strict asepsis were used at the time of injury. The changes are ob- 
served in the immediate vicinity of the wound at a time when the nerve fibers, 
at a distance of about 1 cm. from the wound and for the remainder of the distal 
stump, show no structural change or alteration in conductivity. In prepara- 
tions of the distal stump in the wound region, stained with differential neuraxis 
methods, Perroncito (1907), Cajal (1908), Ranson (1012) and others noted 
both in medullated and nonmedullaled libers what is regarded as an abortive 
autoregeneration, consisting of temporary side branches ending in bulbous ends. 


This phenomenon is observed in certain nonmedullated fibers during the first 
day after injury, consisting in side branches of the neuraxis, ending in larger 
or smaller discs. Such branches are often quite numerous. They do not 
show much growth after their first appearance, and the majority disappear 
during the first week, after injury, though on certain of the resistant fibers they 
may persist a few days longer. A somewhat similar neuraxis reaction is to be 
observed on certain of the medullated fibers, in the distal wound region, per- 
haps in the more resistant fibers, and persists after neuraxis degeneration is 
observed in the majority of the medullated fibers. The peripheral end of the 
centra! stump of a divided or injured nerve degenerates centralward for a dis- 
tance that varies somewhat with the character of the injury, but generally for a 
distance of approximately 5 mm. The degenerative changes observed here are 
essentially the same as those noted in the peripheral stump, both in the immedi- 
ate vicinity of the wound and distal thereto. They are no doubt primarily 
largely the result of traumatism inflicted on the nerve at the time of injury- 
Kirk and Lewis (1917) believe that there is an early hyperplastic reaction of 
the neurolemma sheaths, adjacent to the line of section, first noticed as an 
increase of protoplasm surrounding the sheath nuclei, followed by proliferation 
of the nuclei by mitosis, so that between the fourth and sixth days proto- 
plasmic bands have become well developed. Ranson was the first to de- 
scribe lully the changes to be noted in the nonmedullated nerves in the distal 
portion of the central stump. An early abortive regeneration was noted by 
this observer. This is analogous to the abortive regeneration noted for the 
central end of the distal stump, and consists in the formation of lateral branches 
during the first 24 hours after injury, in the last 0.3 mm. of the proximal stump. 
These lateral branches may end in cylindrical end bulbs. They do not appear 
to develop much after their lirst appearance. In silver preparations they begin 
to stain less deeply with the third day and appear only as indistinct shadows 
during the fourth day. The fading in staining reaction is coincident with the 
beginning of a cellulipctal degeneration which is observed in the nonmedullated 
fibers beginning with the third day and extends perhaps 2 cm. centralward in 
the central stump. The manner of the degeneration is the same as that 
described for the nonmedullated fibers of the peripheral stump, the intensity 
of the process decreasing rapidly in a central direction. 

In preparations stained after one of the differential, silver neuraxis stains, 
certain neuraxis phenomena are observed in the medullated fibers in the region 


distal stump, and may thus be described with the degenerative changes. In 
certain of the medullated fibers, 0.2 mm. to 0.5 mm. central to the cut surface, 
in which final segment a disintegrated portion of the neuraxis is found, a zone 
of reaction is observed in which the neuraxis is several times its normal thick- 
ness, and stains quite deeply owing to the fact that there is present a dense, 
deeply staining neurofibrillar reticular network, the whole within the old 
neurolemma sheath, the myelin having degenerated. In some of the medul- 
lated fibers two such zones of reaction are to be noted. There is further ob- 
served what Ranson has designated a fibrillar dissociation, due to an accummu- 
lation of interfibrillar substance and hypertrophy of neurofibrils. Finely 
striated, large neuraxes, which fill the neurolemma sheaths and form large 
cylindrical bulbous ends, are found in suitable preparations in sections stained 
with other than silver methods. Very early branching of the neuraxes in the 
immediate neighborhood of the lesion is observed. These branches may grow 
into the exudate beyond the sheaths of the nerve fibers, often ending in fine 
cylindrical expansions, with the fibrillar substance located at the periphery, or 
fine branches may arise from the surface of the neuraxis, within the sheaths, 
where they become entangled in further growth, presenting complex skeins. 
It seems quite evident that these neuraxis reactions of the central stump, ob- 
served soon after the lesion and in the immediate vicinity of the wound, are 
in the central stump as in the peripheral to be regarded as abortive regenerative 
changes, thus associated with the degeneration phenomena. 

The behavior and ultimate fate of the neurolemma sheaths, during degen- 
eration of a peripheral nerve fiber, deserves brief consideration. During the 
early stages of degeneration while the protoplasm of the neurolemma or sheath 
cells shows hypertrophy and the nuclei proliferatie by mitotic cell division, 
the neurolemma sheath itself appears to show no definite structural change. 
In certain silver preparations of the wound region of a peripheral nerve 
injected with absolute alcohol into the living nerve, and removed within sLx to 


nucleated protoplasmic bands, developed from the sheath cell protoplasm and 
nuclei. In making this statement it must be admitted that we possess no 
differential neurolemma sheath staining method. Such a sheath is most 
clearly made out in segments of degenerated nerve fibers in which myelin 
remains in the form of myelin globules are still evident. In such regions of 
the degenerated nerve fibers a delicate sheath surrounding the nucleated 
protoplasmic strand and the myelin globules is clearly to be observed in 
both cross and longitudinal sections. In experimental observations 12 
to 15 months after injury, in peripheral nerves completely degenerated, what 
is regarded as contracted neurolemma shcalhs. surrounding the nucleated 
protoplasmic bands, are thought still to be observable. According to the 
observations of Cajal, the neurolemma sheaths are said to disappear several 
weeks after the degeneration of the myelin and neuraxes of the peripheral 
nerves and the formation of the nucleated protoplasmic bands is well estab- 
lished, these bands remaining surrounded by a fibrillar sheath of connective 
tissue origin, the fibrillar sheath of Retzius or of Henle. That delicate sheath 
structures, either of ectodermal origin, neurolemma sheath, or of mesodermal 
origin — Retzius' or Henle's sheath — surround the nucleated protoplasmic 
bands months after the degeneration of a peripheral nerve is well under way 
seems well established by abundant observation. There is at hand no evi- 
dence to indicate that the. old neurolemma sheaths function in the new fibers 
should regeneration ensue. 

Long before the process of secondary degeneration, which leads to the 
formation of the syncytial, nucleated protoplasmic bands in both the central 
and peripheral segements of a divided nerve, is complete, there may be recog- 
nized the initial stages of the process of regeneration. A topical and timely 
separation of the two processes cannot be made, since they may occur side by 
side in the same fiber. However, a separate consideration of the two processes 
is justified not only for the sake of clearness in discussion, but since in essence we 
are dealing with two distinct processes. The fact that evidence of regeneration 
may under favorable circumstances be recognized in fibers not completely 


touched upon in the brief review of the literature given at the beginning of this 
chapter, and it will there have been noted that with the introduction of the 
Cajal silver methods and modifications permitting of differential staining of 
neuraxes from early stages of development, in the majority of the experimental 
observations dealing with the problem of nerve regeneration in which these 
silver methods were used, the out growth or the monogenetic theory of the 
development of the neuraxis in regeneration has been adopted. Boeke (1916), 
one of the more recent workers, expresses himself as follows: "I place myself 
without question as adopting the viewpoint that in regeneration, as in develop- 
ment of embryonic nerve fibers, the regenerating nerve fibers arise exclusively 
through out growth from the divided nerves of the central stump, which enter 
the peripheral path and in this reach their peripheral destination." The 
studies of Perroncito (1905), Cajal (1908), Ranson (1912), Boeke (1 916-17), 
Kirk and Lewis (191 7), Dustin (191 7) Ingebritsen (19 18), have been especially 
helpful in bringing clarity to this subject. In each of these studies the develop- 
ment of the neuraxes in regeneration was given special consideration in prepa- 
rations stained with differential neuraxis staining silver methods. With 
them may be grouped Krassin (1908), who successfully used the intra vitam 
methylene blue method in the study of nerve regeneration. While unanimity 
of view has not been reached on all points there is agreement in recognizing 
as a sine qua non of regeneration of the peripheral degenerated portion of an 
injured nerve, down growth of neuraxes of central origin. The application 
of these silver methods has enabled the determination that there is not a dis- 
continuous regeneration of the neuraxes of a degenerated peripheral nerve as 
contended by the supporters of the theory of peripheral autoregeneration or the 
polygenetic theory of nerve regeneration. These more modern observa- 
tions have confirmed in full and extended the work of a group of observers 
working some 25 years ago who contended for down growth of central neuraxes 
in nerve regeneration. One quotation may be permitted, Huber (1895), who 
at the conclusion of an extended study in nerve repair after loss of substance 
expressed himself as follows: "The regeneration of the peripheral end (which 
always degenerates so that only the old sheaths of Schwann containing a band 
of nucleated protoplasm, developed from the hypertrophied protoplasm and 
proliferated nuclei of its fibers, are met with) is the result of an out growth of 
a new axis cylinder from the undegenerated axes of the central stump, the 
budding axes following the paths of least resistance." Evidence of regenera- 
tion was noted in the distal end of the central stump by Perroncito (1907) a 


few hours after injury, and by a number of observers within 24 hours, in the 
form of very fine branches given off from the central neuraxes, which grow out 
into the exudate or remain within the old neurolemma sheaths, this in the 
immediate vicinity of the lesion. (See Figs. 18 and 19.) This very early evi- 

Fio. 18.— End of the central slump of the sciatic o 
tion. .1, Fine neura\is with end bulb; rt, branching 
lion; D, fibrillation of neuraxis; £ and F, phei 
Trav. du Lab. de Recher. Biol., 1907.) 

, : ! -i days after section. Silver prepara- 
*is; C, neuraxis not as yet in rcgenera- 
; PcrrnnciUi; 6" to K, end discs. (Cajal 

dence of regeneration, which involves certain of the medullated nerves, may in 
part degenerate again, in any event progresses slowly for a number of days, 
while the degenerative changes involving the ends of the cut fibers of the central 
stump are initiated and in progress. The more purposeful regeneration begins 
somewhat later, but is well under way by the end of the first week after sever- 



branches, usually several tenths of a millimeter from the cut ends. By use of 
the differential silver staining method it has been clearly shown that from a 
single central neuraxis of a medullated nerve fiber numerous branches may be 

Fig. 19. — End of central stump of the 
A and B indicate region of the beginning of regei 
C, larger and D, smaller end disc; a and b. larg 
with terminal branches. (Cajal. Trav. du Lub. 


given off, the number varies but is by Kansur 
fifty or even more buds or side branches fur 
increase in the number of the central neuraxes 
sections of the more distal portion of the ccntn 

(10,2) estimated as liigh as 
l single fiber. This marked 
is most clearly seen in cross 
segment of a divided nerve. 

made at the proper level and two to three weeks after injury, in preparation 


subjected to suitable differential silver staining. In such preparations clearly 
differentiated, line neuraxes, in varying though appreciable numbers, may be 
seen within the old neurolemma sheaths often surrounding the undegenerated 
portion of the old neuraxis. These newly formed neuraxes grow toward the 
periphery of the central stump, within the old neurolemma sheaths in the form 
of bundles of fine fibers having in the main a parallel course and in longitudinal 

of the dog. 32 days after section, 
number of large end-discs, and branch- 

arrangement. Within oilier she; 
explanation has yet been gi 
presenting a more or less parallel ! 
arrangement, more or less compli 
often surrounding a portion of the 
spiral structures were first cle.i 
Fig. ro.'i These more recent obse; 

ihs, for reasons for which no satisfactory 
■ en. the budding neuraxes. instead of 
.mgitudinal course, assume a spiral or coiled 
xly woven, forming larger or smaller skeins. 
■Id eii neuraxis. These complex 
]y described by Perroncito 1.1907V (See 
wttion*. made witli the use of silver methods, 


pear-shape or cylindrical form, directed for the most part toward the periphery, 
now and again centralward. In the spiral complexes many end discs or end 
bulbs are frequently observed, forming a part of the spiral. The growing 
end discs or end bulbs, found on the out growing neuraxis branches, are very 
similar to those observed in the developing central and peripheral nervous 
system of embryos, and the growing end tips and end discs observed by Harrison 
in tissue culture preparations of isolated ganglion cells from the embryonic 
spinal cord of frog grown in clotted lymph. The growing end discs or end 
bulbs observed in silver preparations of regenerating nerves are often quite 
large, many times tbe diameter of the neuraxis, and it is conjectured that the 
size of the end disc is in a measure proportionate to the resistance met by the 
down growing fibers. 

Ranson (191 2) has determined that the nonmedullated nerve fibers of the 
central segment of a cut nerve begin regeneration about the fourteenth day, 
after the abortive regeneration and cellulipetal degeneration have taken place. 
There occurs a down growth of neuraxes from above the point where the degen- 
eration ceases. The down growing neuraxes, the branches of the non- 
medullated fibers, present small end bulbs and are arranged in quite compact 
bundles. Their number increases in the distal end of the central segment of a 
divided nerve, for several weeks after their regeneration begins. It seems 
quite clear that there is formed an increased number of nonmedullated fibers, 
through branching and budding of the central nonmedullated fibers, though 
this is not easily demonstrated owing to the compactness of the bundles. 

The branches of the neuraxes of both the medullated and the nonmedullated 
fibers, when first seen, appear as fine nonmedullated fibers. The marked 
increase in the number of these fibers was not appreciated until the differential 
neuraxis staining methods with silver salts were available, and all who have used 
these methods successfully confirm these results. These observations have with 
justice been used to confirm and substantiate the theory of the out growth of the 
neuraxis in nerve regeneration. The practical value of these observations will 
receive consideration in the following pages. 

From the beginning of the formation of branches of neuraxes within the 


increase in the number of the branching fibers reaching the exudate over the end 
of the nerve progresses slowly for the first few days after the division of the nerve, 
but is accelerated toward the end of the first week after injury by which time the 
number of new neuraxet which have extended beyond the limits of the central 
fibers am) cut neurolemma sheath* is quite considerable. Immediate suture 
after injury docs not appear to influence the rate of down growth of neuraxes. 
As the new neuraxes leave the old neurolemma sheaths, within which they show- 
in the main a quite regular arrangement, and reach the exudate over the cut end 
of the nerve and the organizing embryonic connective tissue, whether the 
nerve was sutured or not, of neuraxes lose their regular 

arrangement and direction ] cis of the nerve, and assume an 

irregular, crisscross course, B or small bundles of fibers as 

they course through the e> ic connective tissue. In serial 

suction of the wound region ! direction, removed one to two 

weeks after injury and stuine ilver method, fine neuraxes can 

be traced from the central ! izing scar tissue, in which they 

pass in all directions, their ance for which they penetrate 

the scar varying directly wit tfter the injury the observation 

is made. In such preparatio t o distinguish between neuraxis 

branches derived from medull ved from nonmedullated fiber*. 

There is often noted an excha n small adjacent bundles and it 

is not difficult to observe dr n !ura*.es, usually directed toward the 

periphery. Now and again a fiber may be traced through several divisions in 
the same or successive sections. Neuraxes terminating in end discs within the 
organizing scar tissue of the wound are to be observed in nearly every well- 
stained preparation. These end discs have in general a direction toward the 
periphery, others are found directed centralward and again others toward the 
organizing scar tissue surrounding the nerve in the wound region. In serial 
cross sections of the wound region removed several wceksafter injury, and staine.: 
alter the pyridine silver method, it may be observed that there is a loss of the 
funicular arrangement of the nerve as represented by the down growing 
raxc>. penetrating I lie organizing scar tissue of the nerve wound, the neunixes 
pa—ing in all dim lion?, and often for a considerable distance in the plane of tb; 
i ru~ -n i i< in. Serial i ro" ■•<■. linn- of the wound region, taken at suitable it-LT^ 
and Mai m-d in pyridine ilver. arc al-o instructive in showing a gradual diizir-- 


In case immediate or primary suture of the severed nerve has taken place, 
new neuraxes will be found to have entered the distal stump only a few days 
after they are found in the organizing scar tissue of the wound region. Serial 
longitudinal sections, including the wound region and approximately i cm. of 
the nerve central and distal to the wound, taken at intervals of 2 to 3 days 
during the first three weeks after injury to the nerve, and stained after the 
pyridine silver method, enable the observer to trace step for step the formation 
of the neuraxes branches in the distal end of the central segment of the injured 
nerve, their gradual penetration of the organizing scar tissue of the wound 
and the entrance of the new neuraxes in the central end of the distal segment. 
At first only a few neuraxes will be found in the central end of the distal seg- 
ment, their number increasing directly with the length of time after the nerve 
injury and suture the observation is made. Once the new neuraxes have 
penetrated to the central end of the distal segment, their course becomes again 
very regular and parallel to the long axis of the nerve. In both cross and longi- 
tudinal sections of the more central portion of the distal segment, made after 
central neuraxes have reached it. it can readily be determined that at first only 
a few neuraxes reach the distal stump, the great bulk of the fibers presenting a 
stage in nerve degeneration. Under favorable conditions new neuraxes 
may penetrate to the distal stump before its nerve fibers have reached the end 
stage in degeneration; namely, the formation of the syncytial, nucleated proto- 
plasmic bands. It is not unusual to observe several new neuraxes in one old 
neurolemma sheath in the distal stump. In longitudinal section, neuraxes with 
end discs are often noted, indicating termination of the new neuraxis within the 
limits of the section. Such end discs or end bulbs arc directed toward the 
periphery. In case cross and longitudinal serial sections are made, at intervals 
of the distal segment of an injured nerve, after regeneration begins, it may 
readily be determined that new neuraxes are found first in the immediate 
vicinity of the wound, while beyond a certain region only degenerated fibers 
are found, and where it is possible to determine clearly the ending of new 
neuraxes in the distal segment, these will be found to terminate in end discs 
directed toward the periphery. The area of neurotization in the peripheral 
segment of a divided nerve, after the initial stage of regeneration, is estimated 
to progress toward the periphery at the rate of 1 to 2 mm. in 24 hours. 
It progresses gradually, not only in the depth of penetration of centrally 
derived neuraxes, but also in the general increase in the number of new 
, which reach the distal segment; the number of the new neuraxes 


gradually decreases as one passes from the region of the wound toward the 
periphery. Attention has been called to the very great increase in the number 
of neuraxes formed in the distal portion of the central segment of a divided 
nerve; only a variable percentage of these reach the distal segment, propor- 
tionately more the more favorable the path. The down growing neuraxes 
derived from the central segment are diverted from the more direct path toward 
the periphery by the organizing scar tissue of the wound. Numerous neuraxes 
are deflected so as to be directed toward the central segment into the endoneural 
tissue in which they may grow for a short distance. Others are directed toward 
the periphery of the organizing scar tissue of the wound to be lost in the con- 
nective tissue surrounding the wound. In experimental work it may be easily 
observed that the more successful the suture the earlier may down growing 
neuraxes be found in the central end of the distal stump, and the greater propor- 
tion of new nerve fibers reach the distal stump. In case primary suture is not 
made and the severed nerve ends are not in close approximation, even though 
there be not extensive loss of nerve tissue, the down growing central neuraxes 
become dispersed in the scar tissue forming about the distal end of the proximal 
stump and penetrate only very slowly in the direction of the periphery. 

As has been stated, the down growing neuraxes derived from the central 
neuraxes, whether formed as branches of medullated or of nonmedullated nerve 
fibers, are at first all of the type of nonmedullated nerve fibers. They penetrate 
the tissue of the wound and reach the central end of the distal segment as non- 


end bulbs, thought to possess amoeboid properties, found at the end of growing 
neuraxes as within the nucleated protoplasmic bands. The same may be 
thought concerning the complex spiral structures and the numerous neuraxes 
found sprouting from a single central neuraxis of a medullatcd fiber. It is 

Fie. 21.— Newly formed neuraxes in the peripheral stump of the nerve of a rabbit ^7 days affer 
section. Silver preparation, a. Interstitial fibers with end bulb; b, end bulb within a "bandfaser;" 

c, d, e, g, newly formed neuraxes passing to one side of myelin remains within the neurolemma sheaths; 

d, division of a neuraxis; /, bundle of neuraies within a single sheath. (Cajal, Trabajos del lab. 
de Investlgaciones Biol., roodi.) 

known from experimental embryological evidence that neuraxes may develop 
without the presence of sheath cells, and it has been the contention of the writer, 
based on negative as well as positive evidence, that the same possibility must 
be ascribed to down growing neuraxes in nerve regeneration. What appear 
to be naked neuraxes without the presence of sheath cells are often followed 
for quite long distances in the connective tissue sheaths, sometimes several 
centimeters from the wound region. 

A number of authors have voiced the opinion that the degenerating fibers 


of the peripheral stump, more particularly the syncytial nucleated protoplas- 
mic bands, exert a chemiotactic influence on the down growing neuraxes. 
causing them to bud or grow in the direction of the peripheral stump. So far as 
I am aware, there are no conclusive experimental observations to substantiate 
this. On reaching the central end of the peripheral segment the down growing 
neuraxes are found to penetrate and grow into the old neurolemma sheaths of 
the degenerating fibers. A certain number are also to be found in the endo- 
neural connective tissue between the degenerating fibers now and again even in 
the perineural and epineural sheaths. The relation of the down growing 
neuraxes, found within the old neurolemma sheaths, to the syncytial nucleated 
protoplasmic bands, the end result of degeneration, has been differently inter- 
preted by observers; as playing only a passive role, or serving as conduits 
for the down growing neuraxes- Ranson (1912) states that "all new axons lie 
in protoplasmic bands, never between them." Boeke (1916), on special 
study with various methods, reached the conclusion that the neurofibril strands 
are always intraprotoplasmic. The prevailing opinion at the present time 
regards the down growing neuraxes found in the peripheral neurolemma sheaths 
as having intraprotoplasmic position. 

So far as has been determined there is no reason to assume that the down 
growing neuraxes show any selectivity on reaching the peripheral stump. Thus 
branches derived from the central neuraxes of motor neurones may and no doubt 
do enter the neurolemma sheaths of peripheral sensory fibers, and branches from 
central afferent nerves into distal efferent nerves, and no doubt branches of the 
central nonmedullated fibers may enter distal medullated fibers, either motor 


degenerate. The enormous increase in the number of new neuraxes formed in 
the peripheral end of the centra! stump permits many new fiber branches to go 
astray in the scar tissue and in the peripheral stump and still leave a sufficient 
number to admit of structural and functional regeneration. It has seemed to 
me that the purely mechanical interpretation is more nearly in accord with 
observed facts than any other that could be given. 

Huber (1900), Tello (1907) and Boeke (191 6) have studied the regeneration 
of motor and sensory nerve terminations in striated voluntary muscle tissue 
after experimental degeneration of nerves, with the aid of differential neuraxis 
stains (methylene blue and silver staining methods). Experimental observa- 
tions indicate that a muscle which fails to respond to electrical stimulation of its 
nerve, degenerated by reason of interruption of its continuity, again responds to 
electrical stimulation as soon as motor endings can be demonstrated in the 
muscle with suitable stains. Down growing neuraxes can be demonstrated in 
the small muscular branches within the muscle, here and there seem to end in end 
discs, at a time when there is no response by the muscle to electrical or mechanical 
stimulation of the nerve. Developing motor endings in regeneration have been 
demonstrated either as forming by branching from terminal end discs or as end 
branches of collaterals, led to the muscle fibers within old neurolemma sheaths, 
or as along syncytial strands of sheath cells or possibly also along cells of con- 
nective tissue origin. Boeke (10.16) has shown that there is often an over pro- 
duction of motor endings in regeneration, since certain muscle fibers may show 
more than one nerve termination. It has been found that the motor nerve 
endings regenerate before the sensory nerve terminations in the muscle. Coarser 
and finer nonmedullated nerve fibers, often showing branching, may be observed 
within the fibrous capsule of the neuromuscular and neurotendinous spindles 
before the characteristic endings can be demonstrated. Complete regeneration 
of the complex neuromuscular spindles, so far as concerns the nerve termin- 
ations, has been observed. For the study oi these endings the intra vitam 
methylene blue method appears on the whole to give more satisfactory results, 
in case positive results in the form of successful staining have been attained. 
Negative results, want of staining, cannot be regarded as trustworthy, owing to 
the precariousness of the method. 

As has been stated, in the processes of regeneration of a peripheral divided 
nerve, all of the branches of the central neuraxes, whether derived as out 
growths from medullated or from nonmedullated fibers, appear first as non- 
medullated fibers and as such penetrate and pass through intervening scar 


tissue, and as nonmcdullated neuraxes enter the central end of the distal 
segment, and proceed distalward therein. It seems quite clear that formation 
of the medullary or myelin sheath of fibers destined to become medulla ted 

Fig. si. — The proximal end of the peripheral nerve of a cat 72 days after section. Silver 
preparation. The neurotization of the peripheral stump was delayed. The figure shows division of 
a number of neuraxes, a, b, c, and d, after passing the wound and reaching the nerve fibers of the 
distal stump;/, terminal end discs. (Cajal, Trabojos del lab. de Investigations Biol., 1906.) 

fibers proceeds distalward, beginning with the proximal end of the divided 
nerve. The manner of the development of the medullary sheath, both as con- 
sidered in histogenesis and in a regenerating nerve fiber, has not been finally 
determined. Two general views have prevailed: First, that the medullary 
sheath is the product of the neurolemma or sheath cells; second, that it repre- 


sents a differentiation of the outer portion or layer of the neuraxis. In the 
more recent studies of de- and regeneration of peripheral nerves, with the aid 
of differential neuraxis stains, the study of the development of the neuraxes 
has been given prime consideration. The methods used have not been suitable 
for the study of the development of the medullary sheath. The medullary 
sheath can be recognized first in the newly formed fibers of the proximal seg- 
ment of a divided nerve, toward the end of the first month of the injury, in 
the form of a very delicate sheath, not recognized in silver preparations but 
brought out in chromatized tissue followed by differential myelin staining. 
The structural appearance presented suggests differentiation of the medullary 
or myelin sheath from the peripheral layer of the neuraxis, though this has not 
been definitely determined. Medullary sheath formation proceeds distalward 
relatively slowly, and does not involve all of the nerve fibers at the same time. 
Medullary sheath formation begins in the proximal segment of the divided 
nerve before functional connections, in the form of nerve terminations, have 
had opportunity to develop. Whether myelin formation is dependent on the age 
of the fiber, or whether other factors play a part, cannot at present be stated. 
It would seem quite clear, although this has not been definitely determined, 
that the neurolemma sheaths of the new fibers are new formations, developed 
from the sheath cells wandering out from the distal end of the proximal stump 
or found in situ by the down growing neuraxes, the result of sheath cell prolif- 
eration during nerve degeneration. 


An endeavor has been made in the preceding pages to make clear the fact 
that, according to the prevailing view, regeneration of the distal segment of a 
divided peripheral nerve is due entirely to the down growth of neuraxes from 
the proximal segment, and that the down growing neuraxes reach the proximal 
end of the distal segment in a relatively short period, if proper approximation 
of the divided nerve ends is attained and maintained by suture. In case an 
adequate approximation of the divided nerve ends is not obtained at the time 
of injury, down growing neuraxes may or may not reach tbe distal segment, 
depending on the character of the intervening scar and the distance of separa- 
tion. In case the divided nerve ends, owing to loss of nerve substance, are 
separated to such extent that they can not be brought to approximation and 
maintained so by suture either at a primary or secondary operation, a method 
of bridging the gap so as to give a conduit for the down growing central 
neuraxes is deserving of consideration. The question of bridging defects in 


injured nerves has engaged the attention of surgeons and experimentors almost 
since the beginning of our knowledge of nerve de- and regeneration, and an 
extensive literature dealing with the question has developed. Certain phases 
of the experimental work bearing on the problem of bridging nerve defects 
may here be considered, since the results attained throw light on the process 
of nerve repair and confirm in a very substantial way the down growth or 
monogenetic view of nerve regeneration. 

Of the several methods of bridging nerve defects which have been tried 
either experimentally or clinically, that of nerve transplantation has received 
the most extensive consideration, and deservedly so since in experimental 
work it has given the most satisfactory results. 

The first systematic histological study of the degeneration and regenera- 
tion of a nerve transplant was made by Huber (1895). He then reported on an 
experimental study of the repair of peripheral nerves after loss of nerve sub- 
stance. This study included twenty-six experiments of heterotransplantation, 
in which the sciatic of a cat was transplanted to a resected ulnar of a dog, 
the several experiments varying in length from 2 days to 182 days. A careful 
histological study of the operated nerve, including the transplant, was made. 
The morphological changes, noted in the nerve fibers of the heterotransplant, 
were reported as not differing materially from those noted in a peripheral nerve 
during degeneration. The degenerated fibers of the nerve transplant were 
found to contain nucleated bands of protoplasm ; however, the nuclei were found 
to be much less numerous than in the syncytial nucleated bands found in the 
degenerated peripheral nerve. Regeneration was found to begin in thecentral 
stump of the resected nerve and to proceed centrifugally. The process of 
regeneration was studied by means of the Stroebe method of neuraxis differ- 
entiation. Neuraxcs derived from the central stump could be traced through 
the central wound, into the transplant, and through the distal wound into the 
distal segment of resected nerve. Both in sections and in teased preparations 
could newly formed neuraxcs be found in the old sheaths of the fibers of the 


work of this observer auto-, and homonerve transplants survive in the host 
and would thus degenerate as does the peripheral segment of a divided nerve, 
while a heteronerve transplant becomes necrotic. These results were in the 
main confirmed by the observations of Segale (1905). As a result of experi- 
mental observations Verga (1910) and Maccabruni (191 1) reached the conclu- 
sion that the results were the same whether homo- or heteronerve transplants 
were used. Ingebrigsten (1915), who has given special consideration to the 
behavior of the nerve fibers in nerve transplants, expresses himself as follows: 

"In autoplastic transplanted nerves a degenerative process occurs which 
resembles the ordinary Wallerian degeneration, but appears a little more 
slowly than the latter. The cells of Schwann are in a condition of survival 
and are capable of multiplication after the transplantation. In homoplastic 
transplantednerves I have found a degenerative process resembling a Wallerian 
degeneration, somewhat delayed. The cells of Schwann multiply, and for a 
time at least are in a condition of survival. After twelve to fourteen days an 
abundant and increasing immigration of lymphocytes is observed, and from the 
eighteenth day cells of Schwann develop a necrobiotic appearance. In 
heteroplastic transplanted nerves, numerous myelin ovoids are formed 
during the first four to five days, but there is no proliferation of the cells of 
Schwann and no Wallerian degeneration is seen. The graft becomes necrotic 
within about two weeks." Throughout this work stress is laid on the behavior 
of the sheath cells, the cells of Schwann; their survival and multiplication. 
He states: "The solution of this point, which is the only reliable sign of the 
survival of the transplanted piece, gives the key to the problem and will influence 
the procedure of surgeons in case of nerve defects." As the result of more 
recent observations by Ingebrigsten (19 18) in which use was made of stored nerve 
transplants, the conclusion was reached that the cells of Schwann of auto- and 
homotransplants are without any biological significance for the regeneration 
of neurofibrils, which grow into the transplant from the central stump whether 
the transplant is living or dead. 

An extensive series of experiments on nerve transplantation, carried out in 
conjunction with the Division of Head Surgery of the Office of the Surgeon 
General, 1 has been reported upon in a brief preliminary note by Huber (1919). 

1 This experimental work was carried out in the Department of Anatomy, University of Michi- 
gan, under the direction of G. Carl Huber; Lieut. Col. Dean D. Lewis, Major J. F. Corbett, Major 
Byron Stookey and Major T. Roberg in succession received assignment to this laboratory with a 
view of assisting in an experimental study of nerve repair. To their initiative, untiring and hearty 
co-operation, the progress of the work is greatly indebted. 

G. Carl Huber. 


This series covers somewhat over 150 experimental operations on nerve trans- 
plantation made on the sciatic nerve of dogs and rabbits, and includes experi- 
mental observations on auto-, homo-, and heterogeneous nerve transplants, 
either used as fresh tissue, immediately after removal, or as nerve transplants 
stored in sterile media for varying periods of time. The primary object of this 
extensive series of experiments was to determine the virtue of a nerve bridge 
as a means of conducting down growing central neuraxes from the proximal to 
the distal stump, with a view of ascertaining the value of the nerve transplant 
in practical surgery. Under the conditions of work, the biology of the nerve 
transplant was of secondary consideration. In the histological study of the 
operated nerve, at the conclusion of the respective experiments, special con- 
sideration was thus given to neuraxis differentiation. In nearly all of the 
experiments use was made of the Ranson pyridine-silver method of neuraxis 
differentiation. This method admits of block staining and this facilitates the 
cutting of serial sections, so essential to the determination of neuraxis down 
growth and development. The nuclei of the sheath cells and of the connective 
tissue are by this method not clearly brought to view. The myelin sheaths 
are stained a bright yellow, and the fragmentation of the myelin is not always 
clearly followed. Therefore, the histological preparations obtained from this 
series do not permit of drawing final conclusive observations as to the behavior 
of the nerve libers of the transplants, especially as concerns their degeneration, 
while definite conclusions may be drawn relative to the down growing neuraxes. 
derived from the proximal segment. 

So far as may be determined on gross inspection and in histological pre- 
parations, she character oi the transplant does not materially influence the 
fibrous union of the resjuvtive ends o\ the transplanted nerve segment and the 
resected nerve end- llu- fibroblastic reaction appears to be essentially the 
same whether auto . homo or heterogeneous nerve segment is used, the general 
conditions 01 the .v. -, .:■..-.■ : -.. the same. The same may 

Ik- said oi the tea. - . - connective tissue to the transplant, 

v \ ... , Immaterial stained alter thepyridine silver method, 


of the sheath cells in the nerve fibers of the transplant during the fragmenta- 
tion and removal of the myelin is difficult to ascertain in silver stained prepa- 
rations, since they are generally only very lightly stained and not clearly 
differentiated . Therefore, we are not in a position to add to the observations 
of Ingcbrigtsen as regards the sheath cells of the transplant. The considera- 
tion of the behavior of the sheath cells of the nerve fibers in the transplant 
assumes less importance when regarded from the viewpoint of practical surgery, 
since it has been experimentally demonstrated that homo-nerve transplants 
stored in sterile media deserve serious consideration in bridging nerve defects. 
Following the suggestion of Dujarier and Francois (1918), homo-nerve trans- 
plants were stored in sterile petrolatum and liquid petrolatum, kept at 3°C. 
for intervals varying from 8 to 40 days, and then in 48 experiments used to 
bridge nerve defects, and in 18 experiments, following the suggestion of Nage- 
otte (1918), homo-nerve transplants, stored in 50% alcohol, for intervals vary- 
ing from 7 to 25 days, were similarly used. In these series of experiments the 
nerve segments thus stored do not retain a latent viability. The sheath cells 
show no evidence of proliferation and appear not to have biological significance. 
In the nerve fibers of the nerve segments thus stored and used as transplants, 
the fragmentation of the myelin and neuraxes takes place relatively slowly, 
proceeding less rapidly than in the peripheral segment. The removal of the 
debris, derived from the fragmentation of the myelin sheaths and neuraxes of 
the transplanted fibers, appears to proceed less rapidly in the nerve transplant 
than in the peripheral segment in the resected nerve. Many of the fibers for 
periods of weeks show distended neurolemma sheaths, filled with globules of 
myelin. Especially is this true in hetero-nerve transplantation. The forma- 
tion of the characteristic nucleated syncytial protoplasmic bands, the end result 
of the degeneration of periphreal nerve fibers, has not been clearly demonstrated 
in the degenerating fibers of the nerve transplant, irrespective as to whether 
these be of auto-, homo- or heterogeneous nerve tissue. The neurolemma 
sheaths of the transplanted nerve fibers are thought to persist, after the breaking 
down of the myelin sheaths and neuraxes, as in the peripheral segment of the 
nerve, even when heteroplastic tissue is used. The perineural anil epineural 
sheaths of the nerve transplant are not materially altered by transplantation, 
except that they may show leucocyte invasion, irrespective of the character of 
the nerve transplant. 

Regeneration of the distal segment of a resected nerve, with gap bridged by 
a nerve transplant, is by down growth of neuraxes derived from the central 


stump, through the transplant to the distal segment. This has been clearly 
demonstrated in pyridine silver preparations obtained from the long series of 
experimental operations above referred to. In the course of this experimental 
work there was devised an operation which we designated as "cable autonerve 
transplant," in which a number of segments of a smaller nerve were used to bridge 
a defect in a larger nerve. In the experiments in question four segments of the 

after passing through lint of 

cutaneous radial branches of the ulnar of a dog were used to bridgea defect in 
the sciatic nerve of the same dog. Within the first week alter the operation the 
several segments of the nerve transplant became surrounded hy newly formed 
connective tissue, binding the several segments together in one common trunk so 
as to form a common epineural sheath in which the funicular arrangement of 
the several transplant ed segment sis fully maintained. In an experiment termin- 



the connective tissue uniting the transplanted nerve segments to the proximal 
end, but none are found in the nerve transplant. In a similar experiment termi- 
nated the twenty-sixth day after the operation, down growing neuraxes in 
appreciable numbers have penetrated the central wound and are found in 
all of the funiculi of each of the four transplanted nerve segments. Practically 

Fie. 34.— Microphotograph of cable transplant, zG days after suture. Cross section 
through middle of graft transplant. Ranson pyridine silver stain. Note that the funiculi are filled 
with 'down growing neu rases. 

no down growing neuraxes are found in the connective tissue surrounding the 
transplanted nerve segments. The down growing neuraxes fount! within the 
funiculi of the transplanted nerve segments are found mainly within the neuro- 
lemma sheaths of the transplanted nerve fibers. (See Figs. 23 and 24.) They 
have not as yet reached the distal wound, a distance of 2 cm., and no new neuraxes 
are found in the dista! segment of the sciatic. In experiments terminated approxi- 
mately three months after the operation, one a primary operation and the other a 
secondary operation, new neuraxes were found to extend from the centra! stump, 


through the four transplanted segments, into the distal sciatic and in this to the 
muscular branches found within the calf muscles, white the more distal sciatic 
was as yet completely degenerated. In similar experiments terminated approxi- 
mately one year after operation, down growing neuraxes had extended distally 
so as to include the smaller foot muscles. (See Fig. 25.) In fresh homoplastic 
nerve transplantation, a fresh segment of the sciatic of one rabbit transplanted to 
the resected sciatic of another rabbit, down growth of central neuraxes through 
a transplant of 1 cm. length was noted in an experiment terminated 33 days 
after operation, and for a distance of about 2 cm. into the distal segment of the 
sciatic in a similar experiment terminated two months after operation. The 
down growing neuraxes were found both within the neurolemma sheaths of the 
l ransplanted nerve fibers and also between the fibers. In an extended series of 
experimental observations in which stored homoplastic nerve transplants were 
used, down growth of neuraxes through nerve segments stored in sterile petrola- 
tum, liquid petrolatum and 50% alcohol was demonstrated. Homonerve 
transplants of nerve segments stored in liquid petrolatum readily formed con- 
nective tissue union with the resected nerve ends. In such an experiment ter- 
minated at the eighth day, down growing neuraxes were found in the connective 
tissue of the central wound. In a similar experiment terminated the twenty- 
third day. down growing neuraxes derived from the central stump may be traced 
through the central wound in the proximal end of the nerve transplant in which 
they are found in large numbers. In many of the old neurolemma sheaths of the 
lUTvetihers of the transplant more than onedowngrowingneuraxisistobefound. 
The down growing neuraxes are found to be progressively less numerous 
as the distal portion of the nerve transplant is reached, and do not extend to the 
distal wound, a distance ol 3 cm. The distal segment of the nerve was completely 
degenerated; no neuraxes could be differentiated in it. In experiments termi- 
nated more than three months after the operation in which homo-nerve trans- 
plants oi.i cm. length, stored in liquid petrolatum were used, satisfactory, 
neuratiaation of the distal segment of the sciatic was obtained. The down 
growing neuraxes could be traced from the distal end of the proximal segment, 
through the transplant and distal wound into the distal segment of the nerve. 
In the longer time experiments regeneration of the motor endings in the calf 
muscle* was observed. The experiments with homonerve transplants, with the 
«Y! ■■■ wents suwdin 50 of sped*! interest since it cannot be 

inirstioned s »l lead nerve tissue, and a survival of 

:t in sciatic nerve. Ranson pyridine silver stain. Tun centimeters excised [n>m the sc 
e in the thigh and defect bridged by four antotmisplvit& Section shows regenerating n 
s between the muscle bundles. 


assumed. In these experiments the sciatics of rabbits were placed in 50% 
alcohol in wh>ch they were kept until desired. At the time of an experiment the 
nerve segment to be used was taken from the alcohol and placed in warmed, 
sterile saline solution for 15-30 minutes and then used as transplant. Such 
a nerve transplant makes connective tissue union with the resected nerve ends 
very readily and there is noted very little reaction in the connective tissue 
surrounding the nerve transplant. In such an experiment terminated 23 days 
after the operation, new neuraxes could be traced from the central stump 
through the central wound into the central end of the nerve transplant. In a 
similar experiment terminated 42 days after operation, very few new neuraxes 
could be traced through the transplant into the proximal end of the distal seg- 
ment. In this experiment the new neuraxes were quite abundant in the central 
end ol the transplant. In eight experiments in which alcohol-stored homo- 
nerve transplants were used, the period of observation was more than three 
months, and in each of these neurotization of the distal segment through the 
transplant was attained. The down growing neuraxes, derived from the 
central stump, in these experiments were found in part in the old neurolemma 
sheaths of the nerve fibers of the transplant, as well as in the connective tissue 
between the libers. Within the transplant, the down growing neuraxes present 
a quite regular, longitudinal arrangement, quite different from that found in the 
central and distal wounds, in which they have a very irregular course. 

In the experiments on hetero nerve transplants, segments of the sciatic 
nerve of guinea-pigs were transplanted to the sciatic of rabbits. The gross 
appearance of a hetero nerve transplant, seen two to three weeks after 
operation, is quite similar to that of an auto- or homoplastic nerve trans- 
plant similarly observed. Fibrous tissue union with the two ends of the 
resected nerve is easily attained. In pyridine silver preparations the remains 
of the neuraxes of the nerve fibers of the heterotransplant may be seen three to 
four weeks after the operation, especially in the portions of the transplant 
bordering the proximal and distal wounds. These neuraxes remains are of 
irregular contour and, though they may stain differentially, are readily dis- 
tinguished from the tine, down growing neuraxes derived from the central 
stump. From a study of pyridine silver preparations, it is quite clear that down 
growing neuraxes derived from the central stump may enter a heteroplastic 
nerve transplant and pass through it to the distal segment. The number of 
clown growing neuraxes that are observed to pass through a heteronervc trans- 
plant, however, is not nearly so great as thai observed in auto- and homoplastic 


nerve transplants. In heteronerve transplants many down growing neuraxes 
were found in the connective sheaths of the transplant and in the surrounding 
connective tissue, and thus reach the distal segment not so much through as on 
the transplant. Return of motor function was attained in a number of long- 
time experiments in which heteroplastic transplants were used. The results, 
however, were not nearly so satisfactory as when auto- or homoplastic nerve 
transplants were used. The experimental observations on nerve transplants 
give very convincing evidence in support of the down growth or the mono- 
genetic theory of nerve regeneration. Especially in the experiments of auto- 
and homogeneous nerve transplants may it be observed that the down growing 
neuraxes, developed from the distal end of the proximal stump, penetrate the 
organizing connective tissue of the central wound very much as in primary or 
secondary nerve suture. These down growing neuraxes reach the central end 
of the transplanted nerve segment, whether auto- or homoplastic, or homoplas- 
tic stored in petrolatum or 50% alcohol, from the tenth to the fifteenth day 
after operation, depending on the degree of successful approximation of nerve 
ends. In the transplant, the down growing neuraxes may be traced progres- 
sively through the transplant to the region of the distal wound, at a rate 
which is on the whole very similar to that pertaining in regeneration of the 
distal segment of a divided nerve. Within the transplant many of the down 
growing neuraxes are found within what are regarded as neurolemma sheaths of 
the transplanted nerve fibers; even though these do not contain distinct, nucle- 
ated syncytial protoplasmic bands. Other neuraxes appear to be between the 
nerve fibers of the transplant. That the sheaths or neurolemma cells of the 
transplant are not of special or specific significance to the down growing 
neuraxes is shown by the experiment of stored homonerve transplants. The 
supposition is permissible that in nerve segments stored in petrolatum and liquid 
petrolatum at a temperature of 3°C. some degree of viability in the neurolemma 
and connective tissue cells is retained, even though there is no satisfactory 
evidence of the proliferation of the sheath or neurolemma cells of the nerve 
fibers of the stored nerve transplant. In the case of the transplant of the 50% 
alcohol stored nerve, it cannot be supposed that viability is retained in any 
of the cells or tissue elements of the transplanted nerve fibers. Their participa- 
tion in any way in the down growth of the central neuraxis through the trans- 
plant, therefore, may be excluded. In the transplant the down growing 
neuraxes have a regular longitudinal arrangement much as that observed in a 
regenerating distal segment of an injured peripheral nerve. In pyridine silver 


preparations ol successive stages, the down growing neuraxes may be traced to 
the distal part of the nerve transplant at a time when neither in cross nor longi- 
tudinal sections any neuraxes may be observed in the distal segment of the 
resected nerve, all the nerve fibers presenting an advanced stage of degenera- 
tion. After reaching the distal portion of the nerve transplant the new neuraxes 
may in longer time experiments be traced into the distal wound, which, consist- 
ing of more fully developed connective tissue than that of the central wound 
at the time of its penetration by down growing neuraxes, offers proportionately 
greater resistance to the down growing neuraxes. In the region of the distal 
wound the neuraxes present show a very irregular course, taking circuitous 
paths, usually as single fibers or small bundles of fibers, between the connective 
tissue bundles. From the distal wound the neuraxes may be traced to degen- 
erated nerve in the proximal end of the distal segment. In none of the experi- 
ments on nerve transplantation were new neuraxes found in the degenerated 
fibers of the distal segment unless they could in cross and longitudinal sections, 
stained after the pyridine silver method, be traced from the central stump 
through or on the nerve transplant to the distal segment. 

A further series of experiments were considered as giving confirmatory 
evidence in support of the down growth or monogenetic theory of nerve 
regeneration. In certain experiments in which the ulnar nerve of dogs was 
resected to the extent of 4 to 5 cm., the resected ends of the nerve were 
inserted into the lumen of formalized arterial tubes, stored in 95 % alcohol, 
and before use placed for about 30 minutes in warmed, sterile saline solution. 
The resected nerve ends were retained within the ends of the arterial tubes by 
means of fine silk sutures. Arterial tubes thus prepared are retained without 
absorption for a period of at least five months. Their presence in the tissues 
does not especially incite connective tissue formation. There is practically 
no penetration of connective tissue through the wall of the tube. While the 
arterial tube is found collapsed, sufficient lumen is retained to admit of down 
growth of neuraxes derived from the central stump. In four of the experiments 
kept longer than four months down growing neuraxes derived from the central 
stump had passed through the lumen of the artery, in one experiment a distance 
of approximately 4 cm., and reached the distal segment of the nerve, in which 
beginning regeneration was noted. In these experiments no neuraxes were 
found in the distal stump of the divided nerve, unless they could be traced 
from the proximal end of the nerve through the lumen of the arterial tube to 
the distal segment. 


Arnemann: Versuche uber die Regeneration an lebenden Tiercn, Giittingen, 1787. 
Balfotjr: On the development of the spinal nerves in elasmobranch fishes. Phiios, Trans., 

Ballance and Stewart: The Healing of Nerves, Macmillan and Co., igox. 
Hi. nn . Allgemeine Anatomic inul ['hysiolo^ie des X erven systems, 1003. 
Boeke: Studien zur Nerven regeneration. No. 1. Die Regeneration der motorischen 

Nervenelemente, etc., Verhand. der Kon. Akad. van Wet., Amsterdam, 1916. 
Boeke: Studien zur Nervenregeneration, No. 2. Die Regeneration nach Vereinigung 

unglichaniger Nervensiiicke, etc., Verhand. der. Kon. Akad. von Wet,, Amsterdam, 1917. 
Bunger: Uber die Degenerations- unci Regenerationsvorgange am Nerven nacb Verlet, 

zungen, Ziegler's Beitr. z. path. Anat. ,v. 10: 1891. 
Cajal: Nervenregeneration, Barth, Leipzig, igoS. 
Cruikshank: Experiments on the nerves, particularly on their reproduction, etc., Philosoph. 

Transactions, 1795. 
Dohr.v: Die Schwannchen Kerne, ihre Herkunft und Bedeulung, Mitteil. d. Zool. Stat. 

Napels, v. 15: 1901. 
Doinikow: Beitrage zur Histologic' und Histopathologic der peripheren Nerven. Nissl- 

Alzhcimer, Hisiologischc und Histopalhologischc Arheiten, v. 4: ign. 
Dujarier ct Francois: Sur vingt cas ile griffe homoplastique dans les sections nerveuses 

Bull, ct mem. Soc. dc Chir. dc Paris, v. 44: 101S. 
Dustin: Les lesions posttraumatiques des nerfs. Ambulance de 1'occan, Vase. 2: 1917. 
Galeoti and Levi; Uber die Xeubildung des nervoscn Elemente, etc., Ziegler's Beitr. z. 

Path. Anat. v., 17: 181)5. 
Haighton: An experimental inquiry concerning the reproduction of nerves, Philosoph. 

Transactions. 1705. 
Harrison: Further experiments on the development of peripheral nerves, Amer. Jour. 

Anat., v. 5: 1906. 
Harrison: Observations of the living developing nerve fibers, Proceed. Soc. Exp. Biol. 

and, Med., v. 4; 1007. 
Held: Die EnUvicklung des Nervengewehes bci den Wirbcltieren, toog. 
His: Histogenese und Zusammenhaug der Nervenelemente, Arch. f. Anat. und Phys. 

Suppl., i8go. 
Howell and Huber: A physiological, histological and clinical study of the degeneration 

and regeneration in the peripheral nerve fibers. Jour. Phys., v. 13: 1892. 
Huber: Uber das Verhallcn der Kerne der Schwann'schen Scheide be! Nervendegenera- 

ttonen. Arch. f. Mik. Anat.. Bd. 40, 180^. 
Huber: A study of the operative treatment for loss of nerve substance in peripheral nerves. 

Jour. Morph., v. 2: 1895. 
Huber: Observations on the degeneration and regeneration of motor and sensory nerve 

endings in voluntary muscle. Amer. Jour, Phys,, v. 3: 1900. 


Ingebrigtsen: A contribution to the biology of peripheral nerves in transplantation, Jour. 

Exp. Med., v. 22; 191 5. 
Kennedy: On the regeneration of nerves, Philosoph, Transactions, v. 188: 1897. 
Kirk and Lewis: Regeneration in peripheral nerves, Johns Hopkins Hospital Bull., v. 

28: 1917. 
Krassin: Uber die Regeneration des peripheren Nerven nach Verletzung, Internat. 

Monatsch. f. Anat. v. 25, 1908. 
Langley and Anderson: An autogenetic regeneration in the nerves of limbs, Jour. Phys., 

v. 31: 1004. 
Lugaro: Zur Frage der autogenen Regeneration des Nervenfasern, Neurol. Centralbl. 

v. 24: 1005. 
Maccabruni: Des Degenerations-prozess der Nerven bei homoplastischen und heteroplas- 

tischen Propfungen, Folia Neuro-Biologica, v. 5: 191 1. 
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versuchen) Neurolog. Centralbl., v. 24: 1905. 
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tiere, etc., Arch. f. Mik. Anat., v. 54, 1899. 
Nageotte: Etude experimentale sur les inconvenients de la suture nerveuse directe et sur 

un proce*de de suture indirecte, permettant de les eviter, Bull, et mem. de la Soc. de 

Chir. de Paris, v. 44: 191 8. 
Nasse: Uber die Veranderung der Nervenfasern nach ihrer Durchschneidung, Muller's 

Archiv., 1839. 
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Philtpeax et Vulpian: Journal de la Physiol., v. 3: i860. 
Poscharissk y : Uber die histologischen Vorgange an den peripherschen Nerven nach 

Kontinuitatstrennung, Ziegler's Beit. f. Path. Anat., v. 41: 1907. 
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jos, Madrid, v. 5: 1907. 
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During the development of peripheral nerve surgery numerous methods of 
nerve repair have been evolved, both clinically and experimentally. Some are 
based on a correct conception of the histological processes of nerve regeneration, 
and others in ignorance of such processes, have applied to nerves methods 
suited to tendons, due to the more or less gross resemblance of the two. 

Standardization of Terms. — Before discussing the value of the various 
methods of nerve repair, it might be well to discuss the terms that common 
usage has applied to them. Unfortunately, there has been considerable 
variance and lack of standard terms both in this country and abroad. By 
retaining some of the descriptive terms and discarding others less exact, con- 
fusion may be overcome and a greater uniformity reached. Shcrren (1906) 
appreciated the need of clarification and suggested a re-arrangement offering one 
or two new terms, some of which are of distinct advantage while others are 
lacking in histological accuracy. 

The terms neuroplasty and neurorrhaphy have been used to designate 
almost any nerve operation, end-to-end suture, nerve crossing, nerve flap, etc., 
and consequently may apply to any form of nerve suture. In the German 
literature neuroplasty is referred to occasionally as the Hueter-Czemy method 
of nerve flap operation, though neither author originated the method, while by 
Bruns Neuroplasty." partial nerve suture is meant. Since neither neuroplasty 
nor neurorrhaphy in themselves designate any particular type of operation, it 
would seem advisable to discard these terms altogether and to use only explicit 
terms which indicate more precisely the method of repair, such as nerve flap, 
nerve crossing, etc. 

Nerve Transplantation.— In the English. American, as well as the Conti- 
nental literature. lack of uniformity has been conspicuous, particularly in the use 



that the word "greffe" be omitted because it meant inplantation in French 
literature and transplantation in English and American literature. However, 
since this objection was made, the French have come to use the word in the 
other sense, so that now the term "nerve graft" (greffe nerveuse) is used univer- 

FlG. 76. — Nerve 

Use of cable or multiple Ira 
or heterogenous. 

sally to designate the interposition of a nerve segment between nerve ends and 
has been used by Duroux and Couveur, Babinski, Dejcrinc. Nageotte, Gosset 
and others. The word graft in English literature, in conformity with long 
established usage, designates the transference of any tissue from one site to 
another — skin graft, bone graft, etc., consequently, there is little reason to 
omit this word from nerve surgery. The terms 
transplant and graft have been used interchange- 
ably, hence the use of either would lead to no 
confusion, though in more recent literature the 
term transplant has been given the greater currency 
and may be preferred. In view of the more 
recent experimental advances in repair of nerve de- 
fects, with different varieties of grafts, the term^ 
nerve graft or nerve transplant must be further quali 
tied in order to convey any concise meaning. A nerve 
transplant or graft may be autogenous (nerve taken 
from the same individual), homogenous (nerve from 
individual of the same species), or heterogenous 
(nerve taken from some other species). It may be 
either living or dead, fresh or preserved (on ice, in 
alcohol, etc.), a single strand or multiple strands, 
the latter being called "cable transplant" or "cable- 
graft." (See Fig. 26.) 

Nerve Implantation. — Sherren has suggested that 
the term nerve anastomosis be used to designate the operation of nerve implan- 
tation, " greffenerveusc" of L6tievant, and in the German "' Nervenpjropfung." 
Sherren also includes under anastomosis the operation whereby a small flap is 

Fir., 17— Nerve implanta- 
tion. Jn true implantation 
the funiculi arc separated and 
the nerve is implanted in the 
space between the funiculi. 
By implantation between the 
funiculi neuraxes are not cut 
and neurotization of the im- 
planted end does not take place 
unless neuraxes are accident- 


raised in a sound nerve and sutured to the distal end of a severed nerve F 

anatomical standpoint, this last operation is quite a different proced 

simple implantation. In this the severed end of an injured nerve is br • 

direct apposition with the cut end of a nerve flap in which there -,,- 

* LIt: are severed 

neuraxes, whereas, in implantation, whether the central, peripheral or hnth 

be implanted, the severed end of the injured' 
nerve is implanted in a slit between the funiculi 
of the sound nerve. (See Fie *-, \ tl 
. . ,. , s " ■*/•) these 

funiculi may not be cut and the neuraxes there 
fore, do not escape to grow into the implanted 
nerve except when they are accidentally cut 
The severed nerve ends lie between funiculi and 
not against severed veuraxes, as is the case when 
a flap,eitherlargeorsmall,is raised frorna sound 
nerve and sutured to the distal end r.f » 

cna ot a severed 
nerve. Thus, fn m the standpoint of nerve 

Fifi. 3° 
e of the distal end of one nerve t. 

Fig. 29 
■sing. An cnd-lo-end 5 
[he central cud "f another. 

Fie, -.). -Partial nerve crossing. By raising a email flap and direct end-to-end suture of the flap 
to the nerve, better approximation is obtained and better downgrowth of neuraxes secured than bv 

Fig. 30-— Partial nerve Crossing, wrongly called implantation, Neuraxes have been cut 
before implantation has been done. This method consequently is partial nerve crossing 

regeneration, the term nerve anastomosis as suggested by Sherren would 
include two distinct surgical procedures, histologically different. It miodit 


of raising either a large or small flap from a sound nerve with end-to-end suture 
of it to a severed nerve to be included under nerve crossing. 

Nerve crossing is perhaps the most descriptive term in use. By it is meant 
the union, end to-end, of the central end of one nerve with the distal end of another. 
This would be" complete nerve crossing." (See Fig. 28.) When a flap is raised 
from a sound nerve and sutured to the end of another, the operation should be 
designated as "partial" or "incomplete crossing." (See Fig. 29.) Both pro- 
cedures have the same anatomical basis and should be included under the 
same term. 

Nerve Implantation.-- -Since the operation of partial nerve crossing is 
removed from the category of anastomosis and placed in the division of nerve 
crossing, it might seem advisable to discard altogether the term anastomosis, and 
to revive the use of the term "nerve implantation" to designate the implantation 
into a sound nerve of either the central, peripheral or both ends of an injured 

Implantation may become nerve crossing if the funiculi of the sound nerve 
are severed and grow into the implanted nerve. (See Fig. 30). However, if 
true implantation technic is practiced as advocated by the author of the 
implantation method the funiculi are pushed aside and 
not injured. When the central and distal ends are 
implanted it was supposed that the neuraxes of the 
central grew into the endoneural and perineural spaces 
until they reached the distal implanted end and thus re- 
gained their own nerve trunk. While I do not agree that 
this takes place, this is what is said to follow such double 
implantations. Consequently, this method is not in any 
sense nerve crossing and must be differentiated from nerve 
crossing by use of the term implantation. 

Suture a distance is used to designate suture as de- 
scribed by Assaky (1886). whereby the nerve ends are 
brought into alignment but not in contact and held in align- 
ment by afietwork of catgut or silk sutures supposedly form- 
ing a scaffolding for the downgrowth of neuraxes. 

End-to-end Suture. — In addition to the above the descriptive term end- 
to-end suture should be continued in use to indicate the suture of a severed 
nerve when the cross areas of both the central and peripheral ends of the nerve 
;ire rirnmrht tno-ethpr CSpp Fie jrl 

[I.— Nerve 

ends prepared ftjrcnd- 

the method of choke. 


IS = 




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it ■ i 












Ji t 














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i * i 1 














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fi E 









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Nerve suture may also be further qualified according to the time at which 
suture is done. Those sutured at the time the primary wound is first treated 
surgically have been called primary sutures, while those repaired after the 
original wound has healed, no matter how great the interval between injury 
and repair, secondary sutures. 

In resume the terms retained here are: 

A. Primary or secondary nerve suture. 

B. End-to-end suture, partial or complete. 

C. Nerve graft or nerve transplantation, furthur qualified as autogenous, 
homogenous or heterogenous, fresh or preserved, single or cable graft. 

D. Nerve crossing, partial or complete. 

E. Nerve implantatidn, distal end only or both central and distal. 

F. Nerve flaps- — formed from central end. or distal end or from both. 
(7. Suture a distance. 


Recent experiences, both clinical and experimental, have offered oppor- 
tunity to evaluate various surgical procedures employed in the treatment of 
nerve injuries. Careful study of clinical results has shown that methods 
most successful experimentally were also most successful clinically, and con- 
versely, that methods clinically unsuccessful experimentally were of least 
value. While it may be true that it is not always possible to reproduce experi- 
mentally conditions comparable to those found in the human, yet it has been 
shown that methods of little value under the more favorable circumstances 
of experimental conditions were of as little or less value when applied clinically. 
By constant checking of the experimental with the clinical and the clinical 
with the experimental, it has been possible to eliminate methods which have 
demonstrated their futility. Unfortunately, in the years past the clinical 
lagged notably behind the experimental. But at present the clinical has again 
caught up with the experimental and the two have progressed co-ordinately. 

As a result of both clinical and experimental studies, some methods may 
safely be discarded, either as valueless, or as offering such slight opportunity 
for successful regeneration that methods more successful should be used in 
their stead. 

Nerve Flan Method. Amonir the nmrednrri tn 1>p dkrnrded is the ll f}.nt> 


Fig. 32.) In a critical review oi all cases published up to 1914, from the first 
operation by Letievant, Stookey (1919) has shown that not a single case, so 
far as one was able to judge from the published reports, gave any evidence of 
successful regeneration, while the two cases which were responsi- 
ble more than any others for a continuation of this method, 
Tillmanns' (1885) and Kenneth Mackenzie's (iooq-iqiS), were 
totally lacking in evidence of satisfactory regeneration. (See 
Chart I.) 

In Tillmanns' case the greatest part of the disability was 
due. not to paralysis of the flexor muscles, since the median and 
ulnar nerves were injured at the wrist, below the level at which 
the flexor muscles receive their nerve supply, but rather to the 
fact that these tendons were bound down in a "tendonous knot" 
which was freed at the operation when nerve flaps were per- 
formed on both the median and ulnar nerves. The only improve- 
ment reported in this case was an increase in the range of 
motion of the fingers so that the patient was able to perform 
such total movements as picking up a glass or holding a pen 
lightly, etc. This increase of flexor movement is rather to be 
attributed to the freeing of the tendons than to bridging irrele- 
vant nerve defects by means of nerve flaps. 

Kenneth Mackenzie's case of tumor of the sciatic nerve, 
from which "10.75 inches of the sciatic (was excised) in Mo from 
the lower border of the gluteus maximus to 1 inch above the pop- 
liteal space," and the defect bridged by two flaps taken from the 
peripheral segments offered no satisfactory evidence, so far as the report 
showed, of either motor or sensory recovery. 

Flaps wheth- 
er from the 
central, distal 
or both ends 
skoulil never 



Central Flap. — By splitting or cutting a flap from the central portion of the 
nerve a definite number of downcoursing neuraxes are permanently destroyed 
in proportion to the width of the flap. It has been argued by Stoffel (1913) 
that each funiculus has a definite course within the nerve trunk, extending from 
the plexus to its ultimate distribution in the periphery. While this may not 
be true, yet in certain portions there are definite nerve paths w-hich arc irrepar- 


regeneration is rendered impossible. In flap operations in which two flaps are 
made from the same stump, one-quarter to one-third of the nerve or more is 
removed from each side of the trunk. This damage done to the central nerve 
end, from which regeneration must take place, is considerable. 

Were the flap cut from the area of an internal nerve plexus, or central to it, 
greater damage would be done the nerve trunk than if the flap were made below 
a plexus. In either instance, considerable permanent longitudinal loss of 
substance ensues. The neuraxes, central to the site from which the flap is cut, 
will attempt to regenerate. The conducting paths having been removed, 
these regenerating neuraxes are then apt to grow out into the surrounding 
tissue or they may coil upon themselves and form a lateral neuroma on the nerve 
trunk itself. 

Thus, if one-third to one-half the diameter ol the nerve trunk be cut as a 
flap, one-third to one-half of the neuraxes are permanently eliminated and are 
deprived of any possibility of reaching the distal stump. 

Dittel (1891) and others thought that by turning down a flap from the 
central stump neuraxes were carried across the defect and that, at the point of 
suture, union of the central neuraxes with the peripheral would take place or 
further growth of these neuraxes follow. Such, of course, is not the case. The 
central flap, when cut centrally and turned down, is nothing more than a 
degenerated segment of nerve. Since the neuraxes within the nerve flap degen- 
erate, the only tissue bridging the nerve defect is connective tissue in which the 
neuraxes have undergone degeneration and the sheath cells of Schwann pro- 
liferation; showing in short the same Wallerian degeneration as occurs in the 
severed portion of any peripheral nerve. The central flap is bent down at a 
rather sharp angle upon itself over its connection with the central stump, and 
on account of the angulation really offers very slight opportunity for the 
down-growing neuraxes to make their way into the iew conducting paths 
offered. Thus, these paths within the flaps mechanically are so placed that 
they not only do not come in contact with the severed neuraxes but are 
practically unable to reach them. Hence, the flaps do not serve the purpose 
for which they arc intended and, furthermore, inflict permanent damage to the 
nerve trunk. 

Peripheral Flap. — Flaps cut from the distal stump deprive the peripheral 
nerve of a definite portion of its conducting paths. In Mackenzie's case a flap 
was turned up from both the tibial and peroneal nerves, 16 inches long. 


manently the possibility of regeneration in the area of the leg and foot to which 
their funiculi would have gone. A still greater damage is done by severing 
numerous muscular branches from the nerve trunk. One need only recall the 
anatomy of the tibial and peroneal nerves, and the numerous muscular branches 
which lead from them, to realize the extent of permanent damage done in the 
formation of such a flap. When a branch from the nerve trunk to the muscle 
is thus removed and taken altogether out of the field, the down growing neuraxes 
are deprived of any possible path from the remaining nerve trunk to the muscle. 
This is an extremely important point. Even were regeneration to take place 
and neuraxes grow down into the distal segment they would find no paths from 
the nerve trunk to the adjacent muscles. The muscles thus severed from their 
nerve branches would remain permanently without the possibility of neurotiza- 
tion. It is of course obvious that the peripheral flap is also a degenerated nerve 
segment, the same as the distal segment from which it is cut. 

The method of uniting the central or peripheral flaps to the other stump 
would be of importance if the flap method were of value. The severed end of 
the flap may be brought into apposition with the freshened central or peripheral 
end in order that the downgrowing neuraxes might come in definite contact 
with what conducting paths the flap offers. "To insert the flap into a split" 
in the central or peripheral stump merely places the proffered conducting- 
paths between funiculi and out of contact with their ends. For proper down- 
growth severed neuraxes should lie in as close contact as possible with the 
conducting paths used to bridge the gap. Unless this is accomplished, they 
become lost and dispersed in the surrounding connective tissue. Thereby 
the number of available neuraxes already reduced in the formation of flaps is 
further diminished, and even the remote possibility of a few neuraxes finding 
their way down is removed by such union. 

It is possible that the nerve flaps may be cut so nearly completely from 
the parent trunk that they lie in fairly good apposition with the nerve end, 
thus in effect becoming practically a free nerve transplant. Such a flap may 
then transmit neuraxes, with all the limitations of a single graft as compared 
with multiple grafts, but with the additional disadvantage of injury to the 
nerve trunk from which regeneration is to take place. An occasional case 
may be successful if the flaps are thus made. The method, however done, 
should be condemned, since a graft taken from any skin nerve will serve 
equally well or better in that end-to-end approximation may be more accu- 
rately obtained and no damage done the parent nerve. 


The use of nerve flaps to bridge defects is based probably upon the close 
resemblance of a nerve to a tendon in its gross appearance. Bridging defects 
in tendons by means of flaps is well founded because histologically the tendon 
is made up of one tissue— the densest variety of white fibrous tissue. It is 
a tissue unit in itself. Healing by primary union establishes complete ana- 
tomical continuity. On the other hand, a nerve, while grossly similar in appear- 
ance, histologically is made up of two distinct elements: the conducting tubes 
and the neuraxes from the ventral column or dorsal spinal ganglia cells which 
lie within these tubes. Severed neuraxes must grow down from the central 
stump. The sheath cells of Schwann united to form syncytial strands serve 
as conducting paths. Thus when two flaps are brought together anatomical 
union takes place as in a tendon, but neurotization does not until central neuraxes 
have grown into the distal stump. 

From this it will be seen that flap operations, either central or peripheral, 
cause permanent and irreparable damage to both the central and peripheral nerve 
ends, utilize degenerated nerve segments which offer relatively negligible con- 
ducting paths for the severed neuraxes, and that immediate union of nerve 
flaps cannot establish conductivity. 

Experimental Evidence. — The above conclusions are ably proved by the 
experimental work of Huber (1895). Seven flap operations were performed on 
the ulnar nerve in dogs. By means of both central and peripheral flaps, defects, 
varying from 5 to 6 cm., were bridged. The animals were killed at intervals 
up to a hundred and forty-seven days, the first on the sixty-fourth day, 
and thus both late and early stages of repair were investigated. 

When examined physiologically and histologically in no instances were 
any evidences of regeneration found neither within the flaps nor the distal 
portion of the nerve. "In sections through the regions of the down-turned 



In order to supply a scaffolding for the downgrowing neuraxes Assaky (1886) 
interposed between divided nerve ends, from which approximately 3 cm. was 
excised, a cable of catgut fixed with sutures to both the central and peripheral 
nerve stumps. In all five experiments originally performed by Assaky, regener- 
ating neuraxes were found both within the tissues between the nerve segments and 
in the distal segment. Huber (1805) repeated these experiments in a more 
thorough manner, excising a longer segment from the nerve, so that the neuraxes 
would have farther to travel, and found that in two out of three experiments, 
observed more than one hundred and twenty days, physiological, as well as 
histological, evidence of regeneration was present; while in the third, no evidence 
of regeneration either physiological or histological was obtained. In the latter 
experiment, catgut remains were still present between the nerve segments 
though the duration of the experiment was one hundred and forty days. In 
experiments of less duration, four early and two late, the catgut was gradu- 
ally absorbed and replaced by connective tissue through which the down- 
growing neuraxes had to pass to reach the peripheral stump. The invading 
connective tissue assumes a strand-like arrangement similar to the strands of 
catgut, thus forming a network of connective tissue, younger and, therefore, 
looser than the surrounding connective tissue, as a scaffolding for the down- 
growing neuraxes. The catgut strands resist connective tissue invasion for a 
short period so that when finally replaced this connective tissue is younger than 
the surrounding scar. Downgrowth through this young and loose connective 
tissue offers less resistance than through older, denser connective tissue. Huber 
felt that in the experiment in which the catgut was not absorbed and in which no 
regeneration had occurred that the catgut may have served as an obstacle to the 

Clinically cases have been recorded in which successful regeneration has 
taken place; however, the reports are too meager to admit of a thorough critical 
review being made, and more recently most surgeons have recognized that 
though downgrowth may take place following ''suture <i distance," other methods 
offer greater opportunities for bridging nerve defects. 

It is obvious that when downgrowth must depend upon the haphazard 
formation of an intervening scar scaffolding, too precarious a network for suc- 
cessful downgrowthis offered. Not only is the directing influence not predeter- 
mined as in other methods, but the density of scar tissue, increasing with time, 
might eventually strangle the neuraxes or offer too great an impediment to 


further downgrowth, especially if a long distance is to be bridged. Since a 
better means of supplying a scaffolding for downgrowing neuraxes than scar 
tissue is available, suture a distance should be abandoned as a method, clinically 
only remotely possible of success. 


As the result of Hoffmann's strong championship of this form of bridging 
nerve defects, nerve implantation has been rather extensively used in Germany. 
This method is originally the work of Letievant (1873), and was later modified 
by Tillmanns (1885) so as to be applicable to two parallel nerves. Letievant 
suggested that the distal segment of a severed nerve may be implanted into an 
adjacent sound nerve, after removing the epineurium from the latter at the site 
of implantation. Despres (1876) was the first to adopt this method clinically, 
and the first report of a successful case was by Sick and Sanger (1897). In 
their case not nerve implantation was done but partial nerve crossing, since a 
flap of the median nerve was raised and sutured to the musculospiral with return 
of function twenty-seven months later in all of the extensors except those of the 
thumb. Tillmanns modified the method so that when two parallel nerves 
were severed at different levels a cross suture could be performed upon the two 
long stumps while the two short stumps were implanted into the sutured long 
ones. This latter method really consists of two different types of operation, 
end-to-end nerve crossing and implantation. 

Ample experimental and clinical observations have substantiated that end- 
to-end nerve crossing permits excellent regeneration of the neuraxes within the 
peripheral segment. However, such favorable results do not follow implanta- 
tion, either clinically or experimentally. Powers' (1904) review attributed 
about 50% successes to the implantation method, and Sherren (1908) found that 
out of twelve cases observed sufficiently long "only two were failures; some 


cates of this method, on!y a slit is made in the adjacent nerve and the distal 
segment is implanted into the slit. (See Fig. 27.) 

By such implantation of the distal segment of the severed nerve, the 
theoretical intention is that the neuraxes of the sound nerve will grow down 
paths offered by the implanted nerve. However, as has been said if the funiculi 
are merely separated and the implantation made, no funiculi are cut and the 
conducting paths of the implanted segment abut into the endoneural connec- 
tive tissue between the funiculi where there are no neuraxes available for 

When both the central and peripheral segments are implanted it is pre- 
sumed that the neuraxes from the central stump will grow between the funiculi 
of the nerve trunk, using the nerve trunk as a scaffolding, and reach the distal 
implanted segment. Apparently the object of such double impiantation is to 
use the endoneural spaces as a scaffolding. However, instead of growing down, 
the implanted central end forms a small neuroma and the few outgrowing 
neuraxes are lost and sufficient downgrowth does not occur. Thus, by growing 
in the connective tissue between the funiculi, the neuraxes have little chance to 
reach the distal implanted segment. The fate of the distal implanted segment 
has already been discussed. 

In the majority of instances whatever success has been reported from 
implantation has been due to ingrowth of neuraxes from those funiculi inci- 
dentally cut at the time of implantation, as in the case of Sick and Sanger which 
was in reality a partial nerve crossing. In other words, implantation is success- 
ful in so far as it is partial nerve crossing, though imperfectly accomplished. 
Hence, it would be better to perform partial nerve crossing in the first place, 
care being paid to supply an appropriate number of neuraxes and to insure more 
exact end-to-end apposition. Huber (1895) found experimentally that im- 
planted nerve segments showed neither physiological nor histological evidence 
of downgrowth, while end-to-end nerve crossing gave evidences of functional 

It must be recalled that in implantation of either the distal or central 
segment, permanent injury may be done the parent nerve, if the funiculi inci- 
dentally cut happen to be motor funiculi having already been segregated into 
definite paths destined for a definite muscle or muscle group such as exist in the 
vicinity near which branches are given off. 

Consequently, since nerve implantation offers comparatively little oppor- 
tunity for successful downgrowth, certainly less than other available methods, 


preference should be given those procedures which present fewer obstacles and 
better facilities for downgrowth and do not entail injury to adjacent sound 

methods to be used 
Eud-to-bmd Suture 

The method of nerve suture most desirable is that which approaches the 
nearest to the normal anatomical arrangement of the nerve injured and unites 
a distal end of a nerve with a central end, having identical segmental and inter- 
segmental connections in the cord and connections with identical higher centers 
as formerly existed. The nearest approach to this aim is end-to-end suture 
of a divided nerve. Even with end-to-end suture the ideal is not attained, 
since in many situations it is impossible to bring identical funicular paths in 
approximation. The ideal would be so to suture a severed nerve as to bring 
identical funicular paths together so that identical peripheral connections, both 
motor and sensory be made by processes of identical cells of the ventral gray 
column and dorsal ganglia. Were such regeneration made possible the ideal 
suture would be attained. Rearrangement of the hbers within the plexuses 
of the nerve trunk would be unnecessary; reflex paths would be unaltered and 
unchanged connections with the associated centers maintained. 

End-to-end suture can attain this ideal result only extremely rarely if ever, 
yet this end must be the goal which we must seek. By accurate apposition of 
the nerve ends without axial rotation and with a minimum of trauma and con- 
nective tissue formation the best results arc obtained. Only in rare instances b 
separate funicular suture possible. In one case of tumor of the median nerve the 
funiculi had been dissected free by the tumor into separate bundles by stretch 
ing of the perineural connective tissue so that an ideal situation for individual 
funicular suture presented, and this was readily performed. Langley and 
Hashimoto (1017) advocated individual funicular suture but felt that the extra 
traumatism incidental with such suture outweighed the advantages. 

In order to overcome the misdirection of neuraxes into channels foreign 
to them, Nagcotte (1918) proposed that, if end-to-end suture were done without 
bringing the nerve ends into close apposition, but so as to leave a space of 3 to 
4 mm., rearrangement of the neuraxes into their proper paths might take 
place. Whereas if the suture were made so that the funiculi are brought end 



between the funiculi of the central and distal segments rearrangement of the 
fibers might take place at the point of suture and the fibers find their proper 
channels. This idea is seductive but it has not been shown that such rearrange- 
ment at the point of suture takes place, while the increased amount of scar 
tissue which forms between the nerve ends is a serious drawback and hemor- 
rhage from nerve ends cannot be checked unless the ends be brought in apposi- 
tion. Blood between the nerve ends always increases materially the amount of 
scar. It is of course true that the sutures should not be drawn too tight so as 
to squash the nerve ends, but only sufficiently to bring the funiculi in contact. 

Fig- 33- 
Figs. 33 and 34. — Methods of end-to-end suture which should i 
e cut obliquely or a wedge removed greater damage is done, mon 
e nerve ends, and funicular approximation cannot be 1 

Fig. 34. 

ot be used. When nerve ends 

scar is liable to form between 

Exact apposition of the funiculi minimizes the amount of connective tissue 
formation, while accurate union of the epineurium prevents connective tissue 
invasion from the surrounding tissues. 

It is obvious that union of the nerve trunk by primary intention occurs 
only for the connective tissue elements, whereas the ueuraxes must grow out 
centrally and penetrate through the layer of connective tissue union. Con- 
sequently, methods should be used which minimize the extent of connective 
tissue formation. 

Oblique suture and inverted V methods of end-to-end suture (see Figs. 
22 and 34) are not suitable for nerves, since they prevent accurate funicular 
indent incation and suture, and increase the amount of connective tissue 
between nerve ends. These methods have been taken over from tendon 


surgery and while perhaps admirable for tendons they are not adapted to 

End-to-end suture is the method of choice and should be done whenever 
possible, however, if too great a sacrifice of other important principles of nerve 
syrgery must be made in order to bring the ends together other means of su- 
ture must be employed. The methods available to obtain end-to-end union 
and their limitations are described later. (Sec p. 103.) 

Nerve Crossing 

Nerve crossing, partial or complete, as a means of re-establishing nerve 
function may be indicated when it is not possible to reunite the ends of a severed 
nerve, providing that the nerve used to furnish neuraxes to the distal segment 
can be spared without too great physiological loss or inconvenience. The 
nerve used should have close correspondence in function; a motor with a 
motor, a sensory with a sensory, and a mixed nerve with a mixed nerve. The 
closer the nerves are associated functionally in their peripheral distribution, 
by reflex collaterals and with higher centers centrally, the better are the ulti- 
mate results, especially if partial nerve crossing is done. The synergic action 
of muscle groups is dependent partly on the proprioceptive impulses from the 
muscles, etc., so that less re-education of nerve centers may be required after 
total than after partial crossing, since in partial nerve crossing impulses from 
both old and new groups are carried simultaneously to the same centers, 
and confusion, therefore, is more apt to occur. 

The co-ordinate use of muscle groups thus abnormally innervated depends 
among other things on the proper co-ordination of the proprioceptive stimuli. 
If these impulses reach normal connections, or are able to form new satisfactory 
connections, muscular movements may be controlled both in amplitude and 


(1859) and others performed nerve crossing using the lingual and hypo- 
glossal nerves without finding any functional reestablishment and concluded 
that functional return, following crossing of motor and sensory nerves was 

Philipeaux and Vulpian (1870) on the contrary, claimed to have obtained, 
in seven instances, successful return of function by crossing the lingual and 
hypoglossal nerves. They believed they were "able to establish the trans- 
mission of impulses from the lingual to the hypoglossal. The movements 
thus produced were not limited to the corresponding half of the tongue but 
involved movement of the other half . . . analogous to that which results 
from the stimulation of the intact hypoglossal nerve. " These authors concluded 
"that sensory fibers can unite with motor fibers and that stimulation pro- 
duced in one set can be transmitted to the other.' ' These findings are in di- 
rect contradiction to previous experiments and also are contradictory to all 
later work. 

Downgrowth of neuraxes, as has been said, however, may take place 
from the central nerve stump of one nerve into the distal segment of another, 
even though the central be a motor and the distal segment a sensory nerve, 
or vice versa. Langley and Anderson (1904) were able to trace efferent fibers 
from the anterior crural into the internal saphenous nerve and Osborne and 
Kilvington (1908), fibers from the posterior interosseous into the superficial 
radial. Following suture of the hypoglossal and lingual neives, Boeke (1913) 
was able to trace nerve fibers into the lingual as far as the epithelial cells of the 
tongue, between which the nerve endings ramified. 

Thus the problem of nerve crossing is really not one of regeneration, since 
downgrowth of neuraxes will take place providing the mechanics of the suture 
are technically satisfactory, but it is rather one of functional correspondence and 
the relative physiological expense of losing a nerve. Close correspondence in 
function of any two motor nerves may, perhaps, be of little importance in the 
re-establishment of gross movements of large muscles; but for finer movements, 
such as those of the face, many of which are associated movements, emotional in 
origin, consideration must be given to functional correspondence. Failure of 
dissociation of associated movements as occurs following suture of the spinal 
accessory to the facial, with the facial musculature violently twitching on move- 
ments of the head and shoulders, etc., frequently extremely difficult to over- 
come, is a drawback to nerve crossing. These points will be taken up in greater 
detail in connection with the facial nerve. 

98 surgical and mechanical treatment of peripheral nerves 
Nerve Transplantion 
The first nerve graft in human surgery was done by Albert (1878) eight 
years after Philipeaux and Vulpian (1870) had shown experimentally that a 
segment of the lingual nerve interposed between two ends of the hypoglossal 
nerve was capable of permitting motor impulses to pass. Following removal of 
a sarcoma from the median nerve Albert transplanted, between the severed ends, 
a nerve segment 3 cm. long taken from an amputated limb. In a second 
patient following excision of a tumor of the ulnar nerve with neurofibromatosis 
10 cm. was taken from the posterior tibial nerve and interposed between the 
nerve ends. The transplanted segment in the latter case sloughed, whereas in 
the first case primary union of the wound took place. Unfortunately no 
further report of this patient was given. Following Albert's cases of trans- 
plantation numerous other attempts were made with homotransplants, auto- 
transplants and heterotransplants. As he tero transplants the sciatic nerves of 
the rabbit, cat and dog have been used, and in one instance even a segment of 
the spinal cord of the rabbit (Mayo Robson, i8go). 

Several reviews, including a tabulation of cases of nerve transplantation 
have appeared, notably those of Huber (1895), Powers (1904) and Sherren 
(1906). Attempts have been made to draw deductions from cases reported in 
these collections and to compare results of homo-, auto- and heterotransplanta- 
tions, but unfortunately this is hardly possible, since the original reports do 
not admit of critical study, for, in many, the time between the operation and 
report is too short to allow of regeneration, and in others the data given is 
insufficient and the criteria accepted by the authors as evidence of return of 
function do not warrant the conclusion that regeneration took place. Albert's 
case was tost sight of after ten days, that of Atkinson (1890) on the sixteenth 
day, those of Hoffmann (18S4), Landerer (18S8), Kaufmann (1890), Maydl 
and Kukula (1803), Heath (1893) and others before the end of two months. 

Of thirty cases included in Sherren's collections only nine were observed 
one year or longer and in only two was there any improvement which could be 
accepted without reservation — those of Mayo Robson ( iSSS) and Dean (1896). 
The latter case is completely reported and the criteria offered as evidence of 


supplied by the tnusculospiral nerve reacted in a normal manner to the interrupted 
current. Perfect recovery" Results similar to those obtained in this case 
should be found when the final results of nerve transplantation done during the 
past five years are available. The final results of nerve transplantation will 
depend, in great measure, upon the most scrupulous care and precision in the 
operative technic. In estimating the percentage of recoveries consideration 
must be given to this point. There are certain technical difficulties encountered 
in suturing nerve transplants which may account for variation in the results 
obtained by different surgeons. If the nerve grafts are not accurately sutured, 
and unless the transplanted segment lies end on with its cross areas both 
centrally and distally in exact apposition with those of the nerve ends between 
which it is placed, the chances for successful downgrowth into the nerve seg- 
ment, while not precluded, may be greatly diminished. (See Fig. 58.) 

Experimentally there can be no doubt of the possibilities of this method as 
Huber (1895, 1918), Nageotte (1917), Cajal (1918) and others have shown. 
Thus far their results have been substantiated by a few clinical cases. A com- 
plete tabulation of the recent cases of nerve transplantation is not feasible at this 
time. However, there are a few published cases which indicate the probable 
value in clinical surgery of this method of bridging defects. Swan (191 9) 
reported a case of ulnar nerve injury in which a gap of 5J/2 inches was 
bridged by a single strand taken from the radial nerve. Return of voluntary 
movement in the interosseii muscles occurred and the patient returned to com- 
plete active duty. In a second a defect in the posterior interosseous nerve was 
bridged by a single graft taken from the radial nerve. Complete return of 
voluntary extension of the wrist, fingers and thumb took place. In one of my 
cases a defect of 5 cm. in the lower third of the arm was bridged with a single 
strand taken from the radial. A single strand was used, since the two nerves in 
this position are nearly equal in size and consequently the cross area was 
adequately covered. Fifteen months after suture extension of the wrist and 
fingers was possible but no extension of the thumb, while twenty-three months 
after the operation extension of the wrist, fingers and thumb was voluntarily 
accomplished, though faradic response had not yet returned. Gosset (1917) 
reported a case of ulnar nerve defect with interposition of a single segment of 
the musculocutaneous, followed fourteen months later by some return of ulnar 
sensation. In a case of median nerve injury at the wrist a single graft from the 
musculocutaneous of the leg was inserted and fourteen months later the R.l). in 
the muscles of the thenar eminence had lessened, the muscles responded to the 


faradic current and faradic cutaneous sensation was perceived even on the tip of 
the index finger. In another median nerve injury operation was done seventeen 
months after the original wound and a segment of the internal cutaneous nerve 
was interposed between the nerve ends. The patient was much improved nine 
months later, with return of both voluntary and faradic contraction. This is a 
remarkable result in view of the interval between injury and operation and the 
rapidity with which regeneration occurred. 

Joyce (1919) reported seven cases of nerve grafts, in all of which some 
improvement occurred. They are as follows: 

1. Ulnar nerve operated two and a half months after injury with a defect 
of 2% cm.; bridged by two strands taken from the radial. Twenty-eight 
months later partial motor and sensory return was observed. 

3. Ulnar nerve operated twenty-three months after injury, with defect 
of 3.6 cm.; bridged by one strand taken from the radial with partial motor and 
sensory return one year after operation. 

3. Ulnar nerve operated six months after injury, with defect of 3.5 cm.; 
bridged by a single strand taken from the radial nerve. One year later no 
improvement was seen and the nerve was re-explored. "A large oval neuroma 
densely adherent to surrounding muscles found at upper end of transplant. This 
bulb when liberated from the compressing scar tissue which surrounded it pre- 
sented normal nerve tissue in size, shape and consistency. A smaller and similar 
bulb was found at the lower end of the transplant. Seventy-nine days after this 
liberation some sensory recovery and progressive sensations of formication had 

4. Ulnar nerve operated ten months after injury, with defect of 12 cm.; 
bridged by a segment of the external peroneal nerve. This case was re-explored 
rather early, only seven months after the graft had been done. Here again 
"a soft spindle-shaped neuromatous enlargement was found present at the 


cm.; bridged by three strands taken from the radial. Partial motor and 
sensory recovery was reported. 

These cases are of extreme importance since they show, in a measure, 
what can be accomplished by nerve graft in human surgery. In the majority 
of the cases reported, only single strands were employed, whereas when the 
diameter of the nerve permits, three, four or even six strands forming a cable 
graft should be used. The aim should be to approximate, as nearly as possible, 
the number of funicular paths and offer a sufficient number of conducting tubules 
for the neuraxes. In many instances a single strand may approximate in 
diameter only one-fifth the size of the nerve trunk in which it is placed, and, 
therefore, cannot be expected to carry anywhere near the same number of 
neuraxes as the trunk, yet a relatively large proportion of the neuraxes of the 
trunk must be transmitted if a good functional return is to be expected. 

Re-exploration of a grait is indicated in certain instances, but should 
not be done before growth to or beyond the distal end of the graft has had time to 
take place. In some cases exposure of the graft and section of the distal line of 
union with resuture may be done, if it is considered that further downgrowth 
of neuraxes is blocked at the distal line of union. Thus scar tissue, which may 
have prevented further downgrowth, may be removed and regeneration be 
again facilitated. 

Among many surgeons a more pessimistic outlook for nerve graft is held. 
Piatt (1920) reports eighteen cases and to his number Stopford (1920) has 
added twelve additional, in none of which regeneration was found. These 
authors condemn nerve grafts since in their cases no improvement was observed 
up to three years. It seems difficult to reconcile such total failures with the 
results of Sherren and Dean, Swan, Gosset, Joyce and others, as well as with the 
abundant, brilliant experimental evidence in support of nerve transplantation. 

A drawback to the use of autogenous grafts is the additional time required 
to obtain them in an operation already sufficiently long. The time may be 
lessened by two operating teams: One to prepare the nerve ends, and the other 
to obtain the segments to be transplanted. In children autogenous grafts are 
rarely feasible, since the skin nerves are relatively short and small and the 
extra time required can hardly be taken as in an adult. 

Preserved Grafts. — Huber (1920) has shown that grafts preserved in 
liquid paraffin and held in cold storage can be used though they are less desirable 
than fresh grafts. Dujarier and Francois (1918) without any previous experi- 
mental work utilized this method in twenty cases. In all but one the wound 


healed by primary union. Unfortunately the report was made too early for 
end results to be available. Nageotte (1018) recommended that nerves 
preserved in 50% alcohol may be used with success. Nageotte advised 
the use of nerves taken from calves. Huber (1920) repeated Nageotte's 
experiments using homogenous grafts and found that regeneration took place. 
(See page 71.) If clinical experience substantiates the experimental work in 
the use of preserved grafts a great advance will have been made, in that the 
additional time required for autogenous grafts will be saved, and an additional 
operation avoided. In Germany, following the recommendations of Bethe 
(1916), nerves were obtained from fresh cadavers and immediately used, or 
preserved on ice for three to seven days. Possibly this method of obtaining 
homogenous grafts may be satisfactory, depending on the cause of death and 
the interval between death and the removal of the nerves. This method has 
been used by Steinthal (1915), Burk (1917). Cahen (1917J and others without 
infection or other untoward effects; however, no reports of their end results 
are available. 

In a large nerve it is extremely dimcult to place the required number of 
grafts so as to cover the greater part of the cross area. Consequently a con- 
siderable number of funiculi will remain without channels for downgrowth, 
though it is true that neuraxes may grow down between the nerve transplants. 
Such a loss is particularly regrettable if the funiculi uncovered happen to consist 
of important efferent fibers. Following loss of nerve substance with inter- 
position of a cable graft, even under favorable circumstances, a tremendous 
rearrangement and intermingling of the nerve paths with possible bad shunt- 
ing is also apt to occur. 

In a few selected instances, depending both on the size of the nerve and 
the funicular structure, an indirect funicular suture may be accomplished and 
the nerve graft interposed so that it connects each end of a funiculus. Where 
funiculi can be identified in both the central and peripheral nerve ends, as 
being motor in function, these should be sutured first, particular care being 
taken to insure the establishment of the connection. 

Thus where individual technic may enter so largely in the determina- 
tion of the value of this method of bridging nerve defects and where in each 
case the percentage of the cross area covered by nerve grafts must also be con- 
sidered, marked variations in the results are bound to follow. Unless these 
facts arc reckoned with, a method which experimentally has given satisfactory 
evidence of its value may be discounted, not because the method itself is at 

i f* xrxvx xepjui 

; m ucbatc *»d still in inns- 
t in tke icsahs of nerve grafts will be toond nth 

■ DunjRsxntG Kexve Dsffcts 

•■ is not possible in nerve detects there are 

. to permit end-to-end suture. These 

. oi the nerve ends; nerve stmching. either 

: transposition oi the nerve to a shorter COOTS! 

■ oi the extremity and. in rare instances, shortening ot the Kmb by 

a of the Herve. — This may be accomplished by wide exposure, 
; the nerve irce in iu bed. both centrally and distalty. and liberating 
the branches which may prevent tree mobilization. Most nerve branches 

may be dissected up in the epineurium of the nerve trunk for quite a distance- 
often to the point at which their funiculi arise, since nerve branches generally 
are formed higher in the nerve trunk than the poittl at which they leave It- 
Consequently, freeing them in their intraneural course may permit greater 
mobilization of the main nerve. Wide incisions are oi a further advantage, 
permitting indentification of the nerve both above and below 1 he level of I lie 
injury as well as facilitating the mechanics of nerve suture. 

Nerve Stretching— Schiiller (1888) was the first to call attention to the 
laxity of the nerve trunk and the increased distance which might be gained by 
moderate stretching. Separated nerve ends may frequently be brought in 
apposition by gentle traction and by adjusting the position of the limb so as 
to relax the nerves and diminish the distance between any two points in the 
course of the nerve. In the nerve bed there is normally a certain amount of 
slackness to admit of free movement of the extremity without tension upon 
the nerve trunk, which may be taken up by gentle traction upon the nerve. 
The greater amount of traction should be applied t" the longer nerve end, 
preferably the distal, and sufficient only to take up the 110rtn.1l laxity in the 
contiguous parts of the nerve bed. If forcible traction is applied, the ventral 
gray cells undergo central chromatolysis (sec Fig. 35) with consequent degen 
eration of their peripheral processes within the central stump (Warrington, 
i8q8). When still greater force is employed rupture of the funiculi may 01 cur 
within the nerve trunk or evulsion of the funiculi from the spinal cord. I he 
blood supply of the nerve trunk may be seriously damaged, not in any rcstrii tetl 


the collateral blood vessels which enter the nerve from the adjacent tissues. 
The only continuity of the nerve trunk which may remain intact is that of the 
connective tissue coverings; these are capable of greater extensibility. It must, 
of course, be recalled that there is no elastic tissue in the nerve trunk and 
stretching beyond the normal laxity is at the expense of anatomical continuity. 
Thus, if large defects be overcome by extensive stretching, continuity only of 
the connective tissue coverings is maintained, while grave damage is done the 
nerve elements, not only in the trunk, but even in the ventral gray cells. 

.. ... • • j ■ ^ ,-<* ■ 

*.«■■■ % 

Fie. 35.— Rabbit medulla, five days after evulsion or tie left hypoglossal nerve. Note 
central chromatulysis of motor cells ol left hypoglossal nucleus Nissl stain, a, normal ventral 
gray cell; b, ventral gray cell after evulsion. (Collection of Oliver S. Strong.) 

St off el (1915) has placed great emphasis upon the mechanical relation of 
the nerve to the position of the extremity. The optimum position which will 
permit the nerve ends being brought together may be determined at operation 
by manipulation of the extremity, using flexion, extension or adduction as the 
case may require. This varies not only according to the nerve injured, but also 
with the level of the injury. (See page 18S.) 

When a defect is too large to be overcome by gentle stretching and altering 
the position of the limb, a two-stage operation may be undertaken. In the 
first stage the nerve ends are freed but not freshened. The position of the 


silk sutures taking up as much of the laxity of the nerve as possible. By gradu- 
ally lowering the limb during the next few weeks the nerve is slowly stretched. 
Nerve suture may then be done. In two patients, one with a sciatic, the 
other a median nerve injury, the freshened nerve ends could not be approxi- 
mated, so the bulbous ends were sutured without excision of scar, 
and the limb put in extreme over correction, then gradually lowered until 
straightened. A second operation was done in the median nerve case, approxi- 
mately six weeks after the first stage. While some lengthening of the nerve 
trunk had occurred, elongation of the connective tissue had taken place between 
the nerve ends. On attempting to suture the nerve ends, normal appearing 
cross sections were not obtainable, even by sections made at a more remote 
distance than is usually necessary. The cross section showed increase in scar 
tissue with some pigmentation. The cause of this condition was not fully 
understood until the second case was operated. Operation upon the second 
patient was not possible until three months after the first-stage operation had 
been done, due to the fact that he had absented himself from the hospital. 
In this patient, at the second operation the unfreshened nerve ends were fairly 
well united, though marked elongation of the connective tissue between the 
nerve ends was found. On section of both the central and distal segments 
normal appearing nerve ends such as are usually found close were not obtained, 
by even remote sections. The funiculi on cross sections appeared as if strangled 
by a marked increase of endoneural and perineural scar — an appearance similar 
to that found in the distal portion of a neuroma, but the funiculi were separate 
and small though surrounded by a large amount of scar tissue. Finally, when 
as much had been excised as was deemed expedient, without normal cross 
sections being obtained the nerve trunk was palpated both centrally and distally, 
and both the central and distal ends were found not compressible and markedly 
sclerosed as far as exposed. 

With these findings we were then able to interpret the pathological appear- 
ance of the nerve in the first patient. /;/ both intraneural hemorrhages had 
occurred; probably throughout a great extent of the nerve trunk, with subse- 
quent scar formation and sclerosis. While these two cases are not conclusive. 
they would seem to indicate that overstretching, even when gradually applied, 
may cause intraneural hemorrhage with subsequent intraneural scar formation. 
The anatomical basis for such hemorrhage is seen in Fig. 77. This section of a 
typical nerve, stained to show the blood vessels, demonstrates the rather exten- 
sive vascular supply extending throughout the nerve trunk not only in the 


epineurium but in the perineurium and endoneurium, in intimate relation with 
the neuraxes. Thus any rupture of the blood vessels over an extensive course 
would cause serious endoneural changes which may destroy neuraxes or block 
their downgrowth and conductivity. 

In view of the dangers of central chromatolysis of the ventral gray cells, 
rupture of the funiculi, evulsion of the funiculi from the spinal cord and intra- 
neural hemorrhage with subsequent scar formation, stretching must be done with 
great caution. The author holds that nerve stretching may be permitted only 
up to the point of taking up the normal laxity of the nerve trunk. If greater 
stretching be applied, there is danger of grave injury to the nerve, propor- 
tionately greater the greater the degree of stretching. 

Transposition. A nerve may be changed in its course and thus shortened, 
as when the ulnar nerve is passed in front of the medial condyle of the humerus 
or the musculospiral nerve along the medial surface of the arm. In transposi- 
tion the nerve branches must be carefully dissected up the nerve trunk to permit 
Ireer mobilization of the nerve. In some instances, depending upon the 
nerve or the branches, it may be necessary to sacrifice one or two branches in 
order to permit transposition. Deliberate destruction of nerve branches must 
be carefully considered and if done, with full knowledge of the resulting 
paralysis and only after it is determined that the gain would more than outweigh 
the additional loss. No set indications can be given; each case must be decided 
individually. For example the decision to sacrifice the branches to the flexor 
carpi ulnaris and the ulnar half of the flexor digitorum profundus is justified, 
if by so doing end-to-end union may be obtained and the intrinsic muscles of the 
hand thus innervated. The latter muscles are extremely important for the 
accomplishment of the finer movements of the hand and they cannot be com- 
pensated fur by tendon transplantation; whereas by transplantation of the pal- 
tnaris longus into the flexor carpi ulnaris and the tendons of the flexor digitorum 
profundus to the fourth and fifth lingers into those of the second and third, the 
function of these muscles may be compensated. Transposition of the nerve 
does not interfere seriously with the nutrition nor the degree ot regeneration. 
In ulnar nerve injuries Slopford 110:0^ tound that regeneration was more 
. ompletc with transposition than when transposition had not been done. It is 
possible thai with suture of the nerve at the elbow without transposition 
the lino of suture is subject to trauma on movements of the elbow which in an 
imacl normal nerve would not cause my injury but would interfere seriously 


evidence to permit this suggestion, particularly in the ulnar nerve and in its 
relation to old fractures of the elbow. (See page 369.) Transposition, when 
possible, offers the most favorable method of obtaining end-to-end apposition 
in nerve defects. 

Resection of Bone. — The cases in which this procedure is justifiable are 
exetremely rare. Due to the grave compensatory static changes which would 
follow, it is impossible to consider this method to overcome nerve defects in the 
lower extremity. In the upper extremity shortening of the humerus may be 
justified when a concomittant fracture without union exists. This is also true 
in ununited fractures of the radius and ulna. Each case must be considered 
individually and resection done only when it is determined that other methods 
are less suitable. It is only in extremely rare instances that it can be considered. 


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Both experimental and clinical evidence show that if the central end of a 
motor nerve be implanted into a muscle whose nerve has been cut it will form 
motor end plates and re-establish motor function. Practically, this method 
only can be used in those rare instances in which a motor nerve can be devoted 
to the exclusive supply of one muscle, or when branches sufficiently large to 
offer an adequate nerve supply are available. It is here that its greatest field 
of usefulness will be found, particularly where muscle branches destroyed near 
their entrance into the muscle may be freed and implanted into the muscle at 
a higher level. 

Clinically, Hacker (190S) was the first to try direct nerve implantation, and 
claims to have obtained functional return. The operation was done on a girl 
twenty-four years old, with paralysis of the trapezius muscle following injury to 
the spinal accessory nerve during an operation for glands of the neck. Hacker 
implanted the central end of the spinal accessory into the trapezius and also a 
motor branch from the cervical plexus. He also implanted a flap of muscle from 
the levator scapulfe and, at a second operation a year later, implanted an 
additional muscular flap from the deltoid muscle. Electrical stimulation of the 
deltoid and levator scapula; subsequently caused partial contraction of the 
trapezius, and stimulation of the spinal accessory nerve and the cervical plexus 
at the point of implantation with the trapezius caused contraction of part of this 
muscle. It was noted that contraction took place more forcibly in the immediate 
vicinity of the site of both muscular implantations. Kolliker (1917) reported 
two cases of motor return in the biceps muscle, in which six months previously 
he had implanted the entire end of the median nerve. 

Forrester (101S) performed direct nerve implantation of the median, 
musculocutaneous, and peroneal nerves with complete return of function in 
four, partial in one, and complete failure in one. Lehrmann (rgrS) foundno 
motor return thirteen months after implantation of the musculospiral into the 
supinator longus, or twenty-three months after implantation of the spinal 


Experimentally, Erlacher (1914) implanted the median nerve into the 
biceps of a monkey after having severed the musculocutaneous nerve. Twenty- 
eight days later contraction of the biceps was obtained on stimulation of the 
median nerve, using the same strength current as was required to obtain motor 
response in other nerves of the same animal. Histological examination 
(Bielschowsky's method) of the biceps showed normal-appearing nerve fibers 
throughout the muscle (see Figs. 36 and 37), thus both histologically and physio- 

Fig. 36. Fit;. 37. 

Fig. 36. — Direct implantation. Very delicate reddish-lirnwn impregnated end plate of the 

implanted ulnar nerve. Very few nuclei. (Erlacher, Zeitschr, f. Orthop. Chirurg., igi4.) 

Fig. 37. — Direct implantation. Newly formed end plate of the ulnar nerve with distinct sole plate 

anlage. (Erlacher, Zeitschr. f. Orthop. Chirurg,, 1914.) 

logically demonstrating the establishment of neuromuscular connections. 
Heinike (1914) and his pupils, Haberlanrl and Miller, obtained neurotization of 
the gastrocnemius of the rabbit, after severance of the tibial portion of the sciatic 
by direct implantation of the peroneal nerve. Regeneration occurred within 
twenty-eight days, and at the end of fifty-six days the gastrocnemius showed 
normal contraction on stimulation as well as contraction of the neighboring 
flexor group previously paralyzed. This latter fact Heineke has made no 
attempt to explain. It is difficult to conceive of a nerve implanted into one 
muscle reaching adjacent muscles when these muscles, normally, not only are 
not in direct connection, but are separated from each other by intermuscular 
spaces. It is not possible to accept these results until they have received further 


Steindler (1016), following the work of Heinike and Erlacher, obtained 
active contraction of the vastus externus in two or three of his animals on stimu- 
lation of the implanted nerve. The contraction was greatest nearest the point of 
implantation, and in one experiment, examined early, contraction of the 
distal part gave slow undulating waves instead of a rapid sharp response. Such 
a response was also reported by Gerster and Cunningham (191 7) and is similar 
to that found clinically by Hacker in which contraction was greatest nearest the 
site of implantation. 

s obtained from stimula 
■le. (Ulnar nerve implar 

a [ureiyn nerve implanted directly i 
i) the biceps in a rabbit.) 

Hoessly (1016) implanted the motor branch of the spinal accessory nerve 
to the slerno-cleido-mastoid into the muscles of the larynx on the right side, in 
three dogs, after having excised 6 cm. from the right recurrent laryngeal 
nerve. Examination of the vocal cord following the operation showed the right 
cord to be in the cadaveric position. Examination five months later showed 
the position of the vocal cord very much improved in two of the dogs and they 
were no longer hoarse. The third dog showed no improvement. Hoessly 
obtained neurotization of the larynx adductors so that the vocal cord could be 
brought to the midline, and histological studies (Bielschowsky's method) 
showed numerous nerve libers, motor end plates and normal muscle tissue. 
As the result of these experiments he suggested the possibility of a similar 
operation in selected cases in the human, and presented a theoretical operative 
techntC. tSee [>age4-'0.) 

Elsberg (it)"?) working on rabbits, found that in eight to ten weeks 
" paralyzed muscle tissue regularly regenerates under the influence of the 
regenerating ^implanted) motor nerves." and that of two nerves implanted 
one lite severed nerve of the muscle, the other a foreign nerve, the normal nerve 



Erlacher (1914) implanted the ulnar nerve eight times and the median nerve 
twice in a normal biceps having its normal nerve supply. In each instance he 
obtained neuromotor connections, so that stimulation, using the same minimum 
current, of either the musculocutaneous or the implanted nerve gave identical 
motor responses. He concluded that the additional implantation of a motor 
nerve had increased the nerve supply to the muscle which he termed hyper- 

TN. M.N. 


a eurotizatiun 
of a muscle having normal nerve 
supply. (Erlacher, P. Amer. Jour. 
Orthop. Surg., 1015) 

Fie. 40. — Muscular n 
of a paralyzed muscle. (Erlacher. 
P. Amer. Jour. Orthop. Surg., 1915.) 

neurotization. (See Fig. 39.) Histological studies in serial sections of the 
biceps muscle showed young growing neuraxes from the implanted nerve, which 
he was able to trace as far as the formation of young motor end plates. 
"The microscopical examination demonstrated that the musculocutaneous 
nerve showed its normal distribution in the muscle and the presence of normal 
motor end plates. While in the vicinity of the implanted nerve, and 
adj'acent to thick, deeply impregnated, black, myelinated nerve fibers, 
small, fine and reddish-brown nerve fiber of either the ulnar or median 
developed, and on apparently perfectly normal muscle fibers, delicate end 
plates were formed as are usually seen from motor nerves." These newly 
formed "end plates" were readily distinguishable from the normal end plates 



of the normal nerves. The investigations of Steindler (1916) ami others arc 
in direct contradiction and led them to conclude that hyperncurotization of 
normal muscle is impossible. However, the presence of two or more motor end 
plates on a single muscle liber cannot be taken to indicate hyperneurotization, 
since it' is well known that a single muscle fiber may possess two or three 

lii.s. 41 and 4.'. Direct nerve 
passed through the epincurium about : 
(hen slit and alter a moment's wail [o 
B arc passed in the muscle .is mattress 
two additional epineural si 

Fie. 41. 
wo nnc waxed silk sutures. .1 and B, are 
mm. from the nerve ends at opposite points. The muscle is 
hefflostasb, the nerve is implanted. Both ends of A and 
uturri and tied. The slit in the muscle is then sutured and 

ind /'. hoi 

-■V ■: 

sharp angulation at the point 

motor end plates. Agduhr (iQjgl studied degeneration of nerve endings in the 
flexor digitorum sublimis muscle after cutting, .11 different intervals, the sev- 
entli and first thoracic root- leaving the eighth cervical intact, and in this 
manner found that the individual muscle liber may have two or three motor 
end plates .is shown by the presence of motor plates in different 
degenerative phases, lit regeneration of previously denervated muscle 
Boefce tQto) found more than one nerve ending on individual nerve 
bers Complete neurotiaaUon of muscle by direct nerve implanation 


trapezius, serratus anterior, subscapularis, etc., made up of fibers running in 
different directions or having digitations each more or less separate except near 
the insertion, innervation occurs in the digitation into which the nerve is 
implanted and is not apt to extend to adjacent digitations or to include the 
whole muscle. Implantation is most successful in muscles whose fibers run a 
parallel course and whose normal innervation is from a nerve which supplies the 
muscle by breaking up into terminal branches within the muscle, rather than 
in muscles whose fibers arc arrangeti in digitations and whose nerve supply is by 
separate branches to each digitation. 

Technic of Nerve Implantation. — The central end of the nerve to be 
implanted is freshened to a scar-free area and normal-appearing funiculi. 
Two fine epineural sutures are passed at opposite points 2 mm. from the 
nerve end. The point in the muscle at which the nerve is to be implanted is 
selected, bearing in mind the movement of the muscle during contraction and 
during changes in position of the extremity, selecting a point so that there will 
be no tension on the nerve. A slit is then made in the muscle in the direction 
of the muscle fibers. A small, moist, warm cotton pad is placed in the opening 
of the muscle and over the nerve end and a moment waited for complete hemo- 
stasis. Both ends of the epineural sutures are passed in the muscle as mattress 
sutures. These are placed so as to direct the nerve end downward in the direc- 
tion of the muscle fibers. The opening in the muscle is then closed and two 
additional epineural sutures are passed to hold the nerve in place and prevent 
angulation of the nerve at the point of suture. (See Figs. 41 and 42.) 


Neurotization of paralyzed muscle through nerve fibers contained in a 
transplanted muscle flap, by direct outgrowth of the neuraxes from the 
flap into the paralyzed muscle, offers a seductive method of re-establishment 
of motor innervation. If proven successful, the opportunities for clinical appli- 
cation of such a method, contrary to direct nerve implantation, would be legion. 

The method was first tried by Gersuny (1906) when he implanted a part 
of the trapezius into the paralyzed deltoid and claimed to have obtained a 
functional result. Hacker transplanted a part of the levator scapulae into the 
paralyzed trapezius with functional return. However, at the same time the 
spinal accessory nerve was implanted directly into the muscle, so that it 
is difficult, in this case, to determine the source of the regenerating neuraxes, 
though Hacker's electrical stimulation might support the view that outgrowth 


had taken place from both sources. Erlacher (1914) attempted muscle im- 
plantation, experimentally, in guinea pigs, in which he transplanted slips of 
the deltoid or pectoralis major into a previously paralyzed biceps. (See Fig. 40. ) 
He reports that neurotization of the biceps was obtained, as demonstrated by 
physiological stimulation of the biceps and by microscopical studies of the 
biceps. Normal motor end plates were found with a distinct neurohbular 
outgrowth from the neuraxes of the implanted muscle flap, and complete 
regeneration of the muscle fibers of the biceps. At first, on stimulation- 
simultaneous contraction of both muscles followed, that is, stimulation of the 
deltoid caused contraction of the deltoid and the biceps, but in later stages 
isolated contraction of either muscle could be produced. Such dissociation in 
function is indeed remarkable, and calls for further substantiation. 

Erlacher advises that the implanted muscle flap have a broad base, so as to 
insure its nerve supply. The flap retains its power of contraction and at once 
begins to send outgrowths of neuraxes into the adjacent muscle tissue in which, 
later, normal motor end plates may be found. " After forty-eight days, electri- 
cal stimulation of the implanted flap caused contraction of the biceps, and in 
microscopical preparation I found nerve fibers from the muscle flap growing 
through the line of scar tissue uniting the muscle flaps, into the paralyzed 
biceps, and there forming young regenerating end plates." 

Erlacher says, "muscular neurotization may be obtained in three different 
ways: First, we may remove the connective-tissue sheath from two muscles 
running side by side and sew them together; this method is to be recommended 
only in the case of muscles with identical action, such as the tibialis anticus. 
extensor hallucis. and extensor digitorum or the extensor digitorum and peroneus 
Second, we may form a long, centrally pedunculated flap from the healthy 
muscle, freshen it widely and graft it into the paralyzed muscle; in this way we 
can bridge intervening spaces. This method is available for the neurotization 
of the tibialis or the peronei from the gastrocnemius, from the quadriceps to the 
flexors of the leg. or from the brachial triceps to the biceps. Third, we may 
sacrifice a whole muscle by cutting it at its tendinous insertion and cither stitch 
it well freshened into the paralyzed muscle (for example, the flexors of the leg. 
or the tensor fascia' femoris or sartorius into the quadriceps), or we may make 
an end-to-end connection with the paralyzed muscle (as, for instance, the tra- 


electrical stimulation of either the peroneal flap or the tibialis posticus muscle. 
However, no movement of the foot took place and only a slight tension of the 
tendon was seen. Two other patients are recorded, one in whom there was 
paralysis of the biceps and in the other paralysis of the deltoid. In each, 
muscle implantation was performed, but unfortunately the cases were reported 
before end results were possible, and. consequently they offer no light on the 
clinical application of this form of neurotization. 

Of twenty muscle implantations done by Nutt (1917) in cases of infantile 
paralysis thirteen were functionally failures, while four showed fair recovery, 
and two good recovery. In this connection it must be recalled that in paralysis 
of anterior poliomyelitis adequate mechanical treatment such as is given, for 
example, after tendon transplantation, may in itself allow return of function. 
Sir Robert Jones has held it as a cardinal principle, which my own experience has 
confirmed, that in paralysis of anterior poliomyelitis no operation such as tendon 
transplantation or reinnervation should be performed until the latent power of 
returning function shall have been given an opportunity for re-establishment by 
complete rest for at least six months. Consequently it is suggested that before 
the return of function in anterior poliomyelitis can be attributed to neu- 
rotization by direct muscle implantation, these muscles should be placed in 
absolute rest sufficiently long to exhaust the possibility of their own unaided 

Though very alluring, direct muscle neurotization by muscle implantation 
needs further confirmation both clinically and experimentally, particularly the 
early dissociation in function, and early isolated contraction of the neurotized 
muscle reported by Erlacher in his experimental work. 


Agduhr, E.: Morphologischer Beweis der doppelten (pleurisegmentalen) motorischen 
Innervation der einzelen quergestreiften Muskelfasern bei den Saugetieren, Anat. 
Anz., 1016, 49, 1-13. 

Agduhr: Sympathetic innervation of the muscles of the extremities, a histo-cxperimental 
study, Verhr. d. K. Akad. v. Wetensch., Amsterdam, 19 19. 

Boeke, J.: Die doppelte motorische und sympathetische efferente Innervation der quer- 
gestreiften Muskelfasern, Anat. Anzeiger, 1913, 44, 343. 
Studien zur Nervenregeneration I, Verh. d. K. Akad. v. Wetensch., Amsterdam, 1016, 

18, 91. 
Studien zur Nervenregeneration II. Verh. d. K. Akad. v. Wetensch., Amsterdam, 191 7, 19. 


Elsberci, C. A.: Experiments on motor nerve regeneration and the direct neurotization of 

paralyzed muscles by their own and by foreign nerves, Science (N. S.), v. 45: (Mar. 30), 

1917. P. iio. 
Erlacher, P.: Hyperneurotisation; muskulare Neurotisation; freie Muskeltranspl.-intation. 

Experirnentelle L'niersuchungen, Zentralbl. f. Chir., April, 1914, v. 41: no. 15, p. 625. 
Ehi.aciif.r, P.: Uebcr die motorischen Nervenendigungen. Histologischc und experi- 
rnentelle Beitragc zu den Operationen an den peripheren Nerven, Ztschr. f. orthop. 

Chir., v. 34: iqi4, p. 561. 
Erlacher, P.: Direct and muscular neurotization of paralyzed muscles, Experimental 

research, Am. J. Orthop. Surg., v. 13: July, 1915, pp. 22-32. 
FoiJtSTBX, 0.: Die Symptomalologie und Thcrapie der Kriegsverletzungen der peripheren 

Nerven, Deutsch. Ztschr. f. Nervenh., v. 59: 1918, p. 32. 
Gerster, J. J. C. and Cunningham, W. F.: Neurotization of paralyzed muscles by implanta- 
tion of motor nerves, Med. Record, v. 93; August, 191 7, p. 223. 
Gf.rsi'SY, R.: Eine Operation bei motorischen Liihniungen, Wien. klin. Wchnschr., v. 19: 

mod, p. ;6,j. 
Hacker, v.: Ertolgrcieh operativ behandclte Cucullarislahmung, Wien. klin. Wchnschr., 

v. 21 : j. 1008, p. 1314 (no. 37). 
Hacker, v.: Direkte NerveueinpSaasung in den Musket und muskulare Neurotisation bei 

cinem Faile von Cuiiillarisliihmiing. Zentralbl. f. Chir., v. 41: 1, 1914, p. 882. 
Hkimekx: Die direkte Einfianzung des Nerven in den Muskel, Zentralbl. f. Chir., no. n, 

v. 41: 1014, p. 465. 
HoESSLY, 11.: Ueber Nervenimplantation bei Recurrenslahmungen, Eine experirnentelle 

Studie, Beitr. z. klin. Chir.. v. 99: 1016, p. 186. 
Kullikkk,; Einptlanzung ewes Astes des Nervus medianus in den Musculus biceps nach 

Hoineke, Zentralbl. f. Chir.. mi;, p. it. 
NlTJT, J, J.: Neurotization of paralyzed muscle by muscle grafting. J. A. M. A., v. 69: 

Ore .'.', 1017. pp. 1083-2085. 
StEIKDLKK, K.: Direct neurotization of paralyzed muscles; further study of the question of 

direct nerve implantation. Am. J. Orthop. Surg., v. 14: 1016. p. 707. 
STEIXDLKR, A.: Method of direct ion of paralyzed muscles, Am. J. Orthop. Surg. 


In addition to the various other methods of nerve repair tubulization 
has been employed to bridge nerve defects either in conjuction with other 
methods or by itself. By tubulization is meant the using of tubes of decal- 
cified bone, hardened arteries, fresh veins, agar, gelatine, fascia lata or car 
gile membrane, etc., as a channel through which the neuraxes may be directed 
toward the distal nerve end. Thus the danger of neuraxes being cut off by 
ingrowth of scar between the nerve ends is minimized and the loss of nerve 
fibers by dispersion into the surrounding tissues lessened. Tubulization offers 
a single large path for the downgrowth of neuraxes and, for this reason, is 
mechanically inferior to nerve transplantation for nerve regeneration, since 
the latter method offers numerous small paths which serve as individual con- 
ducting tubules for the neuraxes. The numerous small conduits of the nerve 
graft direct the neuraxes along a straight path within which they rarely meet 
with resistance; whereas, the relatively large tube in an arterial or fascial 
tubulization may collapse, or be invaded by connective tissue and thus block 
the neuraxes. Evidence of the resistance which such scar tissue offers within 

the lumen of the tube is seen by the tortuous course of the neuraxes and their 
criss-cross direction, becoming more marked the farther the downgrowth 

from the central stump and the denser and older the scar tissue. Nerve trans- 
plantation may be considered individual or neuraxis tubulization as contrasted 
with gross or nerve trunk tubulization. 

Tubular coverings have also been used to isolate and protect the nerve 
trunk from scar tissue following end-to-end suture, with the intention of form- 
ing a scar-free bed for the nerve. Unfortunately not all tubular methods 
accomplish the end for which they are intended, either as a conducting path 
or as a means of nerve trunk isolation. 

Decalcified Bone Tubulization. — The first attempt at tubulization 
was hardly more encouraging than later clinical and experimental efforts. 
Gluck (1881) inserted an Eschmarch-Neuber decalcified bone drain between 
the severed ends of a sciatic nerve and found that only connective tissue 
continuity was established, with no functional return. Vanlair (1885) repeated 


this experiment using similar decalcified bone tubes and found that down- 
growth of nerve fibers occurred, with some of the neuraxes reaching as far as 
the distal segment; but Vanlair's results have not been sufficiently corroborated. 
Huber (1895) performed eight similar experiments, five of which were observed 
more than fifty days, and in only one of these was there any functional regen- 
eration. At the end of a hundred and fifty-five days the downgrowth had 
extended as far as the middle of the forearm, while in the remaining experi- 
ments no functional return occurred, though a few neuraxes were found in the 
upper part of the distal stump. Examination of the Utilization showed that 
the neuraxes were more regularly arranged nearest the centra! stump and that 
as the distal stump was approached the nerve bundles became fewer and more 
tortuous. This Huber thought was due to the "fact that at a time when the 
neuraxes are beginning to grow toward the periphery, the less developed con- 
nective tissue, just below the central stump, offers less resistance to them than 
does the same tissue at a later stage, it having obtained a denser and more 
highly organized structure. " 

Decalcified bone tubes are relatively quickly absorbed, in many instances 
remain less than three weeks in the tissues. Neuber himself dwelt at length 
on their absorbability, while Vanlair claimed they remained about four months. 
Huber's results also support the experience of Neuber that they are readily 
absorbed. The tubes are replaced by connective tissue, more or less similar 
in arrangement to that which replaces the catgut bundles in suture a distance, 
where the scar tissue is said to offer less resistance to the downgrowing neuraxes 
than the .surrounding denser fibrous tissue. 

Arterial Tubulization. Following the experiments of Gliick and Vanlair 
Hiingncr (.1891) successfully bridged a small distance between the retracted 
ends of a severed sciatic nerve by means of tubulization, using a segment of 
sterilized human brachial artery. In this case the nerve was merely severed 
and there was no loss of substance. Such a regeneration as Bungner reported 
over the distance between nerve ends merely retracted, without real defect, 
we now know is possible by unaided downgrowth, without the assistance of any 
form of tubulization. The value of Biingner's efforts was in paving the way for 
the use of blood vessels in tubulization. His experiments were followed some 
years later by those of Foramitti (1904) who used both fresh and hardened 
arteries with success, claiming that hardened arteries did not form adhesions 
with the nerve and that they remained longer in the tissues than fresh blood 


vation being six weeks, and the largest defect bridged 2^ cm. Both Bungner 
and Foramitti found that the elastic tissue in the artery resists absorption 
more than the other tissues of the vessel wall. It is probable that the value 
of arterial tubulization depends upon the integrity and resistance of this 
elastic tissue layer. Foramitti prepared the arteries by stretching them over 
glass tubes and hardening them in 5% formalin solution for forty-eight hours. 
They were then washed in running water for twenty-four hours and boiled 
twenty minutes, after which they may be kept until used in 95% alcohol. 
Such tubes were employed during the Russo-Japanese War by Hashimoto 
and Tokuoka (1907), and also in the Balkan Wars, however, more to isolate 

Fig. 43. — Arterial tubulization. Two epineural mattress sutures of fine waxed silk are passed 
at opposite points. Both ends of the suture are threaded and passed through the arterial wall from 
within out. Sutures must be at opposite points in the tube to prevent the nerve being turned end on 
against the arterial wall. 

nerve trunks after nerve suture than to bridge nerve defects. Huber's (191 9) 
more recent experiments have shown that such hardened arteries remain 
in the tissues more than six months without being absorbed and that they cause 
relatively little tissue reaction. 

Technic of Arterial Tubulization. — Prepared arteries, after removal from 
the alcohol and immediately before using, should be washed in salt solution and 
cut to approximately the size required; about 2 cm. longer than the distance 
to be bridged. Two mattress sutures of fine split silk are passed opposite each 
other on the nerve trunk, approximately 5 mm. from the nerve end. Each 
suture is first passed through the epineurium and both ends of the suture are 
threaded and each needle is carried into the lumen of the artery and passed 
through the arterial wall from within out. The threads arc then tied on 
either side. (See Figs. 43 and 44.) If both sutures have been properly placed 
the nerve will be held within the lumen of the arterial tube equidistantly from 
either side of the arterial wall. 


Unless the two sutures are cquidistantly placed both in the nerve and the 
tube the nerve ends may turn end on against the wall of the tube, and, by adher- 
ing to the tube, prevent outgrowth of the neuraxes; or if the peripheral end 
becomes adherent neuraxes will be unable to gain entrance and though down- 
growth may occur from the central stump, penetration into the distal segment 
would be almost impossible. 

Not only hardened blood vessels but fresh veins and arteries have been 
used to bridge nerve defects. Obtaining fresh veins during the operation is 
bothersome and time consuming. Furthermore, in fresh veins adhesions 
between the vein and the nerve are more apt to form, as also between the vein 
and the surrounding scar, hence not only do they offer little or no protection 

Fiu. 44.— Arterial I U Utilization completed. The dotted lines indicate the nerve ends within 
the artery. The cross section shows how the nerve end is held if the sutures are opposite each other 
in both the nerve and artery. 

to the nerve trunk but are actually harmful. When used to bridge defects 
the vein walls may collapse and become adherent forming connective tissue 
within the lumen. Nagcotte (1915) found as an additional objection that 
neuraxes tended to grow through fresh vessel walls into the surrounding scar 

Eden (1917) advocalcd implantation of nerve ends into the normal blood 
stream in intact veins, claiming that without the blood stream downgrowth 
docs not take place. Experimentally he implanted the femoral nerve into the 
femoral artery and into the femoral vein. In four instances he tied off the 
femoral vein, thus preventing a Sow of blood, and in these downgrowth did not 
occur, while in the remaining six not tied he claims the distance was bridged. 
It is hardly necessary to point out how rarely it is possible to avail oneself 
of a neighboring vein in this manner and even then the danger of throm- 


for neuraxes to grow first into, then out of a vein, through the fibrin which 
must form. 

Since Vanlair's use of decalcified bone tubes numerous other substances 
have been tried, some experimentally and others only clinically, among them : 
magnesium tubes (Payr, 1900); gelatine tubes (Lotheisen, 1901); galalith tubes 
(casein treated by formalin, Auerbach, 1915); agar tubes (Edinger, 1916); agar 
tubes filled with blood serum, rubber tubes filled with serum (Steinthal, 191 7), 
(Heile and Hezel, 191 5); rubber bandage made from thin rubber (Meuriot and 
Platon, 1918), etc. 

Magnesium tubes are readily absorbed; they break into rather sharp 
fragments which may lacerate the tissues hence, if for no other reason, are 
unsatisfactory. Gelatine tubes are somewhat difficult to make and are hard 
to sterilize, for they melt unless the heat is carefully controlled. They are 
also too rapidly absorbed for use in nerve bridging, remaining in the tissues 
only about three months according to Lotheisen. Lotheisen used these tubes 
only four times in the human and no experimental work in their application 
to bridge nerve defects was done, so that their exact fate in the tissues or 
the tissue reaction which they may cause is not known. 

The tubes which have received more extensive use than any other in the 
bridging of nerve defects are the agar tubes of Edinger. In Germany these 
have been tried both clinically and experimentally and have been condemned 
thoroughly not only as of no value but actually harmful. Edinger's tubes 
were used by Spitzy (191 7) in eleven cases without regeneration. In addition 
he tried a series of agar tubes filled with blood serum; these also with the same 
result; Blencke (191 7) employed agar tubes twenty-eight times without any 
evidence of regeneration, and advised that " tubulization with Edinger's tubes 
should certainly not be done;'' Mliller and Berblinger (1917), Hoffmann and 
Spielmeyer (19 17), Enderlen and Lobenhoffer (191 7) all disapprove of the use 
of Edinger's tubes on both clinical and experimental evidence. They concluded 
that empty agar tubes were useless in bridging nerve defects as are tubes filled 
with the patient's own serum which were claimed to be preferable to empty 
agar tubes. Agar does not offer a smooth surface for the downgrowth of 
neuraxes but stimulates outgrowth of scar, and rather than facilitating, pre- 
vents regeneration. After extensive histological studies, Spielmeyer concluded 
that Edinger's tubes were not only useless but were contraindicated in nerve 

Similar objections may be offered in the case of rubber tubing as used by 


Steinthal (1917), Heile and Hezel (1915), or the thin rubber tissue advocated 
by Meuriot and Flaton (1918), since rubber remains in the tissues without being 
absorbed and acts constantly as a foreign body stimulating scar tissue forma- 
tion. Heile and Hezel claim that rubber is slowly absorbed and therefore 
found no contraindication to its use. This is of course contrary to the obser- 
vations of al! other investigators. 

Fascial Tubulization. — This form of tubulization was used by Denk 
(1914) in the wounded of the Balkan Wars, as a means of isolation of nerves 
from surrounding scar. Thirteen cases with injuries of the upper extremity 
were thus treated including brachial plexus injuries. In the latter the individ- 
ual nerve trunks were not enclosed separately, but the entire plexus en masse. 
Necrosis of the implanted fascia occurred in two of these cases. Just what 
advantage resulted from the use of fascia lata, as a means of isolation of the 
nerve trunk or in conducting nerve libers, is not apparent from Denk 's report. 
Kredel (1915) employed fascia lata to surround a sciatic nerve, using suffi- 
cient fascia to have encircled the nerve twice, and yet in spile of this the fascial 
tube contracted about the nerve constricting it and causing severe pain, 
necessitating a second operation for removal of the fascia and nerve section. 
Histological examination of the tissues removed at operation showed that the 
fascia was adherent to the nerve, excessive scar tissue had formed and that no 
free space could be made out between the nerve and the tube. Kredel suggested 
that, on account of contraction of the fascia, it should never be used to surround 
the nerve but should be employed rather as a sheet to be passed beneath the 
nerve to form a smooth nerve bed. 

Kirk and Lewis (191 5) recommended fascia lata tubulization to bridge 
nerve defects, as Vanlair had used decalcified bone tubes, and Foramitli hardened 
arteries. Kirk and Lewis found that downgrowth of neuraxes will occur when 
hemorrhage within the fascial tube is prevented and that contraction of the 
fascia about the nerve may be minimized by making the lumen of the fascial 
tube twice as large as the circumference of the nerve to be bridged. They 
believe that secondary contraction of the fascia may be avoided "if the fascials 
sutured into place, and is subjected to the same conditions as regard stress and 
strain as in the part from which it was removed." This of course would seem 
difficult of attainment. They also believe that fascial tubes should not be 
placed in a wound in the presence of fresh scar, since it tends to undergo 
cicatricial contraction. The very precautions, which apparently it is essen- 
tial to observe in order to use fascia lata tubulization successfully, make 


its usefulness extremely limited, since the indication for tubulization in nerve 
injures is either to avoid scar contraction about a sutured nerve, or as a chan- 
nel down which neuraxes may grow. While it is possible by accurate suturing 
to prevent blood from the wound running into the fascial tube, by making 
the fascia fit snugly about the nerve the danger of constriction by contraction 
of the fascia is increased. It is very difficult to obtain complete hemostasis 
from the severed nerve ends when these are not brought together either 
directly or by multiple grafts, since the ends dangle free within the lumen 
of the tube and some hemorrhage is nearly certain to occur. Hemorrhage 
within the lumen causes scar tissue formation, and according to Kirk and 
Lewis this may prevent downgrowth of the neuraxes; while, on the other 
hand, a fascial tube in the presence of fresh scar tissue within the wound 
stimulates scar formation and, therefore, is also contraindicated. Consequently 
fascial tubulization must of necessity have, if any, a very limited field of useful- 
ness. While in a measure successful experimentally, though less than other 
methods, its application to human nerve surgery cannot be commended. 

Cargile membrane has been used in various fields of surgery to prevent 
adhesions. The application of this membrane to nerve surgery as a means of 
isolation of nerve trunks was suggested by Sherren (1906). Unfortunately 
cargile membrane is more or less useless for this purpose, since it is rapidly 
absorbed, remaining in the tissues no longer than catgut sutures even when used 
in double or triple layers. Obviously this is too short a time to be of much 
value in nerve surgery. Huber (191 9) found that cargile membrane fixed in 
alcohol remained in the tissues from five to six months without absorption, and 
without causing any particular tissue reaction. Ordinary cargile is placed in 
95% alcohol and allowed to remain at least a week or ten days before using. 
Immediately before using it is dipped in absolute alcohol, and the alcohol 
allowed to evaporate before placing the membrane in the wound. It is of 
greater value in preventing adhesions following suture or nerve grafting and 
after nerve liberation than as a means of tubulization to bridge nerve defects- 
Huber's cargile membrane is particularly useful for it is readily obtained and 
easily applied, in that it is merely wrapped about the nerve trunk or graft. 


Auerbach, S.: Galalith fiir Tubulization dor Xervcn nach Xeurolysen und X'crvcnnahien 

Munchen. med. Wchnschr., v. 62: 19 15, p. 1457. 
Blexcke, A.: Ein weiterer Beitrag zu den Ueberbriickungsvcrsuchen von Xervendcfektcn 

mit Edinger-Rohrchen, Zcntralbl. f. Chir., v. 44: 1917, p. 236. 


Bungner, O. von.: Ueber die Degenerations- und Regcnerations-Vorgangc an Nerven 

nach Verletzungen, Beitr. z. path. Anat. u. z. a!lg. Path., v. to: iSgi, p. 321. 
Denk, W. : Uber Schussverlctzung der Nerven. Beitr. z. klin. Chir., v. 91: 1914, p. 317. 
Eden, R.: Sind zur Ueberbriickung von Nervendefekten die Verfahren der Tubulisation 

und der Nervemransplantation zu empfehlen, Zenlralbl. f. Chir., v. 44: 1917, p. 138. 
Spontane Nervenregeneralitm im striimenden Blut. (Naturwissenschaftl. med. Gesellsch. 

zu Jena, 23, Nov.. igi6), Munchen. med. Wchnschr., 1917, 6. 
Edinger, L.: Ober die Vereinigung getrennter Nerven. Grundsatzliches und Mitieilung 

eines neuen Verfahrens. Munchen. med. Wchnschr., v. 63: 1916, pp. 225-228. 
En' and Lobf.nhoffer: Zur Ueberbriickung von Nervendefekten, Munchen. med. 

Wchnschr. (Feldarztl. Bcil., Nr. 7), v. 64: 1917, p. 1013. 
Dopfnek, K.: Zur Methodik der Naht peripheral Nerven, Munchen. med. Wchnschr.. v. 

62: 1915, p. 526. 
FORAMITTI, C. : Zur Technik der Ncrvennahl, Arch. f. klin. Chir., v. 73: 1904, p. 643. 
Gluck: Ueber Transplantation, Regeneration und cntzundliche Neubildung, Bed. klin, 

Wchnschr., v. 18: 18S1, pp. 529-554. 
Hashimoto, T. and Tokuoka, H.: Ueber die Schussverletzungcn peripherer Nerven und 

ihre Behandluug (Tubulizaliun), Arch. f. klin. Chir., v. 84: 1907, p. 354. 
Heile and HeZEl: Unsere bisherigen Erfahrungen bei der Behandlung im Kriege ver- 

letzter peripheren Nerven, Beitr. z. klin. Chir., v. 96: 1915, p. 199. 
Hoffmann-. G. and Spielmeyeh, W.: Zur Krilik des Edingerechen und des Betheschen 

Verfahrens iler Ucberbrikkimj,' grossercr Nervenliicken, Miinchcn. med. Wchnschr., 

v. 64: 1917. p. 97 (Feldarztl. Teil.. Nr. 3). 
Hl"ber, G. C: Opera live I real men t of peripheral nerves after severance, morcparlkularly 

after loss of substance— a critical review, J. Lab. & Clin. M., v. 2: Sept., 1917, p. 8.37. 

A study of operative treatment fur loss of nerve substance in peripheral nerves, J. Mor- 

phol., v. 11: 1895, p. 629. 
Transplantation of peripheral nerves, Arch.. Neurol. & Psychiat., v. 3: no. 4, April, 1920, 

P. 437- 
Kirk, C. and Lewis, D.: Fascial lubulization in the repair of nerve defects. J. A. M. A.. 

v. 65; Aug., 1915, p. 486. 
Kredel, L.: Ueber das Yerhallen der auf operierte schussverleUter Nerven iiberprlanzten 

Fascienlappen, Zenlralbl. f. Chir., v. 42: 1915, p. 201. 
Krljger: Beobachtungen und Erfahrungen bei Untersuchungen und Operationen von 

Schussverlelzungen der peripheren Nerven mit besunderer Ik-rucksichtigung der veral- 

teten Falle (Gesellsch. f. Natur-u. Heilkunde ze Dresden, 12, Jan., 1917), Munchen. med. 

Wchnschr., v. 64: 1917, p. 913. 
Lotheisf.n, G.i Zur Technik der Nerven und Sehnennahl, Arch. f. klin. Chir., v. 64: 1901 

p, 310. 
Mauclaire: Suture nerveuse tubulaire avec des trachees despei 

v. 6: 1916, p. 39.. 


nach der Edingerschen Methode 
nervus ulnaris mil ana torn ischer 

, Rev. 

Mkller, O. and Berblixger, \V.: Das Endergebnis eim 

(Agarrohrchen) vorgenommenen L'eberbriickung de 

Untersuchung, Berl. klin. Wchnschr., v. 54: 1917, p 
Naceotte, J.: Le proces de la cicatrisation des nerfs 

Payr, E.: Beitriige zur Technik der Blutgefass- und Nerv 

tlber Verwendung eines rcsorbirbaren Metalles in der C 

v. 61: 1900, p. 67. 
Platt, H.: Results of bridging aps in injured nerve trunks by 

lion and autogenous nerve grafts, Brit. J. Surg., v. 7: Jai 
Sherrex, J.: Some points in the surgery of the peripheral ne: 

1006, p. 297. 
Spitzy, H.: Bemcrkung zur Ucberbriickung von Xervendefeklt 

v. 64: rQi7, p. 372 (Feldarztl. Beil., Nr. 11). 
Steinthal: Die Ueberdeckung von Grosseren Nervendefeklen miltels Tubularnahl, Zen- 

tralbl. f. Chir., v. 44: 1917, no. 29, p. 646. 
Stkacker, O.: Zur I'rognostik der Opera tionen an peripheren Nerven, Wien. klin. Wchnschr 

V. 29: I916, p. 21$. 

Zu den L'eberbrui-kungsvcrsuchen von Nervendefeklen, Zenlralbl. I. Chir., v. 43: iqi6 
p. 985. 
Vanlak, C.: Nouvelles recherches cxperinicnlales, sur la regeneration des nt-rfs peripheri- 
ques, Arch, de Biologic, v. 100: 18S5, p. 1605. 

nnaht nebst Mitlhcilungen 
irurgie, Arch. f. klin. Chir., 

lutogenous fascial tubuliza- 
igso, p. 384. 
■es, Edinhurgh M. J., v. ia: 

1, Miinchen, meri. Wchnschr. 


Nerve minim livity may be Interrupted by pressure upon the nerve trunk 
without any Kiss ol anatomical continuity and probably without severe his 
tological changes in the nerve fiber. Concerning this point there is relatively 
little experimental evidence, yet the anatomical integrity of the nerve fiber b 
indicated clinically, In certain cases with signs ol" complete interruption « 
conductivity, almost immediate return of function has followed liberation of 
the nerve trunk in some instances within twenty-four hours. In these cases 
the return has been loo rapid to admit of re-eslablishment of functkw em 
I he basis of regeneration of (be nerve fiber. When such rapid return of nzaninr 
occurs it is probable that the nerve liber is intact anatomically, and tkxt «ty 
its power of conductivity has been inhibited by pressure exerted upon theMsrve 
litters. It is well known that by physical means alone, such as coU. warm 
conductivity may be interrupted without any demonstrable iiiiimiM n 
changes and lh.ii conductivity may be re-established when the nerve i» wxnatt 
thus showing that propagation of stimuli along the nerve trunk may be afcftirf 
without anatomical interruption. 

Pressure on a nerve may be due to scar or callus about the Hnerant 
or to the formation of scar within the nerve trunk; more ofoca hufli. fata 
neural scar alone may he due to direct trauma, producing ixujmM. hnaeahqa 

wJlhm ill.- »..>-> -.- Mrin.llr,.,-! fmtll ltlf.TV»«»<I» rtf B h)lll#4 .ii Kift, v.U-i-,-««-t 


surgeon, the other by the assistant, and with a little attention the wires may 
be kept apart. 

The minimal threshold to obtain contraction in normal nerves for the indi- 
vidual is obtained in nerves exposed in the wound, and the electrodes are then 
applied to the injured nerve and the current gradually increased. Strong 
currents spread in the tissues, mask the response and should, therefore, be 
avoided. The nerve is usually isolated on glass rods or glass hooks and tested 
not only above but below and in the scar. If a response is obtained in the 
distal distribution complete nerve section should not be done, though partial 
suture of the more damaged portions of the nerve trunk may be indicated if 
these do not conduct. Rarely may a response be obtained in the injured nerve 
by stimulation below the level of the injury while no response may be elicited 
by stimulation above or at the point of the injury. Such is Erb's paradoxical 
response which is found in cases with only slight compression. Slight physical 
changes, may interrupt nerve conductivity, apparently without structural 
changes in the nerve fiber. In Erb's paradoxical response interruption of con- 
ductivity is confined to the point of injury and is entirely comparable to condi- 
tions in experimental interposition on a muscle-nerve preparation of a nar- 
cotizing chamber, or any other set of physical changes which lead to local 
functional depression without destruction of the neuraxes. In such experi- 
ments the passage of an impulse through the narcotized area is prevented, 
while below it conductivity is normal. In one case in which Erb's paradoxical 
response was found, stimulation of the nerve immediately after liberation and 
above the level of the injury was followed by contraction in the peripheral dis- 
tribution, thus indicating how relatively slight and transitory may be the 
interference in nerve conductivity. 

In nerves completely severed no response will be obtained, though in rare 
instances enough stray fibers may have penetrated the scar to give some slight 
response. The amount of the response and the location of the response as 
well as the point at which the nerve is stimulated are important factors. A 
definite positive response in whole muscles is of great value and indicates 
that there is some physiological conductivity in the nerve libers. A nega- 
tive response, it must be recalled, is of little value, since though the neuraxes 
may have penetrated the scar they may not yet have formed their peripheral 
connections. (See Figs. 45, 46, 47, 48.) Great care must be taken to observe 
accurately the motor contractions on stimulation of the nerve. For this 
purpose the extremity must be well exposed and considerable judgment is 


needed to determine whether the response is the result of stimulation of the 
injured nerve or another nerve whose muscles may stimulate the action of the 
nerve in question. 

Figs. 4J, 40, 47, 48.— Schematic drawing to show why a negative electrical response may be 
nU.Liiud from stimulation <>[ the nerve trunk al the level of the injury even though downgrowth of 
neuraxH is taking place. A positive response is not to be expected until the neura\es have reached 
the muscle and have formed motor end plates Fig. 45. no response; Kg. 46, no response; Fig. 47. 
no rc'ijMinsc; Fir. 4S, response. 

The density of intraneural scar may be estimated by injecting salt solution 


between the funiculi and cause a fusiform swelling over a considerable distance 
depending on the amount of fluid injected and the pressure. When the scar is 
dense, fluid will not enter, and the nerve trunk remains unaltered in size. If, 
on the other hand, fluid injected under pressure does penetrate, the intraneural 
scar is neither extensive nor dense. Injection of fluid under pressure serves not 
only to determine the density of the scar, but may also be used as a means of 
breaking up adhesions between the funiculi and thus perform as it were an 
internal liberation. In rare instances a longitudinal incision in the sheath of the 
nerve may be made and the interior of the nerve investigated. Some surgeons 
attempt to separate the funiculi when they are adherent to each other by insert- 
ing between the funcili fine sharp-pointed scissors which are then carefully 
opened. If the incision in the sheath is made at the level of an internal 
nerve plexus with numerous intercommunications, these may be mistaken for 
adhesions and destroyed or broken together with existing adhesions. In the 
author's experience such intraneural dissection is rarely justified except perhaps 
at a level where funicular separation is known to exist normally. If intraneural 
injection of salt solution does not suffice as an internal liberation sharp dissection 
will not, since without means to prevent adhesions reforming in the nerve trunk, 
old and new adhesions occur. When intraneural injection of salt solution does 
not liberate and definite scar contraction remains, excision had better be done 
than sharp intraneural dissection of scar. However, if the nerve bulb is fusi- 
form and relatively soft it can be taken that marked infiltration of scar tissue 
is not present and excision should not be done. 

In order to determine whether nerve section should be done or not, the 
surgeon must be familiar with the complete neurological findings and the prog- 
ress of the case as noted at each examination, and this information must be 
fitted in with the anatomical findings at operation — the results of direct electrical 
stimulation, palpation of the nerve trunk and injection of salt solution. Price, 
Feiss and Terhune (1919) are of the opinion that after considering all of the 
evidence if doubt exists as to whether nerve liberation or nerve suture is indicated, 
excision and nerve suture should be done. The interval between the date of 
injury and operation is an important factor to consider. When early nerve 
exploration is performed a conservative course may be pursued, which in late 
cases might not be justified. Within six to eight weeks following nerve libera- 
tion some signs of returning function should be evident. If these are not found 
within this period the conclusion is warranted that in place 01 nerve liberation 
nerve suture should have been done, and it should then be undertaken. 


In performing nerve liberation the surrounding scar should be excised or 
infolded on itself, callus chiselled away and the bone hammered so as to prevent 
reformation of exostoses. Whenever possible the nerve should be trans- 
posed to a new bed, preferably into the fascial planes between muscles or a 
new bed made for the nerve. The nerve should not be imbedded in torn or cut 
muscles, for the hemorrhage from the muscle fibers increases scar tissue formation 
and may cause strangulation of the nerve. When anew bed cannot be made and 
the surrounding scar is extensive or can be only partially removed the nerve 
may be surrounded with Huber's cargile membrane. (See page 127.) In 
10 >o 30 4" H "sn E Vo ?d bo 90 100 cert2 ' n instances when the nerve is constric- 
ted by smalt circumscribed bands, minute 
longitudinal incisions into the nerve trunk 
called "hersage" may be done. The inci- 
sions are made through the epineurium and 
Chart II.— Table to show the rela- ,, ,, ..,.., ., , T . 

tive Frequency of nerve liberation and so t0 avoid the funiculi if possible. In iso- 
lurvf suture in [ioo nerve operations, lated cases this is an important adjunct to 
liberation of the nerve trunk. 

The results of nerve liberation done in properly selected cases have been 
most gratifying. Price, Feiss and Terhune found that 6$ c 'c showed improve- 
ment following nerve libera lion; of these complete return of voluntary movement 
was found in 20%, almost complete return in 23% and return of sensation and 
definite evidence of some nerve regeneration in 22^. These statistics were 
made after extensive experience and are the result of very careful observation, 
and agree approximately, with the result of other workers; however, some 
claim as high as $o c c ot improvements. Nerve liberation has given the most 
satisfactory results of any form of operative treatment, but it should be borne 
in mind that it is only in cases with relatively little anatomical injury that nerve 
liberation is advised. 

Bi rrows. J. Le F. ami CARTER, H. S.: Preliminary uote on investigation upon 1000 con- 

-ivLitivi cases of peripheral nerve injury. Brit. M. J., v. ;: iqiS, p. 535. 
DELACENIERE, H.: Traitement chirurgical des blosjtires des nerfs; . . . ^45 cas de sutures 
el 11S liberations suivies par le Dr. Tinel. Bull, et mem. Soc de Chir. de Par., v. 44: 
IQiS, p. 5*4. 
Elsbesc, C. A : Technic of nerve sulure and nerve grafting. J. A. -M. A., v. 73: Nov. 8. 

IQEQ. pp. M-- -l J-T 

1-"r.v*i! k. C. II.: Surpc.U problems in the re con*: ruction of peripheral nerves, Ann. Surg., 


Lewis, Dean: Principles of peripheral nerve surgery, J. A M. A., v. 75: July 10, 1920, : 

J.P- 73- 
MoRroN, C. A.: Operative findings in thirty cases of gunshot injury of nerves, Bris 

M.-Chir. J., v. 36: ipiS-iQiq, p. 55. 
NOOK, A.: Observations on 250 cases of gunshot wounds of the peripheral nerves, J. R< 

Army Med. Corps, London, v. .it: toi8, p. 3Q. 
Price. G. E., Feiss and Terhune: Nerve injuries, Arch., Neurol. & i'sychiat., v. r: ig 
?■ S47. 
Peripheral nerve injuries, J. Nerv. & M'ent. Dis., v. 50: iqig, p. 551. 
Spear, I. J. and Baucock.W. W.: Peripheral nerve injuries concomitant to gunshot woun. 

Arch., Neurol. "& Psychiai., v. *: ioiq, p. *53- 


Arrangement of the Operative Field.— The limb must be placed so as to 
give the easiest access to the operative field. Each position will be described 
in connection with each nerve. Most nerve operations are long and tedious 
so that better work will be done if all are made somewhat comfortable, in 
most instances those operating being seated. When it is necessary to hold 
the extremity in some special position it should be held by apparatus rather 
than by an assistant. By mechanical means the limb is held steady and 
slight movements avoided which might cause considerable inconvenience 
by pulling out or deranging a graft as it is being placed. Sheets should be 
placed so as to allow movement of the extremity without disturbing the opera- 
tive field. This is necessary when the position of the limb must be changed in 
order to bring the nerve ends in approximation, or if another incision or exposure 
must be made. As a practical point it will be found helpful in operations on the 
lower extremity to cover that part of the leg and foot not involved in the opera- 
tive field with sterile stockinette, and in operations on the upper extremity, the 
forearm and hand. When the hand is not to be included in the operation it 
should be covered with a tight-fitting rubber or cotton glove covering each 
finger separately. These coverings should fit snugly and thus permit more 
accurate observation of individual muscular movements and palpation of the 
individual tendons during direct electrical examination of the nerve trunk. 

Suture Materials, — Plain ooo catgut and the finest possible waxed silk 
are used. Slight tissue reaction on the part of the mesoblastic tissues only 
was found in experimental work in nerve suture with waxed silk sutures. A few 
cells surrounded the sutures but never sufficient to form any block to the down- 
growth of the neuraxes even in such small nerves as the peroneal of the rabbit or 
the sciatic of the guinea pig. The neuraxes simply glide in a gentle curve 
around the suture points without showing tortuosity, Perroncito spirals or any 
other evidences of resistance to their passage. (See Fig. 49.) In experimental 
studies of various suture materials Sargent and Grenlield (1919) found that 
while .-ilk gave rise to but little tissue reaction, sutures treated chemically. 
as chromic catgut and iodized catgut, caused a more pronounced tissue 

ik<iinh <ir m'.kvk si'Trur: 


reaction. In nerve suture, especially in nerve transplantation, where a mini- 
mum of tissue reaction is desired, these suture materials should not be used. 
Ordinary Corlicelli AAA black silk is untwisted and separated into three 
strands. Each of these is then thoroughly waxed with bee's wax and threaded 
on fine curved needles. By passing the point of the needle through the suture 
two or three times and then threading one end of the suture through the eye 

Fig. 49. — Longitudinal section through a sutured nerve at the point nf suture. Waxed silk 
was used. Note the comparatively slight tissue reaction around the su!urts,V..S'. (Ranson pyridine 
silver stain.) 

the thread may be fastened without tying. In this manner the suture is 
held as if tied but without a knot being formed, and follows through the tissues 
without offering any resistance as may occur when a knot is present. The 
threaded needles are then passed through a cloth, sterilized and rewaxed with 
sterile wax just before using. Silk sutures threaded in this manner are easy 
to handle and tie, and slip readily through the nerve without drawing in the 
epineurium. These points are of importance in the finc_wnrk necessary for 
nerve grafts. 


Instruments.— Sharp knives having small thin blades should be used to 
cut through the nerve, especially if serial sections are done, to determine the 
level al which suture is to be made. Neither the nerve trunk nor a nerve graft 
should be cut with scissors, since scissors tend to crush the nerve ends. A very 
satisfactory knife is one with changeable blades which usually are thinner than 
the blades of an ordinary knife or even than the blade of a safety razor. The 
latter is used by some as a scapal, the blade being held with artery forceps. 
Fine mosquito forceps should be kept for grasping the epineurium or the tine silk 
sutures. If mosquito forceps are used for other purposes they soon Jose their 
precision and are then of little value for delicate work. Fine mouse- tooth forceps 
are used to grasp the epineurium in manipulating and dissecting the nerve, and 
anatomical forceps to tie the nerve sutures, the latter may also be employed 
satisfactorily as a needle holder and are better than a clasp holder since the 
epineural suture may be disturbed in efforts to release the clasp. A sterilizable 
electrode is an essential in any nerve operation. A specially made electrode 
may be procured or naked copper wire used. (Sec page 130.) Thus few special 
instruments are needed. 

Anesthetic. — The long duration of many nerve operations requires that 
extreme care be taken wilh the anesthetic. If a general anesthetic is used it 
should be administered so that a minimum of ether is given. Perhaps the 
most satisfactory general anesthesia in the author's cases have been those in 
which warmed vapor has been given and one of the special ether apparatuses 
used. Willi this method, even alter three or four hours of anesthesia, no unto- 
ward effects have been noted. In place of ether, gas and oxygen may be used 


By this procedure all veins are cut and tied first at the lowest point and further 
bleeding from the same vein is obviated as the incision is lengthened. Super- 
ficial scar when present should be excised as completely as possible. The skin 
edges should be well undermined so as to include the fatty fascial layer bringing 
the fat with the skin edges into the new line of closure. Unless this is done, 
the line of union is certain to stretch and a broad scar result. The flaps should 
be prepared for closure before searching for the nerve, all bleeding points tied, 
and the undermined edges packed with gauze after making certain that a proper 
line of closure has been insured. Unless this is done before nerve suture is 
accomplished, the extra maneuvering, coincident with preparation of the flaps, 
may derange the delicate line of nerve sutures. 

When the deep scar is extensive, it is best to identify the nerve in normal 
areas both above and below the injury, selecting, if possible, such points 
within the field as offer anatomical guides to the nerve in question. Thus, 
for example, the ulnar nerve is recognized in the ulnar groove behind the 
elbow, or by its relation to the flexor carpi ulnaris tendon in the forearm; the 
median nerve just under the mesial border of the biceps muscle, etc. 

Before freeing the nerve it is well to test with the electrode at various 
points on the nerve trunk, both above and below the scar as well as at diff- 
erent points within the scar. In all nerve scars an attempt should be made 
to indentify intact branches by the electrode so as to avoid injuring them in 
freeing the nerve. Not infrequently nerve branches may pass through sur- 
rounding scar without being sufficiently compressed by the scar to cause 
physiological interruption and may, therefore, be identified by the electrical 
current. When the branches do not transmit impulses identification by the 
electrode obviously is not possible, and greater difficulty is encountered re- 
quiring greater care in the process of dissection. In following the nerve from, 
above and below the delicate branches to adjacent muscles must be safeguarded. 
This factor, together with the close proximity to large vessels, compels the 
surgeon to advance slowly and with extreme caution. 

The nerve may be retracted conveniently by passing moist tapes, about 
1 cm. wide, around the nerves, beginning on the side on which there are either 
large vessels, nerves or important branches; thus by keeping these always in 
view, including them can be avoided. The ends of the tapes are clamped with 
artery forceps, the weight of which may suflice to hold the nerve in position 
without injury. 

The knife should be changed frequently while dissecting through the scar, 


so as to have at all times one that is sharp. The scar is often penetrated by- 
stray neuraxes which seem to give to nerve scar a consistency denser and harder 
than other scar, owing, possibly, to the presence of neurokeratin. On cutting 
such a scar a peculiar scraping noise is recognized which speaks for the scar 
density. Hence the need of a knife always sharp. 

The deep scar should be excised, when feasible, but this frequently is not 
possible. Instead, after the nerve has been freed, the scar may be infolded 
on itself and sutured. In this manner a smooth bed may be made, new scar 
formation avoided and troublesome hemorrhage from scar circumvented. 
When a smooth bed for the nerve cannot thus be made, either a small muscle 
belly — not a cut and raw muscle surface, which only increases scar formation — 
may be sutured so as to form, by its fascial covering a smooth surface for the 
nerve; or a fatty flap may be passed under the nerve. A free fatty trans- 
plant will tend to form scar and should be avoided. Care should be taken 
to suture the fatty flap to adjacent tissues on both sides of the nerve in order 
that constriction about the nerve may be prevented. Generally speaking, 
if the line of nerve suture has been made so as to obtain epineural approxi- 
mation, no other protection of the nerve trunk is necessary. If further pro- 
tection be desired, a layer of Huber's modified cargile membrane may be 
passed about the nerve. This causes no scar tissue reaction, and remains 
undisturbed for a period of months, whereas ordinary cargile is about as readily 
absorbed as catgut and, therefore, of little service. 

Owing to the length of most nerve operations the field should be protected 
more than is usual in shorter operations. For this purpose, moist cotton pads 
about 6 by 8 inches may be used. They are carefully placed so as to lie 
smooth and cover all of the field except in the direct line of the nerve. Being 
wet they stay in place, are smooth, and facilitate handling the delicate and 
fine sutures used in nerve surgery. Sutures are easily picked off the cotton, 
remain in place and being black they stand out in contrast against the white 
background of the cotton. Furthermore, at the end of the operation the underly- 
ing tissues, as a result of being covered constantly with moist cotton, are not 
traumatized or dried, and appear as fresh as when first incised. When such 
pads are not used, the threads are often hard to find in the tissues and may 
adhere to them. 

Constant irrigation is maintained with salt solution, particularly when 
the nerve ends are cut and during the time they are being sutured. This 
helps to arrest oozing from the scar tissues and bleeding from the nerve ends, 


and avoids trauma connected with sponging. If sponges are used they should 
be small bits of moist cotton held in forceps and placed over the nerve ends. 
If the bleeding is more profuse, bits of torn muscle held over the bleeding 
points will be found useful, or the nerve may be held between the fingers for 
a few moments using gentle pressure. 

The surgeon should palpate the whole of the nerve trunk exposed in the 
field, not only the nerve scar but the normal nerve as well. Electrodes should 
again be applied and each response carefully noted both by inspection and 
palpation. Occasionally, a response not seen may be appreciated by pal- 
pation. It must be remembered that even though no response results, this 
cannot always be interpreted to mean that neuraxes have not penetrated 
the scar and passed into the distal stump. Although they have passed the 
scar, they may not yet have reached their ultimate destination within the 
muscle ; or, having gained the muscle, they may not yet have formed the motor 
end plates. (See Figs. 44-48.) Hence a negative response does not always 
imply failure of downgrowth. In the decision to excise a part of the nerve 
the whole clinical ensemble as well as the anatomical appearance of the nerve 
must be taken into consideration. 

Special Incisions. — For exposure of some of the nerves, special incisions 
other than those which follow the usual anatomical course of the nerve are to 
be preferred. This is particularly true of the musculospiral nerve, the pos- 
terior interosseous and the sciatic. These incisions will be discussed in detail 
under the chapter dealing with each nerve. 

The skin incision should be made sufficiently long to enable free exposure 
of the nerve both above and below the scar. A small incision delays the opera- 
tion and in the end generally requires lengthening. Secondary enlargement 
of the field entails a waste of time, and is rarely as neatly accomplished as if 
the incision had been made long enough in the first instance. At times it is 
not possible to foretell the required length, particularly if transposition of 
the nerve becomes necessary, so that in these cases secondary enlargement 
cannot be avoided. 

Use of Tourniquet. — A tourniquet should not be used because each 
bleeding point should be dealt with individually, and this cannot be done 
satisfactorily if a tourniquet has been applied. Unless hemostasis is nearly 
complete in a wound in which scar tissue is present, an increase in the scar 
results, due perhaps to the stimulus of the fibrin in the blood clot to the 
fibroblast. However, in a few positions, such as at the wrist, in the hand and 



^B so as to have at all times one that is sharp. The scar is often penet 

^B stray neuraxcs which seem to give to nerve scar a consistency denser ar 

^B than other scar, owing, possibly, to the presence of neurokeratin. Or 

■ such a scar a peculiar scraping noise is recognized which speaks for 

■ density. Hence the need of a knife always sharp. 

■ The deep scar should be excised, when feasible, but this frequerr 
[ possible. Instead, after the nerve has been freed, the scar may ' 

on itself and sutured. In this manner a smooth bed may be ma<I. 
formation avoided and troublesome hemorrhage from scar cir 
When a smooth bed for the nerve cannot thus be made, either b 
belly — not a cut and raw muscle surface, which only increases » 
may be sutured so as to form, by its fascial covering a smooth 
nerve; or a fatty flap may be passed under the nerve. A M 
plant will tend to form scar and should be avoided. Care - 
to suture the fatty flap to adjacent tissues on both sides of [2 
that constriction about the nerve may be prevented. Gci 
if the line of nerve suture has been made so as to obtain 
■nation, no other protection of the nerve trunk is necessi 
layer of Huber's modified cargilc 
This causes no scar tissue t 


ings and striations of the nerve trunk are of little value where there has been a 
loss of nerve substance. 

Level of Suture. — In determining the level of the suture it is best to cut 
only partially through the nerve trunk inspecting the cross sections as they 
present at each successive level, and thus determine by the appearance of the 
funiculi the proper level of suture. (See Fig. 50.) An ordinary large library 
magnifying glass can be sterilized and used to bring out the finer details of each 
cross area. 

In liberating or cutting the nerve forceps should be placed not on the sound 
part of the nerve but on the epineurium or scar of the bulb. Three mosquito 
forceps taking only a fine bite are used, one on either side of the nerve bulb 
and a third at the end. Gentle traction is made to steady the nerve so as to 
permit of clean transverse sections. If the nerve is not properly held it tends 
to rotate on cutting and a ragged uneven surface results. 

As long as there is scar between the funiculi and these do not appear as 
distinct bundles, another level must be sought. Distinct funicular bundles 
must be obtained. When the incision is carried through sound nerve tissue the 
bundles stand out sharply without scar tissue between them, and the epineurium 
tends to retract, leaving the bundles as prominent points on the cut surface. 
When sound nerve tissue is reached, free bleeding occurs and generally from one 
or two points, rather than the slight oozing from the entire surface which is 
seen when scar tissue is still present. 

The end bulb of the central stump is made up of regenerating neuraxes, 
proliferating sheath cells and connective tissue. (See Fig. 216.) The neuraxes 
are interlaced with numerous branchings and end discs, and distinct funicular 
arrangement with fibers in parallel bundles is usually not found until the 
neck of the bulb is reached. On the distal end, the bulb consists only of 
a small connective tissue cap without neuraxes. Scar-free tubules are found 
after one or two thin sections are made, without cutting far into the 
nerve. Rarely more than 5 mm. is excised to obtain a good cross area in the 
distal end. 

If a nerve bulb is found with the nerve trunk continuity maintained and 
excision is determined, the bulbous part of the nerve is held with three mosquito 
forceps as indicated above and successive incisions are made. These should 
be begun in the central part of the bulb and gradually continued first toward 
the distal and then toward the central end until good cross areas are obtained 
both above and below. 



By culling incompletely through the nerve at each incision there is less 
manipulation and less trauma to the nerve ends. It is also easier to suture 
when the nerve ends are not completely free and there is less tendency to axial 

Fie. 50.— Nerve with scar to be excised. Illustrates method of using scar as means of fixation 
of nerve ends, permitting greater accuracy and facility in suturing. (1) By passing needle obb'quely 
sulure is less apt to tear out. Stay suture helps to prevent axial rotation and can be withdrawn 
when other sutures are tied. Note consecutive partial incisions through scar until normal appearing 
funiculi are reached. (Slookcy. Surg., Gyn. and Obst.. igi8.) 

rotation when anatomical continuity is still maintained. Thus greater accuracy 
is gained in placing the nerve sutures and the nerve pattern is less disturbed. 
(See Fig. 50.) 

In some instances the nerve bulb may involve only part of the nerve trunk 

Kltss. ;i ami - .- Partial suture at the sciatic in injury of the peroneal division. The nerve 
is tirst ni.4iiU.-nl .mil iViKc. nt i\ i- incision* are mad.- until normal appearing funiculi are reached. 
\ ItKiiiiiiidii^tl itti-Uion 1- then cleanly made to separate the ecu from the sound nerve. The nerve then sutured in ihc usual manner without tension. (Stookey, Surg., Gyn. andObst., 191a.) 

and only section t»f the nc 
the bulb i> grasped in the same 

e be indicated. In making such an excision 
nan n t*r as for any bulb, care being taken to 


bulb until scar-free cross areas are reached. When these levels are determined 
a clean longitudinal cut is made to separate the bulb from the normal part of 
the nerve trunk and end-to-end suture of the divided part is then done. (See 
Figs. 51, 52, S3, 54 and 55.) 

Figs. 53, 54, 55.— Perforation of sciatic. Demons traits method of partial suture aftercxcisinnol 
scar tissue. Line of excision should be sharp, avoiding normal funiculi as far as possible. Main 
catgut sutures are passed through and through and lied after all are in plate. (Stookey, Surg., 
Gyn. andObst., 1918.) 

Technic of End-to-end Suture.— A ooo plain 
each side of the nerve, equidistantly placed, takinjj ; 
the epineurium. While this suture passes somewhat 
becomes an epineural-perincural-epineural suture; 
used the funiculi are pushed aside and the -uture the 
in the perineural connective tissue and hence dues ve 
By these sutures the nerve is brought together in its 
between the nerve ends is avoided, diminishing the ai 

it r 

atgut suture is passed on 
bite deeper than through 
within the 1 

'or if a smooth net 

1 lies between theft 

v little harm to the 


-!-, hei 


the tension on the fine eipneural sutures. These stay sutures may also serve 
to prevent axial rotation, particularly if they are placed before complete 
excision of the intervening nerve scar and while anatomical continuity is not 

Fig. 56, — Technic of end-to-end suture. .1, Two 000 plain catgut sutures on fine rounded 
needles are passed through the nerve at apposite points, taking a bite a little deeper than the epi- 
neurium. The sutures are then tied and the ends clamped without cutting. These sutures serve to 
bring the ends in alignment and as stay sutures. B, The two stay sutures are held to steady the 
nerve while the fine epineural sutures are passed. Black Corticelli AAA silk is split into three 
strands, waxed and then used (or the epineural sutures. Each suture is cut and tied after it is passed. 
For accurate approximation of the c pi neural cduc- the sittitrt'i m ml h: lied ;.ilhfotcips. C, The upper 
surfaces have been sutured and the stay sutures are now reversed, the lower one passed beneath the 
nerve and the upper one over the nerve so as to expose the under surface. The under surfaces are 
then sutured in the same manner as the upper, I), The ends have been brought together, the sutures 
cut tvfler being tied so as tn evert slightly the epineural edges, (Stookey, J. A. M. A., 1519.) 

entirely broken. These sutures are tied, with ends about 3 inches long 
to which artery forceps are clamped thus holding the nerve firmly and facili- 


The silk epineural sutures are then passed on the upper surface between the 
two stay sutures. With very fine tooth forceps epineurium only is grasped and 
each suture accurately placed and tied with forceps so that the epineural edge is 
everted. If the sutures have been correctly placed, eversion of the epineurium 
is easily accomplished and gives a smooth line of union on its inner surface. Each 
suture is cut as it is tied, sufficient sutures being used to insure complete approxi- 
mation — the number naturally depending on the size of the nerve. 

By reversing the two catgut sutures, i.e., by passing the one over and the 
other beneath, the under surface is readily brought into view and sutured in 
like manner. 

The advantages of two stay sutures over a- single stay are obvious. 
If a single stay is used the nerve rotates as the remaining sutures are passed and 
the nerve is not so firmly held,or its under surface as readily brought into view 

When a single stay suture is tied, the lateral edges of the nerve evert and 
epineural approximation is then difficult. 

Hemorrhage Between the Nerve Ends.— If the sutures have been accu- 
rately placed and tied coaptation of the edges occurs and further hemorrhage from 
the nerve ends need not be feared. After the stay sutures have been reversed the 
open half of the nerve yet to be sutured is constantly irrigated with warm salt 
solution while the remaining epineural sutures are being passed; thus small clots 
of blood are prevented from forming between the nerve ends. Blood clots will 
not form after the nerve has been sutured, providing the ends are in apposition. 

A small amount of connective tissue forms between the nerve ends. The 
thinner the layer of connective tissue, the less resistance will the neuraxes meet, 
and the more complete will be the regeneration. Nageotte (19 18) recommended 
that a small distance, approximately 5 mm., be left between the nerve ends so 
as to allow for greater dispersion of the neuraxes in case the proper funiculi are 
not brought exactly end on. By exact apposition without any intervening 
space, Nageotte holds that there may be more accurate apposition of a few 
funiculi, but nevertheless, with considerable misdirection of the fibers in new 
and foreign channels. Whereas, if a short distance is left between the nerve 
ends greater dispersion of the nerve fibers takes place and the opportunity for 
them to reach their proper channels is more favorable, and downgrowth in these 
instances is more uniform. However, neurotization is not so abundant nor 
early as when the ends are sutured without any intervening space. I have had 


not think that sufficient evidence is offered to warrant the conclusion which is 
reached. It seems to me that the possibility of hemorrhage between the nerve 
ends and resulting thick, scar when ends are not brought in close contact is a 
disadvantage which more than offsets the theoretical advantage presumably 
gained. The thinner the layer of intervening scar the less the resistance to the 
neuraxes. Furthermore there is no evidence to indicate that at the point 
of suture there is any chemotactic or other influence to determine a selective 
downgrowth of neuraxes which would attract each group into its proper sheath. 
There may be a general attraction at the point of suture but not a particular 
attraction for particular groups of neuraxes. 

In the presence of a small nerve defect, end-to-end suture may be accom- 
plished by slight stretching, or by transposition of the nerve and by altering 
the position of the limb. As has already been pointed out, nerve stretching 
should be done with considerable caution, since the distance gained can be 
accomplished only by taking up the normal laxity of the nerve trunk in its 
contiguous parts, or if carried farther by multiple tears within the nerve trunk, 
or by evulsion from the spinal cord. 

Transposition of the nerve may permit defects to be overcome which might 
otherwise prevent end-to-end suture. A nerve may be freed and raised out 
of its bed over quite a distance without interfering with its nutrition or 
its conductivity. In transposing, care must be taken, so far as possible, 
to safeguard nerve twigs and prevent the formation of sharp angles or 

Technic of Nerve Crossing. — Tcchnic of nerve crossing requires no special 
description other than that given for end-to-end suture. The distal nerve 
is brought up to the central nerve trunk to which it is to be united, to determine 
the exact point at which the nerve should be severed, with sufficient allowance 
for retraction so as to permit union without tension on the line of suture. When 
the level at which the distal nerve is to be cut is decided, two catgut stay sutures 
should be passed before cutting; this thus permits placing of the suture more 
accurately and with less trauma to the nerve ends than can be done if the 
severed nerve lies free in the wound. Likewise, whenever possible, the same 
sutures may be passed through the central nerve before it is cut. Care must be 
taken to make sure that no kinks or angles shall result following the suture, 
such as may occur when the nerve is hooked around a muscle, and due allowance 
must be made for the normal contractions of muscles and movements of the 



Partial Neive Crossing.— After determining the level and the thickness 
of the partial nerve segment which is to be raised, two fine silk sutures are 
placed at this point, then a thin, narrow, sharp knife is inserted in the nerve at 
the point to obtain exactly the required thickness, and the incision is carried 
upward the desired length. So far as possible, the longitudinal part of the 
incision is made between funiculi which may in some instances be recog- 

Fig. 57. — Schematic drawing showing iechnic of partial nerve crossing. When the point 
at which the nerve is to be cut is determined and the length of the flap estimated, the sutures are 
passed before making the flap or cutting the nerve to be neurotized. Thus sutures arc placed without 
manipulating the nerve ends and crushing them with forceps. 

nized by rolling the nerve between the fingers. In order to avoid possible injury 
to the remaining nerve trunk the transverse incision which frees the flap is made 
from within out. The figures (Fig. 57) illustrate better than description could 
the points of technic for both partial and complete nerve croning. 

Technicof Nerve Graft. —The technic of the graft is so exacting that unless 
done by those having considerable practice the results may be disappointing. 
The utmost regard for minute points of technic is essential. Success depends 


in a great measure on the accuracy with which the grafts are brought end on 
and in precise contact with the cross areas of both the central and distal stumps. 
If the sutures are not correctly placed, or not tied with just the proper tension, 
the nerve ends are likely to be turned aside and in place of the graft being end on, 
it may be turned so that its lateral surface lies against the central cross area. 
(See Fig. 58.) While neuraxes may grow into the graft, the probability of such 
penetration is greatly diminished by faulty approximation. For these reasons, 
the individual technic must be considered in estimating the ultimate value of 
the graft, for it plays a predominating nMe. 


Fig. 58. — Why dnwngrou-th may not take place in a graft. Such apposition as shown here may 
occur if the sutures arc not properly placed or properly lied. End-to-end apposition must be obtained. 

A sufficient number of grafts should be taken to cover the cross area of the 
central and distal stumps. Unless this is done, many central neuraxes, having 
no path down which they can grow, may become lost, though Huber (1919} 
has shown that a few are able to penetrate, growing as far as the distal stump in 
the small connective tissue spaces between the nerve transplants. The aim 
of the surgeon should be to connect each funiculus with a graft. This may be 
accomplished by suturing each graft separately in the desired position thus to 
establish the central and distal connections with precision. In some of the 
nerves in which the funiculi are numerous, or at certain levels in others where 
the larger funiculi, have been broken up into many smaller ones, this is often 
not possible; nevertheless, the attempt should be made. 

Tecnnic of the Graft. A ttlhor's Method. — When the nerve to be grafted 
is freed from the scar tissue and the nerve ends successively incised until a 
satisfactory cross area is obtained one or two stay sutures are passed at the 
proper level, before the nerve continuity is completely severed, so as to hold the 
nerve in alignment, prevent rotation, and help in fixation of the nerve ends 
during suture. These stay sutures need not be tied but each end may be 
clamped near its exit from the nerve. 

The distance to be bridged is then accurately measured with a centimeter 

A skin nerve, such as the radialis or the external saphenous on the dorsum 
of the leg, may be used. In order to save time another operating team may 



such as one would find in the leg on the side of a sciatic nerve injury. The 
sheath cells in such a nerve are no longer in active proliferation; there may 
also be some increase in connective tissue, particularly if the injury to the 
parent nerve is of some standing. It is possible that whatever of neurotropism 
there may be is diminished in such a nerve as compared with a fresh transplant. 
However, this is of academic interest rather than of real importance. In 
view of the downgrowth of neuraxes in preserved specimens, one must question 
the value of the r61e imputed to neurotropism. 

The skin nerve having been laid bare over the desired length, fine waxed 
silk sutures on fine curved or straight, smooth needles are passed at an interval 
equal to the distance to be bridged, as previously measured. (See Fig. 59.) 






Fig. 59. — Technic of nerve graft. The skin nerve to be used is laid bare, and the length of 
the nerve segments to be used being measured off, fine waxed silk sutures on fine round curved needles 
or arterial needles are passed leaving sufficient margin to cut between sutures. The sutures should 
be of equal length and passed all in one direction. The nerve segments are then cut with a thin 
sharp knife. 

A small margin is allowed for cutting the nerve segments. 

The sutures are all passed in one direction, the nerve being held tense 
by small forceps either central or distal to the grafts. Under no circum- 
stances should the nerve segments to be used in the graft be held by forceps, 

The sutures are then curled carefully so as to prevent entanglement, 
the needles all on one side and the free ends on the other. 

The nerve segments are cut with a sharp, thin knife, avoiding crushing 
the nerve ends. 

Each segment is then picked up by covering it with a smooth, moist 
cotton pad. (See Fig. 60.) If the cotton is carefully placed over the nerve 
and sutures, they adhere to the moist cotton and each segment may thus be 
lifted from the wound and placed in the operative field without handling. 
(See Fig. 61.) 


By folding the cotton pad so that its free border is parallel to the trans- 

Fio. 60.— Technic of nerve graft. The threads are curled to avoid tangling. A moist a 
pad, the length of the nerve segment, is placed over each transplant. The transplant and su 
adhere to the cotton and can be picked up without handling or danger of pulling out the sut 
The segment can- be carried from one field to the other without danger of dropping. 

Fie. 61. — Technic of 

Fig. 62. — Technic of nerve graft. Transplant in place ready for suture. A stay suture is 
passed through the nerve trunk to fix its ends during suture. In place of tying this suture each end 
may be clamped close to the nerve. 

plant, the latter may be placed between the nerve ends so as to be in exact 
position for suture. (See Figs. 62 and 63.) 


By means of the cotton pad neither the nerve nor the sutures are handled, 
the latter do not become entangled, the danger of pulling out the sutures is 
eliminated, and the nerve may be maneuvered into its proper position for suture 
with the least trauma. A small stream of salt solution will be found helpful 
in flooding the nerve off the cotton. During the process of suture the nerve 
is irrigated with warm salt solution, : thus creating a clear field, thereby aiding 
in accurate funicular approximation of the graft. In this manner, each 

Fig. 63. — Technic of nerve graft. One transplant sutured and a second in place ready for 
suture. The under part of the defect is bridged first, unless important motor funiculi can be identified 
when these are sutures first. 

transplant is sutured separately, both distally and centrally, with whichever 
funiculus desired. The sutures must be tied with forceps and cut short. 

The accuracy of the graft depends in a measure on the correct placing of 
the sutures, the exact amount of tension in tying, and delicate manipulation 
by means of the sutures during the process of tying. (See Fig. 64). 


Fig. 64. — Technic of nerve graft. Cable transplant in place. (Stookcy, J. A. M. A., 1919.) 

Elsberg's Method. — In place of suturing each graft separately Elsberg 
(1919) has devised a very ingenuous and skillful method which permits suturing 
the entire cable graft en masse, thus saving considerable time and reducing 
the handling of the graft to a minimum. (See Fig. 65.) 

"After having determined the length of the defect which is to be bridged 
over by the graft, and the number of strands that will be required, one or 
several cutaneous nerves are exposed and carefully dissected out until they 
remain attached only at their upper and lower ends. Two sutures are then 
passed in and out of the nerve at measured distances. For the sake of de- 


scription, let us say that the graft is to be 7 cm. long and is to consist of three 
strands. The one suture (A) is passed through near the attached upper end 
of the freed nerve, from the inner to the outer side of the nerve; a loop is left 
loose and the needle is then passed through the nerve from the outer to the 
inner side a little more than 7 cm. from the first point; again a loop is left, and 
the needle passed through the nerve, from its inner to its outer side, at the same 

Fig. 65. — The cable graft. A, The bulb reftuied and tnris <d nerves exposed; B, the sutures 
passed through the cutaneous nerve used from cable graft; C, the nerve divided into segments; 
I), the cable graft ready fin t run-] i la nl.U inn; E. the sum res passed through ends of cable graft and 
ends of nerve; F, the sutures tied; G, the perineural sutures tied. (Elsberg, J. A. M. A., 1919.) 

distance from the last point. The needle is then laid aside and a second 
needle and suture taken. This needle (B) is passed through the lower end 
of the nerve, from its outer to its inner side, a little more than 7 cm. from the 
point of emergence of needle A. A loop of the suture is left and the needle 
passed through the nerve, from the inner to the outer side, at a point 3 mm. 
above the point of emergence of suture A; finally, the needle is passed through 
the nerve, from its outer to its inner side, 3 mm. proximal to the next point 
above. The points at which the suture A has passed through the nerve 
correspond to the upper ends of the graft; and the points through which needle 
and suture B have been passed correspond to what are to be the lower ends 


of the strands. After the loops have been carefully arranged, the nerve 
cut with fine scissors or a fine scalpel: (i) i mm. above the beginning of A ( 
i mm. below the beginning of B and (3) between each two points through whi 
sutures A and B are passed, apart in the nerve. An assistant then grasps t 
two ends of suture A and the operator the two ends of suture B. When tn 
tion is made, the strands are drawn together. Then each suture is loose 
tied. A brings all of the upper ends of the strands together; B brings all t 
lower ends together. 

"After the cable graft has thus been made, it is transferred to its pla 
between the divided ends of the main nerve and sutured in position, accordi 
to the method shown in Fig. 65." 

Thus from a technical standpoint to obtain successful regeneration, n 
only in nerve graft but also in end-to-end suture, an entire set of exacti 
conditions must be attained during the operation while failure in any one m 
seriously jeopardize the end results. 


Delageniere, H.: Traitement chirurgical dcs blessurcs des nerfs . . . 245 cas de sutu 
et 118 liberations suivies par le Dr. Tinel, Bull, et mem. Soc. de chir. de Par., v. . 

1918, 524. 

Elsberg, C. A.: Technic of nerve suture and nerve grafting, J. A. M. A., v. 73: Nov 

1919, pp. 1422-1427. 

Elsberg, C. A. and Woods, A. H.: Problems in diagnosis and treatment of injuries 

the peripheral nerves, Arch., Neurol. & Psychiat., v. 2: 1919, p. 645. 
Frazier, C. H.: Surgical problems in the reconstruction of peripheral nerves, Ann. Sui 

v. 71: Jan., 1920, p. 1. 
Frazier, C. H. and Silbert, S.: Five hundred cases of injuries of peripheral nerves at U. 

Army General Hospital, No. 11, Surg., Gynec. & Obst., v. 30: Jan., 1920, p. 50. 
Gebele: Zur Chirurgie der peripheren Nervenverletzungen, Munchen. med. Wchnscl 

v. 64: 1917, p. 956. 
Hesnard, A.: Notes de chirurgie nerveuse de guerre, Arch, de med. et pharm., N; 

1920, p. 201. 

Hesnard, A.: Chirurgie des blessurcs des nerfs peripheriques, J. de mod. de Bordeaux, 

48: 1918, p. s^. 
Huber, G. C: Transplantation of peripheral nerves, Arch., Xcurol. & Psychiat., v. 

1919, p. 466. 
Huber, G. C: Repair of peripheral nerve injuries, Surg., Gynec. & Obstet., v. 30: M; 

1Q20, p 464. 
Meige. H. et al: Sutures nerveuscs. Rev. no--' 


Nagf.ottk, J.: Sur une atrophic musculairc rcflcxe prccoce apres suture dcs nerfs par affron- 

lement et sur !es inconvenienls tic la greffe nerveuse vivanle autoplastiquc, Compl. 

rend. Soc. de biol., v. 81 : July, 20, igi8, p. 761. 
Perthes: Uber dase lektrische Verhalten von Muskeln nach Durch Trennung dcr zugeho- 

rigen Nerven, Milnchen, med. Wchnschr., v. 66; igig, p. 1016. 
Perthes: Beob.achiungen bei etektrischei Reizung freigelegter verletzler Nerven im Vci 

gleich mit dem neurologist hen u it- 1 hisiologischen Hcfunde, Deutsch. med. Wchnschr 

v. 45: 1919, p. 897. 
Sargent, P. and Greenfield, J. C: An experimental investigation of certain materials 

used for nerve suture, Brit. M. J., v. 2: pt. I, igig, p. 407. 
Skyberth, W.: Ueber Nerve nope rat ion en und ihre Enderfolge, Berl. klin. Wchnschr. 

v. 55: 1918, p. 996. 
Souttar, H. S.: Injuries of the peripheral nerves from the surgical standpoint. Brit. J. 

Surg., v. 6: 1918, p. 279. 
Stiles, H. J.: Operative treatment of nerve injuries, Am. J. Orthop. Surg., v. 16: 1918, 

P. 35*. 
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Indications for operation on peripheral nerves depend upon a number of 
factors of which the most important are the history of the case, the local examina- 
tion as well as the sensory, the motor and the electrical examination. Evi- 
dences of lack of regeneration, or interrupted regeneration, and the possibility of 
the results to be gained are guiding considerations. 

Value of Complete History. — The history should be an effort to reconstruct 
the probable mechanics of the injury, the direction and nature of the injuring 
force, so that an attempt can be made to determine the extent of the trauma and 
the point at which the nerve has been injured. These points are important in 
estimating the probable type of injury, whether it be concussion, interruption, 
injury by bony fragments, inclusion by callus, etc. The nature of the injuring 
force is an important factor in estimating the character of the lesion in the nerve 
trunk. Obviously, a blow of moderate force by a blunt object, in a region in 
which the nerve is covered by layers of muscle, would cause less damage to the 
nerve than if it were injured in the more exposed situations, such as where 
the peroneal nerve winds around the fibula, or the posterior interosseous nerve 
as it passes over the radius. Blows by blunt instruments are less apt to cause 
anatomical interruptions than stab or incised wounds, or wounds by projectiles. 

Local Examination. — From the direction of the injuring force one may 
generally determine the level of the lesion of the nerve trunk, but this does not 
always hold since a bullet of high velocity may be deflected by bone or even 
tendon, and its course within the tissues be turned from the direction which 
would be indicated by the location of the wounds of entrance and exit. Thus, 
in one patient, the wound of entrance was just ventral to the semi-tendinosus 
tendon and that of exit at the junction of the middle with the upper thirds of the 
thigh. The patient had a total paralysis of the peroneal and tibial divisions of 
the sciatic nerve. It was inferred that the injury to the sciatic was in the 
middle of the thigh, and exposure was made accordingly. No evidence of 
injury to the nerve in this region was found and exposure was made lower down. 


The nerve was found divided in the middle of the popliteal space, the bullet 
apparently having been deflected in its course within the tissues. (See Fig. 66.) 
In another instance diagnosed, however, before operation, 
a hand grenade fragment had entered and made its exit on 
the mesial surface of the arm, in the middle third. Neither 
the median nor the ulnar nerve was involved, as might have 
been expected from the location of the wounds; but the 
musculospiral, which in this position lies dorsal to the 
/'* *"*-'' 1v humerus, was implicated( see Fig. 67) the patient showing a 
dissociated paralysis of the musculospiral nerve. The diag- 
nosis was made on the signs of musculospiral involvement, 
and discounting the evidence indicated by the location of 
the wounds of exit and entrance. In spite of such excep- 
tions winch, in certain instances, may be recognized by a 
1 borough examination, the direction of the injuring force is 
usually an important factor in localizing the site of the nerve 

From the local examination, data of immense importance 
may be gained, which when considered with the more detailed 
neurological examination may be the deciding factor in deter- 
mining exploration in doubtful cases. Other structures in 
the region of the wound such as bones, muscles, tendons, 
and vessels must be investigated. The nature of a fracture, 
whether simple or comminuted, oblique or transverse, and its 
relation to the nerve are important. Examination for 
aneurysm, the result of vessel injury, at the point of nerve in- 
jury must not be forgotten. In injuries of the lower roots 
of the brachial plexus above the clavicle the relation of the 
nerves to the pleura must be borne in mind. The nerve 
should always bo palpated to determine its density and the 
presence or absence of a neuroma and the amount of scar tis- 
sue present 

Sensory Examination. The sensory findings must be 

.tutted .it etch examination so as to form a basis for future 

> ejuVritk and protopathic should be discarded and in 

limine of a bullet as 
presumed from llie 
wound of entrance 
and exil i> >luuvn liy 
a heavy line. The 
tCulltl course of [he 
bullet i* indicated 
t>> the dotted tine. 
Both divisions oi the 

severed in ihe mid- 
ilk »i i'n' popliml 
si*a uid .,,., in 
ihc middle ihii\l .'i 
[he thigh .t* wis in- 

lYimparison. The 

their i>l.ue each form of sei 

should he siMvincallv designated, using the 


designations of discriminative and affective, have much to commend th 
However, for the present at least, greater clearness may be attained 
naming the stimulus employed. For most clinical purposes the sensat 
such as are evoked either by cotton wool or pin point or extreme deg 
of temperature suffice. If different degrees of temperature are emplo; 
the exact quantity of the stimulus may be estimated by determining 


Fig. 67. — The wounds of entrance and exit are indicated on the medial surface of the 11 
extremity (a). The point on the dorsal surface where a small shell fragment was found lying o 
musculospiral nerve (b). Such an injury could not have been anticipated from the position o 
wounds of entrance and exit alone. 

temperature used. For this purpose, large metal tubes having a relatr 
small point are better than glass tubes, since glass does not conduct 
radiate temperature as does metal. If pin point is used great variation 
the amount of the stimulus employed occurs unless an instrument is 1 
which permits measurement of the force of the thrust. For this purj 
several instruments have been designed, but the algesiometer of Casam, 
and Strong has proven most satisfactory both because of ; * 

mnctmrtinn and the facilitv with whu ^ u 


carried on a spring steel band attached to a ruler which is graded in both 
cm. and gms. The needle moves freely through an opening in the ruler. 
By changing the position on the steel band at which it is held fixed varying 
degrees of pressure are exerted and may be measured by noting the mark- 
ings on the ruler. Cobb (19 19) in an excellent paper, has shown that 
if comparative sensory examination is to be of value it must be made with 
constant and known stimuli, alike both in quantity and quality. 

In testing light touch or the cotton wool area, the part should be stroked 
longitudinally in the extremities, that is, parallel to the limits of the nerve area 
in question, in order to avoid impinging upon adjacent areas subserved by nerves 
not involved. By this procedure Stookey (191 6) demonstrated the sensory area 
of the musculospiral nerve on the dorsal part of the distal phalanx of the thumb, 
theretofore attributed to the median nerve. If cross stroking is used, the 
median area which corresponds to the lateral borders of the nail is stimulated 
and sensation conveyed through the median nerve. 

Accurate sensory charts assist in estimating the presence and the progress 
of regeneration. Progressive shrinking of the area of sensory loss is an excellent 
indicator of the advance of nerve regeneration. There is a distinct difference in 
the relative time of return of sensation to cotton wool, to two point tests, to 
moderate degrees of temperature (discriminative sensations), and to pain 
extreme degrees of temperature — below twenty degrees and above forty degrees 
— (affective sensations), when stimuli of like quantitative value are employed. 
Finer appreciation and discrimination return at a later period than the affective 
forms of sensation. It is possible that that form of sensation is the first to return 
which is evoked by a stimulus of the greatest intensity. We know that the 
modalities of pain and temperature centrally have more interposed neurons and 
that each interposition in the path tends to lower the threshold and intensify 
the preception. The affective forms are older phylogenetically and represent 
defense mechanisms. 

Pain is a more diffuse primitive sensation than discriminative sensation, 
and according to Head, Rivers, and Sherren (1905-1908) each is served by a 
different set of fibers in the peripheral nerves acquired at different periods in the 
phylogeny and functionally distinct. Ranson (191 2) believes that if this view 
of the afferent paths in the peripheral nerves be correct possibly the more 
primitive form of sensation may be carried by the more primitive type of nerve 
fibers, namely, the nonmedullated; while the more recently acquired forms are 
served by the more recently acquired fibers — the medullated. 


By using the electrical methods of Lapicque (1907), Keith Lucas (1908), 
Adrian (1920) attempted to determine the presence of two distinct sets of 
sensory fibers. Lapicque and Keith Lucas found that in any given excitable 
tissue there is a definite strength duration curve constant for any given tissue, 
and widely variable for different tissues. The strength duration curve in non- 
medullated fibers was found to be ten to one hundred times as long as in medul- 
lated nerve fibers. In testing the transmission of pain sensations in human 
sensory nerves Adrian found the time constant of the strength duration curve 
to be indentical with that found in medullated motor nerves. Had pain been 
carried by the nonmedullated fibers it would be expected that the time con- 
stant would have been raised. While his experiments do not preclude the 
existence of two distinct sets of fibers, no evidence of any different time 
constant was found. Adrian concluded that there was no great structural 
differences in the fibers carrying affective and discriminative sensations. 

Motor Examination. — A study of the muscular paralyses is of particular 
importance for accurate level localization, since motor branches are given off 
at different levels in the course of a nerve. Individual muscular action rather 
than total movements must be studied. Letievant (1872) showed that total 
movements normally accomplished by definite muscle groups in certain paraly- 
ses may be performed by some of the group or by muscles belonging to other 
physiological groups of different nerve supply. For example, the flexion action 
of the biceps, supinator longus, and brachialis may be performed by any one of 
this group; whereas normally they all take part in flexion of the forearm and 
act as a synergic unit in the total movement of flexion, yet individually each 
may accomplish the movement without the assistance of the others. In injury 
of the musculocutaneous nerve with paralysis of the biceps and brachialis, flexion 
of the forearm may be accomplished with great force by the supinator longus — 
supplied through the musculospiral nerve. In testing muscular action, it is 
desirable to palpate both the muscle belly and the muscle tendon, to determine 
more accurately the role any single muscle is playing in any given movement. 

Electrical Examination. — Faradic and galvanic examination of the 

nerve and muscle is indispensable. In nerve injuries the faradic response is 

lost early and is late to return, reappearing generally a considerable time after 

the return of voluntary contraction. Faradic inexcitability of the nerve 

and muscles is found in any condition in which nerve conductivity is interrupted. 

The thick wire coil is usually used and the examinations made on the nerve 

both above and below the level of injury after having first obtained the far- 


adic threshold for the individual by stimulation of the corresponding nerve 
on the sound side. The muscles supplied by the nerve in question are also 
tested using the threshold that has been obtained by examination of the 
corresponding muscles on the opposite side, employing a sufficient stimulus 
to obtain a minimal contraction. A simple hypo-excitability may be found 
and if strong currents are used the stimulus is diffused and adjacent muscles 
are stimulated thus confusing the examination. 

The nerve and muscle are also tested with the galvanic current. In 
order that comparisons with subsequent examinations may be made the form 
and nature of the muscular contractions as well as the strength of current 
required to obtain a minimal response should be carefully noted. The normal 
muscular contraction to the galvanic current is a sharp, quick twitch. The 
contraction is greater on closure from the negative pole than from the positive. 
The minimal threshold for each pole should be determined on the normal side 
and comparisons made with the injured. Variations in the strength of current 
required are found in different individuals and at different points on corre- 
sponding muscles. Normally two milliamperes are required when the muscle 
is stimulated at the motor point, but if the exact motor point is not found the 
threshold will be materially raised even up to live, six or eight milliamperes. 
In motor paralysis the minimal threshold at the motor point may be raised 
ten to fifteen times and generally the maximum contraction is not obtained 
from the motor point, but over the junction of the muscle fibers with the 
tendon. This shifting of the point of greatest excitability is commonly known 
as the "longitudinal reaction." This reaction is due to the fact that in para- 
lyzed muscles the motor point is in reality no longer present, since the motor 
twig to the muscle is inexcitablc, however, the muscle fibers have retained their 
excitability. At the junction of the muscle and tendon a maximum number 
of muscle libers are brought together and a stimulus applied at this point 


the nature of the muscular response, varying from a relatively slow contraction 
in the earliest stages to a slower wave-like contraction and on to galvanic 
inexcitability in the latest stages of muscular degeneration where muscle tissue 
is reduced to a minimum if not altogether replaced by connective tissue. 

The reaction of complete degeneration consists in faradic and galvanic 
inexcitabiUty of the nerve; faradic inexcitability of the muscle and an alteral- 
Uon in the muscular response to galvanism consisting of a slow, wave-like 
contraction with longitudinal reaction. Polar equality or polar inversion of 
the formula may be present. In the more severe and long-standing paralysis 
galvanical inexcitability is found. The various changes in the electric response 
progress gradually, only in the final stages reaching galvanic inexcitability. 
The entire gamut of changes is not seen in every case for their progress may be 
interrupted at any period by beginning regeneration. 

Results of electrical examination indicate the presence of an organic 
peripheral. nerve injury, thus differentiating it from hysteria, and furthermore 
indicate whether interruption of conductivity is complete or incomplete and the 
relative degree of degeneration in the muscles. Differentiation cannot thus be 
made between complete anatomical interruption and complete physiological 

Thus by combining the information gained from the history of the trauma 
with that from the sensory, motor and electrical examinations, the presence or 
absence of nerve conductivity may be determined. But whether or not an 
interrupted nerve will go on to spontaneous regeneration can be determined only 
by making repeated examinations and by waiting sufficiently long for signs of 
regeneration to take place, or by exploratory nerve operation though the latter 
may not be conclusive. These signs of regeneration may appear from two 
to thirty months after the nerve injury. Frazier and Silbert (1020) are of the 
opinion that in the majority of instances nerve compression, neuroma in con- 
tinuity and complete anatomical interruption may be determined by complete 
sensory motor and electric examinations. "In compression there was complete 
motor paralysis in 45%, complete sensory loss in 15%, and no case with com- 
plete reactions of degeneration. In complete anatomical interruption there was 
complete motor loss in 100%, complete sensory loss in 86%, and complete 
reactions of degeneration in 85%. (The absence of complete sensory loss or 
reaction of degeneration in the minority may be attributable to the fact that in 
the scar tissue intervening between the divided segments a few indistinguishable 

f.U-rt irnv hotTD hffri nrpsonl '\ TV.-, n <i. . r.™ •> in m..i;ni.i'h:m-MorM ■. mYt.irp 


as one might expect, intermediate between compression and interruption. 
Thus there was complete motor loss in only 74%, incomplete in 26%; complete 
sensory loss in only 33%, incomplete in 67%, complete reaction of degeneration 
in 16.5%, incomplete in 8.1.5%." (See Chart III.) 




B ir y 
















m] 1 





m ■ 

IB '1 

Chart III. — Showing percentage of incomplete and complete motor, sensory, and electrical syn- 
dromes in compression, C, neurome in continuity. N, and anatomical interruption, I. (C. H. 
I'razier and S Siluerl, in .Sura., Gyn. and Obst.l 

Signs of Regeneration. The earliest evidence of regeneration is found in 
an improvement of the vasomotor status of the part. This change may be 
extremely early, often earlier than can be accounted for by the growth of re- 
generating nerve fibers. There is a gradual increase in the tone of the paralyzed 
muscles, with a coincident decrease in the degree of the deformity, before any 
signs of return of voluntary contraction appear. Beginning regeneration is 
manifested in the change in the response of paralyzed muscle to electrical 
stimulation. If polar inversion has been present, with beginning regeneration, 
this is changed to polar equality and the slow wave-like contraction gradually 
becomes more rapid with a return from the longitudinal reaction to the motor 
point reaction. Faradic response usually does not return until after return of 
voluntary contraction, though this is not invariably the rule. At first attempts 
at voluntary movements are manifested only by a slight increase in the tone of 
the muscles, frequently associated with contraction of the entire musculature 


opposite limb, when great efforts are made to transmit the impulse to the rein- 
nervated muscles. The muscles regain their innervation in the order from 
above downward of the origin of their branches from the nerve trunk, i.e., 
those branches proximal to the injury are reinnervated earlier than the more 
distal. The intervals in successive innervation of muscle groups may be 
comparatively long if the muscle branches are given off far apart, due to the 
additional time required for the neuraxes to travel the added distance. Duroux 
and Couvreur (1917) and Tinel (1919) found that the neuraxes grow at about 
the rate of 1 to 2 mm. per day. 

Following closely the improvement in vasomotor status and tone, the 
muscles become sensitive to deep pressure and a beginning return of faradic 
sensation in the skin and muscles is found. A gradual shrinkage of the cut- 
aneous anesthetic areas occur, those for pain and extreme degrees of tem- 
perature being the first to show contraction of their borders, while those for 
cotton wool and moderate degree show evidence of return only late. 

The early return of tone, and the decrease in the postural deformity of 
the extremity with the absence of voluntary movements after the normal 
associated movements returned in certain cases, led Ramsay Hunt (191 8) to 
extend his fascinating conception of the neokinetic and paleokinetic motor 
systems to peripheral nerves and predicate in them the existence of two sets 
of motor fibers such as Head, Rivers and Sherren had similarly done for sen- 
sory fibers. The strongest evidence in support of Hunt's view are certain 
related facts, anatomical rather than clinical. Hunt calls attention to the well- 
known functional differences in the sarcoplasm and the sarcostyles. The 
sarcoplasm is concerned with the slow tonic sustained phases of muscular 
contraction, and postural function, while the sarcostyles are involved in rapid 
quick muscular contraction. The functional differences of sarcoplasm and 
sarcostyles advanced by Bottazzi (1897) and elaborated by Roaf (191 2) has 
been generally accepted. Pekelharing and van Hoogenhuyze (19 10) have found 
that there are two distinct chemical catabolic changes in muscle, one the 
result of ordinary contraction and the other characteristic of tonic activity. It 
has been shown that light muscle has more sarcostyles than dark muscle and 
that the rapidity of contraction is greater in light than in dark muscle. Boeke 
(1909) found that both medullated and nonmedullated nerve fibers form end 
plates in striated muscle. In later experiments Boeke and De Barenne (191 9) 
corroborated this view by further experimentation. These investigators cut the 
ventral and dorsal roots of the sixth, seventh and eighth thoracic nerves with 


excision of the corresponding spinal ganglia, and studied the nerve endings in 
the intercostal muscle of the seventh space. They found that all medullated 
nerve fibers and end plates had disappeared, while there still remained bundles 
of fine nonmedullated nerve fibers connected with muscle fibers by means of 
delicate end organs. These were hypolemmal and, therefore, presumably 
motor in function. Similar experiments with similar results were reported by 
Agduhr {1910) after cutting the last four cervical and first two thoracic nerves 
distal to the spinal ganglia and proximal to the white rami communicantes. 
Degeneration of all medullated nerve fibers was found while unaltered non- 
medullated fibers with their end organs were present. Approaching the subject 
from the opposite angle, Agduhr removed the stellate ganglion without injuring 
the spinal nerves and found in the muscle studied degenerate nonmedul- 
lated fibers and unaltered medullated fibers. Ranson (1912) showed that there 
are many more nonmedullated nerve fibers in the peripheral nerves than 
heretofore had been believed. The nonmedullated fiber, the sarcoplasm, and 
the slow sustained contraction are more primitive than the medullated fiber, 
the sarcostyles and the quick rapid contraction; phytogenetically more recent 
acquisitions. Hunt believes that the paleokinetic system is less vulnerable and 
regenerates more rapidly than the neokinetic system, which may account for the 
earlier return of the simpler and more primitive functions such as pain and 
thermal sensations and muscular tone, the slow tonic contraction and postural 
functions. Whatever view of Hunt's theory be taken, nevertheless, he has 
advanced a plausible conception on a tcleological basis to explain the sequence 
of returning function following peripheral nerve injury. 

Tinel's Sign; "le signe du fourmillement.''— A sensation of electricity 
referred to the peripheral cutaneous distribution of the nerve, produced by 
pressure on the nerve trunk, was proposed by Tinel as a means to determine 
not only the existence of regeneration but also its progress. This sensation of 
formication is rarely perceived at the point pressed, but is much more actively 
resented in the peripheral cutaneous distribution of the nerve in question, 
thereby distinguishing it from that of neuritis. This sign was said to be 
found only when newly formed neuraxes arc present in the nerve trunk, and 
is progressive along the course of a nerve undergoing regeneration, advanc- 


tomical continuity, or only a few stray neuraxes within the distal segment; 
and consequently it alone cannot be taken to indicate functional regeneration. 

Fig. 68— The value of Tinel's sign. In this patien! Tinel's sign was obtained from both 
division of the sciatic beiow the knee. Obviously spontaneous function*] ragetictttfon could not 
have taken place for the sciatic nerve was completely severed and a dense wall of scar tissue intervened 
In-tweco the ends, (Stookey, Neurol. Bull., tgip.j 

' Sun Figs. 68, 69 and 70.) Experience has taught thai: (1) Tinel's sign maybe 
elicited when regenerating neuraxes are present within the nerve trunk, irre- 
spective of their number; (2) such neuraxes may be found when functional 
regeneration is impossible, due either to excessive scar or to dispersion of the 
neuraxes, with few penetrating the distal stump; (3) Tinel's sign, although 
present and progressive in its course downard along the nerve trunk, cautiot 

1 68 


alone be considered evidence of satisfactory regeneration; (4) Tinel's sign is 
of greatest value when the anatomical held is known, that is, following opera- 
tion, and when considered with other evidences of regeneration. Here its 

Linn rarried one step 
rot. Bull, iqiq.) 

main limitations are removed, since the nerve ends are known to be in ana- 
tomical apposition and in a position to favor downgrowth. 

Time of Regeneration Following Suture.- Evidences of regeneration are 
rarely found earlier than the third or fourth month and may appear at any 
time thereafter even up to thirty months. The time required is influenced 
by a great variety of factors which make it impossible to set a definite standard 


time for regeneration applicable to all nerves. The period varies wit 
nerve and the level of the injury on the nerve. It also varies with tl: 
of the injury of the nerve trunk and its relation to the origin of nerve br: 
When a nerve trunk is injured only a short distance above the point at \ 

Fig. 70.— The value of Tinel's sign. In this patieni 
of the median nerve and progressed gradually downward 
of tissue continuity existed. Functional regeneration o 
(Stookey. Neur. Bull.) 

Titnl's sij;n «;n present in the di 
as far as the palm. Only a slendi 
>uld not have taken place spotila 

group of branches is given off, innervation of the muscles supplied by 
branches may take place relatively early, whereas if a considerable di 
intervenes between the point of injury and the origin of the. 

Yini „™«M K«. 


appear. Additional factors influencing the rate of regeneration are the time 
interval between injury and suture, presence or absence of infection, the condi- 
tion of the nerves found at operation, the type of operation, the nature of the 
nerve bed and the preoperative and postoperative treatment. Injuries more 
proximally placed regenerate better than those more distal. 

Tabic IV gives a rough idea of the approximate time at which evidences of 
regeneration may be expected in the nerves most commonly injured and at 
levels most frequently seen. The time limits are those which obtain under 
ordinary good and ordinary poor conditions as determined by the variants 
mentioned, but variations from these time limits are seen, for example one 
musculospiral nerve showed advance signs of regeneration in three months and 
one ulnar not until thirty months. 

. I'k(>i;\,jsl 




I. Nerve injured. 
II. Level u[ injury. 

III. Mechanics of suture, 

IV. Condition of nerve ends. 

V. Condition of wound and nerve bed. 
VI. Interval between injury and suture, 
ir expectant evidences nf regeneration. 




Middle third arm. . 

Lower third arm 







Axilla . 

Middle third thigh 

Upper third thigh, 

Headnf fibula. 

Popliteal space 


Popliteal space 


Interrupted Regeneration and Reoperation. — Interruption of regeneration 
may take place in any stage. It is indicated by cessation in the progress of 
the signs above described as indicating regeneration. Regeneration having 
already begun may be temporarily retarded at certain periods due to scar tissue 
or other factors inhibiting the passage of the neuraxes. The surgeon must be 
very cautious in determining upon reoperation in an apparent interrupted 
regeneration, for in many cases the interruption may be only temporary and 
regeneration ultimately take place without interference. But if no signs of 
regeneration appear re-exploration of the wound is indicated. No definite 
time limit can be set applicable to all nerves and to all sutures. Each must be 
judged individually and with knowledge of the anatomical field, the nature 
of the suture, the condition of the nerve ends and the cross areas obtained at 
the time of suture as well as the relative position at which branches are given off. 
It has been the author's custom to make a definite prognosis as to regeneration 
and time for beginning regeneration immediately after each operation and 
to indicate any probable causes of failure which may be anticipated, either 
because of the condition of the nerve ends or the mechanics of the suture. Simi- 
larly, if nerve branches have been destroyed these are indicated and a note made 
that regeneration of their muscles is not to be expected. Re-exploration for 
failure to regenerate may be done earlier when no signs of regeneration have 
appeared than when regeneration begun is interrupted. 

A fusiform and relatively soft bulb is usually found at the line of suture and 
should not be taken to indicate blocked regeneration. But if the bulb is hard 
and the enlargement appears only on the central end, without any increase in 
size distal to the suture, it indicates some obstruction to regeneration. In nerve 
transplantation, especially when a long defect has been bridged, re-exploration 
of the distal suture with excision of the distal union and resuture, end to end, 
may be done, since scar tissue at the distal union may become too dense before 
the neuraxes have gained the distal stump to permit their passage. 

Criteria for Estimating Results. — In order that the cases of spontaneous 
regeneration and the results of nerve suture may be compared without confusion 
a standard terminology should be used. The terms suggested by Gosset 
(191 7) have already been used extensively and warrant adoption. The cases 
are classified as unimproved, improved, markedly improved and reeovered. Under 
" improvement " are classified those with definite evidence of regeneration as 
indicated by return of tone, some voluntary movement, faradic response, 



edly improved," when voluntary movements in previously paralyzed muscles 
have almost completely returned, but to an extent less than can be considered 
as absolute recovery— irrespective of the electrical response or the sensation 
return. As "recovered," when voluntary control of all muscles has returned, 
although some alteration in the electrical reactions may still exist or sensation 
be not completely regained. In estimating motor return the action of each 
separate muscle must be recorded and not group or total movements. 

There is probably no problem more delicate or requiring greater nicety of 
judgment than the indications for operation in nerve injuries. Indeed it is 
almost impossible to give definite 
general rules since a great deal 
depends on the nerve injured, the 
level of the lesion and the nature 
of the local injury. In a nerve 
supplying small muscles serving 
line movements, delay in recovery 
ismore harmful than in a nerve 
to larger muscles of coarser move- 
ments. Again, the nearer the 

injury to the spinal cord the 
the relative frequency ., , 

computed from 1200 g reater tne power of regenera- 
te operations from tj un . Greater vulnerability of 
the more distal fibers is also seen 
hich conditions the more distal fibers are earlier and 
When the local injury is so extensive that the sur- 

Chart IV.— Table 
of operations on ca< 
nerve operations. 

in the neuropathies, in 
more severely involved 
rounding tissues are nothing but a mass of scar and callus delay in operation 
hardly seems justified. With such a diversity of controlling factors it is obvi- 
ously impossible to set down any rule applicable to all nerve injuries. Each 
must be individually considered. 

Time of Operation. — Tn war wounds and in certain civil wounds immediate 
suture is rarely possible due to existing infection. Immediate primary suture 
at the time of the injury is the ideal whenever possible. Results from primary 
suture arc better than from secondary — not only in time required for regenera- 
tion but in completeness of recovery. Other things being equal, a long interval 
between the injury and the repair diminishes the chance of complete recovery, 
not only because of the changes occurring within the nerve itself but also 
because of changes in the structures supplied by the nerve, particularly muscles. 


It is a fundamental principle of nerve surgery that all operations must be 
done in a sterile field, consequently in many civil and war wounds sufficient 
time must elapse to insure a norunfected field. The possibility of recrudescence 
of infection in an apparently healed wound must always be considered, more 
especially where there has been extreme comminution of a fracture or when 
scattered metal fragments remain in the wound. Small foreign bodies, such 
as bone or metal fragments, may be found in a small amount of mucopurulent 
fluid walled off by scar tissue and this when spread may light up infection. 
The presence of such fragments 
may be determined by x-ray and, 
when found, indicate the need 
of a longer delay. 

When secondary operation 
only is possible, at what period 
should it be performed? The 
first consideration, as has been 
said, is the possibility of a sterile 
field; the second is the nature 
of the trauma and the absence 
of progressive regeneration. 
Statistics in this country and Qhwt v .„ Tabk to thow relative frequency of van- 
abroad indicate that between 40 0115 nerve injuries compiled from 12 10 war injuries. 
to bo% of nerve injuries may recover without operation. Gerulanos 
(1914), reporting cases from the Balkan War, estimated that 40% recov- 
ered, while Tinel, .in this war, places the percentage higher— 60%. Frazier 
(1920) found that among five hundred cases 63% recovered without 
operation. Yet some statistics show that in about 60% of all nerve oper- 
ations complete interruption is found with little or no chance of spontaneous 

Statistics showing recovery without operation do not take into account 
the time necessary for spontaneous recovery. It is suggested that possibly 
had these spontaneous regenerations been explored early, nerve liberation would 
have been done and regeneration hastened. It is a noteworthy fact that 
following nerve liberation many cases show surprisingly rapid return of func- 
tion, some within a few days and others a lew weeks. Consequently it is fair 
to assume in a considerable portion of the cases regenerating spontaneously 
without operation, that the time of convalescence might be materially shortened 

174 SURGI 

by consen>ali 
do not perm 
complete ph} 
for the next 
and electric 
to the fara 
showing the 
after nerve 

Brachial Pleiul 


<e nerve exploration and nerv 
y slight operation, 
rica! opinion is agreed that the s 
t the distinction being made 
siological interruption. Imme 
wo or three weeks, the affected 
J. irritability. Gradually they 
die current while preserving 
so-called reaction of degencra 
njury the usual direct mccha 


liberation — in most instances a 

gns which we have at our disposal 
etween complete anatomical and 
iiately after the nerve injury, and 
muscles preserve their mechanical 
lose their electrical excitability 
their galvanic responses, later 
ion. During the first few weeks 
lical irritability of the muscle is 
preserved , or even increased 
after the faradic response is 
lost. During the early stages, 
the muscle responds to direct 
percussion by sharp quick con- 
traction ; but in the later stages, 
when the reaction of degenera- 
tion is present, the contraction 

P»i ill 




Wiwi n mwmiii 

wave is slow and vermicular 

Chart VI.— Table to show relative frequcnev of . . .,,, ... 
various peripheral Mm unions in civilian life. Com- m character. When this con- 
piled frnm 300 cases. traction wave is present, the 
electric reaction of degeneration may be presumed also to be present, and 
when the response to direct mechanical stimulation is lost the muscle is in the 
last stages of degeneration. 

\\ ith the exception of partial and incomplete nerve injuries, it is unfortu- 
nately impossible, as has been said, -to determine whether a nerve will recover 
without operation except by waiting a sufficient length of time to allow for 
evidences of nerve regeneration to manifest themselves. It has been customary 
to wait from three to four months for regeneration and then, if sufficient evi- 
dences of regeneration are not present, to operate. However, a large number of 
cases have been reported which have shown the first evidence ot regeneration 
eight and nine months after the injury and have gone on subsequently to recov- 
ery. It is well known that many nerves regenerate after twenty or even 
thirty months. Hence to select arbitrarily three or four months as the period 
rail regeneration, as has been the custom, does not seem to be based 
Hftds. In effect, operation after four months of waiting is often 
■ferred exploration. Price (1919), from a wide experi- 


ence in the American Ambulance, felt that the anatomical field frequently shows 
a hopeless situation and that by delay nothing results except a loss of time for the 
patient. Such certainly has been my own experience. 

However, if the conditions be known — that is, the status of the surrounding 
tissues and the relation of the nerves to them, and whether there is anatomical 
interruption or only physiological block, such as might be gained by early 
exploration — regeneration may then be awaited with some degree of assurance, 
since the clinical signs of regeneration may be better evaluated. 

Early nerve exploration seems to me to offer a possible means of diminishing 
delay in recovery and at the same time give an opportunity to facilitate regen- 
eration. To explore a nerve involves little danger to the patient and may 
offer the tremendous advantage of hastening recovery. Most nerves are more 
or less superficial and their exposure is comparatively simple. 

In any nerve injury with a history of trauma sufficient to warrant the 
belief that the nerve may have been severed or embedded in scar or callus, etc., 
nerve exploration should be done as early as the condition of the wound will 
admit. Exploration should be done by one familiar with the appearance of 
injured nerves as found at operation and with an intimate knowledge of the 
histology of nerve repair. The need of conservatism during nerve exploration 
cannot be too insistently urged. The rule should be radical nerve exploration 
but conservative nerve operation. 

In a certain number of cases even by early exploration the surgeon will be 
unable to decide with certainty whether to excise and suture or to leave the 
nerve alone. On the other hand, nerves anatomically interrupted may be 
sutured at once with the saving of much time for the patient and with the 
assurance of a more complete return of function. Of two hundred and fifty - 
three cases operated, one hundred and sixty-one showed complete interruption, 
and in these the anatomical field always appeared worse than was anticipated 
from the neurological findings or the appearance of the local injury. Thus, in 
more than 63% of those operated conditions requiring nerve suture are to be 

The limitations of nerve exploration must be constantly in mind, for it is 
only with a realization of this that nerve exploration may be safely advocated. 
We may divide nerve injuries into three groups, in view of the anatomical find- 
ings at operation: those with anatomical interruption (63%); those having 
apparently only slight injury and yet with physiological interruption; and, 
ween these two extremes, a doubtful group which merges on one side into 


the anatomical interruptions and, on the other, the slight injuries. In this 
middle group, nerve exploration will give little definite information to indicate 
what surgical procedure should be followed, even after palpation and electric 
examination. The surgeon doing early exploration will do best to leave 
this group alone. He should reconstruct the field, performing a careful toilet, 
removing scar or infolding it, or surrounding the nerve with Huber's cargile 
membrane to prevent scar tissue strangulation. In such an early explora- 
tion he can then afford to withdraw and await subsequent events, after having 
carefully noted the anatomical conditions. In the remaining two groups 
the indication will be definite: where there is anatomical interruption, the 
nerve must be sutured; where obviously there is but slight injury, the nerve 
should be let alone. When exploration is done early, many cases which 
might not have gone on to spontaneous recovery may be converted into recov- 
eries and abortive regeneration changed into successful regeneration by cor- 
recting the field, excision of scar, liberation, or injection of salt solution intothe 
nerve— all harmless procedures if carefully done, which cannot impede but rather 
facilitate regeneration. Those unfamiliar with the finer histology of nerve 
regeneration may be tempted to be radical and perform nerve suture, failing 
to appreciate that often though the nerve trunk appears damaged neuraxesmay 
-.till grow down through it, better than after nerve suture with its greater 
dispersion and distortion of the nerve pattern. 

Considered from a purely anatomical standpoint, the earlier an operation 
is undertaken the less difficult it is to do. the clearer the anatomical field, the 
better the operative end result and the more complete the recovery. The 
longer the delay, the greater is the amount ami density of scar tissue and 
callus the nerve ends are more firmly bound and fixed in a retracted position. 
hi early operation excision of the nerve need be very limited to obtain good 
nerve ends. Furthermore, the longer the delay the greater are the secondary 
changes in the muscles, tendons and periarticular structures. 

Factors Interfering with Successful Regeneration.— The results of nerve 

■U_» n .» h. HlntM**) ku . «nl v-m^lv nf F«*AK ^mo <lf wh^rh n.« limit 


degree of functional return is less than from early suture. When the lesion in 
the nerve is in the more distal portions — that is, farther from the ventral column 
cells — Stopford (1920) feels that a long interval between injury and operation 
is decidedly unfavorable for recovery; while if the lesion is in the more proximal 
parts of the nerve, this time element is of less importance. It may also be that 
the more peripheral the muscle the greater its functional differentiation and 
more highly specialized movements require more elaborate and more accurate 
neural impulses. 

The bad effect of a long interval between injury and operation may be 
lessened by thorough and continuous massage and electricity to the paralyzed 
muscles. If, on the other hand, circulation and nutrition of the muscles and 
the free mobility of the tendons and joints have not been maintained, marked 
regressive changes may prevent functional return even after successful regener- 
ation. (See Chapter IX.) If delay in operation is caused by extensive infection 
in the region of the nerve injury, regeneration may be limited or altogether 
prevented, due to changes in the nerve trunk. Infection may be a further bar 
to regeneration when the resulting neural scar tissue is too extensive to allow for 
suture after complete excision and when the nerve cannot be transplanted into 
more favorable surroundings. Sclerosis of the nerve may occur, due to prolifera- 
tion of endoneural and perineural connective tissue, and other interstitial 
changes may be found, particularly in partial or irritative nerve lesions. 

Ischemia of the extremities, due to coincident injury of the blood vessels, 
may seriously interfere with regeneration. It is not known whether this effect 
of ischemia is exerted on the nerve trunk itself or on the muscles and tendons, 
etc. Probably they are involved together. The blood vessels of nerves 
receive collaterals throughout the nerve course, so that if this collateral supply 
be absent over an appreciable extent of the nerve course ischemia may have its 
effect upon the nerve. 

If severed nerves be embedded in scar or callus at a point at which mus- 
cular branches are given off, these may be torn from the nerve trunk or may be so 
involved by scar that repair is impossible, and thus their muscle groups must 
remain permanently deprived of innervation even though regeneration takes 
place in the remainder of the nerve trunk. Poor union of the nerve ends may 
permit only a relatively small degree of recovery, because, due to torsion of the 


diminished functional restitution. Functioning nerve endings may be re-estab- 
lished it is true, but it is improbable that all nerve fibers will re-establish their 
peripheral connections with the same muscle fibers which they had previously 
supplied with neuromuscular or neurotendinous end organs. Hence the 
reflex mechanism is disturbed, and readjustment of the impulses within the 
central nervous system must take, place, with re-education of nerve centers. 
This confusion of proprioceptive impulses (afferent impulses from the muscles, 
tendons, and joints), due to distortion in the nerve pattern, may seriously 
interfere with co-ordinated movements, particularly the finer movements of the 
hand, which diminishes the functional value of motor regeneration. The 
patient is unable to estimate the exact force of muscular contractions or the 
precise position of joints; consequently co-ordinated movements are poorly 
performed. Stopford (1920) has also called attention to the importance of this. 
"It is not uncommon to discover, after suture of the median, that all the 
muscles-when tested individually — have recovered voluntary power, and yet 
the hand is of slight practical service, when the patient attempts purposive 
movements. The patient will often volunteer the information that when he 
attempts to work he finds that he loses the grip of his tools, and on inquiry it 
will be found that he can use the hand fairly well as long as he concentrates 
upon the movements, but the hand ceases to function satisfactorily as soon as 
he takes his eye off it. Such patients also frequently inform you that the 
hand is useless in the dark, or when they cannot watch what they are trying 
to do with it. Such complaints may be heard even when cutaneous sensibility 
has made a fair recovery and all the muscles, tested individually, exhibit 
voluntary power. It seems clear that such a disability is due to the loss of 
afferent stimuli from joints, muscles, tendons and other deep structures. It 
is only practicable to investigate directly the recovery of fibers conveying 
conscious impressions from such deep structures as joints, but from an inves- 
tigation of the sense of posture and the appreciation of passive movements 
in the finger and thumb articulations supplied by the nerve, it has been found 
that these were generally lost, or at the best very defective even when 
three years had elapsed since the time of the suture. It would seem that this 
is very important to remember at examinations for the assessment of pensions 
after nerve suture in the upper limb, since the routine investigations of volun- 
tary power and cutaneous sensibility do not, in themselves, provide sufficient 
information to determine the real functional capacity of the hand. It is also 


an awkward problem to contend with during the later stages of recovery when 
muscle re-education becomes of greatest importance, since it provides one of 
the main obstacles to the satisfactory application of this form of treatment — 
an obstacle which is probably insufficiently appreciated. Previous to the war 
our chief experience of muscle training was derived from the treatment of 
infantile paralysis, and consequently many who are responsible for the super- 
vision of this form of treatment are content merely to develop an increased 
range of movement of the individual muscles, and fail to realize the different 
problem which arises in peripheral nerve injury. After injuries to the periph- 
eral nerves, there is usually a serious loss of those afferent stimuli which 
are of such importance for the perfect performance and adjustment of the 
finer and more delicate movements, and consequently in the later part of the 
treatment every effort must be made to develop those purposive and more 
complex movements which the particular patient will require when he returns 
to a civil occupation. ,, 


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The problem of the treatment of peripheral nerve injuries does not begin 
nor does it end with surgical intervention. The treatment of these cases 
requires an understanding, not only of the operative technic and indications, 
but also of the mechanical and postural management of the resulting deformity 
as well as of the mental attitude of the patient toward his condition. This 
mental attitude is of such importance that it cannot be overlooked if a success- 
ful result is to be obtained. In no other field of surgery must the patient wait 
so long to see the first signs of improvement. Hence even the most cheerful 
patients become discouraged and weaken in morale. They see their associates, 
though apparently more seriously injured leave the hospital recovered, while their 
own condition remains practically unchanged. In civil life among the indus- 
trial injuries, the average patient finds it difficult to understand why improve- 
ment is not as apparent in the rest of the extremity as in the superficial wound. 
The development of complications, such as traumatic ulcers and other 
cutaneous regressive changes, causes further discouragement. To obviate this 
constant effort should be devoted to the re-education and use of the paralyzed 
muscles, especially in the early stages of regeneration. The patient must not 
be allowed to become resigned to his disability nor to lose the will to regain 
control of the part, thus superimposing on the underlying organic injury an 
element of functional disorder many times more difficult to handle than the 
original nerve injury itself. 

However skillfully surgical interference may have removed all obstacles 
to downgrowth of neuraxes, the return of motor function may not take place 
unless comprehensive preoperative and postoperative treatment has been 
given. The aim of such treatment is to prepare the paralyzed parts so that 
when nerve regeneration and neurotization is completed return of function may 
not be prevented by mechanical obstacles. One such obstacle may be met 
with in the paralyzed muscles themselves, undergoing marked regressive 
changes due to loss of innervation, which may be hastened and rendered 
more severe as a result of poor nutrition and overstretching. When the nerve 
lesion has been incomplete and neuritis is present, the muscles may show 


severe fibrosis. Another obstacle to return of function may also be encoun- 
tered in the antagonist muscles, which untreated posturally undergo adaptive 
shortening causing permanent contraction with limitation in the range of 
motion. If concomitant bony injuries are present free mobility may be 
interfered with by callus or angulation and faulty alignment. 

The purpose of mechanical treatment is to assist in maintaining the nutri- 
tion of the part, to prevent overstretching of the paralyzed muscles or their 
contraction, to restrict adaptive shortening of the antagonists and to maintain, 
as near as possible, the normal range of motion within the tendon sheaths 
and the joints. 

Clinically it has long been recognized that when a muscle has been ean- 
staiitly overstretched, contractility may not return, or may be greatly delayed, 
in spite of the fact that the nerve injury itself has been repaired by satisfactory 
downgrowth of ncuraxes. Many times it has been found in the treatment of 
anterior poliomyelitis thai paralyzed muscles which have been overstretched, 
due to lack of postural treatment, may show a return of motor function when 
nothing more has been done than to correct the postural deformity thus pre- 
venting further overstretching. Neurotization alone, though complete, may be 
unable to bring about a return of contractility. Uncorrected postural deform- 
ity with constant overstretching of paralyzed muscles, clinically at least, causes 
more permanent loss of contractility and more marked regressive changes than 
where postural deformity has been prevented. Thus, from a clinical standpoint, 
the rirst cardinal principle of mechanical treatment of peripheral nerve in- 
juries is to obtain relaxation of the paralyzed muscles and to prevent thcir 

Unfortunately there has been very little experimental work to determine 
the influence of constant overstretching and other mechanical factors on the 
recovery of paralyzed'muscles. In the usual experimental animals, it seems to 
me extremely doubtful if the mechanical conditions affecting the paralyzed 
muscles can be compared to those found in the human, for there is too great a 
difference in the posture and anatomical arrangement of the extremity. This 
disparity is essentially one of mechanics, due tc the assumption of plantegrade 
locomotion and the upright stature. Consequently.while animal experiments 
to te-t overstretching, may throw some light upon the question they cannot 
be considered deUniteh conclusive. However, experimentally, depriving a 
mils, le 0! it- nerve supply has Yielded other valuable information clinically 


Changes in Denervated Muscle. — The relation of the muscle to its nerve 
apparently varies according to the stage of development of the muscle. Once 
the neuromuscular connection has been established, the muscle fiber appears 
to be entirely dependent upon the nerve for its integrity. Denervated muscle 
begins to undergo degeneration immediately; the degeneration varies in degree 
in proportion to the length of time the muscle is deprived of its nerve supply. 
The muscle gradually regresses in late stages, and assumes the appearance of 
embryological tissue from which muscle developed. At the other end of the 
nerve fiber a similar regressive change takes place in the nerve cell and it 
tends to assume the appearance of the neuroblast — the embryonal cell from 
which the nerve cell developed. Thus it would appear that when these two 
tissues, morphologically highly specialized and metabolically extremely ac- 
tive, are prevented from functioning they revert to more simple fetal forms 
which the organism can maintain with less effort. 

This complete dependence of the adult muscle fiber on its nerve supply 
is all the more interesting since Harrison's (1904) experimental studies have 
shown that in anervated fetal muscle not only does differentiation of the muscle 
fiber occur, but also that differentiation into muscle bundles, having normal 
attachments and tendons, takes place. Harrison found that by removal of 
the spinal cord in larvae of the frog before differentiation of either nerve or 
muscle tissue had begun that muscular differentiation went on normally and 
that the nerve element exerted no controlling influence on the morphogenesis 
of the muscle fiber. The older view that muscle differentiation did not occur 
in the absence of neurotization is thus contradicted. Such muscular independ- 
ence is further indicated by Bardeen (1900) Lewis (1901), who found that in 
the pig embryo and also in the human, muscular differentiation is fairly well 
advanced before neuromuscular connections are made. With such inherent 
power of independent -differentiation in muscle fiber, it seems all the more 
strange that, following the establishment of neuromuscular connections, 
the muscle fiber thenceforth should become dependent on the nerve supply not 
only for its integrity of function but for its structure as well. 

Physiological Changes.- — The reaction of degeneration is not found in 
muscles until after degeneration of the " receptor " or postneural substance which 
does not take place in the early stages of denervation. PatonandFindlay ( 19 16) 
found that curare in doses sufficient to inhibit muscle response to direct stimu- 
lation in normal muscles also inhibited such response in freshly denervated 
muscles after two or three days, at a time when the muscle was still excitable 


mechanically, but not by the faradic current. In denervated muscle of 
longer standing when the reaction of degeneration appears, curare has no 
inhibitory effect. These observations show that the postneural or "receptor 
substance" degenerates later, secondarily to the motor nerve endings. These 
authors thought that the reaction of degeneration "may be a result of degen- 
eration of the 'receptor substance'." Bocke (1921) believes that the mor- 
phological basis of this "receptor substance" is the "periterminal network" 
seen in the motor end plate as a delicate network between the neurofibrillar 
end ramifications and the sarcoplasm. In early stages of degeneration the 
"periterminal network" may still be seen after the neurofibrils are broken 

During the time the muscle is without its nerve supply, it constantly 
shows fine, fibrillary twitching, rhythmic in character (Schiff, 1851), {Langley 
and Kato, 1915). I have seen constant fibrillary twitchings in the tongue 
musculature following section of the hypoglossal nerve persist for fifteen years. 
As a result of more recent experiments Langley concluded that it was possible 
that constant fibrillation, without sufficient periods of rest, prevented the 
anabolic processes from equalizing the catabolic. The atrophy of denervated 
muscle may not only be due to such metabolic inequality, but possibly also 
to extreme fatigue, the result of constant fibrillation. The amount of atrophy 
corresponds largely to the degree of fibrillation. However, he was unable 
to determine whether the fibrillation was the resultant or the cause of the 

The great increase in the oxygen use of the denervated muscle over normal 
shows that catabolic processes are markedly increased {Langley and Itagaki, 
1 01 7) . Not only is there an increase in the breaking down of the muscle fiber 
in denervated muscle, but there is also a decrease in the power of repair, 
shown by the fact that denervated muscle cannot be made to increase in size 
by contractions artificially induced over a long period of time. That a denerv- 
ated muscle is a fatigued muscle is further evidenced by its lowered specific 
gravity (Langley). for as was shown by Bancroft and Kato (1915) fatigued 
muscle lias less specific gravity than unfaligued. 

I'lir importance of correcting postural deformities and preventing constant 
overstretching, though thus far unsupported experimentally, has been generally 
appreciated in peripheral nerve centers where those cases which have been 


untreated show varying degrees of deformity, even total irreducible contract- 
ures and mal-positions. The need for mechanical treatment has been clearly 
indicated by the reports of all peripheral nerve centers, some showing that in 
fully fifty per cent of the cases reporting for physio-therapy deformities might 
have been avoided by proper splinting and by surgical interference not too long 

Many of the earlier appliances attempted to correct postural deformity 
and overstretching without replacing a part of the movement lost. It must 
be recalled that not only should the elasticity and extensibility of the muscles 
be preserved as far as possible, but also the normal mobility of the tendons and 
joints which these muscles move. In the fixed type of apparatus, the tendons 
and joints themselves become fixed, unless special attention is paid to maintain- 
ing mobility within the normal range of motion. Stookey (1918) and others 
have pointed out that " immobilization alone or mobilization alone does not 
prevent contracture. Efficient immobilization must be combined with efficient mobili- 
zation." All movements should be regularly performed and the periods of 
repose guarded by apparatus. 

The Ideal Apparatus. — This should be light, simple, easily applied and 
removed, should immobilize no more than is necessary, and be inexpensive as 
well as inconspicuous. Furthermore, the apparatus must treat the total 
deformity — not merely one of the apparent faulty positions. On the other 
hand, an apparatus should not attempt to correct deformities which do not 
exist; for example to try to support the palmar arch in musculospiral injuries is 
uncalled for, since the muscles supplied by this nerve do not affect the integrity 
of the palmar arch. In so far as possible, the straps should be placed so as to 
rest upon the tendinous parts and not constrict muscle bellies. Great caution 
must be taken to avoid pressure sores, particularly in those cases in which an 
effort is being made to overcome rigid contractures, since it must be remembered 
that there may be anesthesia, not only of the superficial parts but also of the 
deeper structures; thus the warning usually given by pain is not present. All 
splints removed at night should be replaced by other apparatus more com- 
fortable and approximately as efficient. 

Appliances of the more complicated types, such as those used for plexus 
injuries and Thomas splints in anterior crural nerve injuries, etc., should be 
specially made for each individual case. Only general principles of mechanical 
treatment of these injuries will be outlined here. The treatment of the more 
distinct types of peripheral nerve injuries will be treated separately, except in 


those instances in which associated paralyses may be similarly bandied. 
Combined and multiple injuries are variable and will require modified types of 
apparatus for each case. Modification should be made whenever expedient, 
with alterations and changes according to the stage and progress of the paralysis. 
The splint should be made to fit the individual and not the individual or injury 
the splint. 

Early Mechanical Treatment. — The mechanical management of peripheral 
nerve injuries may be divided into the immediate and the subsequent treatment. 
The former includes the first few weeks until the associated injuries have pro- 
gressed far enough to permit of definite treatment directed toward the nerve 
lesion. The early management of these cases will depend very largely upon the 
coincident injuries. However, given a case in which the nerve injuries alone 
predominate, that is, without tendon or bony injuries, the extremity should be 
placed according to Stoffcl (1015) so that the severed nerve ends may be brought 
in as close proximity as possible and held there for a few weeks, during which 
time the nerve ends will become anchored and a more relaxed position may 
then be assumed. 

This is, in practice, applying to nerve injuries the principles long in usage 
for muscle and tendinous lesions. In nerve injuries, such considerations are of 
questionable value, since after the immediate retraction of the nerve ends at the 
time of severance further shortening does not take place as in the case of 
injuries to tendons and muscles. In these, contraction of muscle bellies is 
followed by further pulling apart of the tendon ends. A severed nerve tends 
to assume immediately a definite position and to keep it, being held more or less 
firmly in place by the fascial layers which intimately surround the nerve trunk. 

The position in which the limb is to be maintained will depend not only on 
the nerve, but also on the level of the lesion. 

Upper Extremity. Lesions Above the Elbow. — In injuries to the median, 
musculocutaneous and musculospiral nerves in the upper arm, the arm should be 
adducled and the forearm acutely flexed; in injuries to the ulnar nerve in the 
same region the arm is also adductcd but the forearm is extended. 

Lesions Below the Elbow.— In injuries to the median nerve at this level the 
foreann is flexed to a right angle, supinated and the hand acutely flexed at the 
wrist; in lesions of the posterior interosseous nerve the forearm is held in the 
same position, except that the hand is fully extended dorsally, while in injuries 
to the ulnar nerve the forearm is extended, the hand adducted and held 


Lower Extremity. Lesions Above the Knee. — In injury to the sciatic nerve 
in this region the thigh is held extended and the leg flexed upon the thigh. 
By extension of the thigh the central end of the sciatic nerve is relaxed, and 
the distal, by flexion of the leg upon the thigh. When the injury is below the 
middle third of the thigh flexion of the leg alone generally will be sufficient and 
extension of the thigh on the trunk is not necessary. In lesions of the 
anterior crural nerve the thigh is flexed upon the trunk. 

Lesions Below the Knee. — Little is gained by position in this region, especially 
when the anterior tibial or musculocutaneous is involved. However, in the 
posterior tibial 2 to 3 cm. may be gained by flexion of the knee and plantar 
flexion of the foot. 

When other injuries, particularly fractures, exist with the nerve injury it is 
needless to say that the primary indication so far as position of the limb is 
concerned is to treat the fracture so as to avoid any permanent deformity. 

Late Mechanical Treatment. — Correction of Deformities Before Operation. — 
During the early period of treatment the injury is treated both with a view to 
relax the paralyzed muscles and the severed nerve ends, while in the later 
stages the nerve ends having become fixed no longer need be considered, 
attention being directed in this stage to the position of the paralyzed muscles. 
Prior to operative interference in nerve injuries, it is desirable to obtain as free 
mobility in the paralyzed parts as is possible, so that sufficient flexion or exten- 
sion to bring the nerve ends in apposition may be obtained. 

Contractures and adhesions should be stretched gradually by continuous 
and not by interrupted force. Continuous and gradual stretching is better than 
daily forcible movements, since, when such movements are of sufficient force to 
increase mobility, the fibrous tissue is torn and a new fibroblastic reaction is 
set up which serves to increase the amount of scar. Gradual breaking up of 
adhesions induces less tissue reaction and, therefore, is more permanent in its 
effect. In some cases it may be necessary, at first, to break up adhesions under 
ether and to continue the treatment by application of such appliances as exert 
constant and increasing stretching. It is well to remember that in extensive 
paralysis of long duration, the bones may become brittle, little force being 
required to produce fracture, so that perhaps only tho-e experienced with uch 
conditions may care to undertake this method 01 treatment. 

Contractures of neuritic origin, perhaps more than other-, are the most 
difficult to handle, since immobility may only -<rve to accentuate the deformity; 
the contractures recurring within a few day- aft<r removal of the appliance. 


On the other hand, if these injuries are left untreated postura! disability is 
certain to become worse. The choice seems to be the lesser of two evils. In 
such cases, daily movements and baths with electricity must be combined with 
immobilization. In the earlier stages of neuritic contracture, the muscle 
groups show marked hypertonia, with beginning tenderness of the muscle 
bellies and gradual increasing deformity which may be overcome by skillfully 
planned movements. In the later stages, the tenderness becomes marked, and 
the muscles extremely sensitive to all mechanical stimuli. The slightest effort 
throws the muscles into extreme contraction, almost in a tetanic spasm. The 
phases of relaxation are shorter and shorter until they are practically lost, the 
muscle becoming so rigid that even passive movements are impossible. In these 
cases the effort mechanically is to overstretch the muscles so that for the time 
being all power of contraction is lost. Positive splinting, combined with con- 
trast baths as well as sinusoidal electricity in a hot parafnne medium, will be 
found serviceable in some but not all cases. 

Time to Change Position of Extremity After Operation. — When it has been 
necessary to fix the extremity in an abnormal position to bring nerve ends 
together the question of when the normal attitude may again be assumed 
must be met. It has been customary to maintain the extremity in its post- 
operative position for four to six weeks returning gradually thereafter to 
normal. Within this period union between the nerve ends will have become 
firm and the neuraxes from the central stump should have gained the distal. 
There is some evidence to indicate that union is sufficiently firm much earlier 
and hence motion may be begun sooner. In a few secondary operations follow* 
ing nerve suture it has been shown that union between the nerve ends is com- 
paratively firm within a period of ten days or before. In one case reported 
by Babcock (1919) the patient removed the splint during the first few days 
after operation, necessitating secondary exploration of the nerve. The line 
of suture of the sciatic nerve was unaltered and no separation of the nerve 
ends had occurred in spite of the change in the position of the limb. Possibly 
such early firm union as this is made possible by exact apposition of the nerve 
ends and numerous fine sutures which unite the epineurium. 

If the nerve has been freely mobilized both centrally and distally. or 
stretched, a connective tissue reaction is often set up in the tissue surrounding 
the nerve. The nerve becomes fixed in its bed and is held in a more or less 
continuous splintage by tine fibrous bands over a considerable portion of its 


the nerve in its bed may be impaired; the longer the fixation after suture 
the firmer the nerve is held. Mobility within the nerve bed is essential to 
allow free motion of the extremity without injury to the nerve. 

In several instances in which secondary operations were performed follow- 
ing nerve transposition it was surprising to find the nerve fixed in its new 
bed by numerous, fine bands from the surrounding connective tissue with hardly 
any movement present. Even attempts to move the exposed nerve directly 
were unsuccessful, so tight was the adhesion. Because of this possibility, 
motion should be begun as soon as nerve union is firm, following the prac- 
tice applied to other structures where fixation is to be avoided. Hence, motion 
after suture must not be too long delayed, nor begun too early before connec- 
tive tissue union of the nerve ends takes place. 

In view of these facts one should begin to lower the limb about ten days 
to two weeks after suture, gradually increasing the range of motion so that 
within three or four weeks a normal or nearly normal position may be assumed. 
In cases in which the fixation position has been extreme a longer period may be 
needed to reach the normal. 

Associated Treatment. — Besides mechanical treatment of nerve injuries, 
additional measures remain to help maintain the nutrition and mobility of the 
paralyzed extremity. These measures are massage, electricity and re-educa- 
tion. Unfortunately, it is not possible to discuss in detail in this volume these 
forms of treatment. They are extremely important and should be given by 
those who are fully familiar with their possibilities. 

To advise massage and electricity is insufficient unless specific instructions 
are given. Frequently patients referred for consultation will tell you that 
they have been given electricity, but that it has done them no good, and the 
limb would apparently indicate this. However, upon further inquiry it will be 
found that only the faradic current had been used, which of course is useless 
in denervated muscles. The heartiest co-operation between the surgeon and 
the physiotherapist is essential. 

The purpose of both massage and electricity in denervated muscle is to 
improve the nutrition and aid in the removal of waste products, as well as to 
assist in the maintenance of the usual mobility of tendon sheaths and joints, so 
that peripheral obstacles to resumption of function, following successful 
regeneration, may not be encountered. 

Massage and Baths.— There seems to be some experimental evidence to the 
effect that massage is only of the slightest benefit in preventing atrophy 


(Langley and Hashimoto, 1918). To prevent atrophy is not the purpose of mas- 
sage, but rather to improve the circulation and mobility. It has already been 
pointed out that denervated muscle shows an excess of waste products, and the 
object of massage is to increase the circulation so as to remove the excessive 
waste and increase the supply of new blood and lymph. The lightest forms of 
massage are indicated; due to the extreme atrophy of the paralyzed muscle pres- 
sure may be transmitted to the blood vessels and heavy massage may cause para- 
lytic dilatation thus defeating the end sought. This objection, perhaps, is 
more theoretical than practical. Of the different forms of baths, perhaps none 
is better than contrast bathing. The extremity is placed alternately in hot 
and cold water, thus increasing the vasomotor tone and the circulation. The 
whirlpool baths have distinct advantages, since not only may the benefits of the 
hot bath be supplied, but also a massage effect as well. 

Electrical Treatment. — This form of treatment obviously varies according 
to the stage of the injury. During the time that nerve impulses do not reach 
the muscle, naturally the faradic current is of no value. The advantages of the 
galvanic current were very early appreciated. Brown-Sequard (1859) believed 
that this current improved the condition of the muscle, both by contraction and 
by some direct action on its metabolism. Muscle deprived of motor end plates 
is inhibited by the chemical effects of its waste products and these are removed 
through the increased circulation produced by the galvanic current. This 
action is especially true of the sinusoidal current, which improves the nutrition 
and the circulation, in spite of the fact that contraction of the muscle is not 
possible. A contraction of muscle during atrophy is not necessarily beneficial, 
but it is rather the result of the contraction, which, as we know increases the 


chronaxia. Lapicque at first evolved this method as a means of testing must 
so as to obtain isolated contraction without the confusing element of disper 
and masking of the reaction by contracion of the neighboring sound muse 

An electrical stimulus has both a minimal strength below which it will 
produce contraction, no matter how long applied, and also a minimal dura 
below which time, no matter how strong the current, it will not cause contract 
By determining the minimal threshold of excitation (usually doubled in calc 
tions) and then the minimal duration with which this strength current 
produce a contraction the chronaxie is determined. The chronaxie in nor 
muscle is about one-thousandth second while that of a paralyzed muscle < 
hundredth second or more. In this manner the current may be appliec 
that the chronaxie of the sound muscle is passed before its thresholc 
excitation is reached, while the current is supplied to the paralj 
muscle so that the minimal threshold of the paralyzed muscle is reac 
at its exact chronaxie. By this means, a response may be obtained c 
in the paralyzed muscles without danger of contraction of any of the neighboi 
muscle groups. This, of course, is applicable only as long as the muscle 
shows electrical response or at a time when regeneration is taking place, 
application of this principle of Lapicque has meant a great advance botr 
muscle testing and in the possibilities of the application of electricity to p; 
lyzed muscles. 

Treatment of Denervated Muscle During Stage of Recovery. — 
questions which have arisen in regard to the advisability of the applicatioi 
electricity to paralyzed muscles unable to respond to electricity do not appl; 
those patients whose nerves are regenerating. Some form of electri< 
is advised by most workers. The question arises, however, as to the stren 
of and the time at which the current should be applied. It is held tha 
might be dangerous to pass an electrical current through a young regeneral 
nerve fiber and also that the contraction obtained might be injurious to 
regenerating muscle. Unfortunately, there are no experimental'data of wl 
I am aware dealing with this question. In my own experience I have ten 
to be rather conservative and prefer to wait until the regeneration is fairly > 
advanced before advising the application of the faradic current, on the groi 
that to delay will do no harm cither to the muscle liber or to the nerve. 

Re-education.- — No more important factor of treatment in the stag< 
regeneration can be initiated. The aim should be not onlv *- 
ranere of motion, as for example is d^- 


re-educate the proprioceptive paths (bone, joint, tendon and muscle sense). 
These paths may be seriously damaged, due to distortion of the sensory fibers 
and also to errors arising as a result of injury of the motor, so that the normal 
reflex paths essential for synergic action are often lost. To have such action 
the same group of ventral column cells must innervate the same muscle or 
muscle groups — a probability rather remote following nerve suture. Thus in 
paralysis of peripheral nerve origin, the afferent as well as the efferent functions 
of the nerve are in need of re-education; thereby differing materially from 
paralysis of anterior poliomyelitis in which only the efferent paths — and these 
often only partially — are destroyed. 

This problem of re-education is of great importance, for while the individual 
muscle may regain its power of contraction, its more delicate functions may be 
lost with its proprioceptive sense seriously impaired. This has been found to 
be a serious source of disability and this point must be considered by pension 
boards in determining the amount of pension as well as by industrial compensa- 
tion commissions in civil life. 


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-7 r* m 

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^ v I ' '- ■■■■--■■■■■. deal ■•■: ^.t^s with injury to peripheral nerves. 


Probably there is no musculature more essential to the happiness of the 
individual than the facial musculature. Facial paralysis when unrelieved 
offers to the neuro-surgeon a therapeutic field of great significance, but 
when the divided facial nerve fails to regenerate spontaneously operative 
possibilities are necessarily limited. Anatomically there are but two motor 
nerves in the neighborhood of the facial which can be used for nerve crossing. 
Faure and Furet (1898) first performed spinofacial crossing and Korte (1901) 
hypoglossofacial. Both of these methods give some degree of motor return 
and an improvement in the facial symmetry during repose, but are accompa- 
nied by associated movements in conjunction with the movements of the neck 
and shoulder, or of the tongue which tend to vitiate the excellence of the func- 
tional results. 

Mannasse (1900) was the first to test experimentally implantation of the 
distal segment of the facial nerve into the spinal accessory and obtained, in 
three out of five dogs thus operated, response to the interrupted current in 
the facial nerve distribution. Kennedy (191 1) has shown experimentally in 
dogs and monkeys that in facial crossing with either the spinal accessory or 
hypoglossal gave approximately the same degree of motor return. Increase of 
tone first appears with a decrease in the asymmetry, followed by return ol motor 
control of the orbicularis oculi. Following this regeneration the eye first 
closes separately and not synchronously with the normal side. This lack 
of co-ordination is subsequently overcome; closure becomes an associated 
movement and reflex winking is present. In hypoglossofacial crossing return, 
of this movement is somewhat earlier than in the spinofacial. In the monkey, 
after spinofacial crossing, there were spasms in most of the facial muscles on 
movement of the shoulder, particularly when the movement was sudden. 
Movements associated with tongue movements were generally wanting in 
hypoglossofacial crossing. However, in one dog, in which end-to-side suture 
had been done, winking occurred with the movements of the tongue and still 
more vigorous movements of the tongue were accompanied by synchronous 
movements of the face. Thus, experimentally, there is little evidence favoring 


one method over the other. Both show relatively the same degree of motor 
return, but both show associated movements which are more noticeable in 
spinofacial_than hypoglossofacial crossing. In time of regeneration the differ- 
ence in favor of hypoglossofacial is insignificant. 

In Cushing's (1903) case of spinofacial crossing marked associated move- 
ments of the facial musculature accompanied turning of the head or raising 
of the shoulder. Similar association movements following spinofacial suture 
were found in the cases of Harve (1906), Girard (1906), Davidson (1907), Fagge 
(1909) and others. These associated movements were reported as the only 
evidence of "re turn of function by Ballance (1903) and Gluck (1905), while Ken- 
nedy (1902,1911), Grant (1910) Crandon (1913), Hunt (1915) have reported 
marked improvement with little development of associated movements. 
Kennedy's case showed perhaps the best result " the movements taking place in 
the face. . .were quite independent of any of the associated movements, were 
made quite voluntarily by the patient in a natural manner. When she was 
asked to close her eye, that was done without any movement of the muscles 
supplied by the spinal accessory, and on ordinary movement of the latter no 
facial twitchings were observed." On the contrary in one case under my 
observation ten years after spinofacial end-to-end crossing, the only movements 
of the facial muscles were association movements, synchronous with turning 
the head or raising the shoulder. The eye could not be closed except when 
the shoulder was raised or the neck was turned. The only real improvement 
was in the general tone of the musculature, with attendant decrease in the 
asymmetry of the face. No emotional control had been gained. However, 
by intensive electrical treatment, repeated and constant attempts at re-educa- 
tion intended to re-establish volitional control, the movements of the eye were 
so improved that the eye could be closed without moving the shoulder. Though 
the eye no longer participated in shoulder movements, the remainder of the 
facial musculature still showed violent spasmodic contractions on elevation of 
the, arm or in other movements involving the shoulder and also on rapid 


Ballance, Ballance and Stewart (1895), Frazier and Spiller (1903), Bardenheuer 
(1904), Taylor and Clark {1906), Ballance (1909), Tubby (1909), Welty (1914), 

Fio. 71. --Schema to illustrate the cortical i 
tongue, and shoulder, respectively, and the relali 
It will he seen that the centers of the movement* 
while that for the shoulder is some distance away 
facial nerve in the medulla derives some of its I 
Ballance and Stewart, lirit. Med. Jour,, tgo.j.) 

Stevens (1017), Be vers (tor,*), Deancsly (loi.jj and Perrel (1920). Taylor and 
Clark preferre dimplantation of the facial into a slit made in the hypoglossal nerve. 
In their seven cases there were trophic changes and paralysis of one side of 


the tongue, which in the majority ultimately cleared up, while in all of them 
some return of movement occurred in the facial musculature. Improvement 
was found first in the general tone of the muscles, then contraction in the 
muscles about the mouth, and the improvement gradually extended upward 
to the muscles of the forehead. This sequence of return of function does not 
always take place. Frequently, the movements of the eyelid return first and 
are followed by those of the mouth and lastly of the forehead. 

Ballance, Ballance and Stewart recommend hypoglossofacial rather than 
spinofacial crossing because the association between the cortical center of the 
tongue and face is closer than that between those for shoulder and facial 
movements. (See Fig. 71.) Frazier and Spiller also favor hypoglossofacial 
for the same reason. Ballance reports a case in which the end of the facial was 
sutured into the hypoglossal and the distal end of the hypoglossal to the spinal 
accessory. Twenty months after this double crossing the patient showed func- 
tional return of the facial movements without any associated tongue movements. 
However on sudden movements of the shoulder a wave of contraction was seen to 
pass from the back of the tongue to the tip on the side of the crossing. Perret 
reported a case of hypoglossofacial crossing seven years after operation in which 
there was no facial asymmetry and little lagophthalmus, gradually improving 
tongue atrophy with perfect speech. There remained only a suggestion of 
associated movements of the facial muscles with those of the tongue. Stevens, 
and Welty have reported marked disturbances in the tongue musculature with 
decided speech impediment and difficulty in eating, so much so that Welly 
decided to discard this operation in favor of the spinofacial crossing. 

From purely anatomical considerations, the opportunity for functional 
restitution with closer associational correspondence seems to he more with 
hypoglossofacial crossing. These two nerves are more or less closely situated 
in the brain stem. (Sec Fig. 72.) Both are richly supplied by collaterals from 
the fifth nerves of the same and opposite sides (Cajal). Collaterals are also 
given off from the hypoglossal to the facial. The latter collaterals have not 
been demonstrated anatomically, but their presence has been deduced from the 
fact that certain hypoglossal nerve palsies are accompanied by weakness of the 
labiofacia! muscles. Both nerves are motor: the facial, splanchnic motor and the 
hypoglossal, somatic motor. The functional association of the facial muscles and 
of those of the tongue are many; even from early life they are synergists. The act 
of sucking is a synergic movement, as is also chewing, swallowing, talking, and 
other normal associated movements, hence in these two nerves there is, even in 


Fin. 72. — Schematic drawing of (1;c brjin stem shoeing the mnnections lielween the trigeminal; 
facial, hypoglossal and spina! accessary nerves. Horizontal scil'im. ///. (.Kulomolor nurlcus, 
IV, trochlear nucleus; V, spinal trigeminal sensor) nudcus; 17. j| H |u<in- nuiiiu=, VII, facial 
nucleus; XII, hypoglossal nucleus; XI, spinal nucleus of the ac-a-s^ry; a collaterals from the 
spinal trigeminal to the facial and hipo^!"^! r.ii.ln < i (he *.imc suit; a', t'<<1!>itcraU In the facial 
and hypoglossal nuclei from fibers p.i-sir.^ (run; if. -|.i:il nominal nu. Im» to 1 Sic i>p|»i»iit- >idc : 
a', collaterals to the facial and hypoL,'l.;--;i -inrlei ;iri-ing frum ihr liigi-niinal nucleus i>i ilu 
opposite side;B and C, aberrant pyramidal; H. ,«i ul.ncphalugyric I1u11.ll. I.. III. IV. VI an.l 


the lower centers, a close correspondence in reflex function as well as in ana- 
tomical relationship. Whereas on the contrary, the nuclei of the spinal portion 
of the spinal accessory nerve are placed farther away from the facial, and receive 
no reflex collaterals from the trigeminal. These collaterals probably play an 
important part in the re-establishment of reflex facial movements, since it is 

Fig. 73. — Section to show collaterals ending in the hypoglossal nucleus. Port ion of a transverse 
section of the medulla of a mouse at the level of the commissural nucleus. Chrome-silver impregna- 
tion of Golgi. A, Commissural nucleus B, hypoglossal nucleus C, decussating fibers of the medial 
lemniscus; D, solitary fasciculus cut transversely, E, secondary trigeminal and vago-glossopharyn- 
geal tracts; /, g, i, collaterals from the secondary trigeminal and glossopharyngeal tracts termin- 
ating in the nucleus of the hypoglossal. { Cajal, Hist, du Syst£me Nerveuse.) 

possible that the trigeminal fibers carry (see Figs. 73 and 74) muscle and position 
sense for the facial muscles. It is true that the exact path of these stimuli has 
not yet been determined, but the facial muscles, are so intimately connected 
with the skin that it is probable that the sensation of skin movements in 
the face serve as proprioceptive stimuli, and are carried by the trigeminal nerve. 
This proprioceptive sense in the facial musculature seems to be lost when the 


posterior root of the trigeminal nerve is cut. These patients find it dirncu 
localize the exact position of the cheek, and the face feels "wooden." 
The cranial or accessory portion of the spinal accessory nerve belong 





!l- j 

Fig. 74. — Section to show collaterals endin 
section of the medulla of a mouse several days < 
Chrome-silver impregnation of Golgi. C, Xucli 

collaterals, d, from the secondary trigeminal fiber 
lion; a, b, collaterals from the continuation of the 
geus; B, spinal root of the trigeminus, cut lransv< 
inward forming a ple\us r /-.'. which etuis in the tei 
Systerae Xerveuse.) 

fibers are shown pa 

reality to the vagus, and immediately after its exit from the cranial cavii 
joins the vagus and is distributed through the vagus tn ■'•- 


origin lie in the ventral column of the upper five or six cervical segments 
and not in the medulla, can be used in spinofacial crossing. The spinal acces- 
sory nerve is splanchnic motor, and its nucleus lies in the lateral portion of the 
ventral gray, forming the lower part of an almost continuous column of motor 
cells which includes the splanchnic motor nuclei of origin of the seventh, 
ninth and tenth nerves; all supply structures originally of splanchnic origin. 
The facial muscles and the trapezius are both splanchnic in origin, that is, 
derived from the lateral and not the dorsal mesoderm. The trapezius is 
splanchnic and may be considered homologous with certain muscles moving 
the pectoral arch. It is held that one or more branchial arches are retained for 
the attachment of the forelimb and the muscles which move this arch have been 
preserved in the trapezius (Johnson, 1906). The facial muscles develop from 
the hyoid arch.' 

In spite of this developmental homology, the reflex paths of association of 
the facial and spinal accessory nerves are quite independent, unconnected, and 
widely separated. The muscles of the shoulder and face are not synergists and 
have little or no association in function. Not only in the brain stem but in the 
cortex there is still less connection between the centers for shoulder and face 
movements (sec Fig. 71), as has been shown by Ballancc, Ballance and Stewart, 
and Frazier and Spiller. The face and tongue centers lie closer together and con- 
sequently association paths may be more readily established, so that in hypo- 
glossofacial crossing new associated movements should be more easily developed 
and volitional control more easily gained. 

It remains a mooted question of nerve physiology whether the cortical 
facial center (after severance of the facial nerve and nerve crossing) remains 
inactive, while the* tongue center or the* shoulder center, as the case may be, 
takes on the function of the facial. From the experimental work of Kennedy 
and others, where nerves were crossed, for example, the nerve to flexors into 
that of extensors in the dog, it was found that the flexors and extensors had 
interchanged their function, so that stimulation of the cortical flexor center 
resulted in extensor contraction, and vice versa. In order that there can be 
volitional associated movements following nerve crossing, facial proprioceptive 
impulses must be transmitted in some manner to the new functioning cortical 


end-to-end suture is done the marked hemiatrophy of the tongue resulting 
from complete severance of the hypoglossal is a serious drawback to the utiliza- 
tion of this nerve, unless another motor nerve is sutured into the cut distal 
stump. In unrepaired total section of the hypoglossal one-half the tongue 
becomes little more than a layer of mucous membrane. This disability Welty 
considered serious, while Ballance, Ballance and Stewart, Frazier and Spiller 
do not believe this atrophy of serious importance, and the latter consider the 
paralysis resulting from section of both the spinal accessory and the hypo- 
glossal equally insignificant. Certainly the paralysis resulting from total 
section of the spinal accessory is not very disabling, but it is sufficient to cause 
some disability in the free and forcible movements in elevation of the arm and 
shoulder. These points must be weighed in their relation to the occupation 
and station of the individual. In a singer the spinal accessory should be used 
for crossing. A hod carrier could better sacrifice his hypoglossal. The advan- 
tages of complete end-to-end suture over partial crossing or implantation are 
that dissociation is better established and a more proportionate number of 
neuraxes offered by the substitution. Complete section of the substitute nerve 
allows complete severance of the centers from their former function and all the 
neurons will be called upon to serve only the new and not both the new and old 

Taylor has shown good results from implantation. Yet I do not think 
that this type of operation affords the best opportunities for recovery. Bal- 
lance strongly advises against any method which does not devote the whole 
nerve for suture, condemning end-to-side suture or an end-to-end, where only 
part of either the spinal accessory or the hypoglossal nerves is used. If the 
hypoglossal nerve be used and the descendens hypoglossi separated from 
the main nerve trunk, the latter may be sutured into the distal end of the hypo- 
glossal and atrophy of the tongue thus overcome, providing regeneration takes 
place. Although the descendens hypoglossi is sutured to the distal end, 
nevertheless the hypoglossal nerve is freed from its former central connections, 
since the descendens hypoglossi consists of motor fibers from the first and 
second cervical nerves only, which have become incorporated in the slicatli of the 
hypoglossal in the early development of the embryo. Thus a nerve whose fibers 
are distinct from the hypoglossal is used to offer new motor neurons for the 

In the formation of the cervical flexure the formerly independent horizontal 
buds of the hypoglossal and the first and second cervical nerves come in con- 


tact. (See Figs. 75, 76, 77, 78.) The latter are temporarily incorporated in 
the trunk, of the hypoglossal by the growth of the sheath and separate later 

Hyp^l..*! N. 

D.«=nJ. nI 'h,po8l»>.;N 

C„i,.i.. hyp.jloui N. 

Descan^ns hjpoglossi. N. 

Hyp. 8 l. M UN 

Descend ens hypoglossal^ 

fva. :;. Fie. 78. 

Flos, f5, 7(1, 7 ; . ; v- Si' hematic drawing showing the development of the hypoglossal and the 
lie si' etide us hypos lo*si nerves. The nerves arise .is separate nwllets from the lower part of the 
mrdull.i and llio .id i.i. i'ui -.inneiits of the cervical cord. With the formation of the cervical depute 
ihe two nerves come to lie in ronlicl for .1 short distance before again separating, but the fibers do 
uol intermingle, 

front the sheath as the descendens hypoglossi. From a comparative anatomy 
standpoint ihe hypoglossal nerve itself represents the most cephalic portion of 
(he cervical plexus supplying muscles between the pectoral girdle and the 
region 01 ihe tongue. In the higher vertebrates this most cephalic portion of 


the cervical plexus, supplying the muscles of the tongue, has gradually beco: 
independent, and thus has formed the hypoglossal nerve. By suturing 1 
descendens hypoglossi into the distal end of the hypoglossal, neuraxes wh 
come from the first and second cervical segments, but phylogenetically a 
physiologically closely related to the tongue musculature innervation, 
utilized. Thus the contour of the tongue may be restored and its t< 

Grant (1910) has lessened the disability resulting from total section of 
spinal accessory nerve by suturing to its distal end a motor nerve from 
cervical plexus or the descendens hypoglossi and in this manner offers mo 
innervation to the trapezius muscle. A similar method has been emploj 
by Ballance; the spinal accessory was sutured into the distal end of the hy] 
glossal, thus restoring the muscle volume of the tongue, though on moveme 
of the shoulder, a slight contraction wave in the tongue beginning at the b 
and passing toward the tip took place. In place of the spinal accessory 
descendens hypoglossi, as has been indicated, may be freed from the main nei 
trunk, and sutured into the distal end of the hypoglossal. Since paralj 
resulting from severance of the descendens hypoglossi is barely appreciable, 1 
advantages of this nerve as a substitute for either the spinal accessory 
hypoglossal are apparent. 

Sherren (1906) collected fiity cases of facial nerve suture of which ei; 
were complete and two were partial crossing. In six patients the hypoglos 
was used and in the other the spinal accessory. Only two of these were 
lowed longer than six months after operation, so that only these admit of i 
conclusions of value being drawn. Of the two patients observed six months, 
was spinofacial and the other hypoglossofacial and in both associated mo 
ments were present. Some of the remaining operations were implantations 1 
the others were partial crossings. In quite a few of the implantations a slit ^ 
made deeply into the hypoglossal nerve; in effect possibly partial nerve crossi 
Paralysis of the tongue, either permanent or of several months durati 
resulted, thus indicating that the funiculi were probably actually cut and 
merely separated as is done when a true implantation is made. Even whe 
flap consisting of one-third or one-half the cross area of the hypoglossal nerv 
raised, as in partial nerve crossing, only temporary paralysis, as Sherren 
pointed out, may result. All cases of nerve crossing showed some improvem 
in the symmetry of the face. In a few of the spinofacial cases som<> ' ,: 
from the shoulder movements with •' 1: 


occurred, whereas in hypoglossofacial the movements, especially those of the 
angle of the mouth, showed dissociation, but the amount of volitional control 
in the latter was greater. 

Operative Indications. — The indications for surgical repair of the facial 
nerve depend on the nature of the injury. If the nerve has been- severed by 
trauma, as from stab or gunshot wounds or during an operation upon a mastoid, 
the indications for suture are plain. In fractures of the base the nerve may 
be torn within the cranial cavity. Very rarely, both facial nerves may be 
injured, but such traumatic bilateral paralysis is extremely rare in civilian 
life, only a few cases having been reported, notably those of Koslossky (1892) 
and Ransohoff (1919). When the injury is bilateral, some form of repair is 
imperative for the deformity is distressing, not only in appearance but in 
attempts to articulate and to eat. Moure (1915) and Brindel (1917) have 
shown that in fractures and gunshot wounds facial paralysis may be caused 
by pressure of bony fragments, and that function may be re-established by 
removal of the fragments and cleaning up the facial canal— in short by nerve 

When the paralysis is the result of otitis media, one should wait at least 
six months to allow spontaneous regeneration to occur, and during this time the 
facial muscles should be supported mechanically to prevent overstretching and 
massage and electricity should be given daily. During this interval the mastoid 
should be cleaned out, getting rid of any residual infection, granulation tissue, 
organized exudation or any source of pressure which might interfere with nerve 
conductivity. Excellent results have been reported from this form of treat- 
ment by Galdiz (1911), Catte and Sigaux (1912) and others. However, 
if such treatment is not followed by some return of function within six 
months little may be expected by way of regeneration without nerve 
suture. When paralysis develops some time after a radical mastoid opera- 
tion, it is reasonable to infer that interference in conductivity is due to pres- 
sure upon the nerve or to persistent perineural inflammation and a second 
operation on the mastoid may be undertaken in the hope of removing any 
disease which may remain. 

In Bell's palsy and more particularly in paralysis occurring in infants and 
children, a few facial nerve fibers may be spared, sufficient to maintain the 
vasomotor status and a certain degree of tone, or with even as light innervation 
in some of the muscles, especially those about the mouth. There is some 
ground for the suggestion that retention of tone in the facial muscles in some 


forms of facial paralysis may be due to the integrity of the non-medullated 
efferent sympathetic fiber for it is well known that striate musculature possess 
a dual innervation receiving efferent fibers from the sympathetic as well as the 
ventral gray cells. Evidence of the integrity of some of the nerve fibers in 
these cases is seen immediately after section and suture when the deformity 
becomes more marked due to severance of the intact fibers. These fibers 
possibly prevent marked regressive changes in the muscles; consequently nerve 
crossing may be done at a late period — many years after the original paralysis — 
with excellent functional return in the facial musculature. But when enough 
fibers exist to maintain the tone and prevent very much asymmetry of the face, 
the surgeon should be most hesitant in suggesting operation without first having 
relaxed the muscles by proper support for at least six months to allow for 
spontaneous regeneration. 

Attention has been called to the greater frequency of Bell's palsy on the 
right than on the left side. Leiner (19 19) found that in twenty-six cases of 
Bell's palsy the paralysis was on the right in nineteen and on the left in seven. 
He believes that the greater frequency on the right side is due to the fact that 
the facial canal and stylomastoid foramen is smaller on the right than on the 
left. In thirty-three skulls examined by him, the right stylomastoid foramen 
was smaller than the left in nineteen instances and equal to the left in five, 
while in nine the right was larger than the left. Philip has called attention to 
the fact that in some skulls the stylomastoid foramen is reduced to the size of 
a minute thread. 

When the facial canal or stylomastoid foramen is abnormally small, it is 
extremely difficult, if not impossible, to find the facial nerve as it may be 
reduced to a mere thread, while in agenesis of the facial nucleus the nerve fails 
to develop and consequently is not to be found. 

The facial nerve may be injured during childbirth due to the pressure of 
forceps, often causing a bilateral injury. Congenital maldevelopment of the 
facial nucleus and nerve is also met with but is usually associated with develop- 
mental disturbances in the sixth nerve or other congenital anomalies such as 
spina bifida, mental defects, etc. 

Before operating on facial paralyses, other than those in which it is certain 
that the nerve has been severed, every opportunity should be given to allow 
spontaneous regeneration to take place. Such delay is especially, indicated 
since end-to-end repair of the facial nerve is rarely possible and instead, some 
form of nerve crossing must be done. The operation of choice is obviously 


end-to-end suture — uniting the centra! end of the facial with the distal. This 
is possible in comparatively few cases. In others when both the central and 
distal ends can be identified and yet not brought in apposition a single nerve 
graft may be done, using a segment of one of the cutaneous nerves such as the 
radial or short saphenous. By careful suture and accurate apposition a single 
graft can be made to cover the entire cross area, thus insuring better down- 
growth than when a cable graft is used such as is required in larger nerves. 
Due to the anatomical arrangement of the facial canal there is little opportunity 
for unaided regeneration if scar and callus are present. Because of the rigid 
walls of the canal and the fact that the diameters of the canal and the nerve 
are nearly equal the smallest amount of scar or exudate is effective in blocking 
nerve regeneration or in causing sufficient pressure to produce interruption 
of nerve conductivity. 


Incision. — The incision to expose the facial nerve is made, beginning at the 
ventral margin of the mastoid about 3 cm. above the tip. It is carried 
directly downward for 6 to 8 cm. and then curved slightly forward in the 
fold of the skin usually found at this level. The posterior occipital vein is 
generally encountered just before it joins the temporal to form the external 
jugular. It is best to ligate the vein both proximally and distally and to cut 
between, since it usually crosses the wound and is in the way. 

Exposure of the Facial Nerve. — The deep fascia is cut in the same line as 
the superficial incision, care being taken to avoid opening the sheath of the 
parotid gland. The gland is freed by blunt dissection beginning dorsally and 
working forward, and retracted ventrally by a blunt hook. (See Fig. 79.) The 
tip of the mastoid ventrally may be chiselled off together with the muscular 
attachments of the sternocleidomastoid muscle if there is much scar and the 
nerve difficult to find, thus permitting easier access to the facial nerve at its 
exit just behind the styloid process. Unless the facial is difficult to find the 
mastoid is let alone. The digastric muscle is retracted down and backward; 
but should the muscle be unusually large and well developed a part of the 
muscle belly must be cut transversely so as to permit exposure of the nerve. 
Along the upper border of this muscle the posterior auricular artery will be 
found and should be ligated in order to secure a clear field. Generally the 
finger can identify the nerve at a depth of about 2 cm., or a blunt hook mav 
be inserted in the stylomastoid foramen and the nerve picked up as it makes its 



exit. If the paralysis is not complete, however, a small unipolar electrode will 
be found most valuable. The nerve should be exposed as high as possible. 

With the nerve still intact two fine silk sutures are passed just distal to 
the point at which the nerve is to be cut. These sutures should be placed cqui- 
distantly and the needles left on the sutures. The nerve is then cut clean 


Fig. 7q.— Spiii<if;id;il n 

rossing. Expo; 

across with a fine, thin blade. Sutures can be passed with greater ease before 
the nerve is cut — an important point to remember. The nerve and sutures 
are then covered with moist cotton to protect the nerve until the rest of the 
field is exposed. If the dissection has been properly done, 2^ to 3 cm. of the 
facial nerve may be exposed. After a mastoid operation with much scar 
tissue the exposure is more difficult and here it is best to cut off a little of 
the bone, making a subperiosteal dissection down to the nerve. 


Exposure of the Spinal Accessory Nerve.— The spinal accessory nerve 
passes dorsal to the facial nerve either in front or behind the internal jugular 
vein at the level of the transverse process of the atlas. The occipital artery 
will be met with running along the lower border of the digastric muscle. It 
should be identified and ligated. The transverse process of the atlas can readily 

be felt and the nerve identified upon it lying beneath a layer of deep fascia which 
encloses both the transverse process and the internal jugular vein and must 
be cut in order to expose the nerve. During this part of the operation the 
digastric muscle is retracted upward and the sternocleidomastoid muscle down- 
ward and out. exposing its medial or deep surface across which the spinal acces- 
sory nerve traverses the muscle at about the junction of the upper and middle 
thirds. (See Fig. 80.) The nerve may be identified in the wound by a unipolar 
electrode or by pinching and watching for elevation of the shoulder. 


Lying in front of the internal jugular and the transverse process of 
atlas, between the internal jugular and internal carotid, the hypoglossal 
vagus nerves may be felt. The carotid sheath is split to expose the hypoglo 
nerve at about the level of the occipital artery where it crosses the care 
Running along the outer border of the hypoglossal nerve is the descend 
hypoglossi. The descendens hypoglossi is dissected upward, free from 
inclusion within the sheath of the hypoglossal and cut as low as possible. 
central end of the descendens hypoglossi is then covered with a small cot 
pad and isolated from the rest of the field. 

The spinal accessory nerve is then freed and the point at which seci 
is to be done determined. The nerve should be cut low enough to per 
suture with the facial nerve without tension. The sutures which have aire 
been passed through the facial are now carried through the spinal accessory 
fore the nerve is cut just above the point chosen for section. The sutures 
then held out of the way and the spinal accessory nerve is cut. The central 
of the spinal accessory is then drawn over a small neatly folded cotton 
placed over the lower border of the digastric muscle. The pad tends to hold 
nerve in place during suture and prevents slipping thus avoiding frequ 
manipulation of the nerve. 

The sutures are now tied, using anatomical forceps. If the sutures h 
been accurately placed, and the proper amount of tension employed in tyi 
accurate apposition of the nerve ends is obtained. Unless the sutures are i 
with forceps this cannot be accomplished with thq,. same degree of accun 
The descendens hypoglossi is now sutured into the distal end of the sp 
accessory nerve. (See Fig. 81.) 

No protection is necessary for the suture line. Cargile membrane n 
not be used unless there is scar tissue. Ordinary cargile as has been indica 
is absorbed in two or three weeks and is, therefore, of little value. If prolon 
protection is desired Huberts alcoholized cargile membrane should be u: 
The wound should be dry and closed in two layers and the neck immobili 
for two weeks. For this purpose a Thomas collar may be used. 

Hypoglossofacial Suture.- The same incision, exposure and prcparatio 
the facial nerve is done as for the spinofacial suture with the exception that 
incision is carried somewhat farther forward in the fold of the neck. 

Exposure of the Hypoglossal Nerve. The digastric muscle is pu 
upward and the sternocleidomastoid outward. The 

I w 


of the wound and the hypoglossal nerve identified as it crosses over the external 
carotid artery and below the occipital. The nerve may be identified by an 
electrode or by pinching. The vagus may be distinguished by its position farther 
dorsal and its course directly downward behind the carotid. The hypoglossal 

Fii,. Si. — Spi in i facial nerve crossing. Trie central end 'if I be spinal accessory has been sutured 
Ii> the distal end of the facial. Tlie ilcst'ernlens livpiiirld-si has been separated from the hypo- 
glossal, cut and its central end sutured to tlie distal t ml of the spinal accessory. The insert shows 
the relation of the nerves after the suture. 

nerve curves slightly forward, its convexity downward, across the internal and 
external carotid arteries. The hypoglossal nerve is then exposed farther for- 
ward and the desoendens hypoglossi farther downward nearly to its union with 
the descendena ccrvicis. The dcsccndcns hypoglossi is separated from the 
hypoglossal nerve by careful, sharp dissection, along a line of separation which 
can usually be made out. Dissection of both the hypoglossal and descendens 



hypoglossi is carried high so as to free as much of the nerve as possible and avoid 
any angulation or kinking in the nerve after suture. 

After the hypoglossal nerve has been carefully exposed four sutures of fine 
silk are passed; two on either side immediately above and below the level at 
which the nerve is to be severed. The threads are left long and the needles 


attached. The sutures have been placed so as to allow a margin and the 
hypoglossal nerve is then cut between them. The central stump of the hypo- 
glossal is then carried over or beneath the digastric and sutured to the facial 
in the same manner as in spinofadal suture. (See Fig. 82.) 

The descendens hypoglossi is then sutured to the distal end of the hypo- 


glossal in like manner, using the sutures previously passed in the distal end of 
the hypoglossal. 


In facial nerve paralysis the paralyzed facial muscles should be supported 
mechanically and overstretching prevented the same as in any other nerve 
injury. Support of the facial muscles constitutes a very important part of the 
treatment and should be given both before and after operation. 

Fig. 83. — Appliance to prevent overstretching of facial muscles in facial paralysis. Two strips 
of adhesive connected with a spring metal head piece by a rubber band. The adhesive is attached 
to a small leather piece having a metal button. The rubber band connects this with a similar button 
on the head piece thus giving an elastic support for the facial muscles. 

Jaeger (19 18) has reported re-establishment of function of the facial 
muscles following mechanical treatment alone when a year of electricity and 
massage had failed to show any improvement. Mechanical support has also 
been used by Elsberg, Frazier and others. Some form of adhesive strapping 
is usually employed, the strapping being fastened to a fixed point in the tem- 
poral region. The author prefers, in place of a fixed apparatus, an elastic 
support. A small band may be worn around the head or a spring steel metal 
over the head similar to that worm by telephone operators. (See Fig. 83.) 
Two straps of adhesive or transparent sticking plaster may be fastened to the 
skin over the infra-orbital and infrabuccal muscle groups and then fastened to 
a small metal hook. This hook is then connected to the head piece by means 


of a rubber band thus giving an elastic support which prevents overstretching 
and yet permits free movement of the face. 


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fibres motrices. Bull, de 1'Acad. roy" de Belgique, 3 me. serie, v. 7: 1859, p. 415- 
GrAnt, W, W.: Traumatic facial paralysis; anastomosis of facial nerve to spinal accessory, 

and the peripheral end of accessory to the descenders hypoglossi, J. A. M. A., v. 55: 

iqiq, p. 1438. 
Halstead, A. F..: The surgical treatment of facial paralysis. Surg. Clin. Chicago, v. 2: 

191S, p. 327. 
Havre, van: Trois cas de lesions in t rape t reuses du facial suivis d'anastomose spinofaciale, 

J. de chir. et ann. Soc. beige de chir., v. 6: 1906, p. 194. 
Hunt, R.: Spinofacial anastomosis, with report of a successful case, Pan. Am. S. & M. J., 

v. 20: 1915, 7. 
Jaeger, C. H.: Treatment of facial paralysis. New York M. J., V. 109: 1919, p. 690. 
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Kknnedy, R.: On the restoration of co-ordinated movements after nerve crossing, with the 

interchange of function of the cerebral cortical centers, Roy. Soc. Proc, v. 67; rgoo, 

p. 431. (Abstract): Phil Trans., B, v. 194, 1901, pp. 127-162. 
Experiments on the restoration of paralyzed muscles by means of nerve anastomosis. 

Part 1, substitutes for the facial nerve. Phil. tr. Roy. Soc. London, Series B, v. k»j: 

ton. pp. 1)3-16.1. 
Kn.viNcms. B,: An investigation on the regeneration of nerves, Brit. M. J., v. 1: 109S, 


Knapp, P. C: Facial paralysis; nerve anastomosis, Boston M. & S. J., v. 155: 1916, p. 644. 
Korte: Vorstellung eines Falies von Nervenpfropfung des Nervus facialis auf den Nervus 

hypoglossus, Freie Vereinigung der Chirurgen Berlins, 128 Sitzung am 8 Dez., 1902; 

Deutsch. med. Wchnschr., no. 17, 1903. 
Leiner, J. H.: Study of etiological factors bearing on the therapeutics of Bell's facial palsy 

Med. Rec, v. 95: 1919, p. 319. 
Manasse, P.: Ueber Vereinigung des N. facialis mit dem N. accessorius durch die Nerven- 
pfropfung (Greffe nerveuse), An % h. f. klin. Chir., Berlin, v. 62: 1900, p. 805. 
Moran, T. J.: Operative treatment of traumatic paralysis of the sixth and seventh nerves 

with functional recovery, Penn. M. J., v. 21: 1918, p. 568. 
Moure, E. J.: Trois cas de paralysies faciales traumatiques operees, (abstr.) in J. de Med. 

de Bordeaux, v. 87: 191 5-16, p. 179. 
Paralysie faciale de la guerre, Presse med., v. 24: 19 16, p. 161. 
Murphy, J. B.: Facial nerve paralysis . . . spinofacial nerve anastomosis; 2 cases, Surg. 

Clin. Chicago, v. 3: No. 4, 1914, pp. 745, 751. 
Oppenheim, H.: Demonstration eines Falies von Facialislahmung mit 8 Opera tionsver- 

suchen, Berl. klin. Wchnschr., v. 50: 1913, p. 1585. 
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Ment. Dis., v. 36: 1909, p. 1. 
Perret, C. A.: Nerve anastomosis for facial paralysis, Schweiz., Arch. f. 

Neurol, in Psychiat., v. 5: 1919, p. 141; abstr. J. A. M. A., v. 74: Jan. 24, 1920, p. 291. 
Ransohoff, J.: Traumatic facial paralysis, Ann. Surg., v. 70: 1919, p. 150. 
Sargent, P.: Four cases of facial paralysis treated by hypoglossofacial anastomosis, Proc. 

Roy. Soc. Med., v. 5: (Neurol. Sect.), 1911-1912, p. 69. 
Sherren, J.: Some points in the surgery of the peripheral nerves, Edinburgh M. J., v. 20: 

iqo6, p. 297. 
Stevens, R. H.: Note on a case of anastomosis between facial and hypoglossal nerves, J. 

Roy. Army Med. Corps, v. 28: 191 7, p. 724. 
Taylor, A. S. and Clark, P. L.: Results of faciohypoglossal nerve anastomosis, J. A. M. A., 

v. 46: 1906, p. 856. 
Tubby, A. H.: A case of faciohypoglossal anastomosis for postoperative paralysis; nearly 

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1009, (Clin. Sect.), p. 145. 
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A., v. 62: 1914, p. 612. 



Embryology of the Brachial Plexus.- The morphological segmental 
Arrangement, such as is found in the trunk musculature, is replaced in the ex- 
■tremities by a pleurisegmentul arrangement, so that each muscle is innervated 
■ by nerves from several segments, thus necessitating the development of plexuses. 
| Such a pleurisegmental innervation obtains not alone for each muscle, but the 
individual muscle fiber may possess a bisegmental or trisegmental innervation 
as Agduhr's (1916-1919) experiments in successive motor end plate degenera- 
tions have shown. 

The formation of the limb plexuses and the distribution of their branches 
may be best understood by considering the development of the extremities, fur 
in i he development is found the explanation of the division of the spinal nerves 
into ventral and dorsal branches and, in general, their ultimate muscular 

In the human embryo the limb buds appear at about the third week. The 
cephalud pair lie opposite the lower four cervical and first thoracic vertebrae and 
the caudad pair opposite the lower lumbar and the first sacral. The mesoder- 
mal structures Of the limb are laid down in the limb bud and do not follow the 
myotomk segmentation. The myotomes are present at the axio-appendicular 
junction, but do not enter into the formation of the limb buds. The limb 
bud is developed from the somatopleure by proliferation of the cells lining 
the avloni ventrolateral to the myotomes, the latter, according to Bardeen 
tioo; 1 . being separated from the limb bud by a limiting membrane. Lewis 
1 loo- 1 was unable to determine whether or not some cells from the myotome- 
migrate into the limit bud. though no evidence of such migration was noted by 
him in h\> careful studies of the development of the human arm. The pectoral 
fin musculature in teleosts. Harrison ( 1895) found to arise soley from the si 
tup leu re without any contribution from the myotomes, and similar cottclu 

H\ mi > 1 [S9SI In studing the development of the limb muscles 
livision of the spinal nerves enter ml 


the innervation of the limb bud approximately five for the upper extremity and 
seven for the lower, thus indicating that the limb buds are the outgrowth from 
a number of segments and are more closely associated with the ventral than 
with the dorsal surface of the body, since the ventral and not the dorsal primary 


s of the spinal r 

s are associated with them. 

The limb buds at first 
present a cephalad or pie- 
axial border and a caudad 

or post axial border, a 
ventral surface and a dor- 
sal surface. The ventral 
surface corresponds to the 
flexor, the dorsal to the 
extensor surface of the 
primitive limb. The ceph- 
alad or pre-axial border 
corresponds to the line of 
radius and thumb, tibia 
and great toe, the caudad 
or postaxial to the line of 
the ulna and fifth finger, 
fibula and fifth toe. 

Earlyin its development 
the musculature of the limb bud presents two 

•■ relative frequency of n 
nd upper extremity. 

layers, separated by 
the skeletal anlagc of the humerus into ventral and dorsal premuscle masses. 
The ventral primary divisions of the spinal nerves which grow into the limb 
bud also separate into secondary ventral and dorsal divisions, to supply 
the ventral and dorsal layers of the limb. These secondary divisions 
correspond to the ventral and dorsal branches which form the limb plexus. 
Later the ventral and dorsal branches in the limb bud unite with other 
branches— //re ventral with the ventral, the dorsal with the dorsal thus con- 
stituting the ventral and dorsal divisions of the plexus. The ventral branches 
are distributed to the ventral musculature, the dorsal to the dorsal musculature. 
However, with growth of the limb buds, rotation and torsion of the humerus 
occurs, so that the pre-axial or cephalad bonier of the upper extremity is turned 
laterally away from its cephalic position, thus rotating the structures on the 
primitive ventral surface anteriorly and those on the primitive dorsal surface 


posteriorly. Consequently the anterior or ventral surface of the upper extrem- 
ity and shoulder girdle represent the old ventral musculature and, therefore, 
should be supplied by the branches of the ventral divisions; whereas the poster- 
ior part of the shoulder girdle and upper extremity represent the primitive dorsal 
musculature and should be innervated by the dorsal divisions. This arrange- 
ment obtains. The dorsal musculature is supplied through the subscapular 
circumflex and musculospiral nerves, made up of dorsal divisions; the ventral 
musculature through the anterior thoracic nerves, median, ulnar and musculo- 
cutaneous nerves from the ventral divisions. 

Certain muscles in the primitive dorsal or ventral musculature form by 
fusion with either the dorsal or ventral musculature composite muscles and, 
therefore, are supplied by more than one nerve. If the fusion has been of 
different muscle masses in the primitive ventral musculature, each nerve supply- 
ing such a muscle arises from ventral branches; and if of dorsal musculature, 
from dorsal branches. For example, the pectoralis major is supplied by the 
external and internal anterior thoracic nerves and the flexor profundus digi- 
torura by the median and ulnar nerves. However, such muscles as the brach- 
ialis in the upper extremity, biceps in the lower extremity represent a fusion 
along the prc-axial or post-axial border of the primitive musculature derived 
from both ventral and dorsal layers, and consequently are supplied by two 
sets of nerves, one arising from ventral and the other from dorsal branches. 
This is seen in the supply of the brachialis in which the musculospiral nerve 
(dorsal divisions) and the musculocutaneous (ventral divisions) both participate. 

Anatomical Considerations of the Brachial Plexus.— Considerable variance 
in the number of spinal segments which enter into the formation of the brachial 
plexus exists and variation in the particular segmental supply of the muscles is 
often found, which has led to no little perplexity in more careful attempts to 
determine the exact location of certain lesions by means of the more usual 
anatomical segmental distribution. Accurate localization of paralysis of the 
brachial plexus is frequently difficult due to the complexity of the component 
libers of the nerve roots and to the presence of numerous branches close together 
which may be implicated at one point and the main nerve roots at another. 
Almost any combination may exist and only by clear and concise anatomical 
interpretation may the level of the lesion be placed. 

Anatomically there are two main types of plexuses — prefixed and post- 
fixed — the former having a high cervical origin and the latter a low cervical 



the plexus instead of just a small twig of communication. There is less of 
the first thoracic root with no branch of communication from the second 
thoracic. In the postfixed there is no branch from the fourth cervical root. 
The first thoracic contributes largely to the formation of the inner corti and 
a branch from the second thoracic always joins the plexus. Thus, there is 

Fig. 84. — Prefixed type of plexus. The connective tissue sheaths of llie nerves arc all dissected 
off, and thus the posterior and outer cords arc seen resolved into their component parts. The branch 
to the outer cord from 5-6C has been divided in order to show the origin of the nerve to the coraco- 
bracbialis; the branch from &C to the inner cord has also been similarly divided to show the posterior 
branch of iD. Note the large size of the outer head of the ulnar, piercing directly through the 
inner head of the median. Note also that the inner head of the median is given off from the lower 
and anterior portion of the inner cord, and passes in front nf the ulnar, which is given off from the 
posterior bundles of the inner cord. (Harris, Jour. Anat. A Physiol.) 

more or less shifting cephakid or caudad of approximately one segment in the 

origin of the plexus — a condition analogous to that found by Eisler (1802) in the 

lumbar plexus. This variation in the segmental contribution to the plexus 

may be explained by the fact that the nerves and the particular segments which 

contribute to the innervation of the limb bud is determined by the width of the 

bud and its relation to the neural axis. The presence of the developing limb 


Prefixed Type of Plexus 

Supraspinal us 


lirachialis anticus 

Supinator longus 

Supinator brevis 

Pronator radii teres 

Extensor carpi radialis longior 

Extensor carpi radialis brevier 

Pectoral is major clavicular 

Serratus magnus 

Teres major 
( 'uracobrachialis 
I'irtoralis major (sternal) 
l,atissimu5 dorai 
Extensor carpi ulnaris 
Flexor carpi radialis 

I'ectoralis minor 
Flexor carpi ulnaris 
Extensor communis digitorum 
Extensor ossis metacarpi pollicis 
Extensor primi internodii pollicis 

Extensor secundi internodii pollicis 

Extensor indicis 

Extensor minimi digit! 

Pronator quadratus 

Pal maris longus 

Flexor sublimis digitorum 

Flexor longus pollicis 

Flexor profundus diKittirum 

Thenar muscles 
Hypothenar muscles 

Postfixf.d Type of Plexus 



5-6 C. Biceps 

Brachialis an tic us 
Supinator longus 
Supinator brevis 
Pronator radii teres 
Extensor carpi radialis longior 
Extensor carpi radialis brevior 
Pectoralis major (clavicular) 

5-6—7 C. Subscapularis 

Serratus magnus 

6—7 C. Triceps 

Teres major 

6-7-8 C. Pectoralis major (sternal) 

Latissimus dorsi 

7—8 C« Pectoralis minor 

Extensor carpi ulnaris 
Flexor carpi radialis 
Extensor communis digitorum 

8 C.-i D. Flexor carpi ulnaris 

Extensor ossis metacarpi pollicis 

Extensor primi intemodii pollicis 

Extensor secundi intemodii pollicis 

Extensor indicis 

Extensor minimi digiti 

Pronator quadratus 

P^lmaris longus 

Flexor sublimis digitorum 

Flexor longus pollicis 

Flexor profundus digitorum 

1-2 D. Thenar muscles 

Hypo thenar muxlo 

infraspinatii, the subclavian nerve to the subclavius muscle and those to the 
scalenii. All other branches arc infraclavicular. The uppermost of these are 
the anterior thoracic and subscapular nerves, which arise from the secondary 
cords just prior to their ultimate division to form the nerves of the extremity. 


As there are three cords to the brachial plexus, so there are three main 
types of paralysis which may result from injury to the brachial plexus above the 
clavicle. They are the upper cervical, or Duchenne-Erb, the middle, and the 
lower or Duchenne-Aran. These are the three classical types, but injuries 
to the roots of the plexus may occur in almost any combination. The upper 
cervical is the more common, due perhaps to the greater length and exposure of 
the lifth and sixth cervical nerve roots. 

It follows that in injuries to the brachial plexus above the clavicle, paraly- 
sis is looked for in some of the muscles of the shoulder girdle, particularly the 
rhombodeii, levator angulii scapula?, scrratus magnus, supraspinatus, and 
infraspinatus, though some of these may escape depending upon the exact 
location of the lesion; while in injuries below the clavicle, these muscles of the 
scapula are not involved. 

It is important to localize plexus lesions with precision, and to rule out 
injury affecting one or more segments of the spinal cord, especially such as 
involve the ventral horns. It will be recalled that spinal nerves divide almost 
immediately after their formation into a primary dorsal and primary ventral 
division; the former supplies, besides the dorsal axial musculature, the skin 
over the dorsum in a region bounded laterally by a line running from the mid- 
parietal region to the mastoid, acromion, trochanter and coccyx. From this 
distribution of the sensory branches of the dorsal primary divisions, it follows 
that if a lesion lies immediately outside the spinal cord there would be, as well 
as the other signs of injury, an area of anesthesia to all forms of sensation over 
the region of the back supplied by the primary dorsal divisions, which would not 
be found if the lesion were distal to the primary dorsal division of the spinal 
nerve. Division of the nerve takes place in or close to the intervertebral 
foramina. On the other hand, if the lesion in the nerve is at any point distal 
to the dorsal primary division, the dorsal division escapes and no sensory 
changes are found in the area on the dorsum as above described. In making 
this differential, we must rely upon sensory rather than motor changes for the 
axial musculature has lost its segmental character as a result of a fusion into a 
common muscular mass having a common motor supply, and hence isolated seg- 
mental paralysis is rarely to be observed. On the other hand, if the lesion be in 
the ventral gray column, obviously no sensory loss will be found in the distribu- 
tion of cither the ventral or the dorsal divisions. It must also be remembered 
that in the formation of the limb plexus certain nerves have lost their primary 


sory supply on the dorsum. This loss usually occurs in the nerves which lie in 
the central portion of the plexus and supply the most distal portion of the 
extremity; these are the seventh and eighth cervical nerves in the brachial 
plexus and the fourth and fifth lumbar in the lumbosacral plexus. 

If these anatomical considerations be remembered, more accurate diagnosis 
may be made in plexus lesions, particularly if the individual action of the 
muscles of the shoulder girdle be studied. Unless correct interpretation of the 
movements is made finer localization is not possible. However, the individual 
action of these muscles is difficult to evaluate since they form a synergic group 
having a wide origin and capable of independent contraction in different parts 
of the muscle, each of which may serve different or even opposed actions. In 
order that their action may be better understood it might be well to review 
here the physiological mechanism and action of the more important shoulder 
girdle muscles which serve in elevation of the humerus. The movements of 
the muscles in the arm, forearm and hand are relatively simple and need not be 
given here. 

Mechanism of Shoulder Girdle Movements. — The generally accepted 
view that in raising the humerus to a straight angle the deltoid elevates the 
arm approximately to a right angle, after which the deltoid no longer acts and 
elevation is completed by scapular rotation, is not supported. It has been 
found that the deltoid alone is unable to raise the humerus beyond 6o° and that 
elevation from this to approximately 115 involves scapular rotation, after 
which the deltoid again becomes active and completes the elevation. (See 
Fig. 86 and Figs. 87.) 

If the arm is considered in its position in different stages of elevation, it will 
be seen that the origin and insertion of the deltoid are placed so that it may serve 
this dual function of abductor and adductor. Two muscles whose action in 
elevation has been ignored may serve as supplementary factors of no small 
importance in the accomplishment of the final stage of elevation. They are 
the clavicular head of the pectoralis major and the coracobrachialis muscles. 
These muscles are brought into play particularly when great force in elevation 
is demanded, or when there is some impairment in the normal function of 
the deltoid or of the muscles which fix and rotate the scapula. Normally 
this function of the clavicular head of the pectoralis major may be brought out 
by forcible resistance to elevation or by sudden attempts to lower the arm 
from elevation. The clavicular portion of the pectoralis major will be seen to 
take active part in forcible elevation above 115° or in efforts to oppose lowering 


the elevated arm to 115. The clavicular portion of the pectoralis major serves 
a function similar to that of the clavicular portion of the deltoid. 

Fig. So.— Tracings of the scapula and humerus showing their relation in elevation of the 
humerus- It will lie noted that the greatest scapular rotation takes place between the 60th and the 
1 1 5th degrees of elevation of the humerus. (S too key. Archiv. Neur. Psych., 1020.) 

In this connection it is interesting to note that phylogenetically the clav- 
icular head of the pectoralis major h present only as such in the higher forms 
particularly the chimpanzee and the gibbon, while in all other primates, as well 
as the lower mammals, it is wanting. In them the pectoralis major arises 


forms in which there is no clavicular head of the pectoralis major, the c 
lar portion of the deltoid extends medially upon the clavicle up to the o 
the sternocleidomastoid. The clavicular portion of the pectoralis 
may be considered as a migration of the innermost muscular fibers of tl 
icular head of the deltoid. This view is perhaps further sustained by th 
supply of the clavicular portion of the pectoralis major which occasioi 
supplied by a twig from the circumflex, thus having the same nerve su] 
the deltoid. In the embryological development of the pectoralis ma 
sternal and clavicular portions are distinct and separated by a consic 

TuTM- «^ l) 

T»T»L I 

Fig. 87. — Schematic drawing to show relation of the scapula to the humerus in elevatic 
humerus. Dotted lines indicate scapular rotation during the various phases of elevation 
elevation of the humerus to 6o° the scapula rotates 5 ; with elevation of the humerus fror 
115 the scapula rotates 35 , and with elevation from 115 to 180 scapula rotation is ic 
major part of elevation of the humerus in this last phase is done by the deltoid. (Stookey, 
Neurol. & Psych., 1920.) 

It is not surprising, but rather to be expected, that the clavicuh 
of the pectoralis major should resume its former association and along w 
clavicular head of the deltoid serve in part, at least, a like function, n 
as an elevator of the humerus from above 115°. 

Thus shoulder girdle movements may be extremely misleading an 
localizations reached unless an accurate analysis is made. 


As has already been mentioned there are in general three tvn^ 
of the brachial plexus: the upper radicular, m^ 1 - 11 


The upper radicular or Duchenne-Erb type involves the fifth and sixth 
cervical roots, the lesion being more often at the junction of these two and in- 
cluding the suprascapular nerve at ils origin, whereas if the lesion is closer to 
the exit of the roots from the vertebral canal, the dorsalis scapula; and posterior 
thoracic nerves may be involved. Thus, if the lesion is near the exit of the 
nerve roots from the intervertebral foramina the rhombodeii, levator scapula?, 
and the major portion of the serratus magnus are paralyzed whereas, if the 
injury is more distal, these muscles may escape and the axio-appendicular 
muscles be implicated— the supraspinal us and infraspinatus, teres minor and 
the deltoid. The muscles involved in the arm are the biceps, brachialis, and 
the supinator longus; those in the forearm are the pronator teres, flexor carpi 
radialis, palmaris longus and the supinator brevis. This forearm group is 
generally incompletely paralyzed due to the fact that some of their motor 
supply is received from lower segments. Thus the deformity in injury of the 
fifth and sixth cervical roots may be extensive, not only in its distribution, but 
in its motor effect, particularly if the lesion be near the vertebral canal so 
as to include the posterior thoracic and dorsalis scapula? nerves. If the shoulder 
girdle muscles are involved, the scapula is winged, and the inferior angle 
rotated so that it looks toward its fellow of the opposite side. The scapula? 
cannot be approximated and rotation necessary for elevation of the arm is lost. 
With time the scapular deformity becomes accentuated, the acromion is bent 
downward and forward and may hook in front of the head of the humerus if the 
latter is subluxated. Perhaps this deformity is due to the fact that this bone 
does not meet the resistance of the humerus which normally is present during 
ils various phases of movement. Since the scapula can not be fixed the 
deltoid does not have a fixed point of action, a consideration which must be 
borne in mind, and the scapula manually supported when the deltoid is being 
re-educated in the early stages of recovery. It will be recalled that by develop- 
ment of the serratus magnus and trapezius the movements of the scapula may 
be made to compensate and take on, to a considerable degree, the function of 
elevation of the arm. Hence, in injuries involving both the serratus magnus, 
rhombodeii and levator scapulas, as well as the deltoid and supraspinatus, the 


partially performed since the internal rotators are unopposed in their ac 
and are already in a state of contraction. The forearm is held semi-exten 
and in pronation with inability to flex it due to paralysis of the biceps, brach 
and supinator longus. The palm of the hand faces backward due to t 
inward rotation of the extremity and extreme pronation. The grip of 
hand is fairly good. 

Fig. 88. 

Fig. 8q. 

Fig. 88. — Adjustable abduction splint with adjustable forearm piece for paralysis of the 
cord of the brachial plexus. Tho arm is held in abduction and external rotation with the 
in supination. By altering the pin and lever, the arm can be held at any desired angle of abdu< 
The forearm piece may also be adjusted by a screw lock to various degrees of flexioq. The i 
is made of aluminum and lined with felt. (Stookey, Surg., Gyn. and Obst., Nov., 1918.) 

Fig. 89. — Abduction splint for infants. The splint consists of a padded aluminum pie< 
tending from the hip to the axilla, elbow and hand, with cross pieces to which tapes are fast 
The angle of abduction may be altered by bending the metal at the axilla. (Stookey, Surg. 
N. Am., 1Q21.) 

The mechanical treatment of this deformity requires that two disl 
postures be obtained: first, abduction to relax the deltoid and supraspin; 
second, the one most often overlooked, external rotation in order to overo 
the powerful contraction of the internal rotators, particularly the pecto 
major, the latissimus dorsi and subscapularis. In old and neglected c 
these muscles are contracted, preventing both elevation and external rotn 
of the arm, and require tenotomy in order that the arm may be raised 
placed in external rotation. The arm should be held in abduction «*' 
70 to 80 degrees, and in the midcoronal plane 

<} cr* 

■ piaster and aiterwards 

u qart removed so that 

Tbe arm piece b 


t ii i gutter * line. and the 

iv .*: made very hard and 

■tot the metal sptints 

r and da out need any 

- c siytuai-r oo$je and die ieitoid. Tbe 
- . ,^ .^i-^-^jj^ ^«p«iaie ra«»e ijom the sereBth 

, v rpurairtt in the sheath of the 
. ^j?*apwtans. tews- major are par- 
es mbm (■■■& trum die sixth 
Erwl SUjcnt ability to 
-civr eke <3Wia ■* r J* *^t also receive 
'" - 
:ins iajury is amilar tu that 
, gakflri ander the treat- 


t involves the last cervical 


ulnar side of the forearm, and to the intrinsic muscles of the hand, with 
exception that occasionally the abductor pollicus and the opponens pollicis 
not included, since these muscles may receive some fibers from the fifth 
sixth cervical roots. It is noteworthy that injuries which involve the fifth 
sixth cervical nerves rarely cause paralysis of the opponens, presumably supp 
by the fifth and sixth cervical segments. In only one instance have I seen 
opponens escape in lower radicular lesions, so that it would seem that perl 
the opponens only occasionally receives fibers from the fifth and sixth cerv 

In the forearm the flexor carpi ulnaris, flexor profundus and flexor digi 
umi sublimis, as well as the flexor pollicis longus are paralyzed. As woul< 
expected the resulting deformity is in the hand and on the ulnar or post-a 
border of the forearm. The hand appears as a flattened Simian hand, res 
bling closely that found in combined injuries of the median and ulnar ner 
Adduction of the hand is lost, flexion at the wrist is impaired, but can 
accomplished by the flexor carpi radialis, while flexion of the fingers, abduc 
of the fifth finger, and opponens action, as well as extension of the distal 
phalanges of the fingers, are impossible. 

If this deformity is not adequately treated mechanically, contractures 
likely to occur, and in neglected cases fixed subluxations of the interphalan 
joints may be found. For the mechanical treatment, a straight splint ^ 
grooves for each finger permitting movements at the metacarpophalangeal 
interphalangeal joints offers the most satisfactory treatment. The splint she 
be made of the lightest possible material. (See Figs. 138-139.) The joints of 
fingers should be put through their range of motion daily in order to a^ 
contractures about the joint capsules. One of the most satisfactory form 
exercise for older children and adults is the Zander finger and wrist machi 
By this means the muscles and joints may be put through the greater par 
their normal contraction and range of motion. 

Obstetrical Paralysis 

Rupture of the brachial plexus occurs not only during childbirth bu 
adult life as well. In both the injury is the result of mechanical forces simil; 
applied, showing similar paralyses and similar pathology in the nerve trunl 
the plexus. 

In lesions so readily demonstrable as th" 


changes encountered; some claiming that the deformity is primarily of bony 
origin, or due to a lesion in the capsule of the shoulder joint; and others, that 
the injury is primarily to the nerve roots which form the brachial plexus. As a 
result of these different opinions an attitude of laissez faire has been frequently 
adopted and many times nothing is done by way of treatment. Generally the 
mother is told that the paralysis will disappear in time. No doubt a few of the 
Lesser injuries recover untreated, but the more severe do not. 

Brachial plexus injuries, due to pulling apart of the nerve trunks, differ from 
other nerve injuries not only in etiology and pathology but also in the results 
obtained by their surgical treatment. This difference is due to the fact that 
the nerve fibers and funiculi are torn apart and not simply crushed or cut in one 
place. When the plexus has been overstretched the funiculi break and this 
break may occur at any point from the origin of the roots from the spinal 
cord to the most distal point of the injury. Hence some funiculi may be 
evulsed from the spinal cord and others torn apart within the nerve trunk. 
Consequently, at any cross section within the nerve scar the injury is irregular 
and incomplete. Such an anatomical arrangement makes it difficult to deter- 
mine at what level excision of the scar can be made so as to obtain normal 
funiculi. The different funiculi may be interrupted in more than one place, and 
this not recognized at the area at which suture is done. Funiculi evulsed from 
the spinal cord cannot be repaired; those torn only more distally may be 
successfully sutured. 

Historical. — The early writers considered paralysis at birth to be due to 
fracture or dislocations of the humerus. Duchenne (1867) was the first to 
appreciate the fact that the essential factor in these injuries was a nerve lesion 
and not a fracture as was held at that time. He proposed for these paralyses 
the name of "obstetrical palsy," thus to stress the importance of the nerve 
injury, and divided these into two types: those due to compression and those 
due to laceration. 

Following the work of Duchenne numerous cases were reported, notably 
by Erb (1S74) who presented one case of obstetrical paralysis and subsequently 
published a series of identical paralyses in adults. Erb considered paralysis 
at childbirth to be due to compression of the fifth and sixth cervical roots at 
the outer border of the sternocleidomastoid muscle and at a point 2 cm. 
above the clavicle. This point has subsequently been called Erb's point. 
However, in accounting for the etiology of the one case of birth palsy which 


in the axilla during the process of version and extraction. This view was also 
held by Seeligmiiller (1877) and others. As Taylor (1905) pointed out, Erb's 
explanation is inconsistent both as to the location of the injury and the effect of 
compression in the axilla which he believed essential for the production of this 
type of paralysis. The distribution of the paralysis found in these cases could 
not be accounted for by pressure on the nerves in the axilla. 


Fie. 90. — Schematic drawing showing the anatomical basis of Hornet's syndrome. The 
preganglionic sympathetic libers, a, arise from cells in the lateral column of ihe ventral gray of either 
the eighth cervical or first thoracic segments and leave the spinal nerves via the white ramus com- 
municans to enter the cervical sympathetic. Fur these fiber:- to be involved [lie injury In ihe spinal 
nerve must be central to b, tints vrry clone In I he. vertebral foramen. 

Thorburn (1886) considered pressure of the clavicle on the plexus as a 
possible etiological factor. Experimentally, neither Taylor nor Sever were 
able to produce the lesion by this mechanism. 

A few years after Duchcnne's report on obstetrical palsies Seeligmuller 
(1877) described a similar lesion involving the lower roots of the brachial 
plexus which involved fibers of the cervical sympathetic and showed among its 
signs, the syndrome of Horner (1869), that is, narrowing of the palpebral fissure 
ptosis and miosis of the pupil— the result of paralysis of the dilator of the iris; 
sinking in of the eyeball — enophthalmus — due to paralysis of the intra-orbital 


muscle of Mttller. Whenever this syndrome is present in brachial plexus 
injuries it is indicative of a lesion involving the eighth cervical or first thoracic 
root and is, therefore, an aid in localization. Such involvement of the sympa- 
thetic fibers indicates injury to the plexus very close to the vertebral foramina, 
since the fibers from the ciliospinal center leave the spinal cord through the 
eighth cervical or first thoracic roots and reach the sympathetic through the 
white rami communicantes which comes off the nerve at the beginning of the 
ventral primary division. If either of these nerve roots are injured distal to 
the emergence of these fibers the ciliospinal path is not disturbed. (See Fig. 00.) 
Etiology. — In the succeeding years following Duchenne's observations 
many reports of obstetrical paralysis were made, but it was not until the experi- 
mental work of Fieux (1897) and of Clark, Taylor and Prout (1905) that a 
definite etiological conception of their formation was given. Taylor 
was the first to show experimentally lhafoYerstretching of the nerve roots 
with laceration was the etiological factor in the causation of obstetrical palsies. 
Previously Aniens (1899), Carter (1892) had proposed this theory as a clinical 
explanation of this condition. However, to the thorough work of Taylor 
credit is due for bringing to the attention of the surgeon the need of a definite 
appreciation of the pathological changes resulting from laceration of the 
nerve roots in obstetrical paralysis and for outlining a rational operative and 
mechanical treatment of them. Taylor's excellent studies have shown that 
. birth palsies are the result of overstretching and rupture of the component 
cervical nerve roots of the brachial plexus whenever the head and shoulders 
are forced apart irrespective of the nature of the presentation. 

J. J. Thomas and Sever (1916) after an exhaustive study of obstetrical 
paralysis concluded that this lesion is due to trauma of the brachial plexus 

MfcTlETt'. RUn 


presentations, sixty-six times in breech, and in one hundred and eighty-five 
the presentation was not recorded. In four hundred and nineteen the labor was 
long and laborious; in three hundred and seventeen forceps were used, and in 
thirty-two labor was apparently normal. The Duchenne-Erb type was found in 
four hundred, and in eighty-four the lower roots were involved as well. In nine 
cases both arms were affected, and in each the lesion involved the component roots 
of the brachial plexus from the fifth cervical to the first thoracic, inclusive. 

Rupture of the nerve roots occurs first in those roots under the greatest 
stress; the stress is greatest on the fifth, sixth, seventh and eighth cervical in 
the order named. The fifth cervical arises highest from the cervical spine and, 
therefore, is stretched the most when the head and shoulder are forced apart and 
hence is the first to give away. 

Location of the Injury to the Nerve Roots. — The most frequent location 
of injury to the brachial plexus in obstetrical palsy is at the junction of the fifth 
and sixth cervical roots at about the point at which the suprascapular nerve 
is given off. In infants the fifth and sixth cervical roots extend approximately 
2 to 3J4 cm - from the intervertebral foramina and the combined primary trunk 
is approximately i cm. long. 

Clark, Taylor and Prout found in twenty experiments in which the head 
and shoulder were forced apart that the lesion was as follows: 

Fifth Nerve Sixth Nerve 

Above junction. i6-3o% 17-85% 

At junction 2-10% *-i°% 

Below junction , 1-10% 1- 5 % 

"In seven experiments (35%) the sixth cervical root was evulsed from the 
spinal cord including the root ganglion." 

Secondary Injury to the Spinal Cord.- Boyer (191 1) made a complete 
neuropathological examination of a case of birth palsy in which the seventh 

™nriral milt wae runt nrfrl in the- nnct^rinr r*ian«T» „f tti» nArlr anH a ten 


Changes were also noted in the meninges in the region of the fifth, sixth, 
seventh cervical and first thoracic segments. At these levels the meninges 
were dense, tough and thickened, and adherent to the cord on the right side 

Fig. o*. — Transverse section through cords of left brachial plexus. Microphotograph of Weigert 
Pal stained section. (Boyer, Proc. Roy. Soc. of Medicine.) 

FlC. 9*0. — Transverse section through cords of right brachial plexus. This is the side of 
the paralysis. Microphotograph of Weigert-Pal stained section, (boyer, Proc. Roy. Soc. of 

though extending somewhat also onto the left. Likewise the area of greatest 
thickening was at the level of the seventh cervical 'segment and diminished 
both above and below this point. The ventral roots from these segments were 
reduced to fibrous cords and the brachial plexus was smaller on the affected 
side and the nerve trunks were bound down by tough fibrous tissues. (See 
Fig. 92-026). 


This case is specially noteworthy because of rupture of the plexus in the 
posterior triangle of the neck, on account of the damage done to the roots arising 
from the cord as well as the injury to the cord itself. Thus if the plexus had 
been operated, no improvement would have been possible. It is probable that 
injuries of this type are more common and unrecognized, thus accounting for 
some of the unfavorable results seen in obstetrical paralyses. 

Somewhat similar cord changes were described by Philippe and Cestan 
(iooo) in which more dorsal roots were involved than ventral with extensive 
spinal cord changes. Burr(iSo2),Xeurath (igoi)are also of the opinion that in- 
juries to the cord in birth palsies are more common than is generally credited. A 
careful search should be made for spinal symptoms. I have seen evidence of 

—Key to Pigs. i)i and 920. 

spinal cord involvement in two patients in one ten and in the other nineteen 
years after birth. In both a small triangle of anesthesia could be outlined 
corresponding to the distribution of the fifth and sixth cervical nerves on the 
back, within the area included between the parieto-mastoid-trochanter coccygeal 
lines. Anesthesia in this area at once places the lesion central to the primary 
dorsal divisions of the fifth and sixth cervical nerves. (Seep. 228.) The knee, 
ankle and hamstring jerks were increased, and the abdominal reflexes diminished 
on the side of the injury. Babinski was present in only one of the patients. 
No evidence of spinothalamic or dorsal column changes were made out. 

Pathology. As has already been indicated the nature of the lesion in 
laceration of the brachial plexus differs materially from that seen in incised or 
gunshot wounds, in that in the former the extent of the lesion is irregular, the 
funiculi are pulled apart at different levels, some ruptured within the central 


Fig. 9J .—Schematic drawing of the brachial plexus seen from hehind. The spinous processes 
and lamina have been removed and the dura opened, exposing ihe spinal cord and the nerve roofs. 
The lines within the nerve roots and the trunks of the plexus represent funiculi, the dotted line the 

Fir.. 04— Schematic drawing; o 

the mechanism of brachial plexus in 

lo the opposite side, thus increasi 
shoulder is indicated by dotted line 
and sixth at their junction. N'ote 
torn at x both central and distal. Ii 

c brachial plevus seen from behind as in Fig. oi 
es at birth. The right shoulder is lowered and C 
the acromiomastoid distance. The former pu< 
The liflh. sixth and seventh cervical roots are 1 

■ ends prewired for 

and si 


Considered from a histological standpoint these pathological differences 
between lacerated and incised wounds of the nerve trunk limit the possibilities 
of successful surgical interference. When the funiculi are torn, rupture of the 
neuraxes, blood vessels and the connective tissue sheath takes place, within the 
nerve trunk so that small multiple hemorrhages occur in and around the 
funiculi which lead to scar formation and eventually to contraction about the 
funiculi or interposition of scar between the ends of the funiculi, thus preventing 
regeneration. Judging from the appearance of the cross section at any given 

Fig. 95. — Schematic drawing of the brachial plexus seen from behind as in Fig. 94. The in- 
crease in the acromio mastoid distance is greater and the injury to the plexus more extensive. The 
fifth, sixth, and seventh roots are completely evulsed from the spinal cord, the eighth is torn within 
the intervertebral foramen and in the first thoracic the continuity of the sheath is maintained while 
the funiculi within are torn. In this case complete paralysis of the extremity would occur and 
Horner's syndrome would be found. Insert shows evulsion of the ventral and dorsal roots from the 
cord, with the axon of the motor ventral gray cell and the central process of the spinal ganglion 


level it is not possible to determine whether the funiculi seen are intact centrally 
or evulsed from the cord or, perhaps, even interrupted peripherally. In severe 
forms the deep cervical fascia is also torn and the fascia may become adherent 
to the nerve roots or interposed between the nerve cords. 

If wide excision is made in an attempt to insure sound funiculi both proxi- 
mally and distally important nerve branches arising from the plexus may be 
endangered and approximation be impossible. In selected cases nerve graft 
may be indicated. An autogenous graft is not feasible due to the small 


length and diameter of the skin nerves in the infant, to the general contrain- 
dications of an additional wound and on account of the length of time 
involved. Consequently preserved grafts should be used if a graft is to be 
done, yet even with these the operation requires considerable time providing 
the suture is accurately done. Always every attempt should be made to 
obtain end-to-end union. Thus, considering the pathology of the lesion and the 
histology of nerve regeneration, obstetrical paralyses offer, perhaps, the least 
opportunity for successful nerve surgery. 

Mechanical Treatment. Deformity. — This has already been described in 
describing the different types of brachial plexus injuries. The treatment of ' 
obstetrical paralyses is, first, immediate immobilization so as to prevent addi- 
tional hemorrhage and further separation of the nerve ends due to movement 
and the unsupported weight of the extremity. As soon after birth as the 
paralysis is recognized the arm should be placed in a sling or the sleeve pinned 
up to a cap and a small pad strapped in the axilla to raise the shoulder, thus 
preventing the arm from dragging down the shoulder and further separating 
the nerve ends. This position should be held until the child is two or three 
weeks old, when a splint may be applied. 

Any of the splints similar to those shown in Figs. 88 and 89 are suitable. 
They should be made of very light material, preferably aluminum or light 
plaster, and readily removable. The arm should be elevated in abduction 
beyond 90 in order to relax the deltoid, and to assist in bringing the shoulder 
nearer to the neck, thus lessening the distance between the torn nerve ends. 
After operation if desired this angle may be increased and the arm held nearly 
vertical. Thus 1 to 2 cm. additional may be gained over that obtained when the 
arm is held abducted at 90. ° The forearm is semiflexed upon the arm to relax 
the biceps and supinator longus. The hand should be turned in full supination 
to overcome the tendency to pronation and the extremity must be held 
in external rotation. 

This splinting should of course be combined with passive movements and 
exercises to overcome any tendency to fixation and to help increase the nutri- 
tion of the part. To this end massage, bathing and electricity should also be used. 

Duration of Treatment. .---If the case has been treated in this manner 
for a year without improvement it is probable that regeneration without 
operation will not take place. On the other hand, if signs of regeneration are 


the sensory examination is of relatively little value as an indication of regenera- 
tion so that we must rely upon the motor and electrical findings together with 
the appearance of the extremity with its indications of alterations in the 
vasomotor and trophic status. (See p. 164.) 

Late Mechanical Treatment. — If the case has been untreated mechanically 
no operation should be undertaken until the muscles have been put at complete 
rest and further overstretching prevented. Even when cases have been 
neglected four or five years or longer mechanical treatment alone may give 
marked improvement and lead to establishment of contractility in the paralyzed 
muscles. Clinical experience in birth palsies has shown that muscles which 
are overstretched do not regain their contractility, even though neurotization 
has apparently taken place until they have been placed at rest and over- 
stretching prevented for at least six months. (See Chapter IX.) Boorstein 
(1919) has demonstrated the advantages of adequate mechanical treatment of 
brachial plexus injuries and has recommended the exercises advocated by 
Sweeney (1913), Thomas (1914), Bucholz (1917), which tend to prevent con- 
tractures and to assist in re-education when regeneration has occurred. These 
exercises are as follows : 

(a) Under the age of two months one uses gentle, irregular movements, 
carried out by the operator, and by the mother between treatments, such as 
moving the baby's hand and arm in various directions, in imitation of voluntary 
movements made by the other arm. 

(b) After two months it is advisable to bend, stretch or spread the baby's 
fingers while using the operator's arm in a similar way. It is best to accompany 
this by a nursery rhyme and the child will begin to imitate that. The hand 
should be flexed and extended at the wrist and then carried to the neck, thus 
flexing the forearm. The forearm should be abducted, adducted with the 
hand supinated and the elbow bent and held at the side; arm extension in 
supination where, with the elbow bent and at the side of the forearm, it should 
be rotated outward, but within the limits of comfort; the hand in supination, 
the arm should be extended] by the operator in the direction of the line of the 

The arm should be lifted to as near a vertical position as possible, from a 
position of extension in supination; then from the vertical position the elbow 
should be lowered to the side bringing the hand to the shoulder or neck. From 
the position with the elbow bent and at the side the arm should be stretched 
out and returned, and the arm in the horizontally stretched out position should 


be swung to describe a curve. These exercises are to be repeated two to eight 
times each. 

Both arms should be stretched sideways three or four times and then the 
hands carried to the head; the arms should be extended upward, and then 
returned to the bent position; the arms form a circle in front of the body, the 
fingers touching, and then the arms should be carried upward until the hands 
are over the head and then separated and lowered to the sides. For a part of 
each day the healthy arm should be bandaged to the body, thus forcing the 
baby to use his affected arm as much as possible. 

At the age of ten or twelve months it is appropriate to use blocks and per- 
haps put the blocks in different places and make the child reach for them. One 
may also induce the child to put blocks in a box held at different places. 

At the age of eighteen months the child can perform in the first group of 
exercises voluntarily, and dumb-bells, wands, balls, bean-bags and such things 
could be used. 

At two and a half or three years, the child will swing on a bar, walk into 
a corner with arms spread out, creep up the wall. 

The last muscles to develop are usually the outward rotators of the humerus 
and supinators. One may use the following exercise: With the elbow bent 
at the side, and the forearm in supination and abduction, with a small iron 
dumb-bell in the hand, the arm is extended in the direction of the line of the 

The following exercises for older children may be used: 

(1) Wing standing; chest raising with deep breathing. 
Position: Standing erect. 

Exercise: Forcible chest elevation with deep breathing. 

(2) On table on back, stick raising with deep breathing. 
Position: On table on back, hands well separated, grasping stick. 
Exercise: Stick raising over head with inhalation, sinking with exhalation. 

(3) Rest sitting, chest expansion. 

Position: Sitting on bench, hands behind head, elbows well back, careful 
not to hollow back during exercise; support should be given by operator. 

Exercise: At inhalation the arms are lifted up and back and returned to 
starting position on exhalation. Good pull should be given to gain the desired 
pectoral stretch. 

Cane exercises: Cane held in both hands. 

(1) Raise cane with arms straight. 


(2) Flex the elbow and lift the cane up in front of the chest; from this 
position the cane is brought forward or upward or to any angle desired. 

(3) One end of the cane is raised up to one side of the body, while the 
other is placed on the other side. 

(4) The cane is held in front of the chin with the hands about 3 feet 
apart; then it is moved horizontally toward one side and then the other. This 
exercise can also be done with the cane on the back of the neck. 

(5) The cane is held on the back, then the affected arm is raised up as high 
as possible, and the patient has to bring scapula, elbow and wrist as much as 
possible in a straight line, pressing these three points against the cane. 

In this exercise the affected arm extends actively, the other hand pushes 
passively, and both together force the shoulder and the elbow in a straight 

Time of Operation. — Due to the peculiar pathology of these injuries it is 
often extremely difficult at operation to determine the extent of the damage 
done, since some of the gross changes may not be apparent such as intraneural 
rupture of funiculi, centrally or distally, or evulsion within the intervertebral 
foramina. Hence, immediate or early radical operative procedures seem 
hardly justified in view of the large percentage that recover within a year 
without operation, if properly treated mechanically. By early operation 
it is often impossible to distinguish those that will go on to regeneration from 
those that will not. Spontaneous regeneration can hardly be expected under 
six months or a year and surgical intervention should not be undertaken 
until the end of this period. If the patient is properly treated mechanic- 
ally such delay is permissible. Taylor prefers to operate at the end of three 
months if there arc no signs of regeneration, while Sharpe (1916) operates 
at the end of a month. Very few patients will show signs of regeneration 
within a month so that this latter view, practically, would mean operating 


changes of a permanent character. If regeneration has not taken place within 
a year, delay longer is not warranted in patients that have been properly treated 
by splints, massage and passive movements. 

On the other hand, the nature of the injury may be such that operation 
can accomplish little or nothing. Obviously where the nerve roots are evulsed 
nothing can be done, but in favorable cases in which the anatomical continuity 
of the nerve trunks can be re-established operative intervention is certainly 
justifiable and offers the best opportunity for regeneration and return of 
function. In some instances when several nerve roots are evulsed or injured 
so that end-to-end suture cannot be done they may be crossed to adjacent 

Operation. — The technic elaborated by Taylor is most satisfactory. 

"The patient is anesthetized and brought to the table with the field pre- 
pared for operation. A firm cushion is placed beneath the shoulders, the neck 
is moderately extended and the face turned to the sound side. The incision 
passes from the posterior border of the sternomastoid muscle, at the junction 
of its middle and lower thirds, downward and outward to the clavicle at the 
junction of its middle and outer thirds. After the skin, platysma and deep 
fascia are divided, the omohyoid muscle is exposed near the clavicle, and lying 
beneath it are the suprascapular vessels. These structures may be retracted 
downward, or, if the case requires the extra room, the omohyoid may be divided, 
and then the vessels cut between double ligatures. The transversalis colli 
vessels are seen a little below the middle of the wound and are divided between 
double ligatures. 

"The dissection is rapidly carried through the fat layer to the deep cervical 
fascia covering the brachial plexus. In all the cases, this fascia was thickened 
and adherent to the damaged nerve roots. This fascia is divided in the line of 
the original incision and is dissected away for the free exposure of the nerves. 
The damaged nerves are usually noticeably thickened and of greater den- 
sity than normal nerves. The extent and distribution of the paralysis, deter- 
mined before operation, gives the clue as to which nerves are at fault. Usually 
the junction of the fifth and sixth roots is the site of maximum damage. The 
thickened indurated areas are determined by palpation and are excised by 
means of a sharp scalpel. Scissors should never be used for this work. 

"The nerve ends are brought into apposition by lateral sutures of fine silk 
involving the nerve sheaths only, while the neck and shoulder are approximated 


anastomosis to prevent connective tissue ingrowth. The omohyoid muscle, if 
divided, is sutured. The wound is closed with silk. A firm sterile dressing is 
applied, and a bandage is applied to approximate head and shoulder so as to 
prevent tension on the nerve sutures. This position must be maintained for at 
least three weeks. The most feasible method of accomplishing this result was 
found to be a plaster-of-paris dressing placed on the child and allowed to harden 
in the proper position before operation. It was then trimmed and removed. 
When the nerve suturing was finished the splint was slipped on, the wound was 
then closed, the dressings applied, and the child put to bed without danger of 
pulling the nerve ends apart, even when the patient was struggling and vomiting 
in the recovery from anesthesia. 

"it will be noticed that (a) the tissues to be excised lie in close proximity to 
the phrenic nerve and internal jugular vein, and to the junction of the cervical 
sympathetic communications with the spinal nerve roots. (b) The supra- 
scapular nerve comes off from the junction of the fifth and sixth cervical nerve 
roots, which, as already stated, is usually the site of maximum damage. This 
nerve is very small in children, but it should be sutured with the greatest care, 
since it innervates the external rotators of the humerus, the paralysis of which 
permits the posterior dislocation of the shoulder often seen in the older cases. 

"In cases in which the lesion is more extensive, especially when it lies 
beneath the clavicle, a wider exposure is necessary (Fig. 97). It is obtained by 
continuing the skin incision downward between the pectoralis major and deltoid 
muscles, which are then separated, dividing the clavicle in the same line, as well 
as the subclavius and omohyoid muscles and suprascapular vessels. 

"When the outer fragment of the clavicle and the shoulder are pulled out- 
ward the entire plexus is exposed down to the upper margin of the pectoralis 
minor muscle, which may also be divided if necessary. When the nerve suture is 
completed the divided muscles are repaired, the clavicle is sutured with chromic 
gut, and the skin closed with silk. In certain cases of extensive damage, in 
which so much nerve must be excised that the ends cannot be brought together, 
a nerve bridge of chromic catgut loops passed through the nerve ends and 
surrounded by cargile membrane may be used. 

"in other cases in which the cicatricial tissue reaches practically to the 
intervertebral foramen and its complete excision would not leave sufficient nerve 
stump to pass sutures through, the root may be divided transversely through 
cicatricial tissue a short distance outside the foramen and then the stump split 
longitudinally upward until good nerve tissue is exposed. The distal stump is 


then sutured up into this cleft, and at least some return of power may be 

Surgical Treatment in Neglected Cases. — In cases which have not received 
mechanical treatment — massage and exercise to prevent contractures — there is 
marked limitation in external rotation and abduction of the humerus. Even 
after spontaneous regeneration such limitation may persist due to adaptive 
shortening of the subscapularis and the sternal portion of the pectoralis major. 
The contracted subscapularis which normally rotates the arm inward prevents 
external rotation and in more severe cases also limits abduction. The latter 
movement is prevented more particularly by contracture of the sternal por- 
tion of the pectoralis major. 

When these contractures cannot be overcome by splinting and exercises 
tenotomy of the subscapularis and the sternal portion of the pectoralis major is 
indicated. In neglected cases without regeneration, tenotomy of these muscles 
may be done at the same time that repair of the nerve injury is undertaken. 
The operation as recommended by Thomas and Sever is as follows: 

"An incision is made situated on the anterior aspect of the arm and extend- 
ing from the clavico-acromial joint to a point below the lower edge of the pecto- 
ralis major tendon. The incision is carried down between the deltoid and 
clavicular portions of the pectoralis major tying or retracting the cephalic 
vein. The tendon of the pectoralis major is isolated and divided on a director. 
Turning the cut pectoralis major back and retracting the deltoideus gives a 
good view of the long head of the biceps and the joint capsule, short head 
of the biceps as well as the coracobrachialis. The arm is now abducted and 
outwardly rotated, bringing into view the transverse fibers of the tendon 
of the subscapularis at its point of insertion into the joint capsule at its inner 
and anterior aspect. This tendon is isolated and a sound or other blunt 
instrument is passed under it, and it is then divided. In this way not only is the 
pectoral divided, which, when contracted, prevents abduction, but also the sub- 
scapularis is divided, which, when contracted, prevents outward rotation. It is 
better to divide the subscapularis by this method rather than to open the 
joint capsule after Fairbanks method, for it does not lead to subsequent adhe- 
sion of the capsule to the joint cartilage and consequent loss of motion. 

"After these two structures have been cut, outward rotation and abduction 
will usually be found to be perfectly free. In case either is at all restricted, 
the coracobrachialis or the short head of the biceps may be found to be tight, 
and partial division of these structures will always lead to full freedom in 


outward rotation and abduction. If the head of the humerus is blocked by 
the hooking downward of the acromion in front of it, so that the posterior 
subluxation cannot be fully reduced, an osteotomy can be easily done on the 
acromion through the upper end of the original incision. 

"If there is an anterior subluxation of the joint, which occurs rarely, 
the pectoralis major is the only muscle which needs to be divided. A division 
of the subscapularis would only tend to increase a deformity already present. 
The pectoralis major and deltoideus are then joined with interrupted catgut 
sutures, and the skin closed by a continuous catgut suture. The arm is then 
put into a plaster cast extending from the crest of the ileum to the tips of the 
fingers, the arm being abducted, elevated, outwardly rotated and the hand 
supinated. This cast should be worn only about two weeks, at the end of 
which time baking, massage and exercises should be started and continued 
daily for several months. After two or three weeks a wire splint may be sub- 
stituted for the cast, in that it is lighter and more comfortable. " 


Ruptures of the brachial plexus in adults, as has already been said, differ 
very little from those in birth palsies. They likewise are produced by any 
trauma in which the head and shoulder are forced apart and the acromio- 
mastoid distance lengthened, such as by a sudden blow upon the shoulder or 
by a fall on the head and shoulder. In two cases of rupture of the brachial 
plexus one, a boy of six, fell off a high chair landing on the right side of his 
head and right shoulder; and the second, a laborer, was struck on the shoulder 
by a heavy stone which fell as it was being raised. The stone struck a glancing 
blow on the shoulder and immediate paralysis in the distribution of the fifth, 
sixth and seventh cervical roots resulted. Thus in both of these the acromic 
mastoid distance was forcibly increased. 

Taylor and Casamajor (1913) reported six cases of rupture of the brachial 
plexus in adults in each of which the mechanism was the same, namely, trauma 
which forced the head and shoulder apart. One of their patients fell from a 
freight car; another was caught in a door being closed by hydraulic pressure, 
and a third was struck on the shoulder by a heavy chain which had fallen from 
the second story. Mills (191 1) has described a unique case of rupture of the 
brachial plexus. His patient was hit on the shoulder as he was walking on 
the sidewalk by the body of another man who had fallen from a third story 
window. The left upper extremity was immediately paralyzed and Homer's 



syndrome was present. Frazier found that the ventral and dorsal roots of 
the fifth, sixth, seventh, eighth cervical and first thoracic nerves were com- 
pletely evulsed from the cord. Such sudden and extensive trauma caused 
hemorrhage in the cord and cord signs, including patellar clonus, ankle clousn, 
and Babinski on the same side of the injury. 

Fie. Q7. — Operation for relief of brachial paralysis. A, Phrenic nerve; B, scalenus anticus 
muscle; C, internal jugular ii-in. D. Iransversalis colli artery; E, omohyoid muscle; F, suprascapular 
artery; (1, eighth ri-rvkal ami hrsl dorsal roots; //, muscular branch; /, subclavian vein; /, hflh 
root; A', sixth root. /.. scalenus medius muscle; M, nerve to subclavian muscle; A', suprascapular 
nerve; O, transversa lis colli artery; omohyoid muscle; K. suprascapular artery; S, clavicle and 
subclavius muscle / . ;«i :■•(.! "■- major, pectoralis minor and deltoid muscles; V . anterior thoracic 
nerve. (Taylor, .1 V M A . 1907.J 

In adults the trauma is generally more severe, consequently the nerve 
trunks are more often ruptured and the ends pulled completely apart. A 
search for signs of spinal cord involvement should always be made, and if 
signs are found they are an indication of the extent and the severity of the 
injury. Complete evulsion from the spinal cord is more apt to occur than in 
birth injuries. Consequently in adults there is less chance for regeneration 
without operation and less indication for conservative mechanical treatment. 


Hence, early exploration is more frequently indicated. Naturally when there 
is evulsion of the roots or rupture within the intervertebral foramina nothing can 
be done, yet in paralyses of such amplitude as to involve the entire extremity any 
gain is of value, and an exploration is, therefore, warranted if any doubt exists. 
Stab Wounds and Gunshot Wounds.- While these injuries are less frequent 
than rupture of the plexus they are not uncommon, since the plexus is in a 

Fie. 98.— Splint for brachial plexus CBSes applied. It transfers the weight (0 the opposite- 
shoulder and to the thigh of the same side. The splint proper is made from ?j 6 iron. The canvas 
straps are held in place with eyelets, (.liuerki, Archives of Neurology and Psychiatry, 1010.) 

relatively exposed position in the posterior triangle of the neck, and docs not 
receive the muscular or bony protection usually afforded structures of such 
importance. In injuries of this type the prognosis is better than in birth palsies 
or ruptures of the adult plexus, in that the funiculi are interrupted, more or less, 
at one level, and are not evulscd from the spinal cord, or interrupted within the 
distal or central stump; consequently end-to-end suture offers greater oppor- 
tunity for regeneration. (See Fig. g6.) 

A large percentage of such injuries recover without operation, hence some 
deem it better judgment to defer exploration and await spontaneous regenera- 
tion. However, early exploration of the wound and conservative correction of 
the field offers increased opportunity for regeneration, providing the mechanics 


of the operation are not too difficult, as may be the case in the presence of an 
extensive scar or associated lesions of the great vessels. Exploration is par- 
ticularly difficult in injuries involving the lower cervical roots. For adequate 
exposure of this region it is frequently necessary to cut through the clavicle; 
consequently in cases of this type operation for exploration alone would hardly 
seem indicated. 

The surgical and mechanical treatment of plexus injuries of the adult 
follow in general those given for obstetrical paralysis. In some adult cases in 
place of an abduction splint such as is shown in Fig. 88. an aiqjlane splint 
will be found more suitable. In adults it is awkward and tiresome to wear a 
splint which holds the arm more or less vertical. 


Surgical treatment of the brachial plexus may be called for in the presence 
of a cervical rib, either an abnormal first thoracic rib, or an apparently normal 
first thoracic rib exerting pressure on the plexus. The seventh cervical or 
the lower cord of the plexus (eighth cervical and first thoracic) is most usually 
involved, causing pain and other sensory changes along the inner side of the arm, 
forearm and hand with atrophy of the muscles of the hand and weakness in some 
of the flexor muscles of the forearm. Sargent (1921) found that the segmental 
distribution in his cases was as follows: 

Sixth cervical, seventh cervical and first thoracic in six cases. 

Seventh cervical, eighth cervical and first thoracic in fourteen cases. 

Seventh cervical and eighth cervical in twelve cases. 

Hramwell (1903), Stopford and Telford (19 19) have shown that an appar- 
ently normal first thoracic rib may produce definite signs of compression of the 
lower cord of the brachial plexus and be relieved by removal of part of the rib. 

Anatomy. — In the embryo the development of the brachial plexus precedes 
that of the costal structures and according to Wood Jones (1904) prevents the 
formation of a cervical rib by the pressure exerted by the developing plexus. 
With the more cephalic position of the limb bud the effect exerted by the pre- 


excalation of segments making it difficult, if not impossible, even in a cadave 
determine whether a rudimentary first rib is a cervical or a first thoracic 
Varieties of cervical ribs have been described depending on the shape and lei 
of the rib, which may vary from a short rudimentary process to a full rib ext 
ing forward to articulate with the first normal rib. The most frequent typei 
those with a short rudimentary process fused or articulating with the sev( 
cervical vertebra and prolonged to the first rib by a dense fibrous band, 
seventh cervical root crossing the tip of the process and the eighth cen 
and first thoracic passing over the fibrous prolongation. Cervical ribs 
found in about i to 2% of all cadavers and according to Streissler (1913) ■ 
are bilateral in 67% and the unilateral are on the left side in more than 6 
They are found more frequently in women than in men. 

Since such costal anomalies are present from birth, it is difficult to un 
stand why the first appearance of nerve pressure signs should occur only 1 
in life, generally not before the second decade. Possibly with complete < 
fication of the ribs at this period elasticity is diminished and with greater rigi 
symptoms may occur. Again, a low grade trauma to nerves may require y 
before any clinical signs are manifested. It has been frequently observed 
years after fracture of the elbow ulnar nerve signs may appear without any o 
injury. (See p. 369.) In like manner it is possible that pressure exe 
on the plexus by a cervical rib may give clinical signs only after a perio 
years. Todd believes the development of late symptoms to be due to the 
cent of the shoulder girdle to a more caudad position. The clavicle is low< 
on its inner end, according to him, by the action and pull of the abdom 
muscles on the sternum, while the outer end of the clavicle, especially in wo 
is said to descend at puberty. 

Probably signs of compression in the absence of a cervical rib ma) 
due to a low origin of the plexus — postfixed variety— with a relatively 1 
contribution from the lowest root to the inner cord. Harris (1Q04) beli 
that the second thoracic nerve contributes motor libers to the intrinsic r 
cles of the hand in postfixed plexuses and consequently these libers w 
be more involved than others by pressure over an apparently normal 
thoracic rib. In these cases a negative roentgen ray examination does 
preclude the possibility of compression of the lower cord of the plexus, 
is it precluded when a relatively short cervical rib is found, sine •'• 
fibrous band which extends forward to the »~ ,r * 


rudimentary cervical rib which was grooved on both the right and left sides not 
by the lower cord but by the seventh cervical root, the lower cord lying free 
beneath the cervical rib which was only 5 cm. long. Such implication of the 
seventh cervical root may explain the appearance of compression signs along 
the pre-axial border of the extremity in certain cases of cervical ribs. However, 
signs on the pre-axial border may also be explained by involvement of the fibers 
of the inner cord which pass through the inner head of the median nerve to 
supply the pre-axial border. 

Deformity. — Atrophy of the intrinsic muscles of the hand and weakness 
with or without atrophy of the flexor muscles along the postaxial border of the 
forearm are found. Wilson (1903) has pointed out that the abductor brevis 
and opponens pollicis may be the only muscles involved, the intcrossei and the 
remaining thenar muscles showing no change. This muscular involvement is 
difficult to explain. (See p. 235.) Marked circulatory or vasomotor changes 
are frequently present and may be due to compression of sympathetic fibers to 
the vessels of the extremity within the nerve trunk or to direct pressure on the 
subclavian artery. As pointed out elsewhere (see Chapter XX), the vessels of 
the extremity, with the exception of the subclavian, are supplied by nerve fibers 
from the nerves in their immediate vicinity and not by continuous perivascular 
sympathetic fibers. Consequently an irritative lesion of the lower cord of the 
brachial plexus may cause extensive vascular changes throughout the extremity 
by involvement of the postganglionic sympathetic efferent fibers within the 
nerve trunk. If, on the other hand, the vascular changes arc due to direct 
pressure on the subclavian artery, the circulation may be improved by changing 
the position of the arm. Also a difference in blood pressure and pulse on the 
affected side will be noted on full inspiration, the pulse volume and blood pres- 
sure being diminished on inspiration or by pulling the arm downward. Hal- 
stead (1916) found direct pressure on the subclavian artery in only 5% of 
three hundred and sixty cases studied. Wood Jones (1904) believes that the 
subclavian groove on the first rib does not lodge the subclavian artery but the 
lower cord of the brachial plexus and for this reason suggested that the sulcus 
subclavian be named sulcus nervi brachialis. Consequently pressure effects 
would be exerted first on nerve roots and not on the subclavian artery. 

Sensory Changes. — Objective sensory changes or paresthesia may be found 
along the postaxial border of the limb and hand. Occasionally the patient 
may complain of awkwardness in the performance of skilled movements of the 



j been in use for some time. This may be due to a disturbance in th 

I ceptive mechanism affecting the smaller muscles and joints of the ] 

* only one instance have I been able to detect any disturbance of 

or muscle joint sense. Stopford and Telford have pointed out that i 
their cases dissociation of sensation was found with greater loss in tin 

', forms of sensation (pain and temperature) than in the discriminativ 

wool, etc.). Pain may be a prominent symptom. 

In an admirable study of fifty cases of cervical rib, Percy Sargent 
that: "Variations in the composition of the brachial plexus are apt t 
ciated with costal abnormalities, prefixation with a seventh cervica 

i postfixation with an abnormal first thoracic rib. There is, however, i 

relationship between the costal and neural anomalies. 

"Of the several different types of cervical rib met with clinic 

■ which most frequently requires treatment by operation is represent 

abnormally large nonjointed costal process, continued onward as a der 
band, to be attached to the first thoracic rib behind the sulcus nervi 
(sulcus subclavian). 

"Symptoms of gradual onset from continual slight traumatic 

1 eighth cervical root or the lowest cord of the plexus, caused by the t 

of the band during respiration and in certain movements of the arm. 
"With a postfixed plexus symptoms referable to the first tho 

' may be caused by the pressure of a normal first thoracic rib." 

Mechanical Treatment. — This is of little value except in cases 
the symptoms have come on after sudden trauma such as a sudd 
ward wrench of the arm. This occurred in one of my cases when a he; 
in which the workman's hand had become entangled, fell. The sudc 
ward pull produced definite signs of lower cord compression which wei 
by placing the arm in a plaster in an elevated position. For this p 
airplane splint similar to that used for deltoid paralysis will also be four 

I able. (See Fig. 98.) However, some cases, not of traumatic ori 

been reported in which an elevated position of the arm increased th 
disturbances, the pulse becoming weaker and the blood pressure 
in the affected arm. Obviously, when such signs occur the elevate 
of the extremity is contraindicated. 

Surgical Treatment. — For short rudimentary processes not 
forward a dorsal exposure offers a means of approach, but for more 


extended dorsally or ventrally, as needed, to expose the ventral end of the rib and 
search for fibrous bands which may extend forward, to the first rib and cause the 
same pressure effects as a complete cervical rib. 

Incision. — A collar incision 10 to 12 cm. long is made beginning in front 
at the insertion of the sternocleidomastoid and extending backward parallel 
to the clavicle as far as the border of the trapezius. Taylor 1 recommends 
an oblique incision which, lying in the line of skin cleavage, will leave a 
linear scar, whereas other incisions eventually show a wide scar, even though 
at first the scar may appear as a line. This is a worth while point, since in 
most instances the condition occurs in young women. 

Exposure of the Rib. — The brachial plexus is exposed between the scalenius 
anticus and medius and the great vessels are identified. The plexus as a whole 
is retracted. For this purpose a moist piece of broad tape is passed and clamped 
with forceps to serve as a retractor. The degree of tension is controlled better 
in this manner than when a metal retractor is used, and tlie injury incidental 
to possible slipping of the retractor is avoided. Tension on the plexus may 
cause transitory palsies, perhaps due to the fact that the pressure is exerted 
so near the ventral gray cells. In freeing the ventral part of the rib the plexus 
is retracted dorsally and the subclavian artery ventrally. A search is made 
for any bands connecting the cervical rib with the first rib. The insertion of 
the scalenius muscles and the intercostals are freed from the rib by sharp dis- 
section. When the ventral part of the rib is freed, the ventral part of the wound 
is packed and the dorsal part of the rib is then exposed in the dorsal angle of the 
wound. The spinal accessory nerve must be identified in this part of the opera- 
tion in order to avoid injury of it. The rib may be followed backward and an 
exposure obtained by splitting the trapezius muscle and retracting the levator 


scapuke together with the inner part of the split trapezius. The muscular 

attachments to this part of the rib are then freed and the rib exposed as far as 
its vertebra. 

Subperiosteal resection, although simpler to do, may result in regeneration 
of the rib as de Quervain (1895), Beck (1905) and Lewis (1918) have shown. 
In freeing the rib the pleura may be injured and possibly the vessels and nerves, 
consequently this makes removal of a structure so deeply situated as a cervical 
rib an operation of considerable difficulty. 

The results of operation for cervical rib are entirely favorable, being more 


atrophied muscles. Sargent found that "vasomotor symptoms were cured 
in fourteen cases, relieved in six, and unrelieved in two; pain was cured in 
nineteen and relieved in eight; muscular wasting was cured in twelve cases, 
relieved in twelve, and unrelieved in seven." It is but fair to state that four 
of those unrelieved were lost sight of before recovery of the affected muscles 
could have taken place. 


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Anatomy. — The musculospiral nerve, the direct continuation of the dor- 
sal cord of the brachial plexus, is derived from the dorsal branches of the 
ventral primary divisions of the last four cervical nerves. It also receives, 
according to Harris (1903), a small dorsal branch from the first thoracic nerve. 
The musculospiral nerve supplies the primitive dorsal musculature of the 
upper extremity, giving also a small branch to the brachialis muscle. This 
muscle, in its origin, is a fusion of both dorsal and ventral musculature, hence 

the dual innervation. 

Course. — In its upper part the musculospiral nerve passes across the ven- 
tral surface of the latissimus dorsi and teres major tendons beneath the axillary 
artery and enters the fascial plane between the long and lateral heads of the 
triceps, lying close to the inner side of the humerus, and thence descends to 
the dorsum of the humerus, in the spiral groove beneath the lateral head of the 
triceps. At the junction of the lower and middle thirds of the humerus it 
pierces the lateral intermuscular septum and passes ventral between the supi- 
nator longus and the brachialis muscles, where it descends almost vertically to 
the lateral condyle, at which point, or slightly above, it divides into its two 
terminal branches, the posterior interosseous and the radial nerves. 

Within the musculospiral groove, the nerve is accompanied by the external 
cutaneous nerve and the superior profunda artery. Upon reaching the outer 
side of the humerus this artery divides into two branches: a smaller, which 
accompanies the nerve through the intermuscular septum, and a larger branch, 
which runs downward on the dorsal surface of the intermuscular septum to the 
lateral condyle. The course of the nerve is more nearly vertical than one is led 
to suppose from the usual anatomical descriptions. It is spiral only in a small 
portion of its middle third; in its upper and lower thirds it is almost perpendic- 
ular — a point worth recalling in exposure of the nerve. (See Fig. 99.) 

Variations in the course of the musculospiral are extremely rare. The 
nerve has been observed to pass with the circumflex through the quadrilateral 


distribution seen from Ihc under surf are. (1'roh: 


crosses over the tendon of the latissimus dorsi muscle. These branches are the 
internal cutaneous, a muscular branch to the long head of the triceps, and the 
ulnar collateral to the medial head (r. collateralis n. ulnaris.n. radialis, Krause, 
1864). (See Fig. 100.) Those of the dorsal group are the muscular branch to 
the lateral head of the triceps, one to the lateral part of the medial head, the 
anconaeus, and the elbow joint, and the superior and inferior external cutaneous 
branches to the lateral part of the arm and dorsum of the forearm. The 
branches of the lateral group are distributed to the brachialis, supinator longus 
and to the extensor carpi radialis longus and brevis. (See Fig. 101.) 

By finer dissection and tracing the branches within the epineurium in 
macerated specimens Borchardt and Wjasmenski (1919) have shown that as the 
nerve lies on the tendon of the latissimus dorsi, the fibers for the external 
cutaneous nerves lie medial to the nerve trunk, cross lateral and then run with 
the main nerve trunk around the humerus in the spiral groove. The internal 
cutaneous arises from this nerve bundle. (See Fig. 102.) 

The next bundle to arise is the muscular branch to the lateral head of the 
triceps, to the lateral part of the medial head a^d the anconaeus. Adjacent to 
this bundle is the motor funiculus for the long head of the triceps, from which 
arises also the ulnar collateral and the branches to the medial head. 

Thus, it will be seen that there are three main bundles in the musculo spiral 
nerve in the arm, from which others arise as secondary branches. All the cu- 
taneous sensory branches arise from one common bundle; the muscular branches 
to the lateral head, part of the medial head and the anconeus as well as afferent 
to the elbow joint from a second, the branch to the long head, and the ulnar 
collateral from a third. 

The branches given off from the nerve as it lies ventral to the intermuscular 



iculospiral nerve to the muscles of the forearm. (Frohse and 


Pin. 102. — Musculospinal nerve. Dissection of macerated specimen. E, Level ol 
|MHlrrit>t Interosseous; 2, superficial radial; 3, branch to bruchio- radial is; 4, branch to exte 
nulfoU* longus; 5, branch to extensor carpi radialis brevis; 6, branches for supinator lircv 
ill* nit Bnil Wjasmenski, Ileitr. 1. klin. Chir., iqiq.) 


of r 


inperfii itil radial; 3 branch to bndilo-nullalis 

t> i'sIiiisipi I'.irpi radial is brevis; (1. branches fn 
nmvmis, Krteiwoi (Kgiti quinti pmfirius, Mter 
, abductor [mllicis longus; 0, terminal bunch 


radial border of the nerve. The same funiculus gives rise to the branches to the 
extensor radialis longus and brevis. The branch to the latter muscle descends 
as a separate bundle a short distance within the nerve adjacent to the superficial 
radial and has a long e.xtraneural course before entering its muscle, while the 
other branches in this region enter almost immediately the muscles which they 
supply. This branch is of considerable importance in view of its supply to the 
extensor carpi radialis brevis, which is a more powerful extensor of the wrist 
than its companion muscle, the extensor carpi radialis longus; consequently 
every effort should be made to save this branch or to suture it separately. 
(See Fig. 114.) 

Terminal Branches. — The musculospiral nerve terminates a few centi- 
meters above the lateral condyle by dividing into the radial and the posterior 
interosseous, nerves. The radial nerve lies medial and in front; the posterior 
interosseous, dorsal and lateral. This relationship identifies at this level these 
two nerves approximately the same in size. 

The posterior interosseous nerve descends in the cleft between the supinator 
longus and the brachialis muscles, then beneath the extensor carpi radialis 
longus and brevis to the outer side of the radius around which it passes obtiquely 
and pierces the supinator brevis muscle to which it contributes several branches. 
One to two cm. below its exit from the supinator brevis muscle, the posterior 
interosseous nerve terminates by dividing into two, or sometimes three or four, 
main branches which in turn rapidly redivide. The nerve in its course around 
the radius becomes flattened and broad, more or less losing its appearance as a 
nerve. The terminal branches are a relatively large branch of short extra- 
muscular course which supplies the extensor digitorum communis the extensor 
carpi ulnaris and extensor digit] quinti proprius; while the second group of 
terminal branches have a long extramuscular course and supply the abductor 
poilicis longus, extensor pollicis brevis and extensor indicis proprius. These 
terminal branches are so small that it is rarely possible lo suture them, especially 
if they are in scar tissue from which they must be dissected. Generally speak- 
ing, if the site of the injury is more than 6 cm. below the lateral condyle, there is 
little chance for successful nervesutureifscartissucorcallusisprescnt. In these 



Nerve Plexuses. — There are three main internal nerve plexuses within the 
musculospiral nerve: the first just above the level at which the highest group of 
branches is given off, the second immediately above the branches to the supi- 
nator longus and the third in the upper part of the posterior interosseous. 
Thus there is a relatively long intermediate region or "zone nodale" in which the 
funiculi are assembled into a few, or even a single, nerve bundle. The cross 
section appearance of relatively the same level varies in different individuals 
(see Fig. 104), and even in the same individual between the right and left 
nerves. "When one compares the cross sections on the left with those on 
the right, they are found to be in no wise congruent in spite of their being exact 
parallel preparations" (Borchardt and Wjasmenski, 1919). This lack of corre- 
spondence of the cross sections, and the numerous intercommunications of 
the funiculi, make it impossible with our present knowledge to localize with 
exactness the various funiculi within the musculospiral nerve on a topograph- 
ical and anatomical basis. However, Borchardt and Wjasmenski, Marie, 
Gosset and Meige (191 5) were able to localize by electrical stimulation fibers to 
the extensors of the wrist upon the lateral quadrant and fibers to the supinator 
on the medial quadrant. It must be remembered that localization by the 
electrode applies only to the nerve exposed at the time of operation, and it is 
impossible to compare accurately with the same nerve of other individuals. 

On cross section at most levels the musculospiral nerve shows compara- 
tively few funiculi, consequently in nerve suture crossing of the funiculi, and 
loss of neuraxes in the interstices between the funiculi, is less apt to occur than 
in those nerves in which the funiculi are smaller and more numerous, such as 
the ulnar nerve. There are relatively few cutaneous sensory and sympathetic 
fibers within the musculospiral nerve and the muscles supplied are large and do 
not perform the finer skilled movements. These factors may contribute, in a 
measure at least, to the excellent results obtained from suture of this nerve. 

Anomalies of Distribution. — The musculospiral nerve is the only nerve in 
the upper extremity arising from the dorsal divisions of the brachial plexus, and 
since dorsal divisions innervate only dorsal musculature it is the sole supply of 
all the dorsal musculature. It is a distinct unit functionally and morphologic- 
ally in its comparative anatomy and development, which probably accounts for 
the fact that variations in its distribution occur less often than in any other nerve 
of the upper extremity. When two nerves have arisen from a common nerve 
trunk in their development, as have the musculocutaneous and the median, 
variations in distribution and communications are apt to occur. Another 


source of variation in nerve distribution may arise when more than one nerve 
supplies a primitive muscle mass. This is true of the ventral musculature of 
the upper extremity which is supplied through three nerves arising from the 
ventral divisions of the brachial plexus, namely, musculocutaneous, median and 
ulnar nerves, while the dorsal musculature is supplied by the musculospiral alone. 


Deformity. — Injuries to the seventh cervical root, the primary middle trunk 
or the dorsal cord all result in total or peratial paralysis of the musculospiral, sub- 
scapularis and circumflex nerves. In this paralysis the supinator longus may 
escape unless the fibers from the fifth and sixth cervical nerves to this muscle 
are injured at the point where they join the dorsal cord, and this differentiates 
injuries here from more peripheral ones in which the supinator is paralyzed 
without involvement of the circumflex and subscapular nerves. In complete 
dorsal cord injuries the subscapularis, latissimus dorsi, teres major, deltoid, 
are paralyzed the triceps and extensors of the wrist, fingers and thumb may be 
but partially paralyzed. In the more distal injuries the subscapular nerves 
may escape. 

The resulting deformity of such an injury is essentially loss of abduction, 
of extension of the forearm, as well as of extension of the fingers, wrist and 
thumb. The arm hangs in adduction, usually with very little inward rota- 
tion, and the humerus is drawn forward by contraction of the pectoralis major 
muscle. Due to paralysis of the triceps and the supinator the forearm is slightly 
flexed and in semipronation, though it may be actively supinated by means of 
the biceps muscle. The wrist falls to a typical wrist-drop position, and the 
thumb and fingers cannot be extended. The motor loss is extensive since all 
of the dorsal musculature is involved. 

Mechanical treatment should endeavor to relax the deltoid muscle and the 
extensors of the forearm, wrist and fingers and overcome the effects of gravity. 
This may be accomplished by placing the arm in abduction, with the forearm 
slightly flexed and the wrist and proximal phalanges dorsiflexed to about 50. 
The splint, shown in Fig. 105 is similar in construction to appliances used for 
paralysis of the fifth and sixth cervical roots. Due to its anatomical arrange- 
ment the triceps is not apt to be overstretched, hence the forearm may be held 
fully extended or in semiflexion. However, on account of gravity, and adaptive 
shortening of the flexors, the extensors of the wrist and fingers are severely 


In complete dorsal cord injuries an objection may be offered to splinting th< 
in abduction since by so doing the teres major, latissimus dorsi, and subs< 
laris muscles are not relaxed, but it is impossible to relax at the same time 
abductors and adductors. When a choice must be made, the muscles of grc 
value should receive first consideration. The function of the deltoid is of gi 
importance in the movements of the upper extremity than that of the addu< 
Unsupported the paralyzed deltoid is subject to greater strain and overstret 
than are the other muscles and consequently greater attention should be 
to the more important deltoid. 

Fig. 105. — Splint for total or partial paralysis of the dorsal cord and musculospiral nerve, 
table aluminum abduction splint with forearm piece to maintain the wrist in dorsiflexion. Ai 
in abduction with the wrist dorsiflexed. (Stookey, Surgery, Gynecology and Obstetrics, 19 


Deformity. — In injuries of the musculospiral nerve below the circui 
complete paralysis of the supinator longus, extensors of the wrist, finger 
thumb occurs, while the triceps generally shows only partial paralysis, 
the branches to the long head of the latter muscle come off relatively higr 
hence one head of the triceps may escape. 

The main deformity of this paralysis is wrist-drop. In cases with ex 
atony of the extensors, the wrist falls almost to a right angle. When negh 
edema over the dorsum of the wrist takes place and subluxations aboi: 
carpus may occur. Without mechanical treatment the extensor m 
become greatly overstretched, due both to gravity and the unopposed r 
ol" the tlexors. It must be remembered that the flexor muscles of the extrei 
are »tronL r er than the extensor-. This difference in strength is seen in 
reilex contracture- in joint injuries in both the upper and lower extren 
in which the deformity i> u-uallv. llexion deformitv. This is seen at the I 
well as at the knee and the ankle of the lower extivmitv. and at the elbo 1 


wrist of the upper. The extensors of the wrist and fingers and the ankle and 
toes are newer acquisitions, and there is some evidence to indicate that muscles 
of more recent origin are more vulnerable. 

Mechanical Treatment. — Correction of the deformity in musculospiral 
paralysis consists essentially in preventing wrist-drop. Even after successful 
repair of the nerve, return of motor function is immeasurably delayed unless 
overstretching is prevented. To accomplish this, numerous appliances to 
maintain the wrist and first phalanges in extension have been devised. There 
is no need to elevate the second and third phalanges, since extension of these 
is accomplished by the interossei muscles acting upon the extensor tendons. 
To obtain the optimum relaxation, the wrist and proximal phalanges should 

be elevated to about 50 . All splints should include the thumb, since the 
extensors to the thumb are also implicated, and it should be held not only 
in extension but in abduction as well. Frequently the thumb is merely pushed 
back to the same plane as the metacarpal bones and held in adduction. 
Contraction in this position causes considerable disability. 

Appliances which hold the wrist straight and in line with the forearm are 
not efficient, as they do not prevent overstretching. Some appliances seek 
to replace the action of the extensor tendons by rubber tubes or flexible metal 
springs. These are very convenient and, so far as motion is concerned, satis- 
factory, in that they permit the patient to make use of his hand in grasping- 
Whatever the appliance used, it is essential that the wrist at rest always be 


this point. Splints which are dorsally placed, leaving the palm unobstructed, 
are more satisfactory for they permit greater use of the h;ind. 

I"[0. io6H. — Splint tor wrist drop with c\lra piece ii> support palmar arch. .4, Adhesive band 
which fits 011 dorsal surface o[ wrist; />, removable canvas band which fits on anterior surface of 
forearm; C, palmar piece to maintain palmar arch held to the main splint by adhesive plaster. 
(Huerki. Archive? of Ncurol"Ky and I'syt-hiatry, iqlo.) 

The appliances illustrated (Figs. 106, 107) show their relative merits and 
need no further explanation. 1 Perhaps those splints are to be preferred which 
not only maintain adequate elevation of the wrist and lingers, but also permit 

Fto. 107. — Splint for wrist-drop. (Modified from Privat and Belot.) The splint is made of 
spring steel wire. At the level of the wrist joint the wires are flattened and a joint made. A single 
or bilateral spring or rubber band offers an clastic support to the wrist in place of a lised support. 
In musculospiral paralysis the palmar arch is unaffected, lu-ticc a palmar piece to maintain the 
palm.ir_arch is superfluous. 

limited flexion. Apart from the convenience of being able to flex the wrist 
and fingers, a certain physiological function is also served by flexion and the 
passive recoil to extension of the paralyzed muscles. By passive movements 
the circulation of the paralyzed muscle is increased with an attendant increase in 
removal of waste products and an improvement in the nutrition. By these 


passive movements the mobility of the tendons in the tendon sheaths is main- 
tained and contractures about the joints are less apt to occur. 

Fig. 108. — K.xposure of the museulospiral nerve behind the humerus anil immediately below 
the teres major tendon (seen from behind with the arm held -it right uncles to the body). The 
foreipn body imbedded in the nerve mused a dis-odatcd paralysis. Nute I lie marked increase in the 
small vessels on (be nerve. 

Dissociated paralyses of various types may be found when partial injury 
to the nerve trunk occurs. In one of my cases the extensors of the wrist, index 
fingers, and third fingers were paralyzed while the extensors of the thumb, fourth 

it,,} fifth «»» lu+oot 4t niurdtum -i f-irninn Krul-17 urac fnnnrl ImK^rlul 



In the nerve involving but part of the nerve trunk. (See Fig. 108.) Similar 
dissociated paralyses have been described by Marie, Meige and Patrikoos (1017) 
and Rousey and Branch (1917). In their cases the paralysis, on superficial 
examination, simulated injury to the ulnar nerve, for only the last two fingers 
were involved. 

Exposure of the musculospiral nerve above the lower border of the lat- 
issimus dorsi and teres major tendons is accomplished in much the same manner 
as exposure in low plexus injuries. 

Fir,. 109. — Exposure and suture of the dorsal cord ol the brachial plexus. The small veins and a 
few of the arteries on the aiillary wall have been cut to permit retraction of the neurovascular bundle. 
The circumflex nerve has been freed up the sheath of the dorsal cord and separately sutured. 

Position of the Arm— The arm is held in external rotation and at a right 
angle with the body with the forearm extended in semipronation. A flat 
sandbag is placed beneath the shoulder. 

The incision begins across the pectoratis major muscle, in the cleft between 
it and the deltoid, and is carried downward into the axilla on the medial surface 
of the arm along the line of the great vessels. In some instances, it may be 
preferable to make the incision entirely within the axilla, beginning at the 
middle of the axilla and carrying it downward along the inner margin of the 
coracobrachialis muscle. In exposing the nerve the branches which lie upon 
the ventral surface of the latissimus dorsi tendon, and medial to the main 


nerve trunk, must be avoided. The branches which arise from the nerve in 
this region are, in the order of their appearance, the internal cutaneous, branch 
to the long head of the triceps, ulnar collateral for the inner head of the triceps 
and anconaeus, and a branch for the lateral head of the triceps. (See Fig. 109.) 
The nerve may be exposed by going between the axillary vein and the median 
nerve, or the entire neurovascular bundle may be retracted laterally, exposing 
the musculospiral nerve beneath. The vessels may be retracted either down- 
ward and inward, or upward and outward'after cutting the small veins from 
the anterior axillary wall, thus freeing the vessels. The direction of the nerve 
is outward and downward, which makes retraction of the vessels in the opposite 
direction usually preferable. By following up the border of the latissimus 
dorsi tendon the musculospiral nerve will readily be found lying upon the 
ventral part of the tendon. Occasionally there is a muscular slip from the 
latissimus dorsi to the triceps or coracobrachialis. This muscular slip may 
be so prominent as to confuse the anatomical field. The axillary vein is formed 
by the junction of the two venae comities, occuring usually at the lower border 
of the latissimus dorsi tendon, though it may be higher or lower than this. If 
the basilic vein has not already joined the inner vena comes, three veins may 
be found. At a higher level the cephalic vein appears. 

Exposure of the Musculospiral Nerve in the Arm. — It is frequently neces- 
sary to expose the nerve over a large part of its course, especially in fracture of 
the humerus with inclusion of the nerve over a considerable length in scar and 
callus. The more usual method of exposure is by means of a spiral incision, 
following more or less the supposed line of the nerve. 

There are certain disadvantages in this incision, for it is rather difficult to 
place a spiral incision exactly over the course of the nerve, and considerable 
difficulty may be met with in locating it. This is the disadvantage of an 
incision which runs parallel to any nerve which follows a winding or spiral 
course. In addition, in the spiral incision to expose the musculospiral nerve 
part of the triceps muscle must be cut transversely. While such transverse 
section of a muscle may not cause extensive paralysis, permanent partial 
paralysis may result, especially if the incision should encounter a motor branch. 


longitudinally until the aponeurosis on its deep surface is seen. This is carefully 
incised and the nerve exposed directly beneath. 

If one of the incisions above described does not give sufficient exposure 
several of them may be combined without making a new skin incision by 
connecting them in an oblique or curved manner and undermining the skin 
edges. (See Figs, m and 112.) By connecting the two skin incisions in this 

ti.— Exposure of m 

the muscle. The s 
Note thai theincisir 

in in the muscle is 

in the direct 

.-third;,. ]>nucil line indicates line of 
ion of the muscle libers, not across them. 

manner, the length of the incision will be shortened and the skin edges may more 
readily be retracted out of the field. Additional exposure is then obtained by- 
carrying the incision as above described, longitudinally through the deep 
structures. (See Fig. 113.) 

These three parallel longitudinal incisions expose the musculospiral nerve 
from the lower border of the teres major muscle to the antecubital fossa with the 


tudinally are damaged but little, and the sensory skin supply, frequently com- 
pletely destroyed by the spiral incision, is in a great measure spared. Thus, the 
main objections to a spiral incision are avoided and a free and easy exposure 

Fie. 113.— Exposure of musculospiral nerve — lower two-thirds. Note the retraction of the 
lateral head of the triceps by means of tape and clamp. By retraction in this manner hleedins 
is stopped and an excellent exposure gained. 

The rather vertical course of the musculospiral nerve is not appreciated 
from the name, or the usual anatomical descriptions. The nerve is essentially 
vertical in its upper and lower thirds, being spiral only in a small portion of its 
middle third. Perhaps this is the reason why a spiral incision frequently does 
not lie over the course of the nerve, the precise position of which is difficult to 

The division of the musculospiral nerve into its two end branches may take 
place as high as its exit through the lateral intermuscular septum, in which 
instance the posterior interosseous will lie lateral, and the radial nerve medial. 


In this region the lateral cutaneous branch of the musculocutaneous nerve will 
be found along the border of the biceps within the interspace between the 
brachialis and supinator longus, and also the slender muscular branch to the 
extensor carpi radialis brevis, which has a long extramuscular course, may be 
destroyed unless its position be recognized. (See Fig. 114.) 

Fig. 114. — Exposure of the lower third of the tnusi-ulospiral nerve, the posterior interosseous 
and superficial radial nerves. Note I he Iojik exlraneura] aiurse of the nerve to the extensor carpi 
radialis h re vis. 

Occasionally, the external and internal cutaneous nerves within the 
musculospiral groove may be nearly as large as the main nerve trunk, for which, 
or for the muscular branches of which, Ihcy may be mistaken. The latter do 
not run with the nerve within the canal, but leave it to pass downward into the 
triceps, while the cutaneous branches, if traced, will be found to pass over the 
intermuscular septum. It is possible that in some instances, when there is 


sensory branches may have been crossed in suture, which might account for 
some cases of failure ami absence of functional regeneration. 

Posterior Interosseous Nerve. — To expose this nerve, the arm is slightly 
flexed across the lower abdomen with the hand semipronated. The prominence 
of the lateral condyle and the radial border of the extensor digitorum communis 
are identified. By rapidly moving the fingers passively, without extension 

Fie. iij. — Exposure of the posterior (if its fillers In lin'at..' I. In- posterior 
Obst., 1910.) 

The supinator muscle is split ii 
(Stookcy and Guild, Surg., Gyn 

of the wrist, the common extensor may be recognized. Lateral to it lie the 
extensor carpi radialis longus and brevis. An incision 12 cm. long is carried 
from the lateral condyle directly downward along the line between the extensor 
digitorum communis and the extensor carpi radialis longus and brevis, through 
the deep fascia. Beginning at the lower angle of the wound, the interspace 
between these muscles is identified and they are separated by blunt dissection as 
far as their common origin. Here the muscle fibers are cut longitudinally up 



to the lateral condyle. This last step is essential in order to obtain adequate 
exposure. The muscles are then widely retracted and the common extensor 
aponeurosis on the deep surface of the muscle mass exposed. Its free medial 
border can be readily found, then freed by blunt dissection and retracted with 
the extensores carpi radialis, thus exposing the obliquely running fibers of the 

1'ig. nO. —Exposure of the posterior 
splitting the supinator niusrlc, the muscle is thi 
Surg., Gyn. andObst.. igtg.) 

.erve. The tier 
. exposing the r 

having been located by 
ve. (Stookey and Guild, 

supinator brevis. These libers run forward and downward toward the flexor 
surface of the forearm. The posterior interosseous nerve is within or beneath 
this muscle. The nerve runs almost at right angles to the muscle fibers, diago- 
nally across the radius toward the extensor surface. At a point two fingers 
breadth below the condyle, the libers of the supinator brevis are separated in 
the direction of their course by blunt dissection, using two tissue forceps. In 
the opening thus made, the fiat posterior interosseous nerve will be seen. 


Having thus found the exact position of the nerve, the supinator brevis is 
cut across or retracted in the line of the nerve, thus exposing it freely in the main 
portion of its course, without danger of injury. (See Fig. 116.) Without the 
part separation of the muscle fibers by blunt dissection at right angles to the 
nerve, difficulty may be encountered in finding it. Should it become necessary 
to expose the posterior interosseous nerve higher than this incision permits, the 
lower incision described above for the musculospiral nerve should also be made. 

Fig. 117. — ■Transposition of the musculospiral nerve. The central end of the 
nerve is exposed as it crosses the I cm Ion of tlic lali-simus dursi and follou-cd down into the scar and 
callus on the dorsum of the humerus, (See Fig. 118.) A silk suture has been passed through the scar 
on the nerve and the central end of the nerve withdrawn so as to lie on the medial surface of the arm. 
A second silk suture has been passed through the scar on the distal end and this passed lo the medial 
surface of the arm heneutli the liii i-p-.. liv I his transposil inn eod-to-end suture can be accomplished. 

Transposition of the Musculospiral Nerve.- Transposition of the musculo- 
spiral nerve from its position behind the humerus to in front may be done in 
extensive injury of the nerve in its middle third. (See Fig. 117.) The nerve is 
exposed above, in the lower part of the axilla as has already been described, care 
being taken to safeguard the motor branches to the triceps which are given off 
at this level. (See p. 280.) 

The nerve is then exposed in its lower third, beginning below in the anti- 
cubital fossa and working upward, following the nerve beneath the lateral head 
of the triceps as shown in Fig. 113. The nerve is then freed from the surround- 
ing scar or callus in its middle third. If the injury to the nerve is extensive (see 


Fig. 118) and end-to-end suture cannot be accomplished, or particularly if a 

suitable nerve bed cannot be made, transposition of the nerve may then be done. 

The nerve is severed in its scar, leaving scar tissue on both the central and 

distal ends so that freshened nerve ends may not be traumatized in the manipu- 

SJuiculospinl nerve 
permit end- 

'■'■n of the mu^uloipiral nervt iime a= Fig. I 
taueht in olios in it; upper and middle third?. Damage to the nerve tc 
W-end suture without tranipoiition. 

lations necessary to bring the nerve to the medial side of the arm. A silk 
stay suture is parsed through the centra! end and the suture grasped with 
forceps and passed back along the course which the nerve has taken to gain the 
dorsum of the humerus. The nerve i~ made to appear in the opening at the 


motor branches given off just below the tendon of the latissimus dorsi are 
kept in view so that they may not be injured. If need be, these branches can 
be separated from the nerve trunk separately for a short distance in order 
to allow freer mobilization of the central end and to avoid sharp angles. The 
distal end of the nerve is now passed in like manner in front of the humerus 
in a tunnel made beneath the brachials muscle, or the nerve may be passed 
superficial to this muscle and beneath the biceps. 

After both the central and distal ends have thus been transposed, the arm 
may be flexed and adducted in order to allow end-to-end suture. By traction 
on the silk stay sutures the scar tissue on the nerve ends are approximated and 
the point at which excision of scar is to be made determined. Thus fresh, 
untraumatized nerve ends are presented for suture. 

This method of transposition is of value in selected cases only. If the 
motor supply to the triceps be endangered by transposition, as may be the case 
in injury to the nerve at certain levels, transposition should not be attempted 
since extension of the forearm is more important than extension of the wrist and 
fingers for the latter movements may be obtained by tendon transplantation. 
If neither transposition, can be done, nor regeneration obtained by nerve graft 
tendon transplantation of the palmaris longus, flexor carpi radialis or pronator 
teres will give fairly good functional extension of the wrist and fingers as well as 
of the thumb, and in selected cases is a method of choice. 

Comment.— Regeneration following suture of the musculospiral nerve has 
been more complete than in any other. This may be due to the fact that there 
are relatively fewer cutaneous sensory and sympathetic fibers in the main 
nerve trunk than in the median and ulnar nerves, and since the funiculi of the 
musculospiral nerve, are relatively large and few in number, funicular cross- 
ing is less apt to occur, hence more accurate funicular apposition may be 
obtained. Again, motor return may be relatively imperfect, yet functionally 
satisfactory, since the muscles supplied generally do not partake in finer 
movements which require not only motor impulses but accuracy in the 
proprioceptive impulses, and also reflex co-ordination of the associated syner- 
gic units. The failure to re-establish proprioceptive sensation or its partial 
loss would be much more noticeable, for example, in the ulnar nerve. Yet 
Stopford (1920) has called attention to the fact that even in musculospiral 

. nerve u ***** to th ; 1 

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. Seisin sequent, a 

, Thel^^ mu>a 

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' ^^ is made to a,yc; 
" — *?', A «, lie —cry <» * 

, .votovathic sensibility. 

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nerve trunk and the rearrangement which may take place in them. Further- 
more, in large muscles, a number of nerve fibers may be lost without gross 
functional impairment. The extensor pollicis brevis is a comparatively small 
muscle, having proportionately few fibers and, therefore, a loss of only a few 
fibers would be more apt to produce marked functional loss. 


This nerve arises from the dorsal cord of the brachial plexus and is made 
up of fibers from the dorsal divisions of the fifth and sixth cervical nerves and 
supplies primitive dorsal musculature- -the deltoid and teres minor muscles, 
as well as the shoulder-joint and the skin over the deltoid. 

.1 surface. (I'rohse 

Course. -Within the axilla the nerve runs in the sheath of the musculo- 
spinal nerve lying along its lateral border. The circumflex leaves the main 
nerve trunk at the outer border of the subscapularis muscle and passes with the 
posterior circumflex artery and vein, the vessels lying above the nerve, through 


the quadrilateral space formed by the teres minor and subscapularis above, the 
latissimus dorsi below, the long head of the biceps laterally and the humerus 
medially. The nerve lies under cover of the deltoid as it winds around the 
surgical neck of the humerus from behind forward. 

Branches. — The nerve really consists of two main bundles, the larger fun- 
iculus lying medial and the smaller lateral. The medial supplies theteresminor 
and a part of the spinal portion of the deltoid, while most of its fibers form the 

ture, Dotted line indicates incision in the periosteum. The periosteum is then pushed back and a 
rirhje of bone together with the insertion of the pecloralis major h removed. The insert on the 
ri>;hl shows the ridge of bone nod pecloralis insertion removed, that on the left, the bone and tendon 
replaced and the tendon and periosteum sutured 

cutaneous branch of the circumflex. The lateral bundle gives off the articular 
branch to the shoulder joint and supplies the remaining portions of the deltoid. 
fSee Fig. .10.) 

Exposure. In the Axilla.— The arm is held in extreme abduction and out- 
ward rotation. A sand bag is placed beneath the shoulder near the midline so 
as I" leave the lateral portion of the shoulder free. An incision 20 cm. long 
i-^ made in the line of the great vessels with its middle over the proximal border 


fascia, and the pectoralis major is retracted upward. In exposure of the nerve 
higher up this muscle obstructs the field and should be cut at its insertion rather 
than through the muscle fibers. (See Fig. 120.) The neurovascular bundle 
is then exposed from below up, and the circumflex nerve may be found by follow- 
ing up along the musculospiral nerve to the origin of the circumflex from this 
nerve. The circumflex arises at a point corresponding to the junction of the mid- 
dle and outer thirds of the axillary artery, and usually from the medial side of the 
musculospiral nerve, though it may occasionally arise from the lateral side. 
The nerve may be sought as it enters the quadrilateral space just above the 
latissimus dorsi tendon, using the latter as a guide to the nerve, which lies close 
to the medial border of the tendon. Once the nerve is identified it can be 
traced downward behind the vessels of the axilla. 

Exposure at the Surgical Neck. — If the nerve has been injured more dis tally 
it may be exposed where it passes around the surgical neck of the humerus. 
The arm is placed in the same position as for exposure of the upper third of the 
musculospiral nerve. (See Fig. no.) A longitudinal incision 12 cm. long is 
made along the dorsal border of the deltoid. This muscle is retracted upward, 
or its most dorsal fibers may be split from the rest of the muscle and the nerve 
sought against the humerus as it makes its exit from the quadrilateral space to 
wind around the surgical neck. 

If the nerve is injured where it is about to break up into its terminal 
branches, suture may not be possible and direct implantation of the central 
stump into the muscle should be done. (See Chapter IV.) 

Deformity.-- Due to paralysis of the deltoid the arm cannot be abducted 
but slight elevation may be accomplished by the supraspinatus. (Seepage 229.) 
In certain instances elevation may be accomplished by the patient lowering 
his shoulder and contracting his biceps, thus fixing the shoulder-joint and, by a 
swinging motion of the trunk, bring the humerus to such a position that 
elevation may be accomplished by the clavicular head of the pectoralis major, 


Mechanical Treatment. — The arm should be abducted to ninety or a hundred 
degrees. The foreman may be flexed and held horizontal so that the patient 
may make use of his hand. To accomplish this an airplane splint is light and 
satisfactory. (See Fig. 98.) However, the patient frequently objects to 
the awkward position in which the arm is thus held. If this position is refused 
the arm may be placed in a sling and an extra sling passed around the elbow and 
over the acromion and tightened. Thus by drawing the humerus upward and 
lessening the distance between the head of the humerus and the acromion the 
deltoid is relaxed and its overstretching by dragging down of the arm is 

Achard, H. P. and Jakkowski, J.: La transplantation tendcneuse comme trailement de la 

paralysic radiate, Progres nu'd., Sept., igjo, pp. 387-3°°- 
Andre-Thomas: Reactions [it!omtitricc» dans In p;ir;dvsie du ncrf radial. Rev. Neurol., 

v. 35: (v. 26}, igtg. pp. 448-450. 
A.VSINN, Otto: Fascien-im plantation bei Radialis- und Peroneuslahinung, Beitr. 1.. klin. 

Chir., v. 105: 1017, pp. 587-59.5. 
Auvrav: Resultnts eloigni's de 30 plaies du nerf radial operees in 1015 and 1016., Bull, el 

mem. Sot. de chir. de Par., v. 45: hjio. p. 1291. 
BAISCIt: Zur Frage der Sehnenopenitiuncn bci irrcparabler Radiulisliihmung, Munchen. 

med. Wchnschr., v. 66: igtg, p. 835. 
Borchardt, M. and Wjasmksski: Dcr Nervus Radialis, Bruns Bcilriige z. klin. Chir., 


M assart, R.: Le traitement chirurgical de la paralysie radiale traumatique par la trans- 
plantation tendineuse, These de Paris, 1918. 
Mauclaire, P.: A propros des resultats elognes des plaies des nerfs, Bull, et m6m. Soc. 

de chir. de Par., v. 45: 1919, p. 1344. 
Perthes, G.: Schussverletzungen peripherer Nerven (XVII Wanderversammlung der Siid- 

wetsdeutschen Neurologen und Psychiater in Baden-Baden, 2 und 3 Juni, 191 7), Mun- 

chen. med. Wchnschr., v. 31: 191 7. 
Ueber Sehnenoperationen bei irreparabler Radialislahmung, nebst Studien iiber die 

Sehnenverpflanzung und Tenodese im allgemeinen, Beitr. z. klin. Chir., v. 113: 1918, 

pp. 280-368. 
Rousey, G. and Branche, J.: Deux cas de paralysies dissociees de la branche post6rieure 

du radial a type de pseudo-griffe cubitale, Rev. Neurol., v. 24: No. 2, Nov. and Dec. 

1917, P- 312. 

Spitzy, H.: Operative Behebungen Lahmung des N. Radialis, Arch. f. Psychiat., v. 59: 

1918, p. 652. 

Stern, K.: Schussverletzungen des Nerves radialis, Deutsch. mil-artzl. Ztschr., v. 46: 1917, 

P. 233- 
Stopford, J. S. B.: The results of secondary suture of peripheral nerves, Brain, v. 43: pt. 1, 

1920, p. 1. 
Stookey, B. and Guild, S.: A method of exposing the musculospiral and the posterior 

interosseous nerves, Surg., Gyncc. & Obst., June, 10 19, PP- 612-615. 
Sudeck, F.: Zur Sehnentransplantation bei der Radialislahmung, Deutsch. med. Wchnschr., 

v. 45: 1919, p. 1000. 


Anatomy.— The musculocutaneous nerve arises from the ventral division 
of the fifth and sixth cervical nerves and is joined by the nerve to the coraco- 
brachial which arises from the seventh cervical. This latter nerve may be 
entirely separate from the musculocutaneous or it may be completely incorpo- 
rated within the sheath of the latter. Through these two nerves the coraco- 
brachial muscle, biceps and brachialisa re supplied; the brachialis occasionally 
receiving a twig also from the musculospiral nerve. The coracobrachial 
and biceps develop entirely from primitive ventral musculature and conse- 
quently are supplied solely by ventral branches, whereas, as has been said, 
the brachialis is a composite muscle formed by fusion of both ventral and dorsal 

Course. — The musculocutaneous nerve separates from the outer cord 
of the brachial plexus generally at a point beneath the pectoralis minor muscle, 
though it may separate more peripherally, almost as a branch, from the median 
nerve. The nerve lies at first between the axillary artery and the coraco- 
brachial muscle, but almost immediately pierces this muscle between its 
two heads of origin and then descends between the biceps muscle and the 
brachialis. It emerges from under the biceps, pierces the deep fascia just 
above the elbow along the lateral border of the biceps and terminates in cut- 
aneous branches for the supply of the outer side of the forearm. (See Fig. 

Branches. — A branch to the coracobrachialis arises just before the nerve 
pierces this muscle. The branch to both heads of the biceps is given off at 
about the junction of the middle and upper thirds of the muscle and the bran- 
ches to the brachialis at a somewhat lower level. (See Fig. 122.) Occasionally 
two sets of branches to this latter muscle are found, consisting of an upper and 
lower group. The terminal branches of the musculocutaneous are cutaneous, 
which pierce the deep fascia slightly above the elbow medial to the cephalic 
vein and descend along the radial side of the forearm as far as the ball of the 





The nerve for the coracobrachialis may be completely separate, as a distinct 
bundle lying on the lateral border of the nerve. Adjacent to this bundle lies the 
funiculus for the biceps, while on the medial border is the funiculus for 

Fig. 1st, — Musculocutaneous mm Surface projection, 

o coracobrachialis; 3, branch lo hiceps (both heads); 4, branch t 

, Mum.u1u cutaneous; ;, branch 
brachialis; 5, cutaneous branch. 

the brachialis. Between the funiculi for the biceps and the brachialis are the 
sensory funiculi of the nerve which terminate in the sensory branches. 

Anomalies.- Abnormalities in the distribution of the musculocutaneous 
and median nerves are important since, in these anomalies, may be found the 



explanation of some unusual and otherwise puzzling paralyses. In no other 


two nerves of the extremity are the variations in distribution more frequent or 
more numerous. The explanation of these variations is found in the compara- 
tive anatomy and development of the musculocutaneous and median nerves. 
Both nerves supply primitive ventral musculature. In man, the outer cord of 
the brachial plexus gives rise to the musculocutaneous and part of the median; 
both nerves receive, in part at least, fibers from the more cephalic of the spinal 
segments forming the brachial plexus. 

The musculocutaneous and median nerves of some vertebrates, such as the 
ruminants, constitute a single nerve trunk. In higher mammals a division 
of this single nerve trunk into two separate nerves occurs. At first the musculo- 
cutaneous appears as a branch, not of the outer cord of the plexus, but of the 
median nerve. Some of the earlier anatomists (Arnold, 185 1. Hyrtl, 185 1) 
considered the musculocutaneous as a branch of the median nerve. Not 
infrequently the musculocutaneous does arise as a branch of the median, but 
such origin is unusual. 

Various abnormalities in distribution have been described by Gruber 
(1849) Hytrl (1859), Gegenbaur (1867), Krause (1868). The median nerve 
may give off the cutaneous branch which should arise from the musculocutan- 
eous, or it may supply muscular branches to the biceps, and even to the brachi- 
alis. The whole motor and sensory distribution of the musculocutaneous nerve 
may be taken over completely by the median. On the other hand, the muscul- 
cutaneous may take over partly, or completely, the motor and sensory distri- 
bution of the median, but this latter type of variation is rarer. The rarity 
of this type is to be expected since the musculocutaneous in its development 
represents a migration of fibers to it from the primitive median nerve trunk. 

Some form of communication between these two nerves is found in 70% 
according to Gegenbaur. A few of the different forms of these variations are 
shown schematically. (See Figs. 123 and 124.) A study of these will help to 
make clear the different abnormalities and variations in the distribution of these 
two nerves. 

The extent of the communication between these two nerves may also vary 
somewhat according to the type of plexus. The libers pas* from the musculo- 
cutaneous to the median nerve more often in the postiixed plexus than in the 
prefixed, possibly due to the fact that in the postfixed plexus the contri- 
bution of the fifth and sixth cervical roots to the median nerve is less than 
in the prefixed. Consequently in a median nerve arising from the latter 





Inner 1 

Br to Coroco Br«t*». M. 

Inn«r Cord. 

Cutooaou* Or. 


Cortco Orach M. 

Br. +0 Pronator Teres J-J. 

Inn»r Cord. 

Fig. 124. — Schematic drawing showing abnormalities in the distribution of the median and 
musculocutaneous nerves. A y The muscular branch to the coracobrachial is given off directly 
from the outer cord of the plexus. The musculocutaneous nerve a is little more than a communication 
to the median. The latter nerve gives off the muscular branch to the biceps, brachialis and the 
cutaneous branch normally from the musculocutaneous nerve; B, the entire distribution of the 
musculocutaneous nerve is supplied through the median; C, the major distribution of the median 
nerve is supplied through the musculocutaneous nerve. 


type there is a secondary reinforcement of its fifth 
cervical component by an additional contribution 
from the musculocutaneous. Conversely, in the 
prefixed variety the direction of the communica- 
tion may be reversed and a reinforcement from 
the median nerve be sent to the musculocutaneous. 
In some instances by finer dissections the com- 
munication of themusculocutaneoustothemedian 
(see Fig. 125) has been shown to consist of three 
funiculi. The first passes to the median nerve, 
and runs in the median for a short distance, to re- 
turn again to the musculocutaneous. The second 
enters the funiculus destined to the pronator teres 
and flexor carpi radialis, and has been traced as 
far as the humeral head of the pronator teres, sup- 
plying [this muscle. The third funiculus immedi- 
ately divides; one branch enters a sensory path in 
the dorsal part of the nerve trunk, while the other 
has been followed through the median to the 
forearm, where it communicates with the funicu- 
lus supplying the thenar muscles. Thus it will 
be seen that in these types of communication the 
musculocutaneous nerve may supply through the 
median the humeral head of the pronator teres, the 
thenar muscles (abductor pollicis.opponenspollicis 
and flexor pollicis brevis), as well as some sensory 
fibers for the palm. 

It is difficult to believe that these various anoma- 
lies occur merely by chance, or as the result of de- 
velopmental differences in adjacent structures. 
They are traceable rather as variants of different 

p 10 , j 5 — Macerated dissection of median nerve (left) 
showing communication with the musculocutaneous nerve. 
A B, C, Communication from the musculocutaneous to the 
median nerve. Bundle A joins with the funiculus 1 for the 
pronator teres and flexor carpi radialis; B enters the dorsal part 
of the trunk to pass possibly to the thenar muscles; C rejoins 
the musculocutaneous nerve. (Modified after Borcbardt and 


degrees from some primitive pattern in the development of the two nerves. 
Cruveilhier (185 1) felt that the origin of the musculocutaneous from the 
outer cord explained the frequency with which the musculocutaneous fused 
with the median nerve. While this may be true, the real explanation 
goes farther back in the phylogeny of these two nerves. These variations 
should be considered as regressive phenomena dating to the time when 
the musculocutaneous and median nerves were one in the ruminants. 

Deformity. — In complete paralysis of the musculocutaneous nerve the 
action of the coracobrachialis, biceps and brachialis is lost. As has already 
been said, a twig from the musculospiral supplies the latter muscle but it rarely 
gives sufficient innervation to permit of a functional contraction. The contour 
formed by the biceps is absent and the ventral surface of the arm appears more 
or less concave. Flexion of the forearm is not, however, completely lost due 
to the flexion action of the supinator longus, which may undergo tremendous 
development and is capable of forcible flexion, even without the other flexor 
muscles. If the upper extremity be allowed to hang by the side the forearm 
cannot be flexed, since in this position the supinator longus is unable to obtain 
the necessary leverage. If such a patient is examined for flexion of the forearm, 
when seated, he will usually swing his arm so that his hand rests upon his thigh 
and thus, with the forearm slightly bent, he will be able to continue flexion 
with considerable force solely by action of the supinator longus. If the hand 
be held in pronation, occasionally, the supinator longus may gain sufficient 
leverage during efforts at supination to obtain further contraction and bring 
about flexion. 

In paralysis of the biceps and brachialis, if the forearm be held in semi- 
flexion the supinator longus will be seen as a strikingly prominent muscular 
band forming the lateral boundary of the antecubital fossa, thus by its promi- 
nence accentuating the absence of any contour formed by contraction of the biceps. 

Rarely the pronator teres may serve as a flexor in combined paralysis of 
the musculocutaneous and musculospiral nerves in which the supinator longus 
is paralyzed as well as the biceps and brachialis. This action on the part of 
the pronator teres is most rare. The hand is held in full pronation and flexion 
is begun by passively elevating the hand a short distance after which flexion is 
completed by the pronator teres. 

The shape of the elbow-joint mechanically prevents the development of 


Mechanical Treatment. — Overstretching of the biceps is unlikely, due to 
the fact that other muscles of different nerve supply support both joints over 
which this muscle passes: the supinator longus flexing the elbow and the triceps 
and deltoid supporting the humerus at the shoulder. However, to prevent 
adaptive shortening of the triceps and to protect the muscles, especially from 
attempts to carry heavy weights and other unguarded movements, the forearm 
should be held at night and during part of the day in semiflexion, the hand in 
supination and the arm drawn toward the opposite shoulder. (See Fig. 126.) 

Pig. 126.— Wrist strap for paralysis nf the musculocutaneous. A, Arm held in semiflexion 
mil drawn across Id the opposite similiter. Hand is held in supination. Metal dorsal extension 
licce supports ihe hand and prevents it from falling into dependent position. The small strap almut 
hi; wrist is attached only In Hie volar surface on the radial side and passes under the wrist, thus 
issisliiig in main lain inj; supination; /*, to illustrate wrist strap and metal extension. Leather 
.■iiverini; is turned li.nk. showine; metal piece which extends from wrist across dorsum of hand. Note 
iiie of attachment of small wrist strap and that it passes under and behind the wrist. (Stookey. 


Incision, 15 cm. long, is started along the inner margin of the coracobrachi- 
al and carried upward over the pectoralis major into the cleft between it and the 
deltoid. The cephalic vein should be saved since the vein within the axilla 
may be involved in scar tissue. After the skin and fascia have been divided 
the inner margin of the coracobrachial is identified and thoroughly exposed. 
The pectoralis major overlies the field and in most instances must be cut to 
obtain a thorough exposure, but this should be avoided whenever possible. 
If the muscle be cut where it crosses the nerve, resuture will be difficult since 
the sutures pull in the direction of the muscle fibers, and hence are apt to 
tear out. It may be necessary to cut only the lower part of the muscle saving 
the clavicular head. While a limb already weakened by paralysis may com- 
pensate for loss of this muscle, it is undesirable to add an additional motor dis- 
ability if it can be avoided. Instead of cutting through the fleshy part of the 
muscle, the insertion of the pectoralis major may better be exposed and a disinser- 
tion done. (See Fig. 120.) At the line of insertion the periosteum is pushed 
back and a small bit of bone together with the insertion is chiselled loose and 
the muscle then reflected. After the operation the bone is replaced and the 
tendon and periosteum sutured. 

The nerve may be identified in the wound by following the medial border 
of the coracobrachialis muscle to the point at which the nerve enters this muscle. 
This takes place very near to the origin of the muscle, approximately 3 cm. 
below the coracoid process. Numerous nerves and blood vessels in this part 
may confuse the field. The axillary vein lies internal to the artery but with 
the arm held horizontal to the body the vein may be found overlying the 
latter. Three veins may be encountered, the cephalic and the two vena? 
comites which unite at the lower border of the subscapularis muscle to form the 
axillary vein. Occasionally the union is effected higher so that four veins are 
seen, the fourth, the basilic vein which usually joins the inner vena comes 
below. The cephalic vein usually enters the axillary proximal to the pec- 
toralis minor. Along the medial border of the musculocutaneous nerve and in 
front of the artery lies the outer head of the median nerve. 

Exposure of the Secondary Cords of the Brachial Plexus. The method 
just given for exposure of the musculocutaneous nerve within the axilla may also 
be used for exposure of the secondary cords of the brachial plexus and is, therefore, 
considered here. If the secondary cords of the brachial plexus are to be repaired 
the pectoralis major must be cut or disinserted and reflected medially to expose 


JM WMGU 1U mechanical treatment of peripheral nerves 

stirtvr must also be cut and reflected in a similar manner. The long thoracic 
artery shouki be isolated before cutting this muscle. The important vessels and 
nerve* should be freed and kept in view to avoid injuring them. This is best 
vKvontpltshed by identifying each structure distal to the injury and dissecting 
HMMld M) when necessary, also beginning above and dissecting downward. 
Injuries in the axilla usually involve at least two nerves in combination; on the 
ouioi >ivU". the musculocutaneous and the outer head of the median; on the 

„ i fcvpuMMY "I the secondary 

i, ,.i ,.i i u, i. kiIi. in .1111! the ulnar 

1 1. ,., . uudli ■ major has I n't » dii 

. I ihuLiuII) k 

..I,. i 

, the n 

hid! pleaus below the clavicle. The 
wen- Involved in scar necessitating excision and 
Hi, the pectaralis minor cut and both have been 
of the pectorulis minor is seen the cephalic vein 
locutaneous nerve with its branch to the coraco- 

,,,1,1 head of the median and ulnar nerve, or the ulnar and 
, . -..v Fig ta?.) 

, ti.V Win wvprh'es the ulnar nerve and the inner head of the median- 

, . ,,,.,. I,. i iwlWMd by cutting one or two of its branches from the 

. , . .. u.,i! especially ihe dorsalis scapula; and the long thoracic. 

.1 kibtxtded in scar (issue liberation may not be possible and 

in necessary, ''"his can be done safely if the cephalic 

uil when the skin incision was made. Lying medial and 



these two nerves at this level are not infrequently injured together. The mus- 
culospiral nerve may be seen by retracting the ulnar nerve and the axillary vein 
inward; the nerve is then sought behind the axillary artery. If this does not 
give adequate exposure the whole neurovascular bundle may be rolled outward 
after cutting a few of the smaller vessels, and the musculospiral nerve then, is 
brought into view as it crosses the latissimus dorsi and teres major tendons 

i:S, — Exposure of the musci 

\rt into the biceps muscle. The distal end nf the n 

Innervation of the biceps is thus Rained by din 

at its origin with direct implantation of 
i- w:is too extensively destroyed to permit 

(See Fig. 109.) As the nerve lies on these tendons it is in close relation to the 
circumflex nerve which is given off the dorsal cord just before it reaches the 
latissimus dorsi tendon. 

The circumflex nerve passes with [he relatively large circumflex artery and 
vein below the tendon of the subscapularis muscle. If the musculospiral fibers 
are involved central to the circumflex the subscapular nerves may be endan- 
gered. The short subscapular nerve, often double, and the lower subscapular 
pass behind the circumflex nerve, on the ventral surface of the subscapular 
muscle, supplying this muscle and the teres major. The long subscapular 


is distributed to the latissimus dorsi. If the injury is too near the main nerve 
trunk or if it is destroyed at the origin of the branches and suture of these 
is not possible, the central ends may be sutured into the main nerve trunk, or if 
the injury is more distal the distal ends may be implanted directly into the 
muscles which they supply. (See Fig. 128.) 

In operations in the axilla traumatic aneurysm either arterial, venous or 
both may be encountered and dealt with. If ligation is necessary the liga- 
tures should be passed both centrally and distally close to the sac, in order to 
save as much of the artery and as many of its branches as possible in order to 
permit the best collateral circulation. 

Exposure of the Middle Third of the Musculocutaneous. — An incision is 
made along the medial border of the biceps and after the latter muscle has been 
retracted outward the nerve will be found lying beneath the biceps and upon 
the brachialis. In this region the motor branches to the biceps and brachialis 
are given off and careful dissection must be done to safeguard them. If the 
nerve is injured below the middle third only sensory branches will be involved. 

Exposure of the Cutaneous Branch. — This branch is desirable for use in 
autogenous nerve grafts; it can be reached through the same incision as for the 
lower third of the musculospiral. If the outer border of the biceps is followed 
the nerve may be identified as it emerges from beneath this muscle to pierce the 
deep fascia a little above the biceps tendon. The nerve may be followed higher 
up by retracting the biceps inward and the nerve may then be cut at the junction 
of the middle and lower thirds of the humerus, thus obtaining a longer nerve 
segment for graft than if taken only at the point where it emerges from beneath 
the muscle, as is usually done. By dividing the nerve in this lower third mus- 
cular branches are not severed. 

Comment. — Following suture rapid regeneration of the musculocutaneous 
nerve with complete return of function in its muscles may be expected. The 
muscular portion of the musculocutaneous being a short nerve is always injured 
relatively near the spinal cord, consequently rapid and complete regeneration 
usually takes place. Also its muscles are not directly concerned in finer move- 
ments and hence functional return is apparently more complete. Such dis- 
abilities as are found in smaller muscles, concerned with movements of greater 
precision and dependent upon exact proprioceptive impulses, are not felt in the 
large flexor muscles of the arm where as a rule movements of precision and 
fineness are not called for. 



Cruveilhier, J.: Traite D'anatomie Descriptive, 4 vols., Labe, ed. 3, 1851-52, Paris. 
Gegexbaur, C: Ueber das Verhaltniss des N. musculocutaneus zum N. medianus, Jen- 

aische Zeitschrift fur Medicin und Naturwissenschaft, v. 3: 1867, p. 258. 
Gruber, W.: Neue Anomalien als Beitrage zur physiologischen chirurgischen und patho- 

logischen Anatomic, Berlin, Verlag von Albert Forstner, 1849. 
Gosset, A.: Resultats fonctionnels des operations faites sur les nerfs peripheriques, Arch. 

de med. et pharm. mil., v. 69: 1918, p. 304. 
Henle: Ueber Kriegsverletzungen der Peripherischen Nerven, Yerhandl. d. deutsch. 

Gesellsch. f. Chir., v. 35: pt. 2, 1906, p. 60. 
Herzog, A.: Zusammcnstcllung von 150 Fallen von Verletzungen der Nerven der oberen 

und unteren Extremitat, Mtinch. med. Wchnschr., v. 64: 1917, pp. 1021-1060. 
Hyrtl: Ueber das Vorkommen eines dritten Kopfes des Biceps brachii, Oesterreichische 

Zeitschrift fiir Praktische Heilkunde, 1859, p. 479. 
Ingham, S. D. and Arnett, J. H.: Diagnosis of peripheral nerve injuries with special refer- 
ence to compensatory movements, Arch., Neurol. & Psychiat., v. 3: 1920, p. 107. 
Sherren, J.: Some points in the surgery of peripheral nerves, Edinburgh M. J., v. 62: 

1906, p. 207. 
Stopford, J. S. B.: The results of secondary suture of peripheral nerves. Brain, v. 43: 


Anatomy.- The median nerve is formed at about the level of the lower 
rder n( the pcctoralis minor muscle by junction of the outer and inner 
ids, arising respectively from the outer and inner cords of the brachial plexus. 

-. the 


ing in front the artery from without inward at about the middle of the arm. 
At the elbow the nerve lies on the inner side of the artery and descends into 
the forearm, passing between the two heads of the pronator teres, separated 
at this point from the ulnar artery by the ulnar head of this muscle. The 
nerve then passes between the deep and superficial flexors until the lower 
fourth of the forearm is reached, at which point it again becomes superficial, 
lying immediately beneath the tendon of the palmaris longus muscle and radial 

Fie. 130. — Schematic drawing showing 

and abnormal 

of the artery. (Rugc, -Morpholog. Jahrbuch.) 

to the flexor digitorum sublimis. The nerve is superficially placed in the 
arm and at the wrist, but lies deeper in the upper three-fourths of the forearm. 

The nerve enters the palm of the hand beneath the anterior annular liga- 
ment on the radial side of the flexor tendons of the fingers, and beneath the 
palmar fascia it breaks up into its terminal branches. In the forearm it is 
accompanied" By a small vessel, the artcria comes nervi mediani, which lies 
on the ventral surface of the median nerve, as far as the wrist. 

Variations in the Formation and Course.— Numerous variations in the 
formation of the median nerve occur. The outer and inner heads may be 
reduplicated as shown in Fig. ijo. a third head of origin may be formed 
from the inner cord (Cruveilhier, 1S51), or union of the outer and inner heads 
may take place in the middle of the arm. or as far down as the elbow. The rela- 
tion of the median nerve to the brachial artery may vary. The outer head of 


the median may pass behind the artery to join the inner bead, while in the arm 
the nerve may pass behind the brachial artery, remain parallel to the artery, 
or pass either medial or lateral to it. Gniber (1867) found in one hundred 

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.li*. Uorphriog. 

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Occasionally the brachial artery may be divided high in the arm and the median 
nerve found between the two branches. (See Fig. 131.) In its course the 
nerve may not enter its deep position in the forearm by passing between the 
two heads of the pronator teres, but may lie superficial to this muscle. In rare 
instances a bony process may be found along the medial supracondylar ridge 
known as the epicondylic process behind which the median nerve and brachial 
artery may pass, or if the process forms a bony or fibrous canal, as reported by 
Gruber (1867), Ruge (1884), these structures may be inclosed within it. Such a 
canal may be considered as atavistic, it being regularly present in some of the 
climbing mammals. 

Branches. — In the Arm. — There are no motor branches in the arm except- 
ing in the lower part of the lower third, at which level one or two nerves may 
be given off for the humeral head of the pronator teres. However, infrequently, 
two branches arise in the middle third of the arm, one a small articular branch 
which leaves the dorsal radial part of the nerve trunk and courses beside the 
brachial artery to the elbow-joint, where it divides, and then turns deeply to 
supply the elbow- joint. According to Frohse and Frankel (1908), this nerve 
ends occasionally in the brachialis and has been called by them the ramus 
collateralis nervi mediani. In about one-third of the cases a relatively promi- 
nent communication is given off from the musculocutaneous to the median. 
(See Fig. 132.) This communication consists generally of both sensory and 
motor fibers which may pass from the median to the musculocutaneous or 
from the musculocutaneous to the median. 

Motor Branches in the Lower Part of the Arm. — The first motor branches 
are those to the pronator teres, humeral head, generally two in number, one 
to the upper and the second to the lower part of this portion of the pronator 
muscle. These branches generally leave the nerve trunk on the ulnar border, 
though they may cross over from the radial side, in front of the nerve trunk 
and enter the muscle almost immediately below their origin, having a com- 
paratively short extramuscular course. (See Fig. 132.) 

Branches in the Forearm— (1) The next branches are those to the pronator 
teres (ulnar head) and also occasionally a small branch to the inferior part of 
the humeral head. These branches arise from the radial and ventral side in 
the region of the elbow-joint, just as the median nerve passes between the two 
heads of the pronator teres. (See Fig. 133.) 

Branches for the flexor carpi radialis arise in the region of the elbow, 
generally from the ulnar border, though they may arise from the radial side, in 


which case they pass over immediately totheulnar 
side, enter the flexor carpi radialis muscle and break 
up into numerous small twigs. 

The muscular branches to the pronator teres 
and the flexor carpi radialis {ia, ib, ic) constitute 
a single funiculus (see Fig. 134) which may be 
traced centrally as far as the union of the outer 
and inner heads of the median nerve. According 
to Borchardt (191 7), the position of this funiculus 
within the nerve trunk varies greatly. In the up- 
per part of the arm it lies upon the ventral and 
medial portion of the nerve trunk, gradually turn- 
ing toward the ventral and radial border, in which 
position it has been found by Marie, Gosset and 
Meige (191 5). However, in bipolar electrical stim- 
ulation tests, instead of crossing, it may be found 
to descend upon the ulnar side of the nerve. Elec- 
trical stimulation of the outer and inner heads of 
the median nerve tends to show that the fibers 
destined for the pronator teres lie in the inner 
head of the median nerve, and those for the flexor 
carpi radialis in the outer head. 

Fig. 132.— Macerated dissection of median nerve (left) 
showing communication with the musculocutaneous nerve. 
A, B, C, Communication from the musculocutaneous to the 
median nerve. Bundle A joins with the funiculus i for the 
pronator teres and flexor carpi radialis; B enters the dorsal part 
of the trunk to pass possibly to the thenar muscles; C rejoins 
the musculocutaneous nerve. 1, 10, lb. ic is the common path 
for the pronator teres and flexor carpi radialis. Note that this 
bundle crosses the nerve diagonally a little below the level of 
the elbow; 2, 2a, ib is the funiculus for the flexor indicis sub- 
limis (sup. belly) and palmaris longus, 20 for the flexor indicis 
sublimis and 2b for the palmaris longus. In this position this 
path lies on the ulnar border; 3 is the bundle to the flexor 
digitorum sublimis of the 3d, 4th, and 5th fingers; 4 is the bundle 
to the flexor digitorum profundus, flexor pollicis longus and 
the anterior interosseous nerve. This path crosses below the 
level of the elbow dorsally from the ulnar to the radial border; 
5, bundle to the deep belly of the flexor indicis sublimis. From 
this dissection it will be noted that identification of any one 
bundle can be made only over a comparatively short course 
and that fusion and intermingling of bundles is frequent. 
(Modified after Borchardt and Wjasmenski.) 


Fig. 133. — Nerve distribution in liic flexor iligiiiirum suMimis. (Frohse ;ind Frankel.) 

322 SRC4CAI. AS» ] 

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Median M. left. 

Ulnar border* 

Radial border 


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Fig. 134&. — Left median nerve, macerated dissection. The typical course of the bundle to the 
pronator teres and flexor carpi radialis is shown, 1, ia, 16, ic, passing from the radial border in the 
middle of the arm to the ulnar border below. Cross sections are shown at 2-cm. intervals; each 
section is placed at its corresponding level. Note the marked variation in the cross section appear- 
ance of each succeeding level. (Modified after Borchardt and Wjasmenski.j 


Immediately below the origin of the preceding branches, a branch arises 
for the flexor indicis sublimis (superior belly) (20 and 26) which divides to supply 
this muscle and the palmaris longus. This branch arises from the ulnar border 
of the nerve trunk, where the median nerve lies between the two heads of the 
pronator teres. The funiculus for this lies on the ulnar or medial border of the 
inner head of the median and then descends upon the ulnar on the dorsal part of 
the nerve trunk. It lies in close proximity with the funiculus for the deep 
flexors, (see Fig. 132) with which it communicates at numerous points. It 
then gradually turns more ventrally, though still upon the ulnar border, and is 
placed ventral to the most medial funiculus of the trunk, close to the funiculus 
for the flexor carpi radialis (ic), at the point where the latter crosses the 

The next branch given off is to the flexor digitorum sublimis of the third, 
fourth and fifth fingers (3), which arises from the ulnar and ventral side of the 
nerve trunk, 5 to 6 cm. below the medial condyle and 2 or 3 cm. below 
the branch to the flexor carpi radialis (ic). This funiculus is found as 
a distinct path only a few centimeters above the medial condyle, where it 
fuses with a funiculus along the ulnar side of the median nerve consisting 
most I v of afferent fibers. 

At about the same level as the above branch the branch for the deep 
flexors (.|) arises from the ulnar side of the dorsal surface of the nerve trunk at 
the upper margin of the pronator teres. It tirst descends along the ulnar 
border, thence crosses behind the nerve trunk to the lower border of the ulnar 
head of the pronator teres. It supplies twigs to the flexor digitorum profundus 
lor the second and third fingers and the flexor pollieis longus muscles, and termi- 
nates as the anterior interosseous nerve, which also gives oii twigs at a lower 
level to the same muscles. The anterior interos>eou> nerve descends in front 
ol the mt ei o^^eoiis membrane, covered bv the radial border <>I the flexor 


re-established in the above-mentioned muscles by means of the lower set of 
branc hes in spite of the loss of the others. 

Branches at the Wrist. — Several centimeters above the anterior annular liga- 
ment a palmar cutaneous branch arises, which supplies the skin of the palm of the 
hand. Approximately 2 to 3 cm. below the anterior annular ligament the mus- 
cular branch for the thenar muscles (abductor pollicis, opponens pollicis, and 
flexor pollicis brevis) arises from the radial and dorsal surface. Within the palm 
the median nerve then breaks up into its terminal branches, five in* number, 
which pass between the palmar arch and the flexor tendons, to supply both the 
radial and the ulnar side of the thumb, the radial side of the index finger, the 
first lumbrical muscle, the adjacent sides of the index and middle fingers, 
the second lumbrical muscle and the adjacent sides of the middle and ring fingers. 

Anomalies. — Variation in distribution of the median and ulnar nerves 
takes place often in the forearm, in the hand, and at times in the arm or axilla. 
These communications have been described by many of the older anatomists. 
Gruber (1870) found a communication between the median and ulnar nerves 
thirty-eight times in a hundred and twenty-five cadavers examined. In ten 
subjects the communication was bilateral and in the remainder it occured four- 
teen times on the leftside, four times on the right. Thompson's (1891) report on 
four hundred and six cadavers found such a communication to be present in 
I 5%- Four types of communication were described: 

(a) A communication arose from the anterior interosseous nerve about 
5 cm. below its origin and joined the ulnar nerve in its middle third, passing 
below the ulnar artery upon the flexor digitorum profundus. 

(6) A communication arose from the main nerve trunk of the median 
and joined the ulnar in the same manner as in (a). 

(c) A sling communication occurred over the flexor digitorum profundus 
formed by both median and ulnar nerves with branches from the sling supplying 
the flexor digitorum profundus to the third and fourth fingers. 

(d) A branch from the median nerve arose in the region of the elbow, 
passed superficial to the flexor muscles arising from the medial condyle, and 
joined the ulnar nerve in its middle third. 

In tracing some of these communications Borchardt (191 7) found that the 
communication to the ulnar nerve divided into two portions, one joining a 
sensory pathway and the other a motor. The fibers of the sensory path joined 
that part of the ulnar nerve which supplies the skin on the inner part of the 
palm, the palmaris brevis muscle and the fourth and fifth fingers, while the 


muscular branch joined that part of the ulnar nerve which supplies the intrin- 
sic muscles of the hand. (See Fig. 151.) 

In the hand there are two communications between the median and ulnar 
nerves of rather minor importance. One twig is sensory, for the adjacent sur- 
faces of the third and fourth fingers, while the other is motor, between the deep 
branch of the ulnar and the motor branch of the median nerve to the thenar 
muscles. According to Frohse { 1908) this branch is constantly present, passing 

Nerve dislribuliun lo the thenar muscles, deep surface. (I'nihse and Frankcl.) 

through the abductor pollids muscle and along the flexor pollicis brevis. (See 
Fig- r 3S0 This branch is difficult to follow except in specially prepared speci- 
mens though clinical evidence of this communication has been observed in cases 
in which severance of the median nerve above the wrist occurred without any 
paralysis of the muscles of the thenar eminence. The abductor pollicis brevis 
frequently receives a twig from the radial nerve which is considered motor by 

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encountered clinically as well as anatomically. Goldmann (1906) Auerbach 
and Brodnitz (1910), Halipre (1917) and others have reported cases in which, 
in spite of severance of the ulnar nerve, no paralysis in the muscles of the hand 
occurred. In these instances the innervation of all the intrinsic muscles 
of the hand has been attributed to the median nerve. Evidence of such a dis- 
tribution of the median nerve I have seen in one of my own cases. The diag- 
nosis of an ulnar nerve tumor was made because of the presence of a tumor in 
the middle third of the arm apparently arising from the ulnar nerve with 
subjective tingling and numbness referred to the fourth and fifth finger and 
also a sensation as if a knife were drawn down the middle of the fourth 
finger when the tumor was pressed upon. At operation a tumor of the 
median nerve in the middle third of the arm was found. To make certain 
that no error in identification of the nerves had been made the ulnar nerve 
was exposed in the groove behind the medial condyle. The nerve was traced 
upward a short distance sufficient to demonstrate that the ulnar nerve did 
not join the median below the tumor. At the time of operation it was thought 
that a mistake in diagnosis had been made and that the ulnar signs present 
were due to pressure of the tumor secondarily upon the ulnar nerve. The 
median nerve was then fully exposed and its course toward the front of the 
elbow determined. Excision of the tumor with end-to-end suture was done. 
Following the operation complete paralysis of the median and ulnar muscles of 
the hand and forearm was found as well as complete median and ulnar anesthesia . 

In Goldmann's case, a tumor and 5 cm. of the ulnar nerve was removed 
above the elbow with no disturbance in the motility of the hand and fingers. 
Auerbach and Brodnitz likewise found no motor paralysis in the ulnar distri- 
bution, after complete section of the ulnar nerve above the elbow with excision 
of a nerve tumor. Halipre also found that in complete severance of the ulnar 
nerve above the elbow there was no motor loss in the ulnar distribution and that 
at operation stimulation of either end of the ulnar nerve gave no response, but 
when the ulnar nerve was stimulated lower down contraction in the ulnar 
distribution followed. The cases of Goldmann, Auerbach and Brodnitz indi- 
cate in a negative manner, as it were, that the median nerve may take over 
the supply of the ulnar, while my own case showed that this supply is in fact 
taken over by the median, since severance of the median nerve resulted in not 
only median but in ulnar paralysis as well. 

From a developmental standpoint association in the distribution of the 
median and ulnar nerves is seen in the common supply by these nerves of the 


same muscle mass with overlapping, for loss of one nerve may result in only 
partial paralysis. (See Fig. 136.) Thus the intact nerve by its partial supply 
may mask the motor loss, assuming, in a measure, the function of the other. 
This is seen in the nerve supply to the flexor digitorum profundus of the third 
finger, in which there is some overlapping of both the ulnar and median innerva- 
tion. In some instances, the median nerve may extend its fibers to the flexor of 
the fourth and fifth lingers, but the ulnar nerve never extends beyond the flexor 
of the third digit. The flexor of the index finger, is supplied only by the 
median nerve. Consequently, following median nerve injuries, the only ap- 
parent paralysis which may be observed in the flexors of the fingers is that of 
flexion of the index linger and thumb, while in ulnar paralysis flexion may be 
carried on in all fingers through median nerve action. 

Deformity. — Complete injury of the median nerve above the elbow involves 
the flexors of the wrist, ringers and thumb, the pronator teres and pronator 
quadratus as well as the opponens pollicis, flexor pollicis brevis and superficial 
head of the abductor pollicis. Of the flexor muscles of the forearm the flexor 
carpi ulnaris and ulnar portion of the flexor digitorum profundus escape. 

Loss of contour on the ventral surface of the forearm is seen and a small 
transverse furrow can be felt over the metacarpal bone of the thumb. This 
latter depression is characteristic and constant in atrophy of the opponens 
muscle. Flexion of the wrist is accomplished by the flexor carpi ulnaris which 
usually draws the wrist toward the ulnar side due to the absence of the pull of 
the flexor carpi radialis. The flexor carpi ulnaris may produce forcible flexion 
of the wrist and this muscle can be developed in re-education when in median 
injuries flexion has been lost. Pronation may be done by the supinator longus 

FlG. 136.— Nerve distribution to the flexor carpi ulnaris, flexor digitorum profundus and abductor o 
flexor pollicis iongus. [Frohsc and Frankcl.) 


muscle. If such an explanation were correct it would seem curious that almost 
constantly such an injury should select this particular funiculus without impli- 
cating the others. Such an apparent dissociated lesion, relatively common 
in the median nerve, is rather infrequent in other nerves. The real explanation 
may be found not in the funicular arrangement and the fact that this funiculus 
does have a very long and separate course, but more likely in the fact that the 
flexor indicis sublimis is exclusively supplied by the median nerve so that 
supplementary innervation does not take place as occurs in other muscles 
supplied conjointly by ulnar and median nerves. Not only are the flexors of 
the index paralyzed, but also the other median flexors. The paralysis of the 
latter with the exception of the flexors of the thumb and index is masked by the 
action of the ulnar flexors, while the action of the flexors of the index is not com- 
pensated for and hence inability to flex the index may be the only striking sign. 

Perhaps one of the most characteristic paralyses in the hand following 
median nerve injury is loss of the opponens action of the thumb. This move- 
ment maybe closely similated by rotation and flexion of the thumb, the thumb 
skirting the base of the metacarpophalangeal joints by action of the abductor 
pollicis and the flexor pollicis brevis. True median opponens action can be 
said to be accomplished only when the palmar surface of the distal phalynx 
of the thumb is in apposition with that of the fifth finger, the interphalangeal 
joints of both being fully extended. 

Mechanical Treatment. — In median nerve paralysis overstretching of the 
flexor muscles is not apt to occur, fur integrity of the flexors supplied by the 
ulnar nerve prevents contractures by maintaining the mobility in the muscles 
and joints. Flexion and extension of the fingers through ulnar nerve action 
passively move the median flexor tendons, thus improving the circulation and 

median- nerve 

In median nerve neuritis contractures may be severe and tax the ingeni 
he surgeon to devise splints which will overcome the contractures and yet 

ilinl for median paralysis applied. !■' 
strips of adhesive tape. (Bucrki, Arc 

are made of thin board hek 
attOogy and Psychiatry, ig» 

Psychiatry, igio.) 

of fixation of the fingers. The s] 
four. (Buerki, Archives of Neuro 

duce contractures in overcorrected positions. Immobilization in o' 
reeled positions cannot alone suffice, for contractures at once occur in 


new and equally vicious position. In these cases particularly, mobilization 
must be combined with immobilization and each case dealt with individually. 

Exposure of the Median Nerve. Position of the Arm. — The arm is held 
at right angles to the body with the forearm slightly flexed to relax the 
nerve. When the arm is fully extended the nerve is stretched and may be 
concealed beneath the border of the biceps muscle. In operations in the 
forearm the wrist should also be flexed. 

■logy and 

Incision. — Exposure of the median nerve, except the part beneath the 
humeral head of the pronator teres, offers no difficulty. By retracting the 
pectoralis major muscle upward and inward the nerve may be exposed along the 
inner surface of the arm as far up as the union of the outer and inner heads. 
(See Figs. 140, 141, 142 and 143.) An incision along the medial border of the 
biceps will readily bring the nerve in the arm into view. In muscular subjects 
with well-developed biceps the nerve will be found hidden beneath the border 
of this muscle. Its relation to the brachial artery has already been mentioned- 
The funiculus to the pronator teres is importnat since it has a more or less con- 
stant position in the nerve trunk near the place at which the upper motor 
branches are given off, viz., the lower one-third of the arm and the upper 
one-third of the forearm. Higher in the arm the position of this funiculus is 
inconstant and variable. It may be said that generally the funiculus to the 
upper belly of the flexor indicis, the flexors digitorum profundus and pollicis 
longus lies along the dorsal ulnar border, while the funiculus for the pronator 
teres and flexor carpi radialis lies ventral and in the middle of the nerve trunk 
in the upper part of the arm, whereas in the lower third the latter funiculus lies 


on the radial and ventral border. The general relation of these funiculi should 
be remembered in operative procedures on the median nerve in this region. 

F10. 140. — Exposure of the media 

Exposure at the Elbow—In order to have adequate exposure of this import- 
ant part of the median nerve the humeral head of the pronator teres is cut as 



close a* possible to its origin and reflected upward and lateral, care bi 
to avoid injury to muscular branches which are given off from t! 

i -.■■■.■.'.. j^ ■--..■ •■ _ '. . 

■.-.■■-■■- v . I i 


flexor digitorum sublimis are split in the direction of their course, since, because 
of its radial origin, this muscle at this level cannot he retracted medialward to 


th llic central slump of the 

open the fascial plane between the flexor digitorum sublimis and flexor digi- 
torum profundus. Injuries to the median nerve at this level offer the greatest 
difficulty to successful repair, since the nerve trunk as well as the branches them- 

selves may l)c involved. In order to save these branches careful < 

Fits. 1 1 ; &Utt< tt I ■;- ■ i-'- rhc ulnar luniwcuon with ihe ,-etitial end of the inM 

has b«n **\TPnJ ami ihe Mro rods ubui nerve have been sutured. Tb 

median iiciM' CYXlU not W 1'ivught together, ntcessitalinf: ,i nerve grail. The ceaml 

lb> rsetiian Dei 

i> demanded as well . - i 

.it Urn in handling the isolated 



injury be near the point of entrance into the muscles they may be implanted 
directly into one or two of the muscles. 

Because of the funicular arrangement in certain levels a cable graft may be 
done so as to reunite' each individual funiculus, thus securing better down- 
growth. Crossing of the funiculi at this level is not apt to be overcome since 

Fie. 144. — Exposure 

■ if the nieiliiiii nuiA 

e at the elbow. 

Complete interruji 

nerve with extensive sea 

■ involving the ner 

it at the point 

where branches are 

branches themselves. 

the nerve pattern is already fixed and branches given off here cannot receive 
additional libers from the nerve trunk as would be the case in suture at higher 
levels. For this reason, lesions at this level offer a poor prognosis due, both to 
fixation of the nerve pattern and to the fact that the branches themselves may 
be irreparably damaged. In estimating the percentage and degree of recovery 
in operations upon the median nerve, the level of the injury on the nerve trunk 
must be taken into consideration, for the prognosis is always more favorable in 

tin- lower third of the arm and below the upper 

f it Ikr Wrist. — Here the nerve is readily found b 
ir border of the flexor tart'' radialis, between the 


of the thenar eminence lies along the radial side and on the ventral surface of 
the nerve, so that in suture of the median nerve at this level particular attention 
should be" paid to this side of the nerve. 

Occasionally, when the radial artery is absent the arteria comes nervi 

140.— Same iis Fig. 145. Transposition of the ulnar nerve with suture of both the ulnar and 
median nerves. A flap of fut has been passed beneath the nerves to cover star tissue. 

median! takes its place, and may be found in the forearm as a large vessel on 
the median nerve. 

Cross Suture of Superficial Radial and Median Nerves.— In certain cases 
in which it is impossible to perform end-to-end suture at the wrist and a nerve 


graft is deemed inexpedient, cutaneous innervation of the hand may be obtained 
by crossing the central end of the superficial radial nerve to the distal end of the 
median. Harris (1920) obtained complete return of sensation by this pro- 
cedure. The median area of sensation is extremely important, involving 
that part of the hand used most in gaining afferent impressions. With 
sensation lost the hand is subject to a great variety of insults from heat, 
cold, or blows which may lead to severe ulceration and even sloughing of the 
fingers; this is particularly true of the index finger. The possibility of regaining 
sensation in the palm more than justifies this procedure. 

The radial nerve is exposed over the dorsal surface of the radius at the 
wrist between the tendons of the supinator longus and extensor carpi 
radialis longus and traced to the base of the index finger where it is cut. 
It is then passed through a tunnel beneath the skin to the volar surface 
over to the previously exposed median nerve and end-to-end suture is then 

Comment. — Prognosis for median nerve regeneration is not as satisfactory 
as for musculospiral, yet more hopeful than in ulnar injuries. The fact that the 
nerve supplies in the main relatively large muscles and but a few small ones 
(thenar group) may contribute to this. Large muscles generally have a large 
nerve supply and consequently they may lose a number of their neuraxes with- 
out appreciable difference in function. The prognosis is better for suture in 
the arm and in the middle of the forearm than at the elbow or wrist. The finer, 
morphological arrangement of the nerve trunk may account in a measure 
for this difference, since in both the arm and the middle portion of the forearm 
the median nerve contains fewer and larger funiculi. At some levels but 
two large funiculi are to be seen, while at the elbow and again at the wrist the 
funiculi are smaller and more numerous, hence distortion of the nerve pattern 
is more apt to occur at these latter levels. As has already been mentioned, 
in the chapter on funicular anatomy, injuries in a nerve trunk near levels at 
which branches are to be given off, give less favorable results, since the funicular 
anatomy at these points, being more or less fixed, additional contributions to 
the nerve branches are prevented. 

In regeneration, returning function in muscle groups occurs in accordance 
with the principle already laid down. The nearer the lesion to the spinal cord 
the greater is the power of regeneration with relatively more rapid return. 
Muscle groups nearest the level of the lesion are usually restored earliest. (See 
Chart XII XIV.) This latter rule, however, does not always hold true since (lis- 



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tortion of the pattern may take place and regeneration appear first in groups 
more distant. 


Auerbach, S. and Brodnitz: Neurofibrom des N. ulnaris Oberarm: Exstirpation, Heilung, 

Mitt. a. d. Grenzgeb. d. med. u. Chir., v. 21 : 1910, p. 589. 
Bernhardt, M.: Beitrag zur Pathologie der Medianuslahmungen, Neurol. Zentralbl., v. 

16: 1897, p. 626. 
Bonnet, P.: De la deviation en valgus de L'avant bras dans les paralysies associees du 

median et du cubital, Lyon Chir., v. 16: 1919, pp. 631-636. 
Borchardt, M. and Wjasmenski: Der Nervus Medianus, Beitr. z. klin. Chir., v. 107: 

1917, P- 553- 

Brandes, M.: Zur Ueberbriickung von Nervendefekten bei gleichzeitiger Ulnaris-und Me- 
dianus Verletzung, Deutsch. Ztschr. f. Chir., v. 153: 1920, pp. 62-69. 

Brouwer, B.: The significance of phylogenetic and ontogenetic studies for the neuro- 
pathologist, Jour. Nerv. & Ment. Dis., v. 51: February, 1920, p. 113. 

Cruveilhier, J.: Traite d'Anatomie Descriptive, 4 vols., Labe, Ed. 3, 1851-52, Paris. 

Dujarter, Ch.: Paralysie du nerf median souleve par le fragment superieur d'une fracture 
de l'extremite inferieure d l'humerus. Intervention, Guerison., Bull, et mem. Soc. de 
chir. de Par., v. 46: 1920, p. 795. 

Fere, Ch.: Traite filementaire d'Anatomie Medicale du Systeme Nerveux, A. Delahaye et 
Lecrosnier, Paris, 1886. 

Frohse, F. and Frankel, M.: Die Muskeln. des menschlichen Armes, (Jena, 1913) in, 
Bardeleben Handbuch d'Anat. d. Menschen, v. 2: sect. 2 part 2, 1913. 

Gierlich: Ueber tonischen Kontrakturen bei Schussverletzungen der peripheren Nerven, 
specialle des Ulnaris und Medianus, Deutsch. Ztschr. F. Nervenh., v. 63: 1918-19, 
p. 145-160. 

Goldmann, E.: 2. Ueber das Fehlen von Funktionsstoerungen nach der Resektion von per- 
ipheren Nerven, Beitr. z. klin. Chir., v. 51: 1906, p. 183. 
Beitrag, zu derLehre von den Neuromen, Beitr. z. klin. Chir., v. 10: 1893, p. 13. 

Gruber, W.: Ueber die Verbindung des Nervus medianus mit dem Nervus ulnaris am 
Unterarme des Menschen und der Saugethiere, Archiv. f. Anat., 1870, p. 501. 

Halipre, A.: D'une cause d'erreur dans l'appreciation de Pimportance des lesions du nerf 
cubital au bras (M. A. Societe de Neurologie de Paris) Rev. Neurol., v. 24: 1917 
p. 236. 

Harkis, R. I.: An operation for the relief of median anesthesia, J. Orthop. Surg., v. 2: 
No. 9, Sept., 1920, p. 519. 

Kramer, F.: Schussverletzungen periphcrer Nerven, Monatschr. f. Psychiat. u. Neurol., 
v. 39: 1916, p. 1— 19. 

Ranschberg, P.: Ueber klinische Untersuchung, operative Biopsie und Heilerfolge bei 
unfrischen und veralteten Fallen von Schussverletzungen der peripheren Nerven, Beitr. 


Reuak, E.: Zur vicariirenden Function peripherer Nerven des Menschen, 
Wchnschr., v. n: 1874, pp. 601-615. 

Ruce, G.: Beit rage zur Get ass lth re des Menschen, Morphologisches Jahrbuch, 
84, P- P- 3*9- 

Spielmeyer, W.: Leber Nerve nschussverlelzungen, Ztschr. f. d. ges Neurol, u. Psychiat., 
v. 20: 1915, p. 416. 

Stopford, J. S. B.: The results of secondary suture of peripheral nerves, Brain, v. 43: 
pi. 1, 1920, p. 1. 

Thomson", A.: Third annual report of the committee of collective investigation of the Ana- 
tomical Society of Great Britain and Ireland for the year i8gi-g2, J. Anat. & Physiol., 
v. 27: i8g 2-0.3, p. 1S3. 

Yerchere, F.: Note sur ['innervation des muscles flechisseurs communs des doigts; anas- 
tomose du nerf median et du nerf cubital, Union med. v. 35: ser. 3, 1883. p. 105. 


Anatomy. — The ulnar nerve arises from the inner cord of the brachia 
plexus and is formed by fibers derived principally from the ventral divisions 
of the eighth cervical and first thoracic roots, occasionally also fibers from 
the seventh cervical, which usually pierce the inner head of the median to 
join the ulnar. The ulnar nerve, composed of ventral branches, supplies 
ventral musculature on the ulnar or postaxial border of the forearm, and all thel 
intrinsic muscles of the hand with the exception of the abductor, opponens 
and flexor pollicis brevis (superficial head). 

Course. — The ulnar nerve lies internal to the median nerve and axillary 
artery between the latter and the axillary vein, passing under the vein when the 
arm is in abduction. Internal to, and on the nerve in the axilla, are the internal 
and lesser internal cutaneous nerves. The ulnar nerve leaves the axilla beneath 
the pectoralis major muscle, lying upon the teres major and latissimus dorsi 
tendons and in this region is in close proximity to the musculospiral nerve, 
lying slightly ventral and medial to the latter. As the ulnar nerve descends 
in the arm it maintains its position medial to the median nerve and brachial 
artery, lying upon the medial intermuscular septum which separates it from 
the triceps muscle. Slightly above the junction of the middle and lower thirds 
of the arm the ulnar nerve separates from the neurovascular sheath and 
pierces the medial intermuscular septum to pass dorsal to the medial condyle. 
In this portion of its course it lies superficially in the fibers of the triceps 
muscle with the inferior profunda artery in front of the nerve. 

About 4 cm. above the medial condyle the nerve leaves its muscular 
bed to enter the groove behind the humerus where it is held in place by an 
aponeurotic expansion extending from the medial condyle to the olecranon. 
This aponeurosis is made up of both transverse and longitudinal fibers, the 
remains of a rudimentary muscle, the epitrochleo-anconaeus, to which the ulnar 
nerve has given a branch. A bursa has been described beneath the nerve 
separating it from the internal lateral ligament, which facilitates free move- 
ment of the nerve in flexion and extension of the forearm. The 


carpi ulnaris muscle. In rare instances the nerve may pass not be/rind but 
in front of the medial condyle and enter the flexor carpi ulnaris through a 
cleft in this muscle (Gruber, 1867). As the ulnar nerve lies between the two 
heads of the flexor carpi ulnaris and in the ulnar groove of the medial condyle 
the posterior ulnar recurrent artery and vein lie either lateral or dorsal to the 
nerve. The artery anastomoses with the inferior profunda which has de- 
scended with the ulnar nerve from above. Because of this free anastomosis 
when cut both of these vessels may cause troublesome bleeding in this region 
and they should be tied both distally and centrally. 

In the forearm the nerve lies upon the flexor digitorum profundus, 
within the sheath of this muscle, first under the flexor carpi ulnaris, and below, 
in the cleft between the flexor carpi ulnaris and the flexor digitorum sub- 
limis. The nerve enters the palm on the radial side of the pisiform bone, in a 
distinct canal formed by the anterior annular ligament, and divides into its 
terminal branches. At the junction of the upper and middle thirds of the 
forearm the nerve is joined by the ulnar artery and vena; comites, the vessels 
lying lateral to the nerve. 

Branches. In the Arm. — No branches are given off above the lower 
third of the arm. Approximately 4 to 5 cm. above the medial condyle 
an articular branch arises and also occasionally at a slightly lower level, a 
motor branch for the flexor carpi ulnaris. (See Fig. 148). 

In the Forearm. — Motor branches are given off for the flexor carpi ulnaris 
and the ulnar part of the flexor digitorum profundus. These muscles are 
supplied by two sets of fibers. The upper set for the flexor carpi ulnaris 
enters the muscle as the nerve lies between the two heads of origin of this 

Fie. 148. — Ulnar nerve. Surface projection. 1, Articular branch to elbow joinl: :, branch to 
flcsor carpi ulnaris; ;, brant h li> in lit r half of llexur tlifjil . >i 11m profundus; .(, dursal cutaneous branch; 
5, palmar cutaneous branch; 6, muscular branch to hypolhcnar group; 7, muscular branch to inter- 
ossei, inner lumbricales, adductor pollicis, oblic|UUS and trausversus, ilexor polllcis brevis (deep head). 




artery, which accompanies the artery to the palm of the hand and anastomoses 
with one of the terminal digital branches of the median. In the lower third 
of the forearm a cutaneous branch is given off which supplies the skin of the 
lower third of the forearm as far as-the hypothenar eminence. 

At the Wrist. — The nerve divides into two main branches, a superficial, 
which lies internal and adjacent to the pisiform bone and crosses the flexor 
digiti quinti brevis; and a deep branch which lies external and passes beneath 
this muscle. The superficial branch is mainly sensory but supplies also the 

Fig. 150. — Nerve distribution to the adductor pollicis muscle s< 
and Frankel.) 

1 from the dorsal surface. (Frohse 

small palmaris brevis muscle which lies in the skin of the hypothenar eminence, 
The deep branch passes between the origin of the flexor digiti quinti and the 
abductor digiti quinti muscles, curves radialward and lies upon the interosseous 
muscles to terminate in supplying the deep portion of the flexor brevis pollicis 
where it forms a delicate anastomosis with median nerve fibers. (See Fig. 150.) 
Funicular Anatomy. — The funiculus for the flexor carpi ulnaris and flexor 
profundus may be identified in the ulnar nerve 4 to 5 cm. above the medial 
condyle lying in the medial and dorsal part of the nerve. (See Fig. 151.) 
Occasionally this funiculus may be separated from the nerve for some distance 



Fie. 151.— Macerated dissection of the left ulnar and median nerves showing two types of 
communication between these nerves. The bundles of the ulnar nerve have been dissected free 
separated. D, Short communication; E, long communication to the deep branch of the ulnar |i n 
trinaic muscles of the hand); 10, branch to pronator teres, humeral head, upper part and lower part f 
muscle; an, branch to superior belly, flexor indicia sublimis; 2b, branch to palmaris longus- 1 bran °h 
to flexor digitorura sublimis, ,*d, 4th and 5th fingers; 40, branch to flexor digitorum profundus id 
4th and 5th fingers; 46, branch to flexor pollicis longus; 4c, anterior interosseous nerve; 5 bran h 
to deep belly of flexor indicis sublimis; 6a and 6b, branch to flexor carpi ulna ' 
branch of the ulnar nerve] 8, palmar cutaneous branch of the ulnar ni 
of the ulnar nerve; 10, superficial branch; 1 
liorchuidt and WjasmcntkJ.) 

is; 7, dorsal cutaneous 
o, deep muscular branch 

:, palmar cutaneous branch of the median nerve. (After 



oove the condyle and have a relatively long extraneural course. The funiculi 
^V the ulnar nerve are small and numerous except immediately above the elbow 

nd above the wrist where the funiculi unite into three or four large bundles. 

These levels are just above those at which branches are given off, and it is 

lere that internal nerve plexuses are found. 

Deformity. — The deformity varies according to the site of the injury. 
In complete ulnar nerve lesions above the elbow the postaxial border of the fore- 
arm is slightly concave due to the disappearance of the contour formed by the 
flexor carpi ulnaris muscle. Flexion of the wrist is weakened and adduction is 
lost, and on attempt to flex, the wrist turns slightly toward the radial side. 
The hand deformity is characteristic with the fifth and fourth fingers extended 
at the metacarpophalangeal joints and flexed at the interphalangeal. The 
third finger also tends to assume this position but to a less extent. The thumb 
is drawn into the same plane as the other metacarpal bones and all interspaces 
are distinctly hollowed. Due to atrophy of the interosseii the hand is narrow, 
soft and flexible and both the longitudinal and transverse arches are lost. The 
hypothenar and the thenar muscles show marked wasting and neither opponens 
action nor abduction of the little finger can be accomplished. The thumb is 
unable to adduct, or grasp objects in the first interspace, but instead, in attempt- 
ing thus to grasp, the distal phalanx of the thumb is flexed and the object held 
against the proximal phalanx of the index by action of the flexors in place of 
the adductors of the thumb. This is a striking diagnostic sign described by 
Froment (19 15). Paralysis of the interosseii prevents flexion of the fingers 
at the metacarpophalangeal joints without flexion at the interphalangeal joints, 
nor can the distal two phalanges be extended. 

Mechanical Treatment. — Contracture at the proximal interphalangeal 
joints of the fourth and fifth fingers with subluxation is apt to occur unless the 

fingers are splinted. Splints shown in Figs. 152 and 1 53 will be found satisfactory. 
Splinting should not be done unless accompanied by mobilization, since the 

tendency to fixation of the proximal interphalangeal joints is marked. When 

this has occurred function may be limited even if regeneration does take place. 

In neglected cases these contractures may be overcome by a splint such as is 

shown in Fig. 154, which can be adjusted to hold the distal two phalanges in 

constant extension and pulls the proximal phalanges in the opposite direction. 


Pic. 152. — Splint fur ulnar paralysis applied, (Buerki. Archives of Neurology and 
Psychiatry, 1920.) 


muscles of the hand very quickly undergo regressive changes and may loose per- 
manently the liner specialized movements of which they are capable. Hence, 
during the intervals both before and after operation special effort should be made 
to maintain the nutrition of these muscles by frequent use of the slow sinusoidal 
current and the Zander finger apparatuses. The latter will be found of great 
help in maintaining normal range of motion and preventing contractures. 

Fig. 154. — Splint to overcome contracture about the metacarptiphalanKeal and interphalanireal 
joints. Aluminum dur-.d cock -up splint with perforated shelf to which s trine-- (nun linger* of glove 
are attached permitting constant pressure lo he exerted. The direction of the perforated shelf may 
be changed to meet the requirements of each cast-, or another shelf may he added above to permit 
a counter pull. An infinite variety of contractures may he treated by this appliance. 

Exposure of the Ulnar Nerve. In the Axilla. — The ulnar nerve in this 
region is exposed in the same manner as has already been described for the other 
nerves of the axilla, (See Fig. 127.) The nerve at this level is rarely injured 
alone but usually in combination with either the median or the musculospiral — 
more frequently with the latter. 

In the Arm. Position of the Patient. The arm is abducted and at right 
angles to the body. The elbow is raised upon a sand bag so that the triceps 
hangs down unsupported. If the arm is allowed to rest on the table the triceps 


is pushed toward the biceps and the space between those two muscles is mure 
or less obliterated, concealing the nerve. 

Incision is made along the line of the great vessels, for exposure of the 
upper two-thirds of the nerve, and for the lower third, along a line drawn from 

Pi 1 : rrtnsposioon ■■■; the ulnar nerve, the deep Easda ^ cut in .» curve so as to be able 

to turn it over the nerve »ft« '.-■.:--- - 
I ... fjie pceatioo by the 

flap uf deep fascia reflected over it 

(he- junction uf the middle and lower thirds of the nerve to the olecranon 

Exposure. In its upper two-thirds the nerve t> readily identified King 
internal to the brachial artery, separated from it by the internal of the two 


is the larger and terminates higher up in the basilic vein. In its middle and 
lower thirds the ulnar nerve is accompanied on its medial border by the col- 
lateral ulnar, a branch of the musculospiral nerve. In the lower third the nerve 
will be found superficial within the fibers of the triceps muscle accompanied 
by the inferior profunda artery which may cause troublesome bleeding unless 
isolated and secured not only above but below, since it receives from below 
the collateral circulation from the ventral and dorsal ulnar recurrent 

At the Elbow. — This exposure is frequently necessary both for transposition 
of the nerve to the front of the condyle when the nerve ends, elsewhere severed, 
cannot otherwise be brought together, and when the nerve on account of angula- 
tion from fractures at the elbow is subject to repeated traumatism. (See 
Figs. 155, 156.) 

Incision. — The incision is made from the junction of the middle and lower 
thirds of the arm, slightly curved with the center crossing the medial border 
of the olecranon, to the junction of the upper and middle thirds of the forearm. 
The anterior edge of the incision is carefully undermined in the line of cleavage 
between the deep and superficial fascia, thus avoiding the veins within the 
latter, for with care the veins can be saved. The flap must be undermined 
forward as far as the medial border of the biceps tendon, to allow enough room 
for the transposition. All bleeding points are secured and a layer of gauze 
is placed beneath the outside of the flap to prevent too sharp angulation of the 
latter when it is reflected, and the flap is also covered on its inner side by a 
large pad of moist cotton. This is maintained in place and kept moist; thus the 
flap will be well protected and the tissues fresh at the close of the operation. 
The posterior flap is also undermined for 2 or 3 cm. to expose the deep 
fascia attached to the olecranon. This fascia is now cut in a curve and dis- 
sected free from the medial condyle so as to allow its use to hold the nerve in 
place after transposition. The nerve now lies exposed and can be freed from 
its bed by sharp dissection, care being taken to safeguard the motor branches 
to the flexor carpi ulnaris and flexor profundus which arise in this region. The 
articular branch, however, may be sacrificed for greater mobilization of the 
nerve. The line of union of the two heads of the flexor carpi ulnaris is now 
opened, the dissection being made precisely along this line. In this region 
considerable bleeding from the posterior ulnar recurrent artery will be met. 
If the motor branches to the flexor profundus and flexor carpi ulnaris do not 
permit sufficient mobilization of the trunk they may be dissected off, up the 


carpi ulnaris and flexor profundus have been deliberately sacrificed they should 
have been cut at the point at which they enter the muscle so that after transposi- 
tion they may be implanted directly into the muscles from which they were cut. 

The two nerve ends are now oriented so that the silk identification sutures 
lie on the same border and the nerve ends are cut until good cross sections are 
seen. End-to-end suture is then done. It is important that the nerve 
be passed through the tunnel before the end is freshened. This subjects to the 
trauma of the pulling only the scar tissue which is to be cut away. 

If the motor branches to the flexor carpi ulnaris and flexor digitorum 
profundus have not been sacrificed the nerve may be transposed superficial to 
the flexor muscles instead of beneath them. This transposition brings about 
1 3^ cm. less into the defect than when the nerve is passed beneath 
the muscles. Some surgeons cut down through the pronator teres, flexor 
carpi radialis, palmaris longus and flexor digitorum sublimis in order to add 
this distance. This procedure, to my mind, is not desirable. It is better, if 
this distance be needed, to sacrifice the twigs to the flexor carpi ulnaris and 
flexor profundus digitorum and pass the nerve through a tunnel made beneath 
the muscles rather than to cut the muscles and leave the nerve between cut 
muscle fibers. In the presence of an existing paralysis of one group the function 
of other and sound muscles should not be jeopardized if it is possible to avoid 
doing so. 

If the motor branches to the flexor carpi ulnaris and flexor profundus have 
been sacrificed the flexor profunds tendons to the fourth and fifth fingers 
may be implanted into those of the first and second and the palmaris longus 
into the tendon of the flexor carpi ulnaris with good functional result. 

Exposure in the Forearm. — The incision is made along the flexor carpi 
ulnaris muscle, over the line of the nerve, which lies between the flexor digitorum 
sublimis and the flexor carpi ulnaris, and upon the flexor digitorum profundus. 
If the opening in the fascia is made in the same line as the skin incision the knife 
will cut down upon the flexor carpi ulnaris muscle since the cleft between the 
flexor digitorum sublimis and the flexor carpi ulnaris is farther lateral. Con- 
sequently the deep fascia should be opened a little more lateral than the skin 
incision. The cleft between these two muscles can usually be palpated better 
than it can be seen. The flexor carpi ulnaris muscle may be readily identified 
by the fact that its tendon is well defined high on its radial side, while on the 
ulnar side the fleshy fibers extend to near its insertion. (See Figs. 159, 160, 161 .) 

The nerve in its middle and lower thirds lies very close to the ulnar artery 



Fig. 159. — Extensive involvement of the ulnar nerve in the middle of the furearm. Note the 
large central bulb and the dense scar tissue between the nerve ends. In this case conservative 
treatment unfortunately was followed (or nearly eleven months with Tincl's sign relied an as evidence 
of regeneration. 

lame as Fig, 139. The nerve ends were freshened until normal -3 
1. A single stay suture held by Forceps was passed. In this 1 
gentle traction made by pulling on the forceps. By rotating the 
thus facilitating suture of the grafts. One graft i? already si 


and internal to it. The same fascial sheath encloses the two and includes them 
in the flexor"digitorum profundus sheath. Because of this proximity the nerve 



Exposure at the Wrist. — The incision is made along the radial border of the 
flexor carpi ul n:i.ri- tendon, radial to the pisiform bone and into the palm in the 
direction of the third interspace. The anterior annular ligament is cut to open 


The nerve here divides into two terminal branches; the cutaneous; superficial, 
and the deep motor. (See Figs. 162, 163.) The opponens and abductor digiti 
quinti muscles may be cut at their origin from the hook of the unciform and 
reflected to the ulnar side thus exposing the nerve. If there is any loss of sub- 

Fio. 163. — Division of deep pall 
of end bulbs and end-tn-end sutur< 
(Elsberg, Archive* at Neurology 

branch ol ulnar nerve by r 
ire. The inserts show the succt 
d Psychiatry.) 

inc nun bullet. Resection 
5 stages of the operation. 

stance end-to-end union may be very difficult to obtain even with flexion at the 
wrist and extension at the elbow, since any mobilization of the distal end is 
hardly possible. Due to the relatively small size of the nerve in this region a 
single nerve graft may be used, and even though the nerve supply tothchypothe- 
nar muscles be lost by destruction of their nerve branches, the interosseii may 


Comment.— Regeneration of the ulnar nerve following suture offers a 
relatively poor prognosis so far as complete functional return of the interosseii 
and hypothenar muscles is concerned. Recovery in the flexor carpi ulnaris 
and flexor digitorum profundus takes place more often, providing the injury to 
the nerve trunk has not destroyed the nerve at the level at which their branches 
are given off. The ulnar nerve contains a relatively large number of afferent 
fibers to supply muscles whose actions require an extremely precise proprio- 
ceptive sense if finer movements are to be accurately done. In man these mus- 
cles have acquired a great range of movements and functions that are relatively 
new, and in order for these to be done with precision synergic control and pro- 
prioceptive sensations must be regained. The ulnar nerve is made up of 
numerous small funiculi and, in suture, misdirection of the nctiraxesismoreapt 
to occur than if the funiculi were larger and less numerous, although internal 
nerve plexuses may help to rearrange and redistribute the fibers within the 
different funiculi. In the ulnar nerve there arc two main plexuses, one just 
above the elbow and the other above the wrist; both situated immediately above 
points at which nerve branches arc given oil. It is possible that poorly shunted 
libers may be rearranged in these areas unless the injury is in such a plexus or 
immediately below it. Another cause of failure may be rapid permanent regres- 
sion of the small muscles before regeneration takes place, causing contractures of 
a permanent nature unless carefully guarded against. Even with regeneration 
recovery may he very slow in these small muscles, but functional return has been 
known to take place after an extremely long period of apparent failure. In two 
of my patients regeneration did not begin until twenty-four months after suture 
and subsequently they went on to recovery, while Herman- Johnson (101S) has 
reported a case in which recovery began forty months after operation. It is 
possible that such delay may not be due to failure in nerve regeneration, but 
rather to failure in regeneration of the small muscles of the hand which have 



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may also be due to solid or cystic tumors in the region of the medial condyle. 
In some cases the ulnar nerve shows no evidence of injury at the time of acci- 
dent but years later, twenty, thirty, or according to Hunt (1916), even thirty-six 
years may elapse before any signs of nerve involvement appear. Similar cases 
have been reported by Sherren (1908), Mouchet (1914), Adson (191 8) andSchaller 
(1920). In one case of the author, signs of nerve involvement first appeared 
thirty-two years after fracture of the medial condyle. At first the patient com- 
plains of tingling and numbness in the peripheral cutaneous distribution of the 
ulnar nerve and this is followed by atrophy of the ulnar muscles. With no recent 
history of trauma to the nerve the condition at first may be thought a syringo- 
myelia or due to a cervical rib, but a careful sensory examination, Roentgen ray 
of the elbow and fuller history will help to make the differentiation. At opera- 
tion the nerve may show little gross anatomical changes, but the vessels are 
more prominent and numerous, and the nerve slightly thickened over a distance 
of 4 or 5 cm. But in more severe cases the nerve shows a fusiform swelling 
with an increase in the endoneural and perineural connective tissue. Trans- 
position of the nerve to the volar surface of the condyle will generally relieve 
the condition eventually. The nerve may be injected with salt solution or the 
neuroma slit longitudinally. By transposition the constant trauma of the 
nerve is prevented and even old severe changes in the nerve trunk slowly 
improve. More rarely suture must be done. The indication for suture should 
be considered with great caution and the nerve divided only after making sure 
that recovery will not take place by transposition alone. The great importance 
of the ulnar nerve to the individual and its peculiarities already described make 
conservative surgical procedures more imperative than in any other. Simple 
transposition should always be given a fair trial when possible before perform- 
ing section and suture. 

In some individuals the medial condyle normally is little prominent and 
the groove for the ulnar nerve is relatively shallow so that subluxation of the 
nerve may constantly occur and eventually give rise to clinical signs of nerve 
injury. Collinet (1896) found that luxation of the ulnar nerve occurred 
congenitally in 3 % of five hundred individuals examined, while Haim 
(1904), Cohn (1904) found that subluxation occurred in flexion of the forearm 
in 20-25%. In these cases subluxation was always associated with cubitus 
valgus, without evidence of any previous bony injury. Only rarely symptoms 
are found and usually insidious in their onset. When signs of nerve irritation 

are present, even without any history of trauma, and with an apparently 



normal bony elbow, the nerve should be transposed as has been recommended 
in those cases when the nerve similarly suffers as a result of fractures of the 

Adson, A. W.: The surgical treatment of progressive ulnar paralysis, Mayo Clinic, v 

1918, p. 944. 
Bernhardt, M.: Beiiriige zur Fathologie tier Medianuslahmung, Neurol. Centralbl., v. 

16: 1897, p. 636. 
BONNET, 1*.: De la deviation en valgus dc 1'avant bras dans lcs paralysies associees du 

median ct du cubital. Lyon Chir., v. 16: 191 9, pp. 631-636. 
Brandes, M.: Zur Uberbriickung von Nervendefekten bci glekhzeiliger Ulnaris und 

Mcdianus Yerletzung. Deutsch. Ztschr. f. Chir., v. 153: 1020, pp. 62-6g. 
Cohn, M. ; L'ber die Aliologie der Ulnarislahmungen nach EUbogentcaumen, Centralbl. 

f. Chir., v. 31 : 1904, P- 1400- 
CotLTKET, I'.: Luxation congenilale du nerf cubital, Bull, et m6m. Soc. anat. de Par., v. 

10; 5th ser. 1896, p. 358. 
Drui'ard, H.: Luxation ct subluxation du nerf cubital, Paris, 1896, Baillierc et Fils. 
Krument, J.: La prehension dans les paralysies du nerf cubital et le signe du pouce. Presse 

m£d., v. 23: (Oct. 21, 1913), p- 409. 
La paralysie de l T adduclcur du poucc ct If signe de la prehension, Rev. Neurol., v. 22— a; 

1914-15, p. 1236. (SocieLe de Neurologic. Oct., [915, p. 1236.) 
Gierlkti: Ucber lonischen Konlrakturcn bei .Schussvcrlclzimgcn der periphercn Nerven, 

speciel des Ulnaris und Medianus, Deutsch. Zlschr. f. Ncrvcnh., v. 63: roiS-igig, 

p.p. 14S-160. 
Gkuher, W-: Ueber den anomalen Yerlauf des Nervus ulnaris vor dem Epitrochlcus, Arch. 

(. Anal., 186;, p. 560. 
Grund: Ulnarislahmung IVerein d. Aerzlc in Halle a. d. S. 7 Feb., 1917}, Miinchen. med. 

Wchnschr., 1917, 34. 
Haim, E.: L'ber Luxation des Ulnaris, Deutsch. Ztschr. f. Chir., v. 74: 1904, p. 96. 
Henle, J.: Handbuch der Anatomic des Mcnschcn, Fricdrich Vicwig und Sohn, Braun- 
schweig, 1 11, 1S76. 
Hermann-Joiinsu\, F.: On treatment of nerves at site of injury, for removal of fibrous 

tissue and relief of pain. Arch., Radiol. & Electroth., v. 23: 1918, p. 66. 
Hunt. J. R.: Paralysis, J. A. M.A., v. 66: Jan. 1, 1916, p. h, 
Klavskr, R.: Verlagerung des Nervus ulnaris, Miinchen. mcd. Wchnschr., v. 74: 1917, 

p. 635. 
KraDSE, W.: Trauma tische Angiectasie des linken Armes, Arch. f. klin. Chir., v. 2: 1861, 

p. 14.'. 
Maas, O.: [Berlin) Angeborener Bnksseiliger Uluarerdefekt, Berl. klin. Wchnschr.. v. 74: 

1017, p- *34- 
MoCcHET: Paralyse tardive du nerf cubiial a la suite des fractures du condyle interne de 


Perls: Ein neuer Fingerpendelapparat, Munchen. med. Wchnschr., 1916, Feldarztl. Beil., 

Nr. 37. 
Pitres, A. et Marchand, L.: Etude sur les greffes cubitales, Rev. Neurol., v. 35: 1919, 

PP- 370-398. 
Pietri, G. A. and Riquier, G. C: Contributio alia determinazione della topographia 

fasciculari del nervos cubitali al braccio, Chir. d. Organi. di. movmento, v. 3: 1919, 

P- P. 336. 
Port: Eine Ulnarisbandage, Munchen. med. Wchnschr., v. 73: 1916, p. 1506. 
Ranschburg, P: Ueber klinische Untersuchung, operative Biopsie und Heilerfolge be, 

unfrischen und veralteten Fallen von Schussverletzungen der peripheren Nerveni 

Bruns' Beitrage, v. 101: 1916, p. 521. 
Schaller, W. F.: Delayed ulnar palsy following elbow injury, California State J. M., Aug. 

Sherren, J.: Chronic neuritis of the ulnar nerve due to deformity in the region of the 

elbow joint, Edinburgh M. J., v. 23: 1908, p. 500. 
Stopford, J. S. B.: The results of secondary suture of peripheral nerves, Brain, v. 43: pt. 

1, 1920, p. 1. 
Stracker, O.: Zur Dauerapparatbehandlung von Nervenverletzungen, Munchen. med. 

Wchnschr., v. 73: 1916, p. 1738. 
Turner: Further examples of variations in the arrangement of the nerves of the human 


Embryological Development. — In the development of the lower extrei 
torsion and rotation of the femur, similar to that described for the humc 
takes place; however, rotaton is in the opposite direction and the exten 
torsion is greater. We have seen that in the upper extremity the prea 
border rotates lateral and caudad, so that the ventral surface looks form 
and the dorsal backward, whereas in the lower extremity the femur rot 
so that its preaxial border is turned medial and cephalad, its post axial, lat 
and caudad. Thus the dorsal or extensor musculature comes to lie venl 
and the ventral or flexor musculature, dorsal; the reverse of the upper extrem 
Primitive ventral musculature is innervated by ventral branches, and do 
by dorsal branches irrespective of the direction of rotation or the migral 
of the muscles. From an embryological standpoint it follows then that 
primitive dorsal musculature, though rotated ventrally, should be innerva 
by the dorsal divisions of the lumbosacral plexus, and the primitive ven 
musculature, though rotated dorsally, by the ventral divisions. This 
tribution of the lumbosacral plexus obtains. 

The anterior crural, the superior gluteal, the inferior gluteal nerves ; 
the peroneal portion of the sciatic nerve are formed by the dorsal division 
the lumbosacral plexus and supply the primitive dorsal musculature, 
gluteal muscles being axio-appendicular do not participate in the rotat; 
but remain in the dorsal position. Being primitive dorsal muscles, they 
supplied by nerves from the dorsal divisions, like the other, originally do 
which have rotated ventrally. namely, the quadriceps, peroneii and the exl 
sors vi the foot and toes. This primitive dorsal group is supplied through 
gluteal, anterior crural and peroneal nerves. The primitive ventral musci 
ture. though rotated medial and dorsal, is supplied by ventral divisions of 
lumbosacral plexus through the obturator nerve, the nerve to the hamstri 
and the tibial division o\ the sciatic. To this generalization of motor ini 
vati«in :he biceps fcnuu'is is an apparent exception, being supplied by two: 


to mm. adductor Diagnnj, 
Km! n] e mbra no a u p , 

longiim m. bltfplUt 

i. perlnci el doraallg pen I, 

Fio. 164. — Right plexus lumbosacral, schematic, viewed from in front (after P. Eisler). (The 
trunks shaded green are derivatives of the dorsal half of the plexus.) 


ture derived from both ventral and dorsal sources this dual innervation i 
readily understood and serves to indicate the embryological development of 
this muscle. The long head of the biceps receives a ventral branch, from the 
first, second and third sacral, through the nerve to the hamstrings, and the 
short head a dorsal branch from the fifth lumbar and first and second sacral, 
through the peroneal nerve. (See Fig. 164.) 

Variations in the segemcntal contribution to the lower extremity are more 
frequent than in the upper extremity, due perhaps to the fact that the position 
of the limb bud for the lower extremity is more variable than the upper in its 
relation to the body segments. Harrison (1907) has shown that the presence 
of the limb bud determines the nerve supply; and the segmental contribution 
varies with the position and width of the limb bud. Variations in the posi- 
tion of the limb bud of several segments more cephalad or caudad result in 
variation in the segmental distribution of the nerves to the extremity. Thus 
the same factors apply to the lower as to the upper extremity. The most 
cephalic position of the cephalic border of the limb bud for the lower extremity 
may be opposite the eleventh thoracic, while its most caudad position may be 
opposite the second or third lumbar— thus relatively wide variations in the 
segmental components may exist. In about one-fifth of the cases examined 
by Eisler (,1892) relatively wide variations were found, though in the majority. 
the lumbosacral plexus was formed from the more caudal segments; hence 
more often the postlixed type than the prefixed type of plexus is met. 

In the prefixed plexus the obturator nerve is made up of first, second and 
third lumbar, and in the postlixed. the second, third, fourth and fifth lumbar, 
while the anterior crural in the former type, is made of twelfth thoracic, first; 
second, third and fourth lumbar, and in the postlixed the second, third, fourth 
and fifth lumbar. Thus, in the anterior crural of the prefixed type the twelfth 
thoracic contributes, whereas there is no such contribution in the postfixed 
variety. Similarly, the tibia! nerve in the prefixed plexus type is made up 
of the third, fourth, and fifth lumbar, and first and second sacral; while in the 
postlixed the third and fourth lumbar do not enter, the nerve being formed 
by the fifth lumbar, lirsl. second, third and fourth sacral; thus it receives a 


certain variations in the motor supply of the lower extremity may be under- 
stood and the correspondence in variations of the upper and lower extremities 
better appreciated. 

Injury to the lumbosacral plexus is comparatively rare due to the fact 
that necessarily associated with any lesion of the plexus are concomitant injuries 
which in themselves are frequently fatal. In my own experience, gunshot 
wounds and stab wounds in this region have not called for neurosurgery. Trau- 
matic rupture of the plexus is difficult of accomplishment without other exten- 




Anterior Crural 

Anterior Tibial 

Lumbar Plexus 

Small Sciatic 


Chart XVII. — Table to show relative frequency of nerve injuries of the lower extremity. 

sive associated injuries. The mechanical factors in the lower extremity differ 
materially from those of the upper, where not infrequently rupture of the 
brachial plexus occurs as the result of heavy objects falling upon the shoulder 
or forcible separation of the head and shoulder. Such injuries are not possible 
in the lower limb because of its alignment with the body. However, one case 
has come under my observation of bilateral rupture of the lumbosacral plexus, 
during violent extraction of a breech presentation, with extensive associated 
injuries including fracture of both femurs. The diagnosis of bilateral rup- 
ture of the lumbosacral plexus in this case has nevertheless not been established 
beyond criticism in my mind, due to the extreme difficulty of differentiating it 
from injury to the lower lumbosacral cord. A satisfactory and detailed sensory 
examination — impossible in an infant- -seems to me to be essential to establish 
the diagnosis. Injuries of the lumbosacral plexus have been reported follow- 


Gaskell, W. H.: On the relation between the structure, function, distribution and origin 
of the cranial nerves together with a theory of the origin of the nervous system of 
vertebrata, Jour, of Physiol,, v. 10: 1880, p. 153. 

Harrison, R. C: Experiments in transplanting limbs and their bearing upon the problems 
of the development of the nerves, Jour. Exper. Zool., v. 4; 1007, 230 ff. 

Jehring: Das peripherisehc Nervensystem tier Wirbclthierc als Grundlage fiir die Krnntniss 
der Regionenbildung der Wirhelsiiulc, Leipzig, 187S. 

Paterson, A, M.: The position of the mammalian limb regarded in the light of its innerva- 
tion and development, Jour, Anal. & Physiol., v. 23: 1888-89, p. 283; also in: Brit. 
M. J., v. 2: 1888, p. 1307. 
The origin and distribution of ihe nerves to the lower limb, Jour. Anat. & Physiol., v. 28: 
'803-04, P- s 4- 


Anatomy.— The sciatic nerve is made up of ven- 
tral and dorsal divisions of the fourth and fifth 
lumbar, first, second and third sacral roots and con- 
sists in reality of two nerves in one sheath: the 
tibial from ventral divisions, and the peroneal from 
dorsal. The former supplies primitive ventral and 
the latter primitive dorsal musculature. Both nerves 
are united by a fibrous sheath into a single nerve trunk 
about 2 cm. wide and }-i cm. thick. They may 
remain together throughout their course or sepa- 
rate at any level. Division of the sciatic nerve 
into the peroneal and tibial nerves takes place in 
about 2Q% of cases high in the thigh (Eisler, 1892). 
If the separation of these two nerves occurs in the 
pelvis, they leave the pelvis separately, the peroneal 
above or through the pyriformis muscle and the tibial 
below it. 

The nerve to the inner hamstring muscles arises 
separately from the lumbosacral plexus in more than 
So^c of the cases, and in the remainder it is incor- 
porated in the medial border of the sciatic sheath. 
(See Figs. 165, 166.) In the lateral border of this 


is found. Thus at the lower border of the pyriformis muscle the sciatic nerve 
contains really four nerves: from within out they are, the nerve to the ham- 
strings, the tibial, the peroneal and the nerve to 
the femoral head of the biceps. 

Course in the Thigh.- Thus arranged the sciatic 
nerve leaves the pelvis, below the pyriformis 
muscle, through the great sacrosciatic notch and 
extends into the thigh as far as the popliteal space, 
where it separates into its component divisions. 
In its course the nerve lies upon the external 
rotators of the thigh (gemellus superior, obturator 
internus, gemellus inferior andquadratusfemoris) 
and on the dorsal surface of the adductor magnus. 
The nerve is covered by the gluteus maximus 
muscle in the thigh and is crossed obliquely from 
within out by the long head of the biceps. In 
the gluteal region the nerve lies at the juncture 
of the inner and middle thirds of a line connecting 
the great trochanter and the tuberosity of the 
ischium. The most superficial parts of the nerve 
are at the lower border of the gluteus maximus 
and at the entrance of the nerve into the popliteal 
lgi space, at which points it is covered only by skin 
Surface projection. ,1, Nerve to ant i fascia. It is important to remember that 

Semimembranosus, semittrnilinnsus ,.,,.,, , , , , , 

and Ion K head of bfctns; 6, nerve to thc fo!(1 uf t,le W»ttot± does not reach to the lower 

short head of biceps; 4. upper group edge „f the gluteus maximus but lies approxi- 

ui l.inim.lii"- In seniimembrannsiis. urul 

ischial head ..[ biceps; j.fowergroup mftfely 4 to '• cm. above It. 

of branches tosemitendlooaus, wtm- i n the popliteal space the tibial division lies 

membrano-us ami aililiii tor macnus. . . . 

Thi~ii i:iir ,i.sWvn 1 „, l npl 1 , ? i.,.tl 1 , superficial. ii!"'n thc popliteal vein, the artery 
point that the nerve in the ham- beneath the vein. The nerve descends vertically 
Eb^h^th^^an-r'llienenT thrauyh the middle of the popliteal space, be- 
to the short head of the biceps may tween the two heads of the gastrocnemius to 
Kir a separate nerve ami in anv ease , .... . „,. 
it lies as a separate huodle along the enter tlu ' Opening HI the Sl.lcUS lUUSCle. The P e- 

lateral margin of the peroneal cTivi- roneal division diverges from the tibial, crossing 

the lateral part of the space, lying upon the 

lateral head of the gastrocnemius, immediately beneath and along the medial 


the tibial and in the upper part of the space lies in a slightly more dorsal 

Though the sciatic nerve is flattened, it is not so in the transverse plane 
but rather obliquely, the peroneal division being lateral and dorsal, and the 
tibial medial and ventral. This disposition of the two main divisions of the 
nerve trunk may be due to the rotation which the lower extremity and its 
muscles undergo in development, thus entailing with their rotation a corre- 
sponding torsion of the nerve trunk. 

The peroneal and tibial nerves though incorporated into one sheath are 
distinct both functionally and anatomically, the former supplying the primitive 
dorsal, now ventral musculature, and the latter the primitive ventral, now 
dorsal musculature. There are no intercommunicating fibers between these 
two nerves throughout their entire length, yet the septum between the divi- 
sions may be so thin that a line of demarcation is made out only with difficulty. 
The line of cleavage between the two nerves lies more or less obliquely so that 
if an incision is carried in a direct ventral-dorsal direction either the peroneal or 
tibial nerve may be injured in efforts to separate them. The tibial component 
is generally larger than the peroneal and may be said to make up about 60 to 
70% of the total fibers of the sciatic nerve. Compton (191 7) believes that this 
relationship must guide one in separating the two nerves when it is not possible 
to make out a line of cleavage between them. In the author's experience he 
has not seen at operation, a sciatic in which, by careful palpation, it was not 
possible to make out a line of separation between the two divisions. Fre- 
quently no line of demarcation is seen, but by rolling the nerve between the 
thumb and index finger the line of cleavage may be felt. 

In its course the sciatic nerve is accompanied by a branch of the inferior 
gluteal artery, the arteria comes nervi ischiatici, which runs downward on the 
dorsal surface of the nerve, generally between the tibial and peroneal divisions 
and is reinforced by branches from the perforating arteries of the profunda 
femoris. (See Fig. 167.) The nerve may also be accompanied by several 
veins or by one single large vein. These veins may become enlarged and vari- 
cosed giving rise to pressure and irritative signs. 

Course in the Leg. — The tibial division continues in the leg as the pos- 
terior tibial nerve entering the calf between the two heads of the gastrocnemius 
and through the tendinous arch of the soleus muscle together with the posterior 
tibial vein and artery. It maintains its position superficial and dorsal to them. 
It lies in a sheath of the intermuscular septum between the deep and superficial 


muscles of the calf as far as the medial malleolus, below which it enters the sole 
of the foot. Thus in the upper part of the leg it lies ventral to the soleus 
muscle and in the lower part ventral and medial to the tendo achilles. 

The peroneal nerve winds around the head of the fibula (see Fig. 168), 
separated from the dorsal surface of the head of the fibula by the tendinous 

ind Charpy.) 

origin of the soleus, and from the external surface by a dense layer of connective 
tissue. The nerve is must superficial in this region being covered only by skin 
and fascia. Here the deep fascia of the leg overlying (he nerve' is thickened to 
form a dense fascial band to protect the nerve. As the nerve gains the front 
of the leg it passes through a fibromuscular canal in the upper part of the 


Fic. 168. — Peroneal nerve. Surface projection, r. Peroneal nerve; 1, recurrent tibial to 
knee-joint, tibiofibular articulation and tibialis amicus; .?, anterior tibial nerve; 3', branch to tibialis 
anticus, extensor h.-illucis toDgUS, extensor digilorum longus and pcronaeus tcrtius; 4, musculocu- 
taneous nerve to peronanis li.n^ii- ami [".tim.n us I ire vis; 4', interim I and external cutaneous (terminal 
branches). .STceki^ ISvi~ 


Branches in Thigh.- The nerve to the inner hamstrings including the 
ischial head of the biceps has been commonly considered as a branch of the 
sciatic nerve. Its relation to the sciatic trunk has already been pointed out. 
Due to the separation of this nerve from the nerve trunk, it is rare, even in com- 
plete severance of the sciatic nerve at the level of the pyriformis muscle, to find 
paralysis of all of the hamstring muscles. The fact that the hamstrings receive 
a separate nerve supply is a point of great clinical significance. Failure to 
appreciate this has led to error in interpreting sciatic nerve injuries. Thus 
ability to flex the leg on the thigh following excision of a tumor from the sciatic 
nerve below the gluteal fold was interpreted as evidence of regeneration by Mack- 
enzie (1909), whereas, as a matter of fact, the nerve supply to the hamstrings, 
given off above, had at no time been severed. This nerve to the ischial head of 
the biceps, semitendinosus, semimembranosus and adductor magnus muscles lies 
on the medial border of the sciatic nerve, and is made up of ventral divisions 
for the supply of these primitive ventral muscles. The nerve is distributed in 
two groups of branches: a higher group which sends twigs to the ischial head of 
the biceps and to the semitendinosus, at their origin from the ischial tuberosity, 
and a lower which reaches the semimembranosus and semitendinosus about the 
middle of the thigh. The branch to the semitendinosus is rather long and sup- 
plies this muscle on its ventral surface in the interspace between it and the 
adductor magnus. The branch to the adductor magnus supplies it on its 
dorsal surface at several points in the middle third of the thigh. (See Figs. 
169, 170.} 

The nerve to the femora! head of the biceps runs as a separate funiculus 
on the lateral border of the peroneal division of the sciatic nerve and gradually 
turns so as to lie on the ventral surface. It is made up of the dorsal divisions 
of the plexus and leaves the main nerve stem about 4 to 5 cm. below the 
ischial tuberosity, and enters this head of the biceps on its dorsal free border. 
In this manner it runs a more or less separate course of 12 to 15 cm. 

Branches in the Popliteal Space and in the Leg. — The nerves to the two 
heads of the gastrocnemius arise from the tibial division near the apex of the 
popliteal space and gradually diverge from the nerve trunk to enter the medial 
and literal heads of this muscle. (See Fig. 171.} Higher up the two branches 
unite into a single nerve which has a rather long intraneural course on the 
dorsal surface of the nerve trunk, from which it may be readily dissected up 
for 6 to S cm. above the point from which it makes its emergence. The nerve to 

Itif intwK maw Mi-i-,. ,lin.,ll,- fi™*i tVif. ti"hi"!i1 rliVi'Einn «r frnm tho norro tn th» 


the adductor magnus and adductor brevis. (Frohse and F rankle.) 


^o.— Nerve distribution to the flexor group in the thigh. (Frohse and FiSiikel.l 


gastrocnemius. It descends vertically upon the dorsal surface of the popliteus 
muscle jand in front of the lateral head of the gastrocnemius to enter the soleus 
muscle on its superficial surface. (See Fig. 172.) A branch to the plantaris 
muscle is also given off at this level. The branch to the popliteus passes over 
the muscle, winds around the lower border and supplies it on its deep or ventral 
surface. It also gives off minute muscular branches to the tibialis posticus, 
vascular branches to the posterior tibial and peroneal arteries, and an anterior 
interosseous branch which supplies the anterior tibial artery. Besides these it 
gives off an articular branch for the knee-joint and the tibial communicating 
cutaneous branch. The latter unites with the peroneal communicating to form 
the external saphenous nerve which is distributed to the skin on the dorsum 
of the leg. 

In the leg the tibial nerve gives off muscular branches to the deep flexors 
of the calf — the tibialis posticus, flexor hallucis longus and flexor digitorum 
longus. (See Fig. 173.) The branch to the tibialis posticus arises immedi- 
ately below the opening in the soleus and enters its muscles in the middle 
portion, giving off also a branch to the lower half of the soleus. Thus the 
soleus muscle receives both upper and lower branches. The nerve to the 
flexor hallucis longus may arise independently or with the nerve to the tibialis 
posticus. It descends with the peroneal artery and supplies the flexor hallucis 
longus by several branches. 

Below the medial malleolus the posterior tibial nerve terminates by divid- 
ing into the internal and external plantar nerves. The former is the larger and 
supplies the muscles along the inner margin of the foot, namely, the abductor 
hallucis, flexor digitorum brevis, flexor hallucis brevis and the first lumbricale, 
while the external plantar supplies all the remaining muscles of the sole of the 
foot. The internal plantar supplies the skin of the inner three and a half 
toes, the external planter the fifth and part of the fourth toe. 

In the popliteal space two cutaneous nerves arise from the peroneal divi- 
sion, the peroneal communicating and the sural. The former nerve is generally 
larger than the tibial communicating, arises from the peroneal on its medial 
border near the apex of the popliteal space and descends vertically across the 
lateral head of the gastrocnemius. It has a long intraneural course lying, in 
the thigh, on the dorsal surface of the peroneal division. The sural nerve 
usually arises below the peroneal communicating but may arise with it. It 
supplies the skin of the upper two-thirds of the leg on its lateral surface. 


Hribution to the soleus muscle (left) 



FlO, 172. — Nerve distribution to the soleus muscle (left) r 
and FrSnttcl.) 

1 the deep surface. (Frohse 


breaks up into its terminal branches — the recurrent tibial, anterior til 
musculocutaneous. (See Fig. 174.) The recurrent tibial arises from th 

(o the pcritnnius longus, extensor dipilorum locgus and peri 
(crtius. (Fn.hsc and Friinkel.) 

border of the peroneal and supplies the knee-joint and the upper pa 
the tibialis anticus. The anterior tibial nerve descends between the ti 


anticus and extensor digitorum longus and extensor hallucis longus, lying 
above, lateral to the anterior tibial vessels, then ventral, and below, medial to 
them. The nerve is mainly muscular for the tibialis anticus, extensor digi- 
torum longus, extensor hallucis longus and peronaeus tertius. (See Fig. 175.) 
These branches are given off near the origin of the muscles which they supply 
and enter them immediately, so that injury of the nerve in the middle third 
of the leg would be little apt to interfere with its main muscular distribution. 
The anterior tibial also gives off articular branches to the ankle-joint, vascular 
branches to the anterior tibial vessels and cutaneous branches to the space 
between the first and second toes. 

The musculocutaneous nerve supplies the peronaeus longus and brevis and 
the skin over the lateral and dorsal aspect of the leg and foot. The nerve 
arises obliquely from the lower margin of the peroneal and passes vertically 
downward in a sheath of the intermuscular septum, which separates the 
peronaeus longus and brevis from the extensor digitorum longus. 

Funicular Anatomy of the Peroneal Division. — The peroneal nerve in the 
thigh has an upper nerve plexus, corresponding roughly to the upper third of the 
nerve, consisting of numerous nerve bundles with rich interlacing of nerve 
fibers. This plexus is followed by an intermediate zone occupying approxi- 
mately the middle third in which the funiculi are arranged in two or three main 
bundles, each of which may be further divided into smaller bundles, though 
rarely completely. Immediately beneath the intermediate zone the lower 
nerve plexus is found. This plexus begins at about the divergence of the 
peroneal and tibial divisions and extends downward to near the point where the 
peroneal nerve breaks up into its three terminal branches. (See. Fig. 176.) 

From the upper plexus three nerves arise: the peroneal branch to the fem- 
oral head of the biceps — though this branch may exist as a separate nerve even 
into the pelvis — the sural nerve and the peroneal communicating. The latter 
nerves have an extremely long separate intraneural course, being formed high in 
in the thigh and separating from the peroneal nerve in the popliteal space. 

The relative position of the nerve bundles in the lower third of the peroneal 
nerve varies with the level examined. Immediately after the divergence of the 
peroneal nerve from the tibial the funiculi are arranged, according to Compton 
( 191 7), in three groups: the peroneal group to the dorsal, beneath this the mus- 


break.* -p :r.t/j its ter=i£-il bnrches — ere recurred:; dbiiL anterior tibial and 
rwMOl>jC;tin«ijC3. :•« F:z. :-x_ Tie mctk: tfoiil arises from the upper 

iuii'>n to (he pcronacus longus, extensor digitorum longus and peronaeus 
tcrtius. (Fn>hse and FrSnkel.) 

bonier of the peroneal and supplies the knee-joint and the upper part of 
Hit; (il)ialis anticus. The anterior tibial nerve descends between the tibialis 


■ anticus and extensor digitorum longus ai*J eutawi »al 
above, lateral to the anterior tibial vessels, tht„ 
them. The nerve is mainly muscular for the lUtofc J 
torum longus, extensor hallucis longus and neronaeus vm . 
These branches are given off near the origin of the ., : 
and enter them immediately, so that injury of the •. 
of the leg would be little apt to interfere with its mail 

~"7 *«MW,„, 

The anterior tibial also gives off articular branches to theaak 
branches to the anterior tibial vessels and cutaneous branch** t ,i 
between the first and second toes. 

The musculocutaneous nerve supplies the peronaeus longus ami bn 
the skin over the lateral and dorsal aspect of the leg and foot. The 
arises obliquely from the lower margin of the peroneal and passes vertical! 
downward in a sheath of the intermuscular septum, which separates \\„. 
peronaeus longus and brevis from the extensor digitorum longus. 

Funicular Anatomy of the Peroneal Division. The peroneal nerve in the 
thigh has an upper nerve plexus, corresponding roughly to the upper third of the 
nerve, consisting of numerous nerve bundles with rich interlacing of nerve 
fibers. This plexus is followed by an intermediate zone occupying approxi- 
mately the middle- third in which the funiculi are arranged in two or three main 
bundles, each of which may be further divided into smaller bundles, though 
rarely completely. Immediately beneath the intermediate zone the lower 
nerve plexus is found. This plexus begins at about the divergence of the 
peroneal and libial divisions and extends downward lo near the point where the 
peroneal nerve breaks up into its three terminal branches. (See. Fig. 176., 

From the upper plexus three nerves arise: the peroneal branch to the fem- 
oral head of the biceps — though this branch may enst as a separate nerve era 
into the pelvis the sural nerve and the peroneal communicating. The facer 
nerves have an extremely long separate intraneural course, being formed hi* « 
Ln the thigh and separating from the peroneal' nerve in the popliteal $>■*- 

The relative position of the nerve bandies in the lower third ottir^^ B1 
nerve varies with the level examined- bmedrately alter the d 
peroneal nerve from the tibial the fnokofi are imnged. ace 1 
1 1917). in three groups: the peroneal groap to :-. 
culocutaneous, and beneath this again the w 
they lie in a strict ventrodorsal pkne, wfenns. 
bundles is altered, so that th*r5e»deW side will 



4* en 

Yin. 176. l)ri)[in of nerves the srialic plexuses in man. The plexus is only drawn at the 
(mint of origin of the nerves and irrc^Mxtive of whether it is in the anterior or posterior surface. 
The NmrkrtR show the extent of U.I'., upper plexus; /, intermediate region; L.P., lower plexus, in 
the rcspiTiive peroneal and tibial divisions. In the peroneal, P marks a stretch of the upper plexus 
In whii h Die plexus was less than above and below it; / marks a stretch in which the characters of 


most medial. This change in their position is to be expected in view of the 
rotation of the muscles which they supply from a dorsal to a ventrolateral 

In a comparative study of the peroneal nerve in the cat, rabbit, dog, goat 
and man, Langley and Hashimoto (191 7) found a close correspondence in the 
anatomy of this nerve. In all these mammals an upper and lower nerve plexus 
with an intermediate region was found with the lower nerve plexus terminating 
in three main nerve bundles — a common group for the peronaeus longus, brevis 
and tertius, an intermediate group for the cutaneous fibers of the musculo- 
cutaneous and a third for the anterior tibial, to the tibialis anticus, extensor 
digitorum longus and extensor hallucis longus. The nerve to the peronaeus 
tertius, while arising from the musculocutaneous nerve in man, can be traced in 
the nerve trunk above, into the funicular bundles which form the common 
peroneal group, whereas, in the cat, Langley and Hashimoto found it to arise 
directly as a peripheral branch from the nerve to the peronaeus longus and 
brevis. Occasionally in man also this branch may be given off from the nerve 
to the peronaeus longus (MacAllister). 1 

Funicular Anatomy of the Tibial Division.— The tibial nerve in the thigh, 
like the peroneal, shows an upper and lower plexus with an intermediate zone 
between the two, though the latter is less sharply defined. The upper plexus 
extends well into the pelvis and seems in reality to be almost a direct con- 
tinuation of the fiber distribution which takes place in the lumbosacral plexus 
itself. In most instances there are no branches from this part of the tibial 
division. The nerve to the hamstrings, appearing to arise from it, is in reality a 
distinct and separate nerve. As has already been pointed out, this nerve must 
be considered as an independent nerve and not a branch of the sciatic. 

The intermediate zone consists of separate bundle groups with some inter- 
mingling of the fibers. The number of the bundles varies; frequently ten to 


fourteen may be found depending on the level of the section. This region 
is not as truly an intermediate zone as in the peroneal, some rearrange- 
ment of fibers taking place, practically forming small plexuses. The bundles 

Fig. 177.— Section through [he middle of the popliteal space. Same limb as Fig. 178. 1, Tibial 
trunk; 1, popliteal vessels; 3, common peroneal trunk showing peroneal cutaneous bundle (dark) 
dorso- medial, 'anterior tibial, ventral and musculocutaneous bundle between the two; 4, tibial 
cutaneous bundle; 5, gastrocnemius; 6, skin. (Compton, Journal of Anatomy, 1917.) 

Fig. 178.— Transverse section through right fetal leg at level of upper end of tibial diaphysis. 
t, Tibia] trunk; 2, popliteal vessels; 3, biceps; 4, gastrocnemius, outer head; 5, nerve to outer head of 
gastrocnemius; 5, nerve to inner head; 6, nerve to popliteus — between this and the nerve to the outer 
head of the gastrocnemius is seen the nerve to the soleus; 7, anterior tibial bundle (deep peroneal); 
8, musculocutaneous bundle (superficial peroneal) ; q, branch to the peronaeus longus; peroneal 
cutaneous bundle; 11, tibial cutaneous bundle (posterior cutaneous nerve to the calf); 12, skin. 
(Compton, Journal of Anatomy, 1917.) 


are not united into a few large bundle groups as in the peroneal. (See Figs. 

There is a rather close resemblance between the funicular anatomy of the 
peroneal division and its homologue, the musculospiral nerve of the upper 
extremity, and between the tibial division and the median and ulnar nerves. 
In both the peroneal division and the musculospiral nerve the funiculi are 
united into one or two large bundle groups in the middle third of the thigh and 
arm, while in the corresponding position the tibial, median and ulnar nerves are 
made up of numerous small funiculi. 

From the lower plexus which extends upward in the nerve trunk about 10 
cm. above the middle of the popliteal space two nerves arise, the tibial communi- 
cating and the branches to the gastrocnemius. These two nerves usually fuse 
forming a single bundle which joins with the bundle forming the nerve to the 
soleus. The latter nerve and the nerve to the outer head of the gastrocnemius 
may form one branch and the nerve to the inner head of the gastrocnemius a 
separate branch, though these usually unite in the tibial nerve into a single 
bundle. The tibial communicating, like the peroneal communicating, has a 
distinct intraneural course though very much shorter than the latter, since it 
arises from the lower plexus in place of the higher. Emerging from the lower 
plexus are the branches for the calf muscles, namely the tibialis posticus, 
plantaris and popliteus. The posterior tibial nerve in the calf is made up of two 
main bundles, an inner and an outer which, at the medial malleolus form the 
internal and the external plantar nerves. 

Exposure of the Sciatic Nerve. Position of the Patient. — The patient is 
placed on his belly with sand bags under one shoulder and hip. The lower leg 
is slightly flexed so as to relax the hamstrings. For this purpose a small table 
which can be raised is placed at the foot of the operating table and the foot fixed 
to the small table so that the desired position may be maintained without the aid 
of an assistant, and the elevation may be altered to suit the convenience of the 
operator. The patient is draped so that the limb is entirely free and can be 
moved in any direction without deranging the sheets. A separate sheet should 
be passed beneath the lower extremity, as well as over it. A stocking made of 
stockinette material put on the lower part of the leg and foot will be found very 
convenient as it has the added advantage of fitting snugly, thus permitting 
observation of muscular movements when electrical stimulation of the nerve at 
operation is done. Ordinary stockinette is quite satisfactory. 

Incision; Exposure of the Upper Third. — For exposure of the sciatic nerve, 


in its upper third, the incision advocated by Konig (19 16), Guleke (19 16) and 
Iselin (1917) is modified so as to permit the surgeon to follow the nerve into the 
thigh without making a separate skin incision. (See Fig. 179.) The principle 
of this incision is to cut the tendon of insertion of the gluteus maximus muscle. 
The muscle is then reflected medially and upward together with the vessels, 
thereby avoiding transverse section of the muscle fibers and also the profuse 
bleeding which frequently accompanies the old direct incision over the course of 

Fig. 179. — Skin incision for exposure of the upper third of the sciatic nerve. (Stookey, J. A. M. A. ; 


the nerve. In this region both the veins and arteries so near their origin are very 
large, and in making an incision across the muscle these vessels are repeatedly 
cut the same branch being severed time and again. This makes the operation 
with the old incision extremely tedious and expensive physiologically, in view of 
the blood loss and the fact that muscle fibers are cut transversely. 

The new incision begins approximately at the dorsal inferior iliac spine and 
is carried obliquely downward and out to a point about three finger's breadth 
medial to the great trochanter, thence curving downward and inward over the 
gluteal fold to the median line of the thigh dorsally. The incision is more or 
less in the shape of a question mark. The lower and outer angle of the skin 



incision is undermined to the line of attachment of the gluteus maximus and 
this attachment is freely exposed. The deep incision is now made parallel to 
the fibers of the gluteus maximus, separating them in the direction of their 
course, beginning above at the upper angle of the skin wound and passing 

Pig, iSo. — Expi 

the hamsf rings, the s 
muscle has been cut 

n[ l lit- si-ialik' nerve with separate suture nl tilt small sci; 
', ami the liranch to I he Ft inn nil head nf (lie hiccps. The gluteus minimus 
reflected medially, together with lilt large gluteal vessels. 

directly downward to the tendon of insertion. The insertion is then cut approxi- 
mately 2 cm. from its bony attachment and the whole muscle is reflected up- 
ward and toward the median line. If the incision has been correctly placed, the 
main vessels are reflected upward on the muscle and little bleeding is encoun- 


tercd, and the nerve is freely exposed from the lower border of the pyriform 
its entrance into the thigh. With this exposure the nerve may be traced any 
distance farther down the thigh merely by a direct prolongation downward of 
this incision. (Sec Fig. 180.) 

Exposure of the Sciatic Nerve in the Thigh. — The most accessible portions 
of the sciatic nerve are just below the gluteus maximus muscle and at its en- 
trance into the popliteal space for it is covered in these regions only by skin and 
fascia. For exposure of the nerve in its upper portion, the incision should 
begin midway between the tuberosity of the ischium and the great trochanter 
over the gluteal fold, and extend directly downward into the thigh the required 
distance. In fatty individuals, a large amount of subcutaneous fat is encoun- 
tered. The lower border of the gluteus maximus muscle must be freed from its 
deep fascia and retracted upward. At the junction of the middle and upper 
thirds of the thigh the nerve is crossed by the biceps which passes obliquely 
from within outward,, hence in this exposure the hamstrings are retracted 
medially and the biceps laterally, but if the lesion be slightly higher the biceps 
is retracted medially as well. The semimembranosus tendon may be mistaken 
for the nerve, since both lie close together. The nerve is surrounded by fatty 
tissue in which will be found the perforating branches of the profunda femoris 
artery and their accompanying veins. Along the medial border of the nerve 
the muscular branches to the hamstrings will be met and along the lateral 
border the branches to the short head of the biceps. If possible these are identi- 
fied within the scar by the electrode in order to avoid injury of them, or an 
attempt may be made to identify them by dissecting downward, freeing the 
branches as they arise. The two divisions of the nerve may be separated by 
beginning below where the line of division is usually more distinct. In certain 
casus no line of separation may be seen but can be felt. The plane of separation 
between the two nerves must be carried obliquely in order to avoid injury, 
especially to the peroneal division. Separation of the nerves is frequently 
called for since it often happens that one division is injured without interruption 
of conductivity of the other. The peroneal is more frequently involved than the 
tibial and by separation of the two nerves suture of one may be accomplished 
while only liberation of the other may be necessary. In determining the con- 
ductivity of the two nerves the electrode will be of immense help. If loss of 
nerve substance has been extensive flexion of the knee and extension of the 
thigh will generally permit end-to-end union. The leg can be held flexed by 


splint. The foot should be supported by a Jones metal club foot splint, or 
plaster gutter splint. 

Exposure in the Popliteal Space. —By prolongation of the incision used for 
exposure of the nerve in the thigh both divisions of the sciatic nerve may be 
exposed in the popliteal space where they lie superficial to the popliteal artery 
and vein. (See Figs. 181, 182.) Separation of the nerve into tibial and 

peroneal divisions, even in low separation, occurs at the upper part of the 
space. The tibial division descends through the middle of the space to pass 
beneath the superficial muscles of the back of the leg, while the peroneal 
division descends obliquely, crossing the outer head of the gastrocnemius 
muscle and passing superficial to the head of the fibula. 

Both nerves are covered by (he popliteal fascia, fat and the tower portions 



ther branches in the popliteal space are those to the plantaris and to 
muscles. The latter nerve arises just above the point at which the 
rs the tendinous arch of the soleus muscle and at this level the tibial 
gives off a deep branch for the deep flexors of the calf. 

Kposure of the external anil intcrniLl popliteal n 

liti-al anil inn nl" the internal ]i<i|iliu-;il. 

bial communicating and peroneal communicating nerves arise in the 
the space from the dorsal and superficial aspect of the tibial and 
ivisions. These branches need not be considered for suture if the 
s region is extensive for they are purely sensory and their supply is 
xlapped by the internal saphenous nerve and the cutaneous branch of 


cargile membrane may be used to advantage, not to surround the nerve nec- 
essarily, but merely as a sheet between the vein and the nerve. 

If the motor branches to the gastrocnemius are destroyed at their origin 
they should be sutured into the nerve trunk at a lower level, or if injured as they 
enter the muscle, they may be directly implanted into the muscle at a slightly 
higher level. 

Exposure of the Tibial Nerve. — The tibial nerve in the upper part of the 
leg may be exposed by continuing the line of excision used to expose the popliteal 
structures. (See Fig. 184.) The nerve passes through a tendinous arch in the 
soleus muscle along with the tibial vessels and lies between the deep and superfi- 
cial muscles of the calf in a sheath of the intermuscular septum which separates 
these two muscle groups. The gastrocnemius muscle is widely retracted and 
the line of union of the outer and inner heads is split and the fibers of the soleus 
are separated as far as possible. The tendinous sheath on the superficial aspect 
of the soleus may be mistaken for the fascial plane between the deep and 
superficial muscle layers. 

If the tibial nerve is to be exposed in the middle or lower third of the calf, 
an easier approach than through the soleus is gained through an incision made 
along the medial border of the calf about 3 cm. from the tibial margin. 
The deep fascia, recognized by its transverse fibers, is cut, and the fascial plane 
between the superficial and deep muscles is then sought. The tibial nerve will 
be found lateral to the artery. The lower the nerve is sought the easier becomes 
the exposure and the more readily is it brought into view. In the upper part of 
the calf the nerve lies upon the tibial artery, while in the middle third thenerve 
lies between the tibial and the peroneal arteries. The latter vessel lies adjacent 
to the motor branch for the flexor hallucis longus. 

Internal and External Plantar Nerves. — These nerves may be exposed 
behind the medial malleolus by a curved incision 10 cm. long parallel to the 
dorsal border of the malleolus. The internal arcuate ligament is exposed and 
divided. Immediately beneath the malleolus will be found the sheath for the 
tibialis posticus tendon and adjacent to it the sheath for the flexor digitorum 
longus. In a larger space below this tendon the plantar nerves and vessels are 
found, and below them a space for the flexor hallucis longus tendon. The 


digitorum brevis and quadratus plants. The external and internal plantar 
nerves in the foot correspond in their manner of distribution respectively 
to the ulnar and median nerves in the hand. 

l''ic. 185. — Exposure of the peroneal nerve in the popliteal space. The nerve lias been separated 
into its two divisions — anterior tibial and musculocutaneous — and each sutured separately. Note the 
small artery between the two divisions below the suture. Insert shows the funicular arrangement of 
the peroneal nerve at the level 0! the suture. 

Exposure of the Peroneal Nerve, Position. — The patient is placed in a 
semipronc position and the leg is slightly flexed. The entire limb is then held 
by sand bags in internal rotation so as to expose a part of the dorsal surface of 
the popliteal space. The sheets are placed so as to enable the position of the 
limb to be altered at will without disturbing the field. 

Incision. — The incision is made obliquely from above the middle of the 
popliteal space along the medial border of the biceps tendon and across the 


fibula about an inch below its head. The popliteal fascia is exposed and incised 
in the same line as the skin incision. The nerve is then sought beneath the 
border of the biceps tendon and followed downward across the fibula. (See 
Fig. 185.) As the nerve crosses the fibula it is somewhat flattened and is covered 
by a dense connective tissue layer which is a lateral expansion of the biceps 
tendon with a thickening of the deep fascia. Two main bundle groups in the 
peroneal nerve may be distinguished in the popliteal space, one lying adjacent 
to the biceps tendon and the other more lateral and dorsal: the former forms 
the anterior tibial nerve and the latter the musculocutaneous. On cross 
section of the nerve in this region the dorsal bundle consists of three funiculi 
while the ventral bundle is made up of one and sometimes two funiculi. Be- 
tween these two bundle groups of the peroneal nerve a small artery and vein 
are sometimes found. 

Separate suture of these two bundles must be done if the nerve injury is at 
the level of the head of the fibula. When end-to-end union cannot be accom- 
plished, due either to wide separation of the nerve ends or extensive callus from 
the fibula, nerve graft may be done and an attempt made to unite each graft 
with the same bundle centrally and distally. 

If callus is extensive the surgeon may consider excision of part of the fibula 
but leaving the attachment of the biceps to the head of the fibula. In this 
manner 1 to 2 cm. may be gained and a better nerve bed made. Or with 
an exposure similar to that used for the tibial nerve the distal end of the nerve 
may be transplanted through the soleus muscle and a nerve graft done. To 
transpose, an incision is made along the lateral "border of the fibula through 
the deep fascia which separates the soleus muscle and the peronaeus longus. 
About 5 cm. below the head of the fibula a small artery will be seen passing 
from under the soleus and crossing dorsally onto the gastrocnemius. (See Fig. 
186.) If the fibers of origin of the soleus are exposed here a small split in the 
fibers will be found— a small tendinous arch through which this artery passes. 
This cleft in the soleus fibers forms a natural space through which the peroneal 
nerve may be passed into the back of the calf to the same fascial plane in which 
the tibial nerve and vessels lie. In this manner a splendid bed is formed for the 
nerve and, because the space through which it passes is a natural arch, compres- 
sion of the nerve is not likely. In freeing the distal end of the nerve the per- 
onaeus longus muscle is cut at the point at which the peroneal nerve passes 
under it and the unimportant recurrent tibial branch must be sacrificed. After 
the nerve has been freed sufficiently to permit transposition without angulation, 


well as lower. Hence these two muscles are rarely involved in paralysis of 
the sciatic. The semitendinosus escapes more often than the long head of 
the biceps and it alone is capable of performing, to a remarkable degree, the 
function of the other hamstrings as well as the slight flexion action of the leg on 
the thigh contributed by the gastrocnemius muscle. Even in total paralysis of 
all the flexors, with the exception of one head of the biceps or the semitendino- 
sus, relatively little impairment of function is shown when a suitable apparatus 
is worn. One patient having a combined sciatic and anterior crural paralysis 
was able to walk without much inconvenience, when fitted with proper mechan- 
ical support, due to the action of the semitendinosus and the compensatory 
action of the flexors and extensors of the thigh on the trunk. 

The contour of the dorsal surface of the thigh is symmetrically flattened 
and tapered, but if the innervation of the semitendinosus is retained this muscle 
may be distinctly seen as a raised band on the inner part of the thigh. 

In paralysis involving both the tibial and peroneal divisions, innervation 
of all the muscles below the knee is lost. The foot hangs flaccid, dangling 
in the position of complete foot-drop. Either varus or valgus deformity 
together with flatfoot are also found. On account of the loss of all sensation the 
painful symptoms of flatfoot are not present and it may not be recognized until 
after regeneration has taken place. 

Mechanical Treatment. — The aim of proper mechanical treatment is 
to give stability to the lower leg and foot, to correct postural deformity and 
faulty deviation of body weight and to give support to the relaxed arches of 
the foot. Unless all these factors are taken into consideration, the mechanical 
treatment will be only partially of value. 

Probably one of the most satisfactory appliances, where all the flexors 
of the thigh are paralyzed, is a modified Thomas caliper, permitting flexion 
of 45 at the knee. (See Fig. 194.) This apparatus is light, comfortable and 
extremely serviceable. There are many splints more complicated, but none 
more efficient. In place of a stop lock, a spring lock may be used, so that the 
patient walks stitT-legged and on sitting is able to release the lock and bend 
the knee. The caliper is fixed to a plate in the sole of the shoe which extends 
from the heel to the metatarsophalangeal joints. The upright is so fixed to 
the sole plate that it maintains the foot slightly dorsiflexed, thus preventing 


weakened arches of the foot by deviating the body weight to the outer, stronger 

In sciatic paralysis, involving both tibial and peroneal divisions with 
retained flexion of the knee, a splint, similar to the one in Fig. 187, will be 
found extremely serviceable. An outside fixed iron with a stop lock to prevent 
valgus deformity and extreme plantar flexion, together with a spring arrange- 
ment to overcome toe drop and assist in elevation of the foot, makes a very 
light and efficient appliance. 

Deformity in Peroneal Nerve Injuries.— The ventral and lateral muscle 
groups of the leg are paralyzed with inability to dorsiflex or evert the foot. 

There is complete toe-drop and tendency to varus 
deformity, and, in neglected cases, equino- varus oc- 
curs. Dorsal elevation of the os calcis is marked, 
clue to the unopposed action of the muscles of the 
calf, which are normally about five times more 
powerful than the extensor group. In untreated 
cases with marked contracture of the tendo-achilles 
subluxations may be present. Flatfoot may some- 
times occur due to loss of support to the arches of 
the peronei and the extensor groups, the former 
supporting both the transverse and longitudinal 

Fig. i8 7 .^Outsidc iron fitted archeS > and the laUer the inner ' The 8 ait is Ver y 

with rubber device to replace ex- awkward due to increased flexion at the knee in 

tension in paralysis of both tibial Qrder tQ dear the toes f rQm lhe fl an( j partic . 

and peroneal nerves. Stop lock 

and sole plate prevent plantar ularly noticeable in walking up hill or upstairs, or 

flexion. (Stookey, Surg., Gyn. j n wa lkj ng f as t 
and Obst., 1918.) 6 

Mechanical Treatment in Peroneal Nerve In- 
juries. — In treating this paralysis it is obvious that more should be done 
than simply to correct the t toe-drop though this alone is of great help. An 
outside leather support should be sewed to the shoe to give support to the 
ankle and the shoe elevated on the outer border both of the sole and heel, 
thereby deviating the body weight to the inside of the foot, thus tending to 
correct the varus position. Flatfoot, if present, should be supported by an 
inside plate, such as described in paralysis of the tibial division. 

Most appliances used in this paralysis attempt to correct but one of the 
deformities, namely the toe-drop, and ignore others of almost equal importance. 
The spring shoulder strap of Marie and Meige corrects, rather awkwardly, 


^Sothing more than the toe-drop and does not assist in the correction of the asso- 
ciated deformities. To obtain elevation of the foot by a strap running across 

•^the opposite shoulder seems rather farfetched. The metal spring device of 

* : L6ri, which passes up the front of the shoe likewise corrects but one deformity. 

"The more satisfactory appliance of Robin-Chiray (1916) (Fig. 188), having a 

-" spring effect obtained by bending spring steel 
wire, is a very convenient and useful appliance, 
being light and inconspicuous and yet assisting 
admirably in elevation of the foot, though it 
also corrects only the toe-drop. A similar appli- 
ance has been advocated by Buerki (1920). (See 
Figs. 189, 190.) When a spring wire appliance is 
used, as well as in the other appliances, the sole and 
heel of the shoe should be raised J£ inch on the 

The spring appliance with inside iron illus- _ n „ _ . f _ ,. 

r ° rtr Fig. 188. — Device of Robin- 

trated (see Fig. 191) not only mechanically corrects Chiray for foot-drop. (Tinel, "Les 
the associated deformities, but also tends to replace Blessuores des Ncrfs >" IQl6 -) 
the action of the extensors. An inside iron may 

be used, with a stop lock placed to prevent plantar flexion and the iron fixed 
to hold the foot slightly dorsiflexed. Either a metal spring or a rubber band 
is attached to the shoe at or just beyond the metatarsophalangeal joint and to 
the upright inside iron above the middle of the astragalotibiofibular articulation, 
thus giving to the spring or rubber band an adequate ventrodorsal pull. Any 
slight tendency toward inversion in the pull is prevented by means of the fixed 
iron, the outside strap and the elevation of the shoe. About as useful is an in- 
side iron without a stop lock, the iron being rounded at the end and made to fit 
into a socket in the heel of the shoe, with a rubber band or spring to prevent 
foot-drop. However, of these two appliances, the former with the stop lock is 
to be preferred. 

Deformity in Tibial Nerve Injuries. — In injuries of the tibial nerve, paraly- 
sis of the muscles of the calf and sole of the foot is found, with loss of flexion of 
the toes, abduction and adduction as well as plantar flexion of the foot. The 
gait is without spring, the step heavy and inelastic, the weight falling entirely 
upon the heel. Due to the unopposed pull of the dorsal flexors, the dorsal 
surface of the os calcis tends to look downward in place of backward. The arch 
appears slightly more concave, depending upon the extent of the contraction of 


the tibialis anticus and the extensor group and also because of the atrophy of the 
intrinsic muscles of the foot. Valgus deformity is usually due to the unopposed 
action of the peronei. 

Fig. ilij,— Splint for foot-drop made of No. ti spring steel wire and helel to the shoe with four 
pieces 1>I piano wire. The splint is held In the le>z by a eanvas kind pa^sini; around the calf between 
the two wires. (Huerki, Archives of Neurology and Psychiatry, 1021.) 

Mechanical Treatment of Tibial Nerve Injuries.— Proper mechanical 
support should attempt to prevent extreme dorsiflexion, calcaneous deformity 


plantar arches. An outside iron with stop lock to prevent dorsiflexion beyond a 
little more than right angle will correct dorsiflexion and calcaneous deformity. 

Fig. 191. — Spring device giving passive extension in foot-drop. A, An inside iron with fixed 
sole plate and stop lock is fitted with metal spring or rubber band extending from above center of 
a st ragalo tibiofibular articulation to beyond metatarsophalangeal joint. The dorsal pull of the 
spring is substituted for the action of the extensors. The inside iron and ankle strap and the eleva- 
tion of shoe correct the associated deformities; B, the same without stop lock or sole plate. Inside 
iron fits loosely into socket in the heel and is fitted with spring device similar to that in '.4. (Stookey, 
Surg., Gyn. and Obsl., 10,18.) 


iurg., Gyn. a 

c nerve. ,[ . Outside fixed iron and 

I preventing calcaneus deformity; 

on sole and heel. (Stookey, 

[See Fig. 192.) A slight bend to the side bur. together with an inside leather 
support sewed to the shot', as well as a lift on the inner border of the sole and 
heel will deviate body weight to the mechanically stronger outer arch and correct 


the tendency to valgus. Inside the shoe an arch plate should be worn to offer 
support to the arches. 

In paralysis of the peroneal and tibial divisions, weakening of the arches of 
the foot may be found. Perhaps Whitman's inside metal plates could not 
be indicated more clearly than in these cases, yet they are rarely employed, 
because as long as the loss of sensation persists no painful symptoms of the 
condition are noted. A plaster cast or dental wax imprint of the foot should be 
taken and a plate made. Great care must be used, since, if the plate is not 
properly fitted, pressure sores may develop without warning due to the loss of 
sensation. With care trophic changes may be avoided. 

By walking without a proper splint, relaxed paralyzed muscles become over- 
stretched and the effect of prolonged splinting may be undone. At night the 
muscles should not be left without some support since the weight of the bed 
clothes may cause constant overstretching. A Jones clubfoot splint should be 
worn or a light plaster dorsal gutter splint made. The latter type will be found 
very satisfactory since they can be made so as to fit each individual and by 
baking can be made very hard and light with less plaster used. 

Comment. — In injuries of the sciatic nerve the peroneal division is more 
frequently involved. Many times the gross appearance of the tibial division 
would seem to indicate a lesion as severe or even more severe than that of the 
peroneal, yet conductivity may be present in the former and totally inter- 
rupted in the latter. This peculiar vulnerability of the peroneal division was 
observed in the Russo-Japanese War, the Balkan Wars and the World War, 
and is seen not only in injuries but also in systemic toxins such as alcohol, 
diphtheria, beri beri, etc., where the neuraxes of the peroneal division are 
involved, while those of the tibial may escape. In support of the view that 
functions and structures of more recent acquisition are more readily lost and 
more vulnerable, it is perhaps significant that increased vulnerability should be 
found in both the peroneal and musculospiral nerves, both of which supply 
functions and muscles of more recent acquisition. 

Peroneal Nerve. — As the peroneal nerve winds around the head of the 
fibula, or as it leaves the popliteal space it is especially liable to direct injury. 
Because of its exposed position indirect injury frequently occurs and inclusion 
of the nerve in callus in fractures of the fibula is not uncommon. The exposed 
position of the nerve accounts not only for the frequency with which it is 
injured but also, in a measure, for the poor results following suture of the 
nerve in this region. Due to the anatomical arrangement of the tissues it is 


frequently impossible to make a new bed for the nerve, or to free the nerve 
sufficient distally to permit mobilization of the distal segment to more 
favorable surroundings. The unfavorable results of suture in this region 
are somewhat comparable to the poor results obtained in suture of the ulnar 
nerve when the line of suture is in the groove behind the medial condyle. It is 
possible that the poor nerve bed in these two situations is not alone responsible 
for the results obtained, but the continuous slight trauma due to flexion of 
the leg and of the forearm may also contribute to interference with regenera- 
tion. In suture of the ulnar nerve at the elbow the results are better with 
transposition than without, even when the nerve bed behind the condyle is 
smooth and contains no callus. Constant slight trauma to the nerve at the 
point of suture may interfere with regeneration as similar relatively slight 
continuous trauma may interfere with normal nerve conductivity and lead, 
eventually, to structural changes in the nerve fiber. Another possible cause 
of failure in regeneration in injuries of this region is the fact that final arrange- 
ment of the nerve fibers within the trunk has already taken place for distribu- 
tion to the three branches which arise at this level. Consequently misdirection 
and crossing of the fibers here would be apt to cause more permanent distor- 
tions, leaving little opportunity for rearrangement of the neuraxes. However, 
through its three branches, the nerve supplies a physiological unit serving 
functions closely alike and not concerned in finer movements; consequently 
bad shunting alone of the nerve fibers should not entail any great physiological 

Injury of the tibial nerve in the calf may cause very few apparent motor 
changes, since the long flexors of the ankle and toes will have already received 
their innervation, and only the small muscles of the sole of the foot will be 
paralyzed. For this reason injuries to the tibial nerve in this region may be 
overlooked, if only a superficial examination be made, but the cutaneous anes- 
thesia and analgesia in the sole of the foot are characteristic. In incomplete 
injuries of the tibial nerve causalgia and other painful conditions are not infre- 
quently found, even when the injury is as low as the middle third of the leg. 
The internal and external plantar nerves are rarely injured but they may be the 
source of intractable pain, due to compression or inclusion by callus in fractures 
of the tarsal and metatarsal bones. Painful symptoms and trophic disturb- 
ances in the sole of the foot in these cases mav be relieved by nerve liberation of 














"3 "5 











































" 1 




. " 




























































brought together, but when the loss of nerve substance is great, or in condition: 
such as ankylosis of the knee-joint, contractures in 
muscles and tendons about the joint which interfere 
with flexion, approximation may be impossible, even 
after free exposure and moderate traction. Due to the 
great size of the sciatic nerve a cable graft that would 
cover the entire cross area of the nerve and afford an 
approximate number of conducting tubules for the 
neuraxes is very difficult to accomplish. If grafts of 
large diameter are used the cross areas are better cov- 
ered, but experimentally, at least, the large grafts do 
not transmit neuraxes well through their central pw 
| tions. Consequently, though a greater proportionate 
I _. number of tubules are offered only those at the circum- 
„ " " ference of Ihe graft arc utilized. 

u j 3 Separate suture of either the peroneal or tibial division 

a jx "' '' u ' sciatic may be done without interfering with the 

K & s | function of the other. If there has been some loss of 

* S j ? nerve substance the intact nerve will of necessity be 

u 3 si~ longer than the sutured nerve so that some angula- 

* K J tion of the intact nerve may occur. By separating 

— £ ' the two divisions a little distance above and below 

| - the suture a sharp kink is not apt to form, and so far 

as my experience goes, the function of the intact nerve 

is not thereby interfered with. When the entire nerve 

is sutured it is advisable to separate the peroneal and 

tibial divisions and do a separate suture of each, so as to 

obtain more accurate apposition of the nerve ends. 

Suture of the peroneal nerve in the thigh offers a better 

prognosis than suture of the tibial at the corresponding 

level, and, in both, suture in the intermediate zone 

where the funiculi are grouped into larger bundles, is 

^ ™ more successful than suture in the upper or lower nerve 

.£ plexus. Separate suture of the individual nerve bun- 

&* dies, asLangley and Hashimoto have pointed out, maybe 

done, particularly in the lower third of the peroneal and tibia! divisions, and 

8 : 



S £ 



:l — 


apparently not been followed by detrimental effects attributable to hemorrhage 
or scar formation. Obviously the greatest gentleness is needed, and a minimum 
of handling of the nerve bundles is imperative. 

The time of regeneration in sciatic nerve injuries may be nearly twice as 
long as in other nerves and may not be complete, in high sciatic sutures, until 
the end of the third year. The increased time required is rather to be expected 
when one considers the distance which the neuraxes must grow in high sciatic 
injuries and the distance from the cells of origin if the injury is in the leg or 

When nerve suture cannot be done or when nerve regeneration has failed, 
foot-drop may be satisfactorily overcome by tendon fixation, as advocated 
by Robert Jones and McMurray, and is to be recommended highly. The 
peronaeus brevis and tibialis anticus tendons are passed through a hole drilled 
in the tibia and fixed, thus holding the foot in dorsiflexion above a right angle. 


Ansinn, O.: Fascien implantation bei Radialis und Peroneuslahmung, Beitr. z. klin. Chir., 
v. 105: 1917, pp. 587-593- 

Brouwer, B.: The significance of phylogenetic and ontogenetic studies for the neuro- 
pathologist, J. Nerv. & Ment. Dis., v. 51: Feb., 1920, p. 113. 

Cheorier, L.: Quelques resultats eloignes d'interventions nerveuses sur le sciatique poplite 
externe (statistique integrate), Rev. Neurol., v. 24: IQ17, p. 284. 

Gillert, E.: Uber ischamische Muskelkontrakturen, Arch. f. klin. Chir., v. 112: 1920, 

p. 4I4-43I- 
Heile, B.: Operative Freilegung der verletzten peripheren Nervcn, Beitr. z. klin. Chir., 

v. 108: 1917, p. 82. 
Hoffman: Die Freilegung des N. ischiadicus im subglutalen Teil., Zentralbl. f. Chir., v. 

44: 1917, p. 159. 
KoxiG, F.: Die Freilegung des N. ischiadicus in seinem obersten Teile, Zentralbl. f. Chir., 

v. 43-2: 1916, p. 1023. 
Kunzel, I.: Zur Prognose der Xerven Schussverlelzungen, Beilr. z. klin. Chir., v. 107: 

iqi8, p. 5S3. 
Lanv.ley, J. X. and Hashimoto, M.: On the suture of separate nerve bundles in a nerve 

trunk and on internal nerve plexuses. Jour. Physiol., v. 51: 1917, p. 318. 
Nieny: Kinfache Stutzen fiir Peroneuslahmungen, Miinchen. med. Wchnschr., v. 63: 

(Xo. 2), iqt6, p. 68. 
Perron e. G. and Tavifani, G.: Contributo alia topogratia fascicolare dello sciatico pop- 

liteo esterno in un caso di lesione isolata del nervo muscolo cutanco in prossimita del: 

collo del peroneo. La chirurgia degli Organi Mow, v. 3: ioiq, p. ^^2. 


Poirier, P. and Charpy, A.: Trait6 d'Anatomie Humaine, Paris, Masson et cie., 1899 

p. in. 
Stopford, J. S. B.: The results of secondary suture of peripheral nerves, Brain, v. 43: pt. 1 

1920, p. 1. 
Worster-Drought, C: Lesions of the posterior tibial nerve, Brain, v. 44: pt. i, 1921, p. 5 



The recurrent laryngeal nerve may be injured by bullet or stab wounds and 
during operative proceedings. Besides these, peripheral paralysis may be due 
to pressure by tumors of the neck and thorax as well as by pressure on the nerve 
by the heart and the aorta. Ortner (1897), Guttman and Neuhof (19 16), 
Rosenthal (1916), Brown and Hempstead (1918) have called attention to 
paralysis as result of pressure of the dilated auricle against the aorta in mitral 

Suture of the Recurrent Laryngeal Nerve. — Suture of the recurrent laryn- 
geal nerve was reported by Stierlin (1907). He was able to obtain end-to-end 
suture and complete functional return was found six years later with only a 
slight lagging of the vocal cord on the operated side to indicate the former 
paralysis. Shelton Horsley (1910) described a successful suture of the recurrent 
laryngeal nerve three months after the nerve had been severed by a bullet. In 
suturing the nerve he made "an incision along the anterior border of the left 
sternocleidomastoid muscle. The center of the incision corresponded to the 
lower limit of the larynx. The sternomastoid, together with the carotid 
artery and jugular, was retracted toward the left. The left lobe of the thyroid 
gland was exposed and was retracted along with the trachea and larynx to the 
right. The recurrent laryngeal nerve was identified, where it runs in the groove 
between the trachea and the esophagus. It was found to be injured just before 
its entrance into the larynx, and was involved in a small mass of scar tissue 
where the bullet had evidently grazed the nerve. The diseased portion, approxi- 
mately a third of an inch in length, was excised, leaving a small filament, which 
was probably the posterior portion of the sheath of the nerve with a few fibers 
that had escaped direct injury. The proximal part was freely loosened to 
relieve tension and the nerve sutured with No. o twenty-day chromic catgut in 
a fine curved needle. Some muscular tissue was drawn over the sutured nerve." 

One year later almost perfect mobility of the affected side was present 
with only slight lagging, especially in adduction. Adhesions between the 
anterior thirds of both vocal cords had formed, possibly the result of their close 


that spontaneous regeneration of the recurrent laryngeal nerve had not 
taken place. 

Hoessly believed that this method of neurotization of the laryngeal muscles 
might be utilized and suggested the following operative technic. (See Fig. 193.) 
"Local anesthesia similar to that employed for thyroid operations. Collar 
incision. Blunt dissection along the lateral border of the small neck muscles. 
The hyothyroid muscle is cut at its base. The thyroid cartilage is thus exposed 
and easy access afforded when the larynx is retracted to the opposite side by 
means of sharp retractors. A window is then cut into the ala of the thyroid 
cartilage at the level of the muscles to be neurotized and a branch of the spinal 
accessory to the sternocleidomastoid muscle is taken and the central end 
implanted into the small muscles of the larynx and fixed with catgut. The site 
of the implantation is then covered with a flap of fatty tissue, the window closed 
and the wound sutured in the usual manner." 


The spinal accessory nerve may be injured in gunshot and stab wounds or 
in operations for removal of tumors in the neck, tubercular glands or a cervical 
rib. When the nerve is injured near its point of entrance into the trapezius 
the paralysis of this muscle is more marked than when the nerve is injured near 
its exit from the cranial cavity since it receives contributions from the third 
and fourth cervical nerves lower down. In injuries of the nerve near its exit, 
as compared with those at a lower level which I have seen, there has been no 
appreciable difference in the extent of the paralysis or the deformity. 

As the spinal accessory nerve makes its exit from the jugular foramen it 
may be one of the three or four nerves to be injured in the retroparotid space. 
Vernet (191 7) has described as the syndrome of the foramen lacerum, injuries 
involving the glossopharyngeal, vagus and spinal accessory nerves, and Villaret 
(191 7) the syndrome of the retroparotid space when the injury involves not only 
the glossopharyngeal, vagus and spinal accessory but the hypoglossal and 
cervical sympathetic as well. Pollock (1920) has described additional cases 
involving some of these nerves. It will be recalled that immediately after their 
exit these nerves are close together and that the hypoglossal nerve lies medial to 
the spinal accessory and winds around the cervical sympathetic, glossopharyn- 
geal and vagus nerves from behind forward and downward, hence injury in 
this region may involve any or all of these nerves. 


Anatomy. — The spinal accessory nerve arises by five or six rootlets from the 
upper five or six cervical segments. The cells lie in the lateral or splanchnic 
motor column of the ventral gray. The accessory portion arises from a con- 
tinuation upward into the medulla of the same column of cells and is incorpor- 
ated in the vagus, joining it immediately at its exit from the cranial cavity and 
consequently has no representation in the peripheral distribution of the spinal 
accessory nerve. The spinal accessory nerve is distributed to the sternocleido- 
mastoid and trapezius muscles, supplying the former completely in junction 
with the third and fourth cervical nerves. 

Course. — Each rootlet of the spinal portion joins with the rootlet above to 
form the intradural portion of the nerve lying in the subarachnoid space between 
the dentate ligament and the dorsal roots. The nerve thus formed enters the 
cranial cavity through the foramen magnum and makes its exit through the 
jugular foramen in company with the ninth and tenth nerves and the internal 
jugular vein. 

In the neck the nerve is directed downward, outward and backward passing 
behind the transverse process of the atlas, beneath or through the sterno- 
cleidomastoid — rarely superficial to this muscle — to enter the dorsal triangle 
of the neck where it lies rather superficial, being covered only by skin and the 
cervical fascia and enters the trapezius muscle on its under surface. 

Variations. — Occasionally the spinal accessory nerve apparently communi- 
cates with the dorsal roots of the first and second cervical nerves and possesses 
a dorsal ganglion. These communications and ganglia have aroused con- 
siderable interest since this nerve is entirely motor so far as its cells of origin are 
concerned, and no peripheral sensory distribution has been found. The commu- 
nication with the dorsal roots and the presence of the ganglia represent merely 
a superficial fusion over an extremely short course where the spinal accessory 
nerve passes close to the dorsal roots, the fibers of each remaining distinct. 
In one instance the spinal accessory nerve on both sides ended in the sterno- 
cleidomastoid and the trapezius muscle was supplied by the third and fourth 
cervical nerves only (Curnow) . While this may suggest the importance of the 
contribution of the third and fourth cervical nerves to the spinal accessory, 
such innervation of the trapezius is difficult to interpret on a developmental 
basis since the cervical nerves, somatic motor in origin, should not supply 
splanchnic musculature such as the trapezius. 

Deformity. — In injuries of the spinal accessory nerve both the sterno- 
cleidomastoid and the trapezius are paralyzed, the former completely and the 


latter partially, but it is only in extremely rare instances that the trapezius 
receives sufficient innervation from the cervical nerves to permit contraction 
functionally efficient. In the cases of spinal accessory paralysis the author 
has seen, no contraction of the trapezius muscle could be detected, but some 
observers have found a partial paralysis only. Schultz believes that it is only 
the lower part of the trapezius which is supplied exclusively by the cervical 

In paralysis of the trapezius the contour of the neck is altered, due to an 
increase in the angle formed by the shoulder and neck. The shoulder on the 
affected side is lower, the vertebral border of the scapula more prominent, 
the inferior angle approaches the midline and is turned toward the opposite 
side in place of directly downward. 

The functional loss in the movements of the arm may be relatively slight, 
and in long-standing paralysis the disability is in a great measure compensated. 
The function of the trapezius muscle varies according to the position of the arm, 
the movement performed and whether the whole muscle or only part of the 
muscle contracts. By a muscle of such wide origin a great variety of functions 
are served. The clavicular portion elevates the scapula as a whole and raises 
the shoulder during inspiration — an accessory respiratory muscle. It also helps 
to draw the head backward and turn the chin toward the opposite side. The 
middle portion elevates the scapula, draws its vertebral border toward the mid- 
line, and rotates its outer angle upward. The lower portion moves the scapula 
inward and helps to fix it during arm movements, and, when acting alone, 
rotates the outer angle downward. When the muscle acts as a whole the 
scapula is fixed, thus rendering the action of the muscles moving the arm more 

Mechanical Treatment— No form of splinting is of real value. In in- 
operable cases efforts should be directed to re-educate the muscles associated 
with the trapezius in the movements of the shoulder and arm, particularly 
the rhomboideii, levator scapulas, serratus anticus, clavicular head of the 
pectoralis major, deltoid coracobrachial and biceps. If these muscles arc 
developed the limitation of movement in spinal accessory paralysis will be 
relatively slight. 

Exposure.- -The exposure of the spinal accessory nerve has been described 
under the facial nerve (see page 212). If the spinal accessory nerve is injured 
more distally, that is, after its entrance into the dorsal triangle of the neck, it 


fused with the cervical nerves in this region. Identification by the electrode 
unfortunately may not be possible if the nerve is injured. The surest way of 
finding the nerve is to begin centrally and trace it downward. However, in 
complete interruption, particularly with loss of substance, the distal end can 
rarely be found. In these cases an attempt should be made to implant the 
central end directly into the trapezius muscle. This method has not been very 
successful in this muscle, probably due to the transverse or oblique direction of 
the muscle fibers, allowing only a small portion of the muscle to be innervated; 
not sufficient for function. 


The long thoracic nerve is rarely involved in brachial plexus injuries, 
unless complete evulsion of the cervical roots has occurred, since the nerve 
arises from the cervical roots immediately after their exit from the interverte- 
bral foramina. Isolated paralysis has been seen from carrying heavy weights on 
the shoulder and in stab wounds and gunshot wounds, but this is extremely 
rare. In one case the long thoracic nerve was injured relatively high in the 
neck. Complete paralysis of the serratus anticus followed with marked winging 
of the scapula and an unusual degree of downward rotation of the external angle 
so that the long axis of the scapula was directed almost transversely. Some 
months after the injury complete paralysis of the muscles supplied by the 
suprascapular nerve appeared. It was felt that this late paralysis in the dis- 
tribution of the suprascapular nerve resulted from the marked rotation of the 
scapula and was caused by pressure exerted on the nerve as it passed through the 
suprascapular notch. So far as I am aware such a mechanism for injury of the 
suprascapular nerve is most unusual. 

Anatomy. — The long thoracic nerve arises as dorsal branches from the 

ventral divisions of the fifth, sixth and seventh cervical nerves, immediately 

after their exit from the intervertebral foramina. The nerve pierces the 

scalenius medius muscle in two bundles and descends behind the brachial 

plexus, crossing over the upper digitation of the serratus anticus to enter the 

axilla between the serratus anticus and the axillary artery. It descends on the 

outer surface of the serratus anticus and supplies separate branches to each 

Deformity. — In total paralysis of the serratus anticus the scapula assumes 

a characteristic position with the entire scapula drawn away from the chest 

wall, so much so that in some cases the hand can be inserted between the scapula 


and the thorax. The scapula is rotated so that the inferior angle is directed 
transversely and the outer angle downward and forward. This position of 
the scapula is due mainly to the weight of the upper extremity and the lack 
of support for the scapula. The arm can rarely be elevated beyond the hori- 
zontal, and there is marked disability in attempts to carry weights, due to 
the fact that the scapula is no longer a fixed point for the action of the shoulder 
girdle muscles. The arm, however, can be raised beyond a horizontal by the 
deltoid provided the arm is assisted in elevation to above no or 115 . 

Mechanical Treatment. — The shoulder should be maintained in elevation 
by an axillary pad or an abduction splint and pressure should be exerted upon 
the scapula to maintain it against the chest wall. By elevation of the arm 
the marked rotation of the scapula is prevented and the danger of injury to 
the suprascapular nerve is avoided. If the scapula be held against the chest 
wall rotation of the scapula and elevation of the arm can be accomplished, by 
action of the associated muscles, especially the trapezius, rhombodeii and leva- 
tor scapulae. By being held against the chest wall the scapula may be used 
as a fixed point for the action of the other muscles — an important factor in the 
mechanics of shoulder and arm movements. 

Exposure. — The long thoracic nerve may be exposed above the clavicle by 
the same incision as for the brachial plexus. The nerve will be found lying 
behind the plexus, but if difficulty is encountered in finding it, it may be picked 
up at its origin as it emerges through the scalenius medius muscle and then 
traced downward. By elevation of the shoulder and bending the head laterally 
a considerable loss of nerve substance can be overcome. Attempts to implant 
the central end directly into the serratus anticus is of little value, since only 
the digitations into which the nerve is implanted would be innervated. Each 
digitation is more or less a separate unit, normally supplied by a separate nerve 
branch, and neuraxes from the implanted nerve would very likely be unable to 
extend to other digitations. 


Isolated paralysis of the suprascapular nerve is most uncommon, while 
involvement of this nerve in brachial plexus injuries is extremely frequent; 
rupture of the outer cord occurring at about the point at which the supra- 
scapular nerve is given off. (See'Figs. 96, 97.) Like the long thoracic nerve 
the suprascapular nerve may be injured in carrying heavy weights upon the 


wrenching of the arm and, as has been pointed out, as an associated paralysis 
in paralysis of the long thoracic, due to injury of the nerve in the supra- 
scapular notch by extreme rotation of the scapula. 

Anatomy. — The suprascapular nerve arises from the outer cord of the 
brachial plexus, close to or at the junction of the fifth and sixth cervical roots. 
The nerve is relatively large, lies above the outer cord and between it and the 
long thoracic nerve; crosses over the first digitation of the serratus anticus 
and behind the clavicle, turns lateral along the upper margin of the pectoralis 
minor, together with the suprascapular artery, enters the suprascapular notch, 
and is distributed to the supraspinatus and infraspinatus muscles. 

Deformity. — In injuries of the suprascapular nerve atrophy of the supra- 
spinatus and infraspinatus muscles is seen with characteristic depressions 
above and below the spine of the scapula. Due to paralysis of these muscles, 
external rotation of the arm is lost. Some observers have described external 
rotation due to the action of the teres minor muscle, but this the author has not 
been able to verify in any of his cases. However, slight external rotation may 
be accomplished by action of the scapular portion of the deltoid, but this is 
possible only when the arm is held horizontal, and none occurs with the arm at 
the side. According to Duchenne (1867) the supraspinatus acting alone holds 
the humerus against the glenoid fossa. With the arm raised above a right angle 
it also helps in elevation of the humerus. The loss of external rotation is 
important since without this movement considerable disability exists. 

Mechanical Treatment. — No mechanical treatment is indicated and any 
form of adequate splinting would interfere seriously with other movements 
of the arm. By passive motion and active exercises, contracture in internal 
rotation can be avoided. 

Exposure. — Exposure of the suprascapular nerve is that for the brachial 
plexus. (See page 249.) 


The close relationship of this nerve to the great femoral vessels probably 
accounts for the relatively few anterior crural nerve injuries met with, since 
probably the great vessels are injured at the same time and fatal hemorrhage 
results. Immediately below the exit of the anterior crural nerve from the pel- 
vis, under Poupart's ligament the nerve breaks up into its numerous muscular 
and cutaneous terminal branches, so that even if the nerve were injured in this 
region, end-to-end suture would be almost impossible. If suture were possible 



t would be extremely difficult to distinguish the motor from the sensory 

tranches and to avoid uniting a motor to a sensory nerve. In general the 

rauscular branches lie deeper, usually arranged in three groups. An inner 

group which follows the medial border of the long saphenous to where the latter 

enters Hunter's canal, supplies the vastus medialis and intermedius, the branch 

to the latter being given off rather early in its course. The middle group 

supplies the rectus femoris and vastus externus, entering these muscles from 

their under surface and sending branches through to the crureus. The outer 

Fig. 194. — Thomas caliper for paralysis of anterior crural nerve. Note angle at which caliper 
should be inserted into shoe to obtain slight inversion of foot. The shoe is elevated on the inner 
border so as to deviate body weight and lessen the strain on the knee-joint. A spring lock at the knee 
may be used to permit flexion on sitting. (See p. 407.) (Stookey, Surg., Gyn. and Obst., 1918.) 

group passes under the sartorius, supplies this muscle with both an upper 
and lower set of branches. The latter enters the muscle at about its middle 

Surgical Treatment.— As has been said, suture of the anterior crural is 
rarely possible. However, direct implantation of the central branches into the 
muscles of the quadriceps femoris may be tried, but the most satisfactory 
method to overcome the deformity with complete paralysis of these mus- 
cles will be tendon transplantation either of the biceps alone or of the 


Deformity. — The quadriceps femoris, the sartorius and pectineus muscles 
being paralyzed, extension of the leg is impossible. The patient walks with a 
swinging gait, coming down upon the heel. By action of the tensor fasciae lata?, 
supplied by the superior gluteal nerve, the knee is held locked in hyperextension, 
or in place of locking the knee the patient may walk bent over, the hand 
resting heavily on the semiflexed thigh. Unless the knee-joint is guarded it 
becomes a trigger joint, and by suddenly giving way may let the patient fall. 
In all neglected cases genu recurvatum may result due to gravity and constant 
fixation of the knee in hyperextension. 

Mechanical Treatment. — Stabilizing the knee by preventing extreme 
hyperextension and the tendency to trigger joint formation can be accomplished 
by a Thomas walking caliper fitted with either a stop or spring lock permitting 
flexion of not more than 35 . (See Fig. 194.) The spring lock is very conven- 
ient since it permits the knee to be slightly flexed while sitting and, by limiting 
the degree of flexion, overstretching of the extensors will be avoided. With 
the support of the quadriceps femoris gone, strain on the knee-joint and weaker 
internal lateral ligament occurs but can be minimized by shifting the body 
weight by raising the shoe one-third inch on the inside, and by changing the 
relative position of the external and internal bars of the caliper as they fit into 
the heel. 


Injury of this nerve is even more rarely met with than injuries of the ante- 
rior crural, possibly for the reason that fatal hemorrhage from adjacent large 
vessels, or serious pelvic injury, usually accompanies injury to the nerve. Its 
muscular branches are given off almost immediately after its exit from the pel- 
vis, have a short extramuscular course and peripheral paralysis, therefore, is 

Deformity. — Weakness in adduction of the thigh is due to paralysis of the 
adductor longus, brevis and magnus as well as the gracilis. However, the ad- 
ductor longus is also supplied by a small branch from the anterior crural nerve 
and the adductor magnus by a branch from the nerve to the hamstrings. The 
adductor magnus is formed from the same primitive premuscle mass as the 
hamstrings, hence its dual supply through the obturator and the nerve to the 
hamstrings both of which are made up of fibers from ventral divisions. The 
quadratus femoris and lower fibers of the gluteus maximus also serve as adduc- 
tors. Hence adduction is not entirely lost even in complete obturator paralysis 


due to the dual nerve supply of the adductor longus and magnus and to the 
action of the gluteus maximus and part of the quadriceps femoris. 

Exposure. — The lower extremity is held in extreme adduction and the 
thigh slightly flexed on the abdomen so as to relax the medial muscle group. 
An incision 10 cm. long is made along the medial border of the adductor longus, 
beginning at the os pubis. After cutting through the deep fascia the oblique 
space between the adductor longus and the pectineus and adductor brevis 
is opened. Unless it be recalled that the pectineus overlaps the adductor 
longus some .difficulty may be met with in finding the fascial plane between 
these two muscles. The adductor longus is retracted medially and the pec- 
tineus and adductor brevis laterally. The medial border of the adductor 
longus is followed upward to its origin. At about 3 cm. below this point both 
the superficial and deep branches of the obturator nerve may be found as it 
emerges from the obturator canal. In some instances the deep branch pierces 
the obturator externus to pass dorsally between the adductor magnus and 
adductor brevis. If this branch is not found at the obturator canal it had 
better be ignored for it may be very difficult to find and it is not of great motor 


Isolated paralysis of the gluteal nerves without injury to the sciatic nerve 
is extremely uncommon. These nerves arise separately from the lumbosacral 
plexus deriving their fibers from the dorsal divisions of the fourth and fifth 
lumbar, first and second sacral nerves. Both gluteal nerves leave the pelvis 
through the sciatic notch: the superior above the pyriformis along with the 
superior gluteal artery; the inferior below the pyriformis with the inferior 
gluteal artery and sciatic nerve. The superior gluteal nerve runs between the 
gluteus minimus and medius, supplies the former from its dorsal surface and the 
latter from its ventral, and ends in the tensor fasciae latae. The gluteus inferior 
lies superficial to the sciatic nerve and immediately after it makes its exit from 
beneath the pyriformis muscle it breaks up into muscular branches for the 
supply of the gluteus maximus. (See Fig. 195.) 

In injuries of the superior gluteal nerve the internal rotators of the thigh, 
namely the gluteus medius and minimus, and tensor fasciae latae are paralyzed. 
External rotation is also weakened due to loss of the action of the dorsal fibers 
of the gluteus medius and minimus. If the inferior gluteal is paralyzed the 
external rotator and adductor action of the gluteus maximus is lost. 


Exposure. — Both of the gluteal nerves may be exposed by an incision begin- 
ning at the inferior spine of the ilium and directed downward to three ringer 
breadths below the great trochanter. In certain cases the incision may be 

Fie. iqs- — Superior anil inferior gluteal nerves. Surface projection, i, Superior gluteal nerve 
o gluteus medius anil glu'eus minimus; i', branch to tensor fascia? lata?; 3, inferior nerve lo 


carried lower so as to expose the insertion of the gluteus maximus muscle as is 
done in operations on the proximal third of the sciatic nerve. (See page 395.) 
The gluteus maximus fibers are separated in the direction of their course 
until the pyriformis muscle is encountered. By wide retraction, by cutting 
if necessary the insertion of the gluteus maximus, exposure of both the sui 
and inferior gluteal nerves may be obtained. 


If end-to-end suture is impossible the proper procedure will depend on 
the point at which the injury has occurred. When the injury is close to where 
the nerves emerge from the pelvis the distal segment should be crossed into the 
sciatic — the superior gluteal into the tibial portion and the inferior gluteal into 
the peroneal portion. If the injury be close to the entrance of the nerve into 
the muscle the central segments should be directly implanted — the superior 
gluteal into the gluteus m.edius and the inferior gluteal into the gluteus maximus. 


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with mitral stenosis, J. A. M. A., v. 70: 19 18, p. 4. 
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of tuberculous glands of the neck, Rev. Neurol. & Psychiat., v. 13: 191 5, p. 51. 
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Lyon med., v. 125: 1916, p. 163. 
Paralysie du recurrent par balle, Lyon med., v. 124: 1915, p. 188. 
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Erlacher, P.: 1. Hyperneurotisation; muskulare Neurotisation; freie Muskeltransplant- 

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2. Ueber die motorischer Nervenendungen, histologische und experimentelle Beit rage 

zu den Operationen an den periphercn Nerven, Ztschr. f. orthop. Chir., v. 34: 1914. 

p. 561. 
Guttman, J. and Neuhof, S.: Radial pube difference and left recurrent nerve paralysis 

due to mitral stenosis, J. A. M. A., v. 66: 1916, p. 335. 
Hacker, v.: Direkte Nerveneinpflanzung in den Muskel und muskulare Neurotisation be, 

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Hoessly, H.: Ueber nerven Implantation bei Recurrenslahmungen, Beitr. z. klin. Chir. 

v. 99: 1916, p. 186. 
Horsley, J. S.: Suture of the recurrent laryngeal nerve, Ann. Surg., v. 51: 1910, p. 524. 
Suture of recurrent laryngeal nerve, Southern Surgical Gynecological Transactions, v. 22: 

1909, p. 161. 
MacDonald, F.: Transplantation of the recurrent laryngeal, Atti. del XI Congresso Medico 

Internazionale, v. 2: 1894, p. in. 
Meinzner, R.: Medianuslahmung mit folgender Phrenicuslahmung nach Schussverletzung, 

Neurol. Centralbl., v. 39: 1920, pp. 84-86. 
Ortner, N.: Recurrenslahmung bei Mitralstenose, Wien. med. Wchnschr., v. 10: 1897, 

P- 753- 


Picot, G.: Le reflexe oculo-cardiaque dans les 16sions traumatiques incompletes du pneumo 

gastrique, Presse Med., v. 27: 1919, pp. 191-192. 
Pollock, L. J.: Extracranial injuries of multiple cranial nerves, Arch., Neurol. & Psychiat., 

v. 4: Nov., 1920, p. 517. 
Rosenthal, J.: Paralysis of the recurrent laryngeal nerve resulting from mitral stenosis, 

J. A. M. A., v. 66: 1916, p. 333. 
Schmerz, H.: Zur operativen Beeinflussung der Recurrenslahmung, Beitr. z. klin. Chir., 

v. 118: 1919, pp. 272-284. 
Schuster, P. : Isolierte Lahmung des N. glutaeus superior durch Schussverletzung, Neurol. 

Centralbl., v. 34: 191 5, p. 418. 
Serafini, J. and Uffraduzzi, O.: L'implantation peripherique totale du nerf laryngien 

inferieur sur le pneumogastrique, Arch, de Med. exper., v. 28: 1918, pp. 209-27. 
Stierlin, R.: Nervus recurrens und Kropfoperationen, Deutsch. Ztschr. f. Chir., v. 89: 

1907, p. 78. 
Symonds, C. P.: A case of a lesion of the suprascapular nerve and first dorsal root, with 

hemisection of the cord produced by a single missile, Proc. Roy. Soc. Med., v. 13 

Sec. Neur., 1920, p. 43. 
Vernet, M.: Sur le syndrome du trou dechire posterieur, Paris med,. v. 7: Jan. 27, 1917, 

p. 78. 
Villaret: Le syndrome dc l'cspace retroparotidien posterieur, Paris med., v. 21: 1917, 

p. 430. 



Neuroma.— Virchow early pointed out that this term to designate tumors 

Kr-nerves was a misnomer since in tumors of nerve trunks neither nerve cells 

• nerve fibers participate in the new growths, and consequently neoplasms 

^■t of nerve tissue origin cannot be called neuromas. True neuromas are 

ind as hyperplasia following nerve injuries, forming the classical amputation 

uroma; these being an expression of an attempt at regeneration and consist- 


ing, in the main, of newly formed neuraxes, twisted and intertwined, and Per- 
roncito spirals. Not only are new nerve fibers found but there is also a pro- 
liferation of the cells of Schwann and of the endoneural connective tissue. 
Perhaps the application of the term neuroma is not even here as accurate as 
might be desired, since these enlarged nerve ends are not really neoplasms, but 
rather bulbs; the results of physiological attempts at regeneration. 

Fibroma. — Brans (.1892) has placed under the term elephantiasis nervorum 
a group of tumors arising either from the nerve trunks (multiple fibroma) 
(see Fig. 108) or from the terminal branches within the skin (multiple fibroma 


graph showed the relation and common origin 
of multiple fibroma of the skin, fibroma mollus- 
cum and multiple neurofibroma, both arising 
from the perineurium and endoneurium of peri- 
pheral nerves; in the one instance from the 
terminal twigs within the skin, and in the 
other from the larger nerve trunks. 

Location.- — Neurofibromas may occur singlv or 
multiple on any of the nerve trunks of the spinal, 
cranial or sympathetic nerves. They may be 
found in the peripheral course, or within the 
cranial cavity (n. acusticus, n. intermedius, 
and vagus, etc.) or on the dorsal roots of the 
spinal nerves within the spinal canal. 

They may cause clinical manifestations refer- 
able to the peripheral distribution of the nerves 
from which they arise, and also because of their 
anatomical location may cause pressure upon 
adjacent nerve structures. Those arising from 
the nervus acusticus within the cranial cavity 
give risetocentral nervous system signs referable 
to the cerebellopontile angle, while others caus- 
ing pressure upon the cord may give rise to 
signs of spinal cord compression. When two 
or three nerves lie close together in their course 
a tumor of one may give rise to signs referable 
to adjacent nerves; for example, tumors of the 
median nerve in the middle of the arm may 
cause pressure upon the ulnar nerve and give 
signs referable to ulnar distribution, and vice 
versa, while tumors of the vagus within the 
jugular foramen may cause pressure upon the 
glossopharyngeal and spinal accessory nerves. 

These peripheral nerve tumors generally lie 

within a definite capsule either within the nerve 

I 11 trunk separating the funiculi and making them 

University Pathological Collection.) appear as definite bundles, or they may sur- 



round the whole nerve trunk as a fusiform swelling, the neuraxes forming the 
central portion. The former type, if well circumscribed, may be enucleated 
without interruption of the funiculi, while in the latter complete nerve section 
is necessary. Occasionally the tumor may lie on one side resting within a con- 
cavity in the nerve with all the funiculi pushed to one side. 

Neurofibromas arise from the endoneurium, more generally perineurium, 
and rarely epineurium. The tumor tissue is usually poor in cells, with the 
fibers closely woven, running parallel with the neuraxes 
and many times interlacing or encircling them. Ashoff 
(1913) has shown that tumors do not arise from the 
nerve fibers, since in nerve section and degeneration of 
the neuraxes they are unaltered and new tumors even 
may appear after the neuraxes have degenerated. The 
nerve fibers, consequently, do not participate in the 
new growth. The neuraxes may remain unaltered or 
may undergo degeneration as a result of pressure. 
Degenerated fibers may be seen adjacent to normal 
nerve fibers. 

These tumors may attain relatively large size, grow 
slowly and cause relatively few signs. (See Fig. 198.) 
Pressure on adjacent nerves depends on the location of 
the tumor, its size and its consistency. When there 
is room for dispiacement of neighboring structures and 
when the tumor is soft neighborhood signs may never 
occur or only late. Motor paralysis and atrophy are 
seldom seen. There may be some motor weakness but 
the electrical reactions are often unaltered, though if 
measured currents are used the strength required to ob- 
tain contraction is increased. Most often the patient 
complains of a sensation of burning, tingling, or other 
paresthesias. In one patient seen by Dr. Casamajor 
and myself the principal complaint was a sharp cutting 
pain as if a knife were being drawn down the middle 
of the fourth finger. (See Figs. 199, 200, 201, and 202.) Neither anesthesia 
nor hyperesthesia may be present. In those with hyperesthesia the nerve 
trunk may be painful to pressure over its course distal to the tumor. Pain is 

19S.— M ultiple 
neurofibroma involving the 
musculirepiral, circumflex, 
musculocutaneous, median, 
ulnar and internal cutan- 

■ves. (Columbia 
University Pathological 


)i. — Stages during the dispnlio 
s found to spread out and mm] 

as Fig. igo. The pedicle of the 
i- necessitating section o[ the ncrvi 

Fig. 202. — Suture of the median nerve after removal of the tumr 
In this instance it was possible to suture each funiculus separately 
superficial surface supplies the pronator teres and Itesnr carpi radialii 


of neurofibromas collected by him, malignant degeneration occurred in about 
12%. Courvoisier (1886) found fifty-three cases of sarcomatous degeneration 
in eight hundred neurofibromas. Of these fifteen were pure sarcoma; the 
remaining being myxosarcoma and fibrosarcoma . (See Fig. 203.) 

When malignant change occurs the virulence and the vehemence with 
which recurrence takes place is amazing (Garr6). The majority show a local or 
regional recurrence within a year; in others this may be delayed for a number of 
years. Volkmann operated on one case several times and finally at the end of 
ten years amputation became necessary, while in another case recurrence 
occurred only after six years. Garre has called attention to the fact that in 
secondary malignant neuroma metastases occurs regionally; that is, within the 
vicinity of the primary tumor, within the same nerve or adjacent nerves, and 
only late are more remote metastases found. The opposite occurs in primary 
sarcoma with remote metastases early and not regional. 

Clinically it is difficult to distinguish between simple neurofibroma and 
those in which malignant change has occurred. Within the same tumor, areas 
of malignant change are found adjacent to simple neurofibromatous tissue. 
However, when a slowly growing neurofibroma with few symptoms shows rapid 
increase in growth, together with increasing signs, such as paresthesias, hyper- 
aesthesias or motor changes, malignant degeneration is to be suspected. When 
sarcomatous change has occurred, the tumor may break through its capsule 
and invade the funiculi and the surrounding tissues with increasing signs 
of nerve involvement due to the increased pressure and damage to the 

Genesis. — von Recklinghausen, Garre (1892), Ribbert (1904) and others 
believe that this entire group of nerve tumors described under the term of ele- 
phantiasis nervorum and including neurofibroma, plexiform neuroma, secondary 
malignant neuroma and fibroma molluscum represent "a congenital affection 
with a congenital predisposition to the formation of connective tissue tumors 
of the nerves, perhaps due to some irregular distribution and arrangement of 
the connective tissue elements of the nerves permitting of independent growth." 
This congenital predisposition is further suggested by the appearance of such 
tumors in early childhood, their multiplicity and the hereditary tendency. 
Garre believes that "in the tendency to sarcomatous degeneration in neuro- 
fibromas of elephantiasis neuromatoides congenita trauma plays perhaps a 
slight r61e in initiating the secondary malignant change, serving merely to 
quicken the inherent malignant tendency already present." 

normal., ™"l»n,|,,, , - sl >°»-n by „ ses « 

;-"=:::?- I.""--* 

'■";.■•; — - .:::c,7""--. 

' ,w '%W,.. F . |r , ,. ' ° ut more r ^^,,,,, „. ,, gnosis sJ>o u , , 

TO »™ «f *eo nd - - ' ™*ra [ions „;;'""« «« into so „^ V »» 
. ■ °' Wnpl, cra , - <"« attention haa . 

v a Sc 
'■ ^'PQeraJ , UT ,,,. . ' " "centta has, i 

""' * « ^rt^^^:::-*^ 

a Jar; 



* masses and strands of rather small, rounded cells, many of which showed 
"^mitoses, separated by trabecular of connective tissue. Scattered through the 
"tumor eclls at irregular intervals are many rosettes. . . . These were small 
■circular holes surrounded by a sharply outlined membrane which is red with 

Mallory stain." Stout concluded " that the tumor was a malignant neoplasm 

Fig. 304.— Micropbotogmpb of section of tumor of die 

epirondyle of the humerus. .1, Iiunillc of nerve fibers in its 
is shown with a mass of lumot cells, I", sharing the ipace u 
fibers. F. Note large size iind hyperplasia of the neurnlem 
Report. Nov York City, 1918.) 

e taken just below the interna 1 
■ tissue capsule; /', perineurium 

;ile reliitiifii5-tii|i with the nerve 
(Stout. Presbyterian Hospital 

which grossly resembled (he sarcomas, and that since the neurolemma cells of 
peripheral nerve are probably homologous to the neuroglia of the central 
nervous system, this type of tumor may arise from the neurolemma cells or 
lemmocytes." (See Figs. 204, 205, 206.) 

This type of tumor described by Verecay and Stout, as has been said, is 
comparable to the glioma of the central nervous system, since the neurolemma 

rplk nf tbr, r. P rmUrnl n«v<*> aro hnTVinUmia vAth tW lummoUi Tt hns. alronHv 



been pointed out (see p. 26) that the neurolemma cells are ectodermal cells which 
migrate from the neural crest and neural tube along with the developing nerve 
fibers. Hence, the possibility of two different types of tumors in the peripheral 
as in the central nervous system — the sarcoma of mesodermal origin and the 
neuroblastoma of ectodermal origin. 

Leprosy. — While leprosy cannot be classed under tumors, nodu la ^enlarge- 
ments of peripheral nerves, especially the ulnar, may occur in leprosy. 

Fig. 105.— Mai lory 
andcontiL'tlivi.- lis: 

York City, 191} 

trabecule, C. (Stout, Prcsliylerian Hospital Re 
possibility of this condition must be considered when motor signs, atypi 
sensory changes without pain, and skin changes are found with a nod 
enlargement of the nerve trunk. If a thorough examination is made 
in the texture and thickness of the skin will be found which do not corresj 
exactly with the cutaneous distribution of the nerve and are not met with in 
other nerve lesion. A patient having an old fracture of the radius and ulna 
presented for ulnar nerve operation; but on account of the atypical si 
findings and the peculiar skin changes the diagnosis of leprosy was 



It was afterwards found that the patient was a native of Haiti. In some 
instances a localized nodular enlargement may be found on a nerve with typical 
motor and sensory changes referable to the nerve involved, but no other sensory 
or skin changes, and the diagnosis of leprosy is not made until operation. If 
the lesion is well localized excision and suture are indicated. 

Fig. :o6.— Same as Fig. 205. Mallor; 
R, showing deeply stained membrane or rin 
rounding tells; C, trabecula of p 
City, 1918.) 

stain— high power micro photograph of three rosettes, 
froni which radiate the tine fibrils between the sur- 
ue. {Stout, Presbyterian Hospital Report, New York 


>e und ihre Komplic 

. klin. Chit 

Adrian, C: Uebcr Neu re fibre 

1901, p. 1. 
Aschoff, L.: Pathologische Anatomic, 3d edit., Gustav Fischer, Jena, ioij, v. 2. 
Auerbach, S. and Hrodnitz: Ncurofibrom des N. ulnaris am Oherarm; Extirpation; 

HeilunK, Mitt. a. d. Grenzgeb. d. Med. u Chir., v. 11: 1910, p. 589. 
Bloodgooq: Sec Mackenzie: Resection of the sciatic nerve, Ann. Surg., v. 1: igog, p. 295. 
Bobrov: The removal of sciatic nerve over an extent of 12 centimeters, Khirurgicheskaya 

Wright, J.H.: Neurocyte 


Bhons, P.: Ueber das Rankcnneurom, Beitr. z. k!in. Chir., v. 8: 1S92, p. 1. 
CoL'RVOisiEK, L. G.: Die Neurome: Eine klinische Monographic, Basel, Beano Schtik I 

Garre, C: Ueber Sekundar Maligne Neurome, Beitr. z. klin. Chir., v. 9: 1892, p. 46; 
Goldman*, E. : Beitrag zu der Lehre von den Neuromen, Beilr. z. klin. Chir., 

P- *3- 
Ueber das Fehlen von Funktionsstoerungen nach der Resek'tion von peripbei 

Beitr. ?.. klin. Chir., v. 51: 1006, p. 183. 
Knauss, K.: Zur Kenntniss der iichten Neurome, Neuroma verum multiplex amyat I 

aim gangliosum. Virchow's Arch. f. path. Anat., v. 153: 1898, p. 
McArthitr, L. L.: Sarcoma of the posterior tibial nerve; excision; removal of n 

focci in retroperitoneal lymph glands three months later, Surg. Clin. Chic, v. 4: 1% 

p. i.i 1. 
MACKENZIE: Resection of the sciatic nerve. Ann. Surg., v. 1: 1909, p. 295. 
v. Recklinghausen-, F.: Ueber die Multiplen Fibrome der Haut und ihre Beziehungwto 

Mulliplen Neuromen, Festschrift zu Rudolf Virchow, Berlin, A. Hirschwald, tSfe 
Riuhkrt, If.: Gcschwulstlehre fiir Arzte und Studiercnde, F. Cohen, B01 
Stuit, A. P.: A tumor of the ulnar nerve, Med. and Surg. Report Presbyterian Hus? I 

New York, v. 10: Oct., 1918, p. ^36. 
Verecay, J.: Multiple Gcscruvuldste als Syslemerkrankung am nervorem Appar 

schrift f. Chiari, I'rag., 100S. p. 378. 

a kind of lum< 

not generally recogD 


Sicard (191 6) was the first to recommend alcohol injection of the nerve 
trunk in the treatment of causalgia. His suggestion was based upon work 
which he had done previously with Brissaud and Tanon (1906), in the alco- 
holization of the facial nerve for facial spasm and tic. Two years earlier 
Schlosser (1904) in Munich had attempted to inject alcohol in the region of the 
facial nerve at the stylomastoid foramen. Pitres and Vaillard (1887) tried to 
prove that peripheral nerves were susceptible to the action of chemical sub- 
stances, though they were more resistant than the surrounding tissues. They 
injected a series of substances in the neighborhood of different nerves, among 
them alcohol and ether, which previously had been used by Salvat (1889) and 

Pitres and Vaillard found that by injecting ether in the region of the 
sciatic nerve in the guinea pig complete motor and sensory paralysis ensued 
below the site of injection, both anesthesia and paralysis appearing immediately 
after the injection. Histological examination showed that at the level of the 
injection and below this point the nerve had undergone typical Wallerian 
degeneration, while above the level of injection no changes were found in the 
nerve. These authors conclude that injection of ether in the neighborhood 
of nerve trunks, by provoking local degeneration equivalent to physiological 
section of the nerve, might be applicable to the treatment of those clinical 
conditions in w r hich nerve stretching or nerve section had been employed to 

According to Sicard, 60% alcohol does not act on motor but only on sen- 
sory neuraxes, producing anesthesia, not paralysis. Sicard reported twenty- 
one cases of nerve irritation treated by alcohol injection — six median, three 
median and ulnar, five sciatic, five brachial plexuses, and two amputation 
neuromas. To these, he added nine patients treated by Pitres — seven median 
and two sciatic; those treated by Grinda (1916) — one sciatic and one 
median, and seven by Godelewski (1916), all of whom were relieved following 
injections of 60% alcohol. Godelewski also injected, with immediate relief, 
an amputation neuroma which had remained painful in spite of two operations. 


Sicard recommended injection of approximately 3 cc. of 60^ alcohol, 
using a very fine needle, and to make sure that the injection reaches all the 

FlC. 307. — Involvement of the median nerve in a delicate veil of scar in a patient w 
nerve causalpia. Pain relieved by liberation. 

funiculi, he inserts the needle in several places in the nerve trunk. It is most 
important that the injection should be made at least 3 or 4 cm. above the 

Zlesion, thus reaching all collateral branches of the neuraxes in the region immedi- 
ately above, for these might also carry painful impulses. In several cases in 
--which the injection was not carried above the lesion, but within or below the 
lesion, no relief was obtained because these collaterals remained intact. 

He advises sterilization of the alcohol in sealed glass tubes in order to 
conserve its proper strength. However, this seems hardly necessary since 
^>o% alcohol is already bactericidal. 

In cases of causalgia of longer duration, injection of 80% alcohol is advised. 
Before injection, the nerve should be freed from all surrounding scar 

tissue (see Figs. 207 and 208) and the field reconstructed so that the nerve may 
lie in as smooth a bed as possible. 

Since Sicard's report, numerous others have used the method with success, 

particularly Pitres and Marchand (1916). The latter have tried alcohol 

injections, above the site of the nerve lesion according to the method of Sicard, 

in more than thirty cases, and so far with complete success. They showed 

that following injection of 60% alcohol into the nerve trunk, motor function 

may persist even though complete reaction of degeneration is present. Thus 

in one case of injection of the sciatic for causalgia with all movements of the 

leg preserved, the causalgia disappeared following injection while voluntary 

motion was unimpaired. 

Pitres and Marchand further conclude that alcohol injection does not 
accentuate an already existing paralysis nor cause additional paralyses. In 
one case of injury to the median in the arm, injection was done not above the 
lesion but below, and here the relief was but transient. In causalgia of the 
median nerve with an associated paralysis, as for example that of the musculo- 
spiral and the ulnar nerve, the relief from severe pain of causalgia dissipated 
the apparent paralysis of the other two nerves, which had been merely protec- 
tive. These authors are convinced of the value of alcoholization of the nerve 
trunk in causalgia. 

Meige and Athanassio-B6nisty (19 16) have laid special stress on the 
probable role of the sympathetic in causalgia. According to them it is only 
by a lesion of the sympathetic that the widely variant symptoms found may be 
explained. The sympathetic may be involved either on the great vessels 
such as the brachial artery, or on the small vessels which run within the nerve, 
particularly the median and the sciatic, or the sympathetic fibers within 
the nerve trunk itself. Either of these two sympathetic systems, or both, may 
be involved. If the sympathetic is implicated within the nerve, then the 

ipain corresponds more exactly to the peripheral distribution of the injured 

In certain cases in which it appeared that the perivascular sympathetic 
was injured, Leriche (191 7) attempted removal of the sympathetic along the 
great vessels in the region of the injury for a distance of 8 to 10 cm. In these 
instances marked diminution in the size of the vessel occurs, decreasing its 
normal caliber to one-fourth; the pulse is barely felt and the blood-pressure is 
lowered, but is followed in two or three hours after operation by a local rise in 
temperature with increase in the size and volume of the pulse, as well as a local 
rise in blood-pressure, which persists from two to four weeks. Changes in the 
motor and vasomotor condition of the extremity are strikingly seen in paralyses 
and contractures of reflex origin, as described by Babinski and Froment (1917), 
when perivascular sympathectomy is done. A certain amount of motion 
returns almost immediately and usually coincident with this, evidences of local 
vasodilatation are seen. 

Leriche believed that voluntary movement is in a certain sense dependent 
upon the sympathetic system. Integrity of the somatic efferent nerve and 
muscle alone does not complete all factors involved in muscular innervation, 
but equally essential is the integrity of the postganglionic sympathetic fiber. 
When the sympathetic is implicated, the muscles may become hardened and 
undergo contracture. Relaxation and contraction of these muscles is impossible 
by voluntary effort. Perivascular sympathectomy may remove this inhibition 
and permit progressive improvement of voluntary motion. In eighteen cases 
of this type operated, eleven were improved, two cured, with two failures and 
with two recurrences. Thus in sixteen operations improvement with some 
return of voluntary movement and disappearance of contractures occurred in all 
very soon after operation and lasted as long as vasodilatation was present, but 
with diminution of vasodilatation a decrease in movements again occurred. 

Following operation, Leriche supplements measures intended to increase 
the circulation, such as hot baths in paraffine heated to sixty degrees, contrast 

*$t VllGBtvZ. £JJ1 JE£X£Hil* 

ant Jite tmtttii ^im-ranm-i:! j 
it -joae 3se in. Tinea ir_ oca 

lesthesialgM aud ulnar ner , 

itruUr >ym fiat net to my in a paiieni with s, ., _ „_„„_ u(jl 

li/a'.liiil artery is '.ontracted to about one fourth its nomul size. The inser 
-ivavuUr aympathelic being stripped. Blunt dissectors and fine iris scisso 

IJ*«i Ri;ir in found to include the median nerve and in which there is though 
to in- litvrdvfrrii'titof the peri vascular sympathetic, as evidenced by the decreas 
In flit' (jiIJIj't of On; brachial artery— previous ligation or occlusion of the vess* 
liiivliitf Iiwii cxi Imliwl the perivascular sympathetic may be stripped and th 
run ilmi frrrd; but altwi injection of alcohol into the median should be done a 
well In two i mu*H of mine, alcohol was not injected into the median, the latte: 
wmt lued, ntul I hi' perivascular sympathetic removed from the brachial. Fol 

_ lowing it some amelioration of the symptoms occurred, but improvement was 

[ not complete until alcohol was injected into the nerve. 

In performing perivascular sympathectomy, fine blunt-pointed iris scissors 
and broad-pointed anatomical forceps should be used to tear off the layer of 
loose connective tissue which surrounds the vessel wall and in which the sympa- 

J thetic fibers lie. (See Fig. 209.) When the line of cleavage is once established 
there is relatively little difficulty, providing care is taken to maintain the sepa- 
ration along the proper layer. The tissue should be stripped from above down, 
for in this manner the small blood vessels are more readily recognized and are 
laid bare with less danger of being torn at their origin before it is realized that 
they are included in the tissue which is being removed. 

Recently Veillert (1918) attempted perivascular sympathectomy in a case 
of Raynaud's disease, in which he stripped off the sympathetic from the brachial 
artery on one side and noted amelioration not only on the side of operation, 
but also in the opposite extremity. This he believed to be an indication of the 
purely sympathetic affect in this disease and also of the metamerization of the 
functional association characteristic of the sympathetic system. 

The value of perivascular sympathectomy may be questioned in view of the 
work of Kramer and Todd (1914), and Potts (1914) showing that the sympa- 
thetic supply of the vessels of the extremities, with the exception of the sub- 
clavian, is not through a continuous perivascular sympathetic system, but 
through the adjacent nerves which distribute sympathetic branches to the 
vessels at various intervals along their course. (See Figs. 210, 21 1.) Branches 
are given off more frequently to the more peripheral portions of the vessels, 
probably because, as Kramer thought, the diminishing caliber of the vessel 
required greater vasomotor regulation. The vessels receive sympathetic 
fibers from the same nerves as supply the adjacent parts. 

The nerve supply to the posterior tibial, peroneal and plantar arteries, as 
given by Potts, explains on an anatomical basis causalgia in sciatic nerve injuries 
involving the tibial division. The vascular nerve supply in the dorsum of the 
leg and the sole of the foot is through the tibial nerve and its branches. (See Figs. 
212 and 213.) However, the explanation of causalgia in injuries of the median 
nerve is more difficult to understand since the vascular nerve fibers for the ves- 
sels of the upper extremity, as given by Kramer and Todd, are largely through 
the musculocutaneous, ulnar and radial nerves. However, the median nerve 


Fig. 210. — Diagram to illustrate the nerve supply to the radial and ulnar arteries and tt 
superficial volar arch. The radial artery, though sometimes receiving a branch from the mus. 
cutaneous nerve, obtains branches from the superficial terminal ramus of the radial nerve. 
ulnar nerve supplies its companion artery by twigs from its main trunk and from its palmar cutan 
branch. The complicated supply from median and ulnar nerves to the superficial volar arch 
digital vessels is also shown. (Kramer and Todd, Anatomical Record, 1914.) 


deep ramus ■ 



—Diagram of the branches of the ramus profundus of the ulnar n 
volar arch. (Kramer and Todd, Anatomical Record, IQI4-) 


- Axygoa Nerve 


Fie. 211. — Distribution of i 
arteries. Note the large twig r< 
malleolus. Twigs marked V art 

;rvcs to the inferior gluteal, popliteal, posterior tibial and peroneal 
:eived by the posterior tibial artery immediately above the medial 
distributed to vena- comites. (1'otts. Anat. Anzeig., 1914-15.) 

—Distribution of 

the medial and lateral plat 
(Potts, Anat. Anzeig., 1514-15.} 

id their branches. 


ulnar nerve. If other investigations should support this limited vascular supply 
through the median nerve it would be difficult to account for the extensive vas- 
cular changes noted in incomplete lesions of this nerve. 

Since the vascular nerve supply reaches the vessels of the extremity at 
various intervals, localized perivascular sympathectomy over an area of 10 
to 12 cm. as recommended by Leriche would suffice for only approximately 
the area of vessel denuded, since below, at various intervals, intact sympa- 
thetic fibers are received from adjacent nerves. On the other hand, extensive 
vascular lesions remote from the site of the injury may be explained by involve- 
ment of the sympathetic fibers in the main nerve trunk, since it has been 
shown that these fibers reach the vessels not through a continuous perivascular 
system of fibers but intermittently through the adjacent nerve trunks. Stop- 
ford (191 8) has shown that extensive changes in the vessel walls may result 
from irritative nerve lesions without direct injury to the vessel wall producing 
an extensive endarteritis over a considerable distance. 

In view of such findings it must be considered that perivascular sympathec- 
tomy is not as yet on a sound anatomical or clinical basis; however, in view of 
Leriche's experience the method should not be condemned until further clinical 
evidence is gained. 

Lor tat and Hallez (191 8) in a case of median and ulnar paralysis, 
with section of the brachial artery, ligated the median nerve with catgut and 
found, subsequently, complete cessation of pain, vasomotor and secretory dis- 
turbances. While this method may have advantages in certain cases the author 
has had no experience with its use. 

Causalgia may not be the only form of pain demanding operative inter- 
ference. Nerves caught in scar or callus may give definite signs of irritation with 
areas of exquisite hyperesthesia. Minute foreign bodies in the nerve may cause 
painful symptoms referable to only part of the nerve distribution — dissociated 
hyperesthesia. In such conditions operative measures are indicated to relieve 
pain even without motor disturbances being present. 


Barth, H.: Les injections sous-cutanees d'6ther dans le traitement de la pneumonic 
adynamique, Gaz. hebdom. series 2, v. 18: 1881, pp. 801, 816, 839. 

Bidder, F.: Versuche tiber die Moglichkeit des Zusammenheilens functionel vershiedener 
Nervenfasern, Mullens Archiv., 1842, p. 102. 


Brissaud, Sicard, and Tanon: Essais de traitement de certain cas. . . par l'alcoolisation 

locale des troncs nerveux, Rev. neurol., v. 14: 1906, p. 633. Also in: Bull, et mem. Soc. 

me*d. d. hop. de Par., v. 23: 1906, p. 831. 
Dangers des injections d'alcool dans le nerf sciatique, Rev. neurol., v. 15: 1907, p. 633. 
Leriche, R.: De la sympathectomie pSri-arte'rielle et de ses resultats, Presse Medicale, 

v. 25: Sept. 10, 1917, p. 513. 
Lortat, J. and Giron, E.: Guerison rapide de la douleur dans la "causalgie" du median 

avec troubles paralytiques graves par la ligature du nerf avec catgut, Paris me*d., v. 8: 

1918, p. 493. 
Lortat, J. and Hallez, G.: Traitement de la causalgie du median avec trouble paralytique 

grave par la ligature du nerf au catgut, Bull, et mem. Soc. m6d. d. hop. de Paris, 

Series 3, v. 42: 1918, p. 239. 
Marie, P. and Athanasio-Benisty: Forme douloureuse des blessures du nerf median 

Presse me*d. v., 18: March, 1915. 
Les signes cliniques des lesions de Tappareil sympathique et de Pappareil vasculaire 

dans les blessures des membres, Presse med., v. 24: 1, 1916, p. 153. 
Mitchell, S. W., Morehouse, G. R. and Keen, W. W.: Gunshot wounds and other injuries 

of nerves, Phila. J. B. Lippincott Co., 1864. 
Perthes: Ischiadikusresektion wegen Schussneuritis (Medizin-Naturwissenschaftl. Verin 

Tubingen, 15 Jan., 1917), Miinchen. med. Wchnschr., v. 64: 1917, p. 920. 
Pitres, A. and Vaillard, L.: Action de Talcool sur les troncs nerveux, Soc. de Biologie, serie 

3, v. 4: April 9 and May, 14, 1887, p. 228, p. 299. 
Nevrites p6riph6riques experimentalement provoquees par des injections hypodermiques 

de diverses substances, Compt. rend., Soc. de Biologie, series 8, v. 4: 1887, pp. 228-299 
Potts, L. W.: The distribution of nerves to the arteries of the leg, Anat. Anz., v. 47: 1914, 

p. 138. 
Salvat, A. F.: Etude sur les nevrites consecutives aux injections hypodermiques d'ether, 

Th. Doct. Bordeaux, 1884. 
Schlosser: Berl. klin. Wchnschr., 1904. 

Sicard, J. A.: Traitement des nevrites douloureuses de guerre (Causalgie) par l'alcoolisa- 
tion nerveuse locale, Presse med., v. 24: 1, No. 31, 19 16, p. 241. 
Veillet, L.: Traitement de la maladie de raynaud par la sympathectomie p£riart6rielle 

Bull, et mem. Soc. m6d. d. hop. de Par., Ser. 3, v. 42: May 31, 1918, p. 571. 


Unfortunately many surgeons have considered that any painful ampu- 
tation stump is to be attributed to tender severed nerve ends, but severed 
nerves are not the only source of pain in amputation stumps. Thus Hirsch 
and Bunge found that the presence of periosteum and endosteum over the 
end of the bone tends to produce a tender amputation stump. Generally, 
in true neuromas, the pain is localized definitely over the end of the nerve in 
one or more nerves of the region, while in neuritis of the ascending type the 
nerve trunk is tender to pressure even some little distance above the site of 
injury and not only over the nerve end. When the nerve trunk is implicated, 
pressure over it causes pain similar to that of which the patient complains. 
Of course, it must always be borne in mind that in many amputations, pain 
and dysesthesia of all sensations may exist on a purely psychogenic basis, 
that is, hysterical or neurotic. These must be carefully differentiated and 
the surgeon had best restrain himself in the diagnosis of amputation neuroma, 
only where there are signs of definite involvement of the nerve ends, and 
recommend for nerve operation only those cases in which such signs exist. 

Corner (191 8) has tried to divide painful neuromas into several forms 
depending on the nature of the pain: those with immediate pain, coming on 
at once and lasting a relatively short time; and those with pain of imflamma- 
tion, developing later and due to an ascending neuritis. This form is generally 
superimposed upon the immediate pain without any remission, the pain 
becoming more severe and more persistent. 

He believes that contraction of scar tissues about newly formed neuraxes 
may cause pain by strangulation which persists until the neuraxes die off and 
then gradually diminishes. Another source of pain may be from nerve ends 
which have become fixed on the bellies of the adjacent muscles, and are drawn 
upon with each contraction of the muscle; or the whole nerve trunk may be 
caught in the amputation flap and streched over the end of the stump. This 
is apt to occur in the older methods of amputation where flaps are transfixed. 
Unless the nerve has been cut very high, the neuraxes escape from the nerve 
end and grow into the scar and callus. The connective tissue may serve to 



fix the nerve trunk in the wound where the fibers may be compressed and the 
trunk subjected to tension and stretching on movement of the limb. 

It is interesting to note that severed nerves without amputation of the 
limb, even though they be fixed in scar and callus and with the outgrowing 
neuraxes invading all the contiguous tissues, seldom give rise to pain similar 
to that found in painful amputation neuromas. 

Marinesco (191 8) has shown in his study of painful amputation neuromas 
that the majority of them show evidences of a generalized infective neuritis: 
endarteritis, periarteritis, perivascular exudation, and infiltration with lym- 
phocytes and leucocytes, and the presence of giant cells. In one neuroma 
removed three years after amputation, a low-grade infection was discovered 
with bacteria still present. In a number of neuromas minute foreign bodies 
were found. 

Histology. — A neuroma represents an attempt at regeneration on the part 
of a severed nerve and may be said to form regularly on any severed nerve unless 
prevented. Neuromas may be present without pain and even without undue 
sensitiveness or tenderness, so it is likely that painful neuromas present addi- 
tional changes within the nerve of an irritative character not found when simple 
enlargement of the nerve end is present. No clear histological characteristics 
have been determined which differentiate simple non-painful neuromas from 
those with spontaneous pain. Infection and ascending neuritis may play a 
role; yet painful neuromas have been found in wounds which have healed 
without infection and in which there was little or no scar tissue. That the 
irritation once well established is not exerted only locally may be assumed 
from the fact that in secondary operations even when the nerve is amputated 
very much higher, in normal muscle planes without scar or infection painful 
nerve ends frequently reform. 

An amputation neuroma consists mainly of proliferated endoneural and 
perineural connective tissue, neurolemma cells and regenerating neuraxes. 
The neuraxes may follow a more or less straight course as they enter the proxi- 
mal part of the neuroma, but soon the fibers become interlaced and many of 
them are turned back on themselves. A few fibers may penetrate the connec- 
tive tissue cap which forms over the end of the nerve and escape into the 
surrounding tissues. Numerous end discs and bulbs, called growth cones, are 
seen, frequently extremely large, and many branching fibrils are met. These 
end discs and branching fibrils show the regenerative power of the neuraxes. 
When certain neuraxes encounter resistance, the fibrils turn back on themselves 


and form spirals within the neurolemma sheath, curling around the neuran 
from which they have arisen. These are termed Perroncito spirals, and in 
measure indicate the degree of resistance the neurai 
have encountered. The spirals vary in size and shap 
some being long and slender and others short ai 
thick, depending somewhat upon the direction fro 
which they meet resistance. They may be found 
any portion of the neuroma and are often seen 
clusters. The spirals give off numerous small branch 
with end discs. 

Marked overgrowth of the endoneural and perinei 
ral connective tissue is seen, with embryonal chara 
teristics retained until late. In older neuromas U 
tissue contracts and sclerosis takes place. Huber an 
Lewis (1920) are of the opinion that the chief facti 
in amputation neuromas is this outgrowth of conne 
tive tissue, stimulated to increased activity by tl 
continuous attempts of the neuraxes at regeneratioi 
"It is quite probable that the developing neuraxi 
during their regenerative activity stimulate this conne 
tive tissue to an excessive growth which continues f< 
some time." 

Treatment. — Until recently, most surgical methoc 
of treating amputation neuroma have been attemp 
to prevent the escape of neuraxes into the surromu 
ng tissues. Sicard (1916), Godelewski (1916) ac 
others have tried to allay the pain in painful amput 

Fig. 214. — Section of dis- 
tal end of proximal segment 
of a rabbit's sciatic nerve, go 

days after injection with ab- . .... _ , ,. , . . 

solute alcohol. Tapering end tion neuromas by injection of 60% alcohol and ha^ 
of nerve wthout any evidence reported numerous successes with this method. Th( 
of neuroma formation may be.. , . , „ . , . j__ 

. a ti, *.n,i= r.i „„,T t claim that 60% alcohol causes degeneration of on 

noted. 1 nc enas oi nerves 

treated in this way often pre- the sensory neuraxes. Huber and Lewis were tl 

sent in the earlier stages a 
peculiar yellowish-while ap- 
pearance due to the dejtener- 

£1. ,°S J"°^™- »'hich causes complete degeneration of all neuraxes di 
igjo.) tal to the point injected, and in guinea pigs, rabbits an 

dogs, found that six months after injection such amputated nerves presented 
apering, finely pointed stump with little or no tendency to bulb formatioi 

first to attempt to prevent the downgrouth of a 
neuraxes. These investigators used absolute alcoh 


<See Fig. 214.) When compared with controls, the difference was striking. 
In the early stages following alcohol injection, in place of the neuraxes, 
myelin and neurolemma cells, granular detritus and phagocytic cells were 
found. (See Fig. 215-) In later stages, downgrowing young nerve fibers 
having a straight course with little or no criss-crossing were encountered, 
accompanied by bands of nucleated protoplasm. In older specimens, the 
neuraxes had reached the distal end of the cut nerve in parallel bundles without 

Fig. 215. — Effects of absolute alcohol injection 

<k-i:crieraiol ni-ur.iM-. Ni'iirnli-iniTwL >licu.lh~. many i>f which rcn 
;iml ^l"l>ulu- iif fa l. I Hulitr ami Lewis. Archives of SurRtry, iy. 

Finely granular rcmaii 
are filled with granular ro 

interlacing or forming Perroncito spirals, and the ends of all nerve trunks 
were tapering without any tendency to bulb formation. (See Fig. 216.) 
Huber and Lewis concluded that " absolute alcohol injected into the nerve some 
distance (from three-quarters to an inch above the plane of section) is more 
successful in preventing neuroma formation than any of the other methods 
ordinarily employed." 

Many of the old surgeries show ingenuous figures illustrating attempts to 
prevent the formation of neuromas. In them we see nerve stumps turned upon 
themselves and sutured to the parent trunk, nerves split and sutured again to 



Corner (1918) produces a " swinging-door flap" and is thus able to close off the 
nerve end by epineural sutures. This method is comparatively successful in 
preventing the escape of neuraxes providing accurate approximation is obtained, 
for connective tissue union takes place before downgrowth of neuraxes can occur. 
The great and only value of this method is that it permits one to close off the 
nerve stump from the surrounding field and possibly prevent an ascending neuritis 

1 \ 



* 1 

Fig. 217. — Method of treating nerve ends in amputation stumps. The nerve ends are closed 
by Connor's "swing-door" method to t prevent an ascending infection in the nerve — not to prevent 
outgrowth of neuraxes. Two to 3 cm. above the nerve ends absolute alcohol is injected so as to 
reach all parts of the nerve and a second series of injections is carried at a slightly higher level. 

in those cases with infection. To try to prevent an ascending neuritis is the 
real reason for closing off the nerve end by suture. 

Based on these considerations the author has used a combination of Corner's 
closure of the amputation stump, followed by alcohol injection 2 or 3 cm. 
above the point of section, as advised by Huber and Lewis. The alcohol 
should be injected at two or three points on the circumference of the nerve and 
repeated again at a slightly higher level so that all of the funiculi may be 
reached. (See Fig. 217.) The nerve should always be drawn down into the 


wound and cut short so that by retraction the nerve end cannot be caught and 
compressed in scar and callus. 

When an ascending neuritis involves the dorsal ganglia surgical measures 
directed toward the nerve trunk will naturally be unsuccessful, and when 
more than one nerve is involved treatment of each in the amputation stump 
may be impracticable due to difficulty of dissection and identification in scar 
tissue. In these laminectomy with dorsal root section may be tried, although 
it may be successful in only a small percentage of the patients. 

Bardenhei.'ER: Mitteilungen aus dem Gebictc der Nervenchirurgie; VI. Behandlung 

der Nerven bei Amputation zur Yerhiitung der Amputationsncuromen, Deut&ch 

Ztschr. f. Chir., v. 96: 1008, p. 128. 
Chappie, W. A.: Reamputalion, Brit. Med. J., No. 2956, v. 2: 1017 (Aug. 25), p. 342. 

Prevention of nerve bulbs in stumps, Brit. Med. J., No. ao88, v. 1: iqiS (Apr. 6), p. 399. 
Corner, E. M.: The surgery of painful amputation stumps, Proc. of the Roy. Soc. of Med., 

v. 2: No. 7, May, 1018, p. 7. 
The structure, forms and conditions of the ends of divided nerves, Brit. J. Surg., v. 6: 

igiS-10, p. 273. 
Nerves in amputation slumps, Brit. Med. J. T No. 3047, v. 1 : May 14, iqio, p. 638. 
Godelewski: Sec Sicard, J.: Trailemenl des nevrite-s douloureuses de guerre (Causalgie} 

par l'alcoolisation nerveuse locale, La Presse med., v. 34: 1, No. 31, 1916, p. 241. 
Ht_3EK, G. C. and Dean Lewis: Amputation neuromas: their development and prevention. 

Arch. Surg., v, 1 : No. 1, July, 1020, p. 85. 
Kkugeh: Ueber Xervenquetschung zur Yerhiitung sch mcrzh after Neurome nach Amputi- 

tionen, Miinchen. med. Wchnschr., v. 63: 1016, p. 368. 
Marinesco, G.: The characteristics of amputation neuromata, Proc. of the Roy. Soc 

Med., v. 2: 1917-18, p. 5. 
Sicard, J. A.: Trailemenl des nevrites douloureuses de guerre (Causalgie) par l'alcoolisi- 


Note. — The folios in ordinary type refer to text, those in bold face to pages on which illus- 
trations occur. 

Abortive autoregeneration, 51 

regeneration, early, 52 
Adductor magnus and adductor brevis, nerve 
distribution to, 383 
pollicis muscle, nerve distribution to, 351 
Adhesions, mechanical treatment of, 189 
Adults, injuries of brachial plexus in, 252, 253 
Affective sensations, 160 
Afferent nerve, 17 
Agar tubes, 125 

Airplane splint for brachial plexus injury, 255 
Alcohol injection, effect of, on neuraxes, 458, 
459. 460 
in amputation neuroma, 458, 461 
of nerve trunk in treatment of causalgia, 445 
Alcoholized cargiie membrane, Huber's, 127 
Algesiometer, 159 

Amphioxus, adult, dorsal root and ramus ven- 
tralis of, transverse section through, 19 
spinal nerves from, 19 
motor and sensory components of spinal nerves 
in, 18, 18 
Amputation neuroma, 456 

alcohol injection in, 458, 461 
histology, 457 
treatment, 458 
stumps, method of treating nerve ends in, 461 
Anastomosis, nerve, 82 
Anesthetic used in nerve surgery, 138 
Apparatus, ideal for correcting deformities, 187 
Arterial tubes, 123 

tubulization, 122, 123, 124 
technic, 123, 123 
Autogenous grafts, drawback to use of, 101 
Autoplastic nerve transplantation, 69. See also 

Nerve transplantation. 
Autoregeneration, abortive, 51 
Axial rotation, minimal, prevention of, difficult, 
of nerve trunk, avoiding, in nerve su- 
ture, 142 
Axolemma, 23 
Axonc, 26, 23 

B \ndfasern of Hunger, 42, 49 
Baths, iyi 

Baths, electrical, 192 

Bell's palsy, operative indications in, 208 

Bethe's cell chain theory of origin of neuraxes, 

Bipolar stimulation, funicular identification 

by, 34 
Birth palsy, rupture of seventh cervical root 

in, 239. See also Brachial plexus. 
Bone, decalcified, tubes, 122 
tubulization, 121 
resection of, for diminishing nerve defect, 107 
Brachial plexus, 220, 223, 224 
anatomical considerations, 222 
cervical ribs complicating, 256 
anatomy, 256 
deformity in, 258 
mechanical treatment, 259 
sensory changes in, 258 
surgical treatment, 259 
dorsal cord of, exposure and suture of, 280 
embryology of, 220 

exposure of, above clavicle for stab wound 
of fifth and sixth cervical roots, 253 
below clavicle, 254 
of secondary cords of, 311 
technic, 249 
gunshot wounds of, 255 
illustrating mechanism of birth injuries, 243 
injury of, airplane splint for, 255 
anatomical types of, 225 
in adults, 252 

splint for, 256, 233, 255, 276 
paralysis of, 231 

lower radicular or Duchenne-Aran type, 

228, 234 
middle radicular type, 234 
obstetrical, 235 
deformity in, 245 
duration of treatment in, 245 
etiology, 238 , 243, 244 
exercises for, 246, 247 
historical, 236 

Horner's syndrome in, 237, 237 
late mechanical treatment, 246 
location of injury to nerve roots in, 240, 
239, 243, 244 




Brachial plexus, paralysis of, obstetrical, me- 
chanical treatment, 245 
operation in, 249 

pathology of, 242, 239, 241, 242, 243, 

secondary injury to spinal cord in, 240 

splint for, 233 

surgical treatment in neglected cases, 

time of operation in, 248 
operation for, 253, 254 
types of, 228 

upper radicular or Duchenne-Erb type, 
228, 232 
deformity in, 232 
prefixed, 222, 223 
post fixed, 222, 224 

relation of, to development of limb, 220 
right and left, transverse section through 

cords of, 241, 242 
ruptures of, 235 
in adults, 252 
secondary cords of, exposure of, 280, 298 

seen from behind, 243, 244 
stab wounds of, 255, 253 
surgical treatment of, in presence of cervical 
rib, 256 
Bridging nerve defects, 68, 103. See also Nerve 

Bruns' neuroplasty, 80 
Buerki's splint for foot-drop, 410 
Bunger, bandfasern of, 49 

Cable autonerve transplant, 72 
graft, 81 

transplant, 81, 81 
in place, 153 
in sciatic of dog, 74 
26 days after suture, 73 
Caliper for paralysis of tibial division of sciatic 
nerve, 411 
Thomas, for paralysis of anterior crural 
nerve, 427 
Cargile membrane, in nerve surgery, 127 

Huber's alcoholized, 127 
Causalgia, 445 

alcohol injection of nerve trunk in treat 

ment, 445 
of median nerve, involvement of nerve in veil 

of scar, 446, 448 
painful phenomena in, 449 
perivascular sympathectomy in, 449, 450, 451 
rdle of sympathetic system in, 447 
Cell chain theory of Bethc of origin of neu- 
raxes, 27, 44 

Cells, motor, nerve stretching causes change 
103, 104 

sheath, 26 
origin of, 26 

experimental evidence to show, 27 
types of, 26 
sympathetic, migration of, 29 
Central flap in nerve flap repair, 87 
Cervical ribs complicating brachial plexus. 
See also Brachial plexus. 
anatomy, 256 
deformity in, 258 
mechanical treatment, 259 
sensory changes in, 258 
surgical treatment, 259 
surgery of brachial plexus, in pres 
of, 256 
Chromatolysis, central, in nerve stretching, 

Circumflex nerve, 297 

branches of, 298, 298 
course, 297 

exposure of, 298, 280, 299 
at surgical neck, 299 
in axilla, 298 
injury of, deformity from, 299 
mechanical treatment, 300 
Collaterals ending in facial nucleus, 203 

in hypoglossal nucleus, 202 
Compression, nerve, electrical examination 

Conductivity, nerve, interrupted, 130 
Contractures, mechanical treatment of, 189 
Crossing, nerve, 82, 96 
complete, 82, 82 
downgrowth of neuraxes in, 97 
hypoglosso facial, 197, 215 
incomplete, 82 
partial, 82, 83 

technic, 149, 149 
proper coordination of propriocep 

stimuli in, 96 
radial and median, 341 
spinofacial, 197, 211, 212, 214 
technic, 148 
Crural nerve, anterior, 426 
injury of, 426 
deformity in, 428 
mechanical treatment, 428 
paralysis of, Thomas caliper for, 427 
surgical treatment, 427 
Cutaneous nerves for transplantation, 150, 31 
multiple neurofibroma from, 434, 435 

Decalcified bone tubes, 122 
tubulization, 121 




Defects, nerve, in regeneration, bridging, 68 

methods for diminishing, 103 
Deformity, correction of, before operation, 189 
from anterior crural nerve injury, 428 

mechanical treatment, 428 
from cervical rib complicating brachial plexus, 

from circumflex nerve injury, 299 

mechanical treatment, 300 
from complete dorsal cord injuries, 275 

mechanical treatment, 275 
from Duchenne-Erb paralysis, 232 

mechanical treatment, 233 
from long thoracic nerve injury, 424 
mechanical treatment, 425 
from median nerve injury, 328 

mechanical treatment, 330 
from musculocutaneous nerve injury, 309 

mechanical treatment, 310 
from musculospinal nerve injury, 276 

mechanical treatment, 277 
from obturator nerve injury, 428 
from peroneal nerve injury, 408 
mechanical treatment, 408 
Robin-Chiray device in, 409, 409 
from sciatic nerve injury, 406 

mechanical treatment, 407, 427 
Thomas caliper in, 407, 427 
from spinal accessory nerve injury, 422 

mechanical treatment, 423 
from suprascapular nerve injury, 426 

mechanical treatment, 426 
from tibial nerve injury, 409 

mechanical treatment, 410 
postural, ideal apparatus for correcting, 187 
Degenerating nerve fibers of peripheral stump of 

sciatic of rabbit, 48 
Degeneration and regeneration of nerve, 41 
of medullated nerve fibers, 47 
of nerve endings, 50 
of nerves, complete, reaction of, 163 

secondary, 46 
of nonmedullated nerve fibers, 50 
Wallerian, 41 
Deltoid muscle, right, nerve distribution to, 297 
Denervated muscle, changes in, 185 
physiological changes in, 185 
treatment of, during stage of recovery, 193 
Descendens hypoglossi and hypoglossal nerves, 

development of, 206 
Direct muscle implantation, 117, 115 
nerve implantation, 112, 113, 115, 116 
technic of, 117, 116 
Discriminative sensations, 160 
Dissection of macerated nerve trunks, ^^ 
Dissociation, fibrillar, 53 

Dorsal cord injuries, complete, 275 
deformity in, 275 
exposure of, 280, 289, 298 
mechanical treatment, 275 
splint for, 276, 276 
dermatomes, 228 

primary division of spinal nerve, 17 
root and ramus ventralis of adult amphioxus, 
transverse section through, 19 
of spinal nerve, 1 7 
Duchenne-Aran paralysis, 228, 234 
Duchenne-Erb paralysis, 228, 232 
deformity in, 232 
mechanical treatment, 233 

Efferent nerve, 17 

Electrical baths, 192 
examination during operation, 130 
in nerve compression, 164 
of injured nerves, 161 
of nerves, 130 
response, negative, from stimulation of nerve 

trunk at level of injury, 132 
treatment, 192 

Ellipsoids, myelin, 47 

Elsberg's method of nerve graft, 153, 154 

End-to-end suture, 83, 94 

inverted V method, 95, 95 

methods which should not be used, 95 

nerves prepared for, 83 

oblique, 95, 95 

technic, 145, 146 

Endoneurium, 24. Opposite p. 24 

Entrance and exit wounds, possible relation of, 
to course of missile, 158, 159 

Epincurium, 24, 145. Opposite p. 24 

Equality, polar, 162 

Erb's paradoxical response in injured nerves, 131 

Evulsion of funiculi from spinal cord, 236 

Exploration, nerve, early, 175 

Extensor digitorum longus, nerve distribution 
to, 390 
group, nerve distribution to, 389 

External plantar nerve, exposure of, 403 

Extremity, lower, development of, 220, 372 
mechanical treatment of, 189 
rotation of, 372 

variations in segmental distribution to, 374 
ventral and dorsal musculature of, 372 
position of, time to change, after opera- 
tion, 100 
upper, 220 
mechanical treatment of, 188 
muscles of, motor root supply of, 226 
relation of brachial plexus to development 
of, 220 



Extremity, upper, rotation of, 221 

ventral and dorsal musculature of, 


Facial muscles in facial paralysis, overstretch- 
ing, appliance to prevent, 216 
musculature, proprioceptive sense of, 202 
nerve, 197 

congenital maldevelopment of, 209 

cortical connections, 200, 209, 199, 201 

crossing, 197 

choice of graft, 210 

choice of nerves, 204 

disassociation of associated movements, 

experimental studies, 197 
with hypoglossal nerve, 197, 198, 215 
with spinal accessory nerve, 197, 198, 204 
with spinofacial, 197, 198, 214 
exposure of, 210, 211 
incision for operation on, 210 
injury at birth, 209 

implantation into spinal accessory, 197 
liberation, 208 
operative indications, 208 

technic, 210 
paralyses, mechanical treatment in, 216 

operative indications in, 208, 209 
paralysis, bilateral, 280 
transplantation, autogenous, 210 
nucleus, collaterals ending in, 200, 201, 203 
paralysis, appliance to prevent overstretching 
of facial muscles in, 216 
from otitis media, operative indications 

in, 208 

operative indications in, 208, 209 
Failure in operations, cause of, 157 
Faradic current for electrical examination of 

injured nerves, 161 
Fascia lata in tubulization, 126 l 

Fascial tubulization, 126 
Fibers of Remak, 23 
Fibrillar dissociation, 53 
Fibroma of peripheral nerves, genesis, 439 
location, 433, 434 
malignant degeneration in, 438 
plexiform, 438 
treatment, 438 
Flap method of nerve repair, 86, 87 
central flap in, 87 
peripheral flap in, 88 
Flexor carpi ulnaris muscle showing variation 
in innervation, 350 
group in thigh, nerve distribution to, 384 
muscles in arm, nerve distribution to, 304 
Forearm, distribution of musculospiral nerve to 
muscles of, 269 

Foreign body in partial injury of nerve trunk, 

Foot-drop, Robin-Chiray device for, 409, 409 

splint for, Buerki's, 4x0 
Frog larva, nerves of abdominal wall of, 27, j8 
Funicular anatomy, theoretical importance 
of, 29 

identification by bipolar stimulation, 34 
Funiculi, 24 

Galvanic current for electrical examination of 

injured nerves, 162 
Ganglionic crest, changes in, 25 

formation of, 24 
Gastrocnemius, right, nerve distribution to, 386 

400, 401, 402 
Gelatin tubes, 125 

Gluteal nerves, superior and inferior, 429 
exposure, 430 
injury of, 429 
surface projection, 430 
Grafts, autogenous, drawback to use of, 101. 
See Nerve transplantation. 
cable, 81 
preserved, 101 
Gray rami communicantes, 29 
Greffe nerveuse, 80, 81 
Gunshot wounds of brachial plexus, 255 

Hamstring muscles, nerve to, 377, 378 
Harrison's experimental work to show origin of 

neuraxes and sheath cells, 28, 44 
Healing of nerves by primary intention, 95 
Hemorrhage between nerve ends in nerve suture, 
intraneural, and scar formation from nerve 
stretching, 105 
Hensen's theory of origin of neuraxes, 27 
Hersage in nerve liberation, 134 
Heteroplastic nerve transplantation, 69 
His', outgrowth theory of origin of neuraxes. 

27, 44 
Homoplastic nerve transplantation, 69 

I Horner's syndrome, anatomical basis of, 237 

! in obstetrical paralysis of brachial plexus, 

! 237 

1 Huber's alcoholized cargile membrane, 127 

\ Hucter-Czerny method of nerve flap opera- 
! tion, 80 

i Humerus and scapula, tracings showing their 

1 relation in elevation of humerus, 230, 231 

Hypoglossal and descendens hypoglossi nerves, 

development of, 205, 206 

nerve, exposure of, 213* 2II i 2I2 » 2I 4» *I5 

facial nerve crossing with, 197 
nucleus, collaterals ending in, 201, 202 



Hyperneurotization, 115, 115 

of muscle having normal nerve supply, 115 
Hypoglossofacial nerve crossing, 197, 215 
cortical connections in, 199, 201 
suture, 213 

Identification sutures in nerve suture, 142 
Implantation, muscle, direct, 117, 115 

nerve, 81, 83, 92, 82. See also Nerve im planta- 
direct, 113, 116, 313 

muscle curves obtained from stimulation 
in, 114 
Incision, skin, in nerve suture, 141 
Incomplete nerve crossing, 82 
Indications for operation, 157. See also Opera- 
tion, indications for. 
Injections, alcohol, effect of, on neuraxes, 458, 

459i 460 

in amputation neuroma, 458 
of nerve trunk in treatment of causalgia, 445 
Instruments, 138 
Intermediate regions, 35 
Internal nerve plexuses, 35 
plantar nerve, exposure of, 403 
topography, Stoffel's views on, evidence not 
in support of, 30 
Interosseous nerve, posterior, exposure of, 287, 

287, 288 
Interrupted nerve conductivity, 130 
regeneration and reoperation, 171 
Intraneural dissection in nerve liberation, 133 
hemorrhage and scar formation from nerve 

stretching, 105 
injection of salt solution in nerve libera- 
tion, 133 
scar, density of, estimating in nerve injury, 132 
Ischemia of extremities interfering with regenera- 
tion, 177 

Lapicque's method of electrical stimulation, 

192, 193 
Laryngeal muscles, neurotization of, Hoessly's 
technic, 421 
nerve, recurrent, 419 

direct implantation of, 420, 420 
suture of, 419 
Leprosy, peripheral nerves in, 442 
Le signe du fourmillement as contraindication to 

operation, 166 
Level of suture, 144 

Liberation of nerves, 130. See also Nerve 
electrical examination of nerve in, 130 
excision of scar in, 134 
nerve section in, 133 

Liberation of nerves, results of, 134 

Limb buds, development of, 220 

Longitudinal reaction, 162 

Lower extremity, mechanical Treatment of, 198. 

See also Extremity lower. 
radicular or Duchenne-Aran type of brachial 

plexus paralysis, 232 
Lumbosacral plexus, 372, 373 

embryological development, 372 

injury to, 375 

prefixed, 374 

primitive distribution of, 373 

postfixed, 374 

variations in segmental contributions to, 374 

Macerated dissection of left ulnar and median 
nerves, 31 
of median and musculocutaneous nerves, 32 
nerve trunks, dissection of, 33 
Magnesium tubes, 125 
Massage, 191 

Mechanical treatment, 183, 186 
apparatus for, 187 
associated treatment, 191 
baths in, 191 
early, 188 
late, 189 
massage in, 191 
of lower extremity, 189 
of upper extremity, 188 
purpose of, 184 
Median and musculocutaneous nerves, macre- 
ated dissection of, 32, 322 
and ulnar nerves, association in distribution 

of, 329 
communications between, 325, 326 

in hand, 326 
exposure of, below pectoralis major, 333 f 

334i335. 33* 

left, macerated dissection of, 31 
macerated dissection showing communica- 
tion between, 352 
nerve, 316 

abnormalities in distribution, 306, 307 
anatomy, 316 
anomalies, 325 
branches, 319, 320 
at wrist, 325 
in arm, 319, 280, 298, 3131 333i 334* 335i 

336, 446, 448 
in forearm, 319, 321, 340 
motor, in lower part of arm, 319 
causalgia, involvement of nerve in veil of 

scar, 446, 448 
complete interruption of, with connective 
tissue continuity of ulnar nerve, 338 

Median nerve, complete severance of, below 
pronator teres, 340 

crossing with radial, 341 
exposure of, 332 

at elbow, 333, 337, 338, 339 
at wrist, 364 

human, cross section, 32, 33, 32a, 323 
injury of, deformity in, 318 
mechanical treatment, 330 
splint for, 330 
transplantation in, 100 
left, macerated dissection, 313 
macerated dissection showing communica- 
tion with musculocutaneous nerve, 310 
neurofibroma of, 3^7, 435, 436, 437, See 

paralysis of, splints for, 331, 332 
regeneration in, 341 
relation of, to axillary and brachial artery, 

showing communication with musculo- 

spiral nerve. 308 
surface projection, 316 
variations in formation and course, 317, 
317. 3l8 
Medulla of rabbit five days after evulsion of left 

hypoglossal nerve, 104 
Medullary sheath, 13 
Medullated fibers of spinal nerve, 23 

nerve fibers, degeneration of, .1; 
Membrane, cargile, Iluber's alcoholized, 127 

in nerve surgery, 127 
Metabolic changes in muscle, 1(15 
Middle radicular type of brachial plexus paraly- 
sis, 234 

Mobilization of nerve, for defect, 103 
Motor and sensory components of spinal nerves 
in Amphioxus, 18 
endings in regeneration, overproduction of, 65 

neurone, peripheral, 22 * 

root supply of muscles of upper extremity, 226 
Movements, shoulder girdle, mechanism of, 2:9, 

Muscle, catabolic changes in, 165 

denervated, changes in, 185 

physiological changes in, 185 

treatment of, during stage of recovery, 193 
implantation direct, 117, 115 
paralyzed, muscular neurotization of, 115 

Muscle, striated, motor terminations i 

degeneration of peripheral nerve. 

Muscles, deep, of calf, nerve distributi 

laryngeal, neurotization of, Hoessly 

of forearm, distribution of musculosj 

to, 269 
of upper extremity, motor root supr 
re-education of, 193 
Muscular neurotization, methods of 
of paralyzed muscle, 115 
Musculocutaneous nerve, 302 

abnormalities in distribution, 306, 

anatomy, 302 

and median nerve, macerated < 

33, 321 
anomalies of, 303 
branches, 302, 304 
course, 302 

exposure of, at origin with direct 
tion of nerve into biceps mus< 
in axilla, 3ro, 208, 31a 
of cutaneous branch, 314 
of middle third of, 314 
injury of, deformity in, 309 
macerated dissection showing coj 

tion with median nerve, 320 
mechanical treatment, 310 
paralysis of, wrist strap for, 310, 3 
surface projection, 303 
Jln'cul spiral nerve, 265 
anatomy, 265 

anomalies of distribution, 274 
branches, 266, 267 

terminal, 272 
course. 265, 166 
cross section of, 273 
crossing with median, 341 
dissection of macerated specimen, : 
dissociated paralysis of, 279 

foreign body in, 279 
distribution to muscles of forearm, 
exposure of, 280, 283, 198 

behind humerus and immediate] 

teres major tendon, 279, 298 
of lower third, 286 
of lower two-thirds, 284, 285 
of upper third, line of incision for 
injury of, 276 
deformity in, 276 
dissociated paralyses, 279, 279 
exposure of, 280 
in arm, 381 



x_ Musculospiral nerve, injury of, regeneration 

following suture of, 291 
». splint for, 277, 278 

transposition of, 289, 289, 290 
_ macerated dissection of median nerve show- 

ing communication with, 308 
nerve plexuses in, 274 

right and left of same individual, level of 
nerve plexuses in, 273 
*" surface projection, 266 

terminal branches, 272 
' transposition of, 289, 290 

variations in, 265 
- Myelin, 23 

and neuraxes removal of, in degenerating 

peripheral fiber, 49 
ellipsoids, 47 
sheath, 23 
Myelinated nerve fiber, 23 
Myotomes, 26, 220 

Neokinetic system in peripheral nerves, 165 
Nerve anastomosis, 82 

circumflex, 297. See also Circumflex nerve. 

compression, electrical examination in, 164 

conductivity, interrupted, 130 

cross section of, 24, 32, 33, 273, 322, 323, 


crossing, 82, 96 

complete, 82, 82 
downgrowth of neuraxes in, 97 
hypoglossofacial, 197, 215 
incomplete, 82 
partial, 82, 82 

technic, 149, 149 
proper coordination of proprioceptive stim- 
uli in, 96 
spinofacial, 197, 211, 212, 214 
technic, 148 
crural, anterior, 426. See also Crural nerve 

defects in regeneration, bridging, 68 

methods for diminishing, 103 
degeneration and regeneration, 41. See also 

distribution to adductor magnus and adductor 
brevis, 383 
to adductor pollicis muscle, 351 
to deep muscles of calf, 388 
to extensor group and peroneus brevis, 389 
to flexor carpi ulnaris, 350 

and flexor digitorum profundus, 
and flexor pollicis longus, 329 
digitorum sublimis, 321 
group in thigh, 384 

Nerve distribution to inferior gluteal, popli- 
teal, posterior tibial and peroneal arteries, 


to medial and lateral plantar arteries and 

branches, 453 
to peroneus longus, extensor digitorum 

longus and peroneus tertius, 390 
to right deltoid muscle, 297 

gastrocnemius, 386 
to soleus muscle, 387 
to thenar muscles, deep surface, 326 
to triceps muscle, 267 
electrical examination of, during operation, 130 
ends, degeneration of, 50 
hemorrhage between, in nerve suture, 147 
in amputation stumps, method of treating, 

prepared for end-to-end suture, 83 
exploration, early, 175 
facial, 197. See also Facial nerve. 
fibers, degenerating, of peripheral stump of 
sciatic of rabbit, 48 
from peripheral stump of sciatic of rabbit, 47 
medullated, degeneration of, 47 
myelinated, 23 

nonmedullated, degeneration of, 50 
flap method, 86, 87 
central flap in, 87 
experimental evidence, 90 
peripheral flap in, 88 
technical considerations of, 87 
operations to 1914, summary of, 84, 85 
gluteal, inferior, 429. See also Gluteal nerves. 

superior, 429. See also Gluteal nerves. 
graft. See Nerve Transplantation. 
hypoglossal. See Hypoglossal Nerve. 
implantation, 81, 83, 92, 82 
direct, 112, 113, 116 
muscle curves obtained from stimulation 

in, 114 
technic, 117 
injuries, groups of, 1 75 

of head and upper extremity relative fre- 
quency of, table showing, 221 
of lower extremity, relative frequency, 

table showing, 375 
relative frequency of, table showing, 173 
laryngeal, 419. Sec also Laryngeal nerve. 
liberation, 130 

and nerve suture relative frequency of, 

table showing, 134 
density of intraneural scar in, 132 
hersagc in, 134 
intraneural dissection in, 133 
injection of salt solution in, 133 

472 INI 

Peripheral nerves degeneration of, behavior 

of motor terminations in striated muscle 

during, 50 
development of, 14 
fibroma of, 433 

genesis, 430 

location, 434 

malignant degeneration in, 438 

treatment, 438 
funicular anatomy of, 25 

theoretical importance of, 20 
in leprosy, 442 
injuries, relative frequency of, table show- ', 

ine, 174 
neuroblastoma of, 440, 441, 443, 443. See | 


• ol, 433 

a of, primary, 440 
plexiform neurofibroma of, 438 
proximal end, of cat 72 days after section, 66 
regeneration of, 54 

-= of, 


Popliteal nerves, exposure of, 399, 400, 41 
Position of extremity, time to change 

operation, 190 
Possible relation of entrance and exit woi 

course of missile, 158 
Postaxial border, 211,372 
Posterior interosseous nerve, exposure a 

Postfixed type of plexus, 222, 224 
Preaxial border, 221,371 
Prefixed type of plexus, 221, 223 
Premuscle mass, 221 

Preserved grafts, roi. See Nerve transpla. 
Pressure on nerve, interrupted condu 

from, r3o 
Primary neurosarcoma of peripheral nerv 


:-. B5 

stump of nerve of rabbit 27 days alter section, \ 
newly formed neuraxes in, 63 
of sciatic of rabbit, degenerating nerve 
fibers from, 48 
nerve fibers from, 47 
Perivascular sympathectomy in causalgia, 449, ; 
4 SO, 45* 
in synesthesialgia and ulnar nerve injury, 450 | 
Peroneal nerve, exposure of, 404, 404 
injury, deformity in, 408 
mechanical treatment, 408 
Robin-Chiray device in, 409 
left, extensive injury of, with callus and 

scar formation, 406 
paralysis of, appliances for correction of , 

deformities in, 409, 410, 411 
surface projection, 381 
suture of, results, 412 
Peroneus brevis, nerve distribution to, 389 
longus, nerve distribution to, 300 
tertius, nerve distribution to, 390 
Petromyzon, motor and sensory components of 

spinal nerves in, 18 
Plantar nerves, internal and external, exposure 

of, 4°3 
Plexiform neurofibroma of peripheral nerves, 438 
Plexus, prefixed type, 223 

postfixed type, 324 
Plexuses, nerve, internal, 33, 35 
Polar equality, 162 
Polarity, reversal of, 161 

Polistotrema, adult, spinal nerve and vagus 
trunk from, 18 
embryological development of, 21 

Proprioceptive impulses, confusion of, 178 
Purposive movements, loss of, 178 

Rami collaterals nervi mediani, 319 
Ramus ventralis and dorsal root of adul 

phioxus, transverse section through, 19 
Ranvier, nodes of, 33 
Reaction, longitudinal, 162 

of complete degeneration, 163 

zone of, S3 
Recurrent laryngeal nerve, 419 

direct implantation of, 420, 420 

Re-education, 193 

Reili-x mechanism, disturbed, 178 

Regeneration, 41 

abortive, early, 52 

following suture of musculospiral nervt 
table showing, 1 70 
time of, 168 

interrupted, and reoperation, 171 

of a peripheral nerve, 54 

signs of, as indications for operation, 164 

successful, factors interfering with, 176 
Regions, intermediate, 35 
Remak, fibers of, 23 

Reoperation, interrupted regeneration and 
Resection of bone, for diminishing nerve 

(ect, 107 
Response, negative, in nerve trunk from stin 

tion at level of injury, 132 
Retraction, nerve, r39 
Reversal of polarity, 16) 
Ribs, cervical, anatomy, 156 

surgery of brachial plexus, in pres* 
of, 255 
Robin-Chiray device for deformity of pero; 
nerve injury, 409 



Neuroblasts, 26 

Neurofibroma, multiple, from cutaneous nerves, 
434» 435« See Tumors. 
plexiform, of peripheral nerves, 438 
of median nerve, 327, 435, 436, 437 
of sciatic nerve, secondary malignant degen- 
eration of, 438 
of ulnar nerve, 433, 441, 442, 443, 
Neurokeratin, 23, 140 
Neurolemma, 23 
sheaths, behavior and ultimate fate of, 
during degeneration of peripheral nerve, 53 
Neuroma, amputation, 456 
alcohol injection in, 458 
histology, 457 
treatment,- 458 
of peripheral nerves, 433 
Neurone, motor, peripheral, 22 
Neuroplasty, 80 
Neurorrhaphy, 80 
Neurosarcoma, primary, of peripheral nerves, 

440. See Tumors. 
Neurotization, muscular, methods of obtain- 
ing, 118 
of paralyzed muscle, 115 
of laryngeal muscles, Hoessly's tcchnic, 421 
Nodale, zone, 35 
Nodes of Ranvier, 23 

Nonmedullated nerve fibers, degeneration of, 50 
of spinal nerve, 23 
sheath of, 23 
Nonmyelinated fibers of spinal nerve, 2^. Sec 
also Nonmedullated nerve fibers. 

Obstetrical palsy, 23*6 

paralysis of brachial plexus, 235. See also 

Brachial plexus. 
Obturator nerve, 428 

exposure, 429 

injury of, 428 
deformity in, 428 
Operation, causes of failure, 157 
indications for, 157 

criteria for estimating results in, 171 

electrical examinations in, 161 
results of, 163 

interrupted regeneration in, 171 

le signe du fourmillement, 166 

local examination in, 157, 158 

motor examination in, 161 

sensory examination in, 158 

signs of regeneration in, 164 

time of regeneration following suture, 168 

Tinel's sign in, 166 

value of complete history in, 157 

Operation, time for, absence of progressive re- 
generation in, 173, 174 
early nerve exploration in, 175 
sterile field in, 173 
Operations on various nerves, relative frequency 

of, table showing, 172 
Otitis media, facial paralysis from, operative 

indications in, 208 
Outgrowth theory of His of origin of neuraxes, 
27, 44 

Paleokinetic system in peripheral nerves, 165 
Palsy, obstetrical, 236. See also Brachial plexus. 
Paradoxical response, Erb's, in injured nerves, 

Paralysis, Bell's, operative indications in, 208 
Duchenne-Aran, 228, 234 
Duchenne-Erb, 228, 232 
deformity in, 2^2 
mechanical treatment, 2$^ 
facial, from otitis media, operative indications 
in, 208 
mechanical treatment in, 216 
operative indications in, 208, 209 
obstetrical, 235. See also Brachial plexus. 
etiology, 238 
historical, 236 

location of injury to nerve roots in, 240, 239 
mechanical treatment in, 245 
operation for, 249 
pathology, 242 

secondary injury to spinal cord in, 240 
surgical treatment in neglected cases, 251 
time of operation, 248 
of brachial plexus, 231. See also Brachial 
Duchenne-Aran, 228, 234 
Duchenne-Erb, 228, 232 
obstetric, 235. See also Brachial plexus. 
types of, 228 
resulting from section of substituted nerve, 204 
Paralyzed muscle, muscular neurotization of, 115 
Partial nerve crossing, 82, 83 
technic, 149 
suture of sciatic nerve in injury of peroneal 
division, 144, 397 
Pectoralis major muscle, insertion of, exposure 

of, 298 
Perforation of sciatic nerve, partial suture of, 

after excision of scar tissue, 145 
Perineurium, 24 

Peripheral flap in nerve flap repair, 88 
motor neurone, 22 

nerves, degeneration of, behavior and ulti- 
mate fate of neurolemma sheaths 



Splint for paralysis of brachial plexus, 233 
of median nerve, 331, 332 
of sciatic nerve, 408 
of ulnar nerve, 353, 354, 354, 355 
for wrist-drop, 277, 278 
Spongioblasts, 26 

Spring device for correction of deformities in 
peroneal nerve paralysis, 408, 408, 409, 410, 
Stab wounds of brachial plexus, 255 

exposure for, 253 
Standardization of terms, 80 
Stimulation, bipolar, funicular indentification 

by, 34 
StoffeFs views on internal topography, evidence 

not in support of, 30 
Stookey's method of nerve graft, 150. See 

Nerve transplantation. 
Stretching, nerve, central chromatolysis in, 103, 
for defect, 103 
in suture of nerves, 142 
Striated muscle, motor terminations in, during 

degeneration of peripheral nerve, 50 
Stumps, amputation, method of treating nerve 

ends in, 461 
Suprascapular nerve, anatomy, 426 
exposure, 426 
injury of, 425 
deformity in, 426 
mechanical treatment, 426 
Surgical treatment. See Operation. 
Suture a distance, 83, 91 
a lambeaux, 86, 87 
end-to-end, 83, 94 
inverted V, 95 

methods which should not be used, 95, 95 
nerves prepared for, 83 
oblique, 95 
primary, 86 
secondary, 86 
technic, 145, 146 
hypoglossofacial, 213. See Facial tierve. 
identification, in nerve suture, 142 
level of, 144 
materials, 136 
regeneration following, time of, 168 

table showing, 170 
tissue, reaction from, 136, 137 
Sutured nerve, longitudinal section through, 

at point of suture, 137 
Sympathectomy, perivascular, in causalgia, 

449i 450> 45* 
in synesthesialgia and ulnar nerve injury, 


technic, 451 

Sympathetic cells, migration of, 29 
system, distribution of, to vessels of lower 

extremity, 45 it 453 
of upper extremity, 45 1 , 45 2 

motor end plates in muscles, 166 

role of, in causalgia, 447 

! Syndrome, Horner's in obstetrical paralysis of 

I brachial plexus, 237 


Taylor's technic in obstetrical paralysis of 
brachial plexus, 249 
! Terms for nerve repair, specific, 80 
standardization of, 80 
Thenar muscles, deep surface, nerve distribu- 
tion to, 326 
1 Thomas and Sever's operation in neglected cases 
I of obstetrical brachial plexus paralysis, 251 
[ Thomas caliper for paralysis of anterior crural 

nerve, 428, 427 
1 for sciatic nerve deformities, 407 

Thoracic nerve, long, 424 
anatomy, 424 
exposure, 425 
injury of, 424 
deformity in, 424 
mechanical treatment, 425 
transverse section through thoracic seg- 
ment of 1 7 mm. human embryo, 25 
Tibial nerve, exposure of, 402, 403 
injuries, deformity in, 409, 
mechanical treatment, 410 
Time of regeneration following suture, 168 
table showing, 170 
to operate, 172 
Tinel's sign as contraindication to operation, 166 

value of, 167, 168, 169 
Topography, internal, StoffeFs views on, evi- 
dence not in support of, 30 
Tourniquet, use of, in nerve suture, 141 
Transplantation, nerve, 67, 80, 8i f 98. See also 
Nerve transplantation. 
autogenous grafts, drawbacks to use of, 101 
autoplastic, 69 
cable autonerve, 72, 81, 81 
i in place, 153 

, in sciatic of dog, 74 

, 26 days after suture, 73 

I heteroplastic, 69 

I homoplastic, 69 

1 preserved grafts, 10 1 

1 re-exploration, 101 

technic, 149, 150, ^53, 33$, 3^2, 363 
cable transplant in place, 153 
Elsberg's method, 153, 154 
Stookey's method, 150 
value of, 99 

hy downgrouth may 1 

not take place in, 150 
1 Transposition of musculospiral nerve, aSg, 2! 

: of nerve, for defect, 106, 358, 289, 339- 35°, 3 

of peroneal nerve, 405, 406 
r of ulnar nerve, 357, 35°, 359 

Triceps mu-clc. nerve di-tribution to, 267 
Tubulizntion, 121 
agar, 125 

arterial, in, 1 2 3, 123, 124 
technic, 123, 123, 124 
value of, >23 
cargilc membrane,^? 
decalcified bone, 121 122 

fresh vessels, 114 
gelatine, 125 
magnesium, 125 

Tumors of peripheral nerves, 433 

neuroblastoma, 440, 441, 44 3 i 443 
neurofibroma, multiple, 434, 435 

of sciatic nerve, secondary maligns 

degeneration of, 438 
of ulnar nerves, 433, 441, 442, 443 

Ulnar and median nerve 
distribution of, 320 
communications between, in hand, 326 
e\posure of, below pcctoralis major, 333, 

334, 335, 336 
left, macerated dissection of, 31 

showing communication between. 


% 347 

n arm. 348 
n forearm, 348 
jf ramus profundus of, 
arch, 452 

» 475 

Ulnar nerve, course, 347 

division of deep palmar branch, by machine- 
gun bullet, 365 
exposure of, 355, 350, 361, 362," 363, 364 

at elbow, 357, 338, 339, 359 

at wrist, 364, 364 

in arm, 355, 333. 334, 335, 336 

in axilla, 355, a 98, 3", 3'3 

in forearm, 360 
extensive involvement of, in middle of 

forearm, 361, 362 
funicular anatomy, 351, 352 
injury, deformity in, 353 

mechanical treatment, 353 

splint in, 353,354, 355 

transplantation in, 100 
neurofibroma of, 433, 441, 441, 443 
paralysis of, splint for, 354, 355 
regeneration following suture, 366 
surface projection of, 349 
transposition of, 338, 339, 356, 359 

with suture of both ulnar and median, 339 
tumor of, 441, 442, 443 
Upper extremity, 220. See also Extremity, 
radicular type of brachial plexus paralysis, 
232. Sec also Brachial plexus. 

Vf.stral primary division of spinal nerve, 17 
roots of motor nerves of Polistotrcma, 21 
of spinal nerve, 17 
formation of, 26 

Wall eh. 1 an- degeneration, 41 

Wounds, entrance and exit, possible relation of, 

to course of missile, 158, 158, 159 
Wrist strap for paralysis of musculocutaneous 

nerve, 310 
Wrist-drop, 276 

prevention of, 277 

splint fur, 277, 278 



IS t 

OCT 30 


MAY 12 194 



: s •)' 9 

AUG 1 1950 

M595 Stookey, B.P. 53 
S88 Surgical and 
19SS mechanical trea'tm