r^c^^N oV^ Columbia ^ntbcnsttp (Balh^t of pijijattlanH anb ^Mrgrnna Sffprfttr? ffilibrarg Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/injuriesofnervesOOsher INJURIES OF NERVES AND THEIR TREATMENT BY JAMES SHERREN, F.R.C.S.Eng. ASSISTANT SURGEON TO THE LONDON HOSPITAL ; SURGEON TO THE POPLAR HOSPITAL FOR ACCIDENTS; LATE ERASMUS WILSON LECTURER, ROYAL COLLEGE OF SURGEONS NEW YOEK WILLIAM WOOD AND COMPANY MDCCCCVIII /G -^1 PRINTED IN LONDON, ENGLAND TO HENRY HEAD, M.D., F.R.S. IN APPRECIATION OP VALUED HELP, THIS BOOK IS DEDICATED PREFACE ^HIS manual is intended as a guide to the exami- nation and treatment of cases of nerve injury. While includino' all that the author believes to be o essential to this^ it does not claim to be an exhaustive account of the subject. A large proportion of the material used has appeared in papers published in '' Brain ' (with Dr. Head)^ in the 'British Medical Journal/ 'Clinical Journal/ and ' Lancet.^ The illustrations are^ with three exceptions^ original. Of these three^ two are modified from illustrations given by Gushing^ one from a diagram in a paper by Morriston Davies. The photographs have been taken by Mr. Wilson^ photo- grapher at the London Hospital_, to whom my thanks are due. JAMES SHERREN. Devonshire Street, W. February, 1908 CONTENTS CHAPTER PAGE I. Classification and Method of Produc- tion OF Nerve Injuries ... 1 II. Symptoms resulting from Complete Division of a Peripheral Nerve . 15 III. Symptoms resulting from Incomplete Division of a Nerve .... 35 IV. Method of Examination of Nerve Injuries ...... 45 V. Differential Diagnosis .... 61 VI. Treatment of Nerve Injuries . . 72 VII. Plastic Operations upon Nerves . . 85 VIII. Method of Recovery after Complete Division of a Nerve and Suture . 99 IX. Method of Recovery after Incomplete Division of a Nerve .... 123 X. Pain Complicating Nerve Injuries . 132 XI. Cranial Nerves ..... 150 XII. Nerves of the Cervical Plexus and the Cervical Sympathetic . . .178 XIII. The Brachial Plexus .... 183 XIV. Nerves Supplying the Muscles of the Shoulder Girdle . . . .211 XV. Diagnosis of Lesions of the Brachial Plexus 219 XVI. Nerves of the Upper Limb . . . 230 XVII. The Cauda Equina 276 XVIII. Nerves of the Lower Limb . . . 287 Index 305 INJURIES OF NERVES AND THEIR TREATMENT CHAPTER I Classification of Nerve Injuries — Method of ProcUictiou of Nerve Injuries : (1) by Penetrating Wounds, Accidental or Oj)era- tive ; (2) by Pressure ; (3) by Traction — Nerve Injuries complicating (a) Fractiu-es ; (b) Dislocations; (c) Sui-gical Procedures — Gunshot Injuries of Nerves. Injury to one of the principal nerves of a limb is an accident of extreme gravity. Its recognition^ exact diagnosis and correct treatment is of tlie utmost importance. Under tlie most favourable circumstances a period of incapacity results which often extends into months and may necessitate entire change of employment. It is necessary to be acquainted with the prognosis of the various forms of injury to Avhich each nerve is liable ; such injury often affects the future career of the patient^ and in many cases the interests of 1 2 INJURIES OF NERVES employers or their representatives are also involved. It may fall to tlie lot of any medical man to be called npon to statC; for example^ the probability of a patient after primary snture of one of the nerves of the hand^ being able to again follow employment requiring manual dexterity, and at what date. The subject will be dealt with from the clinical standpoint with these questions in view. Classification of nerve injuries. — All nerve injuries fall into one of two groups : (a) Those in which the symptoms indicate complete interruption of continuity; (b) those in which the symptoms point to incomplete interruption of continuity. For these two groups I employ the terms (a) " complete '' and (6) '' incomplete ' division/ ^^ the word " divi- sion '' being used in connexion with the conducting portion of the nerve. This avoids terms such as '' concussion/^ " contusion/^ " laceration/^ Avhich are of use in describing the method by w^iich a nerve is injured but do not form the basis of a useful classification ; they omit the one fact of importance in treatment and prognosis, whether the separation from the central nervous system of the structures supplied by the injured nerve is complete or incomplete. But it must be remembered that interruption of conduction, permanent or transitory, complete or incomplete, may result from an injury which leaves the naked-eye continuity of the nerve intact. For this CLASSIFICATION 3 type of injury I use the term " physiological " ; when the injury results in anatomical solution of continuity^ "anatomical^' division. Hence the complete classi- fication is into — [Anatomical. Complete division { ,^, . , . . ^ ll'hysiologicai. [Anatomical. Incomplete division 1,^1 - ^ • ^ ^ LPhysiological. There is no sign apart from inspection of the nerve by which it is possible to tell into which of the subdivisions (anatomical or physiological) the injury falls. The second part of the classification must therefore often be omitted^ or added after operation. Methods of production of nerve injuries. — All nerve injuries may be referred to one of three causes : (1) Wounds^ accidental or operative; (2) pressure; (3) traction. These affect the individual nerves in varying frequency. For example^ the median and ulnar are most often injured by penetrating Avounds, the musculo-spiral as the result of pressure, the brachial plexus as the result of traction. Wounds of nerves, accidental and Operative. — Accidental wounds in the region of the wrist and lower third of the forearm are responsible for a large proportion of the nerve injuries of civil life. They are often complicated by division of tendons and form one of the most serious accidents w^e are called upon to treat. In the lengthy operation for the 4 INJURIES OF NERYES union of the divided tendons the nerve injury is not infrequently overlooked. Sometimes the nerve is divided through a small punctured wound, and for this reason nerve injury is not suspected. The nerves which most often suffer in this way are the median and ulnar, alone or together, and the radial. It is impossible to avoid the division of many small cutaneous nerve-branches during^ the course of a surgical operation. Such injuries are, as a rule, of little importance ; regeneration and restoration of function follow if the edges of the wound are brought into accurate contact and the wound heal by first intention. In some cases larger branches are divided, of necessity or accidentally, and the symptoms persist. The nerves most often injured during the course of surgical operations are the branches of the cervical plexus and the spinal accessory in operations upon the neck, and the facial nerve. In ojoerations ujDon the neck the spinal accessory should be carefully avoided, or if divided, sutured. Its section produces a noticeable deformity of the shoulder {vide p. 175), which is more marked if, as usually happens, the branches given to the trapezius from the third and fourth cervical are divided at the same time. Injuries of the sensory branches of the cervical plexus may cause pain and tenderness in their area of distribution. The trunk of the facial nerve is METHOD OF PRODUCTIOX 5 most often injured in operations upon the mastoid and middle ear^ its branches^ in operations in the parotid and submaxillary regions. Next in frequency the nerves of the abdominal wall suffer. Incisions in the linea semilunaris must of necessity divide the lower dorsal nerves supplying the rectus abdominis^ and may aid the formation of post-operative ventral hernia. Fortunately it is rarely imperative to open the abdomen through an incision in this situation. In most operations in the upper abdomen the incision should be made through the posterior sheath of the rectus^ after pulling the muscle outwards. If this is inadvisable, as in the operation of cholecystostomy^ the fibres of the rectus should be separated. The last dorsal, ilio-hypogastric and ilio-inguinal nerves, particularly the former, are exposed to injury in their course behind the kidney. This injury may be avoided by making all incisions parallel to their course and remembering their position when it is necessary to enlarge the wound. The last dorsal nerve is occasionally included in a ligature with the first lumbar artery. Severe symptoms may be pro- duced by injury to any of these nerves {vide p. 144). The ilio-iuguinal nerve, as it lies beneath the structures forming the spermatic cord and passes out at the external abdominal ring, is sometimes cut into or included in a ligature during operations upon inguinal hernise. This nerve should be always 6 INJUEIES OF XEEYES recognised and carefully preserved. Considerable inconvenience may result from its injur}^ ; I have knoAvn the pain severe enough to render operation necessary. In all operations^ hoAvever simple^ the course of the neighbouring nerves should be borne in mind. Pressure on nerves. — The pressure may be momen- tary or long continued^ the result^ for example^ of a blow or involvement in callus. As an example of the former^ a blow on the ulnar nerve behind the internal condyle of the humerus leading to a tem- porary interference with the functions of the nerve may be cited. Of the latter^ involvement of the musculo-spiral nerve in the callus repairing a fracture at the junction of the middle and lower thirds of the humerus. The musculo-spiral nerve suffers most often from this tj^pe of injury. It may be pressed upon during sleep, or by crutches, iuA'-olved in fibrous tissue or callus, or compressed by a displaced fragment of bone. Less often the brachial plexus is compressed by the dislocated head of the humerus, the external popliteal by the violence producing a fracture of the neck of the fibula or other direct pressure. The median and ulnar nerves may be injured by tight splints or bandages. In Yolkmann's ischaemic con- tracture of the forearm muscles, when, as is usually the case, it results from splint pressure, involvement of these nerves is rarely absent. The pressure of COMPLICATING FEACTUEES 7 the strapping used in putting up a fracture of the clavicle by Sayre^s method is responsible for some cases of injury to the ulnar nerve leading to a tem- porary loss of conduction. Traction injuries. — Injuries due to overstretching — traction — aifect chiefly the brachial plexus. They form an extremely important group to which atten- tion has recently again been directed. Brachial birth paralyses and injuries of the plexus due to a fall upon the shoulder or violence applied to the side of the head owe their origin to this cause {vide p. 187). The great sciatic nerve or its external popliteal division are sometimes injured during the manipulations necessary to the treatment of a con- genital dislocation of the hip^ or the reduction of a traumatic dislocation. The overstretching may result in anatomical or physiological division, which may be complete or incomplete. Physiological is more common than anatomical and incomplete than complete division. Nerve injuries complicating fractures. — The nerve may be injured at the moment of the fracture — ^v'l- mary ; involved in the process of repair, or pressed upon by the displaced end of the bone — secondary. The primary injuries fall into two groups, (ft) in which the nerve injury is caused by the fracture, for example, injury of the musculo-spiral from bruising or laceration by the fragments of the fractured humerus ; (/>) in whicli the nerve injury 8 INJUEIES OF NERVES results from the violence producing tlie fracture, a fall on the point of the shoulder causing a fracture of the clavicle and a traction injury to the brachial plexus, or direct violence applied to the outer side of the leg", a fracture of the neck of the fibula and an injury to the external popliteal nerve. The nerve may be ruptured, contused, lacerated, or compressed between the ends of the bone. In most cases the symptoms result from pressure and cause weakness or paral3^sis of muscles accompanied by a loss of sensibility according to the nerve injured and the degree of the injury. Occasionally, when the nerve is lacerated, pain may arise in the distri- bution of the aifected nerve a few days after the injury [vide p. 43). In secondary injury the nerves become involved in fibrous tissue, or compressed by exuberant callus or bone. The musculo-spiral is the nerve most often affected in this way. The interference with the functions of the nerve may arise many years after the fracture, as occurs in the late involvement of the ulnar nerve after fractures in the region of the elbow-joint {vide p. 256). Primary injury is rarer than secondary, but it is diificult to obtain the exact percentage, for it often happens that no examination for nerve injury was made before the limb was put in splints and the fact of the injury is first discovered on their removal ; in by far the greater number of cases also, no operation COMPLICATINa DISLOCATIONS 9 is necessary, so that the exact condition of the nerve is a matter of conjecture. In both primary and secondary injuries the division is more often incomplete than complete, and even in the primary form, more often physiological. In every instance of fracture careful examination should be carried out before the limb is put up. The musculo-spiral nerve suffers most often in the upper limb, the external popliteal in the lower. Bruns found the order of frequency to be as follows : Out of 189 cases of involvement of nerves in frac- tures 77 were instances of musculo-spiral, 25 external popliteal, 19 ulnar, and 17 median. All others were rare. These figures correspond to the relative frequency in the patients with nerve injuries complicating fracture which have been treated at the London Hospital. Nerve injury complicating dislocations. — As in the nerve injuries complicating fractures the injury may be primary or secondary. The primary may be caused by the direct pressure of the head of the bone at the moment of dislocation, arise during attempts at its reduction, or may be due to the violence which caused the dislocation. Secondary involvement occurs only in unreduced dislocations, and is due to the long-continued pressure of the head of the bone, or to inflammator}^ chansfes around it. Both primary and secondcary involvement is met 10 INJURIES OF NERYES with most often as a complication of subcoracoid dislocation of the hmnerusj and is by no means an uncommon accident. The brachial j^lexus or the nerves arising from it are injured^ in most cases the plexus itself. The whole plexus may be injured, but it is usually the inner cord alone, or to the greatest degree. The whole plexus sometimes suffers in injudicious attempts at reduction by the " heel in axilla" method. In subglenoid dislocations the circumflex or musculo-spiral nerve may be injured. The ulnar nerve is sometimes injured in dislocations of the elbow, the posterior interosseous in forward dislocations of the head of the radius, and the great sciatic or obturator nerve in dislocations of the hip. Nerve injuries complicating surgical procedures. — It is still by no means uncommon to find a localised paralysis resulting from surgical procedures carried out under a general anaesthetic. The majority of these fall into the group of " post-anaesthetic paralyses," due to the position of the patient. But in a few, the operative manipulations of the surgeon are re- sponsible; such are the injuries to the brachial plexus, following the reduction of a dislocation of the humerus by the '' heel in axilla " method, or of the great sciatic or its external popliteal branch from manipulation of a congenital dislocation of the hip, or the reduction of an acquired dislocation, or the large number of injuries resulting from wounds of POST- ANAESTHETIC PARALYSIS 11 nerves. These have already been referred to in their appropriate sections. The cases in which no manipulative cause can be assigned fall into two groups. The first, which is uncommon, includes the injuries resulting from direct pressure ; such are injury to the musculo- spiral, due in most cases to the direct pressure of the edge of the table, or injury to the external popliteal nerve, from the application of a Clover's crutch or Esmarch's bandage. In the second group are the traction injuries. The brachial plexus of the right side suffers most often, and the muscles supplied by the fifth cervical nerve are usually paralysed alone; if muscles supplied by other nerves suffer as well, those supplied by the fifth are always the most severely affected. This type of injury can only occur when the patient\s arm is abducted from the body or raised above the head ; in none of the recorded cases did it follow an operation in which the arms were kept to the side. It most often happens when the right arm has been abducted and externally rotated, and the patient, for the convenience of the surgeon, has been brought to the edge of the table ; in this way the weight of the upper limb falls on the brachial plexus and its cords are stretched. In a few cases the paralysis follows elevation of the arms above the head ; in these the nerves may be injured as the result of the direct pressure of the 12 INJURIES OF NEEYES liead of the liumerus over wliich. tliey lie. It lias been suggested that the injury is due to the nerves being crushed between the clavicle and first rib or trans- verse process of cervical vertebree; this is improbable. The violence results most often in incomplete physiological division_, and the majority of the cases recover without active suro-ical interference. In all o the patients that have come under my notice_, spon- taneous recovery occurred^ and I have been able to find record of one case only in which recovery was incomplete. In this patient the deltoid remained permanently jDaralysed. These paralyses occurring after a routine abdominal operation^ are a reproach to all concerned, and not to the anaesthetist alone_, to whom the blame is often imputed. They are ^preventable in most cases, and thought must be taken to avoid attitudes which are likely to produce injury to nerves, and particular care exercised to avoid undue abduction or elevation of the arms. Gunshot wounds of nerves. — The recent wars in South Africa and the Far East have added much to our knowledge of these injuries. Makins, in his Stirgical Ex'periences in South Africa, states that ^Hhe occurrence of these injuries has undoubtedly increased in frequency with the employment of bullets of small calibre.^^ This was also noticed in the Russo-Japanese war and recorded by Hashimoto and Tokuoka. It is impossible to give the exact frequency with GUNSHOT WOUNDS 13 whicli the various nerves were injured^ but of those cases needing prolonged treatment or operation the great sciatic suffered most often^ next in frequency the musculo-spiral. Thus, out of 38 cases treated by Hashimoto and Tokuoka, 18 were sciatic, 16 musculo-spiral, 2 median, 1 ulnar, and 1 posterior tibial. The comparative frequency agrees fairly well with that of the cases that have come under my observation, with the exception that injuries of the brachial j^lexus and the nerves arising from it were more often met with. The sciatic suffered most often from a primary injury, the musculo-spiral in fractures of the humerus in a greater percentage of cases than seen in fractures of this bone in civil life. In a large number of cases the injury is an incomplete physiological division, primary, or secon- dary, from involvement in fibrous tissue or callus. The temporary loss of conductivity, complete or in- complete, not uncommonly met with when the track of the bullet passes near one of the peripheral nerves, is an example of primary incomplete physiological division. Complete anatomical division is rare. In many instances the wound does not completely divide the nerve, but the signs of com- plete division develop later from the resulting fibrosis, and indicate operative treatment. In other cases pain and tenderness {vide p. 134) occur, rendering neurectomy necessary. 14 mJURIES OF NERVES Several instances have been recorded in wliicli a nerve was penetrated by a bullet, tlie nerves of tlie brachial plexus and tlie great sciatic most often, without producing even complete physiological divi- sion. One case has come under my notice in which the median nerve was so affected without any per- manent interference with conduction. CHAPTER II Symptoms following tlie Complete Division of a Peripheral Nerve — Changes in Sensibility produced by Division of a Peripheral Nerve — Three Systems of Afferent Fibres — Changes in Sensi- bility resulting from Division of Posterior Eoots — Division of a Nerve " without Sensory Change " — Changes in the Muscles following Complete Division of their Motor Nerve — Paralysis — Electrical Changes— Changes in the Skin, Nails, Hair, Bones, and Joints. Complete division of a mixed peripheral nerve results in the loss of those forms of sensibility which it ^^exclusively" supplies^ and paralysis of the muscles to which it sends motor fibres. Changes in sensibility. — Section of a sensory nerve enables us to map out its " exclusive " supply, that is, the area to which it alone sends fibres ; it gives no information with regard to the much larger area to which it supplies fibres in common with other nerves. To obtain this, its " full " supply, we must study the sensibility remaining after » division of the surrounding nerves ; this method of residual sensibility or residual sesthesia, first employed by Mr. Jonathan Hutchinson sen., to map out the dis- tribution of the median nerve on the dorsal surface of the fingers, has in the hands of Sherrington given valuable results in experimental work. 16 INJUEIES OF NEEYES The area of full supply deduced from residual sensibility corresponds closely to tlie extent of skin wliicli becomes tender on stimulation of the trunk of the nerve. This was done experimentally by Weir Mitchell^ whO; following the example of Waller, stimulated the ulnar nerve behind the internal con- dyle with a mixture of ice and salt. He experienced an intense burning pain over an area larger than that which later became anaesthetic as the result of the continued action of the freezing mixture. Most peripheral nerves are too deeply seated to admit of this method of stimulation. But after certain in- complete injuries, particularly those due to gunshot wounds {vide p. 134), marked tenderness may arise in the territory to which the injured nerve sends fibres. This is always more widespread than the loss of sensibility which results from its therapeutic division and corresponds to its full supply. After section of a mixed nerve, such as the median at the wrist, if no tendons have been divided at the same time, the patient is, in most cases, able to appreciate those stimuli commonly called tactile ; a tC)uch with the finger, a 23encil, or a piece of paper may be not only readily distinguished but accurately localised. When pricked with a pin the patient recognises that he has been touched but fails to perceive the sharpness of the stimulus. Any- thing-, in fact, which deforms the skin produces an effect on consciousness. To this form of sensibility DEEP SENSIBILITY 17 which persists after the division of all the cutaneous nerves supplying the skin^ Dr. Head and the author gave the name of '' deep sensibility " or ^^ deep touch/^ The fibres which convey this form of sensi- bility have widespread anastomoses and run for the most part with the motor nerves to the muscles and along their tendons and other fibrous structures to the bones^ periosteum and ligaments. While deep Fig. 1. — To illustrate the loss of sensibility resulting from division of a peripheral nerve. The area of loss of sensi- bility to light touch is bounded by a line; the shaded portion represents the area of loss of sensibility to prick and all degrees of temperature. The unshaded poi-tion rejDresents the " intermediate zone." sensibility is present the patient is able to recognise the position into which his joints have been placed. Through this deep system the patient is also able to appreciate increase of pressure and the pain of deep pressure, this being ill defined and often compared by the patient to that produced by bruising a bone. 2 18 INJURIES OF XEEYES The sharpness of a stimulus^ a prick with a sharp needle and all degrees of temperature are not recosrnised over an area which varies somewhat from patient to patient {vide Fig. 1). Surrounding this area and corresponding closely to the distribution of the nerve as figured in ana- tomical text-books is a territory within which the patient is unable to appreciate liglit touches with cotton-wool and to discriminate between temperatures of about 22° C. and 38° C. (called minor degrees)^ and fails to distinguish as two^ the points of a pair of compasses when separated to many times the dis- tance necessary over the corresponding part of the sound limb or the unaffected portion of the injured (compass test) . The boundary of this loss of sensi- bility to light touch is well defined and liable to very little variation even when many patients are examined. Within the area between the border of the loss of sensibility to prick and the loss of sensibility to light touch (called the intermediate zone), the patient is able to appreciate the sharpness of a pin-prick and to differentiate between water below about 20° 0. and water above about 45° 0. All stimuli in this zone appear to have an unpleasant tingling, diffuse character. A prick causes a sensation of pins and needles, which radiates widely; the patient often withdraws his hand, describing the sensation as a " numb, tingling pain," or " as if you were INTERMEDIATE ZONE 19 touching a sore place/^ and rubs the part ; this pain may persist for a considerable time. Changes in atmospheric temperature affect this portion of the skin very readily, the slightest coldness in the weather causes the part to become cold and blue, and of this the patient bitterly complains. On jDalpation it feels definitely colder than tlie sound portion of the limb. The boundary of this intermediate zone may be marked out by dragging a sharp needle across the skin from normal towards abnormal j^arts ; imme- diately the boundary of the loss of sensibility to lio'ht touch is reached a marked chang-e in sensi- bility is noticed by the patient,, the sensation pro- voked having the characteristics just described. This is spoken of as the " line of change to prick ^^ [vide also incomplete division, p. 38). We see, then, that complete division of a mixed or sensory nerve causes a well-defined loss of sensibility to light touch, which varies little from patient to patient and an ill-defined and smaller area of loss of sensibility to prick, which varies within wide limits, sometimes being almost as extensive as the loss of sensibility to light touch, at others falling far short of it. The outline of the area of loss of sensibility to prick may also vary somewhat in the same patient; on a bright, warm day it will be a little smaller than on a cold, damp one, and may vary with the state of the patient's health. But this variation is 20 INJUEIES OF NERVES sliglit only, and is easily overlooked unless the con- dition is charted each time the patient is examined. A loss of sensibility to deep touch may be present if the nerve has been divided above all its motor branches^ or if tendons have been severed in addition to the nerve^ but is rarely as extensive as the loss of sensibility to prick. Hence we see that division of a nerve rarely produces an area of loss of all forms of sensibility; deep touch can usually be appreciated everywhere and the only loss of sensibility at all corresponding in extent to that usually assigned to the nerve^ is the loss of sensibility to light touch. For these and other reasons the afferent fibres in a peripheral nerve may be divided into three systems, as sug- gested by Dr. Head and the author. These have the following characteristics : (1) Those which subserve deep sensibility. These conduct impulses produced by pressure; its gradual increase can be perceived and the pain produced by excessive pressure recognised. Through this system the patient recognises the extent and direction of the movements of joints and muscles. These fibres run mainly with the motor nerves, have widespread anastomoses, and are not destroyed by division of all the sensory nerves to the skin. (2) Those responding to painful cutaneous stimu- lation and to the extreme degrees of temperature. To this system of fibres and end organs we gave the EPICEITIC, PROTOPATHIC SENSIBILITY 21 name " protopathic." All sensations evoked by the stimuli to wliicli this system is capable of reacting are badly localised^ radiate widely and are accom- panied by tingling. It is the form of sensibility which exists in the intermediate zone^ between the boundary of loss of all forms of cutaneous sensibility and that of the loss of sensibility to light touch. Reflex movements owe their origin to this system, which produces a rapid response unaccompanied by any definite appreciation of the spot stimulated. (3) A system of nerve-fibres and end organs res- ponding to light touches with a well-localised sensa- tion. Through it minor degrees of temperature are differentiated and two |)oints discriminated. To this system we gave the name of " epicritic." In describing the loss of sensibility which results from the division of individual nerves I shall employ these three headings, and use the terms ^^ epicritic " and " protopathic '' sensibility as synonymous with sensibility to light touch and to prick. These last two forms of sensibility are differently represented in each peripheral nerve, but in all cases the fibres subserving protopathic sensibility have a much wider overlap than those which subserve epicritic sensibility. The investigation of the distribution of deep sen- sibility is beset with many difficulties ; it can only be examined in cases in which all cutaneous sensibility is absent. It is impossible at present to formulate any further hypothesis with regard to its distribution. 22 INJURIES OF NEEYES Mucli difference of opinion lias existed with regard to tlie loss of sensibility wliicli results from division of a peripheral nerve. It was pointed out by Richet, in 1867^ that sensibility may be retained after divi- sion of the median nerve ; many similar cases have been recorded^ and I have known good observers in other branches of surgery overlook the fact of divi- sion of this nerve. The method used by Richet in testing sensibility explains why no loss could be discovered. An account of it has been preserved in a letter written to the Lancet by Lockhart Clarke, in which he stated "with a piece of paper rolled up into the form of a stick he (Richet) tickled in the most perplexing Avay different parts of the fingers and palm supplied by the median nerve. . . . Nevertheless sensi- bility, though not abolished, was somewhat imj)aired, as was evident when a pin was used instead of pajDer to excite the skin. The application of heat and cold was not attended with very satisfactory results.^^ It is quite evident that the ordinary loss of sensi- bility produced by division of the median nerve Avas present in this case with retention of dee^o sensibilit3^ Similar methods of testing have led to similar errors in numberless cases since. Richet considered that tlie retention of sensibility was duo to tlic |)resence of tlio recurrent fibres described Ijy Claud Bernard. The next year, Savcny explained tlie phenonjcnon as it occurred after SUPPLEMENTARY SENSIBILITY 23 division of the musculo-spiral nerve by the presence o£ anastomoses with neighbouring nerves. In the same year Letievant enunciated his wider theory, that of supplementary sensibility {.sensibilite siqoplece) , including in the term not only recurrent sensibility and anastomoses, or, as he expressed it, copa'se and fine anastomoses, but also sensibility taken up from an ansesthetic region by the end organs of the neighbouring sound skin, called by him " mediate sensibility,^^ and corresponding in its characteristics to that form of sensibility to which we gave the name of " deep/^ His researches received apparent confirmation from the researches of Arloino- and Tripier, published the following' year. In 1873 Letievant published his work, Traite des Sections Nerveuses, in which he gave an extended account of his doctrine applied to the various nerves. Richelot, and more recenth^, Laborde, confirmed his observations, while most modern writers on the sub- ject have taken supplementary sensibility as the explanation of the varieties of loss of sensibility met with after division of a nerve. But however widely applied, this fails to explain the well-defined and little varying loss of epicritic sensibility, the varying protopathic loss, the presence of deep sensibility and the curious dissociation of sensibility seen after division of j^osterior roots and certain nerves of the dorsum of the hand {vide p. 241) in which light touch and the minor degrees of temperature can be appre- 24 IXJUEIES OF XERYES ciated over a part insensitive to protopathic stimuli. It also leaves unexplained the method of sensory- recovery {vide pp. lOlj 123). These can be most satisfactorily explained by the theory brought for- ward by Dr. Head and the author. The loss of sensibility present immediately after the injury remains unchanged until regeneration of the peripheral end and reunion with the central nervous system takes place. There is no gradual encroachment upon the anaesthetic area by the nerves supplying the surrounding skin. In cases of secondary suture performed some weeks after section^ if any improvement in sensibility has taken place^ freeing and freshening the ends of the nerve results in the sensory loss becoming identical with that which was present immediately after the accident ; all the restoration in sensibility has been due to reunion with the central nervous system. This reunion may be through divided nerve branches in the surrounding tissues and not through its own central end^ but this does not take place to any great extent in adults. Division of posterior roots. — The effect of the divi- sion of posterior roots throws a further light upon the sensory distribution of the peripheral nerves. A knowledge of the nature of this distribution is of extreme importance in diagnosis. Division of posterior roots produces an area of loss of protopathic sensibility larger than the area DIVISION OF POSTERIOR ROOTS 25 of loss of light toucli (vide Fig. 2). A territory, therefore, remains within which the patient is unable to appreciate the sharpness of a prick or the extreme degrees of temperature, but is able to recognise stimu- lation with cotton- wool, and may be able to discrimi- nate between warm and cool, although totally unable to detect any difference between ice and water at 55° C. Fig. 2. — To illustrate the loss of sensibility resulting from division of posterior roots. In this patient (Head and Sherren, No. 52) the fifth, sixth, seventh, and eighth cervical, and first and second dorsal posterior roots were divided. The thick continuous line represents the area insensitive to prick ; the thin dotted line the area insensi- tive to light touch. A represents area within which light touches with cotton-wool were appreciated, but painful stimulation was unrecooiiised. The peripheral nerve may be looked upon as the unit of epicritic supply, the posterior root as the unit; of protopathic supply. The nearer a peripheral nerve represents the supply of one or more posterior roots, the more definite will be the borders of the loss of sensibility to prick produced by dividing that nerve, and the more nearly will the loss of proto- 26 I]S[JUEIES OF NERYES jDatliic correspond to the loss of epicritic sensibility. For example, tlie external popliteal nerve {vide p. 297) corresponds closely to tlie distribution of tlie fifth lumbar root_, its division produces a widespread and well-defined loss of protopathic sensibility corres- ponding almost exactly to the area of epicritic loss. The median nerve, on the other hand, represents the supply of no single ^Dosterior root, but contains sensory fibres from the seventh and eighth cervical, and possibly also from the sixth cervical and the first dorsal nerves ; consequently its division will produce loss of protopathic sensibility over the relatively small area to which this nerve carries all the protopathic supply (its exclusive supply). Division of peripheral nerves without sensory change. — There are certain nerves which can be divided in certain situations without producing- sensory change that can be appreciated by any of our present methods of testing. These are, the musculo=spiral in the lower third of the arm, that is, below the point at which its external cutaneous branches are given off, the radial nerve in the upper two thirds of the forearm, and certain of the anterior primary divisions of the cervical nerves which enter into the formation of the brachial jjloxus. These nerves supply no area of skin exclusively with any form ot" sensibility, hence division of other branches in addi- tion is necessary to produce any sensory loss. Motor symptoms. — Couiplete division of a nerve MOTOR SYMPTOMS 27 containing motor fibres results in immediate paralysis of the muscles supplied by it. But this paralysis is not always obvious^ and its detection may require careful examination. No movement ordinarily em- ployed in daily life is the result of the contraction of one muscle only ; in investigating the paralysis of muscles after a nerve injury this must be remem- bered. It is the action of the individual muscles that must be investigated^ not the movements with which their contraction is usually associated. For example^ after division of the median nerve at the wrist; the action of the abductor and oppo- nens pollicis muscles must be investigated^ not the presence or absence of abduction and opposition, these movements can be imitated by the contraction of other muscles. Again, extension of the fingers in a line with the hand is due to the contraction of the extensors of the fingers, supplied by the musculo- spiral nerve, of the flexors of the wrist supplied by the median and ulnar, and of the interossei muscles supplied by the latter nerve.* That mistakes might arise in this way was first pointed out by Swan in 1834, in recording the results of his experiments. He wrote : '^ I was at first astonished at seeing how much an animal could move its limb a short time after operation (division * Those iuterested in the subject of aniscular movements will tiud ii full account in Dr. C. E. Beevor's Croonian Lectures, delivered in 1UU3. 28 INJURIES OF NERVES of sciatic nerve)^ and concluded that misconceptions have arisen from considering the general motion of the limb as evidence of the regeneration of the nerve /^ Letievant^ nearly forty years later^ de- veloped this and named the movements " supple- mentary/^ He speaks of supplementary motility (motilite suppleee), meaning thereby the imitation by unaffected muscles of movements usually associated with contraction of the paralysed muscles. The affected muscles atrophy Avith a greater or less rapidity according to the means used to keep up their nutrition^ and unless care be taken may become converted into a mass of fibro-fatty material devoid of all contractile power. Unless precautions are taken they become over- stretched by the action of the opposing muscles, and these latter become permanently contracted — conditions that seriously interfere with complete recovery. Electrical changes. — Muscles in communication with healthy anterior horn cells respond readily and briskly when stimulated with the interrupted (faradic) and the constant (galvanic) currents. With the former current, Avhen the interruptions are rapid the muscle remains contracted as long as the current is passing; with the latter, a brisk twitch occurs at the moment the current is made or broken, but no contraction is evoked while the current is passing through the muscle. A contraction is produced by ELECTRICAL CHANGES 29 the smallest amount of current when the kathode is used as the testing electrode and the current is closed (K.C.C.), then when the anode is used and the current closed (A.C.C.). After division of its motor nerve, a muscle ceases to respond to stimulation with the interrupted current applied over its motor point in from four to seven days. At about the tenth day it may be exceedingly difficult to obtain any contraction to the constant current, and at or about this time the muscles respond to this form of stimulation with a sluggish, wave-like contraction starting at the spot stimulated, and a stronger current must be used to call it forth than on the sound side. The contraction appears first at the closing of the circuit, when the anode is used as the testing electrode (A.C.C. > K.C.C.), but this, although usual, is probably not invariable. To loss of irritability to the interrupted current with this specific alteration in the type of the contraction given to stimulation with the con- stant current the name ^^ reaction of degeneration ^' (R.D.) is applied. The name should be reserved for this one type of reaction and terms such as " partial n.J)." avoided. The length of time after separation from their anterior horn cells that the muscles retain the power of reacting to stimulation with the constant current varies ; so long as contractile substance is present in the " muscles " they will respond to this 30 INJURIES OF NERVES stiuinlus. When once a nmscle lias lost the power of responding to this current its recovery is impossible. But great care is necessary before coining to this conclusion, for contraction may be evident at one examination and not at another. Purves Stewart has recorded a case in which the muscles responded to stimulation with the constant current sixteen years after separation from its nerve-centre, and I have recently seen a patient in Avliom the muscles reacted to the constant current, although the musculo-spiral nerve had been divided twenty-three years. Changes in the skin. — When one of the nerves of the palm is divided the superficial layers of the epi- thelium no longer desquamate so readily over the area of loss of sensibility to prick. This is well seen in a patient who does manual work, and is a striking feature in the progress of a case of primary suture. On removing the first dressing the normal parts of the hand protected by the cotton-wool are soft and the epithelium sodden, but over the abnormal area the epithelium has not been shed and presents a rough, dry layer marking out the affected area (vide Plate I). If the hand be well soaked the dry epi- thelium can be peeled off, exposing wrinkled, pinkish- blue skin, colder than normal. This area does not sweat. A prick bleeds more readily than elsewhere and leaves, as first pointed out by Israel, a red spot or papule, which may persist for many hours, or even days. This is most striking, and the marks of PLATE I. Taken three weeks after division of the uhiar nerve to sliow the delayed desquamation over the ulnar portion of the palm of the hand. The area enclosed by the line represents the area insensitive to light touch. To face p. 30. Adlard Jf- Sou, Impr, PLATE II. To illustrate the formation of " trophic ulcers." Fig. 1. — Shows a blister on the dorsal surface of middle finger following an injury to the median nerve. Fig. 2. —The blister is shown separating and leaving a raw, red surface. Tof(u-i' I,. -.'A. AcUurd 4' Son, Impr. PLATE III. To illustrate the formation of " trophic ulcers." Fig 1 —Shows destrnction uf the tip of the index finger by an ulcer, general thickening of this finger and the ulcer on the middle finger. Note the ihows the hand of the same patient two years later, after secondary had been performed and protopiithic sensibility had been restored. M-ation spreail and necessitated ami)utation of the terminal phalanx of Fig. 2.— Shows suture ha( The idceration sprt.i..v.v... ^ ^ ^^ the middle finger, and destroyed a portion of the tip of the index. To face p. 32. Adlard S- Son, Impr '^TROPHIC" ULCERS 31 the needle used for testing sensibility to prick can often be readily seen the following day. Changes in the skin of a similar kind^ but less marked, occur after division of nerves supplying other parts of the body. During the time that the skin is insensitive to protopathic stimuli it is peculiarly liable to injury ; a burn or other insult is unperceived, and in this way ulcers may be produced {vide Plates II and III), which, from their situation or from the nature of the infection, may lead to the destruction of a con- siderable portion of the affected member. In many cases the patient continues his work, and one patient who came under my observation, a stonemason, re- fusing to trouble, ground away the terminal phalanx of his fino'er ao-ainst the stone he was sawine'. " Trophic " ulcers usually originate in blisters ; if ke23t free from infection these dry and form a callosity, which on removal leaves a raw surface. The blisters are produced in many instances by injuries of so slight a nature that no damage results to the neighbouring sound skin from application of the same violence. For example, a patient travelling by train on a winter day felt his hand cold; when he arrived at his destination he found blisters on the affected fingers. More often water not suffi- ciently hot to be unpleasant to the sound portion of the hand causes blisters on the affected ; for this reason fomentations must be employed with care in 32 INJURIES OF NERVES the treatment of tliese ulcers. If kept at rest and free from irritation they heal readily and do not spread beyond the analgesic portion of the limb unless complicated by acute sepsis. Blisters may originate spontaneously ; they are often noticed on waking in the morning, and usually occur at a time when sensibility to prick is beginning to return to the affected portion of the limb. The appearance of the fingers and hand of a patient with an old nerve injury is usually typical. The fingers are thin and tapered towards their points, with wasting of the subcutaneous tissues, particularly at the pulp of the fingers. The skin is of a mottled reddish-blue colour, but in simple non-irritative cases never becomes so red and shiny as to merit the term " glossy skin ^^ ; this must be reserved for the condition to which it was originally applied {vide p. 42). Changes in nails. — It has been known for many years that changes in the nails follow nerve injuries. The nails become altered in texture, are harder and more brittle and lose their gloss. They also become more highly curved than normal, and ribbed in both the transverse and longitudinal directions. There is often a heaping up of epithelium under the free edge of the nail. The rate of growth of the nails may be altered. Dr. Head and the author showed as the result of many observations on the nails of the fingers of sound limbs. CHANGES TN NAILS, HAIR, BONES 33 of the fingers of limbs immobilised for the treat- ment of fractures, and as the result of paralysis due to central causes, as well as in nails of fingers insensitive from the division of nerves but retaining the power of voluntary movement, that want of movement was the cause of the diminished growth of the nails after division of a peripheral nerve. When the skin becomes insensitive as the result of injury to a nerve, but that injury has not divided tendons or paralysed muscles, the nails do not show any change in growth. The most profound altera- tions in growth are seen after division of the ulnar nerve ; here, owing to the paralysis of the interossei muscles, the middle and index finger-nails are affected as well as the little and ring. Changes in hair. — Changes may occur in the hair as the result of nerve injuries. This is seen most often after an injury dividing the nerves of the dorsum of the hand. The hairs appear irregular, not lying in regular arrangement as seen on the normal hand, but each hair occupying a different position. They may show, in addition, a chauge in colour and often a change in texture, becoming brittle. Changes in bones and joints. — Acute arthritis fol- lowing a nerve injury must be a condition of rarit3\ I have not yet observed it in any of the cases which have come under my notice. Changes take place in the ligaments and joints 34 m.JURIES OF NERYES retained in an abnormal position. This is most often seen after division of the uhiar nerve ; the thick anterior ligament of the interphalangeal joints becomes contracted and resists full extension. At the same time changes may occur in the joint itself ; occasionally fibrous ankylosis takes place, but such intra-articular change is unusual. Changes in the bones must also be uncommon. I have been unable to find evidence of textural cliange in recent cases by palpation_, the occurrence of spon- taneous fracture or the result of X-ray examination. In the case of nerve division in infancy, for example, widespread birth paralysis, there will be deficient growth of the whole limb with alteration in the shape of the bones, the former due to the want of movement, the latter to the abnormal position of the limb. CHAPTER III Incomplete Division of a Peripheral Nerve — Its definition — Resulting Loss of Sensibility; of Motion — Changes in Electrical Reactions — Cansalgia — Changes in Skin and Nails. Under tlie term " incomplete division " are grouped those cases of interruption or impairment of con- ductivity which do not lead to degeneration of the whole peripheral end of the affected nerve. This incomplete division may be anatomical or physiological_, the anatomical^ due to a wound or partial rupture, the physiological, the result of com- pression of the nerve by fibrous tissue, extrinsic or intrinsic, by bone, blood-clot, growth or external violence. Although the treatment and prognosis of the different forms varies somewhat with their causa- tion, the symptoms are identical, and for this reason it is well to discuss them together. It has been found on examining the condition of the part supplied by a nerve which has been incom- pletely severed by a sharp cutting instrument, that a considerable portion, certainly a third of the trunk, may be divided without producing motor or sensory change or one of a transient nature only. This is most important in connexion with the operation of 36 INJUEIES OF NERYES nerve anastomosis (vide p. 90). In this operation it is essential to divide nerve-fibres in a sound nerve in order that the axis cylinders in the affected nerve may be brought into end-to-end contact with some of those in the sound. I have on several occasions divided one third of the internal popliteal nerve without producing any paralysis, often no sensory change, occasionally a loss of the power of appreciat- ing light touches which returned in a few days. I have also done the same to the hypoglossal without producing more than a temporary paresis of the muscles supplied by it. This was also the experience of Bruandet and Humbert as the result of their experiments upon animals. They came to the con- clusion that the fibres in a peripheral nerve which go to make up any branch do not become grouped together until just before it leaves the parent trunk. But there are exceptions to this rule ; it applies only to the trunk of a nerve well above the point at which branches are given off ; if the incision cuts into the nerve just above the ^^oii^t of origin of a branch the signs of complete division of that branch are produced. In certain situations also — for ex- ample, in the anterior primary division of the fifth cervical nerve — the nerve-fibres are arranged in a well-defined order, and incomplete division of this nerve may entail complete division of those motor fibres which supply the spinati and the deltoid muscles [vide p. 199). Again, in the trunk of the INCOMPLETE DIVISION 37 great sciatic nerve^ the external and internal popli- teal ner\^es remain separate from tlieir origin in the pelvis, hence incomplete division of the great sciatic may cause complete division of the external or internal popliteal nerve (vide p. 292). Bat in the accidental wounds of the trunks of nerves, so uncomplicated a section is rare ; in addi- tion to the incomplete anatomical division there is usually physiological division, the result of the transient compression of the intact nerve-fibres b}^ the cutting instrument or the effused blood. It must be remembered in this connexion that those fibres which are separated from their nerve centres must degenerate and regenerate before they can again carry on their functions. Absence of symptoms in many cases is due to the fact that more nerve-fibres are present in the trunk of a nerve than are absolutely necessary to sujjply the part. When symptoms are present the recovery of function is due to restoration of conduction in the fibres which have suffered an incomplete physiological division. It must, however, be remembered that the injury to the anatomically intact nerve-fibres may be so great that complete physiological division is pro- duced ; this may also arise at a later ^leriod as the result of compression by fibrous tissue. It was for long the recognised teaching that in- complete injuries of nerves affected the motor more than tlie sensory fibres. I showed, in my Erasmus 38 INJURIES OF NERVES Wilson Lectures^ tliat tliis was not the case. Out of nineteen instances of incomplete division of mixed nerveS; from various causes (excluding tlie musculo- spiral)^ seen at that date_, sensibility was affected in all ; in six there was no paralysis^ and in one it did not affect all the muscles supplied by the injured nerve below the lesion. Since that date I have been able to confirm this by many more observations. Motion is ajffected alone or to a greater extent than sensation only when the injury affects nerves such as the musculo-spiral or the fifth cervical anterior primary division, which have no exclusive sensory ^^PPb% ^^^ whose complete division has no demon- strable effect upon sensation. Sensory symptoms. — The first effect of incom- plete division of a mixed nerve is upon epicritic sensibility. In many slight cases there is no area of loss of sensibility that can be marked out by stimulation with cotton-wool ; this can be appre- ciated everywhere and minor degrees of temperature discriminated. But the patient is conscious of an area of skin altered in sensibility, and it is usually possible to demonstrate this by the changed sensibility produced at its borders when a piece of cotton-wool or a sharp point is dragged lightly across the skin from sound to affected por- tions (line of change). If the area of changed sensibility is well marked response to the compass test will be defective. SENSORY SYMPTOMS 39 But in those cases which come under the care of the surgeon, loss of sensibility to cotton-wool is usually absolute, with borders as well-defined as after complete division. Complete loss of epicritic sensibility may be the only sign of the injury, motion may be entirely unaffected. The following is a good example of this tyj^e of injury : " A boy, aged thirteen, was strapped by Sayre's method for a fractured clavicle. When the limb was taken down he complained of numbness. On examination I found loss of sensibility to light touch over the ulnar area, with no affection of the muscles- Yet it was five months before complete recovery ensued with perfect discrimination of two ^Doints.^^ When the injury is more severe, impairment or loss of protopathic sensibility results and the sensory loss may resemble exactly that seen after complete division. The following is illustrative of this. " C. B — , aged twenty-seven years, slipped and cut his wrist with a broken bottle. He came to the London Hospital at once and was seen by me an hour and a half after the accident. An oblique wound was present on the anterior surface of the wrist, running from the tendon of the flexor carpi radialis upwards and outwards for au inch and a half. " The opponens and abductor pollicis muscles acted well. He was unable to appreciate light touch over the full median area ; sensibility to prick was abolished over the terminal two phalanges of index 40 INJUEIES OF NERVES and middle fingers and an area on tlie palm at tlieir base. " I explored the wonnd at once and fonnd the median nerve swollen with a small incised wound on its ulnar side/^ In this patient the loss of epicritic and proto- pathic sensibility was as widespread and of as profound a degree as after complete division of the nervO; yet there was no motor affection. As a rule^ however^ when sensibility is impaired to this degree voluntary power is also affected. Motor symptoms. — Paralysis of some or all of the muscles supplied by the injured nerve may result from incomplete division. It is only after sufficient time (eight to fourteen days) has elapsed^ to allow of the development of electrical changes^ that the diagnosis of incomplete division can be made in many instances. In the least severe cases the muscles, thouo-h paralysed_, retain their irritability to the interrupted current ; this is seen most often in crutch and sleep paralyses ; rarely — though two such cases have come under my care — the muscles retain the ^^ower of voluntary movement^ but do not respond to stimu- lation with the interrupted current. Usually the reactions that I consider typical of incomplete division arc present. On about the tenth da}^ after the injury the muscles do not respond to the inter- rupted current; but react in a characteristic manner MOTOR SYMPTOMS 41 when stimulated with the constant. The strength of current necessary to call forth the contraction is less than on the sound side ; the contraction so produced is brisk as compared with that seen when the reaction of degeneration is present, and polar reversal is, as a rule, absent. When I delivered the Erasmus Wilson Lectures in 1906, I had been able to investigate nineteen cases of incomplete division of nerves associated with paralysis, and in eighteen of these this reaction was present ; in the other patient the muscles reacted to the interrupted current. Since that date I have had the ojDportunity of investigating further cases of this description ; in all — some of them patients sent for operation — the diagnosis made by electrical examina- tion was confirmed by the after-history of the case. After-results of incomplete division. — Pain is a more frequent symptom after both anatomical and physio- logical incomplete division than after complete division, and is often accompanied by tenderness of the skin (hyperalgesia), sometimes by glossy skin and chano'es in the QTowtli of the nails. O a These symptoms only occur as the result of irrita- tion ; they rarely arise immediately, a latent j^eriod of a few days to three weeks usually being present. The pain is most severe when there has been an incom- plete anatomical division, and is most often seen after gunshot wounds. The first case of this nature was reported by Doiniuirk in ISlo ; the patient was a 42 INJURIES OF NERVES soldier wounded at tlie storming of Badajoz. Later^ Paget drew attention to this symptom in injuries in civil life^ and liis words well describe tlie condition and tlie knowledge tliat was then possessed with regard to it. " Glossy fingers appear to be a sign of peculiarly impaired nutrition and circulation due to the injury of nerves. They are not observed in all cases of injured nerves_, and I cannot tell what are the peculiar conditions of the cases in Avhicli they are found^ but they are a very notable sign and are always associated_, I think^ with distressing pain and disabilityc In well-marked cases the fingers which are affected are usually tapering, smooth_, hairless, almost devoid of wrinkles, glossy, pink, or ruddy, or blotched as if with j^ermanent chilblains. They are commonly also painful, especially on motion, and the pain often extends from them up the arm.^^ The cases upon which this description was based were instances of incomplete physiological division. But it is to Weir Mitchell, Morehouse and Keen that we owe the first complete description of this condition named by them " causalgia," based upon their observations of the results of gunshot wounds of nerves during the American Civil War. The following description from Weir Mitchell^s book describes the condition with accuracy : "^ The skin affected in these cases was deep red or mottled, or red and pale in patches. The subcuticular tissues were nearly all shruukeu, and where the palm alone CAUSALGIA 43 was attacked tlie part so diseased seemed to be a little depressed and firmer and less elastic than common. In the fingers there Avere often cracks in the altered skin^ and the integuments presented the appearance of being tightly drawn over the sub- jacent tissues. The surface of all the affected parts was glossy and shining^ as though it had been skil- fully varnished. Nothing more curious than these red and shining tissues can be conceived of. In most of them the part was devoid of Avrinkles and perfectly free from hair. Mr. Paget^s comj^arison of chilblains is one we often used to describe these appearances^ but in some instances we have been more strikingly reminded of the characters of certain large^ thin, and polished scars. ^^ Butj as seen in civil life^ the condition is rarely so severe ; it may result from penetrating wounds, primary injury in association with fractures, or a direct blow. After a latent period of a few days intense burning pain makes its appearance. The painful area is usually extremely tender and maps out the full distribution of the injured nerve, and may present the skin changes described above, but these are by no means constant and only present in the most severe cases. Loss of sensibility may be present, varying accord- ing to the nerve injured and the degree of that injury ; usually the loss is of epicritic sensibility only. The pain soon affects the patient^s general conditicni. 44 INJURIES OF NERVES lie rapidly loses self-control and becomes ^^ hysterical/^ often bursting into tears on the suggestion of a local examination. On exploration the nerve is found locally enlarged and often embedded in fibrous tissue. The condition may perhaps be considered as a neuritis ; it occurs most often in gunshot wounds with delayed union, but in several cases Avhich have come under my care the wounds healed by first intention_, and it may occur as the complication of a subcutaneous injury {vide also p. 134). The skin changes are different to those seen after complete division. The skin sweats profusely and the affected area may often be marked out by beads of moisture. In some cases the subcutaneous tissues appear to be increased in size_, and the nails may become more curved and grow faster than those of the unaffected hand. Blisters may make their appearance and break down to form ulcers ; these may appear not only over the area of sensory loss_, but often over the area in which there is hyperalgesia but no loss of sensibilitv. In cases of incomplete division without irritation the changes in the skin are little marked unless the injury has resulted in protojoathic loss_, when they may resemble those seen after complete division. As_, after complete division_, the changes in the nails will depend upon the extent of the loss of movement resulting from the injury. CHAPTER IV Method of Examination and Diagnosis— History— Examination of the Patient— Method of Testing Sensation— Electrical Exa- mination — Diagnosis : in recent cases ; in old cases. It is necessary to follow some definite plan in tlie examination of a case of nerve injury or points are omitted wliicli are essential to full diagnosis. The full diagnosis consists in the discovery of the nerve or nerves injured, the anatomical position of the iujury and its nature,, whether complete or incomplete. Before commencing the local examination the history should be taken ; much light is often thrown on obscure cases by listening carefull}^ to the patient^s account of the accident and his subsequent experiences. The important points to be elicited are, the date of the accident, and, as far as possible, its exact nature ; then, what symptoms pointing to a nerve injury first attracted the attention of the patient, and the time after the accident at which such sensory change, paresis or paralysis, was noticed. In old cases inquiry should be made for increase 46 IXJUEIES OF NERVES or diminution in the extent or degree of the sensory or motor symptoms. If j)ain has been present at any time^ questions must be put to ascertain the date of its onsets its exact distribution and character, whether neuralgic, burning, etc., if it varies in severity from time to time, if it has spread to areas other than that first affected, or the patient is aware of anything that increases it or can obtain relief from it in any way. Some idea must be formed of its severity, whether keeping the patient awake at night, or affecting his mental condition or general health. If the nerve was injured in a wound, how long the wound took to heal, and the nature of its treatment. It is useful to conduct the routine examination under the following three headings : (1) Greneral inspection of the part injured ; (2) examination of sensation ; (3) examination of muscles. 1. General inspection of the part injured : {a) Position of injured ]3art or limb. (h) Wounds, scars, etc. (e) Condition of skin — changes in colour, des- quamation, blisters, ulcers, alterations in temperature. (d) Condition of nails and hair. 2. Examination of sensation : (a) For tenderness. (h) For loss of epicritic, protopathic, and deep sensibility. METHOD OF EXAMINATION 47 3. Muscular examination : {a) Wasting, general and localised, contractures. (h) Paralj^sis. (c) Electrical changes. 1. (a) The position taken np b}^ the injured limb or part may at once reveal the nerve involved ; the drop wrist of musculo-spiral injury, the drop foot of injury to the external popliteal, the ulnar hand and the true claw hand of injury to the median and ulnar are examples. (b) The presence of wounds and of scars must be noted, their nature and anatomical position. If a scar, whether showing signs of ]3rimary union or of healing by granulations, whether free of the deep tissues, or, if adherent, to what structures ? Palpa- tion in the neighbourhood may reveal the presence of bulbous enlargements, or of tenderness accom- panied by pain referred to the affected limb. (c) The condition of the skin should alwaj^s be investigated ; the desquamating skin seen a few days after the injury, the dry, bluish pink, atrophic skin of a later period or the red glossy skin, often covered with beads of perspiration will all aid in diagnosis. When blisters are present, their exact situation and relation to the area of analgesia, or of epicritic loss. A note should be made as to the mode of onset of the blisters or ulcers, if they originated in response to injury or appeared spontaneously. If the latter, this may point to commencing recovery. 48 INJURIES OF NERVES (d) The nails should be examined for changes in colour or gloss^ for brittleness^ growth of epithelium under the free edge^ curvature, ridging, etc. 2. In testing sensation, quiet surroundings are essential. The patient should be comfortably seated with the aifected part resting easily, so that no restraint is imposed or muscular effort necessar}^ to maintain the position of the limb. The eyes of the patient should be closed, if necessar}^, bandaged. He should be told to speak whenever he feels any- thing, whether a prick, a touch, or any other sensa- tion or change in sensation. No further questions should be asked. The usual method of testing, touching or pricking the patient and saying, " do you feel this, etc.,^^ is more time-consuming and quite untrustworthy. {a) If pain is complained of or the condition of the part is suggestive, the examination should be first conducted to find out if tenderness of the skin is present and its exact extent marked out. This can be done by dragging the point of a pin lightly across the limb from the sound to the affected side, the patient being told to speak as soon as the stimulus becomes painful. Immediately the tender area is reached, the patient withdraws the hand and shows obvious signs of discomfort. (h) Epicritic sensibility should be tested first; it is the system first affected in any injury of peripheral nerves, and the extent of its loss is greater than TESTS FOR LIGHT TOUCH 49 that of prick or deep touch. By this form of sensi- bility light touches are appreciated^ temperatures between about 22° C. and 38 C. discriminated^ and localisation as tested by the compasses^, rendered possible. For routine clinical work the testing of light touch is usually sufficient^ but temperature tests and the compass test are valuable in cases of difficulty or doubt. Light touch is tested by means of cotton- wool rolled up to form a pledget, or a soft cameFs hair brush stroked gently over the affected part. This test must be applied with circumspection. Certain parts — for example, the outer part of the thenar eminence — even of a well-kept hand, are relatively insensitive to cotton-wool and over the greater part of the palm of a working man no response may be obtained. Again, if used roughly, or dabbed on at right-angles to the surface, deep touch may be evoked ; even when lightly employed over desquamating areas this stimulus may be appreciated by means of deep sensibility. Errors may also arise with this form of stimulation over hair-clad parts in which there is retention or return of sensibility to prick. This is particularly liable to happen over the dorsum of the hand or external popliteal area of the leg, and may lead to errors in diagnosis or to over-estimation of the stage of recovery. But the sensation produced by the cotton- wool in these cases is entirely different, from that 4 50 INJUEIES OF NERVES given b}^ stimulation of tlie liairs on a normal part of the limb witli cotton-wool ; it possesses the radiat- ing, tingling character associated with protopathic sensibilit}^ On shaving a part in this condition it becomes entirely insensitive to cotton-wool. In all cases of doubt this should be done and the tempera- ture and compass tests applied. It sometimes happens that epicritic sensibility is altered but not abolished. In these instances the patient is often able to define an area of skin within which sensation is altered; dragging a piece of cotton-wool across the part from sound to affected portions will also mark it out_, and the compass test is in most cases defective. Within the area of epicritic loss, but retained protopathic sensibility (intermediate zone)_, a prick and the more extreme degrees of temperature are appreciated, but the patient entirely fails to discri- minate water' at about 22° C. from water at about 38° C, and sensibility to the compass test is defective. Glass test-tubes containing ice and water at 50° C. are used for investigating the extreme degrees of temperature ; for the minor degrees similar tubes containing water at about 24° C. and 38° C. These temperatures should be readily discriminated by the patient as cool and warm over the corresponding sound part, and should be first employed there and not used as tests for epicritic sensibility unless the patient is able readily to distinguish them over COMPASS TEST 51 normal parts. So many difficulties surround tlie testing of the minor degrees of temperature that too much reliance should not be placed on failure to dis- criminatCj and the test should only be used in cases of difficulty. In applying the compass test the blunt points of a pair of compasses are separated from one another for a measured distance. The skin of the affected por- tion of the limb is touched_, and the patient is asked to say after each stimulation whether he has been touched by one or two points. When they are separated for less than a certain distance^ varying with the part of the body under examination^ the points no longer appear as two on the normal skin. Dr. Head and the author found that two points could be accurately recognised over any part of the normal palm when separated for 1 cm. and applied transversely. This is more convenient than longi- tudinal application^ for the area available for testing is limited and the points are appreciated at a smaller distance apart when applied in this manner. In carrying out the test the method introduced by us is useful. The patient is touched ten times with one pointy ten times with two^ each being applied at random. The results are recorded graphically in the following manner. Every time the patient^s answer is correct a stroke is made, above a hori- zontal line if he was touched with one point, below if he was touched with two. An incorrect answer 52 INJURIES OF NERVES is recorded by a cross. Thus, if lie answers one when toiiclied with two points a cross is placed below the line. A preceding stimulus frequently has an effect upon those Avhich follow it, and to register the order in which the stimuli have been applied is therefore an additional aid to the inter- pretation of the records. Thus^ if the testing began with four double touches correctly answered four strokes would be made below the line. At the point above the line directly over the last of these would begin the record of the subsequent single stimuli j in this way the results of all further stimuli are recorded until the number is complete. Perfect appreciation of the compass points at a distance of 2 cm. would be represented thus : 1 I I I II I I I II 2 cm. ^ 2 II i I i II III If, however, the patient is unable to differentiate the two points at this distance, answering one to every stimulation, the record would stand : 1 I I I I I I I I I I 2 cm. „ 2XX XXXX XXXX Such a formula would show that when 2 cm. apart the sensation produced by two points is well below the threshold at which discrimination becomes possible. Less complete failure would be represented by some such formula as — 1 IIXX IX IXXI 2 cm. 2 XI IX IIXXX TESTS FOE PROTOPATHIC SENSIBILITY 53 where 50 per cent, of the answers are wrong with one pointy 60 per cent, with two j^oiiits. A curious phenomenon is the tendency to appreciate one point as two as soon as the limits of accurate discrimina- tion are passed. Used in this manner the test becomes a valuable one. A sharp needle or pin should be used as the test for pain^ and care must be taken that the patient understands he is only to speak when he feels the ]iain of the prick^ not when he feels pressure or a touch. Unless this precaution is taken mistakes easily occur^ particularly after division of the median or external popliteal nerves^ when large areas are often present sensitive to pressure but insensitive to prick. If any doubt exists it is easy to discover if sensibility to pain is present by using a painful interrupted current. When the iron core is inserted into the primary circuit of an induction coil, the current possesses a painful character due_, as suggested by Dr. Lewis Jones and confirmed by Dr. Head, to the greater duration of the current waves. This painful stimulation is not appreciated over the area where deep sensibility is present but protopathic sensibility is lost. No temperature sensations can be evoked from an area within which cutaneous sensibility is absent. For testing, tubes containing ice and water at 50° C. should be used, and the patient asked to state the 54 INJURIES OF XERYES nature of the stimulation^ whether a tonch^ warm or cold. Deep sensibility may be tested by means of the pressure of a pencil or other blunt object ; no diifer- ence in size can be perceived between the point of a pin and the blunt end of a pencil. One patient was unable to recognise the difference between the point of a pin and the end of a cylindrical rod 2 cm. in diameter; both appeared to be pressure. The appreciation of size (acuaesthesia) is a property of epicritic sensibility. It must be remembered that when deep sensibilit}' is present, pain may be produced if the pressure is excessive and corresponds to the amount necessary on the sound side to produce pain. This can be measured by Rivers' modification of CattelFs algo- meter. To call forth the pain of deep pressure a blunt object must be employed; it is impossible to call it forth by means of the pin or needle used in testing, a pressure of from 2 to 4 kgms. being necessary. In testing the sense of passive position and move- ment, the patient, whose eyes are closed, is asked to imitate with the corresponding sound part the move- ment of the part under examination. For instance, in testing the sense of passive movement and position in the first interphalangeal joint of a finger, the second phalanx is held between the observer's finger and thumb and moved in various directions, the EXAMINATIOX OF MUSCLES 55 patient imitating this with the corresponding finger of the sound hand. 3. The method of examination of the affected muscles is important^ and mistakes often occur from incompleteness of examination. (a) The distribution and amount of wasting and the presence and degree of contracture of the opposing muscles should be noted. (b) I have already pointed out the care which is necessary in this examination to avoid overlooking the paralysis of individual muscles. (c) It is most important that this should he thoroughly understood^ and it should be carried out, if possible, by the surgeon who will be responsible for the treatment of the case. The reactions of the muscles to both constant and interrupted currents must be investigated in most cases. A battery in which both currents are combined, the constant with a galvanometer in the circuit is most serviceable. It is so constructed that with the electrodes attached to one pair of terminals, either the interrupted or the constant current maj^ be used, and the latter reversed. Where electric light is installed the current may be taken from the main and its voltage reduced."^ The testing electrode should be of the closing type, that is, the current should not pass through it * For information on this and on the theoretical side of muscles testing the reader is referred to Dr. Lewis Jones' book on Medical Electricity. 56 INJURIES OF NERVES until the kej is depressed ; it should have a small bulbous end covered with wash-leather. The best form of indifferent electrode is the padded metal plate. The indifferent electrode is attached to the terminal marked +, the testing one to that marked — . The testing electrode is to be applied to the muscles at or near their motor ^^oints. These are situated at or near the point of entry of the motor nerves ; they vary slightly in different individuals, but their general situation is the same and should be learnt by practical muscle testing. The indifferent electrode should be firmly placed against some remote part of the body, where the muscular con- tractions which may be ^Droduced will not interfere with the examination of the affected part. When the legs are being tested, it may be placed in a basin of normal saline which immerses the patient's opposite hand, but this position interferes with the testing of the upper limb. In testing the intrinsic muscles of the hand the best results are obtained when the indifferent electrode is placed on the opposite side of the hand to that under investigation. Both the electrodes and the parts to be examined, not omitting the corresponding sound limb, must be well soaked in warm normal saline solution before commencing to test. Begin testing with the interrupted current, using a strength of current just sufficient to contract the muscles of the observer's thenar eminence. Always ELECTRICAL REACTIONS 57 use the current from the secondary coil (see that the switch is on S) — that from the primary is more painfuL A good light is essential in order to see that the muscle under observation contracts ; in some cases palpation over its tendon of insertion is necessary. If the muscles under examination react to the inter- rupted current no further investigation is necessary. If they do not react to this form of stimulation they must be tested with the constant current. Their reactions to this form of excitation are most important^ for in many cases Ave have to reh^ upon the nature of their response for the diagnosis be- tween complete and incomplete division. A normal muscle responds to stimulation with the constant current with a brisk twitch when the test- ing electrode is negative and the current is closed (K.C.C.). Li examining, apply the testing electrode to the muscle and close the current by depressing the key in the handle of the electrode, and observe on the galvanometer the current necessary to produce a response, then reverse the current, causing the test- ing electrode to become positive (A.C.C.), and again note the strength of current necessary under these conditions. In all cases compare the response given by the affected muscles and the current necessary to produce it with that given by the corresponding mus- cles of the sound side ; this must never bo omitted. In children a general ana3sthetic is often necessary. 58 m.JUEIES OF XERYES Examination in cases of recent injury. — In recent cases the scheme of examination must be somewhat modified. Tlie complete diagnosis cannot be made, apart from exploration, until such time has elapsed as will suffice for the development of electrical changes in the aifected muscles. But in a laro-e number of the cases that are seen soon after the accident, the nerve is injured as the result of an incised wound in the region of the wrist, and it cannot be too strongly insisted upon that a thorough examination of the parts below the wound should be carried out on the lines laid down, before any attempt is made to deal with the wound or divided structures under an aneesthetic. ISTumerous instances have come under the writer's notice in Avhich nerve injuries haA^e been overlooked for want of obeying this simple rule. Before starting a lengthy operation upon recently divided nerves and tendons it is well to know what structures are divided, and not to trust to a chance discovery to enable the correct structures to be found and sutured. Similarly all cases of fractures and dislocations or falls on the shoulder should be examined for signs of nerve injury before being treated. An instruc- tive case of this nature recently came under my notice. A patient sustained a dislocation of the shoulder, which was treated at a hospital and the dislocation reduced; he obtained compensation for this injury. Some time later he was dissatisfied EXAMINATION AND DIAGNOSIS 59 with the use of his arm and came under my care. I found a partial rupture of the fifth cervical anterior primary division^ upon Avhich I operated. The patient, considering that he had received compensa- tion for the dislocation only^ then claimed a further sum, and was successful in obtaining in Court a con- siderable sum in addition to what he had at first received. In the usual glass-cut wounds in the region of the wrist, tendons are in most cases divided in addition to nerves, so that the investigation of the loss of motor power may be attended with considerable difficulty ; but no such difficulty exists in the exami- nation of sensation, for loss of sensibility is always present in cases of division of the median or ulnar nerves, the nerves commonly affected in this way, and the division of tendons in addition entails a loss of deep sensibility, so that no mistakes are likely to arise from mistaking deep for superficial sensibility. Diagnosis. — No difficulty should arise in the diagnosis between complete and incomplete division after the fourteenth day if the examination be con- ducted on the lines I have laid down. When the injury is of sufficient standing to allow of recovery, or, in watching the after-progress of the patient, it is impossible without this complete examination to be certain if regeneration is taking place and to what stage it has advanced. It must be remembered also that if the limb has 60 m JURIES OF NERVES been allowed to remain in a bad position and no attempt made to correct the deformity^ sucli^ for example_, as the claw hand o£ nlnar paralysis, this will in all probability remain permanent ; although the muscles have regained their power of reacting to the interrupted current they remain paretic and wasted. This is also not uncommonly seen in cases of brachial birth paralysis which have been allowed to recover without any attempt being made to correct the deformity resulting or to attempt to prevent over-stretchino' of the affected muscles or contracture in their opponents. I have known cases such as these lead to errors in diagnosis and the patient has been submitted to futile operations in consequence. CHAPTER V Differential Diagnosis — From Lesions of Spinal Cord and Eoots ; Motor, Sensory — From Hysterical Manifestations; Sensory, Motor — From Iscli^mic Contractiu-e. Difficulties may arise in tlie diagnosis of lesions of the peripheral nerves from those of nerve roots^ of the spinal cord, from hysterical conditions and from Volkmann^s ischgemic contracture. Spinal cord. — Difficulties in diagnosis arise in most cases only in injuries of the cervical and sacral regions of the cord due to fracture dislocations of the spine. When the spinal cord is affected we have to deal not only with the effect of destruction, or interference with, the function of the segment of the spinal cord in which the lesion is situated and of the fibres entering into it at this level, but also with interference with the conduction of impulses passing up and down the cord. The resulting disturbance of motion and sensi- bility differs very considerably from that seen after a peri^Dheral nerve injury. Motion. — A lower segment lesion, that is, a lesion of the lower motor " neurone/' anywhere from its 62 INJUEIES OF NEEYES orio'in in an anterior liorn cell to its distribution in tlie muscle it supplies^ produces a flaccid paralysis accompanied by changes in tlie electrical excitability of the affected muscle^ and if complete^ the reaction of degeneration. It should be remembered that the motor fibre may be affected at the anterior horn cells as the result of an injury or anterior poliomyelitis or in the anterior root or peripheral nerve. In all these situations motion may be affected without sensibility ; in lesions of anterior horn cells or anterior roots motion is affected alone ; in the peripheral nerves sensibility is usually affected at the same time. The grouping of the affected muscles may at once denote the peripheral or central position of the lesion. For example^ the deformity produced by an injury of the ulnar nerve is different from the true claw- hand produced by a lesion of the first dorsal root or segment, and in the same way paralysis of the extensors of the fingers and thumb and the ulnar extensor of the wrist, while the supinator longus aild radial extensors of the Avrist remain unaffected, at once denotes the root or central position of the lesion. But the Erb-Duchenne or peroneal group of muscles may suffer as the result of interference with their supply in the anterior horn, root or peripheral nerve. In the former case (Erb- Duchenne) the diagnosis may rust entirely upon the SPINAL CORD AND ROOTS 63 history, for even section of tlie anterior primary division of the fifth cervical nerve, the nerve supply- ing this group, does not produce any sensory loss. In the latter case, if the lesion is in the root or anterior horn cells, the tibialis anticus often escapes and there is no loss of sensibility — an impossibility if the motor affection were due to injury of the external popliteal nerve which supplies these muscles. It is impossible to diagnose by symptoms alone between a lesion limited to the anterior horn cells and a lesion of an anterior root. The necessity for such a diagnosis fortunately does not often arise, and when it does the history of the case usually makes the diagnosis clear. Injury to anterior roots occurs chiefly in the cauda equina ; localised destruction of anterior horn cells as the result of disease ; it is rarely these are affected by an injury without causing some loss of conduction in the cord. The term '^ anterior root " should be strictly limited to its anatomical meaning and not used, as is so often the case, to denote the anterior primary division of a nerve. Paralysis, the result of an uj^per segment lesion, that is, of the upper motor fibres from the cortex to their termination in the cord, is easily distinguished by the electrical reactions of the affected muscles remaining unchanged and, in most cases, by the spasticity present. Seub-atiun. — It was shown by Head, Rivers and the 64 INJURIES OF NERVES author that the afferent impulses are grouped in an entirely different manner when the spinal cord is reached_, hence their interrui^tion will lead to entirely different sensory changes. The tracts in the spinal cord are devoted to the conduction of impulses concerned with pain_, heat^ cold and touch ; it is no long-er a question of epicritic_, protopathic and deep sensibility. This subject has been fully worked out by Head and Thompson J and the following is drawn from their article on the subject. Pain. — After division of a peripheral nerve or posterior root^ those parts only become insensitive to the pain of deep pressure which are at the same time totally insensitive to the tactile element of the stimulus. Unless all deep sensibility be abolished pain will be caused by excessive pressure. But if the lesion lies within the spinal cord sensibility to pain is abolished as a whole whatever the form of stimulation. Heat and cold. — When the lesion is within the spinal cord sensibility to heat may be abolished without sensibility to cold. Y/hen sensibility to heat or to cold is -abolished in consequence of an intra- medullary lesion, the patient no longer appreciates any warm or hot stimulus ; in the same way_, when sensibility to cold is abolished the patient no longer appreciates any cold or cool stimulus. All distinction between the minor and the extreme degrees of SPINAL COKD 65 temperature is lost, the appreciation of heat or of cold is lost as a whole. The patient may be insensitive to all degrees of temperature and yet be able to appreciate the lightest touch and discriminate the points of a pair of compasses — conditions which can never occur from a lesion of a peripheral nerve only. Touch, superficial and deep. — After division of a nerve or posterior root, light touches with cotton- wool are usually not appreciated, though deep touch (pressure) evokes a response. But when the lesion lies within the spinal cord both forms of touch are affected together. Passive movement and position. — After division of peripheral nerves the recognition of passive move- ment and of the position into which any part of the limb has been placed (passive position) is associated with the integrity of deep sensibility. But with an intra-medullary lesion it is entirely dissociated. The patient may be able to appreciate passive position and movement although totally insensitive to every other sensory stimulus, or vice- versa. In a similar way, a patient may be able to appreciate all varieties of touch perfectly, and yet be unable to discriminate two points (compass test). In lesions of peripheral nerves the compass test is always affected with light touch. We thus see that a rearrangement of impulses takes place within the spinal cord and that their interrup- tion causes loss of sensibility to pain, heat, cold, 5 66 IXJUIJIES OF NERVES or tactile sensibility as a wliole instead of to epicritic^ protopatliic^ and^, in some cases_, deep sensi- bility as occurs wlien tlie continuity of a peripheral nerve is interrupted. Put briefly tlie important points are as follows : After division of a peripheral nerve or of posterior roots there may be loss of epicritic_, protopathic and deep sensibility. After division of a peripheral nerve the loss of epicritic sensibility is greater than the loss of protopathic; after division of posterior roots^ the loss of protopathic sensibility exceeds in extent the loss of epicritic. But when the injury affects the spinal cord^ pain^ temperature appreciation^ touch, may be affected separately. Usually light and deep touch are well recognised although sensibility to pain and to temperature is absent. In unilateral lesions of the spinal cord the appre- ciation of pain, heat and cold is affected on the side opposed to the lesion, passive movement and position on the side of the lesion and the motor affection. Hysterical affections. — The hysterical limbs of women are well recognised ; but occurring in healthy men, complicating, as they may, fractures, dislocations, or even a nerve injury, they are not so often diagnosed. This type of functional nervous disorder may follow any form of injury ; thus, I have seen anaesthesia and paralysis of the whole hand follow a burn of the thenar eminoiico in a woman, and a fracture of the radius in a boy of twelve. It may complicate HYSTERICAL AFFECTIONS 67 recovery from operations; in one case that came under my care paralysis of the upper limb was noticed after the evacuation of a large abscess in the supra-clavicular region_, and gave rise to the opinion that the brachial plexus had been injured. The following* is a typical case^in this instance_, complicating a fracture of the humerus. " A seaman^ aged forty-four years^ fractured his humeriis while at sea. It was treated by the master of the ship and kept in splints for six weeks ; union was perfect and the position good. When the splints were removed it was found that the limb was ' completely paralysed.^ He was sent to me as a case of injury to the brachial plexus. " The patient was a robust man who had followed the sea for thirty years^ and had never had any serious illnesses. " All the muscles of the right upper limb were wasted^ the arm, forearm and hand were paralysed and the muscles flaccid. The skin was bluish in colour_, and cold. '' Over the whole of the upper limb he was insensi- tive to all forms of stimulation, including deep touch, and the upper limit of the sensory loss sur- rounded the limb as a ring (stocking anaesthesia). The distribution and nature of the loss of sensibility at once demonstrated that it could not have resulted from injury to peripheral nerves or spinal cord. On testing the muscles electrically they responded 68 INJURIES OF NERYES readily to stimulation with the interrupted current_, as is always the case in this affection/^ The condition may follow an injury in either sex^ but is more often seen in the male. So far as I have been able to ascertain they are usually healthy individuals and may show no other hysterical mani- festation. Careful examination will sometimes reveal the typical hysterical change in the field of vision_, a contraction of the whole field of vision^ more marked on the affected side Avith contraction of the colour field^ appreciation of blue being diminished first in contra- distinction to the diminution of the field of vision for red^ seen in patients with organic disease. As a rule loss of sensibility and paralysis are both present^ but either may be found alone^ the former more often than the latter. The loss of sensibility is to all forms equally (including deep touch) ^ a variety of loss that does not occur after any peripheral nerve, posterior root^ or spinal cord injury ; its upper limit usually surrounds the limb, often at the level of a joint, and all forms of sensibility are lost up to the same level. In the upper limb the loss of sensibility may cover the ]3ectoralis major muscle in front and the scapula behind (fore-quarter type). The paralysis may persist unchanged for years and marked muscular wasting will then occur. It is, as a rule, flaccid, and no attempts are made to throw the affected muscles into action, but occasion- HYSTERICAL AFFECTIOXS 69 ally a patient is met with in whom attempts to perform a movement — for example^ flexion of the elbow — causes an equal and simultaneous contraction of both flexors and extensors_, rendering the dia- gnosis easy. Contractures may be present^ differing from those seen as the result of iujuries to nerves_, in that all the muscles are aifected^ not only those on the same side of the limb as the contracture. For example^ in a contracture at the elbow of a hysterical limb^ not only are the flexor muscles rigid^ but any attempt to further flex the forearm is met by con- traction of the triceps. No diflaculty should arise in the recognition of most examples of this condition : the loss of sensi- bility is diagnostic and the flaccid paralysis with retention of electrical reactions typical. But when complicating a nerve injury it gives rise to difiiculty. It explains many of the recorded cases of nerve ^' concussion" in which paralysis of the w^hole of a limb results from a gunshot injury which may or may not have injured one nerve. In the latter case the widespread symptoms rapidl}^ clear, leaving signs of involvement of one definite nerve. In Civil practice I have seen several examples of this condition some time after the original accident, but have not yet observed it at the time of infliction of the nerve injury. Careful attention to symptoms will enable the diagnosis to be made. The paralysis may be wide- 70 INJURIES OF NERYES spread and affect muscles central to the site of the nerve injury^ but occasionall}?'' — for example^ after division of the median or ulnar nerves at the wrist- all the intrinsic muscles of the hand are found to be paralysed^ and only the electrical examination reveals the functional nature of the paralysis of one group of these. In testing sensibility the remarkable correspondence of the upper limit to all forms of sensibility and the affection of deep sensibility should make the diagnosis^ even in these cases^ easy. Volkmami's ischsemic contracture. — It sometimes happens that difficulty occurs in connexion with the diagnosis of this condition. Several cases of this nature have been recorded as unusual examples of nerve injury. The contracture most often results from the injurious pressure of tightly-applied splints^ and nerves may suffer as well as muscles. In a typical example, arising after splint-]3ressure in the forearm^ it will be found that the forearm is held pronated, with the wrist and fingers flexed ; supination of the fore- arm and active or passive extension of the wrist or fingers is impossible. The contracted muscles are not paralysed and react normally to both interrupted and constant currents^ hence the name " ischasmic paralysis" sometimes given to this condition is a misnomer. On flexing the wrist, so relaxing the contracted muscles, the fingers can be extended, and on ex- ISCHEMIC CONTRACTURES 71 tension of the wrist they again become flexed, showing tliat the condition is due to diminution in length of the affected muscles. The injury to the median and ulnar nerves which so often complicates the condition will affect the intrinsic muscles of the hand; these maybe wasted and paralysed and give the reaction of degeneration, and there may be the usual loss of sensibility seen after complete division of these nerves, but as a rule the nerve injury is incomplete. CHAPTER VI The Treatment of Nerve Injuries — General Lines of Treatment — Treatment of Nerve Injuries in Accidental Wounds — Primary- Suture — Subcutaneous Injuries — Secondary Suture — Treat- ment of Nerve Injuries complicating Fractures — Treatment of Gunshot Injuries. The general lines of treatment of any nerve injury are tliese : to maintain the nutrition of the parts supplied by the injured nerYe_, to prevent over- stretching of the paralysed muscles and contracture in the opponent muscles until conduction is restored, by Nature alone or aided by the surgeon. It is therefore obvious that operation, although in many cases essential, is but one step in the treatment. The patient, and in some cases even the surgeon, are prone to consider that when the ends of the nerve have been united by operation nothing further remains to be done. This erroneous idea is respon- sible for many failures in complete restoration of function; the successful result of the operation depends to a great extent upon the care bestowed on the after-treatment, carried out, it may be, for months or even years. TREATMENT 73 In every case of nerve injury in which muscles are paralysed^ these muscles must be kept relaxed by suitable apparatus until voluntary power is restored. This essential to treatment is often overlooked and recovery in consequence delayed or rendered incom- plete. This is especially seen after injuries of the ulnar and external popliteal nerves. In the former case the ulnar position of the hand often becomes permanent and the muscles remain atrophied^ although they have regained their excitability to stimulation with the interrupted current^ in the latter^ recovery is slow and the talipes equinus may render a sub- sequent tenotomy necessary. The splint or apjDaratus used must be removed daily and massage and systematic passive and active movements carried out. This may be supplemented by stimulation with the interrupted current, and the paralysed muscles excited with whichever form of current they will respond to — usually the con- stant. This electrical treatment should be carried out whenever possible, but is not so necessary as massage and movements ; these should be employed at least three times a week, if possible daily. The patient should be warned that slight injuries may produce serious results, that, for example, water not unpleasantly hot to unaffected portions of the body may cause blisters to appear on the affected. No work should be done with the affected limb. Fortunately this is possible in most cases owing 74 INJURIES OF NERVES to accident insurance and workmen^s compensa- tion. As soon as voluntary power begins to return splints may be removed ; the recovering muscles must be actively exercised every day and massage con- tinued until recovery is complete. Cases submitted to suture are treated on these lines as soon as the wound has healed. Treatment of nerve injury in accidental wounds. — It should be a matter of routine to examine for evidence of nerve injury all patients with accidentally inflicted wounds. This is often omitted_, sometimes with serious consequences to the patient ; the prognosis of secondary suture of certain nerves is much more unfavourable than primary. These wounds are particularly common in the region of the wrist, and are usually caused by broken glass, windows or bottles, and sever in most instances tendons in addition to nerves. The condition of sensibility and the action of the intrinsic muscles of the hand should be investigated before any attempt is made to deal with the divided structures. After this examination, the skin surrounding the wound is thoroughly cleaned and the nerve exposed through an incision of sufficient length and examined ; it is usually necessary to make the incision at right angles to the wound causing the injury. In all nerve operations asepsis is essential ; in no branch of PRIMARY SUTURE 75 surgery does slight supj^nration interfere so greatly witli the success of the operation. If the nerve is found to be incompletely divided, the gap should be closed by a catgut stitch to bring the cnt axis cylinders again into apposition and to prevent the ingrowth of fibrous tissue. If the nerve is completely divided primary suture must be performed. Primary suture. — The modern operation of primary suture is of comparatively recent date. It is said to have been performed first by Baudens in 1836, who sutured all the nerves of the brachial plexus with the exception of the musculo-spiral, which were divided in a sword cut of axilla. But it is only since 1864 that it has been a recognised method of treatment, Nelaton^s being the first of the more recent cases. In the operation of joi'iniary suture it is necessary to bring the divided ends of the nerve into apposition, and to jDrevent, if possible, the ingrowth of fibrous tissue and adhesion of the junction to surrounding- structures. If the ends of the nerve are lacerated they should be trimmed transversely with a sharp scalpel. Scissors should never be used for the purpose ; their crushing- action may prevent recovery. It sometimes happens that a nerve is divided at two or more levels, a portion being loose ; this should be sutured in. It is unusual to find so great a portion of the nerve 76 INJURIES OF NERVES destroyed that it is impossible to bring the ends into apposition; for the treatment of this compli- cation the reader is referred to Chapter VII. Sterile catgut is the best suture material for nerves. It is not necessary to use hardened gut unless there is tension on the stitch, but if con- siderable portions of the ends of the nerve have had to be removed on account of laceration, catgut, hardened to resist absorption for at least fourteen days, should be employed. The suture should be passed with a round needle, both needle and suture being as small as possible. The suture should be passed through the whole thickness of the nerve at right angles to its axis and tied with just sufficient force to bring the ends into apposition. It is some- times said that the catgut should not be passed through the whole substance of the nerve on account of the bad results which would arise if infection were to occur. But paraneurotic suture is an operation involving much more handling of the nerve, if the sheath of a nerve the size of the median or ulnar is to be sutured ; in my opinion the method which I have recommended, passing the suture through the whole thickness of the nerve, is the one least open to objection. In most cases it is only necessary to use one stitch. The nerve should be handled with extreme gentleness and the whole end of the nerve never grasped in the forceps ; the sheath of the nerve only should be picked up with fine toothed PRIMARY SUTURE 77 forceps and the nerve steadied in this way while the suture is being passed. Silk should never be used as a suture material. It remains as a foreign body in the nerve and may give rise to trouble months after primary suture. In one case that came under my notice, following primary suture of the median nerve, restoration of sensibility was almost complete and motor power had returned to the affected muscles, when the occurrence of inflammation around the silk suture used to unite the ends of the nerve put back the condition of the part to that which was present immediately after the accident; the symptoms again became those of com- plete division of the nerve. After evacuation of the abscess and removal of the stitch, recovery was exceedingly slow and was not complete many months after the time usually taken in primary suture of the median nerve. Not only must the ends of the nerve be brought together by suture, but means should be taken to prevent the ingrowth of fibrous tissue between the nerve ends, and the junction from becoming adherent to surrounding parts. For this purpose I use chromicised Cargile membrane. This resists absorption in the tissues certainly for five weeks, and does not cause irritation. I have used it now in many cases of nerve and tendon injury and also in cerebral surgery and have never found it give rise to trouble. Many other substances have been 78 INJURIES OF NERTES recommended from time to time — decalcified bone tubes (Yanlair)^ gelatine tubes (Lotlieisen)^ animars artery (Foramitti)^ paraffin wax (Murpliy). After primary suture of a nerve in an accident- ally inflicted wound it is always Avise to put in a drain for a short time ; it can usually be removed in four and twenty hours. After suture of the skin wound the limb must be put up on a splint so arranged that no tension is thrown upon the junc- tion and the paralysed muscles are relaxed. The further treatment is on the lines I have already laid down. Treatment of subcutaneous injuries. — All the signs of complete division may be present as the result of an injury of this nature ; there is no sign by which Ave can tell if the nerve has been ruptured or injured as the result of compression, in other words^ if the injury is anatomical or physiological_, and in many cases^ at first, if it is complete or incomplete. If seen immediately after the accident,, the limb should be put at rest on a splint with the paralysed muscles relaxed. Daily massage should be employed until such time has elapsed as Avill enable the diagnosis of the degree of the injury to be made. If at the end of a fortnight the reaction of degeneration has developed in the paralysed muscles, the nerve should be exposed. It may be found completely ruptured ; more often it is swollen and firm at the seat of the injury. This damaged portion should be SECONDARY SUTURE 79 removed and the ends brought into contact. If no change can be discovered in the condition of the nerve^ the wound should be closed. When the division is obviously incomplete, relaxation of the muscles is to be kept up Avith daily massage until voluntary power returns, when the splint may be discarded and active movements encouraged. The massage should be continued until recovery is complete. Sometimes a nerve becomes secondarily involved in fibrous tissue, or pressed upon by bone, or in a case of incomplete division, in spite of appropriate treatment the condition does not improve. Explora- tion should be undertaken in these cases, the nerve freed, the cause of the pressure removed and means taken to prevent the nerve from becoming adherent by surrounding it by one of the substances already mentioned ; for this purpose I prefer Cargile mem- brane. Secondary suture. — This operation is of more recent date than primary suture. Said to have been first performed by Nelaton in 1864, it was first carried out in this country by Jessop in 1871. Various meanings have been attached to the term '^secondary suture '^ ; it has been described as suture after the first twenty-four hours. The author uses the term to mean suture after degeneration has taken place in the peripheral end of the nerve. Secondary suture should be unknown after injury 80 INJURIES OF NERVES to nerves in wounds ; but in the case of sub- cutaneous injuries it may be unavoidable. Before proceeding to operation a careful examina- tion is necessary in order to discover liow much improvement is likely to ensue as tbe result of the operation. The time after the injury at which opera- tion is undertaken^ certainly up to three years^ seems to have little influence on the time of recovery^ and there is no reason why success should not be obtained at much longer periods^ although no entirely satis- factory case has been recorded. Of more importance than the time after the accident is the nature of the original injury, if an incised wound, its manner of healing ; suppuration in the original wound seriously diminishes the chance of complete recovery. The condition of the muscles and joints should be investigated. Muscles which have been overstretched for months are unlikely to have their function com- pletely restored, although they may regain voluntary power and electrical excitability as the result of the operation. For example, the ulnar position of the fingers met with after division of the ulnar nerve rarely or never disappears after secondary suture. The interossei muscles have been lengthened, the extensors of the fingers, the ligaments around the metacarpo-phalangeal and inter-phalangeal joints contracted. The electrical reactions must be tested. If there is no reaction to stimulation with the constant current SECONDARY SUTURE 81 it is probable that muscular recovery is impossible, but this opinion must not be given on one examination only, however carefully carried out. From the point of view of sensation it is always worth while attempting secondary suture, especially if " trophic ulcers '' are present, for Dr. Head and the author showed that the fibres upon which the integrity of the trophic condition of the skin depend, regenerate under conditions which render recovery of epicritic sensibility and motor power unlikely. The operation of secondary suture may be divided into three stages. (1) Identification of the ends of the nerve. (2) Freeing and freshening the ends of the nerve. (3) Re-establishment of anatomical continuit3^ (1) The incision should be made over the line of the nerve and be of sufficient length to expose the trunk well above and below the seat of the injury. The nerve should be traced from above and below; any attempt to find it directly at the seat of the injury will only lead, in most cases, to unneces- sary damage being inflicted on the nerve. (2) The bulb with the fibrous tissue, which is usually found surrounding and uniting the two ends, is then well freed and the nerve stretched. After this has been done the bulb on the central end is removed with a sharp scalpel. From the lower end only the fibrous upper extremity need be removed ; the whole of the lower end of the nerve is in the 6 82 INJURIES OF NERVES same condition^ so tliat it is useless cutting section after section in tlie hope of finding sometliing which looks less like fibrous tissue and more like nerve. (3) Catgut should be used for suture material^ and it is best to use catgut hardened to resist absorption for about fourteen days. The junction and the freed portion of the nerve are then surrounded with Cargile membrane. It often happens that the ends do not come readily into apposition after the necessary amount of nerve ends have been removed ; it was for this reason that the preliminary stretching was recommended. This will give fully an inch in the upper limb^ and com- bined with relaxation of all the joints over which the nerve passes^ will rarely fail to enable the ends to be brought into contact. If a gap is still left one of the methods described in the following chapter should be adopted. After closure of the wound the limb should be put up so that there is no tension on the nerve and the paralysed muscles are relaxed. The position neces- sary to prevent tension on the junction must be maintained until the wound is soundly healed and then very gradually corrected. Nerve injuries complicating' fractm^es. — The nerve may be injured at the time of the accident, ruptured^ lacerated, pressed upon by the fractured end of the bone or nipped between the fragments. In primary injury to the musculo-spiral nerve complicating a COMPLICATINa FKACTUHES 83 fracture of the humerus, operation should be carried out, the condition of the nerve investigated and the appropriate treatment adopted. Means should also be taken to mechanically fix the fracture. The same rule should be followed in primary involvement of the external popliteal in a fracture of the fibula. In most cases, however, the nerve injury is not dis- covered until the splints are removed ; in many of these the nerve involvement is undoubtedly secondary. The rules for treatment in these cases are simple. If the signs of complete division are present, opera- tion must be performed; the nerve should be ex- posed above and below the seat of the fracture and traced towards it. The nerve may be found rup- tured, but more often involved in callus or fibrous tissue and altered in shape and consistency, usually being thin and fibrous; when found completely divided anatomically, secondary suture should be carried out. In the complete physiological division the damaged portion should be excised and the con- tinuity of the nerve restored, unless the nerve be found little altered, when freeing and wrapping with Cargile membrane may first be tried. If no improve- ment occurs in a few weeks then the damaged por- tion must be resected. When the signs are those of incomplete division, the limb should be kept at rest and the usual treat- ment carried out. If improvement does not occur the nerve must be cut down upon and tlie cause of the 84 INJURIES OF NERVES pressure removed. It sometimes happens that the involvement comes on some weeks or months after the injury ; in these cases operation should be per- formed without delay. Treatment of gunshot wounds. — These should be treated upon the lines already laid down, remember- ing that primary suture is inadvisable in most cases under ■ the conditions obtaining in war time. In other respects the general rules apply. The limb should be kept at rest and the injury treated as if subcutaneous. CHAPTER VII Plastic Operations on Nerves — Metlaods available to restore con- tinuity — Nomenclature — Nerve Transplantation — Nerve Anastomosis — Nerve Crossing. When exposing the ends of a nerve in order to perform secondary suture, after the excision of a tumour connected with a nervCj or in some cases of primary nerve injury^ it may be found that in spite of nerve stetching and of flexion of the joint or joints over which the nerve passes, it is impossible to restore anatomical continuity. Many methods have been suggested from time to time to bridge over the gap left between the ends of the nerve. Those which have proved satisfactory may be put into one of four groups. (1) Transference of a ^^ortion of nerve from another source (nerve transplantation). • (2) Provision of a path along Avhicli the nerve may regenerate (tubular suture, flap opera- tions, etc.). (3) Utilisation of neighbouring nerves (anasto- mosis). (4) Shortening the limb by the resection of bone. Nomenclatiu^e. — The operation of the transference 86 INJURIES OF NERVES of a portion of nerve from another source has been known in English-speaking countries as '^ nerve grafting/^ But this term conveys a different mean- ing to French and Grerman surgeons ; nerve grafting (greffe nerveuse, nercenjjropfung) is to them synony- mous with nerve anastomosis. This would be an insufficient reason for change had the term '^ nerve grafting ^^ been used consistently by English-speaking- surgeons to mean nerve transplantation. But of late_, with the multiplication of operations on peri- pheral nerves^ it has been used loosely to mean sometimes nerve anastomosis^ sometimes nerve cross- ing, and at others nerve transplantation, in this way causing confusion and retarding progress. Again, the operation of uniting an affected to a neighbour- ing sound nerve has been spoken of as nerve grafting, nerve implantation, etc. For these reasons I sug- gested that the term "nerve grafting" be allowed to drop and the name " nerve transplantation " employed in its stead. Under the term " nerve anastomosis " two distinct ope/ations are often included : (1) In which axis cylinders of the injured nerve are brought into contact with some of the axis cylinders of the sound nerve ; this is the operation to which the term should be restricted. (2) In which a neighbouring sound nerve is divided completely and end-to-end union carried out with the perijDheral end of the affected nerve ; this should be spoken of as nerve crossing. NERVE TRANSPLANTATION 87 We liave therefore the f olio win o* nomenclature : nerve transplantation^ nerve anastomosis, nerve crossing. Group 1, Nerve transplantation. — It was demon- strated by PhilJipeanx and Yulpian in 1870 that a portion of the lingual nerve of a dog could be transplanted into a gap in the hypoglossal, restora- tion of function occurring in due time. It was at first considered that the transplanted portion of nerve played an active part, and Gluck even spoke of its healing by " primary union/^ meaning thereby restoration of function without degeneration in the transplanted portion and peripheral end of the nerve. Tillmans was the first to suggest that a transplanted portion of nerve acted only as a scaffolding for the support of the newly-formed nerve-fibres. Recently Ballance and Purves Stewart came to the same con- clusion as the result of their experiments. But it has been pointed out by Merzbacher and confirmed by Marinesco that the changes which take place in an isolated portion of nerve inserted between the cut ends of another nerve difi^er when the trans- plant is taken from the same animal (auto-trans- plantation) or from one of the same species (homo- transplantation) from those which occur when it is taken from an animal of another species (hetero- transplantation). In the last instance death and necrosis occur, in the first two, degeneration, which is a vital process. Forssman found in his experi- 88 INJURIES OF NERYES mental work on rabbits^ that when the transplant was obtained from another rabbit regeneration took place as rapidly as after primary suture ; but when taken from an animal of another species^ regenera- tion occurred much more slowly^ and in some cases no regeneration at all took place. It appears therefore as the result of ex]3eriment that the transplanted portion of nerve plays an active part when it is taken from the same animal or one of the same species, and does not act only as a scaffolding for the new nerve-fibres^ but has a definite influence on regeneration through the cells of the nucleated sheath. This is borne out by the clinical evidence. JSTerve transplantation was first employed in treat- ment by Albert in 1876, who inserted a portion of the posterior tibial nerve of an amputated limb into a gap in the median nerve. Mayo Robson, in 1888, was the first to perform the operation in this country, and his was the first successful case recorded. Into a gap in the median nerve, due to the resection of a portion of the nerve with a neuroma, he transplanted two and a half inches of the posterior tibial nerve from an amputated liiiilj. '^Fhe affected muscles reacted to stimulation with the interrupted current nine months later and restoration of function was complete three years after operation. After examining the records of all the published cases of nerve transplantation I came to the conclusion that the clinical results bore out the experimental in- FLAP OPERATIONS 89 vestigations of Forsmann, Merzbacher and Marinesco; tliey were incomparably better when auto- or homo- transplantation had been performed than after hetero-transplantation. Thus although only three out of eight cases of auto- and homo-transplantation are reported at a sufficient interval after operation to admit of recovery^ two of these recovered com- pletely ; one showed no sign of motor recovery seven- teen months after operation. On the other hand, out of twenty-two cases of hetero-transplantation, sixteen are recorded at an interval after operation which would have permitted of recovery. Of these only one can be definitely said to have recovered, that is it is the only case in which a complete report is given, including the electrical reactions of the affected muscles, but perhaps recovery ensued in two of the remainder. Group 2. — There is one operation in this group that must be shortly mentioned to be condemned — that is, the operation of turning Haps of nerve from both ends to bridge over the gap. This method, recommended and employed by Letievant under the name '' autoplastic nerveuse a lambeaux,^' leaves a complicated wound on both ends of the nerve and on the flaps used as bridging nuiterial, which must certainly become adherent to the surrounding struc- tures and favour the ingrowth of fibrous tissue. The results are as unfavourable as the method would lead us to expect. 90 INJURIES OF NERVES The other operations in this group aim at the pro- vision of a path^ free from fibrous tissue, along which the new axis cylinders may develop. This was first attempted by Assaky in his ^' union at a distance '' Avith cato'ut threads, in which the ends of the nerve were brought as near as possible by catgut sutures, which bridged over the gap. It has been improved by the introduction of tubular suture (Vanlair), in which, in addition, the ends of the nerve are sur- rounded by a tube. Various materials have been used — decalcified bone, aluminium, collodion, and recently, preserved and hardened animals^ arteries, and a resected portion of one of the patient^s super- ficial veins. This last seems the best form of tube to employ. Tubular suture has given results which are a little better than those given by hetero-transplantation. Group 3. — The possibility of the union of motor nerves supplying different groups of muscles at- tracted the attention of investigators at an early date. Flourens, in 1828, was successful in his attempt to cross the nerves of the brachial plexus of a fowl. But it is from investigations of a more recent date that our knowledge of the subject is obtained. Manasse, in 1898, was the first to experi- mentally investigate what we now understand as nerve anastomosis ; but it is to the work of Kennedy, Kilvington, and Langley and Anderson, that our exact knowledge is due. NERVE ANASTOMOSIS 91 It is essential to separate nerve anastomosis from nerve crossing, for in the former an attempt is made to bring tlie axis cylinders of tlie affected nerve into end-to-end contact with some of those in the sound; in nerve crossing the peripheral end of the affected nerve is united end-to-end with the central portion of a divided sound nerve. Nerve crossing was first worked out experimentally, but surgery led the way A. B. c. I'iG. 3. — Complete peripheral anastomosis, showing the three methods of iinion. The affected nerve is shaded in all the figures relating to nerve anastomosis. a. Insertion of peripheral end of affected into vertical slit in sound nerve. B. Insertion of peripheral end of affected nerve into a gap in the sound nerve, produced by an oblique incision ; c. End-to-end union, with fiaj) raised from soimd nerve. for experimental investigation into the question of nerve anastomosis. Nerve anastomosis. — Letievant first recommended this operation in 1873 under the name of " greffe nervense.'^ He had, however, no opportunity for 92 INJURIES or NERVES carrying it out. Despres (1876) appears to have been the first to perform it^ but the case was re- ported two months after the operation — too early a date to admit of recovery. It was not until 1897 that Sick and Sanger reported the first successful case. Two months after rupture of the musculo- spiral nerve in a compound fracture of the humerus^ Fig. 4. — Partial peripheral anastomosis. Can also be car- ried ont by methods b and c. Fig. 5. a flap of the median nerve was raised and the peri- pheral end of the musculo-spiral united end-to-end with it. Twenty-seven months later all the muscles of the forearm except the extensor longus pollicis acted normally, and reacted to stimulation with the interrupted current. Recently much attention has been directed to operations of this nature by the work of the Ballances NERVE ANASTOMOSIS 93 and Purves Stewart on nerve anastomosis in facial paralysis. The results of tlie operation of nerve anastomosis have been most encouraging. Out of twelve cases (excluding those in which the operation was carried out for facial paralysis or infantile paralysis) reported Fig. 5.— Complete central anastomosis. Can also be carried out by methods b and c^ Fig. 5. sufficiently long after the operation^ oi\\j two were failures^ some recovery taking place in all the others^ although it is impossible to say from the published reports that recovery was complete in any case. Several methods of nerve anastomosis are possible. They may be divided into the peripheral and central^ the partial and the complete. In peripheral anasto- mosis (Figs. 3, 4) the whole or part of the peripheral 94 INJURIES OF NERVES end of the affected nerve is brouglit to tlie sound nerve. In central anastomosis (Figs. 5^ Q), the unaffected nerve is divided completely or partially and its central united to the affected nerve. In some of the recorded cases of nerve anastomosis the peripheral end of the affected nerve was sutured to the sheath of the sound; the failure which Fig. 6. ■Partial central anastomosis. Can also be carried out by methods b and c. Fig'. 3. resulted was to be expected. It should be the aim of the surgeon to bring the cut ends of axis cylinders into contact^ for without this^ union with the central nervous system is impossible. This end -to -end contact may be brought about in three ways (vide Fig. 3) ; in the case of small nerves^ by making a vertical slit in the sound nerve sufficient axis cylinders are divided to ensure a good result; but in larger nerves^ a flap should be raised and the NERYE CROSSING 95 affected nerve sutured in or united end-to-end with it. Raising a flap and uniting it end-to-end with the peripheral end of the affected nerve is the best method to adopts as it avoids the possibility of the union of one axis cylinder in the central end of the sound nerve with an axis cylinder in each peripheral end. In cases of nerve injury complete peripheral anas- tomosis is the variety that must be employed ; it is not justifiable to completely divide a sound nerve. It has been recommended to implant the central end of the divided nerve also into the sound and so use the sound nerve as a path along which new nerve-fibres may make connexion between the two ends. But it has been shown that the axis cylinders in the central end of a divided nerve have no preference for those of its own central end^ but will just as readily make connexion with those in the peripheral end of a nerve united to it. The results are therefore likely to be better if the central end is not used, for the cross union of axis cylinders which must result makes the restoration of perfect co-ordination unlikely. Nerve crossing. — This operation was first carried oat in the human subject by Drobnik, in 1879, in a case of facial paralysis, the peripheral end of the facial being united end-to-end with the divided external branch of the spinal accessory nerve. It has been employed chiefly in operations upon the 96 INJURIES OF NERVES facial nerve, and will be discussed fully in dealing with that condition. Method 3. — This, originally recommended by Lobker, has been carried out successfully by Keen and others in cases of division of the musculo-spiral nerve complicating fractures of the humerus. It is only justifiable in dealing with injuries of this nerve, when, as in one of Keen\s cases, non-union of the bone is present in addition to the nerve injury. The method to be employed to restore continuity will depend upon the nerve injured and the size of the gap. The method of election is undoubtedly auto- or homo-transplantation. This operation is most often necessary in cases of injury to the mus- culo-spiral nerve. Here the treatment is simple. The incision is j)rolonged downwards, the radial nerve exposed, and an adequate portion resected and sutured Avithout tension into the gap between the two ends of the musculo-spiral nerve, the whole being surrounded by Cargile membrane or an absorbable tube. The upper two thirds of the radial nerve may be removed without causing any demonstrable effect upon sensation. This operation was, I believe, first suggested and carried out by Mr. Dean at the London Hospital in 1896, but the method was never published. A portion of the patient's own radial nerve, three inches in leugth, was inserted into a gap in the musculo-spiral. Voluntary NERYE TRANSPLANTATION 97 power began to return six months later, and wlien I last saw liim, five years after the operation, recovery was perfect. A similar operation may be carried out in the case of other nerves of suitable size. We do not yet know how much nerve it is possible to transplant with success. Four inches have been used and recovery ensued, but if the distance exceeds this it v/ould probably be wiser to resort to anasto- mosis. But auto-transplantation may be impossible on account of the size of the nerve — for example, the great sciatic. It may be feasible in hospital practice to transplant a portion of nerve from an amputated limb (homo-transplantation) . This should be done if possible, with, of course, every precaution against infection. If this is impracticable, tubular suture should be performed. A decalcified bone tube or sterile preserved animals artery is passed over one end of the nerve, and the ends are then brought as nearly as possible into apposition by catgut sutures and the tube slipped into position to cover the junction. When the distance between the ends is more than about four inches and a nerve of suitable size and function is near, the peripheral end of the divided nerve should be anastomosed to the neio'h- bouring sound nerve and the junction surrounded with Cargile membrane. No permanent damage need result to the nerve to which the peripheral end 7 98 INJURIES OF NERVES is anastomosed. It is possible^ as I pointed out in the chapter on incomplete division^ to cut tlirougli a third or more of the trunk of a nerve without pro- ducing more than a transient paresis_, unless the nerve be roughly handled or the incision divide a branchy or infection occur. Gentleness of handling is essential in this as in all other operations upon nerves. The after-treatment of these cases of nerve anas- tomosis must be carefully carried out. In addition to the general treatment given on p. 73^ special attention must be directed during the return of voluntary power to the training of the muscles in co-ordinate movements. The method of filling in a gap in a divided nerve may be summed up as follows : Auto- or homo-trans- plantation when possible ; failing this_, nerve anasto- mosis or tubular suture. CHAPTER VIII Recovery after Complete Division of a Nerve — "Primary Union " — Sensory Recovery after complete Division ; three stages — Motor Recovery — Recovery after Primary Suture ; Prognosis — Recovery after Secondary Sntiu-e ; " RajDicl Retiirn of Sensi- bility " ; Prognosis — Complications arising during the Pro- gress of Recovery — " Trophic " Ulcers— Theories with regard to Regeneration. When a nerve is completely divided degenera- tion follows in the whole peripheral end; before con- duction can be re-established regeneration must take place. "Primary union." — By this term was understood union of the divided ends of a nerve with re-estab- lishment of conduction without the occurrence of degeneration in the peri^Dheral end. Until 1839 it was considered that function was restored by union of the divided ends of the nerve just in the same way as another tissue. Swan, in 1834, wrote : " There appears to be two modes which Nature employs for effecting the union of divided nerves, one by the effusion of coagulable lymph, the other by granulation/^ Nasse, in 1839, pointed out that degeneration occurred in the peripheral end of a divided nerve ; but it was Waller^s classical re- 100 INJURIES OF NERVES searches^ publislied in 1852^ that gained general acceptance for this view. In June^ 1864^ two examples of "primary union" of the median nerve were reported at medical societies in Paris. The first was a |)atient operated npon by Nelaton^ who resected a portion of the nerve with a neuroma : the second^ a case of acci- dental division at the wrist, in which Laugier had performed primary suture. Both Avere reported, and have since been quoted, as examples of primary union. But of Nelaton^s case, it is recorded that he observed retention of sensibility before the operation, but " in spite of his astonishment said nothing '^ : and of the second case, that tests applied fifteen days later revealed the usual loss of sensibility, and that even seventeen months after the operation sensibility was still defective. With foundations as slender as these, other cases have been reported. All recent experiments have failed to demonstrate the existence of primary union, and the clinical evidence is equally negative. Weir Mitchell, writing on the subject, summed up well when he wrote : " The evidence offered by surgeons is too open to criticism to allow of our admitting that severed nerves may unite by immediate union." No case has been recorded of immediate return of function in paralysed muscles, with absence of the development of the usual electrical changes ; the early " return " of sensibility means retention of sensibility. SENSORY RECOVERY 101 Difficulties surround the testing of sensation in cases of accidental nerve section; this, together with a want of appreciation of the distribution of sensibility to deep touch and to prick, gave rise to the error. When every case of nerve division is tested carefully before as well as after suture no more will be heard of primary union. Recovery after complete division of a nerve. — After division of a nerve followed by suture, an interval elapses before restoration of function commences. This interval varies somewhat w4th the age of the patient, the nerve injured, the method of healing of the wound and the variety of suture, being as a rule more rapid in the young and in cases of primary suture and markedly retarded by inflammation. Sensory recovery. — This may be divided into three stages : (1) Restoration of protopathic sensibility. (2) Restoration of sensibility to light touch and minor degrees of temperature. (3) Restoration of the power of localisation. In none of the cases of recovery which I have watched did any change in sensibility take place other than that due to regeneration. It is perhaps possible that improvement in the power of appreciation of a prick might take place during the first few days after suture, owing to the " education '' of the over- lapping fibres from other nerves subserving proto- pathic sensibility. This was recorded by Letievant, 102 INJUEIES OF NERVES and was considered by him to be due to the recovery of the " supplementary sensibility " from shock — "local torpor/^ as he called it. Although I have several times been able to examine the condition of sensibility within four hours of the receipt of the injury^ I have not observed it ; auy loss of sensibility that then existed remained until regeneration com- menced. In secondary suture performed several weeks after the injury^ if any improvement in sensi- bility has taken place, freeing and freshening the ends of the nerve always results in the loss of sensibility becoming identical to that which was present immediately after the accident. All the restoration is due to reunion with the central nervous system by means of its own central end or those of divided nerves in the surrounding tissues. I am therefore opposed to the statements made by several writers that " the return of sensibility in a mixed or sensory nerve does not prove that the nerve is regenerating.^^ In cases in which observations are taken immediately after the injury, all sensory recovery will be found to be due to regeneration and union with the central nervous system. At a period which varies somewhat with the age of the patient and the nerve injured, in uncomplicated cases being from about six to sixteen weeks after suture, the first stage of sensory recovery commences. The area insensitive to prick begins to diminish in extent, and protopathic stimuli are usually everywhere SENSORY RECOVERY 103 appreciated in from four to twelve months after suture. This is the first stage of recovery (Fig. 7 b). The whole of the aifected portion of the limb is now in a condition resembling that of the intermediate zone which existed between the area of loss of sensibility to prick and the line bounding the area of insensibility to light touch, but the response to all stimuli is more intense. All the stimuli here appreciated have an unpleasant tingling character, and the patient often complains bitterly of discomfort, and massage may have to be omitted for a time. During this stage blisters may a^Dpear sjDontaneously over the analgesic area, but on its completion all ulcers heal and no further blisters make their appearance. During the whole of the first stage the area of loss of sensibility to light touch remains as extensive and as well defined as immediately after the injury. Gradually its proximal border becomes indefinite and the area slowly diminishes in extent until, at a time varying from about twelve months in the case of primary suture of a nerve at the wrist, to about eighteen months after secondary suture of a similar nerve, the whole of the affected portion is sensitive to light touch and the iutermediate degrees of temperature. This concludes the second stage. The interval between the end of the first and the beginning of the second stage varies with the variety of suture and the distance from the periphery of the Fig. 7. SENSORY RECOVERY 105 point of section. After division of the median or ulnar nerves at the wrist^ followed by primary suture^ an interval of more than about six weeks is unusual unless suppuration has occurred_, and in favourable cases in Avhicli the after-treatment by massage and stimulation w4th interrupted and constant currents has been faithfully carried out there may be no appreciable interval. But if the wound suppurated, or secondary suture has been performed, the hand may remain in this stage for a considerable period of time and recovery may be permanently arrested. It has long been the teaching that the distance from the periphery at which a nerve is divided affects the time necessary for the commencement of recovery — that the nearer the periphery the seat of suture, the earlier the recovery. Taking recovery as a whole, this is in accordance with my experience, but it does not apply to the commencement of the first stage of sensory recovery. The distance from the periphery at wdiicli a nerve is divided doesnot affect the time necessary for the commencement of the first stage of recovery, yet it markedl}^ prolongs the interval bfetween the end of the first and the beginning of the second stage, and final recovery is much delayed. Fig. 7. — To illustrate the method of recovery after com- plete division of a peripheral nerve, a. Loss of sensibility resulting- from division of ulnar nerve, b. Termination of first stage of recovery, sensitive to protopathic stimiili, insensitive to light touch, c. Termination of second stage. Dotted line represents line of change. 106 INJURIES OF NERVES A comparison of tlie following two cases will illustrate this : " A boy suffered division of liis ulnar nerve at the elbow ; seventeen weeks after primary suture sensibility to prick began to be restored^ but sensi- bility to light touch showed no sign of recovery until forty-one weeks after suture_, and was not completely restored until seventy-five weeks after suture." " In an adult patient in whom the ulnar nerve had been divided at the wrist, sensibility to prick began to be restored nineteen weeks after primary suture, to light touch in twenty-five weeks, and the latter was appreciated over the whole affected portion of the hand forty weeks after suture." The method of recovery following the grafting of the whole thickness of the skin also confirms this opinion. In a boy, aged fourteen years, on whom I performed Wolfe^s grafting for contraction of the middle finger, the graft healed by first intention. At the first dressing, ten days after operation, he was able to appreciate pressure at the periphery of the graft ; thirty days after operation he was able to distinguish between the head and the point of a pin everywhere over the graft, and could discriminate accurately between ice and water at 50 C, but was entirely insensible to light touch. Three weeks later all forms of sensibility were restored and the discrimin- ation of two points was perfect at one centimetre. SENSORY RECOVERY 107 In this patient the commencement of the restora- tion of sensibility to prick occurred at the same time as after some cases of division of a nerve at the wrist, but the interval between the end of the first and the beginning of the second stage was not marked, and the time necessary for the complete restoration of sensation was shorter by many months. In several similar cases I have observed the same method of recovery. But after the restoration of sensibility to light touch and the minor degrees of temperature the sensibility of the part is by no means perfect. If a sharp point be dragged across the skin from normal to affected parts, sensation is found to change as soon as the old boundary for the loss of light touch is reached. At this line the stimulus seems to become more diffuse ; patients say that it tingles, or it seems to be more uncomfortable and often withdraw the part. While this area of changed sensibility is jDresent the discrimination of two points (the compass test) is always defective. Improvement in the power of accurate localisation constitutes the third stage of recovery. No sensory recovery should be recorded as perfect unless the appreciation of the compass test is as good as on the sound side. Until this has taken place the part is useless for delicate work, and after division of one of the nerves of the hand all work requiring skilled use of the hand is impossible. 108 INJURIES OF NERVES Tlie time necessary for perfect recovery varies^ and will be discussed more fully under primary and secondary suture. The observations wliicli it lias been possible to make ujDon tlie recovery of deep sensibility have been too few to enable rules to be laid down. The extent of the loss and the rapidity of recovery depend in many instances upon the division of structures other than nerves ; but in those cases in which deep touch was lost as the result of the division of nerves alone it was restored before the restoration of sensi- bility to prick. Moto7' recovery.' — At a time varying with the distance of the point of suture from the periphery and the age of the |)atient_, the muscles regain their voluntary power. This return is usually preceded by a change in the electrical reactions of the affected muscles : the contraction given to stimulation with the constant current loses its sluggish character_, and is obtained with a current smaller than is necessary to produce a contraction in the corresponding muscles of the sound side^ and polar reversal disappears ; the reactions become identical with those I have described as typical of incomplete division. Dr. Head and the author found that irritability to the interrupted current is usually present on the same date as the first return of voluntary power is noticed. Recovery after primary suture. — The following con- clusions are based upon the personal observation of RECOVERY AFTER PRIMARY SUTURE 109 over fifty cases of primary suture. In none of these did any early return of sensibility take' place. The earliest date at which the first return of sensibility to prick was noticed was 5 Aveeks, the latest 25 weeks^ and the first stage was comjDlete in from 23 to 46 weeks. The second stage commenced in from 19 to 46 weeks. The great prolongation observed in some cases was due to suppuration — difficult to avoid in many cases of accidental wounds. Restoration of localisation was not^ as a rule, complete until more than two years after suture, and often yet longer time was necessary. After primary suture of one of the nerves of the hand, no matter at what level, restoration of sensibility to prick will commence in from six weeks to four months, and will be appreciated over the whole of the affected area in from four to six months ; the end of the second stage of recovery will be reached in about a year. It has long been the usual teaching that the further the point of section from the periphery, the longer the time necessary for motor return. The unique series of cases of division of the brachial plexus recorded by Etzold proved this : in all, the muscles nearest the seat of the lesion first regained voluntary power. I have been able to confirm these observations after division of nerves in both the upper and lower limbs. It is well illustrated after division of the ulnar nerve. After primary suture of 110 INJURIES OF NERVES this nerve at the wrist^ motor power returns in about a year ; but if divided at the elbow, nearly two years elapse before the intrinsic muscles of the hand are capable of voluntary movement^ although the flexor carpi ulnaris recovers at a much earlier date. The rule can be laid down that after the usual division of nerves at the wrist motor power will be regained in a year ; if at the elbow^ motor power will not return to the muscles of the hand for two years. Prognosis after primary suture. — By complete re- covery is understood the restoration of perfect appre- ciation of all sensory stimuli and the return not only of voluntary power to the aifected muscles, but of perfect function ; in other words, the part must regain a condition indistinguishable from the normal. This may occur after primar}^ suture. The completeness of the recovery will depend to a large extent, as already pointed out, upon the care taken in the after-treatment : but some recovery is to be expected in all cases, no matter how neglectful the patient may be. In every case of primary suture which I have watched, motor power was re- gained and the second stage of recovery of sensibility completed. All cases uncomplicated by suppuration which I was able to keep under observation for a sufficiently long period, regained perfect sensation. I also investigated the condition of as many as possible of the older cases of primary suture per- PROGNOSIS OF PRIMARY SUTURE 111 formed at tlie London Hospital^ and found that there was only one in which no improvement took place — a patient in whom the wound was infected, leading to a cellulitis which necessitated many incisions. The prognosis will depend to a certain extent upon the nerve injured, the distance of this injury from the periphery, and the condition of the wound. For example, the musculo-spiral nerve in the lower third of the arm carries no exclusive sensory supply to any part of the forearm or hand, and the muscles it supplies are not so intimately connected with delicate movements of the fingers as, for instance, those supplied by the ulnar ; complete recovery will therefore be reached more quickly and in a greater proportion of cases. The further the seat of section from the periphery, the longer the period of necessary after-treatment and the greater the chance of the accidents which hinder complete recovery. After primary suture of one of the nerves of the forearm uncomplicated by suppuration, recovery will ensue and become perfect if appropriate after-treat- ment is carried out. Muscular power and irritability to the interrupted current will be restored in from nine months according to the level of the lesion, but three years will probably be necessary to complete sensory recovery, I*^' Recovery after secondary sutui^e. — From time to time instances of rapid restoration of sensibility after this variety of suture have been recorded. Of recent 112 INJURIES OF NERVES observers Kennedy is the strongest supporter of this possibility. In some of the cases the sensation restored at an early date again became lost. Experimental work does not throw any light upon these records. Head and Ham have shown in their experimental work on cats^ that after secondary suture of a nerve which had been divided for at least two months and consisted of elongated cells, twenty-eight days elapsed before it would conduct impulses. This agrees with the earliest time of return that I have noted in clinical work. In none of my twenty-one cases, in which the suture was performed in patients of various ages, and from four weeks to five years after division, was any restoration of sensibility noticed before the thirtieth day, although carefully looked for. Professor Halliburton, speaking on the subject, suggested that what I have already mentioned as one of the causes of the so-called " primary union,^^ the presence of deep sensibility, has led to similar error here. This is undoubtedly the explanation of most of these cases. My attention has more than once been drawn by Hospital Residents to the ^' rapid return " of " sensibility to prick,^^ after secondary suture, which, on careful testing in the usual manner, proved to be deep sensibility. In one patient upon whom I had performed secondary suture of the median nerve it was said that sensibility to prick had returned on the day following operation. On testing, I found that he complained of pain on RECOVERY AFTER SECONDARY SUTURE 113 pressure^ but could not distinguish tlie sharpness of the point of a pin ; it was equally painful and pro- duced the same sensation as pressure with the blunt end of a pencil ; moreover, he was entirely insensitive to the painful interruj^ted current, and all temperature appreciation was absent. There was no doubt that the pain was that caused by deep pressure, which could be readily evoked before operation. Before concluding that a rapid return of sensi- bility has taken place in any patient, sensibility must be carefully tested in all forms and mapped out on charts before and after suture, at first day by day, later week by week, up to recovery. It is evident, however, that a rapid return of sensibility is not to be expected after secondary suture, and that its " occurrence " must be regarded as unusual. Recovery after secondary suture follows the same general lines as after primary. But much greater variability obtains in the time at which the various stages of sensory recovery begin. Motor recovery follows t'he same march as after primary suture. But although motor and sensory recovery follow the same stages as after primary suture, their time of commencement differs. The time necessary for the commencement of the first stage of sensory recovery may be shorter than after primary suture, the changes in the peripheral end necessary to regeneration of the nerve being advanced at the time of suture. But usually the time is much longer 8 114 INJURIES OF NERVES and tlie interval between suture and the commence- ment of tlie second stage of recovery almost double as long. So far I liave not yet seen complete sensory recovery follow secondary suture^ altliougii I have watched patients for more than five years and seen them at intervals up to fifteen years after suture ; in all the patients some difference could be appreciated between the two limbs^ an area of changed sensibility remaining with imperfect appre- ciation of the compass test. This may be of no moment after suture of the musculo-spiral or external popliteal nerves^ but it materially affects the result of secondary suture of the median or ulnar. Much less variation occurs with regard to motor recovery, but the time necessary is almost always longer. Prognosis after secondary suture. — The first question that arises is, how long after the injury is it possible to perform secondary suture with any hope of suc- cess ; unfortunately it is one to which no definite answer can at present be given. Although instances of " successful " operations have been recorded at intervals up to fifteen years after division, the reports are so meagre that no conclusions can be drawn from them. But an interesting series of cases has been recorded by Bowlby. In these, suture was performed at times ranging from twelve years after division downwards. He came to the con- clusion that muscular recovery was not likely to be PROaNOSIS OF SECONDARY SUTURE 115 marked if operation was delayed longer than two years, and that no instance of perfect motor recovery had been reported after four years. Varied statements have been made respecting the injSuence upon recovery, exercised by the interval between division and suture. Howell and Huber, from a study of recorded cases, wrote : '' In general the prognosis is better and the time of recovery shorter the sooner after the injury the nerve is sutured/^ Kennedy considers it of great importance ; he writes : " Nothing can be of more importance in giving a prognosis than the interval between the operation and the accident. If this interval is within three or four months recovery may be expected, but if it extends to almost a year, recovery of muscles is unlikely." Wide variations occur, as I have already stated, in the time at which the various stages of recovery commence and are completed, but they ajopear to bear no relation to the time which has elapsed be- tween the injury and operation, but often have a close connection with the method of healiuG* of the accidental wound ; suppuration retards the time at which the first stage of recovery commences. For example, I performed secondary suture of the median nerve nine weeks after division ; sensory recovery did not commence for twenty-four weeks and was not complete in 116; the muscles did not act voluntarily until nearly two years after suture. In 116 INJURIES OF NERVES anotlier patient of about tlie same age, in whom the median nerve was divided at the same level, ninety- five weeks elapsed between the injury and operation, and yet sensory recovery commenced on the thirtieth day, and motor at the thirtieth week. Both opera- tion wounds healed by first intention, but in the former case the original accidental wound had suppu- rated severely, in the latter the nerve was severed through a small punctured wound w^hich healed by first intention. My experience coincides with Bowlby^s that the interval between the date of suture and the date of restoration of sensation and motion is irregular, and bears no direct relation to the length of time which has elapsed since the injury in cases where the operation has not been delayed for as much as three years. Out of twenty-one cases of secondary suture which I have had under observation, in whom the interval between injury and operation was less than three years, some motor recovery ensued in all, but in none did perfect sensory recovery take place. The prognosis of secondary suture depends not only upon the time after injury (after three years), but also, to a certain extent, upon the nerve injured, for example, recovery may be expected to become perfect after secondary suture of the musculo-spiral, but is unlikely to become so after secondary suture of the median or ulnar. PROGNOSIS OF SECONDARY SUTURE 117 Before giving an opinion as to the advisability of operation otlier factors have to be taken into con- sideration : the condition of the paralysed muscles as regards their reaction to the constant current^ the amount of atrophy and overstretching present and the contracture in the opposing muscles. If great atropliy of the part and deformity has resulted from the nerve injury, complete recovery of function is impossible, although the muscles may regain the power of voluntary movement. In all cases sensory recovery up to the end of the first stage is to be expected; this is important, as recovery up to this stage abolishes the tendency to the formation of ulcers. Recovery of motor power after long ^Deriods is unlikely, for not only have changes taken place in the muscles themselves and in their opponents which render recovery unlikely, but also in the central nervous system ; it is probable that in patients in whom the nerve has been divided for a long period and the muscles retain their irrita- bility to the constant current, nerve anastomosis is more likely to be successful than secondary suture. In conclusion, recovery, both sensory and motor, will take longer after secondary than after primary suture. Up to three j^ears from the accident muscular recovery will probably ensue. Whether it will become perfect depends to a great extent upon the amount of deformity that has taken place, but it may be complete; perfect sensory recovery is unlikely. 118 INJURIES OF JSTERYES Complications arising during recovery. — Complications may arise during tlie progress of recovery. Pain is, as a rule, present in tlie distribution of the affected nerve during the first two or three days after suture ; this is due to irritation of the central end and is rarely of sufficient degree to need treatment. If severe it points to an infective neuritis. The wound should be inspected, and, if necessary, opened up and drained. If this has been done, the condition of the nerve should be explored at a later period when the wound has soundly healed. In cases in which sup- puration has taken place gradual deterioration of function may occur after a period of improvement, due to involvement of the junction in fibrous tissue ; this usuall}^ arises after silk has been used as a suture. Blisters may arise at two periods during the stage of recovery after complete division and suture. Slight injuries pass unnoticed during the stage of complete insensibility to cutaneous stimuli; the patient not infrequently burns himself, or, if engaged in manual labour, injures the limb while at work. To this group belong the so-called perforating ulcers seen after division of the great sciatic nerve. The ulcers so arising heal readily with appropriate treat- ment. With the first sign of returning sensibility to prick the patient often complains of pain shooting into the affected part, and blisters may arise spon- taneously. These may burst, leaving a raw surface, REGENERATION 119 which^ if infected^ becomes an ulcer. If protected they dry^ leaving a scab under which new epithelium forms. All tendency to the formation of blisters ceases with the restoration of sensibility to prick. The immunity experienced on the restoration of this form of sensibility is often striking ; in spite of work con- tinued under unaltered conditions no further trouble arises. Thus^ a carpenter whose median and ulnar nerves had been accidentally divided suffered^ both before and after secondary suture^ from ulcers caused by burns or blisters from the use of his tools. On the complete return of protopathic sensibility, eight months after suture^ all the ulcers healed and no more appeared. The distribution of these ulcers is further proof of the close association which exists between protopathic sensibility and the nutrition of the skin. Under no circumstances^ except when complicated by acute sepsis^ do they extend beyond the area of insensi- bility to prick. Theoretical consideration with regard to regeneration. — Much attention has recently been directed to the method of regeneration^ and it will be necessary to discuss this briefly, together with the light thrown upon it by the clinical experience of recovery. Investigators are divided into two schools — the central and the peripheral. The former, following Waller, believe that regeneration consists in the 120 INJURIES OF NEEYES downgrowtli of axis cylinders from the central end of the nerve into the nerve sheaths of the peripheral end destitute of axis cylinders ; the latter_, who consider that the new axis C3''linders are formed in the peripheral end from the cells of the nucleated sheath. Prominent authors are ranged on the two sides : Mott_, Halliburton^ Langley and Anderson are strong supporters of the central theory^ while BallancC; and Purves Stewart^ Kennedy and Bethe are prominent upholders of the peripheral doctrine. All recent writers^ however^ are agreed up to a certain point ; at a time after division of a nerve^ varying with the animal used and its age^ whether union Avith the central nervous system has taken place or not^ proliferation of the neurilemma cells leads to the formation of a strand of spindle-shaped cells^ called by different observers^ " embrj'-onic fibres/^ ^'' band fibres/^ or " neuroplastic fibres. ^^ It is with regard to the further changes which take place in the peripheral end of a nerve separated from its central end that opinion is so greatly divided. Ballance and Purves Stewart^ Langley and Anderson^ Bethe and others have found axis cylinders clothed with medulla. Some of these observers considered this as evidence of autogenetic regeneration, but Langley and Anderson showed that the formation of medullated axis cylinders in the peripheral end of a nerve separated from its own central end was due to union with the central nervous system by means of REGENERATION 121 divided nerves in the tissues around. They found that all the meduUated fibres in the peripheral end degenerated when the nerves which run to the tissues near the cut end were divided near the spinal cord. These experiments appear to be conclusive^ and to account for the varying results obtained. It appears certain that no new axis cylinders are formed in the peripheral end of a divided nerve until it ao'ain comes into connexion with the central nervous system^ through its own central end or through the central ends of small divided nerves in the tissues around. But it seems probable that after suture^ regeneration of;, at least^, the fibres sub- serving protopathic sensibility takes place peripher- ally. This is in accordance with the results given by the study of sensory recovery after primary and secondary suture. The first stage of recovery com- mences at about the same time^ no matter at what level th& nerve is divided. But the clinical evidence is not so clear with regard to the fibres which sub- serve sensibility to light touch and those which supply the muscles. I have shown that the first signs of recovery of sensibility to light touch and of voluntary power hi the affected muscles are noticed at a later date the farther from the periphery the nerve is divided. But as the same occurs during the recovery of a nerve from the effects of pressure when no regeneration is necessary, the explanation given by Henriksen seems to be correct: "The injured 122 INJURIES OF NERVES nerve is a bad conductor ; tlie longer the piece of nerve injured the greater the resistance and thus a higher degree of regeneration must be supposed before it can be expected that an impulse will cause movement. ... It cannot be taken as evidence that the nerve is growing from the centre. ^^ In conclusion^ it appears that the clinical evidence^ so far as it is positive, is in favour of the formation of new axis cylinders in situ, and that even when it is negative it discloses nothing against this theory. But union with the central nervous system is necessary before the development of axis cylinders takes place. Taken with the experimental CAddence, it goes to show that regeneration, at any rate of the fibres sub- serving protopathic sensibility, is peripheral but not autogenetic. CHAPTER IX Eecovery after Incomplete Division of a Nerve — Sensory Recovery, Illnstrative Cases — Motor Eecovery — Prognosis. Aftee incomplete division of a mixed nerve tlie loss of sensation and motion may at first resemble that which follows complete division^ but the method of recovery is entirely different. After complete division of a nerve and sntnre, sensibility to prick becomes everywhere restored before the commencement of the recovery of sensi- bility to light touch. There is thus an interval before the commencement of the second stage of recovery (restoi-ation of sensibility to light touch) in which the whole affected area is sensitive to protopathic but insensitive to epicritic stimuli. Complete sensory recovery^ the disappearance of the area of changed sensibility to prick^ and the perfect restoration of sensibility to the compass test often occupies several years. But after incomplete division sensibility to light touch and to prick are restored together (vide Figs. 8 A, B; c), and, unless nerve-fibres have been ana- tomically divided in considerable number the power 124 INJURIES OF NERVES of appreciating two points (the compass test) is soon regained. Knowledge of this method of sensory recovery, first described by Dr. Head and the author, is a valuable addition to our powers of diagnosis. If both forms of sensibility are recovering together, it is certain that the injury has not been severe enough to produce complete interruption of conduction in the injured nerve, with degeneration of the whole peri- pheral end. The following cases illustrate this method of re- covery : " A man, aged twenty-seven years, cut his left wrist Avith a fragment of broken glass, September 20th, 1902. When I saw him two and a half hours later a small incised wound was present over the position of the median nerve at the wrist. The abductor and . opponens pollicis muscles acted perfectly, but sensibility was lost over the area shown in Fig. 8 a. Protopathic sensibility was lost over an area somewhat smaller than usual after complete division of a median nerve with such a large exclusive supply — that is, the loss of sensibility to prick did not involve the radial border of the index finger or the palmar surface of the thumb, although, an extensive area on the palm Fig. 8. — To show method of recovery after incomplete division of a nerve, a. Loss of sensibility after incom- plete division of the median nerve, b and c. Stages in the recovery of both forms of sensibility together. Dotted areas represent ill-defined limits. Fig. 8. 126 mJURIES OF NERVES was affected. The loss of sensibility to light touch was as widespread and as well defined as after com- plete division. I explored the wound at once^ and found the median nerve for half an inch immediately above the annular ligament dark red in colour and swollen^ with a superficial incised wound on its ulnar side, No change in the condition of sensibility took place until six days later^ but the muscles lost their irritability to the interrupted current^ although they retained the joower of voluntary movement. Four- teen days after operation the area of loss of both forms of sensibility began to diminish in extent from above downwards (Fig. 8 b). Over the previously insensitive portion of the palm the compass test was almost perfect at 1 cm.^ and was completely restored in this position fourteen days later. Three months after the injury the muscles again reacted to the interrupted current. In six months the condition of sensibility was as shown in Fig. 8 c ; in nine months it was perfect^ exce^ot over the terminal phalanges of middle and ring fingers.^^ A similar method of recovery is shown in Fig. 9 A, B^ taken from a patient with an incomplete division of ulnar nerve. " This patient sustained a fracture of radius and ulna in the lower third of the forearm eight weeks before I saw him. On examination on January 1st, 1906, sensibility was lost over the area in Fig. 9 a. INCOMPLETE DIVISION: RECOVERY 127 All the muscles in the hand supplied by the ulnar nerve were paralysed and gave the reactions typical of incomplete division. " On January ord I explored the condition of the Fig. 9. — a. To illustrate the loss of sensibility followiurr incomplete division of the nlnar nerve, b. Method of recovery, both forms of sensibility together. nerve. I found it bound down to the ulna through the fibres of the flexor profundus digitorum ; on freeing it there were signs on its posterior surface 128 INJURIES OF NERYBS that it had been wounded by one of the fractured ends of the bone. ^' Ten days later both forms of sensibility began to return together^ and six weeks after the operation the condition of sensibility was as shown in Fig. 9 b." Recovery after a less severe form of injury is illustrated by the following case : "A patient was kicked at football over the inner condyle of the humerus. As a result sensibility to light touch was lost over an area on the palm of the hand corresponding almost to the distribution of the palmar branch of the nerve ; protopathic sensibility was lost over an area almost as extensive. All the movements of the fingers could be performed^ but the little finger was weak and tended to assume the ulnar position ; all reacted to the interrupted current. Both forms of sensibility cleared together^ and at the end of three weeks sensibility was normal even to the compass test." Motor recovery after incomplete division follows the same march as after complete — that is^ the muscles nearest the seat of the injury first regain voluntary power and excitability to the interrupted current. In the cases in which the reactions typical of in- complete division are present^ voluntary power usually returns before the re-establishment of excitability to the interrupted current. Occasionally voluntary power is present from INCOMPLETE DIVISION: RECOVERY 129 the first, altliougli excitability to the interrupted current is lost. But this is unusual, as pointed out in Chapter III ; the least severe form of injury pro- duces paralysis of the muscles supplied by the aifected nerve, with retention of irritability to the interrupted current. In all the cases in which my notes on the subject are complete, voluntary power returned before electrical excitability, often some weeks before. In cases uncomplicated by sepsis or extensive wounds of the surrounding parts, the first return of volun- tary power in the upper limb occurred in from about four to ten weeks, and progressed to complete recovery in all the patients. In one instance in which the external popliteal nerve was affected, voluntary power did not return for nine months, and excitability to the interrupted current was not present two months later. In another patient in whom the muscles supplied by the external popliteal nerve, though paralysed, reacted to the interrupted current, voluntary 'power began to return in three and a half months and was perfect in five. In another patient in whom the reaction of degeneration developed later no recovery took place in two and a half years. Sensory recovery usually begins in about three weeks and is completely restored in about six months. But these times of motor and sensory recovery are 9 130 INJURIES OF NERVES approximate only, and vary Avitli the severity of the injury and the distance of the seat of # the injury from the periphery. Cases in which epicritic sensibility alone is lost recover much more rapidly than those in which both forms of sensibility are affected. When the injury, as is so often the case, affects the brachial plexus, considerably longer time is necessary for the commencement and pro- gress of recovery. In one patient in whom the inner cord was injured as the result of a dislocation of the humerus, sensory recovery did not commence for six months, and was not perfect until fifteen months had elapsed since the injury. To sum up, after incomplete division of a mixed nerve, both forms of sensibility (epicritic and proto- pathic), if lost, return at the same time, commencing at a date which varies with the distance of the injury from the periphery from about three weeks at the wrist to six months in the plexus, and also with the degree of the injury. Complete recovery as a rule rapidly ensues. Muscular recovery com- mences at a time which varies in the same way. In cases in which the muscles, though paralysed, retain their irritability to the interrupted current, recovery commences in three or four weeks, sometimes earlier, and soon becomes perfect. This degree of injury is seen most often as the result of compression of the musculo-spiral nerve, producing sleep, anaesthetic or crutch paralysis. If the reactions typical of incom- INCOMPLETE DIVISION: PROGNOSIS 131 plete division are present a much longer time is necessary. After neurolysis, or when the nerve has been relieved from any form of pressure, recovery follows exactly the same lines. Prognosis. — This is_, on the whole, good. Motor power and irritability to the interrupted current are restored and perfect sensibility regained within a year in most cases. But it must not be forgotten that occasionally, particularly in incomplete ana- tomical division, in which no treatment was adopted at the time of the accident, tenderness may develop in the distribution of the affected nerve necessitating a complete resection of the damaged portion with end- to-end suture ; in other cases gradual deterioration of function occurs. CHAPTEE X Pain complicating Nerve Injuries — The Involvement of Nerves in Scar Tissue — Symptoms due to Involvement of the Trunk of a Nerve, Paralytic, Irritative — Symptoms due to the Involve- ment of Terminal Branches — Pain following Nerve Injuries the result of Operations ujDon the Kidney, upon Herniae — Amputation Neuromata. Pain sometimes arises as the immediate result of nerve injuries^ but more often during the after-pro- gress of the case. At the moment of the infliction of the injury pain may be felt in the full distribution of the nervCj but it is never of long duration. When arising within a few days of the injury it is usually the result of infection. Arising later, it is usually due to involvement of the nerve in scar tissue, either in the nerve itself, the so-called interstitial neuritis, or in the tissues around. The trunk of the nerve or one of its terminal branches may be affected ; the symptoms produced in both may bear a superficial resemblance to each other. In both, j)ain may be present, referred over a large area, accompanied in some instances by hyper- algesia, rarely by glossy skin ; muscular wasting and paralysis may also be present. But in the first case PAIN IN NERVE INJURIES 133 (involvement of the trunk) tlie pain and tenderness whicli often accompanies it marks out the full distribution of the affected nerve, and may be accompanied by loss of sensibility and paralysis of muscles, with changes in their electrical excitability ; in the latter, the pain and tenderness map out the area of distribution of the root or roots from which the injured twig arises, which, in only a few cases, will at all correspond to the area of distribution of a peripheral nerve ; the paralysis is never accompanied by electrical changes in the muscles. The symptoms vary in severity ; in some, slight pain on movement or change in the weather only is complained of, in others, pain of an excruciating nature accompanied by changes in the skin. Symptoms due to involvement of the trunk of a nerve. — The cases in which the trunk of a nerve is involved may be divided clinically into two groups, the non-irritative and the irritative. Non-irritative groiq^. — In this group the functions of the nerve are gradually interfered with by pres- sure, and the symptoms are due simply to interference with conduction ; pain and tenderness are absent, or if pain is present it is slight. The typical example of this form of involvement is seen in the musculo- spiral nerve, following a fracture of the humerus. The main points are illustrated by the following- case A man, aged twenty-eight years, sustained a frac- 134 INJURIES OF NERYES ture of tlie lower third of the humerus. I saw him two weeks after the accident. All the muscles supplied by the musculo-spiral nerve were wasted^ paralysed^ and gave the reactions typical of incomplete division. At operation^ twenty-eight days after the injury, I found the nerve closely bound down by fibrous tissue to the callus. I freed it, and sutured muscle be- neath, in order to prevent it from again becoming adherent to bone, and wrapped it to prevent it from forming adhesions to surrounding parts. Recovery began in twelve weeks, and all the muscles supplied by the injured nerve acted voluntarily eight weeks later, and reacted again to the interrupted current six months after the operation." The treatment of the cases in this group is simple. Neurolysis is followed in a short time by recovery, providing care be taken to avoid the occurrence of compression or reinvolvement in the scar. The nerve must be protected from again becoming adherent ; it has often happened that neglect of this precaution has necessitated another operation. Irritative group. — At the end of the first stage of recovery after complete division the part supplied by the affected nerve is sensitive everywhere to prick, but so great is the discomfort produced by this stimulus that it is not infrequently said to be " hyper- algesic.^' A similar condition is seen in cases of incomplete division with epicritic loss. This tender- ness is confined to the area of loss of light touch and HYPERALGESIA 135 is the expression of protopatliic sensibility. But the tenderness associated with irritative involvement occupies the full area of protopatliic supply of the nerve and may be accompanied by no loss of sensi- bility. The following case illustrates these points : " L. E — , aged fourteen years_, cut his forearm with broken glass. The wound was sutured and healed by first intention. Two weeks later he began to suffer pain, and the wound was reopened without effect ; the pain gradually increased in severity. I saw him fourteen weeks after the accident ; a scar was present on the anterior surface of the forearm, two and three quarter inches above the fold of the wrist. Extending downwards from this the full distribution of the anterior branch of the external cutaneous nerve was mapped out by extreme tenderness. There was no loss of any form of sensibility. " The nerve branch was exposed at the seat of the injury and found implicated in fibrous tissue and adherent to the scar ; it had evidently suffered incom- plete anatomical division. The damaged portion was excised and the ends of the nerve brought together. No loss of sensibility followed the operation, the anterior branch of the external cutaneous nerve of the forearm having no exclusive sensory supply. The patient lost his pain at once and has since remained free." 136 IIS'JURIES OF NERVES Tlie condition may also follow a subcutaneous injury. ^' A boy fell astride a gate and bruised liis perineal region. He was kept in bed for several Aveeks^ the diagnosis of fractured pelvis having been made. ^ Several ' days after the accident pain and tenderness appeared^ the pain radiating from the point injured to the scrotum. "When I saw him nine weeks after the accident he was unable to Avalk without great pain ; when walking he kept the hip-joint of the affected side rigidj for he had found by experience that all move- ment of the hip increased the pain. Marked hyperal- gesia was present running from a tender spot over the ramus of the ischium to the rio-ht side of the scrotum. After division of the nerve all pain ceased and the tenderness disappeared." I have had to operate also in two cases in which the posterior division of the external cutaneous nerve of the forearm was injured as the result of a direct blow over the external condyle of th& humerus. The patients usually present themselves with symptoms resembling those I have just described. But occasionally^ most often as the result of a gun- shot wound, the symptoms are of much greater severity. Instances have been recorded after all the more recent wars. In 1813 Denmark reported the case of a man wounded at the storming of Badajoz. The bullet entered one and a half inches CAUSALGIA 137 above tlie inner condyle of the liumerus and came out on the outer side^, in front of the elbow-joint. He describes the condition as follows : ^' I always found him with the forearm bent and in the supine position, and supported by the firm grasp of the other hand/^ The pain '' was of a burning nature and so violent as to cause a continual perspiration from his face. He had an excoriation on the palm from which exuded an ichorous discharge. ^^ This is an excellent description of the pain and of the '^ trophic '' sore, which probably originated as a blister, but no account is given of the other skin changes which may accompany it. These were first described by Hamilton in 1838. He stated that "the pain may be accompanied by redness and swelling resembling the appearance of the skin in inflammation of the fascia or a deep collection of matter.''^ A fuller description was given by Paget in 1864 {vide p. 41), but to Mitchell, Morehouse, and Keen is due the credit of the exact picture of this con- dition [vide Chapter 111). I had the opportunity of examining several such cases, due to bullet-wounds received during the late war in South Africa. The following record illus- trates admirably the most important points of these severe cases. " L. G. H — was wounded at Tweefontein on July 22nd, 1901, by a bullet that entered four and a half 138 INJURIES OF NERVES inclies below the internal condyle of tlie linmeriis and passed across the forearm to the radial side. The arm did not become painful until he had been in hospital three weeks ; the pain then gradually increased in severity^ and when I saw him with Dr. Head on January 26th; 1902, was constant. ^^ The skin of the affected hand was smooth, glossy, and of a pinkish blue colour, covered with beads of sweat, the fingers tapered and the nails were thin, long and curved. The hand was intensely tender over a large area occupying the palm, the ulnar half of the thenar eminence, the palmar aspect of the little, ring and middle fingers. Over the dorsal surface this tenderness occupied the ulnar half of the hand and extended to the tendon of the ring finger, and the dorsal surface of the little, ring and middle fingers. The tender skin was intensel}? sensitive to pinching, to pressure with the head of a pin and to the pm-point. Epicritic sensibility was lost over the usual ulnar area. Sensibility to the extreme degrees of temperature was present every- where. Operation revealed incomplete anatomical division of the ulnar nerve in the forearm, the ends being intimately bound up in a mass of fibrous tissue. Complete division of the nerve, removal of the damaged portion and re-establishment of con- tinuity completely relieved the pain. Sensibility returned to the hand by the usual stages.^' The latent period which existed in this case CAUSALGIA 139 between the injury and the onset of pain is typical, nothing abnormal being noticed at first; in many cases the wound heals by primary union or aseptic granulations. The pain is intense and described by the patient as " burning '^ or ^' bursting '^ in character. It is aggravated by all external stimuli and is felt over the full protopathic distribution of the nerve — a larger area than becomes insensitive to prick on section of the nerve. It is accompanied by tenderness, usually by sweating, sometimes by glossy skin and blisters. The degree of interference with the functions of the nerve varies with the amount of injury the nerve has sustained, but is always incomplete. In the patient just described the muscles were paralysed, but in a patient with a similar condition of the ulnar nerve the muscles acted well. Causalgia never arises with complete interruption of continuity. It results from the irritation of the protopathic fibres of the affected nerve, and is a further proof of the existence of the efferent impulses in afferent nerves called by Bayliss " antidromic." Treatment consists in resection of the damaged portion of the nerve and restoration of anatomical continuity by suture or transplantation. Symptoms following the involvement of terminal branches. — It was well known to the surgeons at the end of the eighteenth and the beginning of the nine- teenth centuries that a very definite train of 140 INJURIES OF NERVES symptoms might follow the wounds of small nerves. These cases seem to have been first described by Abernethy. Wardrop, in 1823, recorded a case in which pain in the whole distribution of the radial nerve followed ten days after a wound on the radial border of the thumb. Neurotomy of the affected branch gave immediate relief. Hamilton^ in 1838, wrote a paper on the subject, gi^iiig instances following injuries to nerve branches from various causes, in some cases due to the operation of phle- botomy. They were accompanied by tenderness of the skin, and in some cases by paralysis or spasm and contracture of the muscles of the limb, and were often accompanied by symptoms now called hysterical. In some of the instances mentioned neuritis may have been the cause, particularly in those that came on in which the symptoms supervened a short in- terval after the injury, but most were not of this nature, although commonly called neuritis. Yery little attention seems to have been paid to these cases of late years. The most modern paper of im- portance on the subject was written by the late Sir W. Mitchell Banks, in 1869. Irritation of one of the terminal branches of the fifth nerve may cause pain and tenderness, referred to the whole of the distribution of that branch to which it belongs ; this is now a commonplace of medicine. But similar symptoms may follow the in- volvement of the branch of any nerve in scar tissue, INVOLVEMENT OF TERMINAL BRANCHES 141 the result of a wound^ or in some cases^ a sub- cutaneous injury. As occurs wlien the trunk of a nerve is involved, an interval always elapses between the injury and the first symptom. The pain is usually widespread, extending over the full protopathic distribution of the root or roots involved, and is often accompanied by hyperalgesia. There may be in addition, par- ticularly in the lower limb, paresis or paralysis of the muscles supplied by the corresponding nerve or root. The following case brings out the imiDortant points: ^'^Gr. L — , aged thirty-six years, crushed his right foot in September, 1902, fracturing the first and second metatarsal bone. At first the pain was entirely local, but in a few weeks it involved the whole of the great sciatic area and increased in severity. All the muscles of the leg supplied hj this nerve were weak and wasted. He Avas admitted to the London Hospital in May, 1903, and treated by rest and massage, various forms of electricity, injections of strychnine, all without success. In September, 1903, one year after the injury, I explored the first metatarsal space and found the branch of the anterior tibial nerve, which runs to the cleft between the great and second toes, involved in fibrous tissue. It was impossible to free it entirely, so I removed the involved portion and performed end-to-end suture. He lost his pain at once, but it was over a year before full power was restored to 142 INJURIES OF NERYES the wasted muscles. At the end of this time he was quite well and has remained so since. '^ These cases are often described as chronic trau- matic neuritis. But the symptoms arise in in- dividuals who are otherwise healthy, in injuries that are often subcutaneous, or if open, heal by first intention, and the jDain and tenderness disappear immediately after removal of the damaged portion of the nerve. It is obvious, therefore, that the term '' chronic neuritis " does not adequately express the condition. Treatment should be operative ; much valuable time is wasted by general treatment. If the con- dition be recent, and the patient object to operation, absolute rest should be tried ; massage and electrical treatment are absolutely useless unless the cause be first removed by operation. The damaged portion of the nerve must be re- moved, and communication with the central nervous system restored, if possible, by end-to-end suture or anastomosis. But the size of the nerve involved may render this impracticable — for example, when one of the terminal branches of a digital nerve is involved in scar tissue. The best treatment in these cases consists in excision of the scar, and suture or Wolfe's grafting; in some cases amputation of the affected portion may be necessary. Although in the recent cases pain and tenderness disappear immediately, cure is not, as a rule, so CHRONIC NEURITIS 143 rapid in the case of a mixed nerve. The condition of the patient may make him more susceptible to the small area of anaesthesia which may have resulted from the operation, and recovery may be delayed until regeneration has taken place. If the muscles are wasted and paretic^ months may elapse before they regain their full power. During the interval the limb should be kept at rest in such a position that the aifected muscles are flaccid. The splint should be removed daily for massage, and, if jDOSsible, stimulation Avith the interrupted current, to which the muscles always react. The patient should be encouraged to use the affected muscles, and as soon as voluntary power is re-established, the splint removed. These cases are not infrequently met with in connexion with claims for comjDensation ; an injury of this nature will certainly, if muscles are affected, incapacitate the patient for a year, even if operated upon early. The diagnosis of hysteria is often made ; un- doubtedly in many cases hysterical symptoms super- vene, but careful examination will always reveal the nerve affected and lead to the correct treatment. Occasionally a true chronic neuritis is set up ; in these cases removal of the damaged portion of the nerve fails to secure relief, or the relief is transient ; nothing remains but excision of the root ganglia corresponding to the roots affected, or intra-dural division of roots. 144 INJURIES OF NERVES Pain following nerve injuries, the result of operations. — As I have already pointed out in Chapter I^ injuries of the smaller nerves during the course of a well- planned operation are soon recovered from. But it occasionally happens that irritative symptoms arise from the involvement of a trunk or terminal branch iu fibrous tissue. The last dorsal^ ilio-hypogastric or ilio-inguinal nerves may be injured during the course of operations upon the kidney^ unless care be taken to make all incisions parallel to their course. In most of these cases no pain is complained of while the patient is in bed^ and symptoms appear when the patient first gets up^ and increase in severity. Pain and tenderness are complained of below the scar ; this may be severe enough to make the pressure of clothes around the waist unendurable. Examination usually reveals no loss of sensibility, but a well-marked area of tenderness corresponding to the nerve involved. This can be marked out in the usual way by dragging the point of a pin lightly across the skin^ from sound to aifected parts. It occasionally happens that one of these nerves is completely divided ; this may produce a loss of epicritic sensibility, with resultant exposure of pro- topathic sensibility. All stimuli over the area have then, the unpleasant, painful, radiating character associated with this form of sensibility. In both cases the injured nerve must be exposed by operation. If it has been cut into and the PAIN FOLLOAVINa OPERATIONS 145 syiiiptoiiis arc irritativ^e the damaged portion must be resected and end-to-end siittire performed^ or, if it is involved in scar tissue only, freed, and pre- cautions taken to ^irevent its recurrence. If it be found divided an attempt must be made to bring the ends into apposition ; if tliis fails, anastomosis to one of the parallel nerves must be carried out. The ilio-ino'Liinal nerve is liable to iuiurv in the performance of radical cure of inguinal hernia. It should always be seen and avoided as it passes out at the external abdominal I'ing below and to the outer side of the cord. Injury will produce pain and tenderness in its distribution, aggravated by exertion, and may be severe enough to prevent the patient from following his employment. In some cases it is accompanied by pain, referred to the whole first lumbar distribution. Treatment is on the lines alreadv laid down. tJ Irritation of terminal branches as the result of involvement in scar tissue may occasionally give rise to difficulties in diagnosis. It arises in its most typical form after amputation of the breast. In this operation the perforating branches of the intercostal nerves are divided, and their involvement may give rise to severe symptoms. If the first or second dorsal be involved, pain is felt radiating down the inner side of the arm and forearm, often accompanied by tenderness. The following is an example : 10 146 INJURIES OF NERVES " In November, 1905, I carried out the complete operation for mammary carcinoma. The flaps did not come well into contact, and a small area was left at their upper part which healed by granulation. The patient was entirely free from symptoms until early in 1906 pain commenced and increased in severity, bringing her to see me in November of that year. She stated that the pain started in the upper part of the scar and radiated down the inner side of the arm and forearm, and was worse on moving the arm. Over the inner end of the second intercostal space was a tender spot, palpation of which caused the pain to shoot down the inner side of the arm. The skin of the inner side of the arm in the region supplied by the intercosto - humeral nerve was tender to the slightest touch. " I excised the tender portion of the scar, and after freeing the skin sutured the flaps over Cargile mem- brane. She lost her pain and tenderness at once and has since remained free." The rules for the treatment of nerves involved in scar tissue may be summed up as follows : When the symptoms produced are those of incom- plete divisioi), neurolysis and protection of the recently freed portion should be adopted. When irritative symptoms are present and the trunk of the nerve involved, excision of the damaged portion, followed by restoration of continuity. When a AMPUTATION NEUROMATA 147 terminal branch is affected, excision of the dama^-ed portion of nerve. Amputation neuromata. — When a nerve is completely divided the lihres of the upper end spread out in a brush-like manner. This " mop-like protuberance formed immediately a nerve trunk is divided/^ was described by Ballance and Purves Stewart as " the primitive end bulb.^^ New axis cylinders are deve- loped in this, and the bulb eventually becomes a mass of fibrous tissue Avith small nerve-fibres inter- lacing in all directions. After all amputations such bulbs must be formed on the central ends of the severed nerves, but only in a few instances do their presence give rise to symptoms. When the ends of the nerve are pulled down, cut short and crushed with a pair of S^^encer Wells' forceps at the time of the operation, symptoms rarely ensue. They arise from irritation of the bulb by direct pressure or by the traction of muscles or adhesions. The size of the bulb varies widely, and it may be, as suggested by Alexis Thomson, that the increased size in some cases is due to inflammation, and that the condition has become less frequent now that the principles of Listerian surgery are carried out. Pain or discomfort after an amputation correctly performed is unusual. For the first few days the patient may be acutely conscious of the absent limb 148 INJURIES OF NERVES and may describe its exact position in space^ but unless inflammation occurs pain is absent. The consciousness of the position of the absent member may never be lost^ and any irritation of the bulb will cause the pain to be referred to the area of the absent limb which was supplied by the fibres affected. Thus^ in a patient in whom symptoms pointing to irritation of the end bulb originated twenty-three years after an amputation of the foot^ the reference of the pain to the inner side of the absent limb led to the discovery of the bulb on the stum]) of the internal saphenous. The symptoms resemble those described as due to irritation of the terminal branch of a nerve, modified by the absence of a part of the limb. There may be pain widespread in the distribution of the nerve in- volved, accompanied by tenderness of that portion of the stump supplied by branches from the roots involved, and in some cases accompanied by changes in the skin. The pain may be produced by direct pressure on the bulb, and is often felt with changes of the weather. Muscular twitchings often occur in association with the pain, and hysterical symptoms may be present. The time after the amputation at which the symptoms first appear is variable, but the longest interval that has come under my notice Avas in the case just quoted — twenty-three years. The treatment should be preventive — in every AMPUTATION NEUROMATA 149 amputation the nerves slioulcl be pulled down and cut short with scissors to prevent their involvement in the fibrous tissue at the scar, and the ingrowth of fibrous tissue. It has been proved experimentally that crushing the end of a nerve prevents the forma- tion of a large end bulb. When symptoms are present the bulb and three or four inches of the affected nerve must be removed. This has sometimes failed to relieve the pain; in these cases intra-dural division of posterior roots should be performed if the symptoms are severe. CHAPTER XI Method of Injury of Cranial Nerves— Olfactory Nerves : Method of Testing Smell— Optic Nerve — Ocnlo-motor Nerves— Fifth Nerve : Method of Injury : Loss of Sensibility : Taste Fibres : Taste Tests : Motor Supply of Palatal Muscles : Corneal Changes — Facial Nerve : Varieties of Injury : Anastomosis — Auditory Nerve — Glosso-pharyngeal Nerve — Vagus Nerve — Spinal Accessory Nerve : Paralysis of Trapezius Muscle — Hypoglossal Nerve, Appections of the cranial nerveR^ with the ex- ception of the facial and spinal accessory, are rare in surgical practice. They are injured most often as the result of operative procedures and fractures of the base of the skull. The facial is the nerve most often injured in the latter way. Eawling found some interference with the functions of this nerve in twenty-four out of sixty patients ; Kohler in twenty- two out of forty, although other authors do not give such a large percentage. Next in order of fre- quency are the auditory, the sixth, optic, third and fourth. Olfactory nerves. — Injury to the olfactory nerves and the bulb into which they pass must be considered together, as the symptoms produced by their injury are identical. LOSS OF SMELL 151 Loss of smell not infrequently complicates a fracture of the anterior fossa of the skull or of the nasal bones_, resulting from direct violence^ but in only a few of these cases is it due to nerve injury. Anosmia may also follow blows on the back of the head which do not^ so far as can be ascertained, cause a fracture of the anterior fossa. The patient usually complains of inability to taste, less often of the loss of smell. In the majority of cases an immediate diagnosis of nerve injury is im- possible ; the nasal cavity is filled with blood-clot, and the injury to the roof of the nasal cavity may render testing impossible for a time. Li testing for loss of the sense of smelly irritating and pungent substances which may stimulate the sensory branches of the fifth nerve must be avoided. Aromatic volatile materials, such as oil of cloves, peppermint, and assaf oetida should be employed, each nostril being tested separately. Recovery usually follows loss of smell, compli- cating fractures of the skull or nasal bones. Per- manent anosmia is rare from an injury to the olfactory nerves or bulb. Optic nerve. — This nerve rarely suffers direct in- jury. It may be injured in penetrating wounds of the orbit or temporal region ; gunshot wounds in the temporal region have injured both optic nerves with- out causing any injury to the eyeball. It is some- times injured in fractures of the base of the skull. 152 INJURIES OF NERYES involved in orbital cellulitis^, or the fibrous tissue resulting from it^ or pressed upon by growth. Unilateral blindness has^ in rare instances, followed a severe head injury unaccompanied by any evidence of a fractured base. This is usually explained as due to a haemorrhage into the nerve, but Rawling has suggested that it may result from a fracture through the base of the anterior clinoid process, the fragment exercising direct pressure on the nerve. A complete division of the nerve causes loss of vision in the affected eye, with more or less dilatation of the pupil. Ophthalmoscopic examination later reveals optic atrophy. Oculo-motor nerves. — These nerves are most often injured in fractures of the base of the skull, next in order of frequency during operations for removal of the Gasserian ganglion as they lie in the outer wall of the cavernous sinus, or by the pressure of orbital tumours. Most of these cases come under the care of the ophthalmic surgeon. The sixth nerve most often suffers in a fracture of the base by reason of its anatomical position, being implicated as it lies on the side of and grooves the dorsum sellae, next the third, rarely the fourth. The third nerve is more often affected by causes other than injury. In examining for signs of involvement of the ocular nerves, the position of the eye should be first THIRD CRANIAL NERA^E 153 noted, its protrusion or recession, and the presence or absence of squint. The patient should then be asked to follow the movements of the observer's finger in the necessary directions, to detect weakness or paralysis of any muscle. The size, shape and reactions of the pupil to light and accommodation must also be noted. The patient, in most cases, complains of diplopia, and this may be the only symptom indicative of injury to one of the nerves supplying the ocular muscles. For the investigation of this symptom the reader is referred to works on ophthalmic surgery. The third nerve. — Injury to this nerve is un- common, although paralysis of some of the muscles supplied by it is by no means rare. The nerve may suffer injury in fractures of the base of the skull often with other nerves, particu- larly the first division of the fifth and the optic. Injury to the whole nerA^e is unusual ; in most cases some only of its branches are affected, ptosis and dilatation of the pupil often occurring without external strabismus. Complete division of the nerve produces ptosis from paralysis of the levator palpebra? superioris with over-action of the frontalis, so that the eyebrow is hio'her than on the sound side. There is slio-ht exophthalmos and the pupil is dilated and does not react to lio-ht or accommodation. External strabismus 154 INJURIES OF NERVES is present^ and the patient is unable to move tlie eye upwards^ downwards, or inwards. Fourth nerve. — Tliis nerve is rarely injured alone. Its division causes paralysis of the superior oblique muscle, with impaired power of downward movement. This deficient movement is difficult to detect;, but the characteristic diplopia on looking downwards and the feeling of giddiness on going downstairs is charac- teristic. Sixth nerve. — This nerve most often suffers in fractures of the base of the skull. Its injury pro- duces internal strabismus, with inability to turn the eye outwards. Fifth nerve. — Injuries of this nerve or of its branches are uncommon ; it acquires its surgical importance chiefly in connexion with trigeminal neuralgia. It may be injured in fractures of the base of the skull or jaws, or from involvement in the products of bone disease, or pressed upon by inflammatory collections or growth in the frontal sinus, maxillary antrum or skull. Involvement of the whole nerve is unusual, one of its branches only being affected in most cases. Makins has recorded the following facts with regard to gunshot wounds involving this nerve. It suffered most often in fractures of the jaws ; a whole division was rarely affected, and the loss of sensi- bility was, as a rule, temporary. Sensory symptoms. — It must be remembered that FIFTH NERVE : SENSORY SYMPTOMS 155 the fiftli nerve, when injured_, behaves just as any other peripheral nerve ; that j^ressure upon the nerve or involvement in growth will produce a loss of sensibility exactly similar to that produced by pres- sure upon the median or ulnar nerves. This is especially important to remember in connexion with pain in the distribution of this nerve and its treat- ment by operation. Interference with the functions of the nerve or one of its branches produces a loss of sensibilit}--^ first to light touchy then to pain. If severe pain is being caused as the result of pressure ujDon the nerve, some alteration in sensibility will be found ; on the other hand, in some of the cases of referred pain and in trigeminal neuralgia major no sensory loss is j)i'esent. The exclusive supply of the fifth nerve is most readily studied in patients who have undergone the operation of removal of the Gasserian ganglion. Its full supply is shown in cases of division of the sensory branches of the cervical plexus {vide Plate YI, p. 178), but as there is very little overlap between it and the cervical nerves, its exclusive and full supply are almost identical. The exclusive supply was first sj^stematically studied by Krause, and is described in his well-known monograph. But it is largely owing to the re- searches of Harvey Gushing, confirmed recently in many respects by Morriston Davies, that our know^- ledge is due. 156 INJUEIES OF NERVES The loss of sensibility resulting from removal of the Grasserian ganglion is smaller than would have been supposed from reading a description of its supply^ as ascertained by dissection. While varying somewhat from individual to individual^ it retains in all its peculiar outline. Fig. 10. — To show the loss of sensibility resnlting- from removal of the Gasserian gangiion. Sensibility to light touch and to prick are lost over an area which is almost identical^ but fails to correspond in the region of the external ear and the nose. Morriston Davies gives an accurate descrip- tion of the area of epicritic loss, from which the following description is taken. Its anterior boundary is the mid-lino of the forehead and chin. Its posterior FIFTH NERA^E : SENSORY SYMPTOMS 157 border may be described as consisting of three straight lines {vide Fig. 10). The upper is almost vertical and extends from a point in the sagittal plane^ midway between the nasion and the inion, to the free margin of the tragus at the junction of its middle and lower thirds ; thence the second line passes horizontally forwards to a point midway between the external auditory meatus and the outer canthus of the eye ; here the third line begins and runs obliquely down to a point on the lower border of the chin vertically below the angle of the mouth. The posterior boundary of the loss of sensibility to prick runs a much straighter course anterior to the line described above. The anterior wall of the external auditory meatus and the anterior portion of the tympanic membrane are usually insensitive to light touch and to prick. It seems probable that deep touch is lost over an area corresponding roughly to that of the loss of sensibility to prick, and with it loss of sense of position and movement in the muscles of the face. Gushing found loss of the sense of active movement in the facial muscles when stimulated with the inter- rupted current, and also loss of the sense of passive position. Joy and Johnson and Spiller have recorded cases in which " deep sensibility " was present. Morriston Davics confirms the absence of the sense of movement and position, and found that although deep pressure was occasionally appreciated it was 158 INJURIES OF NERVES badly localised on to adjacent sound parts. " Deep sensibility '^ of tliis nature is probably due only to traction on surrounding sound structures ; it differs entirely from the deep sensibility seen after division of sucli a nerve as the median. True deep sensibility appears to be absent in most patients after complete removal of the Gasserian ganglion. The mucous membranes supplied by the fifth nerve become insensitive to epicritic and protopathic stimuli. In the mouth the area includes half the tongue^ as far back as the circum vallate papillge_, and then i^asses outwards along their line to the anterior pillar of the fauces, and then along the anterior margin of the soft palate to the tip of the uvula, thence along the centre of the palate to the upper lip. All on the affected side of this line lose sensi- bility to light touch and prick. The tongue retains its deep sensibility, the fibres conveying which appear to travel by the hypoglossal nerve. Gushing has confirmed the observations made by Krause, and conclusively shown that taste is not permanently affected by the removal of the Gasserian ganglion. Morriston Davies has exhaustively re- viewed the recorded cases and confirmed these observations. The fibres subserving taste in the anterior two thirds of the tongue ])ass in the chorda tympani, running for a part of its course with the lingual nerve (vide also ^^ Facial nerve/^ p. 165). TESTS FOR TASTE 159 Cusliiiig offers tlic suggestion that the temporary loss of taste seen in some cases after removal of the ganglion may be due to degenerative changes in the lingual nerve affecting the chorda tympani, mechanic- ally or toxically. Horsley lias suggested that it might be due to the unilateral furring of the tongue^ so often seen after this operation. It is by no means an easy or rapid matter to test taste perception^ and before any conclusion is reached with regard to loss of taste the patient must first have been proved, before operation, to possess the sense of taste in the anterior two thirds of the tongue ; it is not unusual to find that this is absent in elderly people otherwise healthy. In testing it is better to employ solutions than solids. Solutions of sugar, salt, quinine and acetic acid are used ; these are brushed on to the protruded tongue with a camePs hair pencil or glass rod. The tongue must be kept protruded through- out the test, and as soon as the patient experiences any taste sensation he should make an agreed sign. The mouth must be well washed out between each application. The nasal mucous membrane on the affected side is anaDsthetic, hence the inhalation of irritating sub- stances causes no discomfort or kichrymation, and tickliu"' the affected nostril does not cause sneezinsf. The sense of smell may be defective owing to dryness of the mucous membrane. 160 INJURIES OF NERVES Motor symptoms. — Complete division of the fifth nerve or its motor division produces paralysis of the muscles of mastication^ the masseter, temporal and pterygoids. But this causes little inconvenience, difficulty in mastication being more due to the food lodging between the cheek and gum owing to their anaesthesia. On opening the mouth the jaw is deflected to the paralysed side from the unopposed action of the sound external pterygoid. The paralysis of the anterior belly of the digastric and the mylo-hyoid muscles, said to be supplied from this nerve, cannot be detected clinically. Considerable difference . of opinion has existed with regard to the motor supply of the muscles of the palate, and it has been stated that they, or perhaps the tensor palati only, are supplied by the fifth nerve. Gushing observed in four of his cases an asymmetry of the palate of a greater degree than, in his opinion, could be accounted for by deflection of the jaw. In one case, also, he was able to obtain twitches in the corresponding side of the soft palate on stimulating the stump of the third division of the fifth during the course of a ganglion extirpation. On the other hand, Horslcy was able to detect no movements on similar electrical stimulation in three patients. Krause was of opinion that no alteration of the soft palate was to be seen, and Morriston Davies, from the examination of twenty- six cases, found a slight inequality in five, and came MOTOR SUPPLY OF PALATE IGl to the conclusion that " the balance of evidence seems to show that the fifth nerve has nothing what- ever to do with the nerve supply of the palatal muscles/^ It is quite possible that the asymmetry observed was due to a loss of muscle sense. To obtain conclusive evidence electrical examination of the muscles is necessary. The innervation worked out by Hughlings Jack- son, Aldren Turner, Beevor and others, from the accessory portion of the vagus, corresponds with clinical observations. In the few cases that I have had the opportunity of examining, no alteration was present in the palatal muscles. Their motor supplj^ is through the pharyngeal plexus. Paresis of the facial muscles has been noticed after excision of the ganglion, due to loss of the sense of passive position and movement. First division. — This division may be injured during the course of operations upon the frontal sinus, and may be involved in disease in this situation. It may also suffer in fractures of the anterior fossa of the skull, but the injury is rarely complete, or of the whole division. When involved in disease of the sinus the supra-orbital and supra- trochlear branches are affected ; as the result of fractures, anaesthesia of the cornea and conjunctiva alone, followed by subsequent destruction of the cornea, has been recorded. Its nasal branch may be affected in fractures of the cribriform plate. 11 162 INJURIES OF NEEYES The fir?t division of tlio fiftli nerve snpplies the scalp as far back as the mid-point between the external occij)ital protuberance and the nasion^ to- gether with the conjunctiva of both lids. Deep touch is everywhere present after section of this division. After removal of the whole ganglion transient changes in the ]3upil have been noticed ; immediately after the operation it is smaller than on the sound side. Gushing observed this in eight cases ; it existed for some weeks and was associated with a slight degree of enophthalmos. But in none of the cases recorded by Morriston Davies did it remain for as long as this. No permanent alteration of lach- rymal secretion results. It is well known that after injury of the first division of the fifth nerve changes may supervene in the cornea^ leading in some cases to ultimate loss of the eye. It is a rare condition and present in only a small pro|)ortion of the cases. Considerable diiference of opinion exists with regard to its causation. One thing seems certain: it does not arise spontaneously in cases in which the ganglion has been completely removed, if care be taken to protect the eye from injury during the course of the operation and the succeeding few days. But in cases of incomplete division of this branch it may do so_, thus falling into line with what has been said with regard to ^' trophic " ulcers elsewhere {vide CORXf]AL f'HANGES 1G3 p. 31). In most of the cases it has been noticed daring the first few days following- operation — a period at which there is a diminution of lachrymal secretion. The change begins in the corneal epi- thelium, the cornea becomes dull and its epithe- lium is shed, infection rapidly ensues and the eye is lost. Willibrandt and Sanger have suggested that it is due to irritation of the peripheral end of the nerve, and this theory has the support of Parsons. But it is obviously untenable in cases of complete division, unless arising within a very short time after the operation, while the fibres in the peripheral end still conduct impulses. I am more in agreement with the experimental work of Turner, Ferrier and Hanau that the corneal change is due to external injuries in all cases in which the ganglion has been completely removed, or the first division completely divided. Second and third divisions. — These are rarely affected. They may be injured in fractures of the petrous bone traversing the cavum Meckelii ; the infra - orbital nerve may suifer in fractures of the upper jaw, or be involved in growths or inflammatory affections of the antrum of High- more. The inferior dental nerve suffers occasionally in fractures of the jaw, and the lingual nerve has been injured in extraction of an impacted wisdom tooth. 164 IN.JUEIES OF NEEYES Tlip loss of epici'itic and protopatliic sensibility resulting from injury of either of these divisions or nerves is small ; deep sensibility is unaffected. Facial nerve. — Facial paralysis is one of the most common varieties of peripheral paralysis. But many of the cases are incomplete^ and not^ strictly speakings due to injury. In 265 cases of facial paralysis collected by Bernhardt^ only 5 or 6 per cent, were due to injury^ and 6 to 9 to middle- ear disease ; the remainder belonged to the so-called '^ rheumatic ^' type. Much the same percentage existed in the 130 cases collected by Philip and the 135 of Hiibschmann. But these figures by no means show the importance of the surgery of the facial nerve, for many cases due to non-traumatic causes come later under the care of the surgeon. Facial paralysis is occasionally seen in the newly born, usually in cases in which forceps have been necessary ; Lib in found facial paralysis 25 times in 1063 forceps deliveries. It is usually unilateral. Symptoms. — The symptoms caused by interference with the functions of the facial nerve differ according to the level of the injur}", and fall into three groups owing to the association with it of the chorda tym- pani nerve between the geniculate ganglion and the lower part of the Fallopian canal ; here it leaves the facial to cross the tympanic cavity. Injury to the facial nerve below the point at FACIAL PARALYSIS 165 which the chorda leaves it results, most often, from penetrating wounds of accidental or operative origin in the parotid and sub-maxillary regions ; it also occurs as a birth paralysis. Its complete division produces flaccid paralysis of all the muscles of the corresponding side of the face, and is at once obvious. The natural furrows are obliterated, leaving the affected side of the face, expressionless and devoid of voluntary or emotional movement. The eye cannot be closed and the lower lid droops, allowing the ]3unctum to fall away from the eyeball ; this, with the loss of the suction action of the lachrymal sac from paralysis of Horner^s muscle, is responsible for the lacrymation. The conjunctival reflex is abolished through its motor limb. On attempting to close the eye the eyeball moves upwards. If completely divided where accompanied by the chorda tympani nerve, taste is lost over the corres- ponding half of the anterior two thirds of the tongue. The nerve may be injured in this situation as the result of operations upon the middle ear or a frac- ture of the petrous bone, or be affected in otitis media. When divided above the geniculate ganglion the symptoms resemble those in the first group, but the auditory nerve is usually affected at the same time. It is sometimes stated that a lesion of the facial in this situation produces ]niralysis of the c()rres])o]uliiig 166 INJURIES OF NERVES half uf tlie soft palate ; I have been unable to observe this. In patients in whom the facial paralysis has existed for some time^ contractures of the affected muscles may develop. This may cause momentary confusion and difficulty in diagnosis^ the healthy side, at rest, appearing to be the affected ; voluntary move- ment at once reveals the side paralysed. In investigating a case of facial paralysis, its cause, the site of the injury, and the degree of in- volvement of the nerve must be discovered. The cause is, as a rule, obvious, and shoAvn by the history of injury or operation. Prognosis. — The prognosis varies with the cause of the injury. A very large proportion of the idio- pathic cases recover spontaneously, a few only of the so-called rheumatic type remaining permanently paralysed and needing operative interference. The electrical reactions are of the utmost importance. Complete facial paralysis may entirely disappear in a few days or weeks, or remain permanent. There is nothing except the investigation of the electrical reactions of the affected muscles which will enable a prognosis to be given. If the reactions are those of incomplete division recovery may be confidently expected. If the true reaction of degeneration is present, recovery apart from operation is unusual. In most instances the injury is incomplete and operation is rarely indicated. Facial paralysis. TREATMExVT OF FACIAL PARALYSIS 167 following an operation on the middle ear is, as a rule, due to incomplete division ; recovery takes place in the majority of the cases. In facial paralysis com- plicating fracture of the base of the skuli, whether the involvement is primary or secondary, recovery usually takes place. The partial facial paralysis, paralysis of the lower facial muscles, which is so common as the result of operations in the submaxillary region, is rarely permanent; if apposition of the edges of the wound is accurate and the wound heal without suppuration, recovery is the rule. Treatment. — The lines upon which the treatment of facial paralysis is conducted differ not at all from those laid down in Chapters Yl and VII. If the nerve be completely divided primary suture should be carried out, if possible, but for anatomical reasons this is often impossible. In older cases continuity with the central nervous system must be restored either by means of its own central end, or more often for anatomical reasons, by anastomosis. When the nerve is involved as the result of middle- ear disease operative interference in the antrum or tympanum is indicated. If the facial nerve has been completely divided in the petrous bone, whether as the result of operation or fracture, the sooner operation is carried out the better the chance of complete recovery. AV^hen the injury follows a mastoid operation time must be allowed to permit all inflammation to cease ; it is 168 INJURIES OF NERVES unjustifiable to perform a plastic operation on nerves involving a deep dissection in the neck while a suppurating wound is present behind the ear. If the reaction of degeneration develops in a case of idiopathic facial paralysis, spontaneous recovery is unlikely, but it is justifiable to wait for six months before resorting to the operation of anastomosis. In the large proportion of cases submitted to operation end-to-end union is out of the question, and a neighbouring nerve must be utilised. This was first done by Drobnik in 1879 ; he divided the spinal accessory nerve and united its central end with the peripheral end of the divided facial. But the modern operation for facial paralysis is due to the initiative of Ballance, who first carried out the modern operation in 1895. In a boy, aged eleven years, six months after injury in a mastoid operation, he anastomosed the facial nerve to the spinal acces- sory. It is from the time of the Ballances and Purves Stewart^s paper, published in 1903, that the present interest in the subject dates. Different nerves have been recommended and used, and nerve crossing employed as well as anas- tomosis. We have to consider what operation on what nerve will most quickly restore the power of dissociated movement to the paralysed muscles Avith the least damage to the sound nerve used. The hypoglossal is the nerve of choice ; dissociated voluntary movement is restored much more quickly FACIO-HYPOGLOSSAL ANASTOMOSIS 169 than when the spinal accessory is employed. Nerve anastomosis and not nerve crossing should be carried out. It is unnecessary to sacrifice a sound nerve, emotional movement may bo restored without. The complete peripheral operation should be performed, and nerve-fibres divided in the sound nerve, either by making an oblique cut into the nerve, or by splitting off a portion and uniting it end-to-end with the peripheral end of the facial {vide p. 91). Instances of recovery have been recorded after simply inserting the peripheral end of the facial into a vertical slit in the hypoglossal, but the return of voluntary movement is more rapid if axis cylinders are definitely divided. The primary essential for success in this operation is asepsis. If the Avound suppurates recovery will be delayed and imperfect. The greatest care and gentleness of handling is necessary, and the incisions must be made into the nerve with a sharp, thiii- bladed tenotomy knife. In order to carry out the operation of facio- hypoglossal anastomosis a long incision should be made extending from the mastoid at the level of the external auditory meatus down to the great cornu of the hyoid bone. The anterior border of the sterno-mastoid muscle is first defined and pulled backwards, then the posterior belly of the digastric identified and pulled backwards and down- wards j if large, it may be necessary to divide some 170 INJURIES OF NERVES of the fibres in its upper border. The facial nerve is next sought for; it is most easily found by feeling for the styloid process ; the nerve passes out immediately in front of this and enters the parotid gland. The facial nerve should next be freed, and an attempt made_, in cases in which it has been injured in the performance of a mastoid operation, to pull the stump out from the stylo- mastoid foramen. If this cannot be done the nerve should be divided in the foramen, as high as possible, with a tenotomy knife. The hypoglossal should next be found ; the transverse process of the axis is first felt and serves as a guide to the occipital artery, which runs upwards and outwards across it. The internal jugular vein is identified and retracted inwards ; this exposes the vagus and the hypoglossal nerves ; the latter is easily distinguished by its relation to the occipital artery. After freeing, it is brought towards the facial and an oblique cut made into its trunk so as to divide about one third of its fibres and the peripheral end of the facial sutured in with fine catgut. If there is any tension on the junction it is better to raise a flap and perform end- to-end union. The raw surface left and the junction should be surrounded with Cargile membrane. The after-treatment requires care. The nutrition of the muscles must be kept up by massage and stimulation with the constant current until voluntary power is restored. As soon as voluntary power RECOVERY AFTER ANASTOMOSIS 171 returns to each group of muscles they must be exercised systematically until the patient regains complete control. An operation such as I have described inflicts astonishingly little injury on the hypoglossal nerve. At first there may be paralysis of the corresponding half of the tongue^ but if the wound heal by first inten- tion it is quite transient^ and the slight hemiatrophy which supervenes disappears in a few months. No improvement in the condition of the facial muscles is to be expected for at least six or eight weeks. Abont this time it is usually noticed that the lower part of the face at rest is more sym- metrical ; following this^ from three to six months after o23eration, a return of power in the muscles at the angle of the mouth takes place ; those which regain voluntary poAver last are the muscles around the eye and the frontalis. Preceding the return of voluntary power the muscles show a change in their electrical reactions, the reaction described as typical of incomplete division developing. In some cases, particularly in those following an operation for acute mastoiditis, recovery may be much delayed. Movement is at first associated with movements of the tongue, but soon becomes dissociated. In a favourable case the patient should be able to perform all movements in from nine months to a year, but emotional movement is restored much later. It is at this stage that the patient is able voluntarily to 172 mJUEIES OF NERVES throw all the muscles of his face into action, yet in smiling the affected side of the face remains motion- less. Emotional movement may take years to be restored, but improvement steadily ensues and may be expected to be perfect in a young patient in whom the wound healed by first intention. After facio-hypoglossal anastomosis the return of power is, therefore, as follows : First, movements associated with those of the tongue, then dissociated, and finally emotional. In all the cases of facial nerve anastomosis reported sufficiently long after operation, some recovery took place ; this commenced earlier and became more complete in cases in which the hypoglossal nerve was used, but up to the present few cases of ijerfect recovery have been recorded. In any case we can confidently predict great improvement to follow the operation, which may in time restore the condition of the face to normal. Auditory nerve. — This nerve is usually injured in fractures of the middle fossa of the skull, and is associated in 80 per cent, of the cases with a facial paralysis. Nerve deafness results from its complete division. Glosso-pharyngeal nerve. — No instance of isolated injury to this nerve has been recorded. It is most likely to suffer at the jugular foramen, with the vagus and spinal accessory nerves. But although fractures of the base of the skull frequently involve this region, the nerves usually escape. VAGUS NERVE 173 Tlie symptoms produced b}' its injury arc : diffi- culty in swallowing from paralysis of the middle constrictor and stylo-pharyngeus muscles^ and loss of sensibility on the posterior third of the tongue and pharynx on the affected side. Vagus nerve. — The vagus during its long course through the neck is exposed to many forms of in- jury, but rarely suffers complete division. It or its recurrent laryngeal branch may be injured in operations upon the thyroid gland, ligature of the great vessels, or removal of tuberculous or malignant glands. It may suffer in the thorax as the result of the pressure of growths or aneurysms. It was the belief of the older surgeons that death invariably resulted from division of one vagus nerve, but if it is divided below the point at which the recurrent laryngeal nerve is given off, no symp- toms are, as a rule, present, hence the surgeon should not hesitate to sacrifice the nerve if necessary in operations upon malignant disease. In twenty-four cases in which the nerve has been divided durino- the course of operations in no instance did death result from the nerve injury. Thus, in a case recorded by Rivington, the nerve was divided during the operation of ligature of the internal carotid. No symptoms resulted, and when death occurred later from a cerebral abscess the division was verified. But when irritated during the course of operations, included in a ligature, pulled upon by retractors. 174 INJURIES OF NERYES picked up in .pressure forceps^ etc., alarming sym- ptoms may result. In cases recorded by Michaux and Tilman the pulse and respiration temporarily ceased from sudden stimulation of the vagus during the course of operations upon the neck. This nerve carries the motor fibres to the muscles of the soft palate and larynx. The paralysis of the palate is easily recognised if the patient is told to open the mouth and the raphe of the palate be watched; it is seen to be pulled to the sound side when elevated by producing such sounds as ^^ eh." Hoarseness results from paralysis of one recurrent laryngeal nerve. On laryngoscopic examination the cord of the affected side is seen to be fixed midway between adduction and abduction — the cadaveric position. In investigating a case of paralysis of the larynx, due to an injury to the vagus nerve or its recurrent branch, it is necessary to discover, if possible, the seat of the injury. The condition of the palate is first investigated ; if this is not affected the history of operation or the symptoms of growth will alone reveal the seat of the injury. Treatment is carried out along the usual lines, primary or secondary suture, or if this is impossible, anastomosis to cervical nerves or spinal accessory. Spinal accessory nerve.— This nerve supplies the sterno-mastoid and the trapezius in conjunction with branches from the cervical plexus. The extent of PARALYSIS OF TRAPEZIUS 175 the suppl}' of the trapezius from the spinal acces- sory varies, Init as a rule the upper part is supplied bv this nerve, the lower bv branches from the third and fourth cervical nerves. The spinal accessory is most often injured during the operation of removal of tuberculous glands of neck, and in many of the cases the branches of the third and fourth cervical are also affected and paralysis of the whole trapezius results. It must not be foro-otten that the nerve may be involved in the spinal canal and at the jugular foramen, though in the latter position it is rarely affected alone. Division of the nerve in the anterior triangle of the neck produces paralysis of the sterno-mastoid and upper part of the trapezius. The paralysis of the sterno-mastoid gives rise to no marked symptom. There is no alteration in the position or movements of the head, but the muscle does not become promi- nent on depressing the head against resistance, or on rotating it to the opposite side. The upper fibres of the trapezius muscle usually suffer alone when the nerve is divided in this situation. This produces an alteration in the contour of the neck (vicle infra), slight drooping and rotation of the shoulder, but little interference with movement. Paralysis of the whole trapezius muscle produces considerable deformity and disability, and the greatest care should be taken to avoid this result of operations upon the neck. The patient complains 176 INJURIES OF NERVES of weakness of the whole upper limb. The scapula is dropped and rotated forwards (vide Plates IV and V), and so tilted that its spine is more horizontal than normal and its lower angle is nearer the mid- line than the upper. There is also slight winging of the scajDula, which disappears at once on bring- ing the serratus magnus muscle into action {vide p. 212). The lower border of the rhomboideus major stands out prominently and becomes more marked when the shoulders are thrown back. The contour of the neck is altered and becomes somewhat irregular from the exposure of the levator anguli scapulae. The patient is unable to raise the arm above the head after it has been abducted by the deltoid, but can raise it above the head in front of the body, and this may lead to difficulty in diagnosis. When the paralysis of the trapezius has been in existence for some time the patient may learn to raise the arm above the head by a peculiar manoeuvre. The arm is abducted by the deltoid muscle and then carried a little forward and rotated outwards by the pectoralis major and carried above the head in this position by the serratus magnus. Immediate suture should be carried out in all cases in which the nerve is divided during the course of an operation. If not seen until later, an attempt should be made to perform secondary suture. If it is impossible to find the central end or to bring the PLATE lY. Taken from a patient witli paralysis of tlie whole trapezius following an extensive operation upon tnbercnlovis cervical glands. FiGi^. 1. — The prominence formed by the rliomboideus major and the droi)ping and tilting of the scapnla are well shown. Fig. 2. — Shows the alteration in the contour of the neck. To face p. 17G. Adlard ^- Son, Impr. PLATE Y. From the same patient as Plate IV. Fig. 1. — The forward tiltino- of the shoulder as seen from the side. Fig. 2. — Sound side for comparison. To face p. 170. Adlard .y Son, Impr. HYPOGLOSSAL NERVE 177 ends into apposition tliu periplicral end should be anastomosed to the anterior primary divisions of the third or fourth cervical nerves. Hypoglossal nerve. — This nerve is rarely injured. It has been severed most often as the result of gun- shot wounds and surgical operations. It may be pressed upon by a growth extending deeply into the pterygoid region, but in these cases the muscles of the palate and pharynx suffer as well. The symptoms are characteristic : the affected half of the tongue is flaccid, and, on protrusion, is pushed to the paralysed side ; it becomes atrophic and Avrinkled. At first the paralysis interferes consider- ably with mastication, deglutition and articulation, but this soon passes off and may be little noticed. Purves Stewart records that " the hemi-atrophy and impairment of movement due to division of the hypoglossal nerve causes remarkably little incon- venience, no more than a transient awkwardness in mastication, articulation and deglutition.^^ 12 CHAPTER XII Cervical Plexus : Method of Injury ; Loss of Sensibility produced by Injury to Sensory Brandies ; Injury to Motor Branches — Phrenic Nerve — Cervical Sympathetic. The cervical plexus formed by the anterior primary divisions of tlie upper four cervical nerves rarely suffers injury except as the result of operative pro- cedures. In extensive operations in the posterior triangle of the neck its sensory branches are not infrequently divided. These are^ the small occipital, great auricular and transverse cervical from the second and third, and the descending cervical from the third and fourth anterior primary divisions. Loss or alteration in sensibility in the areas supplied by these nerves is common, and will usually be found after extensive neck operations, but rarely gives rise to trouble, and is still less often permanent when the edges of the wound have been brought into apposition accurately and healing has taken place by first intention. The branches may be injured alone or together; the latter is the more common. The descending branches suffer most often alone ; the extent to To illustrate the loss of sensibility produced by section of the sensory nerves of the cervical plexus. Modified from Gushing. To face p. 179. Adlard S,- Son, Impr.. PHRENIC XERVJO 179 wliicli these brandies descend should be noted (Plcitc YI). W.hen divided during the course of an operation primary suture should be performed, as considerable discomfort may result from non-union. The most important motor branch of the plexus is the phrenic, which arises mainly from the fourth cervical, but receives in most cases a branch from either the third or fifth ; other branches are, to the levator anguli scapulas and scalenus medius from the third and fourth ; the sterno-mastoid and trapezius receive branches respectively from the second and third and the third and fourth in common Avith those given from the spinal accessory. These have been considered with the spinal accessory nerve. Phrenic nerve. — This nerve may be injured as it lies on the scalenus medius during the progress of operations upon lymphatic glands or upon the supra- clavicular portion of the plexus. It has been injured most often during the operation of ligature of the third part of the subclavian artery, being included in the ligature or divided. In one case recorded by Bransby Cooper violent coughing set in immediately after the o2:)eration, and continued until death on the iifteenth day following inclusion of the nerve in a ligature. Erichsen and Keidel also published cases in which death followed a few days after division of this nerve, death being due to pulmonary troubles. 180 INJURIES or NERVES If both phrenic nerves are injured respiration is carried out entirely by means of the extei'nal respiratory muscles. No symptoms may be present while the patient is at rest^ but dyspnoea is marked on exertion. On watching the movements of the abdomen and chest it is seen that the abdomen re- tracts on inspiration and is forced out on expiration — the exact opposite of the normal movements. When injured on one side only, the paralysis is little noticeable, but careful inspection will show the impairment of movement on the affected side. X- ray examination will demonstrate the deficient move- ment of the diaphragm. The prognosis is good : few cases have succumbed to the immediate result of division of one phrenic nerve. Immediate suture should be carried out in all cases in which the nerve has been accidentally divided during the course of an operation. Cervical sympathetic— The cervical sympathetic may be affected as it lies deeply behind the carotid sheath, as the result of a penetrating wound or operation, or be pressed upon by new growth or involved in fibrous tissue. Its white rami communi- cantes from the anterior primary divisions of the first and second dorsal nerves may be injured, especially in traction injuries of the brachial plexus ; it usually suffers when the whole plexus is injured and in the lower arm type of lesion. PLATE YII. From a patient who completely ruptured the left brachial plexus as the result of a fall on the point of the shoulder. The pseudo-ptosis and slight enophthalmos are well seen. To face p. 181. Adlard ^ Son, Impr. CERVICAL SY:\rPATHETIC 181 It must not be forgotten that the pupillary fibres may be injured in the spinal cord itself. The pupillary changes seen after injuries of the cervical sympathetic were recorded first by Petit in 1727, but the earliest complete description appears to have been due to Jonathan Hutchinson^ who^ in 1866, described the effects of its injury with the plexus in a stab wound of the neck, and of its pupil dilating fibres in injuries of the spinal cord. It is by means of the fibres supplying the eye and orbital muscles that affections of this part of the sympathetic are recognised. It carries, in addition, vaso-motor fibres for the blood-vessels of the face and upper limb, and fibres for the suppl}^ of the sweat glands. Section of the cervical sympathetic produces slight enophthalmos and pseudo-ptosis (vide Plate Yll) ; the upper lid droops but can be elevated spontane- ously. The jDupil affected is smaller than the sound, unless seen in a bright light, when both are equal and contracted. It does not dilate when shaded, or in response to the instillation of cocaine or to pinching the side of the neck (cilio-spinnl reflex). The affected side of the face does not flush or sweat and the ear often feels colder to the touch of the observer than the sound one. The area of absence of sweating includes, as first pointed ont b}' Purves Stewart, the whole of the upper limb ; this 1 have been al)le to confirm. No interference with the heart's action has been recorded. 182 IX.JURTE8 OF NERVES Stimulation of the sympathetic much more rarely comes under the care of the surgeon ; it may occur as the result of the pressure of tumours or aneurysms or the traction of adhesions. It results in exoph- thalmos^ widening of the jDalpebral fissure^ dilatation of the pupil_, Avith^ in many cases^ flushing and sweating. The prognosis will depend upon the cause of the injury. Occurring in connexion with injuries of the brachial plexus it is rarely complete; the eye_,altliougli remaining contracted on shadings dilates to the instillation of cocaine. These cases usually recover. If the paralysis is complete, recovery is unlikely when injured in association with the brachial plexus, its treatment under tliis condition is impossible for anatomical reasons. Its division in the neck should be treated by primary or secondary suture. The work of Langley and Anderson has established the fact that the preganglionic fibres of the sympathetic regenerate just as peripheral nerves. If the ends cannot be brouglit into apposition nerv^e anastomosis may be carried out. CHAPTER XIII The Bracliial Plexus : Distribution of its Roots to Muscles and Skin — Classification and Causation of its Injuries— Injuries to Whole Plexus ; Upper Arm Type ; Lower Arm Type ; Inner Cord ; Outer Cord ; Posterior Cord — Treatment and Prognosis of Brachial Plexus Injuries — Eracliial Birth Paralysis. Under the term " brachial plexus '' is included the anterior primary divisions of the fifth^ sixth^ seventh and eighth cervical nerves, with varying portions of the first dorsal and fourth cervical, together with the trunks and cords formed by their junction and decussation. The individual named nerves arising from these are not included. A knowledge of the motor distribution of the various roots entering into tlie plexus is necessary in order to understand the paralysis resulting fi-om injuries. Although fibres from more than one root can be traced to most of the muscles of the up]3er limb, from the clinical standpoint the motor supply depends usually upon one root only. Stimulation of the anterior primary divisions during the course of operations, and the investiga- tion of the motor affection I'osultino* from accidental 184 INJURIES OF XEEVES lesions_, the exact nature of wliicli is made manifest by operation^ are the means by which the extent of their supply is elucidated. These opportunities arise most often in injuries of the upper and lower roots^ rarely in those of the middle of the series ; the distribution of these latter is, therefore, somewhat uncertain. Much more difficulty and considerable confusion exists with reo^ard to the sensory distribution of the posterior roots entering into the formation of the plexus, on account of the different methods which have been used. It is very necessary to bear in mind the distinction between areas of full and exclusive supply [vide p. 15), and also to separate the areas of supply of the different forms of sensi- bility. The distribution of the roots entering the plexus to the skin of the upper limb does not, of course, correspond to the area which would become insensitive to cutaneous stimuli on division of that root. The well known fio-ures of Thorburn and Kocher were obtained by various methods, jDrinci- pally from instances of injury to the spinal cord, others from injuries to roots, sometimes the full supply being obtained, at others the exclusive. This probably accounts for the difference seen in the various plates. In most cases, however, the areas seem to be those of the full protopathic supply. The areas given by Dr. Head, obtained from cases of herpes zoster, should also correspond to the full protopathic supply. But it has to be remembered SUPPLY OF POSTERIOR ROOTS 185 tliat the overlap betAveen adjacent roots is consider- able in the upper limb ; for example, it is possible to completely divide the anterior primary divisions of the fifth, sixth or seventh cervical nerves containing the cutaneous fibres arising from the posterior roots Firj. 11. — Hopresents the full protopathie supply of fifth cervical and first dorsal posterior roots. Vertical shading : fifth cervical. Oblique shadin*^- : first dorsal. of the fifth, sixth or seventh cervical nerves, without producing nny sensory loss that can be discovered by any of the methods at our disposal. It is, there- fore, impossible to delineate all the areas supplied by these roots on any one chart of the upper limb. The diagram given (Fig. 11) represents tlic full 186 lA^.JUPJES OF NERVES protopatliic supply of the fifth cervical and first dorsal nerves, but it must be remembered that the areas of full supply of the sixth and eighth cervical will overlap these considerably. These areas are onl}^ of use from the point of view of residual sensibility and in irritative conditions leading to hyperalgesia. The tables usually given illustrating the root supply to the muscles of the ujoper limb have been obtained, not only from injuries to nerves, but also from injuries to the spinal cord. The following- table differs from those usually given in small details, and is obtained from a study of the paralysis resulting from the section of individual anterior primary divisions and the result of experimental excitation during the course of operative procedures. Fifth cervical. — Deltoid, biceps, brachialis anticus, supinators, rhomboids, usually the spinati, occasion- ally the radial extensors of the wrist, rarely the j)ronator radii teres. Sixth cervical nerve. — Pronators, radial extensors of the wrist, clavicular portion of pectoralis majoi-, serratus magnus. Seventh cervical. — Triceps, extensor carpi ulnaris, extensors of fingers, pectoralis major. Eighth cervical nerve. — Flexors of wrist, flexors of fingers. First dorsal nerve. — Intrinsic muscles of hand. , Classification. — Lesions of the plexus may be CAUSATION OF PLEXUS INJURIES 187 classified into supra- and infra-clavicular varieties. This is important^ for the causation and prognosis of these forms differ in most instances. Causation. — Supra-clavicular injuries result usually from indirect violence, the force being applied to the head or the shoulder ; infra-clavicular, usually from the direct violence of the dislocated head of the humerus. Taking first the supra-clavicular injuries. In addition to those due to indirect violence they may arise occasionally from the presence of a cervical rib, complicating a fracture of the clavicle, or as the result of a penetrating wound or a fracture of cervical spine. 8upra-clavicular ivjurie!^ due to indirect violence. — The injuries resulting from violence applied to the head or shoulder are due to overstretching of the anterior primary divisions of the cervical nerves ; only in rare cases are the ^^ roots '^ affected. They fall into the class of traction injuries ; they are not due to the direct pressure of the clavicle as has been suggested by many authors. The traction falls first upon the upper part of the fifth anterior primary division, then upon its jiinctiuii with six, following this upon the I'emaining divisions in order from above downwards. The slight amount of pressure necessary to produce overstretching of the plexus in a child can easily be seen by depressing tlie shoulder; the cords at once stand out prominently. 188 • INJURIES OF NERVES Injuries of this type, both in children and in adults, affect usually the fifth or fifth and sixth anterior primar}^ divisions and produce the Erb- Duchenne type of paralysis. There is no reason why the injuries sustained at birth should be separated from those of adult life, both occur as the result of similar violence, the same muscles are affected and the treatment identical. If the traction fall upon the plexus from below — for example, a man in falling from a height endeavours to save himself by clutching at some projection — the injury affects the first dorsal, then the others in order from below upwards. The same may result in infants in breech presentations, with the arms extended, or in certain face presentations. In both cases recovery takes places from the root last affected, and may leave an Erb-Duchenne or Klumpke paralysis as a terminal lesion when the original affection was more widespread. The actual method of production of these injuries has been much discussed and many fanciful ex- planations brought forward, such as the compression of the trunks between the clavicle and first rib, or transverse processes of cervical vertebrae. But it was shown by Horsley as the result of experiment in 1884 — although this seems to have been overlooked by most writers on the subject — and later maintained by Duval and Guillain, and demonstrated in infants by Taylor, that the correct cause is tractinu. It has TRACTION INJURIES 189 been sliown^ firsi Ijy Horsluy^ tliat the iiiimt'diiilL' lesion consists in a tearing of the nerve sheatli, witli liBemorrliage ; in more isevere cases a complete or partial severance of nerve-fibres may occur and the fibres give way at different levels. In healing, an excess of fibrous tissue is formed which prevents regeneration in many cases. Po8t-anxdhnt'ic parahj>iLt;. — Under the term " post- ani\:stlietic ^' or " ^^^-^^^"ii'^i'^'^^^c paralysis/^ many nerve injuries of the upper limb liaA'e been included. Most are of the Erb-Duchenne type and so obviously supra-clavicular in origin ; others from their distri- bution are undoubtedly infra-clavicular ; in a few direct pressure has fallen upon individual nerves, such as the musculo-spiral. With this last group we are not at present concerned. These injuries are by no means uncommon, although published cases are few. Cotton and Allen, writing on the subject in 1 903, were only able to collect thirty cases. Many causes have been assigned to the production of these injuries, but all are agreed that the paralysis occurs only in patients in whom, during the course of the operation, the arms are abducted and externally rotated or raised above the head. In my experience they have originated most often on the right side in cases in which the patient has been brought to the right side of the operating table. The weight of the abducted and unsupported arm causes over- 190 INJURIES OF NERVES ^ stretcliing' of tlie plexus. Tliese cases are thus brought into line with the other injuries of the plexus due to indirect violence. Stretching over the head of the humerus with the arms elevated is the probable cause of those injuries which are infra- clavicular. The violence producing the injury is slight^ the division incomplete and the prognosis good. All the cases that have come under my notice have recovered without operative intervention^ and in all the recorded instances recovery ensued^ except in one patient, in whom the deltoid muscle remained permanently paralysed. Injuries associated icith the presence of a cervical rih. — The next most common cause of a supra- clavicular lesion of the plexus, but falling far below those just mentioned in order of frequency, is that due to the presence of a cervical rib or exostosis. Unlike those we have just been considering, it affects fibres from the lowest roots entering into the plexus, and is the result of direct injury. Considerable interest has lately been aroused on the subject. In this country Thorburn and Lewis Jones have directed attention to it, and more recently an elaborate paper has been published in America by Keen, analysing all the recorded cases. Briefly, the points are as follows : The abnor- mality is more common in Avomen than men and is usually bilateral, although the symptoms produced V CERVICAL RIBS. 191 arc, as a rule, uii one side uiilv — tJic riirlit. It lias been estimated that not more than from 5 to 10 per cent, of those with cerv^ical ribs present symptoms, and that in abont two thirds of these they are of a nervous nature. As a rule symptoms do not appear until early adult life, resembling in this way the late involvement of the ulnar nerve after injuries in the region of the elbow in early life. There may be a general weakness of the whole limb noticed at the end of the day or after severe exertion, accompanied by muscular wasting, or, w^iat is more usual, pain shooting down the inner side of the arm and forearm into the ulnar portion of the hand, described by the patient as neuralgic ; this is sometimes accompanied by alterations in sensibility, which are rarely of a greater degree than loss of epicritic sensibility. Wasting and paresis of the intrinsic muscles of the hand is usually present; first noticed and most marked in those of the thenar eminence. The lesion affects the inner cord of the plexus formed of fibres from the eighth cer\ical and hrst dorsal nerves ; hence there is no inter- ference with the cervical symi)atlietic, and tlie llexor muscles of the hngers have been ah'ected in a few instances. This lesion should always be kept in mind in cases of brachial '^ neuralgia '^ and in wasting of the intrinsic muscles of the hand, for many errors in diagnosis have been made. 192 IXJUKIES OF XER^^ES The treatment of tlie condition is simple and in most cases satisfactory — removal of the rib. It rarely happens that the nerves themselves have to be dealt with. After removal of the cause the usual after-treatment should be carried out. Complicating fractures of the clavicle. — As a com- plication of a fracture of the clavicle^ brachial plexus injury is uncommon. Taylor^ in 1903_, was only able to collect ten cases^ and I have had one patient with this complication under my care. In most, including the one I have recorded, the nerve injury was due to the violence producing the fracture and not to pressure on, or laceration of, the nerves by the ends of the bone. In some instances the fracture was due to direct violence, often from gunshot wounds, in others, including the case I have recorded, to indirect violence applied to the point of the shoulder, causing a fracture of the clavicle at the junction of its outer and middle thirds and a traction injury of the plexus. Penetrating wounds. — Penetrating wounds in- volving the plexus are rare. I have reported one such case, in which the fifth anterior primary division was divided together Avith the descending branches of the cervical plexus, producing a t^q^ical Erb-Duchenne paralysis with loss of sensibility over the point of the shoulder. In military practice injuries of the plexus, due to gunshot wounds, have been by no means uncommon. SYMPTOMS OF PLEXUS INJURIES 193 Infra-clavicular injuries of the 'plexus. — In its infra- clavicular course^ i^^j^^y most often results from the direct pressure of the dislocated head of the humerus, occasionally from attempts made to reduce it by the heel-in-axilla method, sometimes from fracture of the upper end of the humerus or of the neck of the scapula. The whole plexus may suifer, but more often the inner cord alone, rarely the outer. In unreduced dislocations of the humerus, pain and tenderness may result from changes in the nerves, due to pressure, and may indicate operation ; in other cases paralysis may supervene from the same cause. In attempts at reduction either by manipulation or open operation, plexus injuries have been produced. Symptoms produced by injuries of the plexus. — There are three well-known types of brachial plexus lesion due to supra-clavicular injuries and produced by indirect violence : the whole plexus, the upper arm type (Erb-Duchenne) and the lower arm type (Klumpke). As a permanent affection the upper arm type is the most common ; more than 60 per cent, of the patients present this form of paralysis when seen by the surgeon. In many instances the symptoms noticed immediately after the accident diminish in extent ; the initial distribution may be the whole plexus, some recovery ensues and the con- dition remains stationary as an upper arm type of lesion. In other cases muscles supplied by other roots are also affected ; these, it is impossible to classify. 13 194 INJURIES OF NERVES In infra-clavicular lesions the inner cord and the whole plexus are the only common types. Here a lesion of the whole plexus often becomes later^ one of the inner cord only. The whole plexus. — This results usually from in- direct violence applied to the head or shoulder^ rarely as the result of a dislocation of the humerus, or from attempts made to reduce it. It is a some- what uncommon accident, for Bristow, in 1902, was only able to collect twenty-four instances of lesion of the whole j)lexus due to indirect violence. I have had three cases under observation. The symptoms produced by division of the whole plexus will depend to a certain extent upon the level of the injury, whether supra- or infra- clavicular, roots, primary divisions or cords. In a supra- clavicular division the loss of sensibility is the same whatever the level of the lesion. Epicritic and protopathic sensibility are lost over the whole of the forearm and hand and over the outer surface of the arm in its lower two thirds, the area overlapping on to the anterior and posterior surfaces {vide Plates VIII and IX). The sensitive area on the point of the shoulder gives the full supply of the descending branches of the cervical plexus, that on the inner side of the arm the portion of skin supplied by the intercos to-humeral and small internal cutaneous nerves. Deep touch is lost over the forearm. In lesions of this type the sympathetic is usually PLATE YIII. From a patient with complete division of the Ijrachial plexus in the supra-clavicvilar region. To show the boundaries of the loss of epicritic and protopathic sensibility. To face p. 194. Adlard 4' Son, Impr. PLATE TX. From the same patient as Plate VIII. To face p. 195. Adhtrd .f- Son, Impr. INJURIES OF THE WHOLE PLEXUS 195 alfected and all tlie symptoms indicative of a lesion of the cervical sympathetic present^ but the pupil, although it does not dilate to shade, usually dilates to cocaine, so that the involvement is incomplete. If the lesion is infra-clavicular the sensitive strip on the inner side of the arm may be absent if, as is so often the case, the injury has been caused by direct pressure, such as the heel in the axilla during the reduction of dislocations. Li all cases of complete loss of conduction in the plexus all the muscles of the arm, forearm and hand are paralysed. The level of the lesion will determine whether the spinati, rhomboids, serratus magnus and pectorals are paralysed or the sympathetic involved. Li the usual type of complete plexus injury due to indirect violence the pectorals and spinati are paralysed and the sympathetic involved, but the rhomboids and serratus magnus escape. Erh-Duclienne paralysis. — When the result of injury, this form of paralysis is usually due to indirect violence, very rarely to a penetrating wound or the pressure of a tumour. It was at one time considered to be due to interference with conduction in the anterior primary division of the sixth as well as the fifth cervical nerves, but it is certain that section of the fifth anterior primary division alone can produce it. Wilfred Harris, as the result of his dissections and of his clinical observations with Warren Low, came to this conclusion. I have been able to confirm 196 IXJUEIES OF NEEYES this, both as the result of operatiye findings in cases of this form of paralysis, and by stimulation of this division during the course of operations. In some instances both five and six may be involved; the involvement of six at its junction vdth five has, in my experience, no further effect, at most paralysis of the clavicular portion of the pectoralis major may result ; the branches given by this nerve to the serratus mao-nns are o-iven off above the level of the lesion. In patients in whom the junction of five and six have been excised no further paralysis resulted than that already due to the injury of the fifth nerve. In several cases in which I performed nerve anastomosis in this region I was able to stimu- late six with the interrupted current ; this produced a contraction of the clavicular portion of joectoralis major, and in one a feeble resjoonse in the triceps. It seems jDrobable, therefore, that the sixth cervical nerve supplies no group of muscles in the arm and forearm in a manner similar to the supply of the deltoid, biceps, brachialis anticus and supinators from the fifth. The main supply of the triceps appears to come from the seventh ; this agrees with the anatomical researches of Herringham. The position of the upper limb in patients with this form of paralysis is typical. The arm and fore- arm hang close to the side, with the forearm extended and pronated. There is obvious wasting in late cases, of the deltoid and flexors of the fore- BRB-DUCHENNE PARALYSIS 197 arm. The deltoid, spinati, biceps, bracliialis anticus and supinators are paralysed. It was pointed out by Harris and Low that the radial extensors of the wrist and the pronator radii teres might be affected. In a patient upon whom I operated and found the fifth anterior primary division torn tlirough, the radial extensors of the wrist were paralysed ; this is the only case in which I have observed paralysis of these muscles from this cause, but in one patient with a lesion of the lower divisions they escaped together with the muscles usually supplied by the fifth. So far I have been unable to observe any affection of the pronator radii teres. A patient with this paralysis is unable to supinate the forearm and to abduct the arm, and in most cases to flex the forearm. But he may regain some power of flexion of the forearm or possess this move- ment on coming under observation, although no recovery has taken place in the paralysed muscles. Flexion of the fully pronated forearm may be carried out by tlie muscles arising from the external condyle of the humerus, the extensors of the wrist becoming feeble flexors of the forearm. There is, as a rule, no loss of sensibility accom- panying this form of paralysis. This was first recorded by Duchenne and has been confirmed by all subsequent observers. Even when the fifth and sixth anterior primary divisions are divided together there may be no obvious change, but there is usually 198 INJURIES OF NERYES some diminution or loss of epicritic sensibility on the outer surface of the arm and forearm. But although there is no loss of sensibility after division of the fifth^ it is not uncommon to have complaint made of peculiar feelings^ ticklings pins and needles^ over the outer side of the arm. In several of these cases careful examination has revealed no objective change^ the compass test was normally appreciated^ and minor degrees of temperature accurately discriminated. After this_, as after other nerve injuries^ the abnormal position of the limb may persist although the muscles have regained their power of voluntary movement^ and these may remain ]3ermanently Avasted although they react to stimulation with the inter- rupted current. Such cases have led to errors in diagnosis and probably to unnecessary treatment. Patients have come under my observation as examples of nerve injury suitable for operation^ in whom examination revealed the fact that recovery had taken place^ but the abnormal position of the limb had remained because of the lack or inefficiency of the after-treatment. In these cases the diagnosis of an old injury to the fifth cervical nerve is obvious^ yet all the muscles are acting and react normally. The injury to the fifth anterior primary division may be incomplete^, and this incomplete division may be anatomical or physiological ; it is very necessary to bear this in mind. Over-stretching of the fifth nerve may produce a haemorrhage in its sheath, with PARALYSIS OF DELTOID. 199 compression of the whole nerve, or, on the other hand, a rnjDture of some of its fibres. In the former case there is paralysis of all the muscles supplied by the nerve with the typical reactions of incomplete division ; in the latter the fibres in the upper part of the nerve supplying the deltoid and spinati suffer, leading to paralysis of these muscles, without affecting the flexors of the forearm and the sujDi- nators. The reaction of degeneration may develop in the spinati and deltoid without the biceps and supinator muscles being in any way affected, or after an Erb-Duchenne paralysis the spinati and deltoid may be left as a permanent paralysis, the other muscles having recovered. I have described cases of tliis nature, upon one of whom I operated, and was able to demonstrate the lesion in the upper part of five, and by stimulation with the interrupted current to obtain contraction in the flexors and supinators, while the deltoid remained flaccid. As this form of paralysis follows a fall on the shoulder great care is necessary in diagnosis ; these are the cases that are usually described as caused by an injury to the circumflex from a blow on the shoulder. Loicer arm tyi^e of j^ciralysis. — This type, usually called after Klumpke, who described it fully, was first mentioned by Flaubert in 1827. It may arise from overstretching of the plexus, as the result of penetrating wounds, sometimes from involvement in growth. When resulting from traction the violence 200 INJURIES OF NEEYES affects tlie roots from below, as in falling from a heiglit and grasping at a projection_, or from over- flexion or over-extension of the neck ; in these last cases it may be bilateral. In a typical example of this paralysis all the intrinsic muscles of the hand are affected and the hand assumes the true claw shape. Sensibility is usually altered over the inner side of the arm and forearm, sometimes also on the ulnar border of the hand, the loss of sensibility to prick being in most cases larger than that to light touch. In some, the lono' flexors of the fino-ers suffer in addition, but it is probable that in these instances the eighth cervical is also injured, but lesions of this nature verified by operation are few, and further study is necessary before coming to any definite conclusion. Characteristic orbital symptoms are present, due to involvement of the branches given from this nerve to the cervical sj^'mpathetic. T}ie inner cord. — Injury to this cord is the most common lesion of the ^^lexus after an Erb-Duchenne paralysis. It is most often produced by a sub- coracoid dislocation of the humerus, and is rarely complete. The muscles paralysed are those supplied by the ulnar nerve with, in addition, those intrinsic muscles of the hand supplied by the median, i. e. all the intrinsic muscles of the hand suffer. Sensibility is affected over the inner (post axial) CORDS OF THE PLEXUS 201 surface of the forearm and ulnar area of the hand. Usually the loss is of epicritic sensibility only^ but when the division is complete both forms are affected. Outer cord. — This may be injured in dislocations of the humerus^ but it is unusual. Its division results in paralysis of the biceps^ coraco-brachialis and all the muscles supplied by the median^ except the intrinsic muscles of the hand. It is easy to overlook this injury unless the action of the individual muscles is studied_, for^ as in a patient that was under my care^ the forearm may be flexed by the supinator longus and supinated by the supinator brevis^ and the paralysis of the long- muscles of the fingers is often not discovered (xide median nerve_, p. 267). Sensation is affected on the outer (pre-axial) surface of the forearm to a degree varying with the injury. Its anterior boundary is well defined, the posterior ill defined and fading away into the normal sensibility of the area supplied in common with the descending branch of the musculo-spiral. Posterior cord. — No difficulty should arise in the recognition of this rare form of injury. The paralysis of the muscles supplied by the musculo- spiral and circumflex nerves and the alteration in sensibility over the areas of skin supplied by them is typical. It results most often from a dislocation of the humerus. 202 INJURIES OF NEEVBS Treatment of brachial plexus injuries. — Treatment is carried out along tlie lines already laid down. As most are subcutaneous injuries it is impossible to make the diagnosis of complete or incomplete division until sufficient time has elapsed to allow of the establishment of the reaction of degeneration. If at the end of fourteen days this is present^ operation should not be delayed. In supra-clavicular lesions of the whole plexus^ good exposure is given through an incision starting at the posterior border of the sterno-mastoid muscle at the junction of its upper and middle thirds^ and carried downwards and outwards to the junction of the outer and middle thirds of the clavicle ; in some cases it will be necessary temporarily to divide this bone. When operation is delayed it is usually im- possible to identify the individual nerves in the mass of fibrous tissue with which they are incorporated^ and to bring ends which have been identified^ into apposition after its removal. Patient and careful dis- section may bring the upper ends into view ; it may be impossible to identify the individual lower ends^ and in many cases they have had to be sutured without exact knowledge. It is only when these cases are operated upon early that complete success is likely to ensue. No instance of perfect recovery after secondary suture of the whole plexus has been recorded. The anterior primary divisions of five and six may be easily exposed through a similar incision. In TREATMENT OF PLEXUS INJURIES 203 deepening tliis it is important to avoid injury to the descending brandies of the cervical nerves. The posterior border of the sterno-mastoid is freed and drawn inwards and the nerves sought as they pass out from under cover of the scalenus anticus. The junction of five and six is brought into view after a little dissection_, with the upper trunk formed by their junction and its division into three branches, the supra-scapular and the branches to the outer and posterior cords. Tracing the nerves up from their junction the seat of the injury is easily found. The supra-scapular nerve should always be examined ; I have found it divided in addition to the fifth cervical. The phrenic nerve exposed on the anterior surface of the scalenus anticus must be avoided. In the cases in which the deltoid and spinati alone are paralysed and give the reaction of degeneration, the damaged portion may be excised and a portion of the radial nerve inserted, or these upper affected fibres may be anastomosed to the sixth anterior primary division. In the typical lower arm type of paralysis the lesion is situated in the first dorsal anterior primary division, too high to admit of direct union. Tem- porary division of the clavicle is necessary to expose it, and anastomosis to the eighth cervical anterior primary division Avill be necessary in most cases. In all cases of incomplete division and after suture the usual after-ti-eatment must be persisted 204 INJURIES OF NERVES in until recovery ensues^ and care must be taken to see that the paralysed muscles do not become over- stretched. Prognosis of brachial plexus injuries. — There are a few points that have to be considered in regard to the prognosis of these lesions. The majority of the injuries are subcutaneous^ and there is no doubt that these have a much worse prognosis than subcutaneous injuries of peripheral nerves else- where^ due chiefly to differences in causation. In an important paper on the plexus^ published by Warrington and Jones^ ^'^'^^J came to the conclusion^ from the examination of cases under their care^ that spontaneous recovery took place only in about 30 to 40 per cent, of the cases. BrQns_, in a paper which has been widely quoted_, came to a similar conclusion ; he found that of cases of injury to peripheral nerves (excluding complete section and suture) _, treated without operation^ 66 per cent, recovered ; of plexus injuries_, 26 per cent. only. But on looking through the cases on which he has based his figures it is at once obvious how different is their causation in the two groups. It is impossible to compare in this way, for example, a case of paralysis of the musculo- spiral due to a fractured humerus, or pressure during sleep, with an Erb^s paralysis due to overstretching of the plexus. In discussing the reason for this relatively bad prognosis he seems to have lost sight of this difference in causation, and considered that in PROGNOSIS OF PLEXUS INJURIES 205 many instances there was an injury to anterior horn cells. But there is no evidence that this is of common occurrence in brachial plexus injuries. In considering the prognosis we have to take into account the cause of the symptoms, and to separate, for this reason, examples of injury above the clavicle from those below. The prognosis has to do first — and this applies to supra- and infra-clavicular injuries — with the distance of the injury from the periphery. To take a simple illustration, division or injury of the ulnar nerve at the elbow is of more serious import than when the injury takes place at the wrist, in the axilla than at the elboAv ; longer time is necessary before recovery ensues, con- sequently the greater the chance of permanent damage. But the nature of the injury bears still more on the question. Situation has to do with time ; causation may abolish altogether the possibility of spontaneous recovery. Years must elapse in a case of suture of the brachial plexus before the muscles can again be innervated, and unless the treatment in the interval has been kept up^ the nerves find fibrotic and contracted muscles to act upon. Traction in- juries make up a large proportion of plexus injuries, and it is easy to understand how little tendency there is in the more severe cases for spontaneous recovery to take place. A complicated scar is pro- duced in which nerve-fibres have been divided at 206 INJURIES OF NERVES different levels^ lience any recovery that takes place is frequently imperfect. The prognosis in infra-clavicular lesions is much brighter. These injuries^ which result in most cases from dislocation of the humerus^ in my experience invariably recover without surgical intervention, although of the cases recorded by Bruns five out of six did not recover power, but the only case reported by Warrington and Jones made an excellent recovery. Brachial birth paralysis. — Although, as already pointed out, these lesions differ in no respect from similar nerve injuries in the adult, yet it w411 be convenient to discuss them a^Dart. Our present knowledge of the subject dates from 1872, when Duchenne described four infants who at birth presented what we noAv call Erb-Duchenne paralysis, without any alteration in sensibility. But these were by no means the first examples of paralysis of the arm described in newborn infants. Smellie, as early as 1768, mentioned its occurrence. It has been demonstrated beyond doubt that the lesion is, as originally described by Duchenne, due to traction. The operative findings and the micro- scopical examination of portions of nerve removed by Clark, Taylor and Prout, and the post-mortem examinations recorded by Schmidt and others have settled the question. In all severe cases the cause of the paralysis is over-stretching of the plexus ; in BRACHIAL BIRTH PARALYSIS 207 some of the less severe cases the direct pressure of the accoucheur's fingers may be the cause. The lesion is produced with almost equal frequency in breech and in vertex presentations. Thus^ in ninty-three cases collected by Schumacher, fifty Avere vertex, forty were breech. The whole j^lexus may be affected or the paralysis may be of the upj^er or of the lower arm type. The injury is usually unilateral and the left arm is more often affected than the right. In about 80 per cent, of the cases the lesion is of the upper arm type. When the whole plexus is at first affected some spontaneous recovery usually occurs, and, as a rule, a residual upper arm paralysis is left. Paralysis of the lower arm type is of great rarity, Stransky found it in twelve out of ninety-four cases, and Thomas was only able to collect sixteen examples, but this by no means represents its true frequency ; it is much rarer than this, for many of the common upper arm type are not recorded. The lower arm type occurred most often as the result of breech presentations with extended arms, a few after face presentations. Batty Shaw has recorded a case in which it resulted from traction a23plied to the axilla. As a rule the paralysis is unilateral, but a few cases of bilateral lower arm palsy have been described. It is not usual, at any rate in hospital practice, to find the lesion recognised at birth. The first 208 INJURIES OF NERYES symptom noticed is often tenderness in the supra- clavicular region, the child crying when this is touched or the arm moved, hence the diagnosis of a fracture of the clavicle or upper end of the humerus is not infrequently made. By carefully watching the child the nature of the lesion is discovered. The position typical of an Erb-Duchenne paralysis is usually present ; in other cases the whole of the muscles of the upper limb are flaccid and the arm hangs powerless ; in still a few others, the arm is abducted, and it is evident that the injury has fallen on the plexus from below. But it is impossible to tell the degree of the injury by inspection alone, electrical examination of the affected muscles is necessary. But in infants this cannot, as a rule, be satisfactorily carried out before the child is three months old, when under an angesthetic reliable results may be obtained. Diagnosis.— Csbve must be taken to avoid mis- taking immobilisation of the limb from other causes, such as fracture, for paralysis, but the fault usually lies in the opposite direction. It is essential to make certain that the lesion is peripheral and not due to cerebral injury. Prognosis. — There is no doubt that a large pro- portion of all cases of brachial birth paralysis undergo spontaneous recovery, but no definite opinion can be given in an individual case until the child is old enough to have the electrical reactions TREATMENT OF BIRTH PARALYSIS 209 of the affected muscles tested. Those cases with marked tenderness rarely recover completely. If, when the patient comes under observation, the reaction of degeneration is present, complete recovery apart from operation is unlikely. Spontaneous recovery has taken place in about 70 per cent, of the cases that have come under my observation. In many the paralysis had completely disappeared by the time the child was brought to have its electrical reactions tested at the age of three months. Complete spontaneous recovery rarely takes place if no improvement is noticed by this date. Brunts figures are more gloomy ; he found 26 per cent, only of spontaneous recoveries. Trbatment. — These lesions are treated on the same lines as similar injuries of the plexus in the adult. The upper limb is kept at rest with the affected muscles relaxed, and as soon as all tenderness has ceased daily massage and passive movement em- ployed. If relaxation of the affected muscles is not insisted upon j^ermanent deformity may result, although the muscles regain their voluntary power and electrical excitability. The electrical reactions should be tested under an anaesthetic at the end of ten or twelve weeks. If the reaction of degeneration is present operation should be undertaken as soon as convenient. If the health of the child will not permit of operation, delay of a few months will probably affect the tinal result little, so long as the 210 INJUEIES OF NEEYES correct non-operative treatment is being carried out. The lengtli of tlie incision necessary to expose tlie anterior primary divisions of the plextis will depend upon the extent of the injury. If the lower divisions are involved it will be necessary to divide the clavicle. In the usual upper arm type the junction of five and six is sought. Often the deep fascia is found thickened and adherent to the injured nerves. The supra-clavicular nerve must always be exposed and examined. In many cases the nerves are found in anatomical continuity^, but on palpating five at its junction with six a scar is found ; this must be excised and end-to- end union carried out. In some cases five may be found completely divided anatomically ;, in others the supra-scapular nerve may be discovered torn through in addition. If end-to-end union is impossible^ complete jDcripheral anastomosis is carried out to a neighbouring nerve. After closure of the wound the shoulder must be elevated so that no tension falls on the junction^ and the limb kept in this position until the wound is soundly healed. For complete success the after- treatment must be faithfully carried out. CHAPTER XIV Injuries to tlie Nerves supplying the Muscles of the Shoulder Girdle — The Long Thoracic Nerve : Winging of the Scapula — The Supra-scapular Nerve— The Nerve to the Rhomboids — The Cii'cumflex Nerve. The long (posterior) thoracic nerve, nerve of Bell. — This nerve, which supplies the serratus magnus, arises by three roots from the fifth, sixth and seventh cervical nerves, that o-iven from the sixth being- tlie most important ; its upper two roots pass through the scalenus medius muscle, and after uniting on its anterior surface lie here for a short distance. The lower root does not perforate the scalenus medius, but passes in front to join the trunk opposite or below the first rib. The upper roots are thus exposed to injury in the neck. Paralysis of the serratus magnus, the result of injury, is seen most often in males between the ages of twenty-five and forty, commonly on the right side. The nerve suffers in most instances as the result of direct pressure applied to the supra- clavicular region in those whose occupation entails carrying weights on the shoulder. It has been said to be due to compression of the nerve between the 212 INJUBIES OF NEEYES first rib and coracoid process of the scapula ; this is unlikely. Paralysis of the serratus magnus is rare as an isolated lesion ; its tetiology explains the reason^ due in a large proportion of the cases to direct pressure above the clavicle^ other nerves ^^assing across this region^ the branches given from the third and fourth cervical to the lower trapezius^ the nerve to the rhomboids^ or the sensory branches of the cervical plexus^ may be injured. Hence the para- lysis of the lower trapezius which usually accompanies it and the sensory disturbance. Considerable difference of opinion has existed with regard to this j^aralysis. Duchenne in twenty cases had never seen an example of isolated paralysis^ and Lewinski^ in 1878_, reviewing the recorded cases^ was only able to find one in which other muscles were not affected. More recently^ following Steinhausen^ authors have come to consider an isolated lesion of this nerve more common. It is certainly uncommon in England. The cases Avhich follow violence above the clavicle are never isolated^ those due to occupation or a sudden muscular effort may be. The nerve is sometimes severed during operations upon the upper part of the axilla, and has been divided during the complete operation for carcinoma of the breast. The winged scapula commonly reputed to be due to an affection of the long thoracic nerve is in most WINGING- OF THE SCAPULA 213 cases a combined lesion, due to paralysis of the serratus magnus and lower trapezius, and the sym- ptoms produced are as follows : Pain is often com- plained of radiating from the supra-clavicular region. There is a conspicuous winging of the scapula; on marking out the spine and lower angle of each scapula and comparing their position, it is seen that in addition to the prominence of the lower angle on the affected side its spine is more hori- zontal and the lower ano-le nearer the mid-line than the upper and than the corresponding lower angle on the sound side. The patient is unable to raise the affected arm in front of the body above the level of the shoulder, and to perform any forward pushing movements ; any attempt to do so at once increases the winging', and the whole scapula can be pushed away from the thorax by backward pressure on the hand when the arm is raised. When the serratus is paralysed alone the de- formity when the arm is at rest is hardly noticeable, and may be overlooked unless the rule is adopted of marking out the land-marks on the scapula. The patient is unable to raise the arm above the level of the shoulder in front of the body, and to perform forward pushing movements above a horizontal plane passing through the shoulder ; attempts to perform this latter movement causes the winging to become more marked. Pushing movements below this plane are possible. 214 INJURIES OF NERVES The slight winging of scapula, produced by paralysis of the lower trapezius alone, at once disappears on raising the arm above the level of the shoulder in front of the bod}^, thus throwing the serratus niagnus into action. It becomes increased when attem^Dts are made to push below the level of the shoulder. Treatment. — In the large proportion of cases the injury is incomplete and does not call for operative interference. Absolute rest to the limb should be ordered, the elbow being supported. The usual treatment with massage, etc., must be carried out. If the reaction of degeneration develops operation must be considered. Direct suture is out of the question, except in the cases in which the nerve is injured in the course of a surgical operation. In the cases in which the lesion is due to jDressure, anastomosis to the posterior cord should be carried out if necessary, or the sterno-costal portion of the pectoralis major trans^Dlanted from the arm to the inferior angle of the scapula. Prognosis. — The large proportion of these cases recover without surgical intervention if treatment is carefully carried out. The supra- scapular nerve.— Injury to this nerve alone is an accident of great rarity. Eleven cases have been recorded, most of them due to carrying- weights on the shoulder or from falls on the out- stretched hand. In two cases of brachial birth SUPRA-SCAPULAR NERVE 215 paralysis I found complete rupture of this nerve to- gether with the anterior primary division of the fifth cervical nerve ; none of the cases other than these have been verified by operation^ and it is probable that in some^ the fibres which go to form this nerve were affected as they run in the fifth anterior primary division. Injury to this nerve affects the spinati muscles. These become wasted and the spine of the scapula unduly prominent. External rotation of the arm, though weak, is still possible, the teres minor and posterior fibres of the deltoid carrying it out. But the spinati muscles are usually affected with the other muscles supplied from the fifth cervical nerve. In these cases external rotation of the arm cannot be performed. Treatment. — An isolated paralysis of the spinati should be treated upon the usual lines; even if com- pletely divided it is hardly of sufficient import to call for operative interference. Electrical examina- tion of the infra-spinatus muscle is easy, but the supra-spinatus is covered by the trapezius; its electrical reactions cannot, therefore, be satisfactorily tested. Nerve to the rhomboids. — Isolated injury to this nerve is almost unknown and is of slight importance; accompanying the paralysis of other muscles, it is an important localisiug aid. It may be injured with the serratus magnus and 216 INJURIES OF NERYES lower trapezius as the result of direct pressure above the clavicle, in penetrating Avounds or divided during the course of operations upon the neck. The deformity produced by paralysis of the rhomboids is characteristic. On marking out the spines and lower angle of the scapula it is seen that the lower angle is further from the mid-line than the upper^ the spine makes a more acute angle with the mid-line than the one on the sound side, and the whole scapula is dropped (vide Plate X, fig. 1). Circumflex nerve. — An injury to this nerve is by no means so frequentl}^ met with as the accounts in the text-books would lead one to believe. Paralysis of the deltoid muscle, however, following an injury to the shoulder is common, but is due in most cases, as I have shown, to injury to the fibres supplying this muscle as they run in the fifth cervical anterior primary division, and is usually accompanied by paralysis of the spinati muscles. Most of the so- called examples of circumflex injury following a fall or blow on the shoulder are of this nature. In a few the wasting is secondar}^ to disease of the shoulder-joint and examination reveals no paralysis. The usual explanation given of an injury to the circumflex due to a blow on the shoulder is that the nerve receives an injury in its intra-muscular course ; no such case has come under my notice. In miners who lie for long periods on the side the muscle may be paralysed by direct pressure on the PLATE X. Fig. 1. — To illustrate the deformity produced by division of the nerve to the rhomboids. (E,.) Fia. 2. — To show dropping- of humerus in paralysis of the deltoid and spinati muscles. To face p. 216. Adlard 5 78 INJURIES OF NERVES injury. As first pointed out by Thorburn, when the injury is incomplete the nerves injured are usually lower in the series than those spared : for example, interference with the functions of the bladder and rectum, and alterations of sensibility over an area on the buttocks corresponding to the supply of the third sacral roots and those below it {vide Fig. 22), are present in practically all the cases. The same changes in the electrical reactions of the affected muscles occur as after injuries of peripheral nerves of a corresponding degree of severity. The sensory loss is of the root type, i. e. the area of loss of light touch is smaller than the area of loss of sensibility to prick. The sphincter ani is paralysed and incontinence of faeces results ; retention of urine is present at first, followed in many cases by true incontinence ; sexual power is usually absent, but the testes retain their normal sensibility, being supplied from a higher level than the angesthetic skin of the scrotum. Sherrington and Langley and Anderson have pointed out that the bladder and rectum have a double nerve supply from the last dorsal and upper lumbar roots, and from the sacral roots through the pelvic splanchnics. The exact function of these two sets of fibres has not been worked out, but clinically, lesions of the lower set cause paralysis of the bladder and rectum. The following illustrates a typical lesion due to a fracture dislocation of the second lumbar vertebra : INJURY OF CAUDA EQUINA 279 "A.P — , a ship^s carpenter, aged twenty-seven years, fell 40 feet into a ship's liold, alighting on liis back. On reoraininf^ consciousness lie found that his \\i Fig. 22. — To sliow loss of protopathic sensilnlity Avhieli i-esulted from an injury to the caiida equina. The saddle- shaped area on the buttocks is that resulting' from injury to the third sacral roots and those below it. legs were paralysed. He was kept in bed for six weeks ; during the whole of this time retention of urine and incontinence of feeces were present, and these s^-mptoms did not improve for three months. 280 INJURIES OF SERVES He began to regain the use of his legs at the same time_, and Avhen I saw him firsts six months after the accident_, he could walk with the aid of a stick, had perfect control of his urine and faeces, and had regained sexual power. " Bony deformity was present in the region of the second and third lumbar vertebrae. The muscles of both lower limbs were Avasted, the right more than the left. All the muscles of the left leg acted, and reacted to stimulation with the interrupted current. The right foot was in the position of talipes equino- varus, the extensors of the toes and the peronei muscles were paralysed and gave the reaction of degeneration, but the tibialis anticus was acting and possessed normal electrical reactions. All the other muscles of the leg and thigh acted normally. Sensation was altered over the area in Fig. 22, and showed the characteristic features of root injury. On the right side all the areas from the fifth lumbar downwards were aifected ; on the left, a portion of second sacral and those below it." I advised laminectomy, but the patient would not consent. I eventually performed complete peri^Dheral anastomosis of the external to the internal popliteal nerve. This operation entirely changed the character of the loss of sensibility over the external popliteal area. From being of the root type, with a larger area of loss of sensibility to prick than to light touch, it became a typical area of loss due to a peri- INJURY TO CONUS MEDULLARIS 281 pheral nerve division witli a loss of sensibility to light touch larger than that to prick. This case is in every way typical of the result of an injury to the cauda e(^uina from a fracture of the lumbar vertebrse, at first complete paralysis of the legs, later improving and leaving some permanent dis- ability behind. The muscles of the anterior surface of the thigh and the adductors escape, and there is a sensitive strip on the inner side of the leg, and the anterior, internal and external aspects of the thigh retain their sensibility. The distribution of the loss of motion and sensibility is, however, often asym- metrical. The conus medullaris may be injured alone or more often with the nerves of the cauda equina. When injured alone, paralysis of the bladder and rectum results with a small patch of alteration of sensibility over the coccyx. When a larger area of loss is present we must assume that the cauda is injured in addition, unless the injury be purely spinal cord. Examination and diagnosis. — In making the dia- gnosis, the extent of the lesion (the segments or roots involved) and its degree, whether complete or incom- plete, must be settled, and its position, whether cord, cauda, or both combined. It must be remembered that a lesion of the conus and cauda combined may, on superficial examination, be mistaken for an injury of the spinal cord at a much higher level, but on a 282 INJURIES OF NERYES thorough examination the typical sensory change in the latter case will enable the diagnosis to be made even in a recent case, while if some time has elapsed no doubt can arise from the muscular examination. The examination follows the lines already laid down. To make the diagnosis of the seat of the lesion and the roots involved it will be necessary to remember roughly the sensory and motor distribu- tion of the sacral and lower lumbar roots. From the sensory standpoint the landmark to remember is the saddle-shaped area of loss of sensi- bility on the buttocks corresponding to the third sacral root (vide Fig. 23). From the motor side, that the muscles supplied by the external popliteal (with the exception of the tibialis anticus) are those supplied by the fifth lumbar root. The sensory diagram (Fig. 23) is modified from one given by Gushing. The position originated with Gushing and shows, better than any previously joublished, the distribution of the various roots. The remarks made in speaking of the distribution of the posterior roots entering into the formation of the brachial plexus apply here, but the overlap is less and the areas on the buttocks may be taken as the exclusive protopathic supply of the sacral roots below and including the third. The following table gives roughly the distribution of the roots to the various muscles ; the remarks DISTRIBUTION OF SACRAL ROOTS 283 made in dealing witli a similar table fur the brachial plexus apply here also. Third and fourth sacral. — Levator ani ; sphincter ani ; perineal muscles. Fig. 23. — Exclusive protopatliic supply of the louver sacral roots. The area dotted is that Avhich usually becomes insensitive to protopathic stimiili in injuries of the cauda equina. (Modified from Gushing.) Second sacral. — Glutei muscles ; biceps ; semi- membranosus and semi-tendinosus. First sacral. — Intrinsic muscles of the foot ; tibi- alis posticus and other calf muscles. Fifth lumbar. — Muscles of antero-external surface of leg (except tibialis anticus). 284 INJURIES OF [N^ERVES Fourth lumbar. — Extensors of leg and tibialis anticus. It is difficult to make this table absolutely correct ; lesions of roots are rarer even than in the cervical region. No difficulty should be experienced in diagnosing a pure cauda lesion. The paralysis is of the peri- pheral type with segmental distribution. The sensory loss has the characteristic features of an injury to posterior roots. Most of the lesions are incomplete ; did such an injury involve the spinal cord^ light touch would be everywhere appreciated^ although sensibility to prick might be lost [vide p. 65). With an injury to the Cauda equina, light touch will be lost, but not to so great an extent as prick. Considerable difficulty may arise in the differential diagnosis of a lesion of the conus from one of the lower sacral roots. A pure conus lesion, however, should give rise to no difficulty, the paralysis of the bladder and rectum with a small area of sensory change below the third sacral area, the loss of sensi- bility being of the cord type, is typical. It is when the two are combined that it may be absolutely impossible to come to a correct conclusion, except by exploration or the after-progress of the patient. The following points should be kept in mind : The distribution of the paralysis. The nature of INJURIES OF CAUDA EQUINA 285 the sensory loss : if cauda, it has root characteristics. Asymmetry is suggestive of a lesion of the cauda ; improvement of symptoms points in the same direction. Prognosis. — This cannot be said to be good, but may be improved by operation. Death seldom occurs as the direct result of an injury to the cauda equina ; it will result most often from urinary infection. Complete recovery is rare ; in most of the cases spontaneous recovery is incom- plete, as in the case I have quoted. Treatment. — The surgery of the cauda equina is in its infancy. Both in traumatic cases and also as a field for nerve anastomosis after fractures of the spine with involvement of the spinal cord, and in old cases of infantile paralysis, there is great hope of success. The nerves lie close together rendering anastomosis easy. In fracture dislocation of the spinal cord involv- ing the Cauda equina, I consider that operation should be carried out without delay. The spinal canal must be opened up and the dural sheath ex- posed ; this should not be opened until careful search has been made for signs of pressure external to it. If no satisfactory cause is found for the symptoms, the dura must be opened and the individual roots investi- gated. The anterior roots can be distinguished by stimulation with the interrupted current for a few days after the injury. After dealing with the con- 286 INJURIES OF NERVES ditiou found tlie dura is closed; the bone removed in performing the laminectomy should not be replaced. It is probable that no great harm will result in leaving the patient for a few days and treating as a case of nerve injury elsewhere and watching the reactions of the paralysed muscles, but it is to be remembered that all delay makes operative inter- ference more difficult, and that the long-continued pressure on the roots may lead to their degeneration ; if this takes place in the posterior roots complete recovery is impossible. Whether operation is carried out or no the usual after-treatment is to be adopted. In long-standing cases the rules governing operative interference in long-standing injuries of peripheral nerves must be applied. When the paralysis of the bladder and rectum is permanent as the result of injury to the conus or sacral nerves supplying the bladder, intra-vertebral nerve anastomosis or nerve crossing may be carried out as advised by Kilvington. In doing this operation sound nerves must be taken outside the dura mater to innervate the injured sacral roots. It is possible to divide the twelfth dorsal nerve in its foramen of exit and bring it to the anterior and posterior roots of the second, third and fourth sacral, cut free from the cord. CHAPTER XVIII Injuries to the Nerves of the Lower Limb — Lumbar Plexus — Anterior Crural Nerve — Obtui'atcr Nerve — External Cutaneous Nerve : Bernhardt's Disease — Sacral Plexus — Paralysis of Gluteal Muscles — Great Sciatic Nerve : Method of Injury : Motor Symptoms : Prognosis — External Popliteal : Injuries Above and Below its Lateral Cutaneous Branch. — Internal Popliteal Nerve — Anterior Tibial Nerve. Injuries to tlie nerves of the lower limb are, with the exception of the external popliteal, rare, and in most instances, subcutaneous. Injuries of the lumbar or sacral plexus are un- common, of the former rare. They have been recorded as a complication of psoas abscess and of ojDeration for its cure, as the result of pelvic operations, prolonged parturition, fractured pelvis and gunshot wounds. Anterior crural nerve. — This nerve is rarely affected. It has been injured as a complication of fractures of the pelvis or femur, as the result of penetrating wounds, during the course of operations upon psoas abscess, and as the result of the abscess, and has suffered from manipulations carried out for the treatment of congenital dislocation of the hip- joint. Its division is rarely complete. 288 INJURIES OF NERVES The most important symptom is the paralysis of the quadriceps extensor cruris. There should be no difficulty in the diagnosis of this ; the patient is unable to extend the leg. He can^ however^ bring it forward in walking by using the adductors after the leg has been everted. Sensation is affected over an extremely well- defined area in the leg (Plate XVII) and over an ill- defined area on the antero-lateral aspect of the thigh. In the lower two thirds of the leg epicritic and protopathic sensibility are lost over an area which has well-marked borders. At its upper part the boundaries become ill defined and it merges into an area on the anterior and internal aspects of the thigh, in which, as a rule, there is no complete loss of any form of sensibility. Obturator nerve. — Isolated injury of this nerve is less often met with even than an injury to the anterior crural. The lesion is usually incomplete and occurs as a complication of protracted labour, particularly when forceps have been necessary. It may also be injured in thyroid dislocations of the hip and in the rare obturator hernia. Pain may be experienced in its sensory distribution on the inner side of the knee in cases of irritative lesion. The adductors are paralysed as the result of its injury, with the exception of the flexor portion of the adductor magnus which is supplied by the great sciatic. Its complete division produces no loss of PLATE XVII. Showing- the loss of sensibility in lower part of the leg after division of the anterior crnral nerve. To face p. 283. Adlard S- Son, Impr. EXTERNAL CUTANEOUS NERYE 289 sensibility as the nerve lias no exclusive sensory supply. There should be no difficulty in diagnosis ; the affection of the adductors is not easily overlooked. The external cutaneous ner^e. — It is rarely that this nerve is divided ; it sometimes suffers in operations upon a psoas abscess or other operative procedures in the iliac fossa or upper portion of the thigh. It supplies exclusively with epicritic and proto- pathic sensibility an area on the outer side of the thigh in its upper third ; deep touch is unaffected after its division. This nerve is of more importance in connection with Bernhardt^s disease or meralgia paraesthetica. This condition^ which is characterised by pain in the distribution of this nerve^ usually with alterations in sensibility^ was described by Bernhardt in 1895, who was followed in a few months by Roth. It is most common in males and usually arises as the result of injurj^ In some cases the injury is long- continued, such as the pressure of a badly-fitting truss j in other cases pain has originated after the patient has over-reached or strained himself, the nerve probably suffering at its exit from the deep fascia. A feeling of tingling or of coldness in the sensory distribution is usually the first symptom to attract attention ; this increases and pain is experienced on standing or walking, and disappears on resting. A 19 290 INJURIES OF NERVES tender swelling is sometimes present just where the nerve issues from under Poupart^s ligament and runs in the deep fascia. The skin in the territory supplied by the nerve shows changes in sensibility ; as a rule sensibility to light touch is defective and there is an area of changed sensibility to the point of a pin. Treatment. — In those cases due to long-continued pressure^ removal of the cause followed by rest should be first tried. If this fails to give relief or the condition has supervened on a sudden injury, resection of the damaged portion of the nerve followed by end-to-end suture Avill cure the condition^ but this is useless unless there has been some definite injury to the nerve, followed by definite change in its trunk. Long (internal) saphenous nerve. — This nerve is occasionally divided during an operation upon a varicose internal saphenous vein or ligature of the femoral artery in Hunter^s canal. Plate XIX gives its exclusive supply in the leg. Gluteal nerves.— The gluteal muscles are supplied by the superior and inferior gluteal nerves. These rarely suffer alone ; they are most often affected in injuries of the plexus itself. The superior gluteal nerve which winds round the lower border of the ilium is sometimes pressed upon in gluteal aneurysm or abscess, and may be injured during the course of operations in this situation. GLUTEAL NERYES 291 Paralysis or weakness of the glutei muscles of both sides as seen in injuries of the cauda equina produces a waddling gait with lordosis. Para- lysis of the glutei muscles of one side only is easily diagnosed ; the flattening of the buttock and failure of action of the muscles is obvious. The action of the gluteus maximus is best tested by attempts at extension of the thigh or in rising from a stooping position. Paralysis of the gluteus medius and minimus alone is difficult of diagnosis^ but weak- ness of outward rotation of the limb is present, and the paralysis of the tensor fascias f em oris will enable the diagnosis of an injury to the superior gluteal nerve to be made. The great sciatic nerve.— Li juries to the sciatic nerve are rare in civil practice, but it suffers from gunshot injuries more often than any other nerve. In addition to penetrating wounds, injury may result from the manipulations necessary in the treatment of congenital dislocation of the hip, occasionally as the result of a traumatic dislocation, or its reduction, or it may suffer, with other branches of the sacral plexus, in fractures of the pelvis. It must be remembered that for surgical jDurposes the great sciatic nerve consists of two separate nerves, the external and internal popliteal, and that these remain separate up to the point at which they are given off from the plexus. Either nerve may be injured alone in an accident to the great sciatic. 292 INJURIES OF NERVES Hence incomplete division of this nerve may differ from that of other nerves. In incomplete injuries of the great sciatic its external popliteal portion suffers more often ; this occurs not only in subcutaneous injuries, such as those produced in manipulating congenital dislocations of the hip, but also as the result of a penetrating wound. In the gunshot wounds of this nerve which have come under my notice it Avas particularly noticeable. This is in agreement with Makins^ experience. He states : ^^ The most striking observation with regard to injuries of the great sciatic was the comparatively frequent escape of the popliteal element (internal popliteal) and the severe lesion of the peroneal. This Avas so pronounced as to amount to as high a proportion of peroneal symptoms as 90 per cent. . . :' It is therefore obvious that an incomplete injury to the great sciatic nerve may produce a complete division of the external popliteal nerve without affecting the internal. No satisfactory explanation of this is forthcoming. The exposed position of the fifth lumbar anterior primary division and the posterior position of the external popliteal element of the great sciatic nerve in the thigh may have something to do with this. But we must remember that the external poj^liteal group of muscles suffers frequently in other nervous conditions; for example, in infantile paralysis it is GREAT SCIATIC NERVE 293 the group most often permanently paralysed^ and it is often picked out in toxic neuritis. Daus, in a research upon the subject_, could arrive at no satis- factory conclusion ; he simply states that the nerve is more vulnerable than the internal popliteal^ and quotes experiments by Gerardt^ j^^i^v i^^ which; after the death of animals the extensor muscles of the leg lost their electrical excitability before the flexors. Hofman came to the conclusion that a difference in their blood supply accounted for the more frequent affection of the external popliteal ; it receives a smaller branch from the comes nervi ischiatici than the internal. It is difficult to believe that this is the explanation. Complete division of the great sciatic nerve is uncommon ; in sixteen patients that have come under my notice with injury to this nerve in two only was the division complete. Motor symptums. — After section of the great sciatic nerve all the muscles of the leg are paralysed and all movements of the foot impossible. If divided in the upper part of the thigh the hamstring muscles are paralysed. But although these muscles are not acting', flexion of the leg on the thigh is still possible by means of the gracilis ; in long-standing cases this muscle becomes hypertrophied and a very efficient flexor. This has led to errors in diagnosis through non-observance of the rule that the action of in- dividual muscles must be investigated, the flexion 294 INJURIES OF NERVES of tlie lesf beino' considered due to the action of tlie hamstring muscles supplied by the great sciatic. Sensory symptoms. — There is a widespread loss of sensibility below the knee^ a strip on the inner side^ the full supply of the internal saphenous alone remaining sensitive. The borders of the area of loss of epicritic and protopathic sensibility are almost co- terminous^ except above {vide Plates XYIII, ^I^)^ and are well defined. In spite of the widespread loss of sensibility deep touch is affected only over a com- paratively small area of the foot. This has led to diagnostic errors. Within the area of loss of proto- pathic sensibility deep touch may be well developed, the patient recognising pressure immediately and localising it well. Prognosis. — After suture of the great sciatic, months must elapse before the patient regains a useful limb. Sensibility to deep touch is first regained, and the foot should be everywhere sensitive to this form of stimulation in from three to six months. About eight weeks after suture, in an un- complicated case, the area of loss of protopathic sensibility should begin to improve, but months will elapse before it is everywhere appreciated. No alteration in the extent of the epicritic loss is to be expected before eighteen months. The first muscles to regain voluntary power and electrical excitability, after suture or after an incom- PLATE XYIII. Shovvinf^ the loss of sensibility resulting from division of the great sciatic nerve. The area of loss of epicritic sensibility is bounded by a thin line, dotted at its ujjper part ; the area of protopathic loss by crosses, the thick line bounds the area of loss of deep touch. The unshaded area is the inter- mediat<; zone, the oblique shading the area of loss of epicritic and proto- yjathic s(;nsi}>ility, th(i area of cross shading that in which all forms of sensibility are absent. To face p. 201. Adlarcl 4" So)i, Impr, PLATE XIX. For description see Plate XVIII. To face p. 294. Adlard .j- Soti, Impr. GREAT SCIATIC NERVE: PROGNOSIS 295 plete injury of the wliole nerve in the upper part of the thigh^ are the hamstrings. This may be ex- pected in about a year after suture, but two years will probably elapse before any change takes place in the muscles of the leg, and complete muscular recovery is unlikely under three years. The internal popliteal group regains power before the external. The prognosis in all cases of injury to this nerve is more unfavourable than after injuries of a similar degree affecting nerves of the upper limb. This has chiefly to do with the time which must elapse between suture and recovery ; unless the nutrition of the skin and muscles is carefully maintained and care taken to prevent overstretching of the paralysed muscles the result will be poor, even although nerve regeneration has taken 23lace. Treatment. — In dealing with instances of incom- plete interruption of continuity in the great sciatic nerve we must be prepared to treat complete division of its external popliteal portion. This must be dealt with as complete division elsewhere ; if after an injury to the great sciatic, the reaction of degenera- tion develops in the external popliteal group of muscles, even although those supplied by the internal popliteal are unaffected, the nerve should be exposed, the damaged portion of the external popliteal found by tracing it up from below, separated from the internal, excised and reunited. During the early stages of recovery the weight of the body must 296 INJURIES OF NERVES D^t be allowed to rest on tlie paralysed foot; perfora- ting ulcers are liable to develop and may necessitate amputation. Tlie foot and leg should be fitted witli a light, well-padded poroplastic splint to prevent deformity and the patient allowed to get about on a bucket leg with the limb flexed. No time after the injury is too long to attempt operation ; amputation should not be advised as a routine measure even in old cases. The tendency to the formation of perforating ulcers ceases with the restoration of protopathic sensibility, and this is to be expected in every case in which the wound heals without suppuration. At the end of the first stage of recovery the whole of the sole of the foot is in that condition of sensibility found in the intermediate zone. All stimuli have an unpleasant tingling radiating character, and for this reason the limb may be useless, the patient being unable to bear an}^ weight on it. This will, in most cases, be only a stage, and as epicritic sensibility is restored the tenderness gradually diminishes. If sensory recovery fails at this stage, amputation ma}^ be necessary on account of the tenderness and pain ; if this is done care should be taken to obtain the flap from the inner side of the leg, from skin supplied with normal sensibility by the internal saphenous. If complete motor recovery fails a suitable surgical boot should be worn, or atbrodesis of the ankle carried out. PLATE XX. To show the loss of sensibility produced by complete division of the small sciatic nerve. To face p. 207. Adlarcl ^ Son, Imj^r, SMALL SCIATIC NERVE 297 The small sciatic nerve. — This is rarely injured alone but suffers in lesions of tlie sacral plexus. Epicritic and iDrotopatliic sensibility are lost as the result of its com^^lete division over the rela- tively small area shown in Plate XX. Deep sensi- bility is unaffected. The external popliteal nerve. — This is more often injured than any other nerve of the lower limb. It may suffer when bound up with the internal popliteal to form the great sciatic^ or^ after it has sej)arated, above or below the point at which its lateral cutaneous branch is given off. Injury in the last position is the most common. Anatomical division of the nerve is rare^ but it has occurred during tenotomy of the biceps tendon and during the forcible straightening of a jSexed knee-joint. It suffers most often after it has separated from the internal popliteal^ from direct violence and in association with fractures of the neck of the fibula^ the nerve injury being primary and caused by the injury producing the fracture. From its exposed position on the neck of the fibula it is exposed to external injary^ and suffers not infrequently from the faulty application of Clover's crutch; Bsmarch^s bandage or puttees. It is occa- sionally overstretched_, and sometimes ruptured, during the forcible extension of a flexed and anky- losed knee. It is occasionally involved in those whose occupation entails work in a crouching attitude. 298 mJURIES OF NERVES Symptoms. — No difficulty in tlie diagnosis is likely to arise from the motor side. Tlie foot is in tlie position of talipes equino-varuSj and tlie tibialis anticuSj all tlie extensors of the toes and the peronei muscles are paralysed. Consequently the foot cannot be flexed or everted and the toes cannot be ex- tended. Difficulties may arise in the interpretation of the Fig. 24. — Illustrating the loss of sensibility resulting from division of the external popliteal nerve below its lateral cutaneoiTS branch. loss of sensibility. Deep sensibility is unaffected, and the patient may be able to appreciate and to localise the slightest pressure causing deformation of the skin. Just before the nerve passes round the neck of the fibula it gives off a large lateral cutaneous branch ; it is most often injured below this point. ''J''ho loss of sensibility which results from this lesion is only absolute on the dorsum of the foot and lower tliird of tlie leg {vide Fig. 24). The anterior EXTERNAL POPLITEAL NERVE 299 boundary of the area insensitive to light touch is as well defined as after division of the whole nerve^ but its posterior border and that on the outer margin of the foot merge gradually into parts of normal sensibility. Sensibility to prick is abolished over a triangular area on the dorsum of the foot_, but is defective over an area almost as large as that Fig. 25. — To show the loss of sensibility resulting from division of the whole external i3ox)liteal nerve above. anEesthetic to cotton- wool. After division of the nerve in this situation similar phenomena may be observed to those seen after division of the ulnar below its dorsal branch. Division above the lateral cutaneous branch produces an area of loss of sensibility on the outer side of the leg and dorsum of the foot with well- 300 INJURIES OF NERVES defined boundaries^ except at its external border in tlie lower third of the leg and outer surface of the foot^ which territory it supplies in common with the external saphenous nerve {vide Fig. 25). The boundaries of the loss of light touch and of prick are almost co-terminous. It is essential to remember the difference in the loss of sensibility that results from division above and below this branch. The small loss of sensibility that results from division in the latter situation is not sufficiently well recognised^ and has lately led to the report of two cases of " injmediate sensory recovery " after suture. Delbet^ in a discussion on the results which follow division of the external popliteal nerve^ pointed out the slight loss which arises when the nerve is divided in this situation. I have been unable to find any other reference to this fact. Diagnosis. — Injury to the fifth lumbar root in the spinal canal^ or to the fifth anterior primary division as it crosses the brim of the pelvis^ will give rise to symptoms resembling those of division of the external popliteal. The seat of the injury must be settled^ whether with the great sciatic or below this^ above or below the point at which its lateral branch is given off. A consideration of the nature of the accident will lead to the correct diagnosis in most cases^ but the symptoms will also point out the correct seat. Injury to the fifth anterior root or anterior primary EXTERNAL POPLITEAL NERVE 301 division usually leaves the tibialis anticus muscle unaffected; in an injury to the lumbo-sacral cord or external popliteal nerve this muscle is paralysed. An injury of the fifth anterior root leaves sensibility unaffected; if the posterior root is affected in addition, the loss of light touch is less extensive than the loss of sensibility to prick. This was beautifully shown in a patient with involvement of these roots in a Cauda equina injury, on whom I divided the external popliteal nerve for purposes of anastomosis. Before his operation the loss of sensibility was of the root type ; after, it showed the typical features of the loss of sensibility resulting from division of a peripheral nerve. Treatment. — Attention must be directed to the necessity for preventing foot drop. Complete recovery is impossible in a patient whose paralysed muscles have been over-stretched for a considerable time. The foot must be kept at right angles to the leg in a light poroplastic splint ; later, the patient may be allowed to walk on the affected limb with a surgical boot fitted with a toe-raising spring*. At night the splint should be worn until the muscles have regained voluntary power. Involvement in fractures. — As already mentioned, this nerve is not infrequently injured in fractures of the upper end of the fibula. The injury is, in most cases, physiological, but a case has been recorded by Duplay in which the nerve was found completely 302 INJURIES OF NERVES ruptured. The nerve usually passes between the fragments^ and unless operation is undertaken the division becomes complete. In all cases of fracture of the upper end of the fibula with involvement of this nerve^ if there is any separation of the frao-ments, primary operation should be undertaken^ the nerve freed^ and the fragments exposed and wired, or the small upper fragment may be completely removed, care being taken to injure the attachment of the biceps as little as possible. If the nerve be found ruptured, suture, after trimming the ends with a sharp scalpel, should be carried out. When the fragments are in close apposition immediate operation is unnecessary ; the usual treatment for a subcutaneous injury should be instituted. In old cases in which the reaction of degeneration has developed, excision of the damaged portion of the nerve must be carried out ; neurolysis is useless. Recovery and fvognosis. — The tibialis anticus is the muscle which first regains voluntary power and electrical excitability, followed by the extensors of the toes, and lastly the peronei ; these latter muscles may remain permanently paralysed. Recovery will follow in most cases if the appro- priate treatment and after-treatment is carried out, and may be expected to become complete in about three years. But if, after suture, no care is taken, complete recovery never takes place. Internal popliteal nerve. — Injury to this nerve is ANTERIOR TIBIAL NERVE 303 uncommon ; it has occurred during the forcible straightening of a flexed and ankylosed knee. The calf muscles, the tibialis anticus and flexors of the toes are paralysed, and the foot takes up the jDOsition of talipes calcaneo valgus ; extension of the foot, inversion in the extended position and flexion of the toes are impossible. No difficulty arises in recognising the paralysis of the muscles concerned in these movements. There is no loss of deep sensibility after complete division of this nerve, but epicritic and protopathic sensibility are lost over the sole of the foot. This area has a well-defined inner border, but the outer border is ill defined owing to its overlap with the external saphenous. The dorsal surface of the outer four toes is insensitive to epicritic stimuli, but there is no loss of protopathic sensibility over their dorsal or plantar surfaces. Anterior tibial nerve. — This nerve is rarely injured alone on account of its deep position, but occasionally it is pressed upon or lacerated in fractures of the tibia, and may give rise to all the symptoms of irritative involvement of a nerve. Anatomically, filaments of this nerve may be traced to the cleft between the great and second toes^ but it has here no exclusive supply. I have on two occasions divided this nerve for therapeutic purposes and failed to produce any loss of sensibility in this situation. INDEX Abduction of thumb, 27, 268 Acusesthesia, 54 Adduction of thumb, 248 Anastomosis, nerve, 86 — in Cauda equina lesions, 285 — in facial paralysis, 168 — in injuries of nerves, 92 spinal cord, 286 — varieties of, 92 Anterior crural nerve, 287 — tibial nerve, 303 injury in fractures, 43, 141, 303 Antidromic impulses, 139 Auditory nerve, 172 Autoplastie nerveuse, 89 Bernhardt's disease, 289 Birth paralysis, brachial, 206 facial, 164 Blisters arising after complete division, 21 — arising- after incomplete division, 44 — arising diu-ing recovery, 73, 103, 118 Brachial plexus, 183 birth paralysis, 206 distribution of roots enter- ing, 184 injuries of, from cervical ribs, 190 ^- complete, 194 infra-clavicular, 193 — inner cord, 200 — localisation of, 225 oiiter cord, 19, 201 post-ansesthetic, 189 — — — prognosis of, 204 — supra-clavicular, 187 — — — traction, 197 -with fractured clavicle 192 Causalg-ia, 42, 137 Cauda equina, 276 diagnosis of injuries of, 284 Cervical nei'ves, 178 — ribs, injuries of brachial plexus, associated with, 190 — sympathetic, 181, 194, 225 injmy of, 181, 182 ' 20 306 INDEX Cervical sympathetic, injury with brachial plexus, 194, 200 Change, line of, 19, 38, 50, 107 Chorda tympani nerve, 164 Circumflex nerve, 216, 227 Classification of nerve injuries, 2 — of brachial plexus injiiries, 187 Compass test, 51 restoration of, after divi- sion, 107, 124 Complications during recovery after complete division, 118 after incomplete division, 132 Contractures, 28, 117 — hysterical, 69 — facial, 166 — ischsemic, 70 Conus meduUaris, 276 injuries of, 281 Corneal changes, 161, 163 Crossing, nerve, 86, 95 — — in facial paralysis, 169 Crutch paralysis, musculo -spiral, 232, 234 circumflex, 217 Deep sensibility, 17, 20 — — recovery of, 108 tests for, 54 Degeneration, reaction of, 28 Deltoid muscle, paralysis of, 199, 216, 226 Diagnosis of nerve injuries, 45, 61 from hysteria, 66 from ischsemic contracture, 70 from spinal cord injuries, 61, 222 Diagnosis of brachial plexus in- juries, 219 Diplopia, 153 Dislocations, nerve injury compli- cating, 9 — injury of anterior crural nerve, 287 of brachial plexus, 200 of musculo-spiral nerve, 233 of obstructor nerve, 288 — — of sciatic, great, 291 of ulnar nerve, 256 Division, anatomical, 2 — complete, 15 — definition of, 2 — in woimds, 3 — incomplete, 35 — X^^ysiolOoical, 2 Dorsal nerves, operative injuries of, 5, 144, 146 Electrical reactions, in complete division, 28 in incomplete division, 55 Electrical testing, 55 — treatment, 73 End bulbs, 142 Epicritic sensibility, 21 recovery of, 101, 123 tests for, 48 Erb, see Paralysis. Examination, methods of, 45 External cutaneous nerve (of forearm), 230, 233 (of leg), 289 — popliteal nerve, 297 injury with great sciatic, 293 in fractures, 301 Facial nerve, 164 INDEX 307 Facial nerve anastomosis, 169 • birth paralysis of, 164 distribution, 165 paresis of muscles after removal of Gasserian gan- glion, 161 — — prognosis, 166 Fifth cranial nerve, 154 — — corneal changes after injiuy of, 162 — — distribution, sensory, 154 — — — motor, 160 — — first division, 161 — — second and third division, 163 Fractures, injuries of nerves in, 7,82 of brachial plexus in, 187, 192 of external popliteal in, 297, 301 of musculo-spiral in, 234 of ulnar nerve m, 256 Fracture of base of skull, nerve injxiry in, 150 Fractux'es of spine, cervical region, 222 lumbar region, 277 Glosso-pharyngeal nerve, 172 Glossy skin, 32, 42, 132, 137 Gluteal nerve, 290 Gunshot wounds, see Wounds. Ganglion, Gasserian, removal of, 155 injuries of nerves in, 152 — posterior root, removal of, 143 Horner's muscles, paralysis of, 165 Hypoglossal nerve, 177 — anastomosis, 169 Hyperalgesia, 41, 132 Hysteria, 66 — diagnosis from nerve injury, 143 Injury, nerve, by pressure, 6 by traction, 7 -by wounds, 3 in wounds, gunshot, 12 operative, 9 complicating fractures, 7, 82 Ilio-hypogastric nerve, 5, 144 Ilio-ingidnal nerve, 5, 144, 145 Inferior dental nerve, 163 Internal cutaneous nerve, 245 — popliteal nerve, 302 — saphenous nerve, 290 Intercosto-himieral nerve, 146 Joints, changes in, 33 Klumpke, see Paralysis. Lacrymation after removal of Gasserian ganglion, 162 — in facial paralysis, 165 Lingual nerve, 163 Lumbar plexus, 287 — roots, distribution of, 283 Massage in nerve injuries, 73, 78, 143 Median nerve, 262 fuU supply of, 267 injury, diagnosis of, 270 motor symptoms, 267 sensory symptoms, 264 — and ulnar nerves, 271 308 INDEX Meralgia parsesthetica, 289 Motility, supplementary, 28 Musculo-ciitarLeous nerve, 230 Musculo- spiral nerve, 232 injiuy in fractures, 234 treatment, 242 Nails, clianges in, 32, 44 Neiu-itis, 118, 132, 140, 142 — of ulnar nerve, 258 Neuromata, amputation, 147 Neurolysis, 131, 146, 245 Obturator nerve, 288 Operations, nerve injuries caused by, 4, 144, 167, 175 — plastic, on nerves, 85 Pain in nerve injuries, 43, 132 — following amputations, 148 — treatment of, 139, 142, 145 Palate, motor supply of, 160, 166, 174 Paralysis, brachial birth, 206 — diaphragm, 179 — Erb-Duchenne^ 195, 288 — following complete division, 27 crutch pressure, 6 incomplete division, 40 splint pressure, 6 — Klumpke, 199 — palate of, 160 — post-ansesthetic, 10, 189 — post-operative, 10 — serratus magnus, of, 160 — sterno-mastoid, 175 — trapezius of, 175 Phrenic nerve, 179 Primary suture, 75 Primary suture,recovery af ter,108 prognosis of, 110 — rmion, 99 Prognosis of brachial birth para- lysis, 208 — of incomplete division, 131 — of brachial plexus injuries, 190, 204 — of post-ansesthetic paralyses, 12 — of primary suture, 110 — of secondary suture, 114 See also under Individual nerve. Protopathic sensibility, 20 recovery of, 101 tests for, 53 Pupil, changes in, following injury to cervical sympathetic, 181 — removal of Gasserian ganglion, 162 — spinal cord injury, 224 Radial nerve, 233, 239 — and external cutaneous, 240 Reactions, electrical, in complete division, 28 — in incomplete division, 48 — in testing, 55 Recurrent laryngeal nerve, 174 — sensibility, 22 Recovery, after anastomosis, facial, 171 for injury, 93 — after complete division, 101 — after incomplete division, 123 — after primary suture, 108 — after secondary suture, 112 — after transplantation, 89 — after tubular suture, 90 Regeneration, 119 INDEX 309 Ehomboid muscles, paralysis of, 215, 255 Eoots, nerve, division of, 143, 149 — loss of sensibility following, 24 — supply of cervical, 184, 186 of sacral, 286 Sacral plexus, 287 — roots, 282 Scapula, alterations in position, 219 — winged, 212 Scars, nerve involvement in, 132, 139 Sciatic nerve, great, 291 — — plastic operations on, 97 small, 297 Sensibility, deep, 17 — dissociated, 23, 25 — epicritic, 20 — protopathic, 28 — rapid retiirn of, after secon- dary sutiu-e, 113 — recoveiy of, 101 — supplementary, 23 — tests foi', 48 Serratus magnus, paralysis of, 211, 225 Sixth cranial nerve, 154 Skin, changes following complete division, 30 — — — incomplete division, 42 — grafting, recovery of sensa- tion after, 106 Spinal accessory nerve, 175 — cord injuries, diagnosis of, 61, 222 Spinati muscles, paralysis of, 214, 225 Stretching, nerve in secondary suture, 82 Supra-scapular nerve, 214, 266 Supply, exclusive, 15 — full, 15 Suture, primary, 75, 108 — secondary, 79, 112 — tubular, 90, 97 Sweating, absence of, 30, 181 — increase of, 44, 139, 182 Taste, 158 — nerves of, 165 — tests for, 159 Tests, compass, 51 — electrical, 55 — for deep touch, 54 — for light touch, 48 — for passive position, 54 — for pain, 53 — for smell, 151 — for taste, 159 — sensory, 48 — temperattu-e, 49, 53 Third cranial nerve, 153 Transplantation, definition of, 85, 86 — prognosis of, 89 — varieties of, 87 Trapezius, paralysis of, 175 Treatment, 72 — of amputation neiu'omata, 149 — of brachial plexus injru-ies, 202 — of brachial birth paralysis, 209 — of facial paralysis, 167 — of gimshot wounds, 84 — of subcutaneous injm-ies, 73 involvement in f ractia-es. !10 INDEX Treatment of scars, 134, 139 — T^oimds, 74 Ulcers, "tropMc," 31, 44, 81, 118 Ulnar nerve, 246 diagnosis of injuries, 261 dislocation, 260 fvill supply, 253 injiu^ies in fractures, 256 prognosis of injuries, 254 treatment, 254 Yagns nerve, 173 Volkman's contracture, 70 Wounds of nerves, accidental, 3, 74 gunshot, 12, 42, 84 operative, 4, 74 Zone, intermediate, 17, 18 PRINTED IN LONDON, ENGLAND