COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANpARD 
 
 HX641 23499 
 RC341 .M35 Neurectasy or nerve- 
 
 RECAP 
 
 The 
 
 'RADSHA\¥ Lecture 
 
 
 1883 
 
 
 WITH Appendix 
 
 1887 
 
 OHN Marshall 
 
 
 '.M:- 
 
 '•:'>•; 
 
 
 ''v'^':^'-^^" 
 
 
 
 . ,. i' -/TV ■• -''^ ?';'■• fee."''" 
 
 ■ ^ ^^" ■<, - 
 
^C^\\ 
 
 W^5 
 
 Cdlmttbta ^tttbmttp 
 
 iAtUtmtt Stbrarg 
 
rxi 
 
\ 
 
NEEVE -STRETCHING 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/neurectasyornervOOmars 
 
N EJJJR E C T_ A_S Y 
 
 OR 
 
 NERVE -STEETCHING 
 
 FOR THE RELIEF OR CURE OF PAIN 
 
 BEING 
 DELIVERED AT THE 
 
 ^ogal ©ollege of gurgcon^ of @nglan6 
 
 On the Qth Dcceviber, 1883 
 BY 
 
 JOHN MAESHALL, F.E.S., LLD, F.E.C.S.E, F.E.C.S.L (Hon.) 
 
 '^^ I llll'> I'lll' IIIHI I OF THE COLLEGE 
 
 AND PKOFESSOR OF SURGERY IN UNIVERSITY COLLEGE, LONDON 
 
 WITH AN APPENDIX BY THE AUTHOR 
 
 Dated March 1887 
 
 AND 12 ILLUSTRATIONS BY VICTOR A. H. HORSLEY, F.R.S. 
 
 L N D (1 N 
 SMITH, ELDEE, & CO., 15 WATEELOO PLACE 
 
 1887 
 
 lAll rights reseried] 
 
J-^^i-^f/'--^ ^" ' 
 
PEEFACE. 
 
 As the ' Bradshaw ' Lecture for 1883, on ' Nerve- stretching for 
 the Kehef and Cure of Pain,' dehvered at the Eoyal College of 
 Surgeons of England, was fully reported at the time both in 
 the * Lancet ' and in the ' British Medical Journal,' I always 
 intended to allow a certain interval to elapse before publishing 
 the lecture in a separate form, in order that the subject might 
 become more matured ; but certainly the delay in its publica- 
 tion has exceeded my intentions. 
 
 I now publish the Lecture almost as it was delivered, 
 subject only to its subdivision into sections, and to such further 
 revision as seemed desirable in order here and there to modify 
 its colloquial style, and to avoid repetitions quite justifiable in 
 a lecture. Such new materials as have offered themselves I 
 have preferred to put into the form of an Appendix, the 
 sections of which correspond with those adopted in the Lec- 
 ture, so that they can easily be read together if it be desired 
 to do so. 
 
 It has not been attempted to exhaust every possible source 
 of information^ nor to mention the numerous individual cases 
 
vi PREFACE 
 
 of nerve-stretching which have been recorded since 1883. 
 This would have involved an expenditure of time beyond what 
 is now at my disposal, and also a detailed criticism as to the 
 bearing of most of the recently recorded facts. I have there- 
 fore restricted myself to a general use of the newer experi- 
 ences of British, Continental, and American surgeons ; but I 
 have added a list of references by means of which access 
 may be obtained to a tolerably complete bibliography on the 
 whole subject from the commencement. 
 
C!)e *33raDsl)ato* iletture 
 
 ON 
 
 NERVE-STRETCHING FOR THE RELIEF 
 OR CURE OF PAIN. 
 
 Mr. Vice-President, Mr. Junior Vice-President, and Gentle- 
 men, — Dr. William Woods Bradsliaw, a physician who prac- 
 tised first at Andover and then at Beading, was M.D. of the 
 University of Erlangen, and also possessed other titles from 
 that University. He was M.A. of the University of Oxford, a 
 member of the Eoyal College of Physicians of London, and 
 a Fellow of this College. He was therefore a man not undis- 
 tinguished in our profession, and he held a high position in 
 the county in which he resided. He contributed a few papers 
 to medical journals, and likewise indulged himself in writing 
 articles on matters of general interest, under the signature of 
 ' Beta.' He died in the month of August seventeen years 
 ago ; and fourteen years afterwards his Widow left 1,000L to 
 the Eoyal College of Physicians of London, and another 
 IjOOOZ, to this College, in order to establish perpetual lecture- 
 ships in Dr. Bradshaw's name. 
 
 This lectureship has been held only once previously to the 
 present occasion, and that by Sir James Paget; and as my 
 predecessor chose for his subject some ' new ' forms of disease, 
 so I have selected as my subject what may yet be called a 
 ' new ' operation ; for it is only within the last dozen years 
 that ' nerve-stretching ' has been extensively introduced, and 
 performed more and more frequently for the ' relief or cure 
 
 B 
 
2 NEUBECTASY, OB NEBVE-STBETCHING 
 
 of pain.' It has also been employed in a variety of spasmodic 
 diseases dependent on nervous distm'bance. But it is in rela- 
 tion to its effects in relieving or curing pain that I now chiefly 
 wish to direct your attention to this particular operation of 
 ' nerve-stretching.' 
 
 1. Extensibility of Nerves. — The first point I have to 
 mention concerning nerve-stretching is that one must under- 
 stand by it not the mere drawing-out of a nerve, so that one 
 may see it lifted from its bed in the body, but a palpable 
 stretching. And this opens up the question — Can a nerve be 
 stretched? Now nerves are extensible to a certain degree, 
 but to a much slighter degree than we would imagine. Here 
 is a Table showing the degree of extensibility of nerves, and 
 
 Table I. — Extensibility of Nerves. HuMiN Nerves after Death (Vogt). 
 
 
 Extending weight in pounds 
 
 Distance 
 lengthened 
 in inches 
 
 Eatio 
 
 to whole 
 
 nerve 
 
 Median nerve . 
 
 >i )»•••■ 
 
 Great sciatic and its branches . 
 
 Great sciatic (rabbit just killed) 
 Great sciatic (living rabbit) 
 
 61 
 Extreme weight possible 
 
 Breaking strain 
 
 66 (supposed weight of 
 
 lower limb) 
 
 3 
 
 4 
 
 H 
 
 4-7f(?) 
 
 (?) 
 (?) 
 (?) 
 
 1 
 
 24: 
 1 
 
 1 1 
 9 T 
 JL i 
 
 4 
 
 you will find that the results, after all, are not very remark- 
 able. One of the observess * states that a nerve may be 
 stretched to one twenty-fourth of its length ; another observer 
 makes out a larger amount of stretching, and another a still 
 larger amount. But after all one is surprised at the resistance 
 of nerves to a force applied longitudinally to them, and at the 
 small amount of stretching of which they are capable. 
 
 The following simple experiment will show you that a 
 nerve is not so very extensible, though it is extensible. I 
 take a piece of tendon and a piece of nerve, and I apply the 
 same weight to the same length of each, and you will see 
 how very inextensible the tendon is, and that the nerve has 
 yielded a very little more than the tendon. You must re- 
 member, however, that the weights employed in the cases 
 
NEURECTASY, OR NERVE-STRETCHING 3 
 
 mentioned in the Table were considerable, some of them as 
 great as 20, 30, and even 80 pounds. Here, however, I have 
 used only a 4 lb. weight. No doubt, with a greater weight, 
 a perfectly fresh piece of nerve would be stretched still more 
 than this ; at the same time the amount of extensibility of 
 nerve is certainly comparatively slight. It is not, nearly so 
 extensible as an artery, but it is a little more extensible than 
 a tendon. It has been noticed with regard to this extension 
 that the nerves nearer to the spinal cord are rather more 
 extensible than those at a distance. This may be owing to 
 the relative thinness of their sheaths. The distant nerves, 
 though smaller, are probably relatively better protected. It 
 has been observed that the nerves of the lower limb are less 
 extensible than those of the upper limb, probably for the same 
 reason, namely, that the nerves of the lower limb have thicker 
 sheaths, for we must recognise that it is the sheath which 
 bears the strain when one pulls upon a nerve. It has also 
 been noticed that a long piece of nerve will stretch a great 
 deal more relatively than a short one, and this is only in 
 harmony with what takes place in ordinary extensible tissues. 
 If you take two pieces of elastic tube, one twice the length of the 
 other, and load them with the same weight, you will find that 
 the longer piece will stretch relatively more than the shorter 
 one. This piece, for example, has stretched about two inches 
 with 1 lb. weight, and this piece measuring twice the length is 
 stretched nearly five inches ; so, also, the longer a given nerve 
 the greater is its relative extensibility. (Appendix, p. 33.) 
 
 2. Elasticity of Nerves. — The next point we come to is 
 the recoil of the nerve. After one has stretched a nerve, does 
 it recoil ? We find observation proves that it does recoil. 
 
 Table II. — Elasticity of Nerves {Vogt). 
 Human nerve (after death) extended 21— ig '■> retracted to ^^5. 
 Rabbit's nerve (living) extended \ (one experiment) ; wholly retracted. 
 
 According to one observer the elasticity of a nerve is so great that 
 when it is stretched by one twenty-fourth of its length it re- 
 coils to within one fortieth of its original length. This shows 
 the recovering power or resiliency of the sheath of the nerve. 
 Lastly, I may remark that in the living body the extensi- 
 
 B 2 
 
4 NEURECTASY, OB NERVE-STRETCHING 
 
 bility of a nerve is greater, and so is its elasticity. A living 
 nerve having all its tissues in a healthy condition — that is, 
 with its sheath flexible and its elements mobile amongst each 
 other — may be stretched a great deal farther than a dead 
 nerve. So, on the other hand, it will recoil more effectually. 
 Its elasticity is greater, and its power of recovery, as shown 
 in Table II., may be absolutely perfect. This is just what we 
 might expect. (Appendix, p. 33.) 
 
 3. Cohesion or strength of nerves as shoivn by their breaking- 
 strain in pounds' weight. — Passing on to other considerations 
 as to the effect of this pulling upon a nerve, the next and 
 most practical question is — How much weight will a nerve 
 bear ? Now it is very remarkable that the nerves will bear 
 such an extraordinary weight before they break. In Table III. 
 you will see a list of the breaking -iv eights of some of the 
 
 Table III.— Cohesion of Nerves: Beeakinq Strain in Pounds 
 (Trombetta). 
 
 Humau Nerves after Death {Trombetta) 
 
 
 
 
 Pounds 
 
 i\. Supraorbital 6 
 
 Trigeminus- 2. Infraorbital 
 
 
 
 
 12 
 
 is. Mental 
 
 
 
 
 5| 
 
 Cords of Brachial Plexus . 
 
 
 
 
 50 to 64 
 
 Ulnar nerve .... 
 
 
 
 
 58 
 
 Musculo-spiral .... 
 
 
 
 
 61 
 
 Median 
 
 
 
 
 84 
 
 Crural 
 
 
 
 
 83 
 
 Internal Popliteal 
 
 
 
 
 114 
 
 
 (Johnson Symington) 
 
 
 
 
 86 to 176 
 
 
 (Tillaux) . 
 
 
 
 
 118 to 127 
 
 Great Sciatic - 
 
 (Gillette) . 
 
 (Trombetta) 
 
 (Ceccherelli) 
 
 
 
 
 165 
 
 82 to 288 
 154 to 220 
 
 Lowest weight 
 
 
 
 
 82 
 
 Highest weight . . . • 
 
 
 
 
 288 
 
 Mean weight 
 
 
 
 
 185 
 
 Living nerves in animals. — Great sciatic will bear 1-8 of the body-weight. 
 
 (Stintzing.) 
 
 Average weight of human body is 150 lbs. ; 1-8 of 150 lbs. = 83-3 lbs. 
 
 The normal functions of healthy sciatic nerve in animals completely re- 
 
 stored, even after the nerve has been stretched with a force equal to a little 
 
 more than half the body-weight. (Stintzing.) 
 
 Safe strain for healthy sciatic (man), GO lbs. Safe strain for diseased sciatic 
 
 (man), 30 lbs. 
 
 
 
 
 
 
NEUBECTASY, OB NEBVE-8TBETCHING 5 
 
 smaller nerves of the body, varying from 6 lbs. in the case of 
 one of the branches of the trigemmus to 12 lbs. for another 
 branch ; and the weights increase gradually with the size of 
 the nerve as one passes to the cords of the brachial plexus, 
 and thence to the crural, and the great sciatic nerves. 
 
 However, for a moment, let us give special attention to the 
 breaking-weight of the sciatic nerve. This has been tested 
 by Symington, Tillaux, Gillette, Trombetta, and others ; and 
 these observers differ most extraordinarily. The weights 
 employed vary from 82 lbs. to 280 lbs. This discrepancy, of 
 course, must have an explanation, and it can be accounted for 
 on various grounds. Thus there is no doubt that the nerves 
 experimented on must have been taken from bodies of different 
 height and conformation, and were those of persons, who, 
 when living, had not been in identical conditions as to health. 
 Some of the nerves, too, might have been themselves diseased. 
 Again, the nerves examined would of course be tested at dif- 
 ferent periods after death, in different climates, and even some 
 in hot and some in cold seasons ; so that, no doubt, the effect 
 of post-mortem changes might account largely for the striking 
 differences in the results. As a mean outcome, however, of 
 all these various experiments, we find that 180 lbs. is the 
 weight that the sciatic nerve will bear. It is easy to under- 
 stand, therefore, that when I just now put only a 4 lb. weight 
 upon a nerve of small size I was far wdthin the power which 
 is required in order fully to stretch that nerve. 
 
 I will now pass from this Table, to which I shall have again 
 to refer, with only one additional remark, viz., that as I just 
 now contrasted the extensibility and the elasticity of the dead 
 and the living nerves, so here it is shown, after Stintzing 
 (whose name I shall frequently mention), that whereas the 
 sciatic nerve in a dead animal broke with '5 or half the weight 
 of its own body, that weight being about 10 lbs., another living 
 sciatic nerve bore 1*8 of the body-weight. This again shows 
 a great difference in the power that exists in the living as 
 compared with the dead nerve to resist longitudinally applied 
 force. (Appendix, p. 34.) 
 
 4. Effects of stretching on the structure of a nerve. — But 
 
G NEURECTASY, OB NEBVE-STBETCHING 
 
 still more interesting results are displayed when we examine 
 the immediate effects of stretching on the intimate structure of a 
 nerve. And here I might express the general results in the 
 form of a truism ; for one may state that experiment has 
 shown that every constituent of a nerve is more or less in- 
 juriously affected or changed by a mechanical force acting 
 longitudinally upon it, just in proportion to the amount of 
 that force. As I have said, this is a truism, but it is useful, 
 inasmuch as it throws a mantle of reconciliation over the 
 various observations and facts which have been accumulated 
 on this question during the last eleven or twelve years. No 
 one who has not perused the literature of the subject could 
 anticipate the widely different statements which have been 
 made concerning it. If, however, we recollect that the particular 
 results must vary according to the force used and the condition 
 of the nerve itself, we shall find that we may follow in a very 
 general way the various effects which have been produced. 
 
 Long before nerve-stretching came into vogue as an opera- 
 tion, Haber and Harless examined the effects of stretching 
 nerves. They pointed out a tension of the sheath, an elongation 
 of the fasciculi and the tubular fibres, and a compression of 
 these within the tightened sheath. Valentin went further and 
 showed that the individual tubules of the nerve were elongated 
 and narrowed in diameter. Vogt added somewhat to these 
 observations, chiefly, however, by confirming them. Gen 
 noticed remarkable constrictions formed on the nerve-tubules, 
 constrictions to which I shall presently refer. Quinquand 
 discovered segmentation in the so-called medullary sheath of 
 the nerve tubules. Schleich observed that these segments at 
 last became broken ; and that, here and there, one saw the 
 axis-cylinder, as it is called, passing between and through 
 them. So that thus we have a series of differing statements 
 concerning the effects of stretching upon the anatomical con- 
 stituents of the nerves. 
 
 But Mr. Horsley, at my instigation, has recently made 
 some interesting observations which throw additional light 
 upon this subject, and for which I think he deserves special 
 mention. He has made sections for me of an unstretched 
 nerve and of a stretched nerve, both properly hardened ; and 
 
NEUBECTASY, OB NEBVE-STBETCHING 7 
 
 in the Illustrations here exhibited, taken from his drawings 
 of specimens under the microscope, we can trace much more 
 effectually than by mere description all the changes which 
 have been noted by different observers as wrought by stretch- 
 ing the constituents of a nerve. In the sheath, or epineurium, 
 which covers the nerve, you see on the longitudinal section of 
 the unstretched specimen (Fig. 1, page 8), that the fibres are 
 beautifully wavy like those of ordinary fibrous tissue. The 
 nerve tubules lie more or less loosely in their sheath, whilst 
 even the perineurium, the fine membrane lying between the 
 epineurium and the tubules, likewise presents a wavy contour 
 in the unstretched state. Bloodvessels, shown dark, are seen 
 plainly at intervals on the section. Contrasted with this 
 specimen is one from a longitudinal section of the same nerve 
 (Fig. 3), the popliteal, stretched by a weight of 28 lbs., which 
 is far within its breaking-strain, which would be probably 
 about 60 lbs. Here the epineurial fibres, instead of being 
 wavy, run in perfectly straight lines, stretched out as tight 
 as they can be, the perineurium is perfectly straight, and the 
 tubules, somewhat narrowed, are also stretched to an extra- 
 ordinary degree. In a transverse section of the unstretched 
 nerve (Fig. 2), you recognise the spaces in which the fasciculi 
 of the nerve-fibres lie, smaller bundles being shown as com- 
 bining into a larger one, and the cut ends of the individual 
 nerve tubules contained in each fasciculus. In this condition, 
 the perineurium is loose, the channels in which the nerve 
 fasciculi lie are more or less open, and there is a space between 
 each fasciculus and the perineurium, that space being most 
 likely a lymphatic space, occupied during lifetime with lymph- 
 fluid. Several open bloodvessels are also shown. But on a 
 transverse section ofa stretched nerve (Fig. 4) we see, irrespec- 
 tive of the changes which have taken place in the bloodvessels, 
 a complete alteration. Thus the epineurium or sheath is 
 tightened out and marked with rigid lines, as if the whole 
 texture were rendered tense, and it cuts like a sort of hard, 
 solid block. The fasciculi are compressed, and the lymphatic 
 spaces within the membrane covering these bundles are oblite- 
 rated, indicating, as it would appear, the compression of the 
 bundles themselves and their constituent tubules. This is the 
 
8 NEUBECTASY, OB NEBVE-STBETCHING 
 
 condition which no doubt Haber and Harless observed many 
 years ago, but they did not exhibit it in the very decided 
 manner demonstrated in Mr. Horsley's preparations. 
 
 Sheath. Nerve-fibres. 
 
 1. liOngitudinal section. 
 
 2. Transverse section, showing fasciculi 
 and sheath. 
 
 Figs. 1 and 2. — Sections from unstretched internal popliteal nerve (human), maguifiud 
 GU diameters. — lloi-sttij. 
 
 Sheath. Nerve-fibres. 
 
 3. Longitudinal section. 
 
 4. Transverse section, showing fasciculi 
 and sheath. 
 
 Figs. 3 and 4, — Sections from stretched internal popliteal nerve (human), magnified 
 eo diameters.— i/o/-«/c2/. 
 
NEUBECTASY, OB NEBVE-8TBETCHING 9 
 
 Let US next consider the minute changes which take place 
 in the nerve-tubules. Here (Fig. 5, a) is the diagram of a 
 nerve-tubule with one of its annular constrictions, or so-called 
 nodes of Eanvier, in its natural form, showing also the 
 nucleus of the outer hyaline sheath of Schwann. The black 
 part, stained by osmic acid, represents the soft medullary 
 sheath ; the lighter part is the axis-cylinder or axis fibre. It 
 
 Pig. 5. — IfTerve-fibres, normal and stretclied ; stained with osmic acid. 
 Magnified about 350 diameters. — Horsley. A, Uninjured nerve- 
 fibre, showing a node of Ranvier, the medullary sheath stained 
 black, and the iuternodal nucleus and protoplasm, b, Uninjured 
 nerve-fibre, showing the peculiar cleavage of the medullary sheath, 
 probably due to the action of reagents, or to contraction of the white 
 substance, c, d, e, nerve-fibres after various amounts of stretching, 
 then relaxed, hardened, and stained, c shows puckering of the 
 outer or tubular sheath, and commencing fissuring or cleavage of 
 the medullary sheath ; D shows well-marked cleavage or segmenta- 
 tion of the medullary sheath; e shows complete destruction of the 
 medullary sheath, the axis-cylinder remaining intact. This last 
 preparation, e, was made from a small nerve stretched to actual 
 rupture, c, D exhibit the amount of change which is probably pro- 
 duced by the ordinary operation of nerve-stretching. 
 
 had been observed by Leuterman that the medullary sheath, 
 after a certain time, often broke up into these curious seg- 
 ments between and independent of the annular constrictions 
 of the tubule, each consisting of small portions of medullary 
 substance, b. This is evidently not a purely accidental occur- 
 rence. It might be a crystallisation, it might be a solidification, 
 it might be a coagulation. At all events, it results in the 
 somewhat regular segmented appearance described by Leuter- 
 man. I wish, however, to mention especially that this cleavage 
 
10 NEURECTASY, OB NEBVE-STBETCHING 
 
 was noticed quite independently by Mr. Horsley, and for that 
 reason I show this diagram, b, which has been drawn under 
 his instructions. 
 
 We further find, that in a stretched nerve, as shown in c 
 and D, there is a puckering of the tubular sheath, the regular 
 nodal constrictions are obliterated, and an appearance of a 
 commencing cleavage or segmentation becomes recognisable. 
 Supposing the stretching process to be carried a little further 
 as represented in b, not only the nodal constriction, but the 
 segmentation of the medullary substance disappears, this 
 becoming broken up into irregular masses ; whilst, as most 
 authorities state, the tubular sheath may remain unrup- 
 tured, and the axis-cylinder entire, though no doubt they may 
 both be broken across. Marcus and Wiet have actually noticed 
 the breaking of the axis -cylinder, but rupture of the fine hyaline 
 sheath has been recorded by many microscopists. These 
 observations have been made not only upon nerves which have 
 been dead for some time, but also upon the nerves of animals 
 quite recently killed. Here, then, we have a series of note- 
 worthy changes demonstrated to be produced upon a nerve by 
 stretching it in various degrees. 
 
 It may be permitted tne in this place briefly to mention 
 an experiment which bears on the question of the kind of 
 compression which the fasciculi and the tubuli of a stretched 
 nerve must undergo. Evidently the channels formed in the 
 perineurium and epineurium for the protection of the fasciculi 
 of tubules are narrowed, the lymph spaces around these 
 fasciculi disappear, and the fasciculi themselves are com- 
 pressed as well as subjected to longitudinal tension. Now, 
 these same channels of course resemble tubes ; and so 
 likewise the fine hyaline sheaths of the separate nerve-fibres 
 are elastic hollow tubes enclosing the medullary sheath 
 and axis- cylinder. Hence it occurred to me to ask, what 
 happens when a more or less elastic tube is elongated ? Is its 
 original total capacity increased or diminished ? You will 
 probably think neither the one nor the other, and that is what 
 I supposed. But a very simple experiment will show you that 
 when I extend an elastic tube its total capacity is increased. 
 Here is a glass tube to the lower end of which a piece of elastic 
 
NEURECTASY, OR NEBVE-STBETCHING 11 
 
 tubing is strongly attached, and is tightly closed below ; both 
 contain a coloured fluid which reaches a certain level in the 
 glass tube. When I stretch the elastic tube, thus, you per- 
 ceive that the fluid descends ; so that given an elastic tube of 
 a certain length and diameter, when it is elongated and 
 narrowed by being stretched, its total capacity becomes 
 greater than it was in the unstretched condition. Applying 
 this to what may happen within a nerve, it would seem that 
 the perineurial channels, although diminished in their trans- 
 verse diameter, might be so much elongated when stretched, 
 that their total capacity would be increased, not diminished. 
 So, also, with regard to the tubules ; for I assume that what 
 is physically true on a large scale must be true on a small 
 one. These microscopic tubules bemg elongated would really 
 have a greater internal capacity than when in their natural 
 condition; and if this be so, we can understand that this 
 stretching may take place without any absolute compression. 
 But, on the whole, one may conceive that here there is a sort 
 of struggle between two conditions, a lateral narrowing pro- 
 ducing a transverse compression, and an elongation producing 
 a longitudinal expansion. There would occur a narrowing of 
 the tubule itself, and a stretching out of its soft contents to 
 fill it, whilst in itself it becomes more capacious, and the 
 result, as we can readily understand, would be such as to 
 shatter — if I may use the phrase — the delicate medullary 
 substance into fragments, and so to produce the temporary 
 destruction of its continuity represented in the diagram, e. 
 (Appendix, p. 34.) 
 
 5. Effects of stretching on the nutrition of living nerves. — 
 If we next proceed to inquire as to what further happens to 
 a living nerve which has been stretched, we find that the 
 structural changes just described are followed by nutritive 
 disturbatices, ending in degenerations, of which I may now take 
 account before I speak of the effects of stretching on the 
 physiological properties or functions of the nerve concerned. 
 First, the sheath becomes hyperaemic, and charged with little 
 ecchymoses and even larger haemorrhages; it is then infiltrated, 
 suffers from proliferation of its elements, and is swollen ; its 
 
12 NEURECTASY, OB NEBVE-STBETCHING 
 
 blood-vessels become tortuous and pressed upon ; and its 
 lymphatics and lymphatic spaces must also suffer compres- 
 sion. Then, with regard to the tubules themselves, the nuclei 
 of the hyaline sheath soften and disappear, and rapid dege- 
 nerative changes set in, during which the fine tubular sheath 
 melts away, the medullary matter liquefies and runs into 
 the form of oil-globules, and so escapes from the tubules, and, 
 lastly, the axis-cylinder, which, however, offers much resis- 
 tance to ' degenerative ' change, is broken up and is absorbed. 
 In this fashion the whole mass of nerve-tissue becomes 
 disintegrated under the effect of soft atrophic changes. 
 After a longer or shorter time, varying according to the 
 severity of the stretching, and usually measured by weeks or 
 even months, these degenerative changes are followed by 
 reparation of all the elements of the nerve-tissue. The precise 
 nature of the reproductive processes is not yet clearly made 
 out, but they are certainly most surprising and have great 
 significance. (Appendix, p. 34.) 
 
 6. Effects of stretching on the functions and ijroijerties of a 
 nerve. — "With regard to the physiological results of nerve- 
 stretching, there is also, as might be anticipated, a consider- 
 able variety of statement and opinion. Speaking generally, 
 it may be said that all the properties and functions of a mixed 
 nerve are affected in a greater or less degree, according to the 
 amount of force with which it is drawn out or stretched. 
 This is so, certainly, as regards its sensory and motor 
 functions, for if the stretching be only of a moderate kind, 
 there is but very little and only a temporary loss of either ; 
 but as the stretching becomes stronger and stronger, both 
 functions are diminished and ultimately are completely lost. 
 The sensory fibres seem to be sooner and more markedly 
 influenced than the voluntary motor fibres. All the modifi- 
 cations of common sensibility in the parts to which the nerve 
 is distributed are affected, not only the sense of touch, but 
 those of pressure, heat and cold, each being depressed or 
 annihilated provided that the stretching is powerful enough. 
 The consequent motor paralysis is also similarly graduated 
 until it becomes complete. These results are easily under- 
 
NEURECTASY, OR NERVE-STRETCHING 13 
 
 stood. But it is somewhat remarkable, if it be true, that the 
 reflex phenomena depei^dent on the action of the stretched 
 nerve, though of necessity these are also gradually interfered 
 with and ultimately suspended, are not so immediately af- 
 fected as the sensory and the voluntary motor phenomena 
 performed through its agency. It has been shown, moreover, 
 that the mherent irritability of a nerve, that is, its general 
 property of conducting impressions, is increased not only by 
 a moderate degree of lateral pressure upon it, and even by a 
 tolerably strong pressure, but also when it is subjected to a 
 slight amount of stretching. Of course, under a heavier 
 pressure and a more powerful extension the proper conducting 
 power of a nerve is finally lost. In these two facts, viz. that 
 the reflex function of a stretched nerve is not extinguished so 
 early as its sensory and voluntary motor functions, and that 
 a certain increase of its inherent irritability follows upon 
 moderate stretching, we may possibly find two important 
 conditions which may assist in explaining the effects of a 
 moderate nerve-stretching as a palliative or curative opera- 
 tion ; for both conditions are probably intimately associated 
 with the vasimotor (which I prefer to vasomotor) and the 
 trophic functions of a mixed nerve, concerning which, how- 
 ever, sufficient is not yet known. 
 
 It is scarcely necessary for me to add that when, after 
 having undergone the degenerations just described as the 
 effects of stretching, the several constituents of a previously 
 healthy nerve are, after a time, reproduced, so all the proper- 
 ties and uses of such a nerve would l)e gradually and more or 
 less perfectly restored. 
 
 The preceding observations by no means exhaust all 
 which may here be stated concerning the effects of stretching 
 upon the functions of nerves. For, in a recent and valuable 
 memoir by Stintzing, which it is scarcely possible to commend 
 too highly, we have an account of a most elaborate inquiry into 
 the whole subject, illustrated by experiments on living animals, 
 and conducted on scientific methods. He confirms to a 
 great extent what was previously known ; but the important 
 feature of his investigation is this, that he aims at obtain- 
 ing exact measurements of his results. Touch he measures 
 
14 NEURECTASY, OB NERVE-STRETCHING 
 
 by an sestliesiometer, cutaneous sensibility by aid of the 
 faradaic current, and muscular contractility by the con- 
 stant current. He records his numerous results by means of 
 curves, so that they can be readily and truly appreciated. 
 He thus compares the effects produced by various stretching 
 weights, having different ratios to the weight of the animal's 
 body experimented upon ; so that he gives the physiological 
 disturbances produced in the great sciatic nerve by a weight 
 of Y%ths, jV^hs, and one half of the body-weight, and so on 
 up to the breaking weight of that nerve, which, as I have 
 already mentioned, is equal to 1*8 of the body-weight. His 
 researches, therefore, supersede the less definite observations 
 of earlier experimenters, who give us no accurate statement 
 of the forces applied, but merely describe the act of stretching 
 of the nerve, whilst they simply noted without measuring the 
 actual results. Stintzing has also tested other nerves besides 
 the sciatic, and he has compared the effects of stretching 
 nerves upwards and downwards, that is, from the branches 
 upwards and from the trunks downwards. He has also 
 studied what may be called the cross-effects of nerve-stretch- 
 ing, and has shown distinctly that by stretching nerves on 
 one side of the body, various degrees of disturbance of nerve- 
 function occur on the opposite side, a highly important factor 
 in all probability in regard to the explanations which may be 
 attempted of the effect of nerve-stretching as a palliative or 
 curative proceeding in cases of disease of the central nervous 
 apparatus. At all events, I repeat, Stintzing's essay, re- 
 cording his measurements and tabulating his positive results, 
 is certainly the most trustworthy monograph we at present 
 possess upon this subject, and no doubt it will largely influ- 
 ence scientific opinion and guide future research and practice. 
 (Appendix, p. 39.) 
 
 7. Effects of nerve-stretching on the nervous centres. — Among 
 the interesting questions which have arisen as to the effects of 
 nerve-stretching is this : Are the actual mechanical effects of 
 pulling upon a cerebral or spinal nerve transmitted onwards to 
 the brain or spinal cord, or are they not ? On this point 
 Vogt, one of the earlier German observers, said, no ; whilst 
 
NEURECTASY, OR NERVE-STRETCHING 15 
 
 Gillette, a French experimentalist, said, yes ! asserting that 
 if the sciatic nerve was stretched, the spinal cord was moved 
 in the spinal canal. 
 
 Later observers have arrived at various conclusions. Thus 
 Gussenbauer and Braun, working together, state that they 
 have seen, in one case, a movement through the whole length 
 of the cord up to the occipital foramen ; in a second case the 
 movement was perceptible but not measurable ; and in a 
 third case they saw no movement at all. In the case'in which 
 the movement was measured, the amount, when recorded in 
 millimetres, looks large, but it was only one-fiftieth of an 
 inch, although the greatest amount of movement, that in the 
 lumbar region, amounted to one-tenth of an inch, which, of 
 course, is a palpable movement. Dana, an American observer, 
 confirms the fact of there being some movement. Symington 
 doubts it. Langenbuch, one of the greatest authorities on 
 nerve-stretching, who has stretched more nerves than any 
 man, found exactly what was met with in one of Gussenbauer 
 and Braun' s cases, namely, that although the movement was 
 propagated to the spinal ganglia and to the sheaths which 
 cover the roots of the spinal nerves as they pass out of the 
 intervertebral foramina, it was not communicated to the 
 intraspinal roots of the nerves, and necessarily not communi- 
 cated to the cord. Mr. Horsley has made four experiments 
 upon the great sciatic nerve in the dead body, and he found 
 no movement of the spinal cord ; and, yesterday, having 
 the opportunity of again testing the point in this College, I 
 repeated this experiment together with him, and we found no 
 appreciable resulting movement. "We did find what may be 
 an explanation of a movement in certain cases, namely, that, 
 when you apply traction to the large nerves, the spinal column 
 has its curves,, slightly altered, so that it becomes straighter 
 in certain parts, and this, of course, produces some movement 
 in the cord. When that alteration was prevented, we saw no 
 proper movement. W^e recognised a slight movement in the 
 dura-mater, and if you remember the attachments of the 
 ligamentum denticulatum on either side between the dura- 
 mater and the cord, you wiU understand that if the duramater 
 be moved you may gently disturb the cord. I believe, 
 
16 NEURECTASY, OB NEBVE-STRETCHING 
 
 in these two ways, such casual movements as have been 
 observed by Braun, Gussenbauer, and Dana may be fully 
 accounted for; and, at all events, that practically there is 
 no stretching effect propagated through the roots of the 
 nerves to the cord itself. We found that the stretching effect 
 passed on to the sciatic plexus, and also on to the main roots 
 of the nerves and their fibrous sheaths prolonged from the 
 dura-mater, and hence it must act slightly upon the spinal 
 ganglia of the posterior roots. It might also sometimes move 
 the cord a very little through the ligamentum denticulatum ; 
 but we found no tension or dragging of the intraspinal or 
 intrameningeal rootlets of the nerves, and no constant move- 
 ment, and certainly no direct stretching effect in or upon the 
 cord. But in this disturbance of the spinal ganglia we may 
 possibly have another important factor of a trophic character, 
 in the modus operandi of nerve- stretching in the palliation of 
 cases of central nervous disease. (Appendix, p. 40.) 
 
 8. Effects of nerve-stretching as an operation for the relief 
 or ewe of pain. — Having thus directed your attention to the 
 special effects of ' nerve-stretching,' as shown by actual experi- 
 ment on dead and on living healthy nerves, let us next con- 
 sider its therapeutical effects. Conscious that you all have 
 access to medical periodicals, and that some among this audi- 
 ence have tested for themselves the success or failure of this 
 operation, I content myself with pointing out to you a Table 
 founded on one published by Artaud and Gilson, but added to 
 from Ceccherelli, who has written a most interesting review of 
 this subject in the Italian journal Lo Sperimentale , which travels 
 very much along the same lines, but in a therapeutical sense, as 
 Stintzing's practical observations. Ceccherelli's figures, added 
 to Artaud's and Gilson's, give us a long catalogue of 252 cases 
 of nerve-stretching in various diseases. Now if you look 
 down the second and third columns, you will find no doubt 
 that the results are most variable. Take, for example, tetanus 
 and epilepsy, the successes are very rare. But the two upper 
 components of the table, namely, the affections classified under 
 the term ' neuralgia ' and the special tabetic spinal disease which 
 produces ' locomotor ataxy,' sclerosis of the posterior columns 
 
NEUBECTA8Y, OB NEBVE-8T RETCHING 
 
 17 
 
 Table IV. — Eesults op 252 Cases of Neeve-steetching in Disease 
 [Artaud, Gilson, and Ceccherelli). 
 
 
 Number o„„„„„ 
 of cases, S"''''^^^ 
 
 Partial 
 Success 
 
 Doubt- 
 ful 
 
 Failures 
 
 Deaths 
 
 Neuralgia of all kinds 
 
 Central disease with pain (tabes) 
 
 Central disease with contractions 
 
 Facial tic 
 
 Traumatic spasms . 
 
 Tetanus 
 
 Epilepsy 
 
 Peripheral paralysis (motor and 
 
 sensory) 
 
 Lepra (included in the above) . 
 Optic nerve (hallucinations) 
 
 Totals 
 
 99 
 36 
 14 
 
 7 
 12 
 45 
 
 4 
 
 34 
 1 
 
 74 
 5 
 
 12 
 6 
 
 10 
 
 14 
 1 
 
 34 
 
 12 
 
 16 
 
 1 
 
 1 
 
 3 
 
 33 
 
 7 
 2 
 1 
 
 6 
 7 
 1 
 1 
 1 
 
 8 
 29 
 
 252 ! 156 
 
 10 
 
 16 
 
 37 
 
 of the cord and the posterior nerve roots, include the morbid 
 conditions which are chiefly responsible for the ' pain ' which is 
 the subject of consideration in this lecture, that is to say, neu- 
 ralgia with all its prolonged torture, and tabes or locomotor 
 ataxy with its lightning flashes of acute suffering. Now, what 
 effect has nerve- stretching on these two sets of cases ? With 
 regard to neuralgia, you see the proportion of successes noted 
 in the first column is very great. With regard to tabes the 
 successes are exceedingly few ; but the instances of partial 
 improvement, in which an amelioration or even a temporary 
 cessation of pain is mentioned, are not to be ignored ; for at 
 least the pains were improved, and that is a part of the general 
 question which I wish to bring before you to-day. I could 
 add to this Table a list of many successes and many failures 
 from other sources, but I will caution you against accepting 
 all such details. We know that statistics must be received 
 with distrust ; that cases of failure frequently remain unre- 
 corded ; that it is extremely difficult to analyse and describe 
 the subjective condition of pain ; that patients often speak of 
 their symptoms too hopefully ; that in another direction the 
 surgeon is only too glad to accept such accounts ; and, lastly, 
 that recurrences constantly pass utterly unnoticed, cases 
 being put down as successes, which, if watched sufficiently 
 long, would not justify that term. Making full allowance for 
 all this, still you will find such a preponderance of facts in 
 
18 
 
 NEUBECTASY, OB NEBVE- ST BET CUING 
 
 favour of nerve-stretching curing or relieving neuralgia, that 
 you cannot resist the conclusion that it is really beneficial in 
 that disease. 
 
 The two additional Tables (V. and VI.), the one taken from 
 Nocht and the other giving the experience of my own hospital, 
 
 Table V. — Eesults of Neeve-steetching 
 
 [Nocht] 
 
 . 
 
 
 
 Total 
 cases 
 
 Cured 
 
 Failed 
 
 Died 
 
 
 Quickly 
 
 Slowly Total 
 
 Sciatica 
 
 Facial neuralgia 
 Traumatic neuralgia . 
 
 Locomotor ataxy (true) 
 
 Total cases 
 
 24 
 17 
 19 
 
 10 
 
 70 
 
 16 
 10 
 10 
 
 5 
 5 
 2 
 
 21 
 15 
 12 
 
 2 
 2 
 6 
 
 1 
 1 
 
 /■Eemoved . 4) 
 Pain ] Eelieved . 3 >■ 8 + 2 deaths 
 ( No effect . 1 ) 
 
 Table VI.— U. 
 
 Sciatica . 
 Locomotor ataxy 
 
 Cases 
 . 9 
 . 2 
 
 C. H. AND Self. 
 Improvement 
 
 4 decided 
 
 4 partial 
 2 „ 
 
 Failure 
 . 1 
 
 both having been compiled from cases treated long after those 
 recorded in Table IV., which, I may state, includes most of the 
 British cases, certainly offer some encouragement to the belief 
 that nerve- stretching is not only available for the successful 
 treatment of neuralgia, but also for the amelioration of the 
 distressing pains of tabes. Time does not permit me to enter 
 further on the clinical aspect of the question, on which we 
 must still wait for the amount of experience which will, in the 
 future, yield its indisputable verdict. (Appendix, p. 40.) 
 
 9. Rationale of the effects of nerve- stretching for the relief or 
 cure of pain. — I proceed now to consider the possible modes in 
 which nerve-stretching relieves or cures the pains of neuralgia 
 and tabes, to which two diseases I must henceforth exclusively 
 confine my attention. 
 
 With regard to the pain of neuralgia, it has such peculiar 
 characters that we can readily distinguish it from the pains 
 produced by tabes. First of all it is often, in fact commonly, 
 
NEURECTASY, OR NERVE-STRETCHING 19 
 
 unilateral ; those of tabes are liable to fly from side to side. 
 The pain of neuralgia runs along the course of a nerve ; it is 
 concentrated, as it were, along the path or territory of a par- 
 ticular nerve. The pains of locomotor ataxy, on the other 
 hand, are diffused over the areas of many nerves ; they may 
 occur on both sides of the body ; they may be in the limbs or 
 in the trunk — in fact, we do not know where they may not be. 
 Agam, the pain of neuralgia is nearly always increased by 
 movement or pressure, and this owing, of course, to its local- 
 ised character. The pain of neuralgia often starts from, or 
 is more severely felt at or near certain apertures where the 
 nerves pass out from the osseous or fibrous framework of the 
 body, or turn around given points of bone. Thus one most 
 painful point in sciatica is where the nerve passes out close to 
 the sacro-sciatic ligament, for every movement or twitching 
 of the adjacent muscles is liable to press upon the tender 
 nerve, and to influence its circulation by acting on the 
 branches of the sciatic artery and vein which supply the 
 nerve. Another painful point is just below the head of the 
 fibula, where the external popliteal turns round the bone, is 
 there bound down by the fascia, and so is liable to tension or 
 pressure. The fact, indeed, is that most neuralgic pains are 
 not only increased by external pressure, but they manifest 
 themselves at particular points of the nerve, which, owing to 
 the construction of the body, are liable to internal pressure, 
 including compression of their bloodvessels, and such hin- 
 drance to the local circulation as would intensify a condition 
 of hypersemia to which they might be subject. 
 
 The symptoms just detailed are those which accompany 
 the simplest or purest form of neuralgia, namely, jperiplieral 
 neuralgia ; w^hich, whatever may have been its original cause, 
 whether peripheral or central, is apparently dependent on a 
 neuritis or inflamed condition of the nerve considered as a 
 whole. But I venture to think that the neuralgic pain in 
 such cases is not a pain in the proper fibres running along the 
 nerve (otherwise it surely would be transferred by the con- 
 sciousness to the extremities of those fibres), but that it is a 
 pain in the nerve itself; and must be due to nervi nervorum, 
 which I here venture to predict will be found to exist in all 
 
 c 2 
 
20 
 
 NEUBECTA8Y, OB NEBVE-STBETCHING 
 
 nerves. Sappey has described sympathetic nervi nervorum 
 running upon the optic nerve, in that case, of course, supplied 
 
 Neural nerve. 
 Nervus iiervi. 
 
 Fio 6.— Diagram of small nerve, mag. 
 nified about 5 diameters. — {Horsley). 
 
 It shows nervi nenmrum as ima- 
 pinefl to exist. A,healthy unstretcheJ 
 part ; b, inflamerl and unstretcbed 
 part : (j, stretched part, to indicate 
 inevitable injury to any nervi ner- 
 vonini ; a, slieath of nerve ; h. nervus 
 nervi. 
 
 RECEIVER. 
 
 CONDUCTOR. 
 
 Sheath. 
 
 Dermal nerve. 
 
 Perimysial „ 
 Arthrodial „ 
 Periosteal „ 
 
 Fifi. 7,— Diagram of various sensory tracts. 
 
NEURECTASY, OB NERVE-STBETCHING 21 
 
 from the ciliary nerves. I think, on the other hand, we may 
 anticipate that in ordinary sensory or mixed sensory and motor 
 nerves, true sensory fibres will be found in the epineurium 
 and perineurium, probably proceeding from the nerve higher 
 up. This has not yet been demonstrated, but I hope and 
 believe that some one will take up the subject and will succeed 
 in finding them. In the meantime, I imagine them to exist ; 
 and m the upper part of this diagram (Fig. 6, a) of a healthy 
 nerve, you will see a nervus nervi, h, supposed to be coming 
 out from the trunk of the nerve and ramifying in its sheath, 
 a, just as nerve-fibres ramify in tendons, ligaments, and other 
 fibrous tissues, in which it is the nerves alone which suffer pam. 
 We speak of neuralgic pain as if there was something peculiar 
 in it, and so there is, seemg that it is pain in a nerve. But 
 all pain is due to impressions on nerves. The periosteum 
 does not feel pain, except through its nerves. So with the 
 skin, muscles, and tendons, no tissue feels pain except through 
 its own nerves. Hence, I contend, the argument is strong in 
 favour of the idea that nervi nervorum are present in the 
 sheath of a nerve. If you prick the endings of a dermal 
 nerve, the effect of that touch is carried up (as may be traced 
 in the diagram, Fig. 7) to the recorder, that is, it is received 
 on the spinal cord, is conveyed to the brain, and produces a 
 sensation of pain at a corresponding cerebral skin-point. So 
 with a periosteal sensory nerve, so with a nerve belongmg 
 to a joint, so with the nerve of a muscle or tendon, and so, 
 likewise, with a neural nerve (if I may so call it) a nervus 
 nervi, coming from the sheath of a nerve, and inducmg a 
 sensation which is referred to its own extremity. Now, sup- 
 posing this to be the case, what happens with these nervi 
 nervorum ? In an inflamed condition of a nerve (represented 
 diagrammatically by the swollen portion in fig. 6, b) the 
 hypersemic condition, plastic effusion, exudation or irritating 
 fluids, gouty or rheumatic, must excite these neural nerves 
 and occasion pain. Again, the lower part of the diagram (c) 
 represents a stretched and narrowed portion of the nerve : and 
 what must there become of the proper nervi nervorum ? They 
 must be stretched, or even broken ; their tubules must be 
 sacrificed very much more completely than the tubules running 
 
22 NEUBECTASY, OB NEBVE-STBETCHING 
 
 along the interior of the nerve. These latter, soft, elastic, 
 and free to move, would become very elongated, but not 
 necessarily ruptured, except in rare instances. But what 
 must happen to nerve tubules, the free extremities of which 
 are fastened into the fibrous sheath. They must be so 
 stretched or broken as to be completely paralysed; and, in 
 this way, I believe, we can account for the relief of the most 
 common form of neuralgic pains. 
 
 Of course, I do not ignore the possibility that, besides 
 these neurilemmal or perineurial inflammations, there may be 
 other conditions in the internal tubules themselves which will 
 cause pain ; these would also be probably arrested or inter- 
 rupted by the shattering of the medullary tissue and the 
 stretching or breaking of the axis-cylinder, which I have already 
 mentioned as taking place. I would not for a moment assert 
 that' all neuralgias are due to excitation of nervi nervorum, 
 but I do think that a large proportion are ; and that these 
 may be considered to be the true peripheral neuralgias. In 
 such cases, nerve-stretching probably acts in the manner just 
 described, but in other cases by partially benumbing or 
 paralysing the internal tubules, and by so arresting their 
 functions for a shorter or longer time. In either sets of cases, 
 the nerve-centres, which have been subjected to continuous 
 over-excitement, also have an opportunity of resting and of 
 recovering their normal condition ; for it is possible, though 
 it is not proved, that in certain instances these centres are 
 themselves the seats of changes capable of producing special 
 neuralgic pains. 
 
 As regards tabetic pains, these are produced in associa- 
 tion, not so much with morbid changes in the nerve-trunks 
 outside the dura-mater or in their peripheral branches, but 
 rather, as far as we know, with changes in the intramenin- 
 geal posterior rootlets of the nerves, and in the posterior 
 columns of the spinal cord. Still, observe, the changes are 
 chiefly in the conductors ; they are not found specially in the 
 grey substance alone, but they occur rather disproportionately 
 in the conducting white substance ; and although we speak of 
 this tabetic affection as a central disease, we should take care 
 to eliminate from our minds the idea that it is solely a grey 
 
NEURECTASY, OR NERVE-STRETCHING 23 
 
 matter disease ; or rather, we should not overlook the fact that 
 it is more a disease of the conductors than of the receivers of 
 nervous impressions. Certainly the conductors suffer obviously 
 more than the receivers, although these latter, no doubt, like- 
 wise undergo change. The grey matter degenerates, but the 
 white matter is more conspicuously affected, especially by 
 sclerosis of its neuroglia and degeneration of its compressed 
 tubules. 
 
 But how can nerve-stretching affect these intrameningeal 
 conditions ? We must here have recourse to some explana- 
 tion different from that of the mere mechanical effects of 
 stretching, because we have shown that these do not pass 
 beyond that part of the roots of the nerves which is enclosed 
 in the sheaths of the dura-mater. But- stretching must act 
 upon the spinal ganglia, and may thus produce an excitation 
 of vasimotor or trophic activity. To reactions of that kind, 
 and to the changes induced in the nerve elements in conse- 
 quence, we may perhaps attribute the benefit obtained in the 
 way of relief or cure (?) of the lightning pains, in those cases of 
 tabes dorsalis which give rise to the phenomena of locomotor 
 ataxy. Whilst, therefore, the explanation of the cure of peri- 
 pheral neuralgias is comparatively easy, the mode of action 
 of nerve-stretching for central neuralgias may be much more 
 complicated. But I must ask to be excused from following 
 any further these more or less hypothetical explanations, the 
 scope of my lecture being rather to illustrate the practical side 
 of the subject ; whilst I will leave to others engaged in patho- 
 logical investigations to pursue those lines of observation at 
 which I have briefly hinted. (Appendix, p. 44.) 
 
 10. Indications for the performance of the operaiion of nerve- 
 stretching. — I next proceed to ask in what special cases, besides 
 neuralgias and tabetic disease, the operation of nerve-stretching 
 may be usefully employed for the relief or cure of pain ; and 
 the preparations before me, mostly obtained from the Museum 
 of the College, will serve to illustrate this part of my lecture. 
 Amongst those specimens are some from cases which might 
 have been so treated, and others from cases which could not. 
 Here are two examples of neuromata from stumps, which 
 
24 NEUEECTASY, OB NEBVE-STBETCHING 
 
 possibly would have been amenable to this mode of treatment. 
 This is a painful ulcer of the skin, for which in former days a 
 limb was sacrificed ; it might probably have been cured by 
 stretching the posterior tibial nerve, and any other nerve in- 
 volved. This, again, is a nerve which has received some injury, 
 but only appears to have upon it a small mass of coagulated 
 blood ; still it caused acute suffering, which would probably have 
 been curable by nerve-stretching. Here is another case of 
 a painful ulcer which, I also think, might have been well 
 treated by the same method. In this jar we have a beautiful 
 example of thickening of the median and ulnar nerves opposite 
 the annular Ugament of the wrist, causing such excruciating 
 pain that the forearm was amputated, — a case which I firmly 
 believe would have been completely cured by nerve-stretching, 
 an operation so well suited to combat peripheral neuralgias. 
 This, again, is a case which suggests another course ; it is the 
 fractured limb of a donkey with a nerve entangled in the 
 cicatrix or in the soft callus. Here, probably, the treatment 
 would be not nerve-stretching but dissecting up the nerve, and 
 restoring it its freedom if possible ; or, if not, paring off the 
 ends of the nerve and suturing them together, as has been 
 done with success by Mr. Holmes and others. Then, there 
 are tumours of nerves for which one could not recommend 
 this operation ; for example, for neuromas situated in the very 
 substance of a nerve, in which case stretching would certainly 
 be useless ; but one would carefully dissect out the tumour, or 
 if not, one must sacrifice the nerve. Then we have still more 
 formidable examples of tumours of nerves, existing in one or 
 in many nerves in various parts of the body. Here is a sciatic 
 nerve in which there are at least a dozen or fifteen little 
 nodules ; and this again is a specimen in which every nerve 
 in the arm has one or two nodules upon it. These multiple 
 neuromas are sometimes cancerous, sometimes sarcomatous, 
 and occasionally they are fibromas ; but all cases of this kind 
 would be utterly unsuitable for nerve-stretching. Here is a 
 remarkable specimen of a tumour, attached to and pressing 
 on the intraspinal sensory rootlets of certain lumbar nerves, 
 fi'om which the most excruciating agony was suffered. In 
 that case I, some years ago, divided as many of the branches 
 
NEURECTASY, OR NERVE-STRETCHING 25 
 
 of the crural nerve which corresponded with the hnes of pain 
 as I could reach outside the pelvis, but without relief. After 
 death, this tumour was found inside the spinal canal, suffi- 
 ciently explaining the pain and the reason of the failure oi' the 
 operation. Could we hope to get any benefit in another such 
 case from nerve- stretching ? The probability, I am afraid, is 
 not ; because we have seen that the stretching does not pass 
 beyond the dura-mater, so as to affect these posterior rootlets. 
 Moreover, no induced change in the nutrition of the tumour, 
 through vasimotor influence, could be expected of a nature to 
 give relief, such as seems possible to occur in the central disease 
 associated with tabes dorsalis. The only operation here would 
 be trephining the spinal canal at a predetermined place of 
 selection. (Appendix, p. 44.) 
 
 11. Mode of iierforming the oiieration of nerve-stretching. — 
 In reference to this practical and almost concluding portion 
 of my subject, I would wish to make this general remark — 
 that one would set very little value on the various physical 
 experiments, anatomical investigations, and physiological ob- 
 servations, at which I have glanced, if they did not furnish 
 us some guides as to the best mode of conducting this com- 
 paratively ' new ' operation. 
 
 In the first place I need scarcely point out that in every 
 case of neuralgia the operation must be directed to the nerve 
 which is obviously concerned. The operation itself consists in 
 exposing the nerve, lifting it from its bed, either upon a hook 
 or upon the finger, and then stretching it to a certain point 
 so as to produce that ixdpahle stretching of which I spoke at 
 the beginning of my lecture, without which the operation will 
 fail. 
 
 But suppose, for example, that we have to deal with the 
 great sciatic nerve — with what force and to what extent may 
 we stretch it ? In answer to this question the Tables I. and 
 III., already given, yield valuable information, but not if we 
 translate them too literally, for if we merely take the mean 
 of the numbers therein recorded, that would be an unsafe 
 guide. Thus the mean breakmg- weight of the sciatic nerve is 
 185 lbs., but this nerve has been broken by a weight of 
 
26 NEUBECTASY, OB NEBVE-STBETCHING 
 
 82 lbs. Therefore the arithmetical mean is not to be adopted: 
 every practical surgeon would either smile or shudder at it. 
 Nor could we take the lowest weight, 82 lbs., because some 
 sciatic nerves might break with a still lower weight. Stintzing's 
 observation, that a living sciatic nerve may be safely stretched 
 with a weight equal to half that of the animal to which it belongs, 
 affords a somewhat safer guide, according to which one might 
 limit the strain applied to the living human sciatic nerve to 
 about 75 lbs., which is half the average weight of an adult 
 man. Stintzing has further observed, which is a great com- 
 fort, that the sciatic nerve may be stretched in a living animal 
 by half the weight of its body, so as to produce complete 
 anaesthesia and complete motor paralysis in the parts supplied 
 by it — in other words, complete loss of all nerve- function — and 
 yet all these states are temporary, and are followed in time 
 by a perfect recovery. The inference would be, then, that in 
 . man every function would be ultimately restored if the limit 
 of force supplied to the sciatic nerve were that of half the 
 body- weight. In short, if one applied a weight of 75 lbs. to 
 the human sciatic, and the nerve did not break, we might 
 feel assured that whatever sensory, motor, or even reflex and 
 vasimotor paralysis or trophic disturbance ensued, it would 
 all be eventually recovered from in an ordinary state of the 
 health. 
 
 But, as I have said, we must translate the results of these 
 experiments in a special sense, that is in their application to 
 diseased and not healthy conditions. The nerves we are sup- 
 posed to operate upon are not quite healthy nerves, nor are 
 the patients quite healthy persons. We must therefore descend 
 far below the limit of 75 lbs. I would myself counsel that no 
 inflamed or diseased sciatic nerve should ever be stretched by 
 a greater weight than 30 or 40 lbs. I should say that even 
 80 lbs. is a reasonable weight. By means of a dynamometer, 
 such as I have here, it may be shown how difficult it is to 
 apply, under the most favourable mechanical conditions even, 
 a force equal to 30 lbs. to a portion of a nerve. If I first 
 pull as hard as I imagine I should do upon a living sciatic 
 nerve during an operation, I find that the force employed is 
 about equal to 20 lbs. ; but if I pull very hard it is increased 
 
NEURECTASY, OB NEBVE-STBETCHING 27 
 
 to 30 lbs,, and that, I believe, is as hard as a surgeon could 
 well pull when holding a soft nerve between his finger and 
 thumb. It takes both hands for a strong man to exert a force 
 equal to from 80 to 100 lbs. ; but if, after the lecture, you will 
 try pulling upon this nerve when held by the finger and thumb, 
 as you would do in an operation, you will find that 30 lbs. is 
 about the limit of your pull. This piece of nerve is somewhat 
 changed by decomposition, but it will quite well bear the strain 
 of 30 lbs., which I take, finally, to be a perfectly safe force to 
 employ. Assuming such a limit for the sciatic nerve, of course 
 this would require to be graduated for smaller and smaller 
 nerves downwards to 3 or 4 lbs. 
 
 A special form of dynamometer was devised by Gillette to 
 be employed in operations of this kind, but I believe he soon 
 abandoned its use, and I should agree with him in that resolve. 
 Surgeons should educate their power of appreciating the resis- 
 tance of a nerve so as to be able safely and adequately to 
 stretch it — adequately in order to relieve or cure, safely so as 
 not to injure a patient. We do, indeed, educate ourselves in 
 a great number of instances without the use of measuring 
 instruments. We can tie an artery without tearing through 
 the outer coat, and either with or even without tearing the 
 middle coat ; we can test the state of tension of the eyeball 
 and determine whether it is greater or less than it should be ; 
 we can displace or extrude a cataractous lens safely ; we can 
 use a certain amount of force in reducing a hernia, so as not 
 to burst the intestine and yet succeed in our purpose. Now, 
 if the surgeon can do these things without dynamometers, why 
 should he not be able to undergo a similar dynamical self- 
 discipline, and cultivate his sense of resistance and the results 
 of his employment of force so as to acquire tact in the stretch- 
 ing of a nerve ? To do this is far preferable to the employ- 
 ment of any measuring instrument, which being set might 
 deceive him at any moment. A given nerve might be so strong 
 that his instrument would be safe, but the next nerve, appa- 
 rently similar, would be in danger of suffering too great injury 
 or even of complete rupture. But if the nerve be held by the 
 hand, and so stretched, you may feel the resistance which is 
 opposed by it, and you may judge, especially after a few trials 
 
28 NEUBECTA8Y, OB NEBVE-8TBETCHING 
 
 upon dead nerves, how much force is needed to produce that 
 adequate stretchmg of which I have spoken. The Hving nerve 
 perceptibly yields to traction ; you may not hear a tearing, 
 but you feel an internal creeping movement in the constituents 
 of the nerve — mostly, no doubt, in the sheath and its pro- 
 longations. You can detect a certain attrition and vibration 
 in the structural elements of the nerve, and being educated to 
 distinguish these you will operate safely. 
 
 There yet remain several other details in connection with 
 the operation, which, I think, do not usually receive sufficient 
 attention, but which here deserve consideration, namely, the 
 situation at which the stretching should be made, its mode or 
 character, whether by jerks or by a steady pull, its direction', 
 and its duration. In most of these respects Stintzing's obser- 
 vations come incidentally to our aid, for we may use his facts 
 in many ways. Thus he found that the best way to obtain 
 results with given weights corresponding with one quarter, 
 one third, or a half of the body-weight, and so forth, and to 
 ensure commensurate and commensurable events, was to keep 
 up a steady traction with given weights for a definite uniform 
 time. Now the times that he adopted in some of his experi- 
 ments varied from three to six minutes ; but in certain special 
 experiments, when he wished to secure exactly parallel condi- 
 tions, he maintained the stretching force uniformly for five 
 minutes. I believe that if stretching with a moderate power 
 prolonged over a certain period had been the customary modus 
 operandi, safer and better results would have been on record. 
 A short sudden pull is not sufficient, however hard it may be ; 
 a series of jerks are inadequate, for each jerk only repeats the 
 mischief produced by a previous one ; but you must pull firmly 
 and steadily, and if you thus put a strain upon the nerve and 
 stretch it continuously, say for from three to five minutes, by 
 means of a moderated force, you will gradually and perceptibly 
 produce those internal changes in the nerve which I have 
 described as being essential to a genuine nerve-stretching. As 
 regards the direction of the pulhng, whether it should be 
 downwards from the nerve centres, or upwards from the 
 branches of distribution, it does not seem in the physiological 
 experiments to have made much difference in the results. 
 
NETJBECTASY, OR NERVE-STRETCHING 29 
 
 Stintzing is, however, of opinion that for therapeutical pur- 
 poses it would be preferable in neuralgic cases to stretch 
 upwards from the branches, but downwards from the spinal 
 cord in tabes. For myself, I should advise stretching both 
 ways for neuralgia, which is commonly a perijjheral affection, 
 and yet is one which extends usually higher than the portion 
 of the nerve which can be reached by the surgeon. It is in 
 connection with this fact that the only remaming point in 
 regard to the operation has now to be considered, namely the 
 situation at which the nerve should be exposed and stretched ; 
 for it should be a rule to do this near to the seat of severest 
 pain, which is usually at the upper part of the nerve where it 
 issues from the body or escapes from the bones of the face or 
 skull, or where it comes off from an accessible jDlexus. 
 
 In the treatment of tabes by stretching the sciatic or the 
 crural nerves, or both, it would seem, as the diseased con- 
 ditions are essentially central, to be of less consequence to 
 stretch the nerve upwards from its branches ; but it would be 
 well to do so. At all events, it is here essential to stretch 
 downwards from the body. (Appendix, p. 44.) 
 
 12. Dangers of the operation of nerve -stretching . — With re- 
 gard to the risks which attend this operation, there are two 
 kinds, immediate and remote. The only immediate risk 
 specially associated with it, is that of completely ruj)turing 
 the nerve, which, however, has happened in the case of very 
 small nerves in the face without serious inconvenience. The 
 remote dangers, both in neuralgias and in tabes, are either 
 failure to relieve pain, or the aggravation of it, or a fatal issue, 
 as shown in Tables IV. and V. Each of these results is rela- 
 tively more frequent in tabes than in neuralgia, as, indeed, 
 might be expected. But the deaths are comparatively few. 
 Of the eight fatal cases recorded in Table IV., one was due to 
 the effects of chloroform, another to thrombosis m the large 
 veins, another to inattention as regards the antiseptic dress- 
 ings, and a fourth to the same cause. Four cases, however, 
 have occurred in which the death may undoubtedly be attri- 
 buted to an acceleration of the morbid changes in the spinal 
 cord occasioned by nerve-stretching ; but in one of these cases 
 
30 NEUBECTA8Y, OB NERVE- ST RETCHING 
 
 there was mncli active spasm as well as pain. There remain 
 one fatal case of severe traumatic neuralgia, and one only of 
 pure sciatica. We may here leave quite unnoticed the large 
 number of deaths in the cases of nerve-stretching for tetanus. 
 I would here observe that fatal results have followed other 
 apparently less severe operations than this. For example, a 
 boy, both of whose hip-joints and knee-joints were badly 
 contracted, had these extended in both limbs by force. He 
 collapsed, and died within three days. At the post-mortem 
 examination hemorrhages were found along the spinal cord. 
 Shampooing even has been known to result in a fatal issue, 
 no doubt from too violent a mode of performing it. With a 
 proper selection of cases, due care in the conduct of the 
 operation, and the employment of a strict antiseptic method, 
 w^hich is indispensable, the exposure and stretching of nerves, 
 I may venture to say, -cannot be condemned as a dangerous 
 operation. (Appendix, p. 48.) 
 
 13. Non-cutting or bloodless operations for nerve-stretching . 
 In completing this lecture, I must remind you that the 
 cutting operation, to which I have hitherto confined your 
 attention, is not the only method by which certain nerves 
 may be stretched. For it has been shown, as regards the 
 great sciatic nerve, that if you flex the thigh upon the body, 
 so that the knee comes close to the chin, then extend the leg 
 upon the thigh, and lastly, flex the foot forwards upon the 
 leg, so as to tighten the ankle-joint, behind, you can produce 
 an extraordinary strain and tension upon that nerve as it 
 passes out of the pelvis. Trombetta, the great advocate of 
 this method — Billroth usually has the credit for introducing 
 it, but I believe Trombetta first performed it — found that in 
 the dead human body the sciatic nerve could be elongated to 
 the extent of one inch by this method. The proceeding must 
 be accomplished resolutely and firmly, and in order to be 
 successful I would say that it should be continued for five 
 minutes, according to the rule which I have indicated in re- 
 gard to the cutting operation. Mr. Horsley, having stretched 
 the sciatic nerve on the dead body by Trorabetta's plan, 
 found that the diameter of the nerve was diminished as in 
 
NEURECTASY, OB NERVE-STRETCHING 31 
 
 the ordinary mode of stretching. In a living person, upon 
 whom I was about to stretch the sciatic nerve for an ordinary 
 obstinate sciatica, I found when that nerve was simply ex- 
 posed, that it could be very tightly stretched by the forced 
 flexion of the straightened-out lower limb upon the body. 
 There thus exists an undoubted means of stretching the 
 sciatic nerve without a cutting operation, but one would doubt 
 its complete efficacy, and the method is hardly applicable to any 
 other nerve. Nevertheless, the results of this non-cutting 
 or bloodless (unblutige) operation, as contrasted with the 
 cutting (hlutif/e) one, appear to be satisfactory, as recorded 
 by Trombetta, Lange, and Stintzing, who adds some clinical 
 cases to his experimental observations. Thus, in tabes 
 dorsalis, in which disease this bloodless operation, so far, less 
 formidable as it inflicts no wound, has been alone employed 
 at present, it has turned out successful in one instance, de- 
 cidedly beneficial in a second, partially so in a third, and still 
 less so in a fourth ; so that it has realised some good results. 
 Lastly, quite recently, I have alighted upon some observa- 
 tions made by Motschutkowski, based on what he has proved 
 to happen in the use of Sayre's suspension apparatus employed 
 in spinal curvature. It is found that thus suspended the 
 living human frame becomes lengthened by an inch to two 
 inches and a quarter, and that the trunk alone is elongated 
 by about seven-eighths of an inch. Having opened the spinal 
 canal, and then suspended the dead body by a Sayre's 
 apparatus, Motschutkowski observed that the spine itself 
 became elongated also by seven-eighths of an inch ; but he 
 mentions, in accordance with what I had noticed when the 
 curves of the vertebral column were straightened out, that, 
 although the membranes were moved, he was not quite sure 
 that there was a very slight amount of tension on the posterior 
 rootlets of the nerves. But considering the powerful mode of 
 stretching which he employed, acting throughout the entire 
 movable portion of the vertebral column, it is probable that 
 the consequent straightening of the spinal curves would produce 
 a certain amount of tension on those posterior rootlets and 
 thus act feebly on the cord. It might certainly act on the 
 spinal ganglia. Motschutkowski's patients wer^ all suffering 
 
32 NEUBECTASY, OR NERVE-STBETCHING 
 
 from tabes ; they were suspended for ten minutes at a time, 
 three times a week. He reports fifteen cases ; in thirteen of 
 these there was a positive diminution of the Hghtning pains, 
 as well as of some of the other abnormal symptoms which 
 characterise that agonising disease ; there was also slight but 
 decided improvement in the ataxic condition, and some re- 
 covery of muscular power ; in two cases there was no observ- 
 able change for the better. This method will have to be 
 further tested. (Appendix, p. 49.) 
 
 14. Conclusions. — On surveying the whole subject, I may 
 now, gentlemen, conclude my lecture by stating that the 
 operation of nerve-stretching well deserves and demands 
 further consideration ; that the facts at present known con- 
 cerning it throw some light on its probable modes of action ; 
 and that its application for the relief or cure of pain in 
 neuralgia and in tabes will probably come to be conducted on 
 different plans. If this lecture should be published, I trust to 
 be enabled to add to it an Appendix, in which some of the 
 gaps now purposely left open by me will be more or less 
 completely filled up. In the meantime, I believe that this 
 comparatively ' new ' operation will find a more prominent 
 place in British Surgery. 
 
 I desire to thank Mr. Horsley for his able assistance, Mr. 
 Thring for collecting the results of the University College 
 Hospital cases, and Mr. John Castaneda for verifying the 
 tabulated records. And now, assuming my official position as 
 President of this College, I beg leave to offer all present my 
 sincere thanks for their attendance here to-day, to express my 
 obligations to the Members, Fellows, and Council of the 
 College for the honour they have done me, and to add, with 
 regard to our visitors, that they have contributed by their 
 presence to the success of this attempt to pay a just tribute 
 to the generosity of the lady who has founded the lectureship, 
 and to keep alive the remembrance of her husband, the 
 physician in whose name it has been founded. (Appendix, 
 p. 49.) 
 
NEURECTASY, OR NERVE-STRETCHING 
 
 ■J 
 
 BEING AN 
 
 APPENDIX TO THE ' BEADSHAW LECTUEE FOE 1883. 
 
 Note. — The term ' neurectasy ' (from vevpov and eKraais) may sometimes 
 serve as a useful change from that of ' nerve-stretching,' and so I venture to 
 introduce.it here. 
 
 1 and 2. Extensibility of Nerves and Elasticity of Nerves. — 
 In reference to tliese two divisions of the subject, it may be remarked 
 that a certain degree of extensibihty and elasticity is obviously neces- 
 sary, particularly in the nerves of the limbs, in order that they may 
 not be injured during extreme movements of those parts. Espe- 
 cially is this the case in instances in which, as in the hind limbs of 
 many animals (such as crouching and leaping mammals and the 
 frog), the several segments can be doubled up very closely and 
 extended very freely. So also it may be observed that, in the 
 secondary operation of suturing divided nerves, where the ends 
 have parted company, and are also required to have a certain portion 
 removed from each before they are brought together, the nerves 
 must evidently be more or less stretched with impunity. 
 
 The safety of the nerves in the former case, and their harmless 
 elongation in the latter, are probably in part provided for by a 
 certain excess of length, and consequent longitudinal looseness or 
 freedom of the nerves and their branches ; but it has recently 
 been observed (Cantlie) that in the sciatic nerve of the frog, and in 
 many nerves in the human body, a coiled or spiral appearance in 
 their structure appears and disappears as they are relaxed or 
 stretched out. I have constantly noticed a delicate, transversely- 
 striated appearance in a loose nerve, and also a delicately wavy 
 outline, both of which disappear when the nerve is slightly stretched, 
 but I have not recognised any proper coiled or spiral disposition 
 of the constituent structures of the nerve. In any case, the 
 
34 NEUBECTASY, OB NEBVE-STBETCHING 
 
 appearances described indicate a provision for a natural and harm- 
 less extension and relaxation of the nerves in their natural beds. 
 In the more powerful and temporarily destructive 'neurectasy,' or 
 'nerve-stretching,' for the relief or cure of pain, such provisional 
 arrangements must be completely overpassed. 
 
 3. Cohesion or Strength of Nerves. — There is nothing to be 
 added in regard to this part of the subject. 
 
 4. Effects of stretching on the structure of nerves. — It has 
 only to be noted under this head, that it has now been abundantly 
 proved that the axis-cylinders of adequately stretched nerves are 
 frequently broken across ; and there is reason to believe that unless 
 these essential elements of the nerve have suffered injury sufficient 
 to suspend or even destroy their functional activity, the operation 
 will be useless, or at best only temporarily successful. In the much 
 more decided proceedings of neurotomy and neurectomy, in which 
 these axis- cylinders are, of course, divided or excised, their con- 
 tinuity, and of necessity their functions, are completely interrupted, 
 so that those operations have more decided effects than simple 
 nerve - stretching. 
 
 5. Effects of nerve- stretching on the nutrition of living nerves. — 
 As regards the changes of degeneration which the nerve-tissues 
 undergo after they have been strongly stretched or submitted to 
 other forms of injury, and again, as to the mode in which they 
 are subsequently regenerated, recent researches of numerous ob- 
 servers tend to make matters very clear. 
 
 It has been shown that, after effectual nerve- stretching, the 
 process of degeneration spreads both ways along the nerve, that is 
 both centrally and peripherally, that it corresponds to the severity 
 of the stretching, and that it does not always affect all the compo- 
 nent fibres of the nerve. It is more decided when the nerve has 
 been stretched over the surgeon's hook than from between the 
 fingers, and is then most marked near the place of application of 
 the hook, as might be anticipated. It has been further shown that 
 after division of a nerve, or after resection of a portion of a nerve, 
 both of its ends or parts show signs of degeneration, but the changes 
 occur more rapidly in the peripheral part. If the separation of the 
 cut ends be permanent, all the pre-existing nerve-fibres will ulti- 
 mately degenerate except such as may belong to anastomotic 
 In-anches proceeding from other nerves. The axis-cylinders are 
 
NEURECTASY, OR NERVE-STRETCHING 35 
 
 certainly the last parts to disappear. Scliiff, indeed, declares that 
 this part of the nerve fibres is one of the ' most resistant tissues of 
 our organism ' ; and Wolberg affirms that they do not undergo de- 
 generation, for he has found them in the sciatic nerve of a cat fifty 
 days, and in another case ninety days, after removal of a portion of 
 that nerve. But there is reason to admit that they generally do 
 undergo degeneration, if permanently cut off:* from their proper 
 nerve centre. 
 
 The union of divided and resected nerves, the regeneration of 
 their constituents, and the subsequent restoration of their functions, 
 constitute examples of living processes so striking, and not many 
 years since so unforeseen, that the records of successful cases of 
 nerve-szcture read almost like a physiological and surgical romance. 
 It is true that Dupuytren is credited with having performed this 
 operation, that it was practised by Arnemann in 1826 and by 
 Flourens in 1828, and that, in 1852, Augustus Waller pubhshed 
 an account of his then exhaustive researches on the degeneration 
 and regeneration of the nerve-tissues. But it is only within the 
 last twenty years that nerve surgery has been extensively practised, 
 and that cases of successful operations have multiplied on all hands. 
 In 1884 Weissenstein had already collected seventy-six cases, and 
 at least twenty-four must now be added to these. In this country, 
 Holmes, Wheelhouse, Birkett, Harrison, Banks, and quite lately 
 Sutton, appear in the list of recent and more or less successful 
 operators. Reverting to Weissenstein's seventy-six cases, forty- 
 three of them are examples of so-called primary nerve-suture per- 
 formed immediately after an injury, while the remaining thirty-three 
 are cases of secondary suture, in which the nerve operated upon 
 had been injured and its continuity interrupted for a shorter or 
 longer period ranging from a few weeks to fourteen years. In the 
 meantime, the numerous experiments and the improved observa- 
 tions of Schwann, Schiff, Schultze, Eanvier, Wolberg, Cattani, 
 Nieaise, Rawa, Tillmann, and Vanlair have revealed the remark- 
 able reparative power of the nerve-tissue, and have elucidated the 
 details of its mode of regeneration, on which the success of the 
 operation of nerve-suture depends. Aseptic treatment has contri- 
 buted largely to these favourable results. A brief summary of them 
 is not without interest in this Appendix. 
 
 In the first place, if the facts have been carefully observed and 
 properly interpreted, it would seem, in accordance with the views 
 of Schiff, Tillmann, and Wolberg, that the cut ends of a divided 
 
 D 2 
 
36 NEURECTASY, OB NEBVE-STBETCHING 
 
 nerve, if immediately adjusted together by means of catgut sutures, 
 mav unite directly ; for, in one case after a few hours, and in another 
 case within four days, the functions of a nerve thus circumstanced 
 are stated to have become completely restored. Usually, however, 
 the process of remiion is somewhat slower, and the restoration of 
 function, implying a regeneration of nerve-tissue, occurs gradually 
 and is still further delayed, A common sensory nerve regains its 
 powers sooner than a motor nerve, and almost without exception 
 the sensory function of a mixed nerve is restored earher than the 
 motor function. According to Eawa, who performed on animals 
 nearly a hundred experiments of various kinds, complete physio- 
 logical restoration may require from six to twenty months. In the 
 human subject, after the operation of primary suture for simple 
 division or rupture of a mixed nerve without separation of the cut 
 ends, both functions have been completely restored within a fort- 
 night, signs of sensibility in the parts supplied by the nerve 
 beginning even at the end of a week. After a secondary nerve- 
 suture, where a mixed nerve has been entangled in a cicatrix, or its 
 long- separated ends have become atrophied or indurated, so that 
 portions of it have to be removed in order to have fresh surfaces to 
 apply to each other, traces of the return of the sensory function 
 have been recognised after an interval of from two to four weeks, 
 and of the motor function in from twenty to sixty days, or this 
 latter event has been delayed for more than a year. Complete 
 restoration of motility has, however, been observed at the end of 
 twenty-six days, though it has been postponed for two years. In a 
 remarkable case in which the long-separated ends of the median 
 and ulnar nerves could not be approximated, small flaps have been 
 turned downwards from the proximal ends, and upwards from the 
 distal ends of those two nerves, and have so successfully united, 
 both anatomically and physiologically, that a considerable restora- 
 tion of their functions ensued. In the experiments of Eawa on 
 animals, it was found that nerves applied and held together side by 
 side united completely ; and hence it has been suggested that, if 
 two adjacent nerves happened to be severed at unequal heights, and 
 their ends could not be duly approximated, the long proximal end 
 of one could be sutured to the long distal end of the other, whilst 
 the short ends of each might be attached to the side of each adjacent 
 trunk ; in other words, the two nerves would be united above and 
 below the lines of severance, whilst the intermediate part would be 
 single, though composed above of one nerve and below of the other. 
 Lideed, a case is actually recorded by Gunn, in which the lower part 
 
NEUBECTASY, OB NEBVE-STBETCHING 37 
 
 of a divided ulnar nerve having been revived by an oblique section, 
 was sutured to the denuded side of the median nerve, with the 
 result of obtainmg some restoration of both sensibihty and move- 
 ment four months afterwards ; and a similar result appears to have 
 followed an operation by Depres, in which separated filaments of 
 the distal end of a divided median nerve were interwoven amongst 
 opened-out filaments of the trunk of the ulnar nerve. As is well 
 known, through Philippeaux's and Vulpian's remarkable experiments 
 on .the lingual and hypoglossal nerves, sensory and motor nerve- 
 trunks may be made to unite interchangeably, with ultimate reten- 
 tion of some proper fmiction. 
 
 In the majority of the above-quoted operations or experiments, 
 the occurrence of anatomical and physiological union is evidenced 
 by the earlier or later restoration of function ; but in certain other 
 cases, usually of an experimental kind, the anatomical condition of 
 the nerve has been ascertained by dissection and microscopic 
 examination. It is conceivable, though it has not been demon- 
 strated, and indeed would not be easily demonstrable, that in 
 instances of rapid recovery of function a direct union of axis- 
 cylinders with axis-cylinders, and of the sheaths of Schwann, takes 
 place through a thin layer of uniting plasm ; and in other some- 
 what slower cases of functional restoration, it is possible that, 
 before any marked degeneration of the peripheral part of the nerve 
 occurs, short new nerve fibres pass through the bond of miion from 
 ■the proximal to the distal part, and so re-establish its structural and 
 functional continuity. Most frequently the process is more elaborate, 
 consisting first of a cicatricial union, and secondly, of a regenera- 
 tive act. In the former stage, the epineurium and its prolongations 
 across the approximated ends of the nerve are joined by means of 
 the usual cell proliferation and formation of a corresponding con- 
 nective tissue ; and the process may end there, in which event there 
 is no restoration of fmiction. In the latter stage there occurs, 
 sooner or later, but often after much delay, a reproduction of new 
 nerve-fibres, the axis-cylinders of which are said to grow down from 
 nerve-cells in the grey substance of the corresponding nerve-centre, 
 and to descend amidst the degenerated fibres and through the 
 cicatricial bond of union, from the proximal into the distal part of 
 the nerve and its peripheral branches ; whilst they receive their 
 hyaline and medullary protective and insulating sheaths, with their 
 characteristic nodal divisions and nuclei, by a local reproductive 
 process originating, according to Holberg, in some action of the 
 nuclei and cells of the perineurium, which undoubtedly has peculiar 
 
38 NEUBECTASY, OB NEBVE-STBETCHING 
 
 morphological properties, like the deep layers of the perimysium 
 and periosteum. 
 
 To omit none of the marvels of nerve repair and reproduction, 
 it may here be mentioned that, in a dog operated upon by Vanlair, 
 nearly two inches of the sciatic nerve having been resected, the 
 proximal end was fastened by catgut to the depth of | of an inch 
 into one end of a tube of decalcified bone, whilst the other end of 
 the cylinder, which was about 2^ inches long, was turned out of the 
 course of the nerve and fixed into a neighbouring muscle ; at the 
 expiration of six months and a half, the conducting cylinder was 
 found to have been partly absorbed, whilst the nerve itself had 
 grown down in the form of numerous small branches, which passed 
 for upwards of two inches into the muscle, some even entering the 
 Haversian canals of the softened bone cylinder. In connection with 
 this endeavour to train new nerve-fibres ' which way they should 
 go,' it has been suggested that even catgut threads between the cut 
 ends of nerves which cannot be closely approximated might serve to 
 lead or train new nerve-fibres to pass from one cut end to the other. 
 It has also been proposed in operations of nerve-suture to make use 
 of any intermediate band of connective tissue which may be found 
 connecting the severed ends of a nerve ; but this idea is inconsistent 
 with the fact that such bands do not of themselves serve to train or 
 lead nerve-fibres along them. Vanlair has, moreover, shown by 
 further experiments that new nerve-fibres rather readily follow con- 
 genial anatomical and physiological paths, namely along the course 
 of other living nerves, which may thus perform the office of trunks 
 to other branches than their own. 
 
 Lastly, it may be stated that both in experiments on animals, 
 and also in operative proceedings on man, transplantation of por- 
 tions of nerve has now been occasionally, and so far as apparent 
 union is concerned, successfully performed ; but in no case has any 
 restoration of function been observed. Gluck has transferred pieces 
 of nerve from rabbits to fowls and they have apparently united in 
 place. Albert, in 1876, inserted a portion of the peroneal nerve, 
 taken from a freshly amputated human limb, between the widely 
 separated ends of the median nerve of another patient ; and Vogt 
 supplied a similar gap in the human subject by a piece of sciatic 
 nerve from a dog ; in both cases living union, as evidenced by heal- 
 ing in of the wound, seemed to occur, but without functional 
 recovery. 
 
 Keturning now from this long digression on the remarkable re- 
 generative endowment of the nervous tissues, to its bearing on the 
 
NEURECTASY, OB NERVE-STBETCHING 89 
 
 question of the ultimate consequences of nerve-stretching, — after 
 which operation the continuity of the nerve remains uninterrupted 
 and the epineurial and perineurial channels are preserved as fit paths 
 along which new nerve-fibres may be trained and developed, — it 
 is evident that one need not fear the non-occurrence of ultimate 
 repair and restoration of function, even after the most complete de- 
 generation of the proper nerve elements, the meduUated fibres with 
 their axis-cylinders. Partly from microscopic examinations, but 
 also from inference, it is believed that here also new axis-cylinders, 
 reproduced from the rterve-cells of the corresponding centre above, 
 grow down amidst the older degenerated fibres, and acquire, as they 
 descend, new tubular and medullary sheaths derived from the local 
 action of the surrounding perineurial elements. Cattani's observa- 
 tions on the sciatic nerves of rabbits stretched by the bloodless 
 method, confirm these conclusions. So powerful is the tendency to 
 reparation in a nerve simply stretched and not either torn or 
 divided, that the practical point to bear in mind is that nerve-stretch- 
 ing, in order to be capable of suspending the sensory function even 
 of the nervi nervorum for a sufficiently long period to bring about a 
 permanent cure, must be thoroughly and adequately accomplished, 
 and that it may be so without risk, if the nerve-centres are in a 
 healthy of sufficiently healthy state. 
 
 6. Effects of nerve-stretcJiing on the functions and properties of 
 a 7ierve. — Upon this part of the subject, there is but little to append 
 to what is stated in the lecture. It had, however, escaped my 
 notice that Weir Mitchell had observed that when a nerve is stretched 
 by about one-fifth of its normal length, it loses its susceptibility to 
 mechanical stimulus ; and if elongated to the extent of one-fourth, 
 surrenders its power of reacting to electrical excitation ; in both cases, 
 provided that the stretching be gradual, not sudden. Zederbaum 
 found, with regard to the effects of pressure on the motor function 
 of nerves, that when the sciatic nerve of a rabbit was loaded 
 with a pinchmg weight of 75 grammes (2| oz.), no effect was 
 produced ; a weight of 400 grammes (13^ oz.) arrested the reflex 
 excitability ; 500 grammes (17 oz.) increased the volmitary motor 
 excitability, but 900 grammes destroyed it. Smaller weights acting 
 longer had the same relative effects. Curiously enough, after 
 weighting one nerve, the reflex excitability of the nerve of the 
 opposite side appears to be mcreased, owing doubtless to some 
 centric irritation. Jendrassic noted that even severe stretching of 
 the crural nerve in a rabbit did not affect the patellar tendon reflex ; 
 
40 NEURECTASY. OB NEBVE-STBETCHING 
 
 which may, however, evidently mean that through anastomosis, 
 certain of the nerve filaments concerned may belong to other nerve- 
 trunks. Billroth has made the pertinent remark, that pressure and 
 stretching seem to act differently on nerves (at least in some cir- 
 cumstances, it may be noted) ; for whilst the effect of the latter is 
 first to diminish and then to destroy sensation, that of continued 
 pressure, as in crutch paralysis of the arm, first shows itself in loss 
 of muscular power. 
 
 7. Effects of nerve-stretching on the nerve-centres. — In regard 
 to this point, it has been shown by Godlee that by pulling on the 
 facial nerve outside the base of the skull in the dead subject, no 
 mechanical disturbance is produced in the intracranial portion situ- 
 ated beyond the petrous bone. In the same way, Horsley has noted 
 that the GrasSerian ganglion remains practically undisturbed by trac- 
 tion on the divisions of the fifth nerve, and is not obviously or injuri- 
 ously affected even by tearing out the superior maxillary division. 
 On the contrary, it is shown by Pauline Tarnowski that by violent 
 stretching of the sciatic nerve in the rabbit, the spinal cord may be 
 seriously injured : for not only does this give rise to extravasation 
 of blood beneath the pia mater, but it occasions capillary haemor- 
 rhages, and consequent traumatic irritation followed by atrophy of 
 both the posterior and anterior horns of the grey matter. It must 
 not be overlooked, that in comparison with the much longer and 
 stronger defensive structures supplied by the meningeal sheaths 
 of the spinal nerves in man, which are found to prevent all but a 
 slightly appreciable disturbance of the spinal cord, the parts are 
 much more slender and delicate in the rabbit. Nevertheless the 
 observations of Pauline Tarnowski have an obvious clinical signifi- 
 cance in reference to the employment of neurectasy in cases of 
 central spinal disease. 
 
 8. Effects of nerve-stretching as an operation for the relief or 
 cure of pain. — Since the delivery of my lecture (Nov. 1883), many 
 separate communications on this subject of nerve -stretching have 
 appeared in journals, or in the reports of the proceedings of societies, 
 in this and other countries, each contributing its share to a more 
 correct appreciation of the value of this operation in regard to its 
 palliative or curative influence in disease. Amongst them may be 
 mentioned the records of cases by Walsham, Morris, Pye, Brailey, 
 and Stokes in this country, whilst other examples too numerous to 
 be particularised have been published on the Continent and in 
 
NEUBECTASY, OB NEBVE-STBETCHING 41 
 
 America, It is not within my purpose to analyse the details of these 
 cases ; nor, indeed, to give a complete list of them, inasmuch as 
 they cover a wider clinical area than that which comprises a dis- 
 cussion of the use of tliis operation as a remedy against pain. 
 But as in my lecture, so here, I prefer to quote the tabulated results 
 of many operations. 
 
 It is right to mention that the earliest important Table was that 
 of Fengor and Lee (1881), which included 95 cases; next in suc- 
 cession came that of Chauvel (1881), containing 116 cases ; after 
 that appeared Artaud's and Gibson's (1882), with 132 cases, which 
 with 91 others added by Ceccherelli (1882), and 29 additional 
 examples, constitutes the hasis of Table IV. presented in my lecture. 
 Next to this must be mentioned Chandler's Tables (1882), including 
 264 cases ; then, the compilations of Harte, in Agnew's Surgery 
 (1884) ; and, lastly, thanks to the remarkable diligence and pains- 
 taking care of Vincenzo Omboni (March 1883), the fullest Table yet 
 compiled, comprehending the results of no fewer than 512 separate 
 operations. It is scarcely necessary to state that the later Tables 
 for the most part contain the cases tabulated in the earlier ones ; and 
 this is certainly true of Omboni's records, which. are, moreover, 
 most carefully constructed so as to give the date of each operation, 
 the name of the operator, the disease, the duration of this, the par- 
 ticular nerve or nerves stretched in each case, the results described 
 under four heads, namely, as cures, ameliorations, temporary im- 
 provements, and failures, — and, lastly, special remarks when these 
 seem to be required. Besides this, the cases are arranged in the 
 following groups : — I. Neuralgias, a, of the cranial nerves ; b, of 
 the spinal nerves, including 1, those of the trunk, 2, those of the 
 upper limb, and 3, those of the lower limb. II. Spasmodic affec- 
 tions, including 1, clonic spasms, 2, tonic spasms, and 8, simple 
 contractions. III. Epilepsy. IV. Tetanus. V. Peripheral para- 
 lysis, 1, of motion, and 2, of sensation. VI. Central diseases, 
 including 1, Myelitis, 2, Paralysis agitans, 3, Athetosis, and 4, 
 Ataxy. Lastly, two unclassed cases. 
 
 The Table of results given by Omboni is too generalised, and is 
 also somewhat confused as to certain of its totals ; so that I append 
 here a more analytical Table, prepared from his very specialised 
 records. 
 
42 
 
 NEUBECTASY, OB NEBVE-STBETCEING 
 
 Table showing the results of Neeve-stketching in 512 cases, 
 FOUNDED ON OvibonV s data. 
 
 Neuralgias 
 
 Cranial nerves .... 
 
 Trunk nerves .... 
 
 XJ^Dper limb 
 
 Lower limb 
 
 Spasmodic affections . . 
 
 Clonic spasms . . . 
 
 Tonic spasms .... 
 
 Contractions (permanent) 
 
 Epilepsy 
 
 Tetanus 
 
 Paralyses (peripheral) . . 
 
 Motor 
 
 Sensory 
 
 Central diseases .... 
 
 Myelitis 
 
 Paralysis agitans . . . 
 
 Athetosis 
 
 Ataxy 
 
 Unclassed skin diseases . . 
 
 Totals (addition of thicker i 
 figures) i 
 
 Cases 
 
 222 
 
 62 
 6 
 
 37 
 117 
 
 41 
 
 25 
 
 13 
 3 
 7 
 
 51 
 
 40 
 6 
 
 34 
 149 
 
 44 
 4 
 2 
 
 99 
 2 
 
 Cures 
 
 Improvements 
 
 perma- tempo- 
 nent rary 
 
 143 
 
 31 
 
 4 
 
 23 
 
 85 
 
 21 
 
 11 
 
 8 
 
 2 
 
 2 
 
 10 
 
 2 
 
 2 
 
 5 
 
 1 
 1 
 
 1 
 
 37 
 
 11 
 
 9 
 17 
 5 
 4 
 1 
 
 36 
 
 2 
 34 
 49 
 11 
 1 
 1 
 36 
 
 512 185 
 
 129 
 
 25 
 
 13 
 1 
 
 4 
 7 
 11 
 9 
 2 
 
 2 
 11 
 
 51 
 
 9 
 
 42 
 
 Failures 
 
 17 
 7 
 1 
 1 
 8 
 4 
 1 
 2 
 1 
 1 
 
 30 
 2 
 2 
 
 44 
 
 23 
 
 2 
 
 19 
 
 100 
 
 98 
 
 from 
 
 the 
 
 disease 
 
 41 
 
 from 
 the ope- 
 ration 
 
 10 
 
 3 
 
 12 
 
 On comparing this with previously published Tables, and making 
 every allowance for errors of statement and premature claims as to 
 the cure or permanent relief of pain, it is certain, first, that nerve- 
 stretching has established itself as an operation capable of both a 
 curative and a palliative action in a large majority of cases of 
 neuralgia ; and it must be admitted that a return of the disease 
 after an interval of a certain duration, say of one year, ought some- 
 times to be regarded as an entirely fresh attack. It is equally 
 certain that this operation has afforded relief in a large proportion 
 of spasmodic diseases, such as facial tic especially, though here the 
 proportion of undoubted relapse of the malady is greater than in 
 the neuralgias. As to epilepsy, the operation is probably useless. 
 In regard to tetanus, it would seem that with an increased number 
 of cases fewer actual cures are recorded, after nerve-stretching, than 
 in the older Tables, a discrepancy not easily explained but casting 
 doubt on those records ; indeed, it is difficult in the present state 
 of pathological science to understand a beneficial modus operandi 
 
NEVBECTASY, OR NEBVE-STBETCHING 43 
 
 of nerve- stretching in cases of confirmed tetanus. Passing over the 
 peripheral paralyses, which here consist simply of cases of lepra 
 anfesthetica, we arrive at the results of nerve-stretching in cases of 
 diseases afi"ecting the nerve-centres. Here the results are palpably 
 unhappy or, it may be said, disastrous ; the few tabulated cures 
 (about two per cent, in myelitis and ataxy taken together) may be 
 regarded as apocryphal ; the instances of amelioration, it is to be 
 feared, are more imposing numerically than actually, most of them 
 being admitted to be only temporary ; the failures are pronounced, 
 and the deaths attributable to the operation are numerous. 
 
 In a prize Thesis, presented to the Medico-Chirurgical Faculty at 
 Eome in 1884, and published under its authority 1885, the author, 
 Vincenzo Morini, in making use of Omboni's materials, deducts 
 twelve cases, in which resection of a part of a nerve was had re- 
 course to after stretching ; and he then incorporates 26 new cases, 
 16 of which were operated on by Italian surgeons, 3 occurred in 
 Germany, and 7 in France. To these there might here be added 
 a few others from Germany, several from America, and those which 
 have been performed in this Country since Omboni's Table was com- 
 pleted. Of Morini's additional cases 17 were neuralgic, and of them 
 9 were cured, 6 were relieved, and 2 died of consecutive phlegmon- 
 ous inflammation ; but the other cases of tetanus, myelitis, and 
 ataxy were mostly failures. 
 
 As regards facial spasm (tic douloureux) Professor Zezas of 
 Vienna, 1885, has collected, tabulated, and commented on 19 cases 
 operated on by various surgeons, including himself ; and these same 
 cases have since been arranged together with others in a new Table 
 by Professor William Keen, of Philadelphia (1886), who again has 
 added 2 cases, one being his own patient. Certain of these 21 cases 
 also appear in a Table published by Godlee (1883), and even in 
 Omboni's catalogue. Professor Keen, in a note, criticises the list, 
 and remarks that the case imputed to ' Germ on " has no existence ; 
 that Chandler's Tables are inaccurate ; that, in four cases in Harte's 
 Tables mistakes have been made between the facial and the inferior 
 dental nerves ; and lastly, that in 4 of the 21 cases in his own Tables 
 neurotomy, or even neurectomy, had been performed previously to 
 neurectasy. He concludes that absolute relief for long periods 
 (cure) was obtained in five cases ; absolute relief for short periods 
 (palliation) in 14 cases, followed by improvement in 8 cases and 
 no improvement in 6 ; the remaining 2 cases, including his own, 
 he declines to classify. His summary is somewhat more favourable 
 than that of Professor Zezas. But it is indisputable that nerve- 
 
44 NEURECTASY, OB NEBVE-STBETCHING 
 
 stretching is much less useful in painful spasmodic disease than in 
 pure peripheral neuralgias. 
 
 My own experiences since 1883, unfortunately for myself limited 
 in number owing to my resignation of active hospital work, enable 
 me to confirm the benefits, not only temporary but persistent, of 
 nerve-stretchmg in cases of pure sciatica or other neuralgias due to 
 obstinate chronic local neuritis. Such cases are invariably relieved 
 or cured more or less permanently in proportion to the thoroughness 
 of the stretching process employed. There frequently occurs a 
 painful stage, subsequently to the immediate paresis, but this sub- 
 sides and disappears. Moreover, I find the direct cutting operation, 
 with its attendant abstraction of blood, more serviceable than the 
 bloodless one. When the operation has failed in any degree, this 
 has been owing to the nerve having been too briefly or insufficiently 
 stretched. I have had but one experience of the bloodless operation, 
 and that not a very satisfactory one. As to the suspending method 
 of treating the lightning pains of tabes, I have had but one case, 
 which, though somewhat promising at first, ultimately ended in 
 disappointment. ., 
 
 9. Bationale of the effects of nerve -sir etching for the relief or 
 cure of vain. — It is gratifying to me to be able here to record that 
 within a few weeks of the delivery of my lecture, Mr., now Professor 
 Horsley demonstrated the presence, in the trunks of the mixed 
 nerves of the body, of those nervi nervorum, the existence of 
 which therein I had ventured to predict. Early in 1884 he showed 
 at a meeting of the Eoyal Medical and Chirurgical Society, some 
 microscopic preparations exhibiting not only the fine non-medullated, 
 doubtless vasimotor fibres previously described by Sappey and 
 mentioned after him by Krause, but also certain medullated, doubt- 
 less sensory fibres running in the epineurium, and terminating in 
 the tactile corpuscles or end-bulbs of Krause, or in small but perfect 
 Pacinian bodies. 
 
 In the discussion on Professor Horsley 's communication, some 
 doubts were expressed as to the interpretation put upon the ap- 
 pearances in the specimens shown. But I am now indebted to him 
 for five drawmgs from preparations recently made expressly for this 
 Appendix. These drawings I have had engraved, as seen in Figs. 8 
 to 12, which are accompanied by Professor Horsley's own descrip- 
 tions. It will be seen from them that he has proved beyond doubt 
 the existence of sensory nervi nervorum ; so that the conjecture 
 I offered in my lecture as to the existence of such nerves, and their 
 
NEUBECTA8Y, OR NERVE-STRETCHING. 
 
 45 
 
 Fig. 8. — Longitudinal section 
 of human nerve stained 
 with osmic acid, mounted 
 in Canada balsam, and 
 magnified about 40 dia- 
 meters. {Hoi-sley.) 
 
 It sliowis a ■branching nervus 
 vasis, or vasimotor nerve, impro- 
 perly described by Sappey and 
 Krause as a nevvus nervi, accom- 
 panying a small bloodvessel ; ep, 
 epineurium, or sheath of connec- 
 tive tissue ; pb, primitive bundle 
 of nerve-fibres ; /, lobule of fat, 
 the corpuscles stained b'ack by 
 the osmic acid ; v, bloodvessel 
 containing blood corpuscles ; nv, 
 the nervus vasis. 
 
 L-it LLsJ 
 
 Fig. 9. — Longitudinal sec- 
 tion of human nerve 
 stained with osmic acid 
 and magnified about 40 
 diameters. (Horsley.) 
 
 It shows two true ne7-vi 
 nervorum arising from a 
 branch of a primitive bundle 
 and running onward in the 
 epineurium, to terminate 
 doubtless as in Figs. 10 and 
 11. After leaving the bundle 
 they exhibit a twist in their 
 course. Compare the size of 
 these true nervi nervorum with 
 that of the nervus vasis in 
 fig. 8. ep, epineurium ; pf and 
 pb, primitive bundle ; spb, 
 V small branch of primitive 
 bundle ; nn, nervi nervor-um ; 
 V, a bloodvessel. 
 
4G 
 
 NEUBECTASY, OB NEBVE-STBETCHING 
 
 ^■l^7;«Wi 
 
 Fig. 10. — Longitudinal section of human median nerve stained in osmic 
 acid, and magnified about 60 diameters. {Horsley.') 
 
 It shows a tactile corpuscle, or sensory nerve-ending, imbedded in the epineurium 
 covering a primitive bundle and lying between bloodvessels. A nervus nervi is 
 seen coursing onwards in the customary spiral manner, and entering the core of 
 the corpuscle, within which the axis cylinder can just be distinguished. The cap- 
 sule of the corpuscle is nucleated, e, epineurium ; /, fat lobule stained with osmic 
 acid ; v, bloodvessel containing altered blood ; nf, nerriis nervi ; ca, capsule of the 
 sensory nerve-ending or tactile corpuscle ; co, core of the same. 
 
 s-ca 
 
 Fig. 11. — Longitudinal 
 section of human nerve, 
 stained in osmic acid and 
 magnified about 250 dia- 
 meters. (Horsley.) 
 
 It shows a sensory nerve- 
 ending or tactile coi'puscle, 
 lying in the epineurium and 
 upon the perineurium. The 
 entering axis cylinder can be 
 easily traced onwards to the 
 end of the core ; but at the 
 tip of the core its bondings 
 are a little too distinctly 
 marked in the woodcut, e, 
 epineurium ; p, perineurium ; 
 6, primitive bundle, stained 
 very dark ; nf, nervus nervi ; 
 ca, capsule of the tactile cor- 
 puscle ; CO, core of the same ; 
 ac, axis cylinder of the nerve- 
 fibre entering the corpuscle. 
 
NEURECTASY, OB NERVE-STRETCHING 47 
 
 /^ 
 
 
 I iii< 
 
 'i'l' 
 
 w 
 
 ^^: 
 
 mmmff 
 
 ac 
 
 CO 
 
 Fig. 12. — Pacinian corpuscle from the epineurium of the human ulnar 
 
 nerve, just above the elbow. Osmic acid preparation. Magnified about 
 
 35 diameters. {Horsley.^ 
 
 Two nervi nervorum are seen entering it. e, epineurium laminated ; c, capsule 
 of the corpuscle ; co, central core of the same ; ac, axis-cylinder prolongation of one 
 nerve-fibre, nf. 
 
 Note. — Owing to the very considerable spiral turn of the fibres at the base of the 
 corpuscle there appears to be a separation of the nerve-fibre from the central core. 
 This, of course, is merely optical. 
 
 relation to certain neuralgic pains, may now be regarded as having 
 been completely verified. 
 
 10. Indications for the performance of the operation of nerve- 
 stretching. — I have nothing to add to this section of the lecture, 
 which was illustrated by actual specimens of disease. 
 
 11. Mode of performing the operation of nerve-stretching .—In 
 Hildebrandt's monograph, already referred to, instructions for the 
 exposure of the several nerves likely to require to be thus operated 
 on are given at length, with illustrations ; but to a surgeon who is 
 also an anatomist, such lessons are superfluous. 
 
 Professor Keen approves of the use of the hooks with which to 
 make traction, and in operations on small nerves (it was the 
 
48 NEURECTASY, OB NERVE-STRETCHING 
 
 facial nerve for painful spasm in his case), this is good advice. 
 Even in dealing with so large a nerve as the sciatic, a sufficiently 
 large hook may offer advantages in preventing slipping of the nerve. 
 As to the amount of force to be used, it is generally held that the 
 stretching should be severe, though short of rupturing ; and it has 
 been observed that the body may be lifted up by the sciatic, and the 
 head by the facial nerve ; so that probably the directions given in 
 my lecture may be on the side of leniency. Even rupture of a 
 nerve, as we shall presently see, is not always to be regretted. One 
 operator msists that the traction should be continued or repeated 
 once or oftener until the stretched nerve lies loose and tortuous 
 in its bed when it is let go. I now believe that I have myself failed 
 to cure at once a case of sciatica owing to not having used sufficient 
 force. 
 
 Every one now agrees that in all cases the pulling should take 
 place m both directions, that is, from the central part, and from the 
 peripheral part of the nerve. It is alleged as an argument for this that 
 the former numbs sensibility,- and the latter suspends both that and 
 motility as well ; and hence the latter is most important in stretching 
 a motor nerve Hke the facial for painful tic. But a better reason is 
 probably this, that it ensures a greater and more extended local effect 
 on the nerve implicated, and thus increases the prospects of a lasting 
 benefit ; for experimental observation and chnical experience combine 
 to show that slight and imperfect stretching is 'useless for the per- 
 manent cure or even the durable relief of pain, and particularly of 
 painful spasm. Thus, it is fomad experimentally that motility is the 
 last property to be lost by stretching, although it is also usually very 
 slow to return ; and, as regards clinical experience, it is certain that 
 both in neuralgia and in tic douloureux, the more perfect and the 
 more lasting the paresis or the paralysis, the better the chances of 
 permanent improvement or absolute cure. It would almost seem 
 as if in a given case a facial spasm should disappear after neurectasy 
 without intervening paralysis, then the operation could not of itself 
 have been instrumental m the cure. Even should a pennanent 
 paralysis ensue, miless in the case of an entire limb, or of an impor- 
 tant portion of one, it would be preferable to continued suffering ; 
 and this is especially true as regards the face, in which a partial 
 paralysis and paresis are quite endurable conditions. 
 
 12. Dangers of the operation of nerve-stretching . — Three in- 
 stances of rupture of a nerve are mentioned amongst Omboni's 512 
 cases, namely, of the spinal accessory, the ulnar, and the great sciatic. 
 
NEURECTASY, 02i NERVE-STRETCHING 49 
 
 In view of the remarkable successes of nerve-suture in modern 
 surgery, already mentioned in this Appendix, an accident of this 
 kind would be promptly met, and need not excite apprehension ; 
 it would doubtless act as a retarding influence towards recovery of 
 sensation and motion, and thus probably, after what has just now 
 been stated, it might prove beneficial in certain cases, as a means 
 of suspending nerve action for a longer time, and so favouring a 
 permanent relief "or cure. It may be remarked that rupture of the 
 sciatic nerve has recently occurred during the operation of resection 
 of the hip joint ; but primary nerve-suture was instantly resorted 
 to with complete ultimate success. In regard to smaller nerves, 
 for example, the superior maxillary, these have been purposely torn 
 out by what is termed avulsion, a process recommended in very 
 aggravated cases with the view of making the operation (for facial 
 neuralgia) more effectual, a purpose I understand from Professor 
 Horsley which has been fully attained by him in two recent cases of 
 resection of the superior maxillary nerve. 
 
 The additional number of deaths recorded in Omboni's Tables, 
 which include all those in the older Tables, leave the proportion of 
 deaths from the operation and their significance practically the 
 same as at the date of my lecture. 
 
 13. Non-cutting or bloodless operations for nerve-stretcJiing .—~ 
 The effects of nerve-stretching by the bloodless method of Trom^ 
 betta have been studied by Cattani on the sciatic nerves of rabbits. 
 He found that these effects, which have already been referred to 
 (p. 39), were more widely extended along the nerve than in 
 stretching it by a force locally applied, especially reaching far into 
 the peripheral branches ; he also found that there was less^ damage 
 to the bloodvessels of the nerve, less inflammatory action, and less 
 subsequent development of connective-tissue elements. In his 
 opinion, it is therefore a milder operation, and better adapted to use 
 in peripheral disease. 
 
 With regard to Motschutkowski's plan of endeavouring to act 
 on the spinal cord and its nerves by suspending tabetic patients, 
 described in my lecture, I am constrained to say that it has entirely 
 disappointed my expectations founded on his statements. 
 
 14. Conclusions. — The practice of neurectasy or nerve-stretching 
 has developed so rapidly since 1880 that, instead of hesitating 
 opinions and tentative conclusions, one may now express a matured 
 judgment as to its value, its worthlessness, or its interdiction in 
 particular forms of nervous disease. Properly to estimate these, 
 
 E 
 
50 NEUBECTASY, OB NEBVE-STBETCHING 
 
 however, it is now essential to compare it with two other nerve 
 operations, which have also attracted much attention recently, 
 viz- neurotomy, or simple division of a nerve, and neurectomy , or 
 resection, or exsection of a portion of a nerve. 
 
 As regards its severity, and its therapeutical results, nerve- 
 stretching may, speaking generally, be said to occupy an intermediate 
 position between neurotomy and neurectomy, being more complicated 
 in its effects on a nerve, and more efficacious as a means of treatment 
 than the former, but less decided and less radical than the latter. 
 This general statement justifies the opinion that, as a rule, nerve- 
 stretching should be tried in a given case, if possible, before neur- 
 ectomy ; it nevertheless demands some further qualifications. 
 
 Simple division of a small nerve, say a cranial nerve, owing to 
 its absolutely local effect, and to the rapidity with wdiich the divided 
 nerve wall reunite, has but a slight effect on the disordered condi- 
 tion of the nerve, and but a transitory effect in abolishing its proper 
 function ; hence restoration takes place so quickly that such dis- 
 ordered condition is naturally very soon re-established. Simple 
 division of a large nerve, say a nerve of the upper or lower limb, 
 has too serious an effect in consequence of the extensive paresis and 
 paralysis thereby induced. On the other hand, nerve-stretching is 
 specially available for larger nerves, like those of the limbs, because 
 sufficient force can be safely applied to them, and the effect can be 
 made to extend over a considerable distance ; whereas, though 
 frequently successful as applied to small nerves, inasmuch as they 
 are easily stretched, it has often failed in aggravated disease affect- 
 ing the smaller nerves of the head and face, probably because the 
 stretching did not extend sufficiently far in a central direction. In 
 the third place, resection of a portion of the trunk of a nerve is a 
 much more certain remedial operation in the case of small-sized 
 nerves of limited distribution, like those of the head and face. 
 Moreover, this may sometimes be a simpler substitute for several 
 simultaneous or successive operations on separate branches, which 
 in the face would be highly objectionable ; whereas the permanent 
 loss of sensibility over a certain facial area which it entails is not 
 of serious moment, nor indeed is a permanent motor paralysis, in 
 comparison with the gain of freedom from the tortures of tic 
 douloureux. But such a resection is wholly inadmissible as regards 
 the larger nerves of the limbs, whose area of distribution is so wide 
 and important, considered in relation to the prehensile and locomo- 
 tive functions. 
 
 All this is abundantly illustrated by the clinical results of neur- 
 
NEURECTASY, OR NERVE-STRETCHING 
 
 51 
 
 ectomy operations, a list of wliicli for facial neuralgia, consisting of 
 83 cases, has recently been published (188Gj by G. R. Fowler of 
 Brooklyn. To this paper I must refer for a careful critical examina- 
 tion of the history, progress, and results of the operation of neurec- 
 tomy, which is, of course, strictly speaking, beyond the limits of my 
 own subject. One can only observe here that, whilst the statistics of 
 Otto Weber, comprising 100 cases, reproduced by Hildebrandt, and 
 those of Wagner, comprising 135 cases, seem to show a very 
 small proportion of lasting cures, the painstaking analysis presented 
 by Fowler of his own Table establishes the fact that out of 26 cases 
 of operation on the superior maxillary nerve, in which Meckel's 
 ganglion was either removed or destroyed, and out of 26 other cases 
 in which merely a portion of the nerve was resected, the following 
 were the periods of relief obtained in each set. 
 
 Number of cases of 
 
 Ganglion removed 
 ,, not removed 
 
 26 
 26 
 
 Totals 
 
 52 
 
 Duration of p 
 — to i i to 1 
 
 eriod of relief iu years, 
 1 to 2 2 to 3 1 3 years 
 
 5 
 
 4 
 
 3 
 
 7 
 
 9 
 
 7 
 
 6 
 3 
 
 3 
 5 
 
 9 
 
 10 
 
 16 
 
 9 
 
 8 
 
 If the results as above stated do not justify the assertion of 
 Carnochan that the removal of the ganglion is the ' key of the 
 position,' they certainly show that the more of the nerve is removed, 
 and the nearer to the foramen rotundum, the better. It may also 
 be suggested that after a neurectomy in which any length of the 
 proximal part of the nerve operated on is left behind, this ought also 
 to be effectually stretched so as to accelerate or complete its de- 
 generation. Sometimes, indeed, nerve-stretching has succeeded, 
 after neurotomy and even neurectomy has failed. 
 
 In conclusion, the sum of opinion as to the special applications 
 of neurectasy or nerve-stretching may be thus stated. 
 
 It is not only useless but it is dangerous, and should be pro- 
 hibited, in all cases of serious central disease, such as confirmed 
 ataxy, myelitis, fully established tetanus, pure epilepsy, and 
 paralysis agitans. 
 
 In reflex forms of epilepsy, in an ascending neuritis bringing 
 about epileptiform seizures, in the early stages of a distinctly trau- 
 matic tetanus, provided that in any of these cases the peripheral 
 cause of irritation can be clearly localised and the affected nerve or 
 nerves be accurately defined, nerve-stretching may be serviceable, 
 if employed soon enough. So, if in ataxy it would appear that 
 
52 NEUBECTASY, OB NEBVE-STBETCHING 
 
 some special peripheral disturbance of sensation or motion lias 
 arisen consecutively to the central disease, it might possibly ame- 
 liorate such local suffering ; but for the genuine locomotor ataxy 
 due to tabetic sclerosis, nerve-Stretching, as just stated, stands con- 
 demned, although it is unnecessary to express this in the unrestrained 
 language of certain, continental Society discussions, now no longer 
 noticeable ; nor would one exempt from this adverse opinion the 
 milder operation of bloodless stretching of the sciatic nerve or 
 nerves in cases of confirmed ataxy. 
 
 As to the hope or suggestion that the excitation of a nerve, 
 which, through vasimotor action and nutritive or trophic changes, 
 follows a slight amount of stretching, might bring about improve- 
 ment as regards pain, hyperassthesia, anaesthesia, or paresis on the 
 one hand, or clonic spasms, feebleness, or paralysis on the other, 
 it seems to rest on but little favourable clinical experience. Such 
 states, being recoverable, are cured more readily by lapse of time, 
 by the use of soothing or stimulating remedies, and by the aid of 
 electricity or massage. 
 
 If, then, neurectasy is to be abandoned in confirmed central 
 diseases, is possibly beneficial in reflex afl'ections, and is certainly 
 so in peripheral disturbances of sensibility and motility, it must be 
 admitted that it appears to be less successful in spasmodic than in 
 sensory or purely neuralgic peripheral disorders. 
 
 In applying this surgical remedy to either of the two last-named 
 classes of nerve disease, whether rheumatic, gouty, or traumatic, it 
 is of course only admissible in aggravated and obstinate cases after 
 other remedies have failed, and after any discoverable or reasonably 
 conjectured local cause has been removed. This last rule is well 
 illustrated by the recoveries which have followed the puncture of 
 cystic growths (Fayrer), the excision of neuromas, cicatricial indur- 
 ations, submucous nodules, periosteal or sub-periosteal fibromas, 
 and bony intra- alveolar growths, the exsection of portions of the 
 jaws, and the removal of a piece of the cranium by trephining 
 (Durham). As to the previous employment of remedies, it must 
 always be remembered that these, whether internal or external, are 
 constantly being added to by modern therapeutical industry, and 
 that more may be expected in the future in this particular field for 
 the display of ingenuity. Quite recently, for example, osmic acid 
 local injections, the internal administration of salol, freezing the 
 nerve, prolonged and repeated percussion (Neale), and some special 
 form or mode of applying galvanism or electricity (Steavenson), 
 have been suggested or highly extolled. 
 
NEURECTASY, OB NEBVE-STIiETCHING 53 
 
 These and all other remedies failing, an adequately carried-out 
 nerve- stretching will certainly give temporary relief, and in propor- 
 tion to its thoroughness prolonged relief or cure. In the case of the 
 sciatic nerve, it may be preceded by a bloodless stretching. In that 
 of any other nerve, the cutting operation should be at once employed 
 as close to the nerve-centre as possible ; and should it fail, the 
 only further measure is to perform neurectomy, and then stretch 
 efficiently or even avulse the proximal nerve-stump, which will 
 probably effectually relieve the patient from suffering, though at 
 the cost of some local paresis or paralysis. 
 
LIST OF EEFERENCES. 
 
 Those who wish to pursue this subject will find special references to nearly all 
 of the authorities mentioned in the Lecture in Ceccherelli's article, contained 
 in the 'Eivista Sintetica ' of the journal ' Lo Sperimentale,' Anno XXXVI., 
 T. 1, Settembre 1882 (Firenze). The writers otherwise quoted from are : 
 Stintzing, 'Ueber Nervendehnung,' 1883 (Leipzig), which contains a useful 
 bibliography; Nocht, 'Ueber die Erfolge der Nervendehnung,' 1882 (Berlin), 
 which is likewise full of references ; Vincenzo Omboni, ' Uno Sguardo alio 
 Stiramento dei Nervi etc.,' ' Ann. Univer. di Med. e Chirurg.,' Parte Originale, 
 MarzD, 1883 (Milano), which contains a copious list of authorities down to date ; 
 Hildebrandt, 'Nervendehnung,' &c., 1884 (Berlin), who gives many references 
 on the subject of Nerve-Suture, quoting Wolberg, Falkenheim, and others ; 
 Vincenzo Moriui, ' SuUo Stiramento dei Nervi a Scope Terapeutico : Tesi di 
 Laurea ' (1884), ' Gazzetta Medica di Eoma ' — also published separately, Eoma, 
 1885 — in which many Italian cases are particularised ; Browning, ' Eecent 
 Contributions to the Surgery of the Nerves,' ' Annals of Surgery,' February 
 1885 (St. Louis and London), which comprehends a notice of the operations of 
 primary and secondary nerve-suture, with references to Weissenstein, Eawa, 
 Wolberg, Tillaux, and other observers, mentioned in my Appendix ; Fowler, 
 ' The Operative Treatment of Facial Neuralgia,' see ' Annals of Surgery,' April 
 1886, in which article references are made to eighty-three cases, treated either 
 by nerve-stretching or by neurectomy, or by both methods ; and, lastly, Kean, 
 ' Stretching of the Facial Nerve, &c.,' ' Annals of Surgery,' July 1886, where 
 exact references to all the cases collected by Professor Zezas are given, in- 
 cluding the cases treated by Godlee, Southam, and others. See also the long 
 and important discussions on this subject in the ' Berlin, klin. Wochenschr.,' 
 1882-3. 
 
 Amongst important papers are, Horsley, ' Proceedings Eoy. Med. and Chir. 
 Society,' January, 1884; Cantlie, 'Bristol Med. Chir. Journal,' 1884; Cattani, 
 ' Notice in London Med. Eecord,' 1885, p. 99 ; Vanlair, ' Archives de Physiol.,' 
 1885 and 1886 ; Zederbaum, ' Centralblatt fiir klin. Med.' 1883 ; PauUne 
 Tarnowski, ' Archives de Nevrologie,' 1885 ; Lesser, ' Deutsche med. Wochen- 
 schrift,' 1814; Lorenzo, 'Notice in Lond. Med. Eecord,' 1885, p. 172; Fayrer, 
 ' Practitioner.' 1886 ; Durham, a case of Trephining, ' Lancet,' 1884 ; Steaven- 
 son, ' On Galvanism for Sciatica,' ' Lancet,' 1886 ; Southam, ' Lancet,' 1886 ; 
 Brailey, 'Brit. Med. Journal,' 1885; Walsham's cases, 'Proceedings Eoy. Med. 
 Chir. Society,' 1884. Consult also excerpts in ' Lond. Med. Eecord,' Neale's 
 valuable ' Digest,' and, of course, the usual French, Italian, and German 
 periodicals. 
 
 SpoUiswoode & Co. I'rinlei's, Seu'-slivc-l tiqiiiii-c, Lomion. 
 
WORKS BY PEOFESSOR MARSHALL. 
 
 ANATOMY for ARTISTS. By John Maeshall, P.K.S., 
 
 i'.R.CS., Professor of Anatomy, Royal Academy of Arts ; late Lecturer oa 
 Anatomy at the Government Si;hool of Design, South Kensington ; Professor of 
 Sufgery in University College, London; Senior Surgeon to the University 
 College Hospital, &c. (Sfc. Illustrated with 220 Original Drawings on Wood 
 by J. S. Cuthbert, engraved by George JSIicholls & Co. Second J^Alition. 
 Imperial 8vo. £1. lis. U. 
 
 A RULE of PROPORTION for the HUM A:N" FIGURE. 
 
 Illustrated by John S. Cuthbebt. Folio, price 8s. in Wrapper; or in port- 
 folio, price 9s. 
 
 A DESCRIPTION of the HUMAN BODY: its Structure 
 
 and Functions. Illustrated by reduced copies of the Author's 'Physiological 
 Diagrams,' to which series this is a companion work. Designed for the use of 
 Teachers in Schools and young men destined for the Medical Profession, and 
 for popular instruction generally. 
 
 The work contains 260 quarto pages of Text, bound in cloth, and 240 
 Coloured Illustrations, arranged in 11 folio Plates, measuring 15 inches by 
 7^, in a limp cover. Fourth Edition, Revised, 4to. with Folio Atlas, 2 Is. 
 
 The HUNTERIAN ORATION delivered at the Eoyal College 
 
 of Surgeons of England, 14th February, 1885. By John Marsha.ll, F.R.C.S., 
 F.R.S., LL.D., Past President of the College, &c. &e. Published at the request 
 of the President and Council of the College. 8vo. 3s. 6d. 
 
 Prepared for the Department of Seienee and Art. 
 PHYSIOLOGICAL DIAGRAMS. An entirely New Edition, 
 
 Extended and Revised by the Author. Eleven Diagrams, life-size, each ou 
 paper 7 feet by 3 feet 9 inches, coloured in facsimile of the originals. Price 
 12s. 6d. each sheet; or selected proofs, more highly coloured, mounted on 
 canvas, with rollers, and varnished, price £l. Is. each. Explanatory Kejj, 
 price Is. 
 
 In the New Edition each subject has been re-drawn on the zinc, and 
 under the supervision of the Author important additions have been made to 
 the Series, so as to render it as complete as possible, and consistent with the 
 present state of Science. 
 
 A SERIES of LIFE-SIZE ANATOMICAL DIA- 
 
 GRAMS. Specially adapted for Schools of Art and Art Students. Seven 
 Diagrams, life-size, on paper 7 feet by 3 feet 9 inches. Each sheet sold 
 separately, price 12s. Qd., coloured in lacsimile of the original drawings; or 
 £\. Is. each, selected proofs, mounted on canvas, with rollers, and varnished. 
 Explanatory Key, price Is. 
 
 To Teachers and Students of Artistic Anatomy this Series of Diagrams will 
 be invaluable. Suspended on the walls of the lecture room or studio, they 
 will not fail to secure, through the medium of the eye, that familiar acquaint- 
 ance with the principal points in the osseous and muscular system so indispens- 
 able, to the Art Student. 
 
 *^^* A Detailed List of the Diagrams will he sent post-free on application. 
 
 London: SMITH, ELDEE, & CO., 15 Waterloo Place. 
 
SMITH, ELDER, & CO.'S PUBLICATIONS. 
 
 Seconfl Erlition, Ee-written, with many New Illustrations, 8vo. 18>t. 
 
 The FUlTOriONS of the BRAIN". By David Feerier, 
 
 M.D., LL.D., F.R.S., Professor of Forensic Medicine, King's College ; Physician 
 to King's College Hospital ; Physician to the National Hospital for the 
 Paralysed and Epileptic. 
 *^* This, though termed a Second Edition, is essentially a new book, having been 
 almost entirely re-written, and embracing the results of new investigations by the 
 author, as well as a critical survey of the more important physiological and patho- 
 logical researches on the functions of the brain that have been published within the 
 latt ten years. The number of illustrations has been doubled, and the chapters 
 devored to the structures of the nerve centres and the functions of the spinal cord 
 have been much enlarged, so that the work forms a complete treatise on the central 
 nervous system. 
 
 ' This work is one of the most imoortant contributions to medical literature which havfi beeu 
 presenteilto the profession and the cultivated public durin^r the present year. ... It i.s the productinn 
 of one who has spent his life in endeavouring, after the true scientific method, to solve the compli- 
 cated problems involved, and who has proved him-elf to be a masterhand, both at practical 
 experimentatiou and sound logical induction.' — BurTiSH MedicaI/ Journal. 
 
 ' No scientific medical man's librar}' can be said to be comolete without Dr. Perrier's book, which 
 contains the records of the author's own work, as well as those of other observers of repu^e.' 
 
 The Lancet. 
 With numerous Illustrations, 8vo. 7s. f>d. 
 
 The LOCALISATION of CEREBRAL DISEASE. By 
 
 David Ferrier, M.D., F.R.S., Assistant-Physician to King's College Hospital ; 
 Professor of Forensic Medicine, King's College. 
 
 Crown Bvo. 4s. 6d. 
 
 On the CONVOLUTIONS of the HUMAN BRAIN. 
 
 By Dr. Alexander Ecker, Professor of Anatomy and Comparative Anatomy 
 in the University of Freiburg, Baden. Translated, by permission of the 
 Author, by John C. Gtalton, M.A. Oxon., M.R.C.S., F.L.S. 
 
 Demy Bvo. 12s. 
 
 DISEASES of the NERVOUS SYSTEM, their Prevalence 
 
 and Pathology. By JuLitrs Althaus, M.D., M.K.C.P. Lond. ; Senior Physician 
 to the Hospital for Epilepsy and Paralysis, Eegent's Park ; Fellow of the Eoyal 
 Medical and Chirurgi-eal Society. Statistical Society, and the Medical Society of 
 London ; Member of the Clinical Society ; Corresponding Member of the 
 Sociere d'Hydrologie Medicale de Paris; of the Electro-Therapeutical Society 
 of New York, &c. &c. 
 
 With Illustrations. 8vo. 12s. 6d. 
 
 The PATHOLOaiCAL ANATOMY of the NERVOUS 
 
 CENTRES. By Edward Long Fox, M.D , F.R.C.P., Physician to the Bristol 
 Royal infirmary ; late Lecturer on the Principles and Practice of Medicine and 
 of Pathological Anatomy at the Bristol Medical School. 
 
 With Illustrations. 8vo. 15s. 
 
 The INFLUENCE of the SYMPATHETIC on 
 
 DISEA.se. By Edward Long Fox, M.D., F.R.C.P.. Consulting Physician t . 
 the Bristol Royal Infirmary; late Lecturer on the Principles and Practice of 
 Medicine and on Pathological Anatomy at the Bristol Medical School. 
 
 Crown 8vo. 12s. 6d. 
 MANUAL of LUNACY: a Handbook relating to the Legal 
 
 Care and Treatment of the Insane in the Public and Private Asylums of Great 
 Britain, Ireland, Unibcd States of America, and the Continent. By Lyttleton 
 S. FoRiiEs Winslow. M.B. and M.L. Cantab. ; M.R.C.P. Lond. ; D.C.L. Oxon. 
 With a Preface by Fohbes Winslow, M.D. 
 
 London : BMITH, ELDER, & CO., 15 Waterloo Place. 
 
?vO hW 
 
 WiA 
 
 M, 
 
 X^i* 
 
 H^v< 
 
 \\€.o>><'00\'^'^ 
 
 % 
 

 y^'