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NERVE WOUNDS
SYMPTOMATOLOGY OF PERIPHERAL XERVE LESIONS CAUSED BY WAR WOUNDS
J.

TINEL
1.1

ANCIEN CHEF DE CLINIQUE

DE LABORATOIRE

DL.VI A

SALPETRIERE

PREFACE BY

PROFESSOR

J.

DEJERINE

AUTHORISED TRANSLATION LV

FRED ROTHWELL,
CECIL
A.

B.A.,

Lond.

REVISED AND EDITED BY

JOLL, M.B.,

M.S., B.Sc.Lond., F.R.C.S.Eng.

SENIOR SURGEON RICHMOND MILITARY HOSPITAL ASSISTANT SURGEON ROYAL FREE HOSPITAL LATE SURGEON-IN-CHIEF MAJESTIC HOSPITAL, CROIX KOIT.L FRANCAISE

NEW YORK

WILLIAM WOOD

&

COMPANY

MDCCCCXVIIl

>

i/PRINTED IN GREAT BKITA1N BY WILLIAM CLOWES AND SONS, LIMITED

LONDON AND BECCLES

" and in one or two other cases where translation did not appear to be helpful. W. Tinel's text. aware that there are excellent manuals on the subject by British authoritatively. I hope that. Tinel's. I wish to thank Mr. Rothwell for great help in the revision of the proofs. of course. at the Royal Free Hospital. Mr. as I his book is most lucidlv written. CECIL WlMPOLE StRIET. A. with the return of peace. will be continued and expanded. James Berry. I have endeavoured to adhere closely to Dr. so and so originally as Dr. but in a duced modified form by my colleague. introauthors. JOLL. 191 <r 2 380212 . how- ever.EDITOR'S INTRODUCTION My fill object in making Dr. the clinic system. is If. Tinel's book available in English has been I to a very definite gap in the literature of peripheral nerve lesions. have throughout preserved the term " griffe " rather than use the rather doubtful translation " claw. the responsibility certainly mine. none of them appears to me to cover the ground so fully. I have retained the original word. am. I have failed to reproduce his meaning. October. The continental clinic system makes it possible for the clinician to investigate a far larger number of cases than under our own individualistic methods. 7.

we possessed of . paresthesia. of compression. of anaesthesia. All surgeons and neurologists still remember how surprised they were. It was also necessary to study the nerve lesion itself. to specify the diagnostic value of partial or total paralysis. at times so intense. various modalities to throw light upon the to problem of vaso-motor secretory or trophic disturbances. in and amenable or not pronouncing them Indeed. These problems have been solved by the understand was specially important to and experimental investigation. at the numerous cases of peripheral nerve wounds brought into our hospitals. for it is admirably adapted work of our military hospitals. the pupil Tinel to the needs of the daily . and to up a frequently insurmountable obstacle formed . irritation or regeneration. in order to my pupils and myself have been enabled It mechanism of interruption irritation or compression. we had first to establish the exact signification of the variable and and differently associated symptoms met with in all these cases. all connect each of these symptoms of all with the determining and of their evolution. or pains in their . are consequently. become acquainted with the exact anatomical conditions which either permit of the regeneration of the nerve trunks or make this impossible. during the early months of the War. Suddenly we found ourselves confronted with so it many facts unlike one another that is easy to understand our hesitation in classifying all interpreting them. of muscular hypotonia electrical disturbances. work of my uncertainty of our clinical and diagnostic knowledge of the nature ot the lesions was complicated by the therapeutic aspect of the problem. and above lesion.PREFACE I am pleased to be in a position to introduce to the medical public this on Nerve Wounds. the By close study these disturbances to set up main syndromes of nerve interruption. We know how which of the set the vicious cicatrices which I have called nerve keloids. It was a big subject of which the few cases observed before war broke out had not enabled a complete study to be made in addition. and the syndromes of dissociated or partial lesions. the regeneration are axis-cylinders. are now acquainted with the particular characters of neuromata and pseudo-neuromata we histological study . or at other times scarcely perceptible. and above to surgical intervention.

or in a fair way towards natural recovery. they have inter- demonstrated the illogical nature and the uselessness of certain . scrupulously conform to the indications of neurologists they must also observations. Whilst it must be confessed that all our problems have not yet been completely solved. Nerve lesions must traced. all the same of our it may be affirmed that the main lines to be followed have now been The time has come to unite in one book the many which form the basis of this new work. irritated. or dangerous in their optimism. of be co-workers. have not yet gone far beyond the sphere of the neurological and surgical centres. anatomy and physiology. Nerve wounds are still a mysterious and disturbing problem to many doctors. and of obtaining not only the best results for the wounded. but they have also enabled us to throw light on many aspects of surgical technique. ventions. physiologists. it is not sufficient that all doctors and surgeons should . we must not allow opinions to be established that are incorrect. Regarding the prognosis of nerve wounds. PREFACE histological vii information which either calls for or proscribes surgical intervention. functional paralysis is disability.. This is the best means of multiplying recording both clinical data and therapeutical indications. And yet it is important that these fundamental principles should be known to all. and clinicians. or of the operations on them which are frequently necessary. No longer must there for whole months. the same histological and experimental discoveries have enabled us to specify the normal conditions of operation . show doctors how almost all clinical problems may be solved by the aid of a few very simple facts of general anatomy and physiolog) . Above and been made. . clinics and neurological centres country have given themselves up to these investigations. all for this reason above that I regard the publication ot the present It will work as necessary. but also a solution of problems on which It is full light has not yet been thrown. and there are still many obscure points. the cure of which so easy when a timely diagnosis has In a word. thus carrying out a task which has completed the unwearied labours of former histologists. For long months all the laboratories. useless electrical or massage treatment of complete nerve sections. investigations not continue to remain unknown be. in the routine of hospital life. or the unnecessary excision of nerves simply compressed. In a word. all. discouraging in their pessimism. It must indeed be recognised that these ideas of nerve pathology. we must not regard as nerve lesions. the utility and rationale of others they have not only encouraged the practice of simple liberations and of nerve sutures.

J. is alike and choice of the information offered. namely. so to speak. of great educational importance. We shall also see that we need only have recourse to the elements of histology and nervous physiology in order to deduce therefrom the logical rules of physical or surgical treatment. Written. It is fulfils the purpose aimed at both by the author a pleasure for its me to witnessed is realisation. his constant endeavours to call attention to the knowledge of anatomy. the carefully photographs.viii PREFACE glad to see once I am more verified the rule which clinical I have always followed. necessary an interpretation of the One must His remarkable qualities of exposition will also be noted. DEJERINE. a book that perfectly clear and scrupulously exact. make this volume executed a fine study in symptomatology. of one's subject to compile. and The wealth one which completely and by the publishers. it a faithful resume of the investigations entered upon in my service by all my fellow-workers of the Charcot Clinic. have encouraged the idea of this work and in my very presence. . Paris. from an enormous be a thorough master mass of observations and documents of every kind. that you cannot have a good neurology without exact anatomy. I cannot sufficiently congratulate the author of for this work on facts. physiology or histology. Consequently. the numerous clear diagrams.

VIII. XVIII. II 17 37 IV. XVI. VII. 60 92 V. X. XI.. 209 "5 PART III LOWER LIMB XV. Brachial Plexus XIV. MUSCULO-CUTANEOUS NERVE 197 The Circumflex Nerve Internal 201 Cutaneous Nerve and Lesser Internal Cutaneou 205 Nerve XIII. General Diagnosis of Peripheral Nerve Lesions PART UPPER LIMB VI. XVII.. Clinical Examination of a Nerve III. XII. II.. Musculo-Spiral Nerve 99 132 Ulnar Nerve Median Nerve Associated Paralysis of the Median and Ulnar Nerves ...CONTENTS Introduction PART I GENERAL SURVEY CHAPTER I.. -3' Small Sciatic Nerve 266 268 Anterior Crural Nerve Obturator Nerve -75 . 170 '9 + IX. Electrical Examination Clinical Types . Sciatic Nerve . Ischemic Paralysis of the Upper Limb . Nerve Lesions in War Wounds ..

Genito-Crural Nerve Ilio-Hvpogastric Nerve 279 280 282 29 + Lumbo-Sacral Plexus Diagnosis of the Lesions of the Lumbo-Sacral Plexus PART IV CONCLUSIONS XXIV.. XXI.CONTENTS CHAPTER XIX. XXVI. External Cutaneous Nerve of Thigh . Surgical Treatment Electrical Treatment INDEX 3'3 . I'AGE 277 XX... Prognosis and Treatment of Peripheral Nerve Lesions 297 300 308 XXV. XXII. XXIII.

amongst them the musculo-spiral nerve. 11 25 27 48 Total 408 . we reach the following results : Upper Limb.. • 14° Ulnar 84 67 . an imperfect knowledge of these nerve lesions it On the other hand. Bv surgical intervention at the right moment..... . Musculo-spiral .. Lesions of the nerve trunks in traumatisms of the limbs cannot be estimated at if less than 18 to 20 per cent. .. and this proportion increases wounds out of account and consider serious traumatisms frequently involving one or more nerves.... An early diagnosis leave slight . may have grave may cause erroneous or unjust calculations as to the degree of disability the patient will suffer in the future. .— INTRODUCTION The number of peripheral nerve wounds in warfare is considerable : this has been one of the surprises of the present war. one form of incapacity following on war wounds. . . ... . .. . Any nerve may be affected by war wounds speaking generally. . we of nerve lesions will alone enable one fully to appreciate the gravity and consequences of the wound. From the 639 cases investigated in this work. . . statistics show a certain preponderance in nerves of the upper limb. by judiciously employed electrical and mechanical treatment. This consideration is most important in every wound all the nerves of the wounded limb must be systematically examined.. or render irreparable cases of paralysis which ought to have been cured. . to formulate an exact functional prognosis and institute proper treatment. make the prognosis of the wounds worse bv the absence of the necessary treatment.. Our own statistics enable us to form some idea of the relative proportion of the different nerves affected. Median Musculocutaneous Circumflex Lesions of the brachial plexus Combined serious lesions of several nerves of the upper limb . an early diagnosis of nerve lesions will enable one to reduce to a minimum results .

. 4 9 1 Short saphenous nerve Obturator .e. the brilliant investigations of P. and of their etc. of Weir Mitchell. Mouzon. • • II Long saphenous nerve Internal popliteal nerve 14 78 29 37 18 7 External Posterior do. of of Waller. inspiring the works of their pupils. that has thus and unceasing collaboration of neurologists and surpresent indebted for the possession of admirably exact It is almost a new science come into being since the war began. Musculocutaneous Anterior tibial . . and Societe Froment of Claude. the remarkable studies of pupils Babinski assistants . all has fortunately grouped together which will be found published in the comptes rendus of this Society. the results of which already surpass our most enthusiastic expectations and hopes. Lejars. of Sicard. have given importance and expansion.. do. tibial . works from the various neurological merate centres. Jumentie. and on a perfect knowledge of the anatomy and physiology of the nerves. etc. or and the histological researches of Nageotte. Dejerine. however. Marie and his pupils. etc. and analysed in the valuable numbers of the Revue Neurologique devoted to war neurology. Anterior crural Sciatic (trunk) . and Mme. Andre-Thomas. recorded and published for the most these fundamental part The by the Societe de Chirurgie de Paris. of Letievant Duchenne of Boulogne. The this study considerable innumerable cases observed during the war.. To this cordial geons we are at and complete information on nerve wounds. de Neurologie de Paris investigations. it has produced an enormous number of . It is impossible to enu- them all here : the illuminating writings of M. External cutaneous Ilio-inguinal nerve 3 1 Lumbo-sacral plexus . . etc. Foix. Broca. Mei<2... Athanassio-Benisty. . .INTRODUCTION Lower Limb. Mme. of Philippeaux and the more recent researches of .. Since the outbreak of war. The works Vulpian. *9 Total 231 The study of nerve wounds is based essentially on certain facts of general pathological anatomy. have already thrown considerable lio-ht on the problems involved in the study of peripheral nerve lesions. To these patient and methodical investigations of neurologists have been added the works of surgeons. Claude and Velter.

union of the formation. In every case there are found two swellings glioma on the peripheral end. may they be pierced by small splinters which remain within the nerve itself may also be contused by the shock. Total section. 3. they frequently happens in lesions may be infiltrated by an itself is interstitial traumatic hemorrhage of the nerve trunk. i. Union of the segments by fibrous cord. of the seg- persistence two segments by cicatricial neuroma on the central end. Finally. the may be wounded either directly or wound may be made by a bullet or by indirectly. i. the nerves are sectioned. which state. this They may be stretched or even torn away by violent traction of the brachial plexus. 2. 4. perforated or crushed by the pro. torn. in a contused 1 . Various types of ner-ve sections. : — — with separation Partial section . compressed by a fractured : bone. they . Total section ments. of a portion of the nerve. a shell splinter. spitted by a bony Fig. splinter.NERVE WOUNDS PART I A GENERAL SURVEY CHAPTER I NERVE LESIONS RESULTING FROM WOUNDS The when jectile peripheral nerves Directly.

Contusions or attritions shown by . Diffuse neuromatous formation. or with interposition of cicatricial tissue. Total neuroma by crushing of the nerve.. — Tearings. forming an insurmountable obstacle above which the contused nerve has produced a pseudo-neuroma. resulting in these different ways may be reduced to a few types. crushing*.— — 2 . The macroscopic lesions. sometimes there is found strangulation by simple fibrous band. by NERVE WOUNDS may be surrounded by callus or shut Indirectly. Partial neuroma after crushing a portion of the nerve. with interstitial. Simple constriction by fibrous cord. the compression corresponds to the narrowed area. central or lateral neuroma. Compressions or strangulations over a greater or less extent . in callus. 3. Very tight compression development of a neuroma above the obstacle. Complete or else partial sections. total. i. 3. Fig. crushings or perforations. Partial 5. Section at the upper part of the pseudo-neuroma showing thickening or the envelopes. producing above the Fig.. 4. . 2. Tearing* and Lateral section. Compression 3. the peripheral nerves in cicatricial fibrous tissue. 2. — constriction a swelling which may occasionally disappear immediately of the nerve are most frequently after the liberation of the nerve.. Compressions. with separation of nerve segments. 2. 4. 1.— neuroma by partial tearing. attacking the whole or part of the nerve.

infiltrations. Recent contusion of a nerve with hemorrhagic infiltration. All the same. some- times very intense. by hemorrhagic or fibrous Pseudo-neuroma by proliferation of the in neuroglial elements. is habitually the seat of a more or less bulky We give the name neuroma to the tumour which essentially consists fibres. Long-standing bruise. 4. A neuroma is found on the central end of the sectioned nerves or else above the fibrous cicatrix resulting from a tearing or a perforation and opposing the regeneration of the axis-cylinder (Dejerine's " nerve keloid "). This is ordinarily the case in simple neuralgia and even in violent neuralgia of a causalgic type. i and z. the tumours formed by thickening of the envelopes. Every wounded nerve neuroma or pseudo-neuroma. often forming an enormous fibrous mass in which the nerve is as it were swallowed up and is frequently very difficult to recognise and isolate. IN NERVE WOUNDS 3 infiltrations. of the local proliferation and entanglement of the regenerated nerve The neuroma and an obstacle invariably indicates an interruption of the nerve fibres to their progress. are pseudo-neuromata. and . in which the macroscopic appearance of the nerve absolutely normal. . with fibrous — and neuromatous infiltration. resulting from bruising takes place contusion-. 3 and +. Pseudo-neuromata resulting from bruising. there exist irritations. infiltration of the nerve. in all likelihood it which probably correspond to two is the interstitial hemorrhage of the nerve for the most part which in the long run produces the fibrous infiltration.— NERVE LESIONS hemorrhagic or fihrous successive stages . like the compressions with which would seem to be the most frequent cause of nerve is irritations of a neuritic type. transformation by injury to the neighbouring connective or muscular tissues. Fibrous hemorrhagic they are often allied. Fig. Almost always the wounded nerve shows not only lesions of the itself but also important changes in its coverings and in the surrounding tissues thickening of the neurilemma which may even constitute a voluminous fibrous sheath for the nerve cicatricial fibrous nerve . On the other hand.

isolate the nerve fasciculi may be thickened. there is never any occasion to make a nerve resection. but there . insures conduction of the regenerated fibres . at the most. be removed. a liberation may spontaneous regeneration is almost certain. no essential obstacle to their regeneration the integrity of the laminated sheath. proliferation of axis-cylinders . on the contrary. This distinction is important. compressions of the nerve the tumour which occurs on the peripheral is end of a sectioned nerve the neuroglial cells . The neuroma always it indicates the presence nerve regeneration^ developes above this obstacle which must almost always On without the other hand. the laminated sheaths which . but Nageotte has shown.4 NERVE WOUNDS . the pseudo-neuroma indicates an interstitial lesion. . is a pseudo-neuroma formed by proliferation of really a glioma^ as it contains no nerve fibres. for it results in very different therapeutic of an obstacle to consequences. be needed . but they are not destroyed the compressed axis-cylinders exists may be injured or interrupted.

The myelin sheath swells in becomes irregular. This is the phenomenon of Wallerian There its is no exception to this rule : every nerve fibre separated from trophic centre (the anterior horn cell in the case of the motor fibres. Such. though the interruption . even immediate suture of the nerve trunk cannot light prevent this degeneration. — It is a fundamental and absolute principle that every interrupted nerve fibre undergoes centrifugal degeneration of the peripheral segment below the interruption. Whilst the peripheral segment is in the inevitable destruction of the degenerating. degeneration. the cell of the posterior root ganglion in the case of the sensory fibres). sinuous and beaded it splits up into lumps or droplets and at last completely disappears. This an empty sheath. confined to a few segments above the evolution of . leucocytes. filled with the droplets of degenerate myelin. are eliminated by way of the lymphatic and the blood streams. Experimental investigations have thrown upon the successive a fibrillary appearance. to first to split up sinuous become thin and finally disappear altogether. is the process of Wallerian degeneration of the peripheral segment. phenomena which segment. surrounded by the multiplied cells of the sheath of Schwann. and. At it it the same time we note the progressive transformation of the myelin . absorbed and eliminated by the also places and . culminating nerve fibre below the interruption. Degeneration. interrupted nerve fibre then consists only of a vague protoplasmic The is frame. inevitably degenerates .— PROCESSES OF DEGENERATION AND OF REGENERATION wounded nerve enables us to analyse the A microscopical study of the processes of degeneration and regeneration of the nerve trunks. Nevertheless it also undergoes slight degeneration. becomes stainable by Marchi's method. then are seen during this degeneration of the peripheral is The axis-cylinder into seen to assume fragments. loses its chemical characteristics and comes to resemble the neutral fats. the central end remains almost intact. two weeks at most. the of which unite with the neighbouring connective tissue and with the leucocytes to absorb the split-up myelin . to three It occurs within a few days. Lastly we witness a rapid multiplication of the nuclei of the sheath or proliferated cells cells Schwann.HISTOLOGICAL STUDY I. these are the granular bodies which effect a veritable clearing-up of the region. as a whole and in schematic fashion.

The consequence is that the regeneration of the nerve always demands considerable time. rapid . by the proliferation of the cells of the sheath This soldering. and whose branches they follow to their motor or sensory endings. cords representing the empty sheaths of the they penetrate into these sheaths or course over their surfaces they slowly all advance into the nerve trunk. that remain in contact. Regeneration. This directing action of the empty sheaths of Schwann on the cylinders of the central end has been proved by it axis. of the separate segments is not regeneration. segment. which seem to attract and direct the regenerated axis-cylinders. the undergoes . . The axis-cylinders do not usually grow more than one or two millimetres per day in favourable cases more rapid in the young and slower in those who are older. their myelin is gradually being reconstructed and they insensibly resume their normal structure. so also among the scar tissue we have the proliferated cells of the sheaths of Schwann. certain slight disturbances. we must repeat. and show its trophic function by the regeneration of the axis-cylinder. It must also be added this Only by work of progressive regeneration. — The apparent union of the sectioned it is nerves is very in three or four days at most brought about between the seg- ments of Schwann. however." attracted and guided by the cells : masses of neuroglia they scatter about as though seeking the cellular peripheral segment . sheath of Whilst these regenerated axis-cylinders are progressing. its we see the axis-cylinder of the central end fibrils termination into very fine which slowly progress right to the level of the section. As in the peripheral nerve. About dividing at the fourth day. peripheral segment reconstructed there is . numerous experiments is called neurotropism. is the no other method of regeneration. crossing the zone of retrograde degeneration. cells of the neuroglia. original nerve cell This ascending or retrograde degeneration. an echo of the peripheral in the swelling traumatism these disturbances show themselves Nissl's of the nucleus and the chromatolysis of this cell is granules.6 this NERVE WOUNDS degeneration is is almost the same as that of the peripheral segment. which is more tardy it does not begin until a few days have passed and is effected only by the penetration and progressive descent of the axis-cylinders of the central end into the empty sheaths of the peripheral . It requires the reconstruction of the nerve terminations and their perfect functional adaptation. that the restoration of the functions of the nerve takes place much later than its anatomic regeneration. Only after a few days does it resume its normal activity. . which they gradually reconstruct. the At same time. . They proceed across the " soldering. For some days itself incapable of entering upon the work of regeneration.

Segmentation of the axis-cylinder. 7. 5. Fibrillation Fig. within a clays or even hours.. of Degeneration and regeneration of a sectioned nerve fibre. caused most frequently by the motor or sensory substitution of neighbouring nerves. Soldering of fragments by proliferated connective tissue cells. 1. gression of the regenerated axis-cylinder in the empty sheath of the peripheral end. contact with each other. myelin bulbs . the functional restoration of a sectioned nerve stated to have taken place. ProRetrograde degeneration. Regeneration of the peripheral segment.— NERVE LESIONS All those cases in IN WAR WOUNDS few is which. the axis-cylinder and swelling of the myelin. Commencement of myelin reconstruction. are manifestly errors of interpretation. 5. proliferated connective tissue cells Retrograde degeneration. Beginning of regeneration in the central end. swelling and displacement of the myelin. the in In order that regeneration of the peripheral segment two segments must remain no great distance apart of the peripheral end. 3.DEFECTIVE REGENERATION— NEUROMATA may occur. Formation of granular bodies . Proliferation of Schwann's sheath cells. attracted by the neurotropism . . 4. or at all events at it has been shown that regenerated axis-cylinders are capable of traversing a certain distance. elimination of degenerate myelin by phagocytes. — II. 6. 2. Disappearance of the axis-cylinder .

but. The axis-cylinders of the central end proliferate. the or again. though ineffec- is abortive regeneration. We and find rolling of the proliferated axis-cylinders on the central end a terminal neuroma. reparable serious by surgical intervention. More or less bulky. will enable us readily to interpret the variable and complex histological aspects. this fibres neuroma appears sinuous the clear in section as made up Some. fruitless This regeneration.— HISTOLOGICAL LESIONS CAUSED BY NERVE WOUNDS We have summarily described the general processes of degeneration as elucidated and regeneration. there an attempt at regeneration. in The knowledge acquired nerves. by experimental investigations. sprinkled with . and Consequently consequences. regeneration of the insurmountable obstacle peripheral segment is impossible. tracing the curious figures described by Peroncito. formed by the winding this is the classic amputation neuroma. they are rolled "neuroma" : upon one another is in spirals and return to their starting point. encountered Section. these it cases. : in certain cases of neuritis. longitudinal section.8 If the separation is NERVE WOUNDS too great. must not be mistaken for absence of regeneration. of in intricate nerve or even of regenerated nerve . but they are . embedded in a fibrous tissue which is more numerous cells resulting from the multiplication of the neuroglial cells of the sheaths of Schwann these cells seem specially grouped along the nerve fasciculi of which they really compose All these nerve fibres are or less dense. they wander about in the cicatricial tissue which impede their advance. an essential disturbance and has III. they cluster at the extremity of the central end and constitute a veritable tumour. 1. sectioned in transversely or obliquely. In tive . segments. resulting from a bad coaptation of the latter. The characterised by absence or delay of activity in the processes of regeneration. being incapable of reaching the sheaths of the peripheral segment. The nerve fibres of the neuroma are already myelinised. results solely from serious disturbances in the nutrition of the nerve also tardy cell or of the central segment . or if the axis-cylinders encounter an between the two segments. it is found only in aged subjects or those in regeneration is poor health inadequate. spaces which seem hollowed out the interstitial fibrous tissue. appear fill and irregular the rest. fasciculi. this is not as in the it is first case a simple accident. traumatic lesions of the — Section of the nerve trunks : presents the simplest features for histological study. the connective tissue framework.

longitudinally. a glioma. usually less bulky. set out in parallel groups corresponding with the fasciculi that have disappeared. transformation. and sometimes present a barbed aspect sfisffi dm Fig. others transversely.— . others are irregular. of which we shall speak later . we find in juxtaposition adult fibres. others have undergone a kind of swelling of their myelin. 6. the cellular columns of which accompany the nerve fasciculi. —Twisting mingling of the fasciculi of regenerated axis-cylindets. up. grouping ami interCertain fasciculi are sectioned They are embedded in rather dense fibrous tissue. 'terminal neuroma of the central end. already young fibres. giving them a vacuolated appearance. To sum The this is up. At the upper part of the glioma. NERVE LESIONS irregular IN WAR WOUNDS and often beaded . or the manifestations of regenerative activity. Above where they enter in the neuroma. at the lower part of the site of glioma. these features are but the remains of retrograde degenera- tion. the cells . peripheral segment also presents a swelling. composed solely cells of the excessive proliferation of the of the sheath of Schwann. and very slender and scarcely myelinised . the nerve These neuroglial cells are clearly to be seen. interspersed with the proliferated cells of the sheath of Schwann. the nerve fibres of the central end almost always show abnormal features some have undergone fibrillary bulky. a false neuroma. as Nageotte has shown.

the proliferation of neuroglial and the grouping of regenerated axis-cylinders. Simple proof the cells of the sheath of Schwann.!:. r? . has produced complete interruption of the nerve fibres. which is more or less proliferation. In very schematic fashion. Complete interruptions without break of continuity of the nerve. Below. 7. or even with series of blocks of myelin still tracing the course of the nerve fibre. but the traumatism. in the neighbourhood of the section.« MffMwtM 15 Fig. laden with degenerate myelin. there is observed a more or less irregular neuroma. forming cellular columns which the accompany empty sheaths. at its upper part. 2. crushing or rending. made up of cicatricial fibrous tissue.'. resulting from unrestrained masses are plunged in a fibrous more bulky and irregular Groups and stroma. At the of the wound. nerve is — The level apparently not sectioned. cells. If the section is not too old. flWlliM.ones in this neuroma may . three different /. some granular bodies. traces of degenerate nerve fibres may still be found in the form of " granular bodies" laden with myelin. dense. the cells form bulky masses in which the fascicular arrangement is no longer recognised. have not yet been completely eliminated.— IO of the sheaths of cellular cellular NERVE WOUNDS Schwann usually constitute masses. — in cellular liferation Glioma of the peripheral segment. Arrangement columns is fairly regular at the lower part of the glioma . Absence of all nerve fibre.

In the lower part of the neuroma is found a denser fibrous tissue which probably represents the cicatrix of the wound. axis-cylinders are piled up and grouped above the obstacle and a lower zone of neuroglial proliferation Fig. the majority ot Some fibres are rolled in spiral fibres have undergone fibrillary transformation. form above the neuioma. neuroma made up of the intercrossing and grouping of axis. where the cells of the sheath of Schwann form. penetration of the central end. Above. In the middle part. . in the neighbourhood wound. to resume in the lower part of the neuroma the more regular aspect of cellular columns of the corresponding to the degenerate nerve In reality these three zones are fasciculi. the proliferation of which forms on the left a veritable glioma. this the nerve keloid of Dejerine . the right. bulky and disorderlv cellular masses. seldom so distinct they are partly . a few regenerated fibres have succeeded in passing into the peripheral (semicellular diagrammatic) segment. the cells of the empty sheaths form 8.— 1 NERVE LESIONS IN WAR WOUNDS is 1 be described: a middle zone of nerve |destruction and of fibro-cicatricial scar tissue constituting the obstacle. — whose On columns. an upper zone where the regenerated .cylinder fasciculi (fibres sectioned longitudinally or transversely). Below. Complex neuroma.

empty peripheral sheaths. constituting and extends over almost a sort of fibrous nucleus. If the nerve fibres are able to pass the obstacle or turn round it and . peripheral end. in which it is difficult to distinguish what results from each of the three processes analysed : fibrous cicatrisation. The between cicatricial notion. surgical must remove the obstacle and restore coaptation between the two segments by resection and suture of the nerve. Pseudo-neuroma resulting from bruising. or whether it is diffused Fig. thickness and density of the cicatricial fibrous tissue depends the regeneration of the peripheral segment. In certain contusions vention — . the is neuroma inter- impermeable. The nerve fibres are not interrupted. spontaneous regeneration impossible . axis-cylinders . but they have not undergone any rupture which permits the egress of the axiscylinders by them the regenerated nerve fibres are readily conducted towards the 9. rejoin the is possible If the fibrous tissue is is too dense or of too great extent. Nerve fasciculus contained in a cicamass. is Whether formation clearly limited as sometimes seen.— 12 NERVE WOUNDS confused and entangled. constituting a complex neuroma. beaded others have assumed a special appearance. The laminated sheaths which separate the nerve fasciculi are infiltrated and thickened. 3. bristling with thorns (which probably represent the dissociation and impregnation of the incisures of Lanteimann). spontaneous regeneration the neuroma is permeable to the regenerated axis-cylinders. irregular. it always sets up an obstacle to the progression of the on the extent. Others have preserved their normal volume some are swollen. barbed in appearance. Pseudo-Neuroma resulting from Bruising'. the entire neuroma. . Most of them have undergone fibrillary transformation and have lost their myelin. however. but they are greatly altered. — tricial fibrous : . of the cicatricial fibrous obstacle the two segments is is a very important one. regeneration of the central end and interposed this degeneration of the peripheral segment with cellular proliferation.

they or thickened. In all cases. preserved. . Fig. but they have may be not undergone any rupture which could permit egress of the axis-cylinders and their budding outwards. 10. certain . . There is always an interstitial infiltration of the nerve by less a more or dense connective tissue. Schwann. we find a simple swelling or fragmentation the of the myelin. axis-cylinder may be irregular. sometimes even the entire is embedded recognise in it. an elongated or fusiform pseudo-neuroma resulting from the bruising. without the axis-cylinders being interrupted consequently there . a cicatricial fibrous mass where it is extremely difficult to This causes increased volume of the nerve. the traumatised zone level. The frame of the nerve The nerve fibres are is. beaded transformation or barbed appearance ot the other fibres. seldom interrupted.— NERVE LESIONS or compressions of the deep. on the whole. interstitial hemorrhage. Fibrillary separation of certain fibres. is no Wallerian degeneration of the peripheral segment at the most. with proliferation of the interstitial cells of the sheath of effusions. lesion of the nerve fibres is gradually confined to the sheaths of myelin may have disappeared at this . or again we encounter small hemorrhagic The nerve envelopes of the nerve are thickened. but only injured at the level For instance. IN WAR WOUNDS 13 nerve. or . Hemorrhagic infiltration of a newe by recent contusion : syndrome of severe Hemorrhage in the sheath of the nerve and. however. with thorns which probably represilver impregnation with of the incisures of Lantermann a veritable barbed appearance of the nerve fibres. nerve irritation. frequently even demyclinisation of the nerve fibres of the lesion. one may these observe lesions that arc not so What infiltrated essentially characterises lesions is that the laminated sheaths surrounding the nerve fasciculi are not destroyed. more frequently it is separated into a bundle of fine fibrils very often bristling we find a special appearance where the axis-cylinder seems sent the displacement and . Integrity of the laminated sheaths (Bielchowski's method en masse). beaded.

end by degenerating. Still it is not always so . temporary. . or may even * be partially permeable. So also certain groups of nerve fibres may have escaped the more or less complete destruction of the nerve. Again.— DISSOCIATED SYNDROMES AND PARTIAL LESIONS The various lesions just investigated may frequently be found on the same nerve trunk.14 fibres. a neuroma may * be permeable or impermeable to regenerated * * * fibres. it assumes the somewhat it is characteristics of the paralytic syndrome of compression lesions resulting . Dejerine and Mouzon. IV. irregular. giving rise in these cases to dissociated syndromes. In these cases of severe difficult. by certain modifications of the myelin or the axis-cylinder. regeneration seems to take place exactly as in cases of complete interruption . irritated and painful neuritis. NERVE WOUNDS more profoundly affected by the traumatism. this is what we certain of simple compression after surgical liberation of the compressed nerve. Whilst we are at the present time well acquainted with the histological regenerations as well as of nerve processes of nerve interruptions and . usually incomplete. they cannot constitute does they are guided by the intact sheaths towards the a real neuroma . Thus. it is in these cases that we almost always encounter the syndrome of nerve irritation accompanied by trophic pains and disturbances. These special by complete paralysis from bruising are not generally accompanied this latter exists. without being completely destructive. elucidated in the works of J. the integrity of the laminated sheaths mined not permit egress of the regenerated fibres. may be reconstituted on the spot. They may find in very rapidly regain cases their functions . are nevertheless very severe. dissociated. the disturbances to their nutrition caused by the local injury. Most of the peripheral fibres do not degenerate they simply indicate. having undergone simple partial and segmentary thus degeneration. regeneration would seem to be particularly slow and trophic as though the function of the cell itself were disturbed a distance by the painful reactions of the affected nerve. Though their the more severe lesion of certain nerve fibres may have deter- complete interruption. for instance. peripheral segment. and A. fibres of the peripheral segment. The nerve fibres. when . without the necessity of regeneration by eruption of the central axis-cylinder. On the other hand. the same nerve may be interrupted in one of its parts and simply bruised or even intact at other points. the young axis-cylinders proceeding from the central end gradually replace the affected. when the lesions.

below. Thus operation it is is by a clinical examination mainly that we must judge if an and Mouzon. DIAGNOSIS OF NERVE LESIONS The on different lesions which a wounded nerve may present syndromes.) (J. 2. 3. In some cases we meet . differentiated in — a way clear enough to enable one. is . 11. previous to any intervention. on the contrary. ruption with lateral pseudo-neuroma resulting from bruising. and A. are examination.i Rarefaction anil fibrillaresulting from bruising without interruption of nerve fibres. are other obscure problems. nerve inhibition. sympathetic reflexes. Pseudo-iieuinm. above. arising we find is nothing to explain histologically the disturbances noticed and one from often led to consider the hypothesis of disturbances irritation. Dejerine Before any intervention takes place. Partial inter1. painful syndromes of causalgia or of ascending neuritis. tion of axis-cylinders. with a few widely disseminated lesions in many others.NERVE LESIONS compressions and irritations. are shown. temporary we know . or a distance^ of the motor or sensory cells which are related to the fibres involved. we must find out if the nerve necessary. of whose pathogen}' nothing. Total interruption. Simple neuralgia from slight contusion of the nerve. glioma. by different Most frequently they Neuroma. FlG. to form a tolerably exact diagnosis of the anatomical state of the nerve. IN WAR WOUNDS 15 we must plete ignorance regarding the at the same time confess our comsyndromes produced by slighter traumatisms. fleeting paralysis from compression.

that must . come first and supply the most important indications is it is this that will decide if intervention legitimate and will regulate beforehand the nature of such intervention. find out if the neuroma discovered by palpation fibres. Marie and the clinical examination. Naturally logical we must not neglect the objective examination and physionerve exploration of the exposed by intervention . i. 3. It necessary to recognise the signs of irritation of the nerve as a its whole or of some of fasciculi. — nerve but imperfectly reveals its histological state. made in the course of systematic interventions for the macroscopic state of the i. and above all the physiological state of the nerve fibres. regenerated fibres. permeable or not to the regenerated this is whether or not signs of it regeneration exist particularly important. It is is logical and capable of being utilised the electrical exploration of the exposed nerve as propounded and carried out by P. Neuroma partially permeable with intact fasciculus. 12. Neuroma permeable to Fig. indicating that while the nerve is preserved.e. of all is the processes suggested for this examination we shall find that there : only one that Meige. 2. the fibres are irritated. as indicates clearly surgical abstention or intervention. however. . Above is all we must .i6 NERVE WOUNDS . It would be most imprudent to trust solely to objective signs . Neuroma impermeable to regenerated fibres. physiologically interrupted or not total also if the interruption is partial or and which is fibres it affects.

for the must be taken of the time that symptoms may change 2 considerably during the few weeks. if the best results are to be attained. Date of the wound. its course and relations. 2. Examination of the wound. be advised following system of examination may I— PRELIMINARY EXAMINATION AND HISTORY OF THE CASE 1. and the cutaneous territory over which it is distributed. and. may change according to the The explored bones situated . for anatomical relations posture. so to speak. it in its damage by a bony splinter. there is never any inconvenience. must be known whether or not there has been suppuration the wound from a suppurating tract may sometimes flow purulent : matter capable of producing irritation in a neighbouring nerve. at intervals of several weeks. the muscles it supplies. the number and position of its branches. . It is investigation made what nerve may have been at important to reconstitute the exact position of the limb the time of the wound.— CHAPTER II CLINICAL EXAMINATION OF A NERVE To be able to explore a nerve implies above all perfect knowledge of the anatomy and physiology of this nerve. having operated too soon in postponing surgical intervention to two and even three months after . A The nerve requires to be examined both minutely and methodically. for the One may often repent evolution of the symptoms is all important. The several examination of a paralysed nerve should not be made until weeks after the wound. the injury. first — Account has elapsed since the wound was received. — The wound as to must first be examined. the orifice of entrance and that of exit located. in the neighbourhood of the wound should also be the existence of a fracture makes possible the compression of the nerve in callus or Finally. It must be made frequently. projectile. following the course of the injured.

The patient will be questioned to the degree of functional inconvenience he experiences. hasty an examination. suddenly traversing like a it the entire extent of the nerve. It is important of the wound. Investigation of the first sequelae — to find out if paralysis has been . immediate or has come about secondarily. At other times the sensation is one of painful numbness. as to his sensations of pain. a certain number of symptoms appear only after some time. Muscular atrophy. the ulnar or the sciatic. preceding the appearance of paralysis. formication in a nerve under pressure appears only about the fourth to the sixth week. symptoms of inhibition may be mis- taken for signs of destruction . such as a sudden cramp. during the early weeks. . sensory. it is the nerve itself that has been directly injured in the second. then. would . paralysis may result simply from compression by callus. or anaesthesia is often more extensive or complete than would be associated with the real lesion. Certain wounded men complain of an immediate and flash violent pain. Indeed. a fleeting contraction the region of the injured nerve. being embedded in a fibrous cicatrix. Evolution of nerve disturbances. of a hematoma which shown itself some hours after the wound and which would appear irritation. or again there may be the formation. of numbness and of formication. around the nerve and has very tissue. or trophic disturbances. — Inquiry will as naturally be made as to the progressive increase or decrease of motor. it is only two months after the its wound that a clinical examination possesses maximum paralysis value. or even from the contact of a plaster apparatus in its . whether be the median. require several weeks and sometimes increase for a to reach their height . In other cases. from 3. The Too electrical reactions of degeneration likewise frequently come about only after three or four weeks. deprive one of a certain number of important signs whereas it seems to be clearly proved that a delay of two or three months previous to surgical intervention is generally of no significance as regards the success of such intervention. Again. In the first event.18 NERVE WOUNDS Speaking generally. the pains of nerve irritation frequently appear only after eight or ten days whole month . the nerve wound is accompanied by signs of motor in irritation. to be one of the frequent causes of nerve Afterwards inquiry must be made into the phenomena which sometimes indicate immediately the presence of a nerve lesion. hypotonia. Only profitably after this previous examination and interrogation can one make an objective examination of the nerve affected. 4.

it is Naturally. a greater or scope of active or passive movements. if movement takes place in an unfavourable attitude. Make (Ed. nerve. raise the The extensors of if the wrist. horizontally. the fore-arm is triceps can effect flexion or extension only when. easy to find for each muscular group the attitude in which the feeblest (b) * movements are readily discernible. particularly if the weakened muscle has to overcome the action Still. paralysis to be readily followed. movements.— ATTITUDE All paralysis produces a characteristic attitude in repose or during action. discovered by asking the patient to execute the necessary to these movements. too. or steppage in lesions of the external popliteal attitudes will be studied in the case of each nerve. These processes enable the evolution of several important causes of error must be borne in mind. These processes are particularly useful when trying to bring back the early It movements which denote is the disappearance of paralysis.— EXAMINATION OF VOLUNTARY MOVEMENT muscular group The loss of power of voluntary movement of a muscle or a may vary from simple enfeeblement to complete paralysis. I. one may employ either a "goniometer" with graphic representations (Lortat-Jacob and Sezary). a greatly weakened biceps or shoulder. These It is important not to confuse paralytic attitudes with those resulting inertia. if they exist. and opposing less resistance.CLINICAL EXAMINATION OF A NERVE 19 II. or adopt the process of moulding the position In measuring the usefully of the limb with lead piping. (a) of gravity. the elbow being raised outwards to the height of the able to move . psychic paralyses. — CLINICAL EXAMINATION OF THE PATIENT musculo-spiral paralysis. can hand only the is arm then remains hanging by the patient's side sufficient to very feeble contraction impart to the hand a slight oscillatory movement. — . Thus we have gr'iffe* the droop of the hand in the of ulnar paralysis. contractures or cicatricial fibrous from functional contractions. For instance. II. Complete paralysis may be mistaken for a considerable degree of weakening of a muscle.) sure that the patient has thoroughly understood the order the claw-like attitude of the hand in certain nerve and muscle The term griffe refers to lesions. if greatly weakened.

in spite of genuine paralysis. the In peripheral paralyses response of the we often find paralysed muscle being incapable of responding to sensory excitation. then. the olecranon reflex in paralysis of the triceps the wrist in musculo-spiral paralysis. The passive movements must consequently be either studied. unless see. and should be made each nerve. one (i) justified in suspecting artificial incapacity. or by immobilisation of a joint. the disappearance of its . frequently follows paralysis and ill artificially or from a conviction of inability. reflexes affords We may study in a reflex the motor response which reveals the paralysis Peripheral paralysis of a muscle reflex. we are dealing with functional psychic the muscle readily contracts beneath the faradic current. In or all suspected reality cases electrical if examination will enable us to judge of the inertia of paralysis. of these functional compensations in the case of is very important. of the anterior crural the Achilles reflex in paralysis of the sciatic . III. or the integrity of the muscle in question. for even a powerless effort to execute movement is always accompanied by the synergic contraction If this of the neighbouring and antagonistic muscles. etc. the reflex of the extensors of Whenever paralysis. On the other hand. Only. is wholly retained must be we are dealing with cerebral lesion. in lesion of the musculo-spiral accompanied by paralysis of the . {/) by attributing to a paralysed muscle the compensatory movements which the neighbouring muscles often succeed in effecting. as we shall in some rare cases of slight compression of the nerve can faradic contractility be retained. of the tendon reflexes. (d) It often happens that the patient does not try to execute the prescribed movement. NERVE WOUNDS all that is needed for this is to Have the movement executed by the the other limb. This may the prescribed readily be discovered. or even from intent. (c) Also ascertain that inability to execute movement is not caused by retraction or contraction of the antagonists. one may deny the existence of real paralysis The study. For instance. This applies mainly to the study is accompanied by is The patellar reflex abolished in paralysis .— EXAMINATION Examination of the OF THE REFLEXES two classes of information. a neighbouring or antagonistic muscles is noticed. it may be affirmed that we are dealing either with functional or with central inversion of the reflexes. is contraction is lacking. All paralysis in which faradic contractility suspected. on from a sort of functional inertia which rather prolongs it.20 given . a paralysed muscle reacts by a reflex movement. for paralysis.

CLINICAL EXAMINATION OF A NERVE
triceps, percussion

21

of the olecranon

may

cause slight contraction of the

biceps; this

is

the inversion of the olecranon reflex.

This

reflex synergic

contraction of the neighbouring or antagonistic muscles exists normally,

though

it is

stimulated

;

masked by the more vigorous response of the muscle directly paralysis of this muscle makes it only the more manifest.

On
applies

the other hand, in a reflex one
is

anaesthesia of the region excited

must consider sensory excitation shown by abolition of the reflexes this
; ;

mainly

to the

cutaneous and periosteal
is

reflexes.

In this case there

no response, either from the muscle appealed
reflex
is

to or
its

from

the

others

;

the

suppressed at

its

source, not only in

motor expression.

The
reflexes
less

study,

however, of the cutaneous and especially the periosteal
delicate than that of the tendon reflexes

is

more

and often supplies
nerve
regions

exact information, on account of the possible diffusion of the sensory

excitation

and of the frequent superposition of several

especially in the case of deep sensibility.

We
regions.

shall also

study the different reflexes with their respective nerve

IV.— OBJECTIVE
(a)

EXAMINATION OF THE MUSCLES

Muscular atrophy.

— The
;

muscular

atrophy

following

a

nerve

lesion occurs rather slowly

it

appears only after two or three weeks and
until the

gradually becomes
a thin fibrous cord.
It

more pronounced

muscle

is

transformed into

may

be

recognised by

the contour of the muscular outline
side,

;

it

is

mainly judged by comparison with the healthy

and

its

progress

may
;

be followed by measuring the circumference of the limb.

Muscular atrophy
is

also varies

according to the nature of the lesion

it

more rapid and pronounced in sections than in simple compressions, and even more rapid still in certain nerve irritations. It retrogresses somewhat slowly, and, though less marked, persists long after the reappearance of the movements.
It
is

increased

by

immobilisation

of the

limb,

whilst

it

may

be

considerably checked by massage and a proper electrical treatment of the
paralysed muscle.

Muscular atrophy in nerve lesions is a somewhat variable symptom and of secondary importance in the diagnosis. It should be distinguished from simple atrophy from prolonged inaction of the muscle and especially
from
reflex atrophy,

which

is

secondary to the osseous, articular and tendon
very important, as

lesions.
(/>)

Muscular tone.

— The study of muscular tone
Mouzon
have shown.

is

J.

and A. Dejerine and

22

NERVE WOUNDS
Tone
is

the state of latent and permanent contraction of the normal

muscle at

rest.

All paralyses by nerve lesions are accompanied by muscular hypotonia,

but simple compressions are usually
characterised by the retention of a
certain

degree

of

muscular tone,
interruption

whereas complete
the nerve after
total disappearance.

of
its

some time causes

Nerve

irritations,

on the other
is

hand, are not accompanied by very

less

marked hypotonia marked than
pressions.

;

it

frequently

in

simple

comtone

On
may
Fig. 13.

palpation,

muscular
of the

be recognised
flaccidity

by the greater
muscular

— Complete hypotonia

or
in inter-

less

ruption of the musculo-spiral nerve.

bellies.
It

may more readily
;

be studied by

causing the antagonistic muscles to contract

then,
is

if

tone

is

maintained,

a slight synergic swelling of the paralysed muscles

perceived.

The

degree of tone

is

even better recognised by the attitude of the

limb, for the disappearance of tone

somewhat

intensifies

the paralytic

FlG.

14.—Return

of muscular tone 73 days after suture, in the preceding case.

attitude.

pression, the

For instance, in musculo-spiral hand remains hanging down
is

paralysis
at

from simple com-

the end of the fore-arm,

but

if

slight pressure

the flexion of the wrist

— this
its

given to the hand, tending further to accentuate accentuation is found to be possible since the
full

hand was not flexed
suddenly
released,

to

extent

— and

if

the

pressure exercised

is

the

hand

rises

slightly,

elastically,

owing

to

some

CLINICAL EXAMINATION OF A NERVE

23

In complete section of the musculo-spiral, remaining muscular tone. however, flexion of the hand after a few weeks reaches the maximum
permitted by the articular ligaments.

Disappearance of tone, therefore,
complete interruption of the nerve.
It

is

an important sign

in

favour of

(J.

and A. Dejerine and Mouzon.)

must, however, be noted that the prolonged inaction of a muscle,
in a certain

even

number of

functional paralyses,

may
It

be accompanied by

hypotonia, which in time becomes considerable.
(c)

Mechanical contractility of the muscle.
local

is

important to

dis-

tinguish muscular tone from idio-muscular contractility.

Percussion of a

normal muscle produces a
muscular
by
fasciculi,

and momentary swelling of the percussed
this
is

and

that

a

genuine

contraction
is

is

shown

more

or

less

extended

movements.

This
in

the

idio-muscular

reflex.

Idio-muscular reflexes are always intensified

peripheral-nerve lesions,

even though there

is

considerable hypotonia or even complete atonia.

This
muscle
tractility

intensification of the
as

mechanical contractility of the paralysed
to the intensification of the con-

is,

we
its

shall see,

comparable

of the muscle under the galvanic current (galvano-tonus),

when

excitability of

nerve at the motor point has disappeared.
slow.

Like conslowness of
It
is

traction of the paralysed muscle under the galvanic current, the contraction provoked by percussion
is

This amplitude and

this

contraction often permit a diagnosis of paralysis to be made. stitutes a veritable " mecano-diagnosis " (Andre-Thomas). This

con-

Sicard's

" mechanical myo-diagnosis."
In a word,
it

may

be said that, in a paralysed muscle, contractility from

excitation of the
disappears,
is

nerve, whether voluntary or electrical,

diminishes or
tissue
itself

whereas the contractility peculiar to the muscular
;

intensified

the former
in
its

is

rapid

and short, the

latter

is

tardy in appear-

ance and slow

execution.

Mechanical contractility of the paralysed muscle, however, diminishes
or even disappears in time, simultaneously with
its

galvanic contractility

;

the atrophied muscle, transformed into fibrous tissue, has then lost every

kind of excitability.
(d)

Sensibility of the muscle to pressure.

— Every paralysed

muscle

is

painless

under pressure, unless there

exists

some nerve

irritation.

The

total insensibility to pain

to pressure

and even the absolute insensibility of the muscle one of the clear signs of complete interruption. (J. and A. Dejerine and Mouzon.)
is

On

the other hand, pain of the muscular bellies under pressure
;

is

the

best sign of nerve irritation

it

is

even more pronounced than pain of the
mobilisation

nerve under pressure.

This pain may be extremely acute, rendering impossible
or massage.
It

all

may

exist

even when the muscle

is

not paralysed

;

then pressure on

24

NERVE WOUNDS
Voluntary contraction
paralyses
also causes violent pains, to

the muscle frequently causes very painful though fleeting contractions and

cramps.
that false

such an extent

may
the

be noticed, resulting from immobilisation of the

muscle through

fear of pain.
in

Nerve
(e)

pain

muscles

is

very often accompanied by

fibrous

contractions.

Whereas compressions and accompanied by hypotonia, flaccidity and progressive lengthening of the muscles; nerve irritation, on the other hand, is almost always accompanied by muscular contraction with fibrous transFibrous contraction of the muscles.
especially nerve sections are

formation.

A
At
joint,

modification in the consistency of the muscle
fibrous, painful

is

then found

;

it

becomes hard,

and adherent

to the

neighbouring
consistence.

tissues

;

certain muscles end by acquiring an almost

woody

the same time, this muscle has a tendency to contract.

These

muscular contractions progressively limit the excursion of the corresponding

modify and so
it
;

far

restrict

the paralytic attitude as sometimes to

mask

finally,

they induce the appearance of special attitudes, no longer

reducible as the paralytic attitudes are, but fixed and frequently difficult to

reduce by prolonged massage and mobilisation.
likely to lead

The

fibrous griffes of the

ulnar and the median, the contraction of the posterior muscles of the leg,
to pes equinus

and

to

necessitate

tenotomy, are so
for

many
fibrous

instances of these nerve contractions.

The
joints.

muscular examination must always end in a search

contraction, by investigating the passive

movements of the corresponding
is

All limitation of articular

movement

a sign of neuritis

;

impossibility
;

of completely extending the fingers or completely flexing them

arrest of

dorsi-flexion of the foot at right or obtuse angles, demonstrate nerve irrita-

tion of the median, ulnar, musculo-spiral or sciatic, associated or not
paralysis of these nerves.

with

One must
articular

naturally avoid confusing nerve muscular contraction with

lesions

and especially with

the

cicatricial

contractions
in

and
the

adhesions of muscles or

tendons, approximately ending

almost

same

and the same limitation. Lastly, certain cases of (/) Muscular contraction and hypertonia. nerve irritation, mostly slight, are accompanied by a state of muscular thus we meet hypertonia, sometimes going as far as real contraction
attitudes

;

with attitudes that are permanent and paradoxical,
almost impossible to overcome.
intensification of the

in

some way the

opposite of paralytic attitudes, reducible with difficulty and even at times

The
in

pain in the muscles under pressure,

idio-muscular reflexes,

the sensory,

vaso-motor or

secretory disturbances

met with

these cases, particularly the increase

of the secretion of sweat (Babinski)
the nerve fibres.

show

clearly the irritated condition of

CLINICAL EXAMINATION OF A NERVE

25

Almost always, however, in these contractions, especially when permanent, we meet with an important functional factor they are certainly emphasised and intensified by inaction of the patient.
;

V.— OBJECTIVE EXAMINATION OF

AND SUPPORTING

TISSUES.

THE INTEGUMENTS TROPHIC AND VASO-

MOTOR DISTURBANCES
After the objective examination
of the muscles comes logically that of the other tissues, investigation of the various trophic and vaso-motor
disturbances.

Speaking generally,

we may

lay

down

the principle that trophic dis-

Cutaneous disturbances in a case of nerve irritation. (Note the smoothness Fig. 15. of the fingers of the left hand and the disappearance of the cutaneous folds.)

turbances are either absent or very slight in almost
interruption or simple compression.

all

cases of nerve

On
(a)

the other hand, they are almost constant in nerve irritations.

Integuments.

— Examination of the integuments
;

is

bv

far the

most

important and cutaneous

may
is

reveal very different disturbances.

Glossy skin

the most frequent

disappearance or diminution of the

folds, levelling

of the papillary crests expressed by the smooth

appearance of the finger-prints

— constitute

its

main

characteristics.

26

NERVE WOUNDS
These disturbances always
exist,

though greatly diminished,

in paralysis

from section or simple compression.

On
and
and

the other hand, they are most marked in cases of nerve irritation.

In these cases

we

are struck by the glossy condition of the'skin,

its

dryness

dull colour, the disappearance of the

cutaneous

folds, the

fibrous con-

sistence of the integuments
difficult to

which are adherent

to the underlying tissue

mobilise: these disturbances, always

more pronounced
fixed aspect

at
is

the extremities, give the hand and foot a
altogether characteristic.
(b)

waxy and

which
is

Sweat reactions.

— The

skin of paralysed hands and feet

often

the seat of excessive sweating, of fetid odour.

This sweating

is

mainly

Fig.

i

6.

— Cutaneous desquamation

in the region

or"

the ulnar (slight nerve

irritation).

found

in

nerve irritations with slight neuritis and, above very important

all,

in

neuralgia,

occurring without complete paralysis.

Dryness of the skin
nerve section and
tion
it is

is

;

it

is

found
fine

is

sometimes accompanied by a
in certain cases

in most cases or branny desquama-

which

clearly delineates the cutaneous

topography of the nerve.

But

also very

pronounced
in

of nerve irritation, especially in
also

severe cases with paralysis,

where there

is

found an abundant cutaneous

desquamation

broad scales.

The skin,

thickened and indurated, assumes

quite a rough, scaly, fish-skin appearance.

may advantageously test for sweat secretions 'with the aid of chemical paper impregnated for instance with nitrate of silver, or more simply by using litmus paper ; the slight acidity of sweat changes blue
litmus paper to red.

We

(Claude and Chauvct, Jumentic.)

Cyanosis more especially indicates vaso-motor It is paralysis. In some cases we find pallor of the integuments. however. redness of the skin found especially slight neuralgic irritations. their dull tint seem to where the thickness of the integumask the colouring of the deeper far Cyanosis and redness of the integuments are the vaso-constrictor apparatus. finger in certain lesions of the ulnar. In certain conditions. without paralysis. when placed alternately dependent and elevated positions. however. it rapidly diminishes and disappears if the limb is an elevated position. and usually coincides with it increase of the sweat secretions. for the most part it would seem to be only the intensified swelling by stasis observed in prolonged dependent positions . cedematous and shiny aspect the fingers are covered with paralysed The must special susceptibility of the extremities to chilblains also be remarked. vigorous rubbing with the produces a white streak which slowly enlarges and nail often may persist for one or two minutes. We healthy need only compare the cyanosis and the pallor produced limb in the in and in the paralysed one. fibres Like the other muscles. GEdema is sometimes found in nerve interruptions . these phenomena show the strictor of tone of the vaso-con- muscles in the paralysed region. the paralysed muscular of the small vessels seem to have lost their nervous excitability. acting upon placed exaggerated by a dependent position and by cooling in . the hands and the soles of the feet. all — Vasomotor disturbances arc It is inevitable in nerve lesions. in neuritic or On the other hand. likewise produced by pressure of the finger. Probably On the sound limb. along with the dryness and thickening of the skin. . Redness or cyanosis of the skin . It is particularly marked in causalgia. Probably degree corresponds to active vaso-dilatation. doxical position. disappears loss more quickly on the paralysed limb. brought out prolonged contraction of the vaso-constrictor by mechanical excitation. mainly found on the palms of ments and planes. may in certain cases reach an extreme for instance. this paralytic white streak and gives way to the usual results from the slow and muscles. the narrow white streak obtained by the nail rapidly disappears red streak. In a word. little we find the index finger in certain irritations of the median. to see that the paralysed limb becomes cyanosed more quickly and pales more rapidly than the healthy limb. and the chilblains. If the cyanosed limb not in too dependent a and the venous pressure not too great. . The white spot. one may notice an apparently parais phenomenon. whilst their idio-muscular contractility has become is intensified. more frequent. assume a red. this is an oedema of posture and disuse.CLINICAL EXAMINATION OF A NERVE (f) 27 practically Vaso-motor disturbances. wine-coloured.

Ulceration in a case ulcer on the sole of the foot. the distribution of the vaso-motor disturbances is exactly spread over the cutaneous region of the affected nerves. with permanent vaso-dilatation and redness of the On But this the other hand. In all cases these lesions. 28 NERVE WOUNDS Along with cyanosis it sometimes produces appearances recalling that of the " succulent hand " in syringomyelia.. in these cases we have seen it rapidly disappear as the result of surgical intervention. that have appeared after too . or else ulcera- by the pressure of an apparatus. — Genuine ulceration is very rare in peripheral nerve lesions. these are secondarily ulcerated bullous lesions. results it will not be forgotten that oedema. more in conformity with the anatomical region of the nerve. 17. Claude and Chauvet justly remark that this vascular topography is often more precise and exact. hot a bath or after a too intense galvanic bath they have the characteristics of burns. it if is . Then again. Almost always we can find the exciting cause. systematically investigated. one which has of complete interruption of developed as usual at the site of a corn and has the posterior tibial nerve. though rare. than the distribution of the sensory disturbances. On the paralysed limbs there may be (/) Thermal disturbances. They would seem to occur both in cases of complete section and in nerve irritation. For instance. really an artificial cooling. rise — re- of the local temperature is found only in certain slight nerve irritations. In all these cases. Actual persistent skin. (d) Ulceration. Finally. marked a lowering or an elevation of the local temperature. oedema is evidently the result of nerve irritation it may j reach a considerable degree . like cyanosis. certainly been caused by pressure in walking. resulting. are dealing with a perforating Fig. surrounding temperature falls. and indeed they doubtless are burns appearing over a region of disturbed nutrition. is lowering of the temperature is very frequent. often from vascular lesions associated with nerve lesions these must be . . The cooled limb slowly becomes warm in wrapped in wadding it almost regains its normal temperature but again cools more rapidly than the sound limb as soon as the from a bed or less active circulation. are scarcely ever spontaneous tion caused — or again we the nerve lesion appears only as a predisposing cause by reason of the dis- turbances in nutrition which it calls forth. on contact with the air.

by nerve irritation. in a case ot (Dejerine. (g) phalanx of the Aponeuroses.— CLINICAL EXAMINATION OF A NERVE Marked and persistent cooling 29 the of a limb mainly results from It is vascular lesions associated with the nerve lesion. sometimes ending in actual fibrous ankyloses of the digital articulations. iS. synovial sheaths are attached to the tendons by adhesions which immobilise them. curved like claws or deformed into the shape of a watch side. . then accompanied by chronic cyanosis. they determine the formation of fibrous claws. on the one hand. similar to Ankylosing and deforming arthrites. The The joint may undergo the same process of sclerosis. by oedema and the progressive fibrous infiltration which lesions. chronic rheumatised type. laminated. to a certain extent reminding one of Dupuytren's disease fibrous . bones and articulations. fascia gives the impression of The trophic disturbances of nerve irritation The thickened and contracted palmar cords. changing place with the growth of the nail and thus marking the date of the paralysis . in simple sections or nerve compressions there found only a simple transverse nerve irritations there are found split. . also reach the deeper planes. 8 July. 191 5. groove. last ends in a sort of tapering conical appearance of the fingers. associated with neuro-muscular contraction. smaller than those of the opposite and this diminution. with atrophy FlG. thinned at the edges. Frequently too they are atrophied. in serious trophic affections of the nails they are striated. the indurated plantar fascia sometimes those of alcoholic neuritis. synovial sheaths. indurated. associated with cutaneous and bony atrophy.) stretching of the two brachial plexuses. contracted. — thickened. — Hypertrichosis is is almost constant in all nerve The nails are specially affected.' presents nodules. on the other hand. Whilst. Presse Medical. characterise ischemic paralysis. (f) Skin appendages. glass. tendons. of the cellular tissue. and. without vascular phenomona..

this analytical description we note how much more intense in fre- quent irritations and nerve all trophic and vaso-motor This is an important point. dermis and osseous decalcification Note the decalcification of the metacarpals and deformations of the In nails.— OBJECTIVE EXAMINATION OF SENSIBILITY pains. give to the articu- lations of the fingers a knotty fusiform may recall the appearance of rheumatoid a rather appearance which in certain cases arthritis. atrophy of the Radiograph of hand (palm facing). intensifying clinical features. almost all nerve lesions. to We have referred possible the conical thinning of the it digital extremities: is to see. Decalcification. now well established. Osseous decalcification is common phenomenon.— 30 NERVE WOUNDS The phalanges themselves. all more so as it is frequently associated with nerve lesions. and of the phalanges of the thumb. ulnar or of atrophy of : hand or cases. especially in certain cases of paralysis of the the posterior tibial. but also vascular found in disturbances and even tendon after prolonged disuse of the limb through muscular or lesions. or resemble the " radish existing in bunch " of gonorrhoea! rheumatism. Fig. and on which we must insist. Lastly. : we the find ourselves confronted with considerable trophic disturbances . is pronounced in certain nerve irritations. thickened at their ends. when than in simple nerve sections are disturbances. we may meet with actual atrophy of the paralysed limb en masse. foot en masse in these with the muscular atrophy sclerous are associated the thinning of the skin. particularly however. Accordingly this must always be sought systematically. There is only one condition capable of producing trophic disturbances as marked as neuritic irritation the arterial obliteration causing ischemic paralysis. Here we are not dealing with spontaneous patient. the middle finger and especially the index finger. 19. or with noticed by the sensations caused by pressure on the muscles or nerve . and modifying their VI.

or piece of cotton-wool. in the neighbourhood true of the next nerve region. that supply us with this important know- ledge. however possible faint. feels intermediate zone. corresponding to terminal apparatuses all the more complex because they supply more all precise notions . quality of the pain the differentiation between hot and cold must be dis- tinguished from an are so exact appreciation of moderate temperatures. up by Head. three it is in an anaesthetic area there is to distinguish main zones. this minute examination is not usually necessary. In the third zone. an objective examina- tion of muscles or nerve trunks. nerve sections they disappear with a rapidity proportional to their complexity and become regenerated ratuses the more slowly as they correspond to appa- more highly differentiated. with these minute examinations. It is 31 a general questioning of the patient. These in many special sensibilities. it largely depends on deep sensibility. between protopathic and is epicritic sensibility the vague sensation of touch to be distinguished from the clear appreciation of the . for the identical. the patient perceives the prick of the pin as simple contact " touch. it affords practically adequate indications regarding deep sensibility. supersensibilities. In reality. we may generally dispense Exploration with a pin alone supplies all necessary information. . Cutaneous —Tactile. Practically. In the second zone. little areas of the three sensibilities are usually almost It may at the same time be stated that thermal anaesthesia is a more widely diffused than painful anaesthesia and the latter than tactile anaesthesia. . the pin supplies both tactile and painful sensations it by the slight pressure exercises." Probably this sensation is mainly provoked he replies . This is the distinction. Speaking generally. We ficial are now simply investigating the disturbances of objective. painful and thermal sensibility should be studied in succession. the patient feels nothing . nature of the contact and sensation of pain of its precise localisation the rudimentary must be . the pricking tactile . the patient little. 1. complete superficial and deep anaesthesia. By a prick. first In the zone. . by pressure of the point.CLINICAL EXAMINATION OF A NERVE trunks." . he answers: "pricks a painful hypo-aesthesia it is in and this zone that slight cutaneous stimuli. in this : zone there a is superficial anaesthesia with the retention of deep vaguely is sensibility. and deep sensibility. There paint brush. for in the we must distinguish the coarse sensation from the fine appreciation of the qualities set of the sensation. begin to be clearly distinguished. in the case of peripheral nerves. differentiated from the ability to distinguish the. hair. with simple superficial. When we reach the intact sensory region of the neighbouring nerve. But here again we are case of each sensibility liable to an error of interpretation.

we find hyperesthesia either to all with hypo-aesthesia to the other sensibilities. pricking provokes no sensation at all. 13th March (51st day after suture of the nerve). from Extent ot the zones of anaesthesia and hypo-aesthesia to pin-prick. : . persistPainful hyperesthesia is specially marked where the crosses are ence of the sensation. replaced by dots. betore and after nerve suture in a case of complete interruption of the median. simultaneous or successive. burning sensations. or to pain only. phenomena hyperesthesia to pain diffusion. In other cases. In horizontal hatched area.— 32 the pricking is NERVE WOUNDS keenly felt . 20. In the cross hatched area. the more so as there sometimes exists slight marginal hyperesthesia. pricking — : In obli(|ue hatched area with crosses panestheaic causes only a sensation of contact. ner-ve lesion. Fig. Examples of different disturbances of sensibility. modes of sensibility This is what . 20th January (139th day after the wound). irradiation.

the exact area of the anesthesia whether superficial or deep. the restoration we find at an early stage certain special phenomena. rather disagreeable. provoked by every cutaneous stimulation and particularly by light stroking. Bony or periosteal sensibility. characterised mainly by a sensation of formication in the diffused. This painful hypo-esthesia the most frequent form of paresthesia encountered in nerve irritation. (J. irradiated neighbourhood. imperfectly localised. The much more extended cutaneous region is than that of cutaneous anesthesia applied at . and we shall often find. after each examination. the region of anesthesia is found to vary from day encountered. suffices to rouse II. —There must be studied . see the concentric shrinking of the zones Only by observation and comparison of the successive areas of 3 . of deep anesthesia than that of cutaneous anesthesia and may to is often somewhat some extent permit of our anticipating a speedy restoration. persistent. Note if pressure is felt in the region of the nerve. for instance. which consists in finding out if the movements imparted to his various joints.CLINICAL EXAMINATION OF A NERVE may same in 33 be called painful hypo-esthesia . successively : Sensibility to pressure the simplest and most practical instrument the rounded end of a stylographic pen. diffused.) On the other hand. is Deep sensibilities. During the regeneration. that pressure fairly the level of an anesthetic well perceived. : pin-prick. to day in cases of simple nerve compression. patient perceives the or less distinctly perceived. for the permanence and fixity of the anesthetic region is one of the best signs of complete interruption. The study of deep sensibilities It is is less important than that of cutaneous error. likewise. Dejerine and Mouzon. Indeed. irradiated for a painful. III. It in must not be confused with paresthesia of nerve regeneration. is sensibilities. and A. and whose vibrations are more sense The of attitudes. I. In every case. These months. which is discovered by means of a tuning fork placed on the bony projection. produce the localised sensation. of cutaneous sensibilities. we of anesthesia. touch. badly differentiated and the neighbourhood and persisting is few seconds. however. cases of paresthesia last long and may persist for several 2. heat and cold arc then imperfectly distinguished all these stimuli. We have seen that the simple pressure of a pin point deep sensibility. subject to more causes of always its results are less constant and the role of collateral region of deep anesthesia is substitutions a greater one. must be drawn up. The earlier disappearance.

possible discovery of a neuroma. it where the nerve is compressed. but almost entirely in the cutaneous .34 sensibility shall NERVE WOUNDS we be able to account exactly for the evolution of sensory is . in to follow If or it remains fixed and limited this is one spot for several in their consecutive weeks regeneration have months. It its it appears only about the fourth or sixth week after the enables us to ascertain the existence of this regeneration and progress. VII. on pressure the lesion. whole course below lesion. for it indicates the presence of young axis-cylinders in process of regeneration. a rule. 2. — When compression we or percussion lightly applied to the injured nerve trunk. L Sensibility of the nerve on pressure. objective : examination nerve supplies three important indications Whether the nerve is painful on pressure or not. This formication in is quite distinct from the pain on pressure. The fixity of formication on a level with the lesion and the complete absence of formication below the lesion would almost warrant our affirming . region of the nerve the neighbouring muscles are not painful. in all cases of section or it — The nerve does not its feel pain on pressure simple compression. a creeping sensation usually compared by the patient to that caused by electricity. 3. painful along On the other hand. indeed.— OBJECTIVE EXAMINATION OF THE NERVE of the The 1. often find. which essentially is indicates irritation local. is Formication of regeneration. 2. or at in least magnified at this always co-exists with the pain the muscular bellies under pressure. is also provoked by pressure and having a totally different Formication provoked by pressure. in the cutaneous region of the nerve. The The existence of formication provoked by pressure. because the axis-cylinders encountered an insurmountable obstacle and are forced to group together on the spot in a more or less bulky neuroma. very often the muscles are more painful than the nerve. which exists nerve irritations. is very painful in neuritic or neuralgic irritation is is of a nerve trunk. Pain on pressure must be carefully differentiated from the sensation of formication significance. disturbances this practice the sine qua non of a complete examination. Formication in the nerve is a very important sign. As wound. on the other hand. The pain. Sometimes the nerve is painful even above the but this is a somewhat rare complication. almost always the very spot spot. of the axisperceived at cylinders and not their regeneration. all but little or not at perceived at the spot compressed.

at other times. the regenerated axis-cylinders can the obstacle and make their way into the peripheral overcome segment of the nerve Pressure we sec a progressive migration of the formication so provoked. with a This is and others which the main point of the view to the prognosis and treatment. is more or less complete regeneration. appearing about the fourth />. and from week to week it may be met with at a spot farther removed from the nerve lesion. both on a level with the lesion and an unfavourable prognostic point it shows that .. not be attached to the information supplied by palpation. cicatricial nodules or enlarged glands. is since it us to see whether the nerve interrupted or in course of re- generation. nerve regeneration taking place imperfectly. a because there are many causes of error . Formication. twelve It months or more.CLINICAL EXAMINATION OF A NERVE regeneration. however. persists during the entire regeneration. according as the axis-cylinders which it contains are or regenerating re- spectively. information whatsoever as to the physiological state of the nerve are there neuromata permeable to regenerated axis-cvlinders. 3. If. sometimes a real at the injured spot. Still. diagnosis. zone of formication so brought out changes its place on the nerve at the same time that the axis-cylinders are advancing. too much importance must First. it lasts a tolerably long time . the nerve simply By careful palpation we often succeed in recognising the existence of . . . discovery of a neuroma affords no . the may easily be neuroma. — Every is nerve lesion tends to cause the formation of a is This sometimes a simple fusiform thickening of the nerve. mainly because of general disturbances of nutrition. The presence of formication provoked by pressure below the nerve lesion this sensation. permit the passage of no fibre whatsoever. for eight. it extends progressively towards the periphery at the same time that it disappears at on the nerve below the wound produces warrants our affirming that there The the level of the lesion. The enables "formication sign" is thus of supreme importance. ten. Again. or whether regeneration fibres. ceases only when the regenerated axis-cylinders have almost regained their adult stage. this absence is is may be absent. these neuromatous formations besides. neuroma neuroma that is more or less bulky embedded in a cicatricial fibrous mass. below it . muscular taken for bundles. gradually drawing nearer the extremity of the limb. is rapid and satisfactory or reduced to a few insignificant Formication week. Search for a neuroma along the track of the nerve. the neuroma irritated so compressed is fre- quently the seat of pain or formication which are provoked. whether a nerve suture has succeeded or failed. 35 the complete interruption of the nerve and the impossibility of spontaneous on the other hand.

examination of the nerve logically terminates the clinical It completes this examination and enables us group together and interpret the various symptoms obtained by a study of the muscles and integuments. search for the neuroma. . examination of the patient.36 NERVE WOUNDS Consequently. As we to see. involving many causes of error. never indicates anything more than the seat of the lesion.

the nerve twig 2. it is the method illustrated by the . It should be applied to the motor point of the muscle which generally corresponds with the point of entrance into the muscle or 1. As a rule. 2. in which we apply the two electrodes to the nerve or muscle to be examined. By the bipolar method. little it used in faradic examination is In our opinion. every clinical surgeon. the bipolar method is but of the muscles. may simple and tolerably adequate fashion. with a in very attention. of a large indifferent electrode and the excitation of nerve and muscles by the small active electrode (negative by preference). involving the application. A setting out of the classic methods of electro-diagnosis. For greater clearness we 1. . . which supplies it. two parts. Still. : 1. method and practice. simpler for making a rapid examination of the muscular groups works of Duchenne of Boulogne. especially by The well-established facts of electro-diagnosis have been for several years largely augmented and illuminated by modern works.— CLASSIC METHODS OF ELECTRO-DIAGNOSIS two stages : Electrical examination essentially comprises Examination by the faradic current Examination by the galvanic current. A resume of the recent notions on electro-physiology which complete them and permit of our interpreting them. on the nape of the neck or on the lumbar region. To make it do this with precision often requires the aid of a little specialist. I. however. Examination by the faradic current may be done in two ways By the unipolar method. so as to include the motor point when separated by a few centimetres.CHAPTER III ELECTRICAL EXAMINATION The electrical examination is the indispensable adjunct to the clinical examination. the application to human pathology of the investigation and the methods will divide this study into of electro-physiology.

whilst not suppressing the trophic action of the centres on the peripheral segment of the nerve . the latter does not degenerate and partly retains its excita- the lesion bility : this is the phenomenon described by Erb in musculo-spiral paralysis by compression. even altogether incorrect. it should be done above and below the nerve lesion. lesion causes may happen no movement is that at the excitation of the nerve above the all. note in being taken of the jerks produced Indeed. preferred. it the corresponding muscles. nerve trunk. . the resistance of which carefully. In this case there are two sometimes pletely it a recent lesion where the peripheral part of the nerve. at any rate in all its fibres. being that the unipolar is more difficult by this method is almost always In any case. It is necessary to sheathe the coil more deeply to obtain equal muscular contraction. in certain cases of simple compression of a nerve trunk. It is which is measured according to the length of for the electric units coil sheathed. has not had time to degenerate . It would be better to substitute for notation of the length of sheathing. this is the faradic threshold. If possible. Simple hypo-excitability is judged by comparison with the same muscle on the healthy side. is sufficient to arrest the transmission of nerve excitation. excitation of the nerve above the lesion provokes contractions it. Faradic inexcitability always accompanies complete : peripheral There is only one exception to this rule the paradoxical phenomenon just mentioned in the slight and fleeting compressions of a paralysis. i. This will be more easily recognised by seeking on each side for the excitation capable of causing very small contractions this . as this is far more painful than examination of the muscles. notation in the quantity of electricitv induced. a successive examination of nerve and muscles should be made. from simple hypo- excitability to complete faradic inexcitability. is unnecessary to remark that method of measurement very uncertain. Examination of the nerve must be made coil.38 NERVE WOUNDS On the other hand. Faradic exploration of the muscles with the thick wire coil enables us to ascertain the entire series of disturbances. examination of the nerve the result method. whereas we note below the lesion a possibilities : relative retention of excitability. always employing a vibration of from one to three shocks per second. separated from the central portion. When in the muscles supplied by we may naturally state that it is not inter- rupted. coil are not at all proportional to the lengths of sheathing. a measure which is quite a relative one. is Use will mostly be made of a thick wire no more than one to two ohms. and which some makers now produced by the inscribe 2. com- or else. on their coils.

law is only true we use a wire coil of feeble resistance. whereas nerve is inexcitable above in a few days or weeks we find the . in the which the nerve and muscles are excitable below the lesion. inexcitability. hysterical or simulated or else of central origin. and always reflexes. etc.ELECTRICAL EXAMINATION Apart from this 39 nerve interrupinexcitability.* we use a sufficiently strong current. one is sure is find with all the galvanic current a reaction of degeneration that partial. Faradic inexcitability appears at an early stage. the slight nerve compressions. first Faradic contractility reappears only very late. cord. signs it is one of the first of the RD and persists for the entire duration of the paralysis. we must also remember. as Duchenne of Boulogne this has demonstrated. are but two On come the the one hand. .i rather rare one. voluntary movements reappearing. from cerebral lesion or injury of the tracts Babinski's sign. after the return of the voluntary movements. very recent paralysis in which the RD has not yet then we find faradic excitability rapidly disappearing. all paralysis characterised is Apart from these two is by maintenance It of a nearly normal faradic contractility not . faradic examination enables us readily to paralysis in dis- tinguish organic peripheral paralysis from functional faradic contractility is which always maintained. foi the thick wire coil. cases. which determined with the ordinary instruments and the thick wire is Indeed. presenting the paradox of Erb. disturbances of the is important to note that we are here speaking only of relative faradic coil. then. On other hand. to this rule. typical or at events On the other hand. we often observe the contrac- tion of the neighbouring and antagonistic muscles. This is what to is called antagonistic contraction. particular case. It has no other significance than demonstrate by comparison the marked hypo-excitability or the complete inexcitability of the muscle involved. we mean this relative excitability. if But. inexcitability with the thick faradic inexcitability muscle ap- we can always get contraction of the paralysed muscles either by utilising far more powerful coils or by greatly increasing the intensity of the original current or even by causing the a muscles examined to undergo electrotonic mollifications by the simultaneous passage of current. is . peripheral paralysis. coil. * It is in the spinal accompanied by manifest objective symptoms. There about . Examination of nerve and important for the clinical inexcitability is muscles by the almost faradic current is very surgeon. produced by diffusion of the current. we speak of faradic inexcitability. inasmuch as when complete to faradic established. we Bball see that this fact only true if we modify the usual conditions of examination. already mentioned. exceptions. Even of the if there exists is complete faradic parent only . functional paralysis. all tion or prolonged compression accompanied by faradic This If is one of the essential features of the reaction of degeneration. galvanic- Whenever.

if a coil of greater electro-motive force the resistance is used. a rather strong excitation produces slight muscular contractions. 1200 ohms or more. of which may reach 800. like those produced by the galvanic current on the degenerated muscle. . we find important modifications. investigation of might with propriety supply the place of investigation of galvanic reactions of regeneration. also take place Examination by the galvanic current. gives inconstant it results and inaccurate information. Delherm. 2. by associating with faradization the passage of a galvanic current into the This latent faradic excitability seems to constitute an intermediate degree between hypo-excitability and utter inexcitability. cannot be measured and so is greatly inferior to galvanic examination. To this method alone apply the In all this description. — method one is far preferable : one might almost say that it is practically the only possible. We P. we shall see how these apparently paradoxical results may be In any case. faradic excitability with a fine wire Later on interpreted. Indeed. It this process of examination is not to be recommended. On fine the other hand. a wire for instance. coil Consequently. This sensibility seems to be the first to reappear during nerve regeneration. currents of relatively great and consequently muscles depend painful the contractions obtained in the degenerated not only on the intensity of the current.40 NERVE WOUNDS Faradic examination also gives us other information of less import- ance : the faradic sensibility of skin and muscles. This examination may by the unipolar or the bipolar method but here the unipolar . etc. have considered only the usual faradic examination. then. may also see the return of faradic excitability as one of the first signs of nerve regeneration. with the thick wire coil. Benisty. teristics it depends on the characwhich is extremely variable on the phenomena of self-induction. when the RD is still complete. but also on the duration of the exciting wave. of the coil. sometimes very short. on the producof rupture sparks. On it is the other hand. Meige and Mme. we may ascertain the persistence of a slight faradic contractility in spite of a very pronounced partial RD or even a complete RD . Babinski. in certain cases. and one might follow the whole progression of faradic excitability up to the normal. which increase the duration of the passage of the . This method. intensity requires . oftener slow. we classic ideas as to faradic excitability of the muscles. coil. tion current. and Jarkovski have shown that possible to cause faradic contraction to reappear in paralysed muscles limb. as shown by Marie.

• w =- ft. TJ a. :- . o / ~ ~ rs I- — O oOPm Pl. r- a..• [_ .

.

.

it varies considerably according to the point of excitation of the muscle from one. ten. It find in the paralysed muscle an apparent simple can be measured by the number of milli-amperes necessary to obtain contraction. must be remembered that muscular contraction takes place only at the moment of the closing and of the opening of the current. Normally induces the is the negative pole which. 2. i. this is expressed in the following formula : KCC > ACC. Almost always we hypo-excitability. five. and this written ACC > KCC. with the . galvanic current The intensity of the current necessary to produce at the closing the . two. galvanic inexcitability a very rare where the degenerated muscle has finally lost all contractile structure and has become transformed into a mere bundle of connective tissue. On of the the other hand. The pole capable of inducing. eight milli-amperes one moves from this point. rising from one or to five. is we have an inversion of the polar formula. is seen only It The in certain pathological states. same current. is generally the only one sought for. is In the paralysed muscle. contraction on opening the current. The closing The contraction. disappearance absolute rule in will be possible to ascertain the diminution or of galvanic excitability. or twenty-five milli-amperes. of muscular degeneration. Three elements of muscular contraction under the require special study. the pole susceptible of inducing minimum positive contraction with the weakest current. . minute search must be made for the motor points of each muscle. strongest contraction . three milli-amperes by excitation as soon as motor point the figure easily rises to four. on the closing of the current. the strongest the contraction or rather. long . this electrode or negative in turn by made positive means of a current reverser (Courtade's key). In an injured nerve.— — NERVE WOUNDS 44 The examination is made with a large dorsal indifferent electrode and is a small electrode applied to the motor points. the stronger one. . minimum contraction this it is the threshold of excitation. all Galvanic inexcitability is the cases of interruption of the nerve. two (the normal figure) The normal theshold of galvanic contraction varies according to the muscle and the patient it must accordingly be sought by comparison with the healthy side. nerve and the muscles supplied by it will be examined in turn. If contraction is stronger at the positive pole. requiring greater intensity. . This is the last stage. We must therefore compare the negative threshold and the it threshold. Consequently. on the other hand. • phenomenon it is found only in cases delayed.

even when there is complete RD. Frequently it when compelled initial to use a current of considerable intensity. to We have its must add seat at the to these characteristics what . is somewhat erroneously no longer called the displacement of the motor point this latter appears upper part of the muscle but to be approaching its lower insertion. 3. it is slow contraction that seems to be hypo-excitability of greatest importance. a sudden flash. and polar inversion at the motor is point. peripheral paralysis with degeneration. particularly the supinator longus. due to inexcitability of the nerve twig involved at the motor point the muscle itself is really hyper-excitable. is Normal contraction In rapid and short. being found at times even in the neighbourhood of its termination on the tendon. . Then is there is observed an short contraction of the antagonists. slow contraction. followed by it slow contraction of the muscles involved. phenomenon of inversion or of polar equality. In reality. — In Reaction of complete degeneresults. distinguish this slow Sometimes difficult to contraction from simple return of the stimulated antagonistic muscles to the normal state. tibialis Certain muscles. ration. Syndrome of nerve interruption. Of these three latter elements. the the peroneals.— ELECTRICAL EXAMINATION If the contractions arc equal. is longitudinal excitation almost always occurs along the negative pole. sometimes exhibit normally the amicus. is As we shall see. This in characterised by the fact that the muscle muscular body and especially Doumer-Huet's longitudinal reaction. there is 45 said to be polar equality. the muscle deprived of its nerve responds the better to electrical excitation from the fact that this latter affects a greater part of the muscular body. The form of contraction. contraction becomes slow and delayed. The typical and classic RD is made up of the following characteristics Faradic and galvanic inexcitability of the nerve Faradic inexcitability of the muscle Galvanic hypo-excitability at the motor point with polar inversion and : . slow contraction seems sufficient to characterise the RD. is diffused over the neighbouring or antagonistic muscles. The slowness of contraction to longitudinal excitation often more . cases of peripheral paralysis both the faradic and the galvanic examination almost invariably give concordant the sum total of which constitutes the reaction of degeneration. this apparent galvanic hypo-excitability . ELECTRICAL SYNDROMES 1. especially at the beginning of the RD. is more excitable at the level of the This the neighbourhood of the tendon. Without great and without polar inversion.

2. does not . is really more excitable than normal condition. — The RD usually incomplete or only faintly indicated . that polar inversion becomes polar equality and then slow contraction gradually accelerates we returns to its normal form ascertain the reappearance of faradic sensibility and faradic contraction . voluntary As the different muscles of the same nerve region resume their functions nerve also slowly resumes according as they are affected by the progression of the regenerated axiscylinders. then faradic contractility with the thick wire coil reappears. dissociations in the reaction of degeneration. the muscle loses and then with the thin wire coil. The longitudinal excitability of the paralysed muscle greater than that of the healthy muscle. facts that its demonstrate the is paralysed muscle hypo-excitability but it apparent. around still the motor point. slow opposite way. at the inversion. resulting from the inexcitability of the motor twig supplying but the muscle in the is itself. easy to provoke only in cases of complete RD. act in exactly the On examining the muscles. is Reaction of partial degeneration. movements appear before the excitability of the nerve. In a paralysed muscle reactions in we may also note the return of the normal some muscular fibres at the upper part of the muscle. The It reaction of complete degeneration is generally related to complete interruption of the nerve. but within a fortnight or three all weeks phases it gradually becomes more pronounced. begins is to give a quick contraction. though generally tardily and preceded by the return of voluntary contractility. As a rule the its normal excitability. 46 marked than excitation at the motor point. in contradistinction to it is the closing contraction. polar contraction and longitudinal reaction become obvious. whereas the lower fibres present the RD and still respond to longitudinal reaction by slow contraction. The we note the first signs of improvement in those muscles supplied There result therefrom by the nerve nearest the origin of the limb. It often persists even when motor point of the muscle. hyper-excitability of the This is one of the . come about all at once. we find that galvanic hypoexcitability diminishes. the its by degrees the nerve faradic excitability with the thick wire . passing through loses all excitability coil . with the thin wire coil. deprived of its nerve. after complete interruption. with hyper-excitability of the paralysed muscle. . Syndromes of compression or irritation. same time that galvanic hyper-excitability. also : often very It is This galvanic hyper-excitability of the muscle marked during the first few weeks of paralysis.— NERVE WOUNDS to excitation at the . Nerve regenerations. in process of recovery. by longitudinal excitation that we most easily find the opening contraction always stronger at the positive pole.

at events with currents of twenty-five to thirty in milli-amperes. be known that this muscle. but excite the muscular body itself or seek longitudinal reaction. In other cases. cases that in these we can at times observe the slowness of the contraction under lacking only one factor to the complete else. it is then characterised by marked hvpo-excitability of the nerves and muscles to the faradic and galvanic currents. we we was retained. Syndromes of fibrous transformation. of muscular hypo-excitability or of muscular inexcitain The syndrome bility is found with quite special frequency often superposed on nerve irritation. is appears met with in certain cases of long-standing nerve interruption more quickly in muscles left untreated by either massage Consequently it .— ELECTRICAL EXAMINATION if 47 in there is no nerve interruption. electro- indicates very profound lesions of the This reaction of muscular hypo-excitability or inexcitability always muscle . it shows that the muscle has lost its contractile structure. Electrical inexcitabimty have seen that galvanic excitif of the muscle. Sometimes it consists of a simple widespread hypo-excitability of nerves and muscles to the faradic it At other times consists of a faradic and galvanic currents. in simple compressions or cases of moderate nerve Very different types of partial RD may be found. ability — In the complete RD. It should. sometimes an enormous degree. It is the RD. the only ones that can practically be utilised diagnosis. In other cases. in contradistinction to the syndrome of the paralytic partial RD. it or electricity. even after fibrous transformation. has a relatively serious prognosis. is the polar inversion that . fails. and that it has undergone more or less a This reaction process of infiltration or one of fibrous transformation. or whilst slow to the positive. This excitability of the muscle all may be seen to diminish or even disappear completely. howmay slowly regain reach it its normal characteristics if the regenerated axis-cylinders soon enough. the galvanic hypo-excitability of the muscles. It is found in these cases that. along with inexcitability of the nerve trunks. irritation. or rather it disappears when we cross the threshold of excitation excitability fails. emphasising. the faradic current. apparently diminished in reality increased if we seek excitation at the motor point. or again we find that longitudinal hyper- 3. ever. and galvanic hypo-excitability of It is the muscles. is quick to the negative. there is RD it : the contraction is not very slow. it exists without the RD. corresponding to the slightest forms of the again it RD . the hypo-excitability of the muscle . which to so often causes fibrous contraction and infiltration of the muscles.

a certain prolongation of the contraction. from lack of attention or else from nerve but at the same time it indicates the persistence of healthy. hematomyelia. Myotonic Reaction — Lastly. tetanising current. motor cells of the spinal cord (poliomyelitis. the RD in particular essentially characterise peripheral paralysis. with interruptions somewhat simply shows. It has shown. limited to a few muscular fibres . is not the true myotonic reaction. or irritation . less rapid than in the normal which This. Sometimes we find in weakened muscles. usually accompanied with contraction. As Huet prognosis. one may even ascertain the apparently paradoxical association of the following symptoms : nerves and muscles are almost incapable of being excited by the usual faradic and galvanic currents . this reaction after all has a relatively favourable a shows that the muscle has undergone more or less pro- found fibrous transformation. without polar inversion. etc. in recent cases of paralysis one traction persisting during the the exaggerated manifestation of galvano-tonus.) . we are surprised to find that these contractions are quick. It essentially characterises Thomsen's at and certain . Reaction of Exhaustion. — The traction muscle makes unequal responses if to successive faradic excitations. or galvanic hyper-excitability of the muscle. and oftener during muscular regeneration. or rather. lasting contraction. In certain cases. we find a con- fail from time if it is time . may times observe a faint con- This is RD. but violent faradic shocks. an indication of the reaction of exhaustion described by Jolly in myasthenia. disturbances of electrical reactions and i. which exists in recent The From ***** passage of the galvanic current. It does not exist so clearly in cases of nerve lesion all the same. after all. 5. seem to be slightly hyper-excitable under the faradic current tetanisation seems to take place state.— NERVE WOUNDS the faradic 48 to and to the galvanic currents at the motor point is not accompanied by the usual longitudinal hyper-excitability. In other cases. however. in some cases of slight neuritis. the muscle is excited by a rapid rhythm or a found to become rapidly inexcitable. lesion those which result of the .e. motor functions. we utilise a somewhat to rapid faradic rhythm. or galvanic currents at the motor point up to twenty-five or thirty milli-amperes produce The rather feeble contractions of small areas. the muscles . persisting after the cessation of galvanic excitation. there are "misses" comparable to those of cardiac arhythmia in myocardial lesions. the arrival of some regenerated axis-cylinders and enables us to predict the slow restoration of 4. which is mainly characterised disease by a tonic. myopathies.

electrical disturbances as is profound as those of the peripheral nerve lesions. — which is always the negative pole. points stand out prominently The The The active pole . the contraction obtained by the positive pole paralysed muscles and characteristic of polar inversion of the attributed to the action of this pole. and penetrates the muscle. 1912. Paris. we see rather the syndrome of fibrous transinexcitability of the nerve formation of the muscles than the true RD . its nerve . we may frequently note im- portant electrical disturbances. Consequently. which A nerve. at the closing of the current 2. At most is from muscular disuse. Marie and Foix. com- pressions. resulting hysterical paralyses and paralyses of cerebral tract origin or from lesion of the pyramidal there slight hypo-excitability (upper motor neurone) are never accompanied by important disturbances of the electrical reactions. as remarked by P. in sections of the cord. affection is Only one and rapid from accompanied by Still. the one for the muscle. the other tor the nerve. 49 of the anterior roots (inflammation of the roots. an may be given. Functional. 3. passes across the partition two separate rooms.— SOME POINTS IN ELECTROPHYSIOLOQY now enable : Modern investigations in electrophysiology us to complete and interpret the information supplied by the classical electro-diagnosis. this ischemic paralysis arterial obliteration. but they manifestly result from the reaction of the grave medullary lesion on the motor cells of the anterior horns below the lesion. falsely from the action of a virtual. At the same time. divided into two compartments by a partition there are by the nerve. is Polar Action. Journal Je Physiologic ct Je Pathologic generate. It results the RD. wide indifferent electrode supports the muscle. galvanic hyper-excitability of the muscle deprived of velocity of excitability or chronaxie. a small active one surrounds the * H.* interesting experiment made by Cardot and A Thus frog's gastrocnemius and the nerve supplying it are placed in a small box traversed made of paraffin wax. and is more marked than the controlling II. 4 . — It now seems proved that the negative pole alone in is capable of producing a closing contraction with the galvanic current. inexcitability of the muscles comes on earlier it. negative pole. .) traumatic lesion of the plexuses or peripheral nerves from the polyneurites. 1.ELECTRICAL EXAMINATION From From lesion . Three important 1. appearing deep within the tissues and in the muscle 1. Laugier. itself. Cardot and A. Laugier As a demonstration. etc.

requires an intensity eight to ten times greater than the closing contraction at the negative pole. with the negative pole if. April 30. Thus. An is experiment of Bourguignon * clearly shows that but apparent. if the nerve compartment and the nerve itself are brought into different temperatures. close to if we apply a small bellies active electrode to a superficial nerve.5o NERVE WOUNDS Each of these electrodes may be made positive or negative at will . the muscle contracts. shown that. the variations of chronaxle can be studied and the problem solved.. of the neighbouring muscles Revue neuro/ogique. affected a distance the muscles next to this nerve. has not taken place in the nerve placed in contact with the electrode . showing the existence of a polar this contradiction inversion and of a closing contraction at the positive pole. if the temperature of the compartment containing the muscle is made lo vary whilst maintaining the nerve at a constant temperature. Thus it is closing of the current for nerve and excitation alone is demonstrated that the negative pole alone is active at the muscle alike. a distance. on the other hand. The hand. the velocity of excitability remains invariable. however. Lapicque shown that the velocity of excitability or ckronaxie of a neuro- muscular system varies with the temperature. 19 14. Positive excitation. at the opening of the current. nerve or muscle. We have to and in whatsoever direction. discover which is the active pole. whatever the variations of temperature. has Now. Thus. the positive But the opening contraction at the positive pole It usually not utilisable in electro-diagnosis. by varying the temperature of one of the two compartments. of the muscle by the negative pole is we find that only excitation affected by the variations of temperature. . Indeed. It has also been is pole alone is efficacious. This principle that the negative pole alone in is active at the closing of the current thus seems formal contradiction to the results of the electro-diagnosis in the paralysed muscles. the other On we notice a contraction in the neighbouring muscles. Excitation of the nerve by the negative pole will produce at the closing of the current a contraction in all the muscles it supplies in the forearm. since the negative influenced by variations of temperature. we apply to the nerve the positive electrode. we obtain by a rather powerful negative or positive excitation very different results.g. e. then. Conversely. in the groove of the biceps or the median at the inner surface of the arm). it has. we shall obtain corresponding differences of velocity . its muscular independent of motor supply (as. and upon what it acts. pole. however. The motor * response. 2. is the musculo-spiral nerve. whenever the current is established. It is is therefore proved that the positive pole in contact with the nerve inactive. biceps and triceps. Bourguignon. closing excitation at the causes no movement in same point by the positive the muscles supplied by the nerve.

find in a healthy Thus we understand why we may equalities muscle with false polar and false polar inversions. must be sensibly increased diffusion. is Its action. however.e. Again. at the level of the muscular belly. The excitation has acted directly. If the muscle is an equally excited outside of the motor point. it requires a far greater intensity to produce the same results. find the positive threshold. on the motor twig of the muscle. along the course of the lines of force. through which it causes to appear deep in the tissues. This excitation. This is because excitation no longer acts directly on the motor twig but diffused with less intensity in the muscle itself. even far we shall see that the muscle responds almost In this as well is and often better to the positive pole. is more diffused. intensity five. positive pole. its case it excited by the virtual negative pole in depth. muscle a virtual negative pole. the following conclusions may be drawn : The precise negative pole. the threshold is at one to two milli-amperes. in upon the mass of the muscles and not energetic fashion on the motor nerve twig innervating them. with a very small current . negative pole. is is we at needed to obtain the threshold of contraction. indefinite and imperfectly limited . at the closing of the current. In these conditions it "has produced the maximum point. These facts enable us to explain the electrical reactions of a normal the virtual negative pole The muscle and of a paralysed muscle. naturally has not the density of the superficial pole represented by the small active electrode. with great (a) If we excite a healthy muscle at the intensity. therefore. capable of producing. exercises a direct. once see that greater For instance. diffused . of useful effect. for instance. applied to their surface. eight milli-amperes are needed to obtain the contraction. the positive pole to cause to appear in the its altogether to ineffective.— ELECTRICAL EXAMINATION is 51 real due to the existence of a virtual negative pole. This virtual pole. causes to appear deep in the tissues a virtual positive pole. inactive and devoid of importance. it is and limited action on the nerves and muscles with which Moreover. having less density. it in contact. it falls a precise- From these facts. six. or when the excitation does not bear is exactly on the accessible motor when the real motor point difficulty on the surface. The intensity of the current i. which the in positive pole. we rind that it under the direct action of the contracts at the closing of the current. . causes to appear the neighbouring muscles. point. appearing deep in the tissues. is At the same with the same current. or by longitudinal excitation. on the surface. acts indirectly at the closing. motor point. in spite of strong excitation. consequently.

The paralysed muscle has lost nerve excitability. causes to appear muscular body a virtual negative pole. The muscle however. difficult to This just as electrical excitability of the paralysed muscle is frequently intensified. however. is — Apparently paralysed muscle is less excitable under the galvanic is current than the healthy muscle. 2. whilst. are two ways of accounting recently paralysed muscle.e. motor point the threshold in the neighbourhood of the the muscle usually responds to the positive pole. The its contrary. more readily by the negative pole. consequently. only under the throughout the muscular excitation of the nerve. we even see shortly that this excitability usually increased. the muscle makes a similar response at the when excited motor point or at a distance from this point . we have found after its mechanical excitability intensified. as shown by the the idio-muscular reflexes. In these conditions. which is more . the negative electrode is applied to the upper motor point. distributed belly. If the negative electrode in the motor point. by excitation of the muscular belly itself and especially by its longitudinal excitation we obtain contraction even a stronger than at the motor point : this is the phenomenon inaccurately designated as the descent of more correctly the longitudinal reaction. has retained its excitability. influence of a current. the muscle has retained is its . it impossible to to excite at the motor point the nerve twig which normally responded itself. i. a very feeble current. in order to produce the it same contraction as the will have to possess greater intensity. near the muscular fibres are excited it only partially and feebly in the . There First. or is applied to the muscle in its lower part or neighbourhood of the tendon. diffused It contracts. we obtain polar inversion. provoke than that of the nerve. Hyper-excitability of the paralysed muscles. will be less great. on the other hand. however.— 52 {l>) NERVE WOUNDS In a paralysed muscle there it is is no longer any real motor point excitability .the case. the Galvano-tonus. the action of which on the muscular fibres is direct and far more effective than surface excitation . the current directly excites the muscular fibres throughout their whole length . Only prolonged some time. longitudinal reaction is the thus almost always produced If. itself On shall the other hand. the part of the muscle. the nerve twig supplying inexcitable. do electrical and mechanical excitability diminish for this hyper-excitability of the and finally disappear. by investigating . disuse and the gradual disappearance of the contractile structure. . if we use the positive electrode. on account of the diffusion consequently it requires greater intensity. with the of the muscle its progress of muscular atrophy. the density of which current.

completely paralysed and thus demonstrate very slight nerve somewhat rapidly as soon as nerve regeneration manifests itself. sometimes called galvano-tonus. however. most important. it diminishes inIt with the progress of the atrophy.. is a measure of the velocity of excitabilitv. Dubois. A therapeutic effect results from this conception of the longitudinal hyper-excitability of the paralysed muscle. capable of determining the threshold of excitation indefinitely. minimum is duration the it must last same current remains if this duration increased. For practical reasons. shown by longitudinal excitation. muscle or nerve supplying threshold of excitation. etc. there no longer any contraction by the liminal current contraction can be obtained only by increasing the intensity of the current. Velocity of excitability may be measured by the minimum duration of the passage of the galvanic current necessary to produce the threshold of contraction with the passage). as are also its practical consequences. This minimum duration of the liminal current. Chronaxie. of effect with the minimum of current. is. Weiss. some time . there must be excitation of the of intensity . minimum may it intensity (for an indefinite duration of In order that a muscle contract. be effective. Lapicque. they are the with feeble currents fuller. most recent researches have utilised another . It I. more complete and easier to obtain method of longitudinal excitation produces the maximum 3. longitudinal we can more easily recognise this hyper-excitability by the far excitation. minimum below this current. It is logical to provoke by longitudinal excitation the contractions used . in galvanic treatment . Secondly. — The conception of velocity of excitability. and this threshold of longitudinal excitation less raised always than on the healthy muscle. Velocity of excitability. however. opening remains the same. This hyper-excitability of the paralysed muscle. The muscle almost always responds is to negative pole. has only of recent years found a practical applica- tion in electro-diagnosis. the muscular contraction obtained to pass. however long the current takes If we is diminish the minimum duration of the passage of the current. . disappears It is may even appear in muscles lesions.— ELECTRICAL EXAMINATION Polar inversion takes place and 53 is we find that the positive threshold often less raised on the paralysed muscle than on the healthy one. introduced into electrophysiology by Engelmann. is particularly clear in cases of recent paralysis It . with a minimum may this is the That ineffectual at the this . In some cases there is also seen to appear the opening contraction which is difficult to obtain on the healthy muscle with bearable currents.

is also an extremely sensible method . etc. frog's We may see this when we reflect that chronaxie of the gastrocnemius muscle. on the other hand. identical conditions it between duration and intensity of the liminal current is For the same muscle of the same species in is invariable. slight compression. The seen to be great . are duration of passage for the liminal current. The minimum chronaxie. of chronaxie has long enough eluded the to be studied are researches of observers. Three excitability been advanced for reckoning the velocity of First. thus is it is excitable only by a relatively prodifference is longed current nevertheless the results. the fact ) In spite of its importance. shown . we shall see that we may reckon at about or even below one- thousandth of a second chronaxie of the normal muscle . its chronaxie is rapid the paralysed muscle. given by the different methods of research. In man. the physiologists determine : the threshold of excitation for a current of indefinite duration this is the rheobase or rheobasic threshold of Lapicque. mainly resulting from the resistance of the variability from the extreme processes have : of muscular excitability applied through the integuments. fifty. are immediately revealed by variations of the velocity of excitability. the slightest and most fleeting of the nerve twigs are . for the durations of passage extremely short. is about three ten-thousandths of a second. easily reaches forty. the works of Lapicque and variations of chronaxie his pupils have demonstrated the considerable according to the temperature and the different physiological and pathological injuries states of nerves and muscles. for instance. Consequently It it supplies a mathematical and measurable basis for reckoning the excitability of a nerve or muscle. are of considerable value. the action of cocaine. however. and the two different measures of the velocity of excitability latter. condensers . that two indirect processes. former is about ten times greater than the relation The particularly important. even approximate. the structure of the nerve. excitability at the second. that of Cluzet by discharges of of Bourguignon and Laugier by comparison of faradic opening and closing of the induced current . minimum duration of passage for a double intensity of the To this rheobase Lapicque gave the name of chronaxie. chloroform. The skin and application of these facts to electro-diagnosis has hitherto en- ***** : its chronaxie slow. by considerable modifications of its chronaxie the traction of a nerve trunk. First. corresponding to fleeting modifications of ( Lapicque and Legendre. ether. at a temperature of 15 . . : sixty thousandths of a second . a . countered many difficulties. Then we seek the velocity of excitability for a current twice as intense as the rheobase.54 measure of velocity of NERVE WOUNDS excitability.

when the primary current (inductor) in is closed. 26 November. or rather at double the rheobasic voltage. but this is of no great importance. 55 recommended by Lapicque. have not the same characteristics. of which we have simply set forth the barest schematic data. naturally. the value of and enable it which. It is well known that — — in is an induction induced coil. they are unequal in duration and intensity a different physiological action. These two induced waves. On the other hand. Then. the simplification of the methods utilised in electrophysiology for measuring the duration of a very short galvanic current. The the closing wave. discharge themselves according to a to — duration proportional to their capacity. The them is results obtained. in the case of a current of constant intensity. in the secondary a current the opposite direction on the opening of the primary current there the arises in the secondary a current of same direction as the inductor current. and intensity greater. consequently the velocity Practically. Journal dt Radiologic ft a"E/cctro/ogie t March 1914. however.* Condensers of different same voltage. there . all We shall find these same difficulties in the methods proposed. this of excitability. this gives them In the induced waves of closing and opening. if the condensers are charged at the same voltage. According duration. It will their capacity they may supply currents of variable be sufficient first to produce the voltage corresponding to the for threshhold of contraction an indefinite current (rheobasic voltage). Their direction is inverse. nevertheless great. constitute only approximations . this The measure of capacity of condenser gives the duration of the discharge. less . involves a certain number of arising mainly from cutaneous resistance which varies according to the intensity of the current and even. 191 I . Lyon Medical. method. Relation between (/. This difference results from the way which the current is is set set the closing current of the primary started in the induction coil * Cluzet. up up . (a) capacity.) The Process of Bourguignon and Laugier. . relative though be. the quantity of induced electricity is is equal. we have only to find out the feeblest of the con- densers capable of producing contraction. the Induced Waves of Opening and Closing. never- theless they are sufficiently precise to reveal the slightest lesions to be expressed in figures. therefore. conits sequently is its intensity wave of opening in short. . of closing and opening. according difficulties to the duration of this current. but of the Discharges of Condensers (Cluzet).ELECTRICAL EXAMINATION direct process. is is long.

Thus. for the healthy muscle. with rapid chronaxie. with the same coil. On the other hand. explains is efficacious. because owing slow chronaxie the paralysed muscle . short. coils (usually of This explains and even 3000 the contractions sometimes obtained in paralysed muscles by thin wire 800 ohms). by the sheathing of the coil. A paralysed muscle. enormously increased by using an induction coil of adequate electro-motive force and considerable sheathing. With a coil of 1600. the opening wave is long.56 NERVE WOUNDS The primary closing current and the slowly. let us produce the threshold of excitation with the long The its healthy muscle will again contract . explained by the smaller efficacy of the closing wave . only the opening wave. with slow chronaxie. we have two waves of unequal though constant duration. a short wave and a long one. with slow chronaxie. both in the if primary and in the induced. self-induction the is wave resulting therefrom. consequently between the intensity of the opening and closing thresholds. because of self-induction. is unless its voltage with slow chronaxie. usually almost double. when the rheobasic threshold has been reached given the less intensity of the closing wave by reason of longer duration. there will be needed a greater sheathing of coil than for the opening wave. resulting induced current are consequently prolonged and slowed down. care to has been taken to extinguish the rupture spark which tends slightly In the induction coils usually employed in faradic excitation.. we can almost always obtain contraction of a paralysed muscle. Let us first produce the threshold of excitation with the short opening wave. there is a considerable divergence. at the opening of the primary. between the sheathing. The paralysed muscle. 1800. in the case of the paralysed muscle the difference to its is consider- ably diminished. consequently it is capable both of exciting normal muscles with rapid chronaxie and degenerated muscles with slow chronaxie. The shortness of this wave why It it is is capable of exciting only the normal muscle. much superior with considerably greater sheathing. the intensity necessary for contraction. will contract if it with the short wave only to the rheobasic threshold attains a far greater intensity. with an intensity . no resistance of takes place. that of the healthy muscle and a scarcely greater In a word.e. with rapid chronaxie. short and intense. but is the intensity very great and the excitation painful. and note. On the other hand. when the threshold of excitation has been reached i. an adequately powerful one. ineffective in the paralysed muscle. ohms. contracts with the it wave as soon as reaches the rheobasic threshold with extremely small sheathing. will also be contracted by the long wave. almost instantaneous even. short A healthy muscle. somewhat higher than sheathing. lengthen the opening wave. Afterwards closing wave.

Paralysed side. almost constant for one and the same bility of the excita- of healthy muscles. Below we an example. . the opening contraction is violent and practically unbearable. The lowering of the index gives the diminution of the constant of offer excitability of the muscle. . (<:) Lapicque's Chronaximetre. . supplies only relative figures . Quantities.i This suitable * is a "rotatory mechanical rheotome. . 1915. . . Comptes rendus. a real indication. 10*75 cm « or 9^ micro- 6 cm. of reckoning the velocity of excitability It enables us to follow mathematically the entire evolution of a paralysed muscle. . Heathy side . 27-5 Paralysed side — . . this indirect method may give tolerably accurate results. extensor carpi ulnaris. . CLOSING (LONG WAVE). clxi. Then. or 4-4. or coulombs. Lapicque. cro-coulombs. things may. . fact that at the intensities at which the closing contraction manifests It is it itself. . the constant varies according to employed the constants of each coil must be determined and an examination made always with the same instrument. 14*375 cm. taken from Laugier. p. however. Examination of the Case of musculo-spiral paralysis from compression. coils. index of excitability determined by the relation between the opening and amounts . . or 27*5 mi- 7 75 cm. . is respectively : Healthy side 288 micro-coulombs . a comparatively intensity. or 288 micro-coulombs. too. Academe des Sciences. carefully either by coninter- sequently necessary to eliminate working the ruptor by hand or by utilising Bourguignon's special interrupter enabling one to eliminate at will the opening contraction.. 643. r . As we see. Distance of coils. we are able to establish coil. Two First. or 10*5 normal figure tor the coil employed.— ELECTRICAL EXAMINATION requires. measured by the ballistic galvanometer). t. it is rather complicated the main difficulty arises from the the coil . seance du 22 Novembre. — Lapicque recently issued the model of a simplified chronaximetre* for clinical use. to which movement is communicated by heavy weight falling from a moderate height and carrying a light shaft by L. Distance of - Quantities. along 57 far greater with the short opening wave. be brought against it it. The closing TT . OPENING (SHORT WAVE). the value of the currents employed. 431 micro-coulombs. If we reduce to quantities (micro-coulombs.

I have obtained at the end of the first turn. Whereas a healthy muscle contracts at one to two thousandths of a second. prolonged several hours are often necessary for the methodical examination of the muscles of a single patient. an angle of specially made interrupters. measurements are entire pathological evolution. This is the well-known the rheobase of the physiologists. and often far below one thousandth. definite Then we measured must. This duration supplies directly the velocity of excitability. starting with the rheobase Perhaps the results are somewhat longer and easier to reckon. degree of excitability and to follow by successive researches. We must remember that physiologists prefer to take as their starting point a double intensity of the rheobase. after are but the objective expression of the same phenomenon. tion of the antagonistic muscles We may eliminate this contraclimit which have remained normal and excitation to the paralysed muscles alone by utilising a progressive current. worked in securely (as experience has a thousandth of a succession by the passage of the pointer. 4. easily thousandths of a second.58 NERVE WOUNDS . try to find the minimum time necessary for obtaining contraction. in a state of prolonged inactivity. negative threshold of electro-diagnosis . manifesting the rises to forty. electro-diagnosis to seek chronaxie. less precise. . and even more. chronaxie of a paralysed muscle. In electro-diagnosis we are considerably impeded by contraction antagonistic muscles excited by diffusion. 7° to 8° per thousandth of a second. with the same current though of duration by the chronaximetre. —A second important of the application of the idea of chronaxie has been proposed by Lapicque.' It suffices first to determine the threshold of excitation to closing of the negative. always too Muscles. which. must be confessed that these . That we may avoid too short durations. for a current of indefinite duration. We readily obtain figures of eight and ten thousandths of a second in cases of hysterical paralysis or on the inactive antagonists of the paralysed muscle. give clearly and 1 shown) current durations that can be regulated from a fraction of second up to a tenth of a second. Two which alone can be used. too. even simplified. it is preferable in clinical itself. but the durations are The variations in chronaxie revealed by this method between the healthy muscle and the paralysed muscle are enormous. Selective excitation of paralysed muscles. Without claiming the rapidity to reckon its its precision of an apparatus in physics. is less This difference easy to estimate than the delay and slowness of all. it Nevertheless. show a sensible diminu- tion in their velocity of excitability. a wire placed over a pulley with decreasing radius this shaft describes a circle at a velocity increasing a pointer fixed as perpendicularly on : the square of the time in this way. sixty RD. the chronaximetre enables us to estimate chronaxie of a muscle with tolerable . galvanic contraction.

and. vibrators.) the use of with immersion vibrators (Bergonie. or even a its above. with slow chronaxie^ on the other hand. thirtv con- microfarads. The in degenerated muscles. which has recently been highly recommended. the diminution of efficacy resulting from this retardation is smaller in proportion as chronaxia is slower. in the we shall do away with the contracutilise produced healthy muscles. the contractions provoked by the current. is necessary to limit to the paralysed muscles. need then only introduce the current by degrees retardation in order to limit contraction to the paralysed muscles alone. are excited by a progressive current. as far as possible. with small short chronax'ie. By progressively greater capacities. This is obtained progressively with special interrupters. The same Indeed. without any pain.ELECTRICAL EXAMINATION In 1907-1908 Lapicque showed that if 59 a current increases gradually to a constant intensity. the use of a the hypo-excitability of the paralysed muscle necessitates intense current. little When we are at the threshold of excitation. can greater intensities. for instance. if the galvanic current gradually attains constant intensity. undergo no excitation whatsoever. or . in six or eight thousandths of a second. to ten. placed in A condenser of two microfarads causes the current to take about six thousandths of a second to reach introducing if 95% its constant intensity. without in any way modifying the efficacy of the current in the paralysed muscle. even if this current reaches its intensity only fifty or one hundred thousandths of a second. the normal muscles and nerves. up twenty. with metallic etc. We series. Lapicque produced this by using of condensers. more we finally suppress altogether the traction of the healthy muscles. By tions utilising currents progressively. it observation is of considerable importance in electrotherapy. Bordier.

sometimes by simple neuralgia. which rather a complication than a consequence of nerve lesions. direct or even ascending. of a character special to the causalgia of Weir Mitchell sometimes by trophic disturbances which especially characterise neuritic forms. in connection fasciculi of with the different or unequal lesions of the various which is it is composed. group A study of nerve distinguish wounds us continually to new categories and in new symptomatic forms. the clinical manifestations of nerve lesions are even more varied and numerous than enables this enumeration suggests. of compression of irritation . . and also complex syndromes produced by association in the same nerve of two or more of the preceding syndromes. Dejerine and Mouzon we may describe clearly characterised : syndromes that are fundamental. particular. enables us to number of clinical syndromes relating to various nerve lesions Along with and involving diametrically opposed therapeutic solutions. indicated in many . different clinical pictures. reality. it This diagnosis requires surgical interenables us to form a prognosis as to the future of paralysis. . To these must be added dissociated syndromes resulting from partial lesions of the nerve. we shall have to dwell at some length on the manifestait tions of nerve irritation and the polymorphous symptoms may call forth. of regeneration. and A. is Irritation of the nerve trunks. . typical and Syndrome Syndrome Syndrome Syndrome of interruption .CHAPTER IV CLINICAL TYPES The is most important and difficult problem to solve in peripheral paralysis that of the nature of the lesion. and sometimes even by states of muscular hypertonia which come under the heading of contracture. The minute study of the many cases of peripheral undertaken since the outbreak of differentiate a certain war in the various neurological centres. however. sometimes by violent pains. vention or abstention the paralysis. Consequently. We In may also add the syndrome of ascending neuritis. four J.

CLINICAL TYPES
1.— SYNDROME

61

OF INTERRUPTION

The syndrome

of interruption occurs in cases of complete section of the

nerve, in very severe compression, in tearing or bruising of the nerve with the formation of a fibrous cicatrix.

In

all

these cases, there

their peripheral

is complete interruption of the nerve fibres ; segment, from the lesion on to the termination of the fibres,
;

undergoes Wallerian degeneration and gradually disappears

their central

segment, above the lesion, remains almost intact.'
In
favourable
conditions,
will

such

lesions

are

capable

of spontaneous
axis-

regeneration.

This

come about by

a progressive

growth of the

cylinders of the central end, which, crossing the obstacle, will slowly advance
in

the

empty sheaths of the

peripheral segment and end by completely

reconstructing and regenerating the original nerve.

But, on the other hand, the obstacle
the regenerating fibres
contact, compression
;

is

frequently insurmountable to

the segments of the sectioned nerve are not in
too great, the cicatricial
all

is

mass

is

formed of too

dense fibrous

tissue.

In

these cases, the regenerating fibres springing

from the central end will be unable to join the peripheral empty sheaths as conductors, they will group themselves at the level of the obstacle, forming a neuroma, or else will stray about in the

which serve them
neighbouring

cicatricial tissue.
call

Thus, complete interruptions often
after resection of the injured

for

surgical

intervention

:

either decompression in certain cases, or,

segment.

more frequently, nerve suture This intervention has no other

object than the removal of the obstacle and the placing of the central and

peripheral segments in

contact with each other, so as to allow of easy

regeneration.

The syndrome
i.

of interruption

is

characterised

By

immediate, complete, absolute and invariable paralysis of the
a progressive and particularly rapid disappearance of muscular
It

muscles supplied by the interrupted nerve.
2.

By

tone, culminating in complete muscular hypotonia.

precedes atrophy,

which occurs more slowly.
3.

By well-marked
spite

progressive and regular muscular atrophy.

In

of hypotonia

and atrophy, the idio-muscular
least,

reflexes

are

intensified, for a very

long time at

whereas the tendon

reflexes are

abolished.

There

is

increase of mechanical contractility of the paralysed

muscle.
4.

By

a reaction of degeneration which

is

gradually set up in about
classical

two

or three

weeks and culminates
to the muscles

in the

complete

RD.

From

the outset the nerve excited above the lesion no longer transmits

any excitation

which

it

supplies.

62

NERVE WOUNDS
For some days
after the

wound

the nerve remains excitable below the

lesion,

then

it

rapidly loses all excitability.

The

muscles also lose
coil),

the thick wire

few days their faradic contractility (with then, much later, after a month or even more, their
in a

faradic excitability with the thin wire coil (the usual coils).

same time we have the disappearance of the motor point, Galvanic contraction polar inversion and longitudinal hypo-excitability. is retarded and its execution slackened. becomes slow, its appearance and invariable anaesthesia in the region 5. By immediate, complete

At

the

supplied by the paralysed nerve.

Anaesthesia

is

a

little

gradually diminishes

for

more widely spread the first few days its area some weeks owing to anastomotic substitutions Acthen it remains definite and fixed. cording to the case, it is somewhat variable
;

;

in

its

characters

;

in principle,

it is

abso-

lute, involving all the superficial
sensibilities,

and deep

though

this

is

true only for

large areas of anaesthesia.

Deep
less

anaesthesia, indeed,

is

always, by

reason of anastomotic substitutions,

much

widely
;

extended
it
is,

than

superficial

anaesthesia

on the other hand,
:

evoked by very slight cutaneous pressure when the patient is pricked with a needle,
1

2
of fixed anaes-

and he
prick,

feels
is

simply the contact not the
because deep sensibility
the
is

Fig. 21.

— Example

this

thesia in complete interruptions.

Section of the sciatic in middle 1. Examination part of thigh. on the 1 6th June, 191 5, six weeks after the wound. 2. Examination on the 9th October, 1 9 1 5.

involved.

In

exploration

process

with the pin which we have recommended, the answer " touch " applies mainly to
deep
sensibility.

In these conditions,
thetised region
is

when

the anaes;

not very extensive, deep anaesthesia
is

is

never complete

the pressure of the pin
abolished,
6.

everywhere

felt,

the feeling of pain alone

is

and
the

we

have simple hypo-aesthesia.
of spontaneous,
bellies.

By

absence

or

induced

pains

by

pressure

on the nerve and the muscular
painful,
pressure.

Not only

are the muscles not
to

but, as

Dejerine

has

remarked, they are quite insensitive

The
7.

nerve lesion

itself is

alone

somewhat

painful.

By

the absence of formications caused by pressure on the
lesion.

nerve

below the

On

the other hand,
;

we

notice at the level of the lesion a focus of

formications produced

they appear in a very limited zone which corre-

sponds to the neuroma of the central end.

The

fixity

of this zone, for

weeks and months,

is

an important sign of complete interruption.


CLINICAL TYPES
It

63

must be remembered

that formication appears as a rule only about
it

the fourth or sixth week, and that
8.

disappears in the end.

By

the absence of trophic disturbances, except occasionally slight
little

oedema, a

cyanosis and moderate hypertrichosis.

Serious trophic disturbances, cutaneous sclerosis, aponeurotic contractions,

tendon and synovial adhesions, affections of the

nails, arterial lesions,

do not belong to the syndrome of complete interruption.
Still,

one may meet with trophic
injury
;

ulcers,

which

are always secondai v

to

a cutaneous

these are, for instance, plantar ulcers

produced

by walking, sores on the great toes or the dorsal surface of the foot
occasioned

by the
all,

foot-wear

;

ulcers

on hand or

fingers

appearing as

the result of a burn, an excoriation, or even at times a simple galvanic
bath.

After

these are always accidental ulcers, favoured and

pro-

longed by malnutrition of the tissues in
nerve.

the region of the interrupted

From
(<?)

this

schematic description

we

conclude that

Several of the signs characterising the

syndrome of interruption,

such as the

RD,

atrophy, hypotonia, formication, etc., only

come about

gradually and after a certain time.
(l>)

Fixity of the
:

symptoms

is

one of the important

characteristics of

the syndrome

Fixity of paralysis

;

Fixity of anaesthesia
Fixity of the

;

RD

;

Fixity of formication.
(c)

Complete interruption of the nerve

fibres

does

not altogether

exclude the possibility of their spontaneous regeneration without surgical
intervention.

Consequently

it is

absolutely necessary to

make

a

number of

successive

examinations at intervals of several weeks before making a formal diagnosis and deciding upon surgical intervention.

II.— SYNDROME

OF COMPRESSION

Simple compression of the nerve takes place when the nerve fibres undergo lesions of such a nature that the voluntary nervous impulse, as well as the electric current, cannot pass, but without there being destruction of the axis-cylinder or centrifugal degeneration.

In a word,

we

have here a local disorganisation which momentarily
peripheral segment

causes to disappear the physiological conductivity of the nerve fibre; but
this fibre
is

not dead

;

its

is

not degenerated

;

it

is

capable, after the disappearance of the

injury, of being reorganised

and


NERVE WOUNDS
This is the syndrome produced in its functions fairly rapidly. momentary compressions of a nerve its classical example is musculo;

64
resuming
the

spiral paralysis, called

" a frigore," produced by compression of the nerve
found
in the

during deep sleep.

Sometimes

this

syndrome

is

permanent compression of
in callus,

a

nerve surrounded by a fibrous cicatrix or encased

but without

marked narrowing.
In induce
these cases, however,

permanent compression, compatible
survival

for

a

considerable
its

time with

anatomical
;

of the

nerve,

may

finally

progressive degeneration

consequently,

we may

find a

syndrome

of compression being transformed into one of interruption.

On
This

the other hand, the same injury
fragile

may

induce destruction of a certain
rest.

number of more
results in a

nerve fibres and simple compression of the

mixed and very usual syndrome, one of incomplete interruption, where the symptoms of interruption are never fully seen, and
where, nevertheless,

we
of

observe progressive regeneration, far slower than

simple restoration of a compressed nerve.

The syndromes

momentary compression must be compared with
:

the fleeting paralyses which often succeed grave injuries of the limbs, and
these which have been described as a kind of stupor of the nerves paralyses disappear after a few days, generally without any disturbance of
electrical

reactions revealing the tiny contusions or the state of shock in

the nerve trunk.

The syndrome 1. By more or

of compression
less

is

characterised

complete

paralysis, generally as

syndrome of interruption, more defined movements.
2.

rarely partial

complete as in the and permitting of a few ill-

By muscular

atrophy,

far

more

rapid

and

less

intense

than

in

complete interruption.

This atrophy may, however, become very
persists.
3.

intense,

if

compression

By

relative preservation of

muscular tone which

is

one of the best
time
this

signs of simple compression.
Still,

one

may

also find

muscular tone disappearing
it

after a

;

muscular atony, however, requires months, whereas

takes only a few

weeks
normal
4.

in

complete interruption.
idio-muscular reflexes are almost always intensified
;

The

if

they are

shows that the compression is very slight. By a reaction of partial and always incomplete degeneration,
it

far

slower

in

taking place
fibres.

;

unless

we

have progressive interruption oi the

compressed
It
is

in slight

compressions, particularly in musculo-spiral paralysis from
that

temporary
reactions

compression,

we may
:

we

have already mentioned

electrical find the paradoxical nerve and muscles remain more or

CLINICAL TYPES
less

65

excitable

by

the faradic

current below the lesion, whilst electrical

stimulation of the nerve above the lesion causes no
in the paralysed region.
5.

movement whatsoever
;

By

anaesthesia, variable
less

in

intensity

and extent

in

general

it

is

far

more reduced and any case it has no
6.

pronounced than the anaesthesia of interruption

;

in

invariable fixity.
lesion, as also of pains
;

By

the absence of pains at the level of the

in the
latter,
7.

course of the nerve or on pressure of the muscular bellies

these

however,

may

retain their

normal

sensibility to pressure.
is

By

the absence of formication.
is

This
and

altogether absent in simple
paralysis

and transitory compressions, as

musculo-spiral

a frigore.

If

we

find,

in

some

cases

of close

prolonged

compression,

slight

Fig. 22.

nerve.

the hand in a case of simple compression of the musculo-spiral is the same as in cases of complete interruption, but the tone retained gives the hand a less drooping posture, one more resembling that ot repose. Freeing of the nerve. First indication of movement 15 days after intervention. (J. and A. Dejerine and Mouzon, Presse Medicate, 18 May, 19 15.)

— Attitude of
The

paralysis

formication of the nerve trunk under pressure, it indicates the destruction In a word it is a and the consecutive regeneration of some nerve fibres.
case of incomplete interruption.

find the

Whilst regeneration of the few interrupted zone of formication extending over the

fibres

is

taking place,

we

tract of the nerve

below

the lesion, signifying the progressive advance of the axis-cylinders.

In other cases, the zone of induced formication remains fixed, limited
to the level

of the lesion.

It is

then to be feared that the constriction ot

the nerve, too great to allow of the passage of the regenerating fibres, will,
in

the long run, cause destruction of the fibres that have remained healthy.
8.

The

absence
in

of trophic

disturbances

is

even

clearer

in
in

pression than

complete interruption.

Usually

we do

not find

comthem

the cyanosis and the slight
type.

oedema which may accompany the preceding

66

NERVE WOUNDS
The syndrome
of compression,
like that

of interruption, includes a

certain

number of

characters noticed during the evolution of the

symptoms

and obtained by successive examinations. Only after a few weeks' observation can one judge of the necessity
for surgical liberation.

Moreover, the
compressions

results of liberation are

somewhat

variable.
in

In simple

we

often

find

that

the

nerve regains

a

few weeks,

sometimes a few days, the whole of its functions. In compression with incomplete interruption, the duration of restoration
is

evidently proportional to the nerve destruction.
fibres
i.e.,

The
lesions,

momentarily or

slightly

limited

to the affected

point,

compressed present only segmentary and are not accompanied by

degeneration of the peripheral segment.

They

need only undergo local

restoration for the nerve impulse to pass into the peripheral

segment which

has remained intact and to supply afresh the paralysed muscles.
If the fibres are

secondarily, and the

more deeply affected, the peripheral segment is injured work of restoration must be carried on over the entire

extent of the nerve.

The

extreme variations

we

find in the time necessary for healing

may

thus be understood.

simple liberation of the nerve
are called for only in cases

In almost every case of compression calling for surgical intervention, Resection and suture is usually sufficient.
nerve into a mere fibrous strand

the

where prolonged constriction has transformed in these cases, the syndrome of ;

compression had given place to that of complete interruption.

III.— SYNDROMES
Irritation of a nerve

OF IRRITATION
itself

trunk

may show
:

by extremely varied and

diversely associated

symptoms.

We

will describe schematically
i.

Serious nerve irritation
Slight nerve irritation
;

;

2.

3.

Irritation of a simple neuralgic

4.

A

special neuralgic

form syndrome accompanied by
;

violent pains

and paroxysms

;

the causalgia of

Weir

Mitchell.

The phenomena of nerve
associated with paralysis,
It

irritation or neuralgia in a

mixed nerve may be
total paralysis.

though they
is

may

also exist without

may even

be stated that paralysis

exceptional in slight neuritic forms,

and

in neuralgic forms.

On

the other hand, disturbances of irritation also

show themselves

in

the sensory nerves or in the purely sensory branches of the mixed nerves.

pains and trophic disturbances are secondary. however. More . comparable sensations of burning. they also extend over the whole limb. pricking ) Pains intensified by movement and muscular friction contraction. Pains. Whereas. motor disturbances occur immediately. Muscular atrophy isextremely variable. Sensory Disturbances is — The main symptom pains pain. which. sometimes even intensified by fibrous infiltration of the muscles. however. although the fibrous transformation of the muscles may frequently mask them. there persists a suggestion of voluntary movements or else a certain degree of electrical excitability. it is less marked by reason of the relative preservation of the nerve fibres.— SYNDROME OF SERIOUS NERVE IRRITATION possess This syndrome is found only in lesions of the mixed nerves which alone numerous vaso-motor and trophic fibres whose irritation produces is neuritic disturbances. occasioned mainly by pressure on nerve trunks and muscular these pains are felt at the compressed point. A. in other cases we find extremely rapid muscular dissolution. for the nerve fibres are irritated. true. to Spontaneous muscular rending. Generally they are more acute on is pressure of the muscles than of the nerve trunks. it is — The skin also painful. The idio-muscular reflexes are always intensified. by heat and more especially by cold.— CLINICAL TYPES 67 I. essential characteristics Trophic and painful sensory disturbances are the of neuritic types. After a few days the pain appears and it gradually becomes pronounced for two or three weeks. is found along with the pain on pressure of the deeper tissue. Pains bellies . persistence of which often brings about definite lesions. we may note the presence of cutaneous anesthesia. however. It is also after a few weeks that trophic disturbances appear. is frequently less complete than in the preceding forms. Cutaneous hyperesthesia. to continue for more months and then slowly disappear. not destroyed. In certain cases. by cutaneous or by contact of the bed- clothes. The RD is frequently partial. For instance. for the most part. Whilst. this paralysis. It almost always accompanied by paralysis . Muscular tone is usually preserved.

split. refractory hand. touch. ***** rapid and pronounced bony decalcification than in any other essentially serious. with the exception of the fibrous sequelae of the healing process. A type. of formication at the level of the calms down. radiated. the tendon scleroses. diffuse. its fibrous infiltration and its desquamation fetid sweats. Fibrous infiltration and contraction of the muscular bellies contraction of the tendons and aponeuroses. the appearance of profuse or again the condition known as glossy skin. which lead to the formation of irreducible griffes. and mucular contractions. Trophic Disturbances strictly to the Trophic disturbances belong In these cases trichosis. mainly by Indeed. even Indeed. B. . Conical atrophy of the digital extremities. Immobilisation of the tendons by fibrous invasion of the synovial sheaths. claw-like. broad scales. Most of these neuritic spontaneously. imperfectly localised and differentiated. we note the appearance . cyanosis and hyperin found nerve interruption. and sometimes remain altogether irreducible. the same painful sensation. however acute they may be. however. Nails curved. already syndrome of nerve irritation.— — NERVE WOUNDS is 68 frequently. the nerve is painful. continuing several seconds and altogether characteristic. furrowed. find More turbances especially do we the whole series of severe trophic dis- Extreme dryness of the in skin. though As soon as neuritis there is no formication when pressure is applied. which usually coexists with a and thermal hypo-aesthesia. there painful hyperesthesia. During the entire period of irritation. . on the other immobilisations. the the fibrous must inevitably diminish and disappear . on the other hand. we note the presence of cedema. griffes. Spontaneous regression is indicated by the mitigation of pain and by the appearance of formication. friction. Fibrous ankyloses of digital or carpal joints and of deformed joints reminiscent of rheumatoid arthritis. cracked. more Pronounced neuritic types are therefore reason of their trophic disturbances. cold and heat are but vaguely perceived but all these cutaneous stimuli produce one and pricking is ill defined tactile . whilst the paralyses that accompany them are always destined to heal spontaneously or by liberation of the nerve. the pains that characterise them. or. the articular too often constitute painful lesions which severe necessitate months or even years of types heal mobilisation and of massage.

is Speaking generally. In other cases aponeurotic contractions prevail. more bulky and resisting than on the healthy side. all of which had been impossible before by reason of the intensity of the pains. where serious and definite trophic disturbances are to be feared. with fibrous con. find neither In these cases of neuritis affecting the muscular system we occasionally whilst. ceases to be painful cation then gradually replaces in the nerve the neuritic pain. forward. the evolution of trophic disturbances suppressed and it is possible to practise massage. . The pain is deep. accompanied by slight contraction and fibrous infiltration of the muscles. the pains are immediately is dis- pelled. liberation of the nerve seems to give variable results sometimes ineffective. driving it . little pain on pressure of the muscular bellies. on hyperesthesia nor even cutaneous hypoaesthesia . a slight fibrous tration of the muscles. without pronounced cutaneous trophic disturbances is the origin of some cases of pes equinus. frequently is it is Probably the inconstant nature of the results . it is right to practise resection of the lesion and suture of the nerve. the muscles are painful when pressed. II. For this we may find pain on pressure of the muscles. We A have described the grave forms of nerve that its but we must infil- remember manifestations may be far more widely disseminated. a few aponeurotic or tendon contractions. or.CLINICAL TYPES lesion 69 then. it brings about a great and rapid improvement . In obstinate cases. be external to the nerve. forminerve which. from slight lesion of the sciatic. resulting in the formation of fibrous grijfcs . mobilisation and electrical treatment. due to the character of the lesion other hand. Moreover we shall see later what relations can be established between these disturbances and contractions from neuritis. . we have even seen cases where slight of the sciatic nerve was shown by actual hypertrophy of the muscles of the calf. the other hand. irritation Muscular atrophy may be absent. sometimes nerve irritation is rather ill-defined and aponeurotic sclerosis so tardy that the nerve lesion may pass unnoticed. Frequently instance. with the neighbouring muscles. on the may take place within In certain particularly intense forms. it is seen to descend along the tract of the . irritation may it. week by week. the slowness of the regeneration in neuritic types discouraging.— ATTENUATED NEURITIC TYPE irritation. By this means. not on the surface. slight cutaneous sclerosis with adhesion of the integuments enable us to conclude that there is irritation of the nerve and therefore that it is incompletely interrupted. traction but slight neuritic disturbances may be dissociated. as it were.

adhesion to the first joints and the limitation resulting therefrom Still. not only a certain degree of pain on pressing the nerve. they may con- continue for several months and then disappear spontaneously. we have seen cases of contraction of the palmar fascia." for which must be reserved the name . The muscular bellies are somewhat . of " causalgia. in flexion of the fingers. certain first In is slight neurites of the musculo-spiral. without appreciable of the electrical Instead of anaesthesia. but even slight formication along its course and hypo-aesthesia of its cutaneous area. there is slight hyper-aesthesia to pin-prick in the area of distribution of the nerve. These traumatic neuralgias are often rather persistent. attention attracted by the fibrous infiltration of the skin its on the dorsal surface of the fingers. or less pronounced neuralgic syndromes. however. is The all nerve at the trunks. Sometimes again cutaneous trophic disturbances preponderate. of a well-marked sensory type. neck and knee in the case of the median and the sciatic. occurring slowly after a wound in the arm or the fore-arm and apparently inexplicable the most . at most a few signs of cutaneous irrita- There is no paralysis. but only a certain degree of weakness and modification muscular reactions. speaking generally. atrophy.— SIMPLE NEURALGIC TYPE we often Following on slight bruises of the nerve trunks. Naturally their intensity is very variable. provoked mainly by the movements involving the lengthening of the limb. They are syndromes of slight irritation. meet with more tion. such as the extension at elbow. III. reminding one of Dupuytren's contracture. are points of election. They are specially to be distinguished from the violent neuralgic syndromes of a particular character. minute investigation has been needed to discover. which are most frequently involved. thus proving slight irritation of the ulnar.7o NERVE WOUNDS For instance. No trophic disturbances occur. and every type may be found. for instance. sensitive to pressure. The patient complains solely of more or less acute pains radiating along the course of the nerve. more so and this pain manifested above all On the sciatic are found the Valleix points and Lasegne's sign . indeed. the exclusively cutaneous manifestation of is trophic disturbances more apt to accompany the neuralgic type which we will now investigate. we are dealing with real injuries to the sciatic.

after the the 71 NEURALGIC TYPE— CAUSALGIA of Secession. patients to a sensation of mingled smarting and burning (kq. firm pressure of the integuments can scarcely be patient felt. that can hardly be credited. an bend of a door creaking. that certain patients resign immobility. Traduction Dastre. walking or the themselves to almost complete slightest shock. a violent exacerbations of pain a carriage appearing at the * S. induce painful paroxysms which often continue for several minutes. but it is particularly the median and the sciatic that produce this syndrome. " Gunshot Wounds and other lesions des nerfs et Philadelphia. Very seldom does almost causalgia appear immediately after the wound five . A slight touch on the skin. de leurs consequences.etc. long duration. at the palm of the hand in the case of the median. . it was referred finally to deep. always finally the. a pin-prick. . By warning his the beforehand. at the sole of the foot in the case of the sciatic . and then continue for months.CLINICAL TYPES IV. street. calming down very slowly. but it radiates simultaneously over the entire area of distribulesion. they take three or four weeks to reach their maximum. Morehouse and Keen. characterised hy its intensity. doubtless by reason of the number. And yet. it is localised at the termination of the nerve. or even. fact. . whilst a gentle touch is atrociously painful. cold especially.* As a rule. An even more curious — keen emotions and sensations induce unexpected letter arriving. ioi." Weir Mitchell. heat. War Weir Mitchell and its descrihed under its name of causalgia a particular neuralgic syndrome.nature." writes Mitchell. Des 1874. All the nerves may be attacked by causalgia. the skin alone. says Weir Its intensity varies "to a red-hot file rasping the skin. of their sensory or vaso-motor fibres. tion of the nerve and even well above the The pains are so greatly aggravated by movement. . p. a sudden Injuries of Nerves. its special pains habitual resistance to every therapeutic agency. and perhaps fragility or special . compared by burning). Causalgia is essentially characterised by violent pains.— INTENSE In 1864. pains supervene only after four or days. a child falling. it we may succeed in openly grasping hand and examining more superficial than The pain is tar without causing him too much suffering. Accordingly these patients show the greatest anxiety when we want to examine the hand. 233. importance. S. etc. Paris. from the most trivial burning to a state of torture Mitchell. p. 1864.v<tiq. " If it lasted long. Weir . and all cutaneous excitations. preface <le Vulpian.

now understand why : those who suffer from violent causalgia have so distinctive an appearance they look anxious. Two of these sufferers carried a bottle of water and a sponge. They grow more quickly than in their normal and their rapid growth raises at the extremity of the finger a small cutaneous swelling. dryness or exaggerated sweating. redness of the skin. in causalgia. a glance NERVE WOUNDS down a staircase or through a window. usually macerated by the moist state kept up. finding relief in the moisture rather than in the coolness of the application. almost always passing beyond the cutaneous region of the nerve." says Weir Mitchell. are almost always of a dull yellow state. to other pains which constitute the main symptom of causalgia. wet the sound hand when he was others " found some ease from pouring water . to be . . important disturbances must be mentioned. We irritable. air. The slightly sometimes a little bent. they are taciturn and they will not leave the house or speak or play. . obliged to touch the other " into their boots. the vasoless Along with the motor and trophic disturbances are often a little more pronounced. The calm patients dryness of the skin causes particularly painful sensations. the healthy hand acting as a shield to protect the other from contact of and appetite. like hyper-aesthesia. they are often seen to surround the hand with a wet cloth constantly renewed. " keep the hand constantly wet. wrap the hand compresses or padded gloves moisture more than anything else gives them appreciable relief. It is sometimes more dry than on the healthy side would seem and slender striated nails. sleep some They walk daintily as though to avoid all shock in hand is held behind the back. If there is no paralysis but at most a slight muscular weakening and atrophy. " Most of the bad cases. . warm and red. supplied by the median or the sciatic to the arteries which they accompany.72 strong light. The skin shows extreme hyper-assthesia. constant in all nerve irritations and particularly painful colour resembling ivory. entirely superficial. The skin. are all so many causes calculated to provoke a painful paroxysm. often extend far beyond the cutaneous region of the nerve affected. Those authors causalgia as the base their conclusions on this fact irritation who tend to regard syndrome of of the vascular nerves. in others it is held in front. and never permitted the part to become dry for a One of these men went so far as . the vaso-motor disturbances. though more frequently causalgia accompanied by profuse sweats. To the their sufferings and at the in same time avoid contact with the ." moment. The fingers are thin . or even as a sympathetic syndrome indicating lesion of the pcri-arterial plexuses. cases the every kind. flexion of the last phalanx is often limited. is smooth. the glossy skin type described by Weir Mitchell. they lose both . Strange to say.

In these conditions. Regeneration of the cut . disheartening. these contractions . Further on. and the regeneration of which. resting for a few days.— HYPERTONIA AND CONTRACTION IRRITATION FROM NERVE slight We paralysis have already mentioned the cases strongly facts. in obstinate cases. both and successes attend almost therapeutic measures. without marked muscular atrophy. have given good results Leriche. Radiotherapy The type. veritable nerve contractions. V. Not without a certain repugnance can we assent to cutting or alcoholising a nerve trunk which is not paralysed. in certain cases has given remarkably soothing effects. in which nerve irritation are indisputable produced simple contraction and fibrous or infiltration of the muscles. the muscles in a frequently paradoxical posture. As from neuritis are often of a later on.— SYNDROME OF REGENERATION The syndrome or tearings of regeneration it is seen in its purest form after nerve sections and nerve sutures. ( Meige and Mme Benisty. the pains of an emotional the vaso-motor disturbances and the radiation of the symptoms beyond the region of the nerve clearly indicate a sympathetic syndrome. crushings partial which are accompanied by complete or interruption of . The present therapeutic uncertainty is largely owing to our ignorance of the true mechanism of causalgia. but even these heroic measures may be ineffectual . after intervention. recommended by Leriche. seem These and well-known But states it would also that irritation of a nerve trunk might produce of muscular hypertonia. fibres to take place with extraordinary rapidity cutaneous hyper-aesthesia soon reappears and all the muscles themselves rapidly regain their excitability. failures we shall study the various all treatments proposed . 73 is the refractory nature of these disturbances . more complex nature we shall study them IV. exists in the compressions. No treatment relieves them .CLINICAL TYPES In all cases. is never certain. the seems patient again begins to suffer. paroxysmal symptoms of causalgia. immobilising a matter of fact.) Denudation of the brachial artery and section of the sympathetic plexus surrounding it. some authors considered the question of after section of the nerve or the injection of alcohol above the lesion. liberation of the nerve remains almost always ineffectual sedative electrical treatment obtains ease only for a few hours.

No end. shown under the microscope as the phenomenon of cellular chromatolysis. which is always limited. a retrograde degeneration. kind has ever been ascertained observations are errors of interpretation caused by compensatory movements or by bility. is theoretically fact of this and practically impossible. periods of a few days when the regenerating activity manifests followed by periods of all rest. On the other hand.e. . it causes a series of profound disturbances in the central segment .74 a nerve trunk . phenomena of consists collateral sensi- The syndrome tions of regeneration. is In cases regeneration shown in the nerve trunk. and afterwards the reaction a distance on the original cell. This progress is not absolutely regular it often takes place in jumps. the degenerated nerve restoration is first . Only after this brief disturbance in the nerve does proliferation of the axis-cylinders of the central end and their advance towards the peripheral segment begin. shown of the muscles and integuments nearest the lesion. coming from the central end. On the one hand. then. beginning of restoration after a suture or a traumatic interruption of the nerve is never immediate . The Any interruption of nerve fibres produces it is two kinds of phenomena. follows a centrifugal course. - . immediate or even rapid restoration of an however short the interruption. regeneration of a nerve is essentially a long and gradual Again we must repeat that interrupted and sutured nerve. and the first signs of regeneration become manifest. this is first an ascending degeneration of the nerve fibre above the lesion. sensory. into the empty sheaths of the degenerated fibre peripheral segment. Thus it indicates the slow progression of the regenerating axis-cylinders. gradually and slowly extending to the more distant muscles and integuments. consequently at the level it Return of the functions of the nerve corresponds with progression of the axis-cylinders in i. : followed by the degeneration of the whole peripheral segment Wallerian degeneration. trophic func- and electrical reactions. No by a neurologist all reported . interrupted or even severely injured nerve can resume its functions except by this budding of the axis-cylinders from the central The process. the first signs of regeneration scarcely ever appear before the fourth or even the sixth week. during itself. and does not extend more than a few millimetres. NERVE WOUNDS it is also shown in cases of severe nerve irritation where the affected or irritated nerve fibres seem to have been gradually replaced by young and healthy ones. : of the progressive reappearance of the functions of a nerve motor. in the muscles and in the integuments.

cation appears at the level of the suture about the eighth week after three it is ascertained to be a few centimetres below . week. the best and almost the only sign of regeneration of the it for not its only does enable us to follow the progress of regeneration. find it on the internal and external popliteal nerves at the upper third of the leg. the less have regained their fully formed state. the latter tardy. and .— SIGNS 75 OF REGENERATION OF THE NERVE may be observed . but has disappeared as the upper third of the leg. popliteal it at the fifth month formicates on pressure from finally. in the course of the nerve. extent or limitation of regeneration. We find that sudden pressure. If the axis-cylinders stray lesion. rapidity of migration and the region in which it even supplies exact information regarding the quality. former comes about at a very early stage and is is most important . spreads centrifugally. at the fourth month we . calls forth a sensation of formication in the cutaneous region of the nerve. has disappeared at the level of the lesion the. and ends few months by reaching the cutaneous region itself. Consequently. the progress of formication on a nerve sutured in sciatic the middle of the thigh : about the fourth week formi. either partially or wholly absence of formication over the . it intensity. but at the it same time the nerve . it extends and shows itself towards the periphery of the marked it becomes. pari passu with the advance of the axis-cylinders. corresponds to the zone of growth of the young axis-cylinders and at last completely disappears when the nerve fibres The more nerve. after a where the nerve divides. reaches the parts It extends towards the periphery. it Then week it gradually becomes after more pronounced. is a nerve in course ol regeneration. lose themselves in the tissues next to the them Andre-Thomas was able formication reveals thus. there is in the course of the nerve a wide zone of formication which can be brought on. but through appears. in an interruption of the musculo- to demonstrate the presence of stray axis- cylinders in the muscles of the forearm. or percussion of the nerve trunk. : In the nerve two signs of regeneration The The The appearance of formication called forth by pressure return of electrical conductivity. almost . the progress of this provoked formication. has reached the foot. Let us follow. and is possible to follow. for instance. It appears about the fourth or sixth week. spinal. below the lesion. months it reaches the popliteal space . Any nerve that formicates below the lesion . finally disappearing at the level of the portions of the nerve which are nearest the lesion. in far as space to the level of the malleoli the sixth month. is Formication nerve . always following on the return of voluntary conductivity it is consequently devoid of interest. is The all-important sign formication.CLINICAL TYPES I.

follows regeneration so far that we regard the coexistence of tone and muscular analgesia as a sure sign of regeneration after interruption of the nerve. II. modification of electrical reactions. Then effort there appear faint voluntary movements. return of voluntary all movement. it may considerably precede the return of voluntary movements. necessitating considerable part of the patient all on the and bringing into play the violent synergic contraction of the muscles of the limb.— SIGNS OF MUSCULAR REGENERATION These The The The The The are appearance of muscular tone. ever. shows the firmer consistence of the muscles on palpation. The may appearance of muscular sensibility Nevertheless it perhaps the earliest sign after the return of tone. clumsy and quickly exhausted. still. efforts of the patient. how- by massage. does not completely disappear. which accompanies the contraction apparent. first it shows itself by a hardening of the muscle. except Atrophy. them . then comes of sensibility to pressure. Finally the movements become definite but they long remain weak. . which normal loses rest. return of muscular sensibility. particularly the energetic is of the antagonistic muscles no movement. the order in which regeneration of the axis-cylinders reaches .— NERVE WOUNDS is 76 entire extent of a degenerated nerve trunk an almost certain sign of absence of regeneration. The At return of voluntary movement slight is the latest manifestation regeneration. one after another. and especially in progressive modification of the paralytic posture of the limb. until many months is motor functions. any tendency to be excessive and approaches a far state of The diminution of muscular atrophy is more tardy . Electrical sensibility is perhaps the first to reappear . gymnastics and after the return of all the repeated electrical stimulation. and . diminution of atrophy. inducing rapid fatigue accompanied by slight trembling. The It return of muscular tone seems to be the itself in first sign of regeneration. however. Only by daily exercise will patients regain the full range and dexterity of their movements. accordingly we find different results in neighbouring muscles it might almost be said that we find in the same muscle different results according to the fasciculi examined. awkward. Naturally in these signs take place muscle by muscle.

which the treatment causes appear gradually. we find. rapidly show almost complete galvanic excitability . are modifications with tone. in quantity. Probably massage and electrical treatment have simply improved the contractility of the paralysed muscles. however. it point becomes predominant. it contraction. as we have seen. rule is This It is true if the usual thick wire coils are utilised. tion long before nerve regeneration can have reached the muscles electrical in some. Thus. At the same time.— ELECTRICAL 77 REACTIONS reactions arc gradually During the modified. entire regeneration. not true. difficult to interpret. as Meige. all its characteristics. slowness of the contraction generally disappears completely only after the return of the first voluntary movements. show electrical signs of ameliora. the RD. the negative contraction stronger than the positive. inexcitability and regain their others we find that their galvanic hypo-excitability diminishes. Marie. and Mme Benisty have shown. First of all. begins to be qualitatively modified only on the arrival of the axis-cylinders and after the reappearance of seen to diminish at the motor galvanic hypo-excitability is point . persists . remains slow for a very long time . the electrical These modifications seem according to the case. but whilst becoming shorter and shorter at the motor The It is remains slow to longitudinal excitation for a longer time. undergoing electrical treat- ment immediately after a nerve suture. however. longitudinal reaction becomes its less clear . P. if the muscle is examined with thinner wire coils of greater resistance and electro-motive force. the muscle gradually loses longitudinal hyper-excitability. These latter. a generally recognised fact that faradic excitability reappears only after the voluntary movements. then the formula again becomes normal. that there exist muscular contractions which long precede the appearance of voluntary movements. from disuse and lack to dis- of attention. gradually accelerates. previously untreated. . the closing contraction at the negative pole becomes stronger and finally equals the contraction at the positive. Moreover. for certain of these electrical modifications seem clearly anterior to the arrival of the axis-cylinders in the Some patients. they are paralysed muscles. These. The point. to take place in somewhat variable order. for instance. showed the early stages of fibrous transformation with the syndrome of muscular hypo-excitability. with the thin wire coils of the ordinary apparatus. There is polar equality at the motor point . its excitation at the motor still.CLINICAL TYPES III. it not in quality .

The return of the deep sensibilities . soothed by scratching or friction paresthesia 2. of anaesthesia. not possible we are . more disagreeable than painful. . Narrowing and disappearance of the zones regions gradually shrink . in process of regeneration formication. Moreover. following the growth of the axis-cylinders. In certain cases and at certain stages of regeneration. —The anaesthetised but this progressive diminution mostly takes place from above downwards.— SENSORY SIGNS OF REGENERATION like Regeneration of the sensory functions takes place. it is to These sensations often occur rather early. : — . 1. An instance of sensory restoration (after suture of the sciatic). by centrifugal extension. induce formication of the axis-cylinders in process of regeneration. At a later period there are observed sensations of cutaneous itching. superficial ones the slightest pressure of the skin whereas pricking. muscular contractions. nothing else than the sign of spontaneous pressure Movements. as the different sensibilities are restored. they gain both in .78 NERVE WOUNDS IV. Indeed. 25th day ' 55th day 77th day 103rd day There may Fig. thermal anaesthesia is a little more protracted than painful sensibility and is always more widespread. that of the muscular functions. now this considering excitation of the nerve is itself. 23. is always earlier than that of the is felt. a zone of total anaesthesia . slight touch. which assume the form of shooting pains and especially of formication felt in the cutaneous region of the nerve. these seem to be connected with the we shall study shortly. As a rule. cutaneous or when transferred to the nerve trunk. a zone of hypobe distinguished three schematic zones a zone of hypo-xsthesia with paresthesia sesthesia where pricking is felt as touch of regeneration (cutaneous formication). and generally regard them as a sign of cutaneous restoration. this results in actual sensory dissociations. Patients often complain of spontaneous sensations. tactile heat and cold are scarcely perceived.

. heat. Generally these are sensations of formication. is It this progressive restoration. so that no cutaneous excitation is yet clearly perceived. 79 the gross sensations of touch. In general. cold.CLINICAL TYPES extent and in precision are first . pain. they appear so early that . provoked by the slightest cutaneous excitation.e. The its period of paresthesia is prolonged. heat and cold then slowly these sensations become definite and allow of the appreciation of the qualities of contact. which penetrate there before the terminal apparatus is completed . V. Their cure is particularly long and difficult. the disappearance of which requires complete restoration of the tissues. they certainly precede the regeneration of the axis-cylinders their exist- ence is then a paradoxical phenomenon. . they are diffused. but all these excitations induce this same sensation of disagreeable. They are produced by touch. Paresthesia. we often have to deal with well-marked cases of very advanced fibrosis. the interpretation of which far we have so been unable to find. who differentiates from the 3. Here too. diffused. articular and other trophic disturbances which accompany neuritic forms are even more obstinate. tendon. We in its appearance Cutaneous. doubtless corresponding to the regeneration the gross protopathic sensibilities of increasingly delicate terminal apparatuses. radiated over the entire region in the and over the course of the restored nerve. — This name describes very special cutaneous sensations which are always found during nerve regenerations. radiated and persistent formication. They are often retarded. however. It is gradually diminishes and restored. epicritic sensibilities. that has been most minutely described by Head.— DISAPPEARANCE OF TROPHIC DISTURBANCES have seen that muscular atrophy was both early and slow in its completion. occasionally. Paresthesia ordinarily precedes the appearance of normal sensibility. pricking. rather intense and at times very disagreeable. they are persistent and are prolonged some seconds after the end of the excitation. synovial. perceived . and in particular by a slight stroking of the skin. at least on their is first appearance . muscular contractions or tendon adhesions which are positively incurable. finer. the shades of temperature and the exact localisation of the sensations. the characteristics of pain. i. y some- what prolonged excitation vicinity of the excitation needed to produce them. sometimes even impossible neuritic types too often leave behind fibrous sequela?. area becomes restricted as normal sensibility Probably these special sensations are due to the presence in the dermis of the newly formed axis-cylinders. Finally.

and. lesions in we may also find the association one and the same nerve. There may cation complete section of the external fasciculi of the sciatic along with the hypotonia. in a nerve trunk of less importance. capable of spontaneous restoration. The us to study of these dissociated types the is of great importance. we may find associated with the syndrome of com- plete interruption over a part of the nerve trunk the painful symptoms and trophic disturbances which characterise nerve irritation of the neighbouring portion of the same nerve. on the other hand. They of the are frequently met with in sciatic. and suture only the affected or destroyed part of a traumatised nerve whilst respecting the healthy fibres. the return of tone. to establish suffi- the analysis of symptomatic part of a which is the it wounded nerve trunk. expressed by different syndromes. On these partially attacked nerves will be possible to practise partial operations. Consequently selves this nerve.— DISSOCIATED SYNDROMES Dissociated syndromes correspond to partial or unequal lesions of the nerve trunks. anterior or posterior fibres correspond to different muscular groups or sensory regions the position of the . is It will be known beforehand that the external part of a neuroma permeable to . is motor. In another case. of a It . in the region of the internal popliteal nerve. this fascicular topography of the nerve trunks seems ciently definite to enable us. the partial gressive formication RD.8o NERVE WOUNDS V. But. in a nerve. remove. enables determine topographic constitution nerve it shows that the internal or external. for instance. according to dissociations. degeneration. tions motor or sensory which point to partial lesions. One may easily imagine all possible associations and find them exemplified. for instance. Further. and fixity of formi- which characterise the syndrome of interruption . but a minute analysis of the wounds of bulky symptoms nerves. pro- and all the signs of regeneration which indicate a slighter lesion. particularly often enables us to dissocia- recognise. it informs us what. we may find partial lesions of a nerve manifesting them- by dissociated paralysis confined to part of the muscles supplied by Lesions of the external or internal part of the sciatic trunk. to liberate. sensory and trophic or vaso-motor Consequently it confirms the theories put forward on the fascicular structure of nerves. fibres. paralyse the region of the external popliteal nerve or of the of unequal internal popliteal nerve. be.

rational and economical surgery. for it may culminate in definite degenera- tion of the nerve. of a fascicular.— ASCENDING NEURITIS Strictly speaking. Severe ascending and sometimes years spinal cord itself. or the sheath of the nerve.CLINICAL TYPES regenerated axis-cylinders. of a violent. we may even find it extending ri^ht to the spinal cord and spreading to the nerves of the opposite side. along the lines of the constitution and fascicular in the direction topography of the nerve trunks. is characterised by the fact that the traumatised its nerve not only degenerates rapidly towards peripheral extremity. It is These pains are often sufficiently acute to enable the patient to trace on his limb a continuous pain with paroxysmal crises. We plexuses gradually see the slow ascent of this pain along the affected nerve. its 81 internal part offers an insurmount- We shall then be led. it permanent itself. The below it nerve is painful as in the on pressure. . seems due to the progressive ascent in the nerve. which radiate over the entire course of the nerve and even above the lesion. Ascending It is neuritis has most frequently as its starting point the per- sistence of an osseous focus of suppuration. . Slight ascending neuritis may stop in its progress and even after a considerable interval. section of the nerve above the lesion. and disabilities that are often neuritis. whereas able barrier to them. progressive. characterised by very acute and spontaneous pains. but its at the level of the nerve also and above the lesion. the course of the nerve involved. atrophy. although these latter are usually incomplete. not only syndromes of irritation. but undergoes a slow. It it is ascending neuritis is not a type of traumatic nerve a complication and often a serious one. it Fortunately is very rare. We see the pro- gressive extension of the area of cutaneous anaesthesia or hyperesthesia. when we have been able to which carry out energetic disinfection or the removal of the initial focus it. We likewise note the ascending advance of muscular atrophy and of paralyses. ascending degeneration of Ascending focus of the neuritis its central segment. are not always sufficient to stop 6 . is usually continued for months seldom stops before reaching the plexus and the causes pain. it Frequently appearing in the vicinity of ascends to the It nerve trunk and finally reaches the origins of the nerve. distressing and intolerable nature. especially caused may retrogress. It however. invades the which become painful. amputation of the limb is to which one sometimes reduced. lesions. VI. of the toxic products or infectious agents of the wound. termination.

culminating in a state of meet with a great number of contractures seemingly paradoxical. mav also induce a kind of muscular hyper-excitability. others as the result of slight neuritis. ever. But if we minutely study these frequently succeeding slight injuries. Meige and difficult Mme Ath. muscles. for whilst experiments on animals show can be stopped by early section of the nerve trunks. profuse sweats. Most. These disturbances have been specially studied by Babinski and Froment who. may last for a period of eighteen months. recognise the existence in these cases of the slight changes studied by . the " acro-contractures" or All neurolo- " acro-myotonies " of Sicard. indeed. Benisty. such as cyanosis. the " mains of H. which one might be tempted to regard as simple hysterical contractures. apart from altogether exceptional cases. slight modifications of the electrical reactions and mechanical of "reflex excitability of the. slight organic lesions. low temperature. hypertonia or even of genuine contracture. this is a solution which one cannot adopt. trophic disturbances of skin and nails. HYPERTONIA AND CONTRACTIONS FROM NEURITIS Slight irritations of the peripheral nerves. . although the hypothesis of the ascent of infectious germs or of toxic agents in the nerve trunks or in their sheath seems very probable. capable. Babinsky and Froment they admit generally that these changes reveal . how- refuse . APPENDIX PARALYSIS. permanent contracture of the it is paradoxical to find that contracture of hand or arm. of inducing fibrous infiltrations and contractions of the muscles. sensory dis- turbances clearly defined. following a simple fracture of the radius or a superficial wound. under the contractures. to admit the purely organic It nature of these paralyses or contractures they interpret them as functional disturbances grafted on to is. as we have seen. name have clearly distinguished them from simple These jigees" are the " painful contractures " described by Claude. illogical and abnormal to find a simple sprain producing a paralytic club-foot or a foot . It gists is extremely to interpret these disturbances.82 it if NERVE WOUNDS the infectious or toxic agent has already gone beyond the point of section. the existence of slight organic lesions some regard them as sympathetic or reflex disturbances. We are almost completely helpless in that it its presence. contractures. We we note the presence of a certain number of characteristics indicating the existence of organic lesion." functional contractures. Its exact nature completely baffles us.

of manifestly nervous origin. Almost complete anaesthesia of the ulnar. painless and reducible. profuse sweats. Trophic disturbances of nails and skin . immobilised in extension with flexion of the thumb Fig. hypoicsthesia of the median. But in almost all cases of clearly defined neurites.) j — cases it is the permanent immobilisation. provoked lesions of a peripheral nerve. is inaction that transforms into obstinate contraction the neuritic hypertonia of the muscles. the muscles affected .CLINICAL TYPES Amongst these accidents of a possible to distinguish a very clear 83 complex and ill-defined nature. it is the inertia of the patient that enables neuritis to proeffect. keep up the vaso-motor. it is easy to prove the existence of a very important functional factor. the prolonged inaction. to duce its maximum shall disturbances which We The seem particularly frequent. it is the dread of pain that immoit a state of paralysis the limb affected with slight neuritis. These neuritic paralyses associations. amplify and prolong these disturbances bilises into . vaso-motor and secretory symptoms.. which thing that strikes one is the parodoxical character of these contractures. the auto- suggestion of impotence and the moral inertia of the patient that intensify. (Slight neuritis of ulnar and median. 24. Nerve irritation and contractures are almost always functional it is the origin of the disturbances found . thermal and trophic study more specially contractures caused by neuritis. of pains and sensory disturbances. perforating wound of" fore-arm. of trophic. provokes the appearance of muscular hypertonia. But in most Contracture of the hand. it is now group of paralyses and especially of by slight irritative contractures. first ***** we find in these cases. in which the nerve lesion produces the exact opposite of the usual paralytic syndrome. To passive movements. Sometimes they are simple rather easily states of muscular hypertonia.

which persist for months and produce the most paradoxical attitudes. In other cases. possible to extend the hand without remains extended much diflictilty it without pain after contracture has been overcome. They offer enormous opposition to attempts at resistance. tracture mainly of the interossei. fixity of which is further increased by the inaction to which the patient too often resigns himself and which ends in complete loss of use. and gradually closes again Almost complete in 5 or 6 hours. caused by the ulnar and the median above the elbow. after eleven slight of of the hand in months. — Contracture lesion flexion. muscular rigidity produces permanent contractures. comparable to the epileptiform tremor of the greater during active patient. anesthesia of the ulnar. . No paralysis. resistance. Seldom painful at . and It is contracture of the palmar fascia. becomes movements which become almost impossible for the This hypertonia induces a permanent posture of the limb. 25. hypo-aesthesia of the median. Connormal electrical reactions.84 NERVE WOUNDS elastic oppose only a certain reduced. the Fig. foot. easily overcome Their : when rigidity they are we frequently notice the appearance of a kind of muscular tremor.

the muscles contract its anew and the limb gradually resumes original posture. These contractures almost always follow on slight wounds at .) existence of an organic factor in the case. — Contracture a arm. electrical re- the usual symptoms of altogether nerve lesions are either scarcely perceptible or are absent. represents the maximum of flexion possible. I. 85 is they become extremely this painful when an attempt made to overcome them. . Many of these contractures are gradually intensified through the relax- ation of the antagonistic muscles and articular ligaments. suddenly with more is fre- quently coming about slowly.CLINICAL TYPES rest. slight lesion of the ulnar in the fore arm. they are found by degrees to adopt the most unusual postures. we find that. times the appearing injury. of the hand from slight lesion of the ulnar in the fore(Contracture of the interossei and of the hypothenar eminence. The patient can bend only his thumb. and very pain seems to increase their intensity. (Contracture of interossei and extensors. they are invariably accompanied by nearly normal actions . or even a few days. Fig a — Contracture of the hand owing to minute study enables us to detect in these "contractures from neuritis " a complete series of symptoms which combine to demonstrate the Still. few hours.) in a tew minutes. . The contracted muscles frequently show. When we have slowly and gradually succeeded its in overcoming these contractures and bringing back the limb to normal position. This figure Passive flexion is fairly easy. Fig. index and middle ringers. along with slight atrophy. long after the wound healed. 26. and even these very imperfectly.

) — 86 NERVE WOUNDS a state of mechanical hyper-excitability indicated by the intensification and slowness of the idio-muscular reflexes. bable ascending neuritis. — Contracture of the hand. hyperesthesia in the area of the (Pro- median and the musclo-spiral. and by secretory disturbances in some cases. Frequently there are profuse sweats which sometimes produce actual maceration of the epidermis. that may correspond of several degrees of temperature. Their special rigidity at reduction often persist and the muscular tremor provoked by attempts during slight chloroform anaesthesia. In other cases we have dull pallor of the integuments. Fig. Babinski and Froment have succeeded in discovering by patellar clonus under anaesthesia. 28. and appear along with a special kind of redness of the skin. The tendon reflexes also often appear intensified during anaesthesia. with dryness of . The hand. at first contracted for eight months in complete flexion. Electrical examination sometimes reveals a certain slowness of con- traction in the shortened muscles. hypertonia of the contracted quadriceps. For instance. has been contracted in extension after gradual opening of the fingers. These contractures are frequently accompanied by more or less pronounced trophic or vaso-motor disturbances. musculo-spiral and even a little of the ulnar just above the elbow. Generally there exists a cooling of hand or to a fall foot. acute pains in the course of the median. Hypertonia of all the muscles of the hand. clearly localised in the region of the irritated nerve. Following on suppurating sore of the wrist.

hyperesthesia. — — brachial plexus). or else 87 At times. the cutaneous swellings which their rapid growth fingers. and Di (probable wrench of the Hypoiesthesia on the region of C6. nail Then we appearance. have disturbances : their dull or sometimes that striated their yellowish hue comparable with raises of ivory. It is seldom that we do not find a more or less definite hypo-aesthesia Fig. or even to a portion and vaso-motor have also a precise topography. some cases. which show slight irritation. or 4. there is slight fibrous infiltration of the integuments. profuse sweats. we have slight contraction of the palmar or showing the similarity of these cases to the neuritic syndromes we have already investigated. disturbances These contractures Sensory. of their area in case of partial lesions. the regeneration in insist of some injured fibres. Almost always there are pronounced sensory disturbances. fall after a "Accoucheur's hand" due to contracture of the muscles or the hand producing fracture of radius. on the pulp of the Finally." to neuritis may be found in the region of all . trophic are generally clearly limited to the region of the nerves involved. thinning of the skin which assumes the aspect of onion rind. states of neuritic hypertonia are "contractures acquainted with These contractures due the motor nerves. in plantar fasciae. Thermal and vaso-motor disturbances. 29. We must on the anatomical character of the changes observed. or the appears frequently. C7 . find in Almost always we presence the nerve itself along its tract of provoked it formications. ***** anatomy. on the other hand. pain on pressure. is Hypertrichosis particularly frequent. In contradistinction to hysterical contractures. in the region of the nerve involved less .CLINICAL TYPES the skin. 3.

Their presence is revealed principally by pain and formication . which spring from infection of the wound. calf and foot. have observed. — disturbances which indicate the irritation or wrenching of the cervical Whilst in certain cases contracture from neuritis is shown in the domain of an injured nerve. produces contractures of . induce contraction of in hyper-extension hand and Likewise with the lower limb. Progressive accentuation for a period of sixteen months. of the sacral — Contracture plexus. These are slight ascending neurites. lumbar. as well as of the muscles of leg and foot. to . however. with hypo-a^sthesia in the region fifth .) . there first . or only certain of them. the anterior crural nerve seems as responsible for certain contractions of the quadriceps. particularly of the musculospiral. there are other more disturbing cases where the seat of the wound seems in no way to justify the appearance of neuritic troubles. These are particularly cases in which wounds of fingers. hands and ringers association of the median causes the appearance of the "accoucheur's hand. musculo-cutaneous may be involved in certain contractures of the We have seen even the musculo-spiral fingers. Acute pains in the course of the nerves of the fore-arm. found sensory disturbances with root-distribution. is just the sciatic capable of provoking certain contractures of the posterior muscles of thigh. and second sacral existed a state of obvious muscular hyper- tonia of the posterior muscles of the thigh. hand or foot are accompanied by extensive contractions. affect- these muscles. of In contractures also are often hand and arm roots.88 NERVE WOUNDS They would seem. a case of extensors of hand and fingers following on a wound of the hand crossing the thenar eminence with prolonged suppuration. have been involved We Fig. We from find pes equinus and club-foot in contracture originating hypertonia through slight irritation of the sciatic or its branches. hzve been found with particular frequency in the region of the ulnar ing all hypertonia of the interossei. Lesions of the plexuses would also seem as though they must in certain cases. The biceps. (Probable ascending neuritis of the musculo-spiral." described by Babinski. of wrench of the for instance. or flexed contraction of hand and fingers. 30.

is as clearly most cases. but rest and convalescence aggravate them we even find certain of these contractions. not so necessary for everyday use. mobilisation. which the neuritic. fascial contractions. to speak. trophic. persist. Whilst. muscular bellies. but the state of defined as in neuritis over a systematised region. neuritis in islets. However factor. so we find . by atrophy of the muscles they supply. ***** muscular hypertonia clear the organic signs noted in Their more diffused distribujumbled together zones of and of almost normal sensibility this is. by hypo-atsthesia or hyperesthesia of their cutaneous region. almost cured by electrical treatment and daily . trophic seemed It them would therefore seem that in most cases neuritis cannot produce such contractions without the aid of the prolonged immobilisation and muscular disuse which aggravate its consequences. We tion is have observed several cases of contraction appearing on frost- bitten limbs without any wound. hypo-aesthesia. are many proofs of the neuritic character of these cases. and are flagrantly inactive treatthey persist for an unconscionable time ment improves. these trophic and paralytic disturbances characterise severe cases of frostbite. of hyper-aesthesia. with immobilisation of the and of the hypothenar eminence. Some forms and so of frost-bite are characterised by localised neuritis of the Sclerous infiltration. manifestly there often exists in the genesis of those contractions an important functional They scarcely ever appear except in patients . whilst disturbances. and often exaggeration of the muscular and tendon reflexes of their entire motor region. We have been able to give a rather curious demonstration of this out of fifteen patients suffering from contraction due to interossei irritation of the ulnar. trophic disturbances of skin the acute pain provoked by pressure on the all frost-bitten extremities. instance. irregular for vaso-motor and slight sensory disturbances. had saved the thumb and succeeded in retaining probably with a little its movements intact . On the other hand. . we found only two cases where there was contraction of the adductor pollicis the other thirteen patients . accompanied bv the same sweats. to give vaso-motor. progressively reappear during convalescence. There is another cause of contraction from neuritis : frost-bite. particularly delicate Energetic mobilisation accentuates them massage and electrical . who are resigned to them.CLINICAL TYPES in the 89 nerve trunks on pressure over a larger or smaller part of their course above the wound. often . effort and patience they might have avoided con- traction of the other fingers. secretory and birth. nails. . neuritis is a . Treatment of contractions from matter. all we may find others disappearing under the effect of treatment. however. slight cases of neuritis may be shown by muscular hypertonia. paralysis with faradic excitability of the muscles.

. popliteal foot. Fig.9o NERVE WOUNDS are stimulation painful at times and unpleasant to bear . interrupted by the metronome. An associated treatment consists of hot baths with faradic current these give Indeed. causes turbances of sensibility revealing slight neuritic external of the lesion popliteal and more partibialis ticularly of the internal nerves. progressive and continuous mobilisation by the the best results. 31. and yet it is is impossible to allow the contraction to continue. a very hot and . at the there is introduced into the its bath a moderate faradic current. dilator action is vasois same time very gentle massage .— Club-foot from contraction following on eighteen sprain. after months In the right foot is contraction of all the plantar muscles as well the of contraction as ! which posticus Disclub-foot.) (Comleft pare with the healthy We have been very successful in bringing about gentle. the more so as there almost always a tendency gradually to become more and more inactive from relaxation of the antagonists and of the articular ligaments. prolonged if bath causes these become remarkably supple further increased. contractions to aid of improvised appliances.

is frequently disuse. 32. with contraction of the feet following signs of slight neuritis and cutaneous hypoitsthesia. that. of several Though this contraction. therefore. and. however.CLINICAL TYPES applied to the 91 contracted muscles . long. main It factor. daily exercise. such it as to prevent all not the case when first shows itself. all — his personal quota of exercises and active movement. We to the discover this by noting the various results of treatment according moral condition of the patient. — Claw-like after on frost-bite. has become so irreducible voluntary movement. resigned to the disuse of his contracted limb. inertia or indifference on the part of the patient that enables it to get a hold on him. Whereas some interest in rapidly improve by it a treatment they follow with interest. they take no the results. is indispensable in the cure of these cases . just as their factor. sincere efforts to recover the use of the limb would rapidly have dispelled contraction. of these disturbances essentially involves a moral factor. patient mobilisation. One ment of condition. others submit to without con- fidence effort and unwillingly. Probably in most cases. these contractions is Indeed. an undulatory faradic current would certainly be even better. quite unconcerned. and then he ceases to contribute to the treatment the Fig. the treatpainful. wearisome and often Too frequently the patient becomes discouraged. The treatment. allow contraction to follow course. must not be forgotten is though slight it neuritis the initial cause of contraction. perseverance and good will on the part of the patient. make no its of their own. pathogeny introduces an important functional . at the end is months.

or hematomyelia. in addition to the spastic signs of spinal cord to paraplegia. . spinal injur)'. absence of the peripheral type of distributing anaesthesia. the history of a first. so that (i) we may once eliminate : Central paralysis. not dwell long on the differential diagnosis of peripheral traufor in the course of our clinical sketch of the subject under consideration. On the other hand.CHAPTER V GENERAL DIAGNOSIS OF PERIPHERAL NERVE LESIONS We shall matic paralysis. predominence of phery of the limb. For paralyses of the peripheral type. cortical brain monoplegias. and the habitual of pyramidal irritation coexistence of some slight indications are all elements which help the diagnosis. Compressions of the cord are nevertheless accompanied by compression of the roots. the greater Almost diffusion. at all events. at invariably. with disturbances of sensation . On the other hand. characterise paralysis related to cord lesions. this study i. but these disturbances are arranged with root distribution variably they are dissociated. these hematomyelias are often accompanied by lesions of the posterior horns. (2) Paralysis by cord lesions. which are somewhat similar to paralysis of the sciatic. hematomyelias vertebral (paralysis concussion or a sort of gaseous which sometimes follow a simple embolus by decompression matter of the from shell shock) are often limited to the grey case. intensity nor the precise limitation of peripheral anaesthesias almost inless we note along with a more or . however. from a lesion of the anterior horns. The same spastic symptoms. progressive change paralysis or of anaesthesia at the peri- to a spastic state. following traumatisms of skull or electrical — characterised disturbances. analogous to those of poliomyelitis. and then they have neither the . cord. exaggeration moreover by the absence of atrophy and of the reflexes. crushing. instance. signs of paralysis of the peripheral type which correspond the roots included in the compression. compression. so that we find. must be remembered that is confined to injuries of the at peripheral nerves from wounds. It we have drawn attention to the main errors possible. indicative of lesion of the pyramidal tract. of the paralytic signs. we may meet with hematomyelias limited to the first and second cause in They this sacral segments.

. Almost always sensory or purely motor. types of anaethesia. signs progressive polyneurites : . etc. generally enable us to recognise them. electrical reactions of nerves The and muscles are normal or almost . Peripheral. the radiating pain provoked by coughing and sneezing. These are segmentary anaesthesias. by a circular line . (4) sheaths Root inflammation. these have naturally the of peripheral paralyses flaccidity. correspond to no definite anatomical region. and disturbances of electrical reactions^ they often show sensory disturbances or pain and the fibrous contractions of nerve irritation . there are found typical hysterical which must be remembered. artificial or rather — paralyses is extremely Following on paralyses. a relative preservaof tactile sensibility and an almost complete integrity of deep (3) sensibility. hypotonia. The tional paralyses. but attack an entire they do not paralyse a movement but rather . absolute parano nerve region but rather affecting whole line or segment of a limb. They are widespread and absolute at . and we continually find it necessary to differentiate them from This matter of important. caused by inflammation of the meningeal surrounding the spinal nerve roots. corresponding to a Almost invariably they are accompanied by widespread. tonia from disuse we also at times note a slight cyanosis which may be due to prolonged disuse or to the dependent posture. distribution of 2. They often to owe their origin to syphilis. all spontaneous. the main characteristics of war wounds. sometimes to tuberculosis. and the extent of the paralytic nature. the evident disproportion wound which is disturbances. between the importance or the site At the first they are almost always striking by reason of their paradoxical of frequently a slight one. more rarely as infectious meningitis such cerebro-spinal meningitis. They Still. boot. are not associated with muscular atrophy. doxical anaesthesia. dis- turbances of the reflexes or trophic disturbances. inflammation of the nerve root of sensory-motor. leg of mutton. nor is there found in the patient any attempt compensation. They limb or segment of a limb a function. seldom lower or upper limb are alike spontaneous and progressive. the signs of concomitant meningeal irritation revealed by lumbar puncture. we see that there occurs in the long run a sort of muscular hypo. clearly limited glove. (1) false — peripheral nerve lesions. most important diagnosis concerned with the group of funcThey are extremely frequent. loss of tone. they are almost always bilateral and symmetrical.DIAGNOSIS OF PERIPHERAL NERVE LESIONS tion 93 marked diminution of thermal and painful sensibilities. The root motor and sensory disturbances. muscular atrophy.

so great incurability. faradisation of the muscle provokes its energetic contraction and demonstrates to the patient the . fractures necessitating prolonged we may have pseudo- These are caused by dread of pain or by a sort of loss of the habitual use of the muscle. patient psychotherapy. Apart. are specially frequent after nerve lesions accompanied by nerve because in these cases the dread of pain and a certain degree of fibrous transformation of the muscles are associated with the auto-suggestion of incompetence. There appears a certainty of its to exist so absolute a conviction of paralysis. And which yet these paralyses patients are placed may be rapidly and thoroughly cured if the under appropriate treatment.94 normal. that the patient comes to take no interest in his paralysed limb. As a sequence of muscular immobilisation. It is possible to NERVE WOUNDS detect a slight hypo-excitability in muscles long These paralyses are almost always accompanied by a special frame of mind. the (4) must be compared muscular incapacity provoked by ceasing to contract his muscles. there are many functional paralyses which must be recognised. these cases With pain. rapidly (3) Pseudo-paralyses from pain. the main elements of motor are isolation. paralyses due to prolonged disuse of the muscles. Nevertheless. Functional paralyses from anaesthesia. the role of auto-suggestion is even more manifest. or even by the simple conviction of incapacity. (6) In these cases. characterised by an absence of effort. wounds. Faradisation again provides the are We now concerned with paralyses The most frequent example is following on lesion of a sensory nerve. movement faradic treatment. Pseudo-paralyses from contraction of the antagonists. from these well-established hysterical paralyses. (2) Paralyses from prolonged inaction or loss of the habitual muscular movements. however. energetic if need be. In certain cases nerve lesion we find that paralysis protracted its when caused by even after the nerve has regained functions and the electrical reactions have become normal. rendering movement (5) Functional paralyses from prolongation of organic is paralysis. tendon lesions or articular injuries. afforded by lesion of the median at the . electrical reactions are normal . paralyses are after all These functional incompetence. he does not seem anxious to recover. paralysed. wounded man impossible. possibility of effects a cure. seen only an exaggeration of muscular recover their lost function. energetic faradisation and re-education. means of diagnosis and treatment. in wounded men who They irritation.

following on a neighbouring fracture or arthritis or on simple contusion of the muscle. This muscular hypotonia caused by a vicious posture is prolongation of musculo-spiral paralysis. whether the result of muscular irritation. and tendon lesions. or following on the tendon adhesions which nerve irritations produce. we have found of the hand which began ten months fracture of the humerus and the wearing and allowing the hand to hand by the months of a . the ulnar pscudo-griff~e produced by contraction of the flexors of the last two fingers or the pseudo-paralysis of the external popliteal nerve. Pseudo-griffis produced by muscular or tendon contraction. defensive . (6) Pseudo-paralyses from hypotonia and muscular stretching. faradisation shows integrity of the muscles and the functional nature of the paralysis. (2) Pseudo-paralyses resulting (3) from muscular destruction.DIAGNOSIS OF PERIPHERAL NERVE LESIONS lower third of the fore-arm lumbricales . It may the be found following contusion of the fore-arm. It a distinct factor in artificial proves the necessity in this paralysis of an apparatus to keep the hand permanently extended. having to supply only the motor twigs to the thenar muscles and to the . The same met with in the lower lesions of the anterior or of the musculo-cutaneous. resulting from fibrous contraction of the calf or of the Achilles tendon. noticing that there anaesthesia in hand and tibial concludes that they are powerless and ceases to is move them. in extreme indicated. muscular. Here. we find an inexplicable paralysis of flexion in the is first three fingers. producing a sort of accidental tenotomy. too. The thing patient. Muscular hypotonia is also accompanied by almost normal electrical . For instance. reactions it is cured after a somewhat prolonged faradic treatment plication . (5) Reflex muscular atrophies. paralysis previously for six in another case after in these For instance. or even as the consequence of a prolonged defective posture. though at the cost of so great an effort that the hand permanently retained the posture of musculo-spiral paralysis and the patient had given up holding it extended. it following hysterical . sling supporting the fore-arm droop at the wrist two cases. 95 this nerve has become almost entirely sensory. after lesion or section of tendons. or shortening of the tendons may even be Contractions. voluntary raising of the lengthened extensors of the wrist was possible. fingers. (1) Paralyses from pseudarthrosis. (4) Pseudo-paralyses of hand or fingers produced by cicatricial adhesion of the tendons. with production of pes equinus. (7) cases. now. we may place the osseous. The type of these is furnished by the pseudo-musculo-spiral paralysis following on hypotonia and stretching of the extensors of the wrist. In a third group 3.

after ligature of the axillary or the sub-clavian. with like lesions. we see the This progressive sclerous infiltration. with the arterial lesions. with the same lesion. is It essentially characterised by ischaemia with cyanosis. simply present fleeting ischaemic disturbances of the hand. resulting from vascular obliteration sometimes most difficult to distinguish from paralysis caused irritation by nerve lesions. cooling and limb. according to the patient. In the second. tendon adhesions and Ischemic paralysis is griffe postures. for instance. considerable in extent and by intensity are rather difficult to interpret.96 NERVE WOUNDS produce postures immobilisation. generally limited to the hand though sometimes extending over a Ligature also of the femoral or popliteal may. hardens the . we may describe two phases syndrome. be well borne or may provoke the appearance of ischaemic paralysis of the foot or even of the leg. the ease or collateral circulation. Still. the brachial. after an average of two to three months. very different from the fibrous resistance of the contracted muscles. fibrous transformation of this oedema. a prolonged posture or a simple hysterical manifestation. together with cyanosis and cooling. trophic disturbances of the wounded There is nothing. the sub-clavian. the femoral or the popliteal after . These contractions disappear under initial anaesthesia. In the first phase there is only an cedematous infiltration of the affected limb. such as the axillary. it may also appear after dressings and especially bandages too tightly applied. occasionally paralysis. difficulty of arterial substitutions and perhaps especially the . invades the dermis. Ischsemic paralysis. Whereas the majority of normal subjects. which makes the sub-cutaneous cellular tissue puffy. Probably the previous state of nerve lesions associated nevertheless the problem the peripheral arteries. show marked signs of permanent ischemia. and especially from syndromes of nerve shown by fibrous contractions. others considerable segment of the upper limb. fairly easy to recognise the elastic resistance of contractions to the attempts at mobilisation. sometimes found following ligature or thrombosis of the great arteries. These differences of ischaemic disturbances. is — Ischaemic paralysis. which might be mistaken for for those of Especially may they be mistaken nerve irritations and fibrous infiltration of the It is muscles or the accompanying tendon contraction. in different patients. however. play an important role is of the pathogenesis of ischaemic paralysis not completely solved. contracts the muscles. more variable than the extent of these disturbances. that occur in the evolution of At this all events. 4. we have seen that very often they had as their cause a slight nerve irritation.

gives the tissues a 97 aponeuroses. affecting without dissociation tactile. Deep pain. too. Anaesthesia predominates at the extremity of the limb and gradually decreases towards its origin . we usually observe considerable anaesthesia or hypo-aesthesia 4. With 1. The electrical reactions of the infiltrated muscles are profoundly disturbed. stimulation of the nerve at a distance provokes the movements more readily than does excitation of the muscle. submerged this special progressive fibrous infiltration. cracked. without serious ischaemic disturbances.DIAGNOSIS OF PERIPHERAL NERVE LESIONS fibrous mass. but we do not the muscles react . of the skin. we have even found an entire absence of blood pressure or of the slightest certain cases of ligature of the axillary. and charactistic appearance are associated certain is signs. the prominence the the articular swellings of muscles disappear or tendons. formication. pressure. 5. note any polar inversion often. sometimes a shining red shapeless the deformed. accompanied by 3. and particularly enormous hypo-excitability. curved nails take on the appearance of . or unpleasant tingling. in and become atrophied. may find tvpical reactions of degeneration. Ischemic paralysis accompanied by the disappearance or consider- able diminution of the radial pulse in the case of the hand. sometimes even the abolition of all electrical excitability We . submerges the tendons and synovial sheaths in a veritable woody consistence and finally transforms the hand into a kind or fibrous bat. we shall find on the affected side a pressure of find 1 we 0-8. 2. Ischemic spontaneous pains with such characteristics as burning. 7 • . in we meet with consider- able diminutions of pressure. All the movements . are suppressed or considerably reduced by fibrous in immobilisation scales. for instance. the glossy skin. The arterial blood pressure undergoes similar diminution. painful. Still. Whereas. the contact of heat and especially of cold. thermal. there are ischaemic paralyses almost free from In contrast with this painful sensibility which mainly appears to be deep-seated. all the superficial sensations. this is rather the . claws the bones become extremely decalcified . fingers have a fusiform appearance the osseous projections. muscles syndrome of fibrous transformation of the only to a very intense current. is there broad without papillary crests and . cold and purple. are often very painful. desquamating here and reliefs. or of 9-8 shown by extremely feeble oscillations. of the dorsalis pedis artery and of the tibialis posticus in the case of the foot. paralysis is almost always painful. consequently it has a segmentary topography. oscillation. In ischaemic paralysis of the entire lower limb following on the obliteration of the common iliac. the wood)' contraction of all the tissues produces wide-spread atrophy of the limb. by Pachon's oscillometre an antibrachial pressure of 16-8 on the healthy side. the . the cutaneous creases. All the same.

means of hot permanent hot-wrappings. these patients are capable of progressive improvement which at times surpasses the most sanguine hopes and expectations. . massage.* Nevertheless. . For months and even years. of the affected nerve. which was and nerve itself slightly injured. not from simple paralyses by nerve section or compression. trophic disturbances and fibrous irritations. mobilisation and galvano-faradic cause rapid retrogression of the symptoms. cooling. 191 5. and the internal popliteal nerve are very often affected by . in a general way. the diagnosis of ischaemic disturbances lesions may easily be made along the following general lines : We soever. able as that of the peripheral nerve lesions. for in certain cases a well-conducted and sufficiently prolonged treatment by baths. baths may * Bonamy and Verchere. we have seen ischaemic disturbances becoming enormously increased in the region Bonamy and Verchere have reported a very interesting case in in which ischaemia of the hand resulting from lesion of the axillary was accompanied by gangrene of the hand and fingers the region of the musculo-spiral. cyanosis. involving the median and the ulnar. fibrous infiltration and anaesthesia are preponderant at the extremity of the limb diminish as we approach its root. "A Case of Gangrene of the Fingers and Hand in the Region of the Musculo-spiral. 21 May. the diagnosis of ischaemic paralyses is far from being as favour- These paralyses are severe and often incurable Still. . from lesion of the brachial. this lesions. the association of nerve lesions with arterial obliterations is the the median and ulnar nerves. one and the same wound is it may be that the association of nerve lesions In several cases of ischaemia an important factor in ischaemic paralysis." Societe des Chirurgiens de Paris. Finally. . the distribution essentially segmentary and centrifugal. set principle must not be up absolutely. but more especially from muscular contractions. they gradually and regularly All disturbances. griffes of nerve very frequent Moreover. find in ischaemic paralysis no peripheral nerve topography whatof ischaemic disturbances is On the other hand. producing permanent incapacity. with the brachial artery popliteal artery.— 98 It is NERVE WOUNDS often difficult to diagnose these ischaemic disturbances.

along with the circumflex. has Anterior aspect its origin from the posterior cord of the brachial plexus. After passing round the humerus. i the space comprised fflljnBw between the inner and outer heads of the triceps and covered by (diagrammatic). its long head. for not may but the nerve be affected directly like the other nerves of the upper it is very often surrounded and compressed in the callus of fractures of the humerus . is by far the most frequent . the musculo-spiral appears on the . It crosses pit Posterior aspect. the arm- behind the vasculo._C ourse of musculo-spiral nerve.PART II UPPER LIMB CHAPTER VI MUSCULO-SPIRAL NERVE Paralysis of the musculo-spiral nerve only limb. nervous bundle it then plunges the the of obliquely posterior towards part arm and the describes round spiral diaphysis of the rus humesemiit the circle which brings of this over the external surface bone. it may also be accidentally compressed at the level of the axilla by pressure of crutches (crutch palsy) or on the posterior pressure of a sharp edge during deep sleep (Saturday surface of the arm by night palsy). it Along pears this course ap- on the posterior surface of the in humerus cy\ |w FlGS# 33 and 3+ . ANATOMY OF THE MUSCULO = SPIRAL NERVE The musculo-spiral nerve.

to the teres minoi Cut. lying on the fibres of origin of the brachialis anticus. right descends into the muscular interspace separating the supinator longus to the line of the crease of the elbow. exclusively sensory. to inner head of triceps (ulnar collateral) (Ext. the less important. to anconeus If Fig. to shoulde Circumflex nerve Musculo-spiral nerve Br. br. passes outwards under the tendon of the supinator longus.— NERVE WOUNDS 100 external border. from the biceps. In its spiral tract round the humerus It it is very often affected by fractures of this bone or surrounded by callus formation. passes round the external edge of the radius. to outer head of tricep triceps Musculo-spiral nerve and anconeus Musculo-spiral nerve Br. to long head of triceps Br. .) Ulnar nerve Br. then on the antero-external surface of this bone. br. 35. follows the direction of the nerve. then divides into two terminal branches The anterior branch. Br. cut. (After Sappey. — Musculo-spiral nerve on its posterior surface of arm ami fore-arm.) It 1. it At the lower part of the fore-arm. proceeding along the internal edge of the supinator longus and covered by it. to inner head of triceps Nerve to outer head of Br.

MUSCULO-SPIRAL NERVE becomes subcutaneous and appears it ici" at the dorsal surface of the wrist. J Radial nerve Muscular blanches Radial nerve Radial anil musculo-cutaneous anastomosis Radial nerve. dig. The terminal branches arc distributed over the periosteum .) between the of the fore-arm. carpi radialis brevior Musculocutaneous nerv< M usculo-spiral nerve. to supinator longus Sr. we shall see that . where divides into three branches. br. post. this branch. br. Under the name of posterior interosseous nerve. intended for the sensory in nervation of the dorsal surface of the hand. to exten. passes round outside radius. The posterior branch. to extensor carpi radialis longior Bifurc. a very important one. supplying all and the deep layer of the posterior muscles of them with motor branches. 2. Fig. (After Sappey. of musculo-spiral nerve Br. then proceeds Musculo -spiral nerve Br. and the articulations of the carpus and the metacarpus their trophic role is a particularly important one. the neck of the traverses the supinator brevis. tore-arm and hand. — Musculo-spiral nerve or superficial layer posterior surface of arm. applied to the posterior surface of the interosseous ligament. 36. extends right to the level of the wrist.

— — NERVE WOUNDS Motor Branches The i. the an- terior branch sometimes the supplies Posterior aspect. the nerve to the inner head to the anconeus. the posterior branch supplies the nerve to the exterior carpi radialis brevior and the branches the posterior surface of the arm. three branches Internal cutaneous branch to the arm which is given oft at the . This nerve twig has no great importance all the same it explains the very slight atrophy of the abductor sometimes found in musculo-spiral (the . this same branch supplies the to the supinator brevis. the nerve to the extensor carpi radialis longior. thenar a little ^IV^ M/Mf (yC" Anterior aspect. 102 musculo-spiral is above : all a motor nerve. Motor distribution of the musculo-spiral. . exthe* terior carpi ulnaris nerves to the extensor communis and then to digitorum extensor the proprius digiti minimi. eminence with branch which partici- Figs. 3. — pates in the innervation of the abductor pollicis median supplies the principal innervation to this muscle). 2. to the extensor longus pollicis and to the expollicis tensor brevis . which extends down : In the bicipital furrow the nerve to the supinator longus . descending. 4. the nerve to the extensor indicis. It gives off in turn the following motor branches Below the axilla at the posterior surface of the . Sensory Branches The sensory contribution of the musculo-spiral describe its is of slight importance. paralysis. arm : the nerve to the nerve to the long head of the triceps the outer head. 37 and 38. manus 5. In passing round the neck of the : radius. the nerves to the extensor l ossis metacarpi pollicis. Finally. On : nerve to the . We may I.

We meet. sensory fibres alone anastomose with the sensory fibres its of the other nerves at the confines of cutaneous region. Anastomotic Branches The musculo-spiral nerve presents no important anastomosis with the Its other nerves. lying posterior surface of the when : it passes . to half the dorsal surface the the Figs. The anterior branch is of the musculo-spiral predominantly sensory. External cutaneous branch. phalanx (the dorsal surface of the last phalanges of these two fingers is supplied by the median). face of It terminates on the dorsal surthe wrist in three branches which supply sensation to the external part of the thenar eminence. 3. between the areas of the musculo-cutaneous and internal cutaneous. however. 39 and 40. which is given off from the musculo- spinal just round the external edge of the humerus and and to the to the postero-external surface of the arm is distributed fore-arm. middle second finger up —Sensory distribution. . These are terminal anastomoses. to the entire dorsal surface of the thumb. 2. in the form of a narrow band. at the lower third of the fore-arm. to the external part of the dorsal surface of the hand. with a small twig of union between the sensory branch of the musculo-spiral and the musculo-cutaneous. to the dorsal surface of the index up of to to the second phalanx.MUSCULO-SPIRAL NERVE lower part of the axilla 103 and goes to supply the postero-intcrnal part of the arm as far as the olecranon.

— NERVE WOUNDS 104 PHYSIOLOGY OF THE MUSCULO = SPIRAL NERVE MUSCULO-SPIRAL PARALYSIS I. the index and the fifth fingers. musculo-spiral nerve essentially the nerve of extension. the hand drooping. is Paralysis of musculo-spiral nerve essentially paralysis of extension. 41. the fingers half flexed by the tonic action of the flexors. — Attitude in musculo-spiral paralysis. This paralysis results in a special deformity : the fore-arm half flexed on the arm. Motor Syndrome is The i. Fig. Extension of the fingers on the hand by the extensor communis and by the extensors of the thumb. But paralysis of the extensors of the fingers involves only the first . Extension of the hand on the fore-arm by the radial extensors on the outer side and by the extensor carpi ulnaris on the inner side. Extension of the fore-arm on the arm by the triceps.

while of act the extensor Ext.. in spite of the his interossei a fingers. in default of the synergic antagonism of the extensor carpi Fie. We Musculo-spiral paralysis paralysis of see that the exterior tendon sends to the first phalanx a slip of insertion which limits its action The slips intended for the to this phalanx alone. patient. also produces a movement of adduction of the hand. 3. by the action of the This interossei in musculo-spiral paralysis. — Although flexed. phalanx I'. second and third phalanges are affected by the lumbricales and the interossei. +2. phalanges on the first. 43. It then occurs along with flexion of the hand. 2. they along their Interossei deep surface. suffering from musculo-spiral paralysis We the also have paralysis of supination (supinator brevis). It is the interossei that ex- tend the second and first third Long slip phalanges upon the by the they tendinous slips which send to the extensor tendons. succeeded. tend. orthopedic appliances to correct musculospiral paralysis have no need to extend more than the first intended phalanx.MUSCULO-SPIRAL NERVE phalanges. Thus. fib. Sign of the supinator longus. 4. a close adLumbricales hesion limiting their action to the extension of the first Exp. if 105 we artificially raise the first phalanges. -Tendons of the common extensor connexions (deep aspect). supplied by the . droop of hand and degree of supination by means of the biceps persists. accompanied by extension of the thumb. Slip to first tendons continue right to the last phalanx really the fingers. which is an extensor of the hand on the fore-arm. abduction is weakened. though it remains possible through the flexor carpi ulnaris (ulnar nerve). . of Aponeurosis phalanges upon the metacarpus alone. and possessing considerable articular At same time a slight laxity of the fingers. For. but this is possible only if" the tore-arm is 5. we find that the patient can easily extend the second and third phalanges.rt. — Extension of second and third ulnaris. in producing with hyper-extension oi the second and third phalanges. on the head the first of phalanx. The extensor carpi ulnaris muscle. is Fig. Consequently.

or hysterical paralysis. then we are dealing with pseudo-musculo-spiral paralysis. in spite of its not an extensor . one of the Indeed. synergically with the biceps. brachialis anticus and supinator longus. 44. however. Any musculo-spiral paralysis where the supinator longus If this dissociation it is is untouched should at once attract attention. arm. which depend mainly on the fifth and sixth cervicals). almost as powerful spiral as the biceps that it it is supplied by the musculo- nerve is quite an anomaly.io6 NERVE WOUNDS is musculo-spiral. standing out prominently. 45. It contracts. Normal subject. the supinator longus supinator. it is not even a name. through root or spinal cord lesion. 6. In musculo-spiral paralysis in flexing we note a considerable diminution of is energy results the fingers. Contraction of the supinator longus accompanying contraction of the biceps. contraction of the . in every flexion of the fore- arm. it is not found in root or spinal cord paralyses which are confined to the root region of the musculo-spiral (essentially the seventh cervical). supinator longus does not contract synergically with the biceps. biceps. The Fig. This. since really belongs to an altogether different physiological group. but from the faulty attitude of the flexed hand . The is disappearance of this synergic contraction of the supinator longus best signs of peripheral musculo-spiral paralysis. of the musculo-spiral type. not a real weakness. polyneuritis. whilst Fig. As we are aware. that of the flexors. It is rather a flexor of the fore-arm on the . not due to lesion of the nerve below the branch which supplies to the supinator longus. — Musculo-spiral paralysis. — leaving untouched the upper root group (deltoid. contraction of the supinator longus is retained in saturnine paralysis.

particularly fractures of the humerus . the fingers will power of flexion. Very frequent tyP e - Anaesthesia extend- ing beyond the typical region (very rare). V\r. Sensory Syndrome is The musculo-spiral nerve but very slightly sensory. brought out by pressure on it exists even in cases where anaesthesia is scarcely discernible. somctines even it . showing the presence therein of sensory fibres. 46. full hand is artificially raised. —Types of anesthesia from sensory role lesions of the musculo-spiral. surface of the arm and behind the fore-arm Typical distribution of anaesthesia. limits itself to a very restricted part first and the second metacarpal. . is In this same region the nerve It . Anaesthesia in musculo-spiral paralysis else is than on the hand. found formication. a tract on the back of the fore- arm and a part of the It must be added scarcely noticeable in dorsal surface of hand and it fingers.. it is exceptional to find complete anaesthesia in this region or less at most we have more marked hypo-aesthesia. even appears at times in lesions of the posterior branch. in any case. still. It is often very slight. its region is confined to the posterior part of the arm.— MUSCULO-SPIRAL NERVE flexors can 107 take place powerfully only If the if the antagonists put the hand in regain their extension. Frequent type. is that anaesthesia of the internal cutaneous branch is and very rare. II. so restricted is its and so great the overlapping of neighbouring not often found anywhere nerves. the musculo-spiral. we can just discern on the external a small area of hypo-ajsthesia. The in external cutaneous branch is more frequently affected. far it Seldom does it reach the typical distribution of more seldom does it go beyond it. Most frequently comprising the dorsal region of the can scarcely be seen . since occurs only in lesions high up the axilla.

Probably this is due to simple relaxation of the carpal ligaments with slight subluxation of the os magnum and of the semi-lunar. the synovial sheaths. 48. It is in neuritic forms that we find the real trophic disturbances. the metacarpo-phalangeal and digital articulations. The nails are very slightly — affected in culo-spiral. clusively on this branch. and especially in neuritis. phalanges. Vascular disturbances are . It would seem extremely probable is that this trophic role due partly in to the posterior branch of the musculospiral. for it is found even cases of the where neuritic irritation acts exFig. sections we it find This is rare. though is oedema of the dorsal met with both in nerve is and in nerve irritation its appearance certainly favoured by the drooping attitude of the hand. Trophic Syndrome In musculo-spiral paralyses we frequently find an abnormal projection of the bones of the carpus. neuritis of the musthat its We is know innervation limited to the first . In some cases. forming the dorsal swelling of the carpus. rather than to genuine trophic disturbance. In some cases of musculo-spiral paralysis surface of the hand. .— io8 NERVE WOUNDS III. usually very slightly marked most frequently they are lacking in any case they never possess the definite character of the vascular disturbances of the median and the ulnar. . (Edema of the hand in a case of musculo-spiral paralysis (section of the nerve). attacking the integuments. it seems to be produced by an actual teno-synovitis of the extensor tendons.

Total Paralysis of the Musculo-spirai. paralysis. II. the base of the axilla. on trying to extend the fore -arm on the arm. succeeds only in raising the arm outwards and hackwards by contraction of the deltoid (circumthe fore-arm hangs vertically. flex) . along with abolition of the olecranon reflex. It is the lower part of the characterised by para- lysis of the triceps. It is any special always accompanied by exaggerated passive flexion of the elbow. After all. atrophy and very seldom RD of the triceps. Lesion at Paralysis of the triceps. and the topographical lesion distri- bution of the paralysis 2. +9. when is not indicated by attitude. for the musculo-spirai its nerve supplies first tricipital branches imaxilla. Fig. in addition to all the other symptoms paralysis. Partial Paralysis of the Triceps supplied by three different branches : The triceps is branches to the internal head. at axilla This is produced by lesions of the nerve and by crutch palsy.—— MUSCULO-SPIRAL NERVE TYPES OF MUSCULO-SPIRAL PARALYSIS These types should be studied 1. and to the external head. nerve irritation or regeneration. Paralysis of the triceps easily passes unperceived unless sought for systematically at rest. compression. to the long head. It mediately below the is seen more frequently in musculo-spirai paralysis associ- ated with that of the circumflex or of the other nerves of the arm resulting from axillary lesions. : 109 According According to the seat of the lesion . to the clinical type produced by the : interruption. . The patient. it is found in its pure state. it . TYPES ACCORDING TO THE SEAT OF LESION I. of musculo-spirai We the note the complete dis- appearance of the movements of extension of the fore-arm on arm . — indeed.

no triceps. the branches of which originate quite close to each other. Only by palpation of RD is . atrophy and of the outer head. for extension persists. dissociated paralysis of the triceps. III. 50. which also supplies the anconeus. one or two centimetres above the branch It is outer head. against resistance. MUSCULO-SPIRAL PARALYSIS ABOVE THE SUPINATOR LoNGUS. often difficult to detect the existence of this partial paralysis of the S Fig. Integrity of the long head and of the inner head paralysis. with more or complete integrity to the of the inner head and the long head. contracting muscle can head. — Musculo-spiral paralysis with extend his arm. triceps.— Dissociated paralysis of the triceps. their disappearance in the case of the outer head. The patient making an effort to Fig. its external cutaneous branch makes . is This that the classic and most frequent type of musculo-spiral paralysis. appearance below the tri- branches its participation is indicated by a faint narrow tract of hypo-aesthesia on the posterior surface of the fore-arm. at the postero-internal surface of the arm. 51. NERVE WOUNDS may produce partial paralysis Lesions between these branches of the In such cases. we recognise the flaccidity and atrophy of the outer Farad ic examination by the bi-polar method also shows the persistence of contraction in the case of the inner head and the long head. by wounds on the external surface of the arm. The The cipital olecranon reflex is retained. we have to deal with a nerve lesion very high up. simple compression of the nerve on a sharp edge. of the fore-arm the and is scarcely diminished at all. We always find paralysis of the less outer head and of the anconeus. fractures of the shaft of the produced .

exceptional for we have always found that paralysis occurs immediately characterised at this level by inaction of the with the wound. 52. Anterior aspect. supplied by the branch to the integrity is indicated by no special attitude or movement. as the anconeus. olecranon reflex is The triceps is is of course untouched. Secondary intact is involvement theoretically in callus . we try to . the compartment of the fore-arm.1 MUSCULO-SPIRAL NERVE humerus with involvement of the nerve tissues. the radial the extensor carpi and the extensors of the fingers. — Musculo-spiral the triceps. be Fig. causing the typical flexed attitude of the hand and of the of the first phalanx fingers. The retained. if it may be a cause of error in electrical examination. with fracture of the humerus. of a it musculo-spiral nerve quite originally possible must. Its is Posterior aspect. Musculo-spiral paralysis supinator extensors. is longus. . 53 and 54. it is no more than a prolongation of the triceps and outer head. this Although muscle is small situated in below the posterior olecranon. however. ulnaris. paralysis below FlGS. but Indeed. 1 1 in the callus or in the surroundino. — Wounds on the external surface of the arm Typical musculo-spiral.

— Paralysis of the supinator satisfactory will be the results obtained. 55. Accordingly usually necessary. elbow and descending on to the posterior surface of the fore-arm. . as may be. the anconeus. make on to the callus trans- a few capable of the mitting nerve. the more flexion of the fingers. the shock enclosed Lesions of the musculo-spiral nerve by involvement larly in callus are particu- likely to induce along symptoms of with nerve pains nerve caused irritation. . may Its be affected by the lesion or remain untouched. tendon adhesions limiting the passive These are cases which call for liberation of the nerve. moreover. Fig. This it the main cause of lack of success after operations. excited by diffusion. and the sooner this is done.— 112 NERVE WOUNDS obtain faradic excitability of the posterior muscles of the fore-arm. and liberations alike. by pressure on and in- muscles. must remember that if the musculo-spiral nerve is found to be enclosed in callus. it is sometimes We rather difficult to bring about the sign of formication at the level of the lesion. musculo-spiral sutures level. Musculo spiral Paralysis below the Supinator Longus fracture Lesions at the lower part of the bicipital furrow. direct traumatism or of the epicondyle. The Operations on nerve at this the . It is necessary to slight taps. to surround the nerve with a muscular or fatty envelope. interruption. . trophic disturbances of digital teguments and articulations. an early stage to massage and mobilise the IV. which emerges on to the external is shown only by a slight on the external surface of the surface of the arm. tracts muscle no longer consynergically with the biceps. below the branch There is then complete paralysis of extension of hand and fingers. and faint narrow tract of hypo-aesthesia. scar. The the case branch. are particularly liable to be followed by secondary involve- ment in the callus or in cicatricial fibrous is is tissue. J?y reason of the proximity of the fractured bone. more than anywhere and at else. .~ longus. may affect the musculo-spiral immediately to the supinator longus. often responds by slight contractions which may be taken for a response of the radial extensors or of the extensors of external cutaneous the fingers. but .

Still. 56. The integrity of the supinator longus might have made one regard it as a functional paralysis. if More the lesion frequently is in the vicinity of the joint we note the in- tegrity of the supinator longus. paralysis of the extensor carpi radialis brevior. nator longus and to the carpi radialis — longior arise near each Integrity of the Fig. weakening of the extensor carpi radialis — longior. carpi radialis electrical ex- amination enables us easily to dissociate these . Origin of the branches to the supinator longus and tothe radial extensors. simple weakenextensor longior ing carpi of the radialis and paralysis of the extensor brevior . 57. whereas the twig to the extensor carpi radialis brevior has its origin much lower accordingly from the posterior interosseous . other from the trunk of the nerve itself. is "3 the untouched and contracts synergically with Several times this we type have in found neglected fractures of the epicondyle with a fibrous loop enclosing the nerve at the level of the line of the fracture.MUSCULO-SPIRAL NERVE the supinator longus biceps. there will often be ob- served weakening of the supinator longus accom- panied by paralysis of the extensor carpi radialis longior. supinator longus. it must that be the remembered branches to extensor the supiFig.

of we may the see the con- Fig. the lesion or else is of the posterior branch alone. Paralysis of the extensors of the ringers. a deviatory . Extension of hand on fore-arm possible. If there is considerable these latter hypotonia muscles. the hand deviates totensors no wards the radial side. 60. Integrity of the radial extensors. the extensors of the thumb and of the index. — Contraction of the is radial ex- traction of the radial extensors raising it hand is by giving out- longer balanced by synergic contraction of the extensor carpi ulnaris . of the radial paralysed The superficial layer of muscles. covering the deep layer made up of the extensor ossis metacarpi pollicis. — Wound on the posterior surface of the Fig. — We find : The untouched there are anterior . 61. this wards the hand and . 59. Fig. Raising of hand is possible but the extensors of the fingers and the extensor carpi ulnaris are paralysed. branch is consequently disturb- no sensory the ances in the hand. — MUSCULOSPIRAL PARALYSIS BELOW THE R. movement because their traction takes place on the radial side of must normally be balanced by the synergic contraction of the extensor carpi ulnaris on the inner side of the wrist. extensor carpi ulnaris and extensor communis digitorum.ADIAL EXTENSORS In this case.ii4 NERVE WOUNDS V. Integrity extensors. below the joint on the outer surface of the neck of the radius or even at the posterior surface of the fore-arm. arm.

63. Integrity The extensor fasciculus to the middle finger may be untouched whilst the underlying fibres are affected. communis digitorum. 64.— MUSCULO-SPIRAL NERVE "5 VI. receives its supply by several twigs different corresponding fasciculi. to the muscular Fig. . Fig. Dissociation of the Extensor radial Communis Digitoru m of the Below the posterior ringers. Fig. and finger persisting we find extension of the middle when the other extensors are paralysed. however. — Dissociated paralysis of the extensor communis digitorum. of the extensor of the middle linger. extensors and the supinator brevis a lesion branch of the musculo-spiral may affect the extensors of the The extensor communis. —Dissociated paralysis of the extensor Integrity of the extensor of the middle finger. 62.

Fig. a twig of which almost always terminates at the extensor of the little finger. 65. the long and short extensors of the thumb and the extensor indicis. 67. Dissociated paralysis ot the affecting the musculo-spiral. may The musculo-spiral nerve by a bony fragment of the humerus. The modified operation performed on this nerve was followed by a rapid return of the functions in the case . very slight Fig. on the other hand. not supinator longus and the radial extensors.— — n6 VII. Consequently we may have isolated paralysis of these muscles from a lesion of the musculo-spiral at the middle of the fore-arm. level with the furrow of the biceps. symptoms confined There was absolute and extensor paralysis of the extensors carpi ulnaris. — Paralysis of the extensors of the at the thumb by wound middle third of fore-arm. Dissociated Paralysis of the Musculo-spiral Partial fascicular lesions of the musculo-spiral are rare. along with complete RD . the supinator longus and the radial extensors had retained some voluntary movements. 66. Fig. the posterior branch of the musculo-spiral supplies the extensor ossis metacarpi pollicis. VIII. seemed to its to present inner part. meet with certain paralysis. — faradic excitability without galvanic polar inversion and also without slow contraction. we which occasion dissociated quote two types of these crushed We lesions 1. cases However. NERVE WOUNDS MUSCULO-SPIRAL PARALYSIS BELOW THE EXTENSOR COMMUNIS DlGITORUM Below the branches intended for the extensor communis digitorum.

the supinator brevis. No operation . as in It is all the other nerves. the extensor communis. somewhat difficult to deter- mainly perhaps on account of torsion of the nerve. — supinator longus. The patient is photographed just as he is extending his fingers. integrity of the extensors . and from front to back. paralysis of the radial extensors and ot the . the supinators on the outer side. There was found to he complete paralysis of the supinator longus and the radial extensors with considerable atrophy and a complete reaction of degeneration. the anterior cutaneous branch. Pierre Marie and Meige. whilst the voluntary mobility of the extensors of the fingers was fully retained along with normal electrical reactions. a fascicular topography. from front to back. each stage modifies the position of the different : But still it must be admitted that we find on the outer side. precisely. Thus mine at it there would appear to exist in the musculo-spiral. 68. the contusion apparently involving only and external part of the nerve. usually flexed in an attitude of repose. . Contusion on the external surface of the arm dissociated paralysis ot the musculo-spiral. Dejerine and Mouzon. persistence of this paralysis three months atter the first examination. (J. the extensores digitorum within and behind. 2. . and A.) According to MM. Fig. we find the extensors of the wrist on the inner side. In another case the musculo-spiral was bruised on the external the surface posterior of the humerus. the radial extensors on the inner side. which fasciculi. the supinator longus. the extensor carpi ulnaris and the muscles of the thumb. whilst paralysis of the extensors and of the extensor carpi ulnaris persisted three months after the operation.MUSCULO-SPIRAL NERVE 117 of the supinator longus and the radial extensors.

by partial This is characterised. 69. 70. . the hand seen to resume its original attitude. — Compression is of the musculo-spiral in callus. — Simple compression of the musculo-spiral is . Persistence ot muscular tone. paralysis "a frigore. as a result of the muscular elasticity. If we on the hand. we cease Fig." Persistence of muscular tone. and the hand assuming the attitude of complete interruption. we may intensify the flexion . especially in preservation of muscular tone for a long period.— n8 NERVE WOUNDS FORMS OF MUSCULO-SPIRAL PARALYSIS ACCORDING TO THE NATURE OF THE LESION I. Syndrome of Compression musculo-spiral paralysis. The than in droop of the hand press slight. pressing. Fig. we find hypotonia becoming pronounced. In the long run. very little if at all more pronounced if the position of simple muscular repose. however.

by compression by callus Hypotonia very pronounced. Hypotonia very — pronounced. Complete section of the musculo-spiral (a separation of 3 cm. prognosis of these forms and muscles below the lesion. of the humerus. 72. Syndrome of Interruption In complete interruptions. 71. between the two segments) at the upper part of the furrow of the biceps. we find that muscular atony rapidly appears and becomes more marked. the incomplete character of the of a slight degree of muscular sensation. and the persistence in slight cases of compression of the musculo-spiral that we may sometimes find by electrical examination the paradoxical preservation of faradic contractility of the nerve The ment.— Complete in a fracture interruption of the musculo-spiral. on the other hand. FlG. Fie. It is RD. the cure comes is particularly benign . about spontaneously in a few weeks. . being accelerated by electrical treat- II.— MUSCULO-SPIRAL NERVE With the conservation of tone is 119 relative associated the absence of muscular atrophy.

of fractured humerus. for it is . muscular analgesia complete. Complete interruption of the Crushing of the nerve and involvement — in callus musculo-spiral.120 NERVE WOUNDS The droop of the hand at the wrist is complete is it : pressure on the back of the hand does not intensify this attitude nor return to the normal attitude. atrophy of the muscle and is RD rapidly appear . Fig. 73. the outer surface of the humerus.) Complete No great reliance must be placed on the fixity of anaesthesia. (In this case there also exists a very slight ulnar griffe. followed by an elastic Fig. Extreme hypotonia. On the other hand. — Section of the musculo-spiral on hypotonia. 74. nine months previously.

on that pressing the nerve at the itself level of the lesion. may . extreme degree ligaments relax. as it is unaccompanied by the acute but slightly sensory its intolerable pains which is characterise neuritis in other nerves. . . Syndrome of Nerve Irritation in the Nerve irritation musculo-spiral it nerve is very frequent. is found to be particularly painful to pressure the antibrachial muscular masses are somewhat tender if pressed occasionally we find radius . lengthen hand is . is . often disregarded. Muscular hypotonia. in spite of the slight importance of sensory it disturbances. slight hyper-aesthesia of its cutaneous region. III. The in musculo-spiral. for reason of the involves a somewhat serious prognosis by it tendon adhesions and articular limitations which Fig. Nerve irritation of the musculo-spiral. it is hanging loose the flexors have ended by losing all action and now exhibit functional inertia from disuse. an . The nerve is at most slightly sensitive the point where the posterior branch crosses the neck of the . Droop or the hand less pronounced. 75. the tendons flexion of the hand reaches an angle of 90 and even more the no longer simply flexed. we must repeat. reach after : some months of complete the articular interruption. it is — duces. had they not retained their normal electrical reactions. Still. Extension of the fingers by contraction of the extensors and adhesion of their tendons to the dorsal surface of the hand. irri- tation consequently not expressed by the painful syndrome of neuritis the ulnar and especially the median. which in certain cases might make one think they were paralysed. and pro- important to investigate.— MUSCULO-SPIRAL NERVK well 121 in known Still. that amesthesia may be extremely reduced musculo- spiral paralysis. is always found formication manifests on the dorsal surface of the thumb and of the second metacarpal.

flexion. disappearance of . — Nerve irritation. place by their to the dorsal surface of the carpus Adhesion of the extensor tendons and is fingers limits or such that it considerably even makes impossible flexion fingers. are sometimes felt to be induinfiltrated. the droop of the hand is less pronounced. longer usual have in we fingers musculo- spiral paralysis they remain extended in on the hand. festations. Impossibility of flexion. of the whether active or passive. and painful under the pressure. desquamation of the epidermis in fine scales. Nerve irritation. Confirst phalanges. 77. muscles flexion of the wrist diminished by fibrous adhesion of the tendons and contraction of the extensor which rated.122 NERVE WOUNDS But whilst sensory disturbances are reduced to these scattered manion the other hand. adhesion of the skin on the dorsal surface of the fingers and first particularly at the level of the digital articulations. trophic disturbances. may be seen — intensified in hyper-extension. The racteristic aspect : of the hand is cha- fibrous infiltration of the dermis. active or passive. Acute pains caused by attempts at The attitude is different is . Pi G. Even if pressure be exercised on the dorsal surface of the hand. Tendency to hyper-extension of the siderable limitation of flexion.76. the attitude of the rigid fingers Fig. half-flexed No . Spontaneous hyper-extension of the fingers. are very important. held contracted tendons.

78. than in neuritis ulnar. however. in cutaneous region of the to musculo-spiral. irritation Fig. the middle third of the fore-arm. thumb. MUSCULO-SPIRAL NERVE of the fingersare very pronounced 123 the cutaneous creases. (In this case the wound is located at musculo-spiral paralysis. Hyper-extension pressure on the the posterior branch or musculo-spiral. hand. The nails. except slighl weakenSevere irritative lesions in the ing of the extensors of thumb and index ringer. are due to . rigidity of the fingers ami tendon adhesions. far less affected of the median and the is For it known that last dorsal innervation of the is phalanges mainly supplied by the palmar All these nerves. °f th e . caused by dorsal surface or the hand. This of the is one to think that they mainly .— Nerve irritation of the musculo-spiral. distributed over the five interosseous N Fig. being pronounced inclines in the case of index and middle fingers. 79. as we know. Smoothness and fibrous infiltration of the skin. It is impossible to flex the fingers. disturbances first not only exist on the the fingers. are simply curved. — Nerve fingers irritation.. which. they extend the entire hand and fingers.) No . swelling of the digital articulations or rather tapering they sometimes recall the appear- ance of of chronic blennorrhagic rheumatism or of certain types arthritis deformans.

NERVE WOUNDS Moreover. 80. even after healing. Syndrome of Regeneration Regeneration of the muscles takes place from above downwards. we find the persistence Fig. one may see isolated all the trophic disturbances of neuritis of the posterior the musculo-spiral in wounds of its branch of the at the musculo-spiral. tion of the fingers is extremely painful. — united to the dorsal surface of the metacarpals and the digital articulations. continue for months and years they may constitute actual accompanied by almost total incapacity of the hand. supinator longus. prolonged flexion of the hand produces an actual lengthening of muscles and tendons This lengthening of muscles lasts for a considerable time. Mobilisa- of flexion of the hand and fingers resulting from adhesion of the tendons united to their synovial sheaths and from the fibrous infiltration of the periarticular tissues . when the muscles have lost their fibrous consistence and regained their functions. unless a partial obstacle to the regeneration of a nerve fasciculus create a dissociated paralysis.I2 4 spaces. All the movements have reappeared. the pains have disappeared. Then we find the muscles successively resuming their movements . Neuritis of the musculo-spiral. however. for. who have recovered the movements of their radial and other extensors are . healed three months previously. atrophy has lessened. flexion of the ringers is still extremely limited. even at wrist. in the fore-arm. however energetically it is attempted the extensor tendons are . and we find that patients. is Neuritis of the musculo-spiral particularly serious on account of its consequences . radial and other extensors. After three months of massage and mobilisation. lower part or almost below all its motor branches. infirmity. But when paralysis has lasted some time. these fibrous sequela?. refractory to mobilisation . and massage. following the path of the axis-cylinders.

To may assure oneself of the complete cure of musculo-spiral paralysis. 1915). the last to resume their functions. matter of fact. — lengthened. 81 and 82. the extensor tendons. "I cannot raise When ! I wish to stretch out as a my fingers. one in request the patient to extend his hand the position adopted little when taking an oath or ask him to stand at attention. I wish to raise my hand. sutured on the 10th of June. 1 9 1 5. are powerless. I am compelled to bend my hand " And. when Two Impossibility of simultaneous extension of hand and fingers.MUSCULO-SPIRAL NERVE temporarily incapable of executing simultaneously the 125 movements of these two muscular groups. as a rule. December. "When my fingers." says the patient. attitudes of the same patient after regeneration of the musculo-spiral (divided at tinPhotographed 20th external surface of the arm. his finger touching . Figs. unless the patient stretches them by previous flexion of the wrist. The extensors of thumb and index are.

these movements are possi- they may be called forth by the will. In these which are usually somewhat complex. istic is very similiar to musculo- But. any defect of the musculo-spiral is indicated by the impossibility of effecting the complete supination thus called for. 2. or. causes of error must be mentioned. Destruction of the muscles of the fore-arm. though he experiences great difficulty in raising his especially in keeping it hand and ble . loss of muscular substance. still. by faradisation. 83. although what remains of the muscle has retained its faradic excitability. cases. or again. a frequent occurrence. — a Violent bruises and injuries of the antibrachial muscles. Almost complete Cicatricial contracdestruction of the radial extensors and of the extensor communis. extended. traumatic lengthening by of their tendons.) DIAGNOSIS OF MUSCULO=SPIRAL PARALYSIS Three main i. cicatricial adhesions and a certain degree of functional inertia of the traumatised muscles are associated most frequently with the nerve lesions in causing loss of motion. — of the wounded muscles which does away with the paralytic attitude and renders the extended hand motionless. or even simply the prolonged attitude of the hand in a state still more curious thing — of flexion. there takes place secondarily a cicatricial contraction Fig.126 the NERVE WOUNDS outer seam of the trouser leg . . if need be. (Pities and Testut. though the patient appears in the attitude character- of this paralysis. Hypotonia and lengthening of the radial extensors and other muscles traumatism or prolonged mal-position. often induce so pronounced a muscular hypotonia of the radial extensors and other muscles that the result spiral paralysis. Droop of fingers is complete. tion of the radial extensors causing immobilisation ot the hand in a state of extension. Large wound on the posterior surface of the fore-arm. Speaking generally.

in obstinate cases. . Voluntary motion. itself 3. crushing or section of the tendons of the radial extensors.MUSCULO-SPIRAL NERVE This muscular lengthening slowly improves with the use of tion. . Attitude of musculo-spiral paralysis with extreme at the cost of hypotonia of the muscles. is retained Considerable effort the patient is able to raise his hand. — .) ~'r3?TJF: Wound on the antero-internal surface of the arm. •Tvorn for 13 months'. . but a comminuted fracture of the humerus. exercise 127 faradisa- and massage . (Delorme. bring about a similar attitude difficulty in extension of the hand. . Hysterical paralysis of the hand almost always presents under the guise of musculo-spiraljparalysis. Prolonged immobilisation. 86. whilst tending to lengthen them. — Wound on dorsal surface of the wrist with contusion and lengthening of the tendons of the radial extensors. shortening or plication of the tendons of the radial extensors may be practised. Sling all. No paralysis at Figs. Fig. 84 and 85. however. Simple contusions and the same also.

as a result of com- pression during sleep. is not sufficiently pronounced to cause degeneration of The latter continue normal below the lesion . the mental state of the subject. in not trust to electrical examination alone. readily enable a diagnosis to be made. cells in the cord on This pression. it often happens reactions. 87.compression. the muscles have This is would appear that nerve. voluntary paralysis is complete. nevertheless. Thus. the disproportion between wound and paralysis. normal electrical the paradoxical phenomenon described by Erb. their motor character and the sign of the supinator longus enable them to be easily recognised. a slight compression arrests the nerve impulse as does electrical excitation. . without interrupting the trophic action of the nerve the peripheral axis-cylinders. — nerve and muscles below the lesion have retained their normal electrical reactions . for musculo-spiral paralysis a frigore. Crushing of the radial tendons and extensors at the level of the wrist caused by the kick of a horse. musculo-spiral from comwithin although the rapid cure of these compressions few weeks. persistence of electrical reactions. The segmentary anaesthesia. even absence of any wound. sufficient to interrupt the voluntary nerve impulse. just as extension is. however. that flexion is impossible. we must that. of the nerve at the upper part of the Finally. ignorance of the fact would expose one to the risk paralysis resulting slight of regarding as functional. the supinator longus does not contract with the biceps. though at the cost of considerable effort. a is important . Attitude of musculo-spiral paralysis has persisted for 6 years. Still. It retained their Fig. Lengthening of the tendons. Voluntary extension of hand and fingers is possible. the the axis-cylinders. electrical stimulation but produces no arm movement whatsoever of causes contraction of the triceps the antibrachial muscles.i28 It is NERVE WOUNDS soon seen.

Persistence ot electrical reactions. or are to be obtained. Attitude of musculo-spiral paralysis. common to all nerve we must insist on the Hysterical paralysis of t hcFigs. 129 we may hold in the case of musculo-spiral paralysis. a during the whole period of the paralysis. an armlet or leather glove. Slight wound at the level of the wrist. 88 and 89. hand of 12 months' standing. — necessity of keeping the hand in an extended position. spring appliance of which many models 9 . We apply either a plaster splint.MUSCULO-SPIRAL NERVE TREATMENT. Apart from the therapeutic ideas lesions. even hyper-extended.

—Spring appliances intended it to correct incapacity of the extensor muscles of the hand and fingers in musculo-spiral paralysis. Lemoing's glove (imitated from Sollier's apparatus). With this apparatus. — A All these appliances not only enable a patient to use his hand and and thus avoid weakening of the flexors through inaction. (Apparatus of Pierre Marie and Meige. 92. (Apparatus of Pierre Marie and Meige. To obtain elevation of the first phalanx is sufficient.) Fig. Aluminium splint fixed by broad leather armlet to the fore-arm. 90. fingers . also permits of objects being grasped. Fig.) — Fig. 91. since the last two are extended by the interossei. A leather ring fixed to a spring keeps the thumb apart. Hinged support allowing the hand to be maintained in the desired position by altering the angle with the fore-arm. small springs produce extension of the fingers by traction on leather rings. steel plate forming a spring is applied to the palmar surface which it elevates . they also do away with muscular lengthening from the prolonged flexed position.' patients are able to write and to roll cigarettes. It permits of flexion of fingers and hand (which are preserved). The apparatus is fastened to the fore-arm by a long leather armlet.130 NERVE WOUNDS The application of rubber bands or springs to the first phalanges will permit of extension of the fingers.

— Apparatus of Mauchet and Anceau.MUSCULO-SPIRAL NERVE '3 1 Fig. . 94. 93. — Lcri and Dagnan-Bouveret apparatus tor musculo-spiral paralysis. Fig.

ulnaris round the inner side of the elbow to reach It passes under the flexor carpi its and then descends along external edge resting on the flexor profundus. behind the median It is nerve and the brachial artery. passes into the posterior Figs. is ulnar and the brachial The internal cutaneous. a little beyond the internal cutaneous and the lesser internal cutaneous. perforates intermuscular tum. closely united with them find as far as the this is lower third of the arm so why we the frequently associated. Starting at the lower third of the arm. lesions of the median. covered by the epitrochlear muscles and the superficial . artery. 95 and compartt fo e 96. to descends internal front of and in the neuro-vascular bundle. It traverses the axilla and descends to the inner side of the arm. and flexor. ment Qf arm am j then into the epitrochlear groove.— Course of ulnar and median (diagrammatic). the ulnar separates from theneurothe internal sep- vascular bundle. CHAPTER VII ULNAR NERVE ANATOMY The It ulnar nerve is supplied from the lower roots of the brachial plexus first dorsal).. at this level. which more superficial. (eighth cervical root and is given off from the inner cord of the plexus along with the inner head of the median. In the fore-arm it passes the anterior region of the fore-arm.

. (ext. It it is thus descends along the flexor carpi ulnaris right to the pisiform canal. br. spir. cut. of here confined in the carpal which it occupies the inmost part. cut. Ulnar N. Motor Branches The ulnar supplies no branch whatsoever to the arm. Int. N. Median N. it To the fore-arm supplies us.) Anterior aspect. At this level it gives off its two terminal branches Superficial palmar branch (sensory).-spir. to biceps."! Iut. The nerve twig to the flexor carpi ulnaris. 1. (ant. Br. to coraco-brach. amicus Anastom. the hand. Br. — Deep nerves of the arm for the (after Sappey). 2. . Deep palmar branch (motor). N. N. Mus. cut. destined for the three muscles of the hypothenar eminence 2. It supplies Three nerve twigs . The nerves destined for all the intcrossei. The deep palmar branch alone is motor. Mus. To 1. both palmar and dorsal .— — ULNAR NERVE — *33 . Mus. 97. br. Two motor branches two internal fasciculi of the flexor profundus digitorum. to brach. cut. with median and musculo-cutan. Fir. N.

br. Inteross. exor carpi radialis Flexor carpi ulnaris Tendon superfic. -Ulnar N.) Ulnar N. (deep br. Brachial artery Ext. the inner head of the flexor brcvis . br. Muse. cut. flexor Ext. palmar. carp. -spiral N. Ulnar artery Median N. — Deep nerves of fore-arm pollicis. br. -spiral N. N.) Pronator radii teres Muse. The nerves destined for the adductors of the thumb and for.) Flexor carpi radia Median N. Opponens Anterior aspect. longior Radial N. carp.) Opponens.J 34 NERVE WOUNDS twig to the inner side of little finger. -Median N. Ulnar N. (dors. (sup. br. Supinator longus. 3. 98. radial. its internal branch supplies the digital collateral Its the external branch supplies digital collateral twigs to the little contiguous sides of the and ring fingers. radial. Supinator longus Pronat. ami hand (after Hirschfeld). cpuadrat. (post. brevior Radial artery Ulnar N. Fig.

branch supplies the its digital collateral twig to the inner side twigs to of the little finger. follows the ulnar artery. The branch to the ulnar artery which begins at the middle third of the fore-arm.) Musculo-cutaneous N. (Ext. brach. becomes subcutaneous at the level of the wrist and goes on to supply the skin of the inner side of the wrist and of the hypothenar region 2.—— ULNAR NERVE Sensory Branches In the hand. — Superficial nerves of fore-arm and hand '(after Sappey). branch) ) j Inter. The . (ant. external little branch supplies digital collateral the contiguous sides of the and ring fingers. In the fore-arm the ulnar supplies Inter. 1. dorsal cutaneous branch of the hand begins at the middle third of the fore-arm. and becomes region of wrist and dorsal it distributes itself over the skin of the dorsal hand. (post. 99. brach. cut. On its inner side it supplies . branch) Radial nerve Musculo-spiral N. (post. branch) Ulnar N. cut. . passes over the inner border of the ulna.) Musculo-spiral N. (dorsal ) ) iranch) Posterior view. the superficial palmar branch Its internal is 135 exclusively sensory. Fig. (collat.

Trophic and Articular Branches The ulnar supplies twigs to the articulation of the elbow. for the little finger. Posterior surface. and. to the palmar aponeurosis and to important. to the articulations of the carpus. to the ulnar artery. The . — Motor supply of the ulnar. Posterior surface.136 NERVE WOUNDS The The dorsal digital collateral of the little finger . the interosseous spaces. supplied by the become spent. We shall find that the trophic role of this nerve is PHYSIOLOGY OF THE ULNAR NERVE Motor Syndrome The ulnar nerve supplies 1. just as the its thumb radial. FlG. ulnar. All the interossei and the inner two lumbricales Anterior surface. 4. The flexor carpi ulnaris : of Ulnar Paralysis and the two internal 2. fasciculi of the flexor profundus . finger and the contiguous margin of the ring-finger The It digital collateral of the outer side of the ring-finger and the con- tiguous margin of the middle finger. supplied as far an exception should be made as its extremity by the dorsal collaterals of the ulnar. dorsal digital collaterals of the little . 100. as do those supplied by the musculo-spiral. the short flexor of the thumb (inner head). partially. Hand. is supplied right on to extremity by the dorsal collaterals of the Vasomotor. two phalanges. . Fore-arm. Anterior surface. must be observed that the dorsal collateral nerves. towards the extremity of the first phalanx. muscles of the hypothenar emi- nence 3. The adductors of the thumb. It is the palmar collaterals which last supply the dorsal surface of the Still.

It will be re- marked lanx is that flexion of the second pha- on the first easily brought of about FlG. flex. Adduction of the hand carpi T.ULNAR NERVE i. (action — the superficial flexor inserted into the lanx). the radial side. also possible by the extensor ulnaris (musculo-spiral Insist. prof. contract. but in this movement felt to the tendon of the is flexor carpi ulnaris no longer is ^Crossing of tendinous fibres. second phathe On other hand. accompanied by a certain degree of articular rigidity of the fingers offering some resistance to flexion. Paralysis of the two is inner heads of the flexor profundus shown only by diminished flexion in the last two fingers. If it is paralysed. flex. 102. superficial flexor the hand towards 2. flex. flexion . its paralysis pro- tendons and is their insertions. In the normal state. protund. sub. of the flexor carpi ulnaris produces a slight in- clination of the hand to the -Flexor ulnar side . but it is ened and is weakaccompanied by greatly hyper-extension of the hand. The duces a slight inclination of inserted into the second phalanx. Action of flexor profundus in a patient suffering from paralysis of the median. The strong contraction of the flexor profundus causes primarily flexion of the last phalanges of the two inner fingers. the flexor profundus into the third. of the hand remains possible through the flexor carpi radialis and palmaris longus (median nerve). the tonicity Insist. nerve). flexion Bifurcation. m flexor The flexor carpi ulnaris is same time a flexor of the hand on the fore-arm and at the Iendon 6ublimh an adductor of the hand.

two. movements of the opponens little finger produced by the abductor. for these fingers. of the index and the middle finger (median nerve). —The palmar interossei are adductors nt the fingers. In ulnar note that is paralysis. then the is first phalanx fingers. 4. flexion — Action by the ulnar. and the minimi the in- Interosseous muscles. are the true flexors of the first B" % phalanges on the metacarpus. — All terossei. is in spite this of ulnar is paralysis. 104. striking of the interfirst of the phalanx. for their role is most important. extension of the last two phalanges. if we request the patient to flex his fingers. impossible. the of flexing feebly interossei they are capable the first phalanx of these fingers and of extending the last two. is — Paralysis of these muscles by of the appropriate indicated by . muscles. not so r much from lack of contraction of the flexor profundus as from paralysis of the interossei. ^m ^H fefeb' - \ which 3. make good. ^^^j Muscles of the hypothenar eminence. Complete of the fingers is still possible. however. atrophy of the hypothenar eminence by the disappearance of the vertical puckering of the skin produced by the palmaris brevis loss . At however. 1. of the may partially supply or . Their paralysis is by far the most change produced by lesions of the ulnar. If it weakened. first takes in the last two phalanges. both dorsal and palmar. the last very weak. ossei . The action lumbricales muscles. 103. flexed as though by progres- sive rolling up of the of this is by traction the last flexor stage. . the brevis flexor digiti. The interossei are flexors of the first phalanges on the metacarpus and extensors of the second and third phalanges on the first. flexion phalanges. are supplied Fig. The action of the interossei flexors of the first totally phalanx flexion — is absent place .— i38 of the last NERVE WOUNDS phalanx on the second only takes place flexion in the case of the last two fingers (action of the flexor profundus inserted into the third phalanx). we flexion of all the phalanges not simultaneous. first Isolated flexion of the with extension is of Fig.

servation of these disturbances difficult if and requires much care precautions are certain not taken. The palmar interossei The dorsal interossei arc *39 arc adductors of the fingers. however. On the other hand. Indeed. ad- mits of several limitations. on condition.ULNAR NERVE 2. that he Lateral flex them slightly. They must be sought for by placing the hand in on a table plane. the extensor communis digiterum (musculo-spiral nerve) is also an abductor. abductors of the fingers. Ulnar paralysis abduction of the fingers is still possible by the action of the extensors (musculo-spiral nerve). 106. 105. abductors of the fingers. but extension of the fingers The dorsal interossei are Fig. however. The patient fingers forcible is may with therefore separate his his extensors. his fingers nor Consequently. movements by the interossei are accompanied neither by PlG. conse- — also noticed. . the flexors of the fingers are adductors : quently the patient may draw together the separated fingers. as it is masked by substituted movements. the paralysed subject can neither separate bring them together. one may altogether misin- terpret an ulnar paralysis. The projections produced by contraction of the extensors are clearly seen. Obis . 'or a plane surface and working them" a strictly horizontal . — extension nor by flexion. This statement.

adduction of the outer two ringers remains possible by the lumbricales.140 NERVE WOUNDS Even in these conditions is we note that approximation of index and middle ringer possible through the action of their lumbricales and the is extensor of the index which slightly adductor . 108. for instance. — or the object is taken between the extremity of the Fig. in the case of a wounded man with ulnar paralysis. Presse MeJicale. In order Fig. resulting (ulnar nerve). possibly be simulated.l P a P er . thumb into and index are each other closely applied is over each other. two movements are t?vu c j Elther *. plete of the ulnar it is the only movement which cannot Thenar eminence.) thumb and that of the index set opposite each is other to form a sort of .— Ulnar paralysis. Adduction of the fifth is impossible. (Froment. by the flexor longus retained to In ulnar paralysis. only the last two This fifth fingers loss cannot approach each other. pincers. 191 5. mutually fitting from the contraction of . it the . — The ulnar sup- plies entirely the adductors of the thumb. the adductor of the thumb and from the inner head of the flexor brevis prehension energetic. and partially the flexor brevis. 5.S firml 7 ? raS P ed the • 1 between the body of the thumb and the of the half-flexed index . Paralysis of the adductors can easily be discovered. to grasp a small object. a sheet of paper. adduction on the part of the is of finger often the only sign paralysis that shows com. between the thumb and -i 1 « P 0SSlble base the index. prehension then weaker though more delicate it is effected by the action of the opponens (median nerve) aided poll icis. 107. the latter type of prehension is . — Position afflicted of the left thumbs in forcible prehension. teristic Apart from the characis atrophy of these muscles paralysis adductors sign of the recognised the by sign the prehension or thumb of Froment.

On the anterior surface. the thumb applied against the index by the action Q f t ^ e on g extensor of the thumb (musculo-spiral) which is seen to project. the entire inner edge of the hand. R. However. Dumas and R. Presse Midicale. 109. rotation outwards of the thumb. no. 141 The former type of prehension by . and . the . — Sensory region of the ulnar (diagrammatic). (H. adduction hold is abolished or rather it is very feeble the patient cannot firmly the paper which he grasps and est which the slight- traction causes to slip through is his fingers. Polak.ULNAR NERVE patient almost always has recourse. Adduction of of the fingers in a state of flexion. Paralysis of ulnar nerve with contraction Fig. but this action is is and then accom- panied extension by an obvious . This by de- why he usually has reto course prehension opposition. a rally slight is gree of adduction retained . gene- thanks to the long extensor of the . separated passing through from the region of the median by a middle of the ring-finger. vertical line I. It comprises Fie. thumb feeble. Claude.) j — Sensory Distribution — Sensory is Syndrome definite : The sensory region of the ulnar far more and far more extensive than that of the musculo-spiral. 191 5.

" 1 st zone.) complete. Anaesthesia in complete section of the ulnar. the entire ulnar edge of the hand. he says " touch. 2. as a result of over- lapping by the median nerve. 3rd zone. from atrophy of the interossei and relaxation of the intermetacarpal ligaments and . extends upwards some centimetres on to the ulnar border of the is fore-arm. are rarely seen on the ring-finger and dorsal surface of the middle finger. we notice the existence of deep sensation and tactile hypo-aesthesia. hi. as far as to a vertical line passing along the It also middle of the middle finger. mainly in the case of the fifth finger and the ulnar edge of the hand. The anaesthesia arising from section of the ulnar almost always very Fig. On the dorsal surface. affecting both the superficial and the deep sensibilities." " pricks a little " (simple hypo-resthesia). he replies 2nd zone. which. We must also neglect which sometimes happens. he says : : — : : (Semi-diagrammatic. As we approach the middle line. We now studying the muscular atrophy which naturally accom- panies paralysis of the muscles and gives to the hand the characteristic appearance of ulnar paralysis. on examination by pin-prick " nothing. however. the three zones correspond to the answers given by the patient.142 It passes NERVE WOUNDS some centimetres upwards to the lower and inner part of the fore-arm. Trophic and Vaso-motor Syndrome The trophic role of the ulnar nerve are not is an important one. for the moment true dislocation of the hand carpal in sections of the ulnar nerve.

01 slight intensity galvanic baths. Lesion of the ulnar at the middle part of Fig. in complete section of the nerve. for instance. consequently of the beyond the cutannerve. cn ilblainS. region is This readily understood when we remember the — course of the deep palmar branch which would seem to play an important trophic Simple suppression of the functions of the ulnar. lea —Section of the ulnar above Trophic ulcers that the epitrochas a by slight ' injuries. etc. c ' (10 to 15 milliamperes). but that it may also reach the entire palmar fasciae as well as the synovial fibrous membranes tendon sheaths and of the flexors of middle finger and going eous index far . we may find ulcerations. In complete interruptions of the ulnar. we shall not insist on the important trophic disturbances which — accompany ulnar. in the fifth. which would almost suggest vascular . Their slow rate of healing fragility is a sign of special of the skin and of insufficient trophic action. This appearance a is some- times extremely pronounced we see the little finger swollen. often shows cutaneous trophic disturbances and Very frequently there is found a state of dryness of the skin throughout the entire distribution of the nerve. shining with a bright red or a dark violet tint. is it sometimes accompanied by a branny desquamation or even by an active scaly appearance. disturbances. have appeared result or a simple galvanic bath. neuritis of the that They show action trophic does not simply extend to the inner part of the hand. 113. interesting vascular changes. Finally we often notice a certain degree of redness or cyanosis in the inner two fingers and particularly . Complete interruption. limited to the cuta- neous region of the ulnar. role. Finally. ii2.ULNAR NERVE aponeuroses '43 permitting hyper-extension of the first phalanges and abnormal mobility of the metacarpals on one another. burns. no neuritic the fore-arm. readily provoked FiG. Scaly desquamation of the skin in the cutaneous distribution of the nerve.

flexors. the disturbances of which are rarely manifested except in movements of the fingers. Separation of the fingers (dorsal interossei) tution of the extensors.144 obliteration. in the case of the index and the middle finger by means of the lumbricales (median). interossei) possible. first. I. second. who are predisposed to cyanosis of the extremities they are really no more than a local exaggeration. Whatever the seat of the lesion. last two phalanges on the (interossei) is still though feeble. nerve irritation or dissociated lesion. frequently overlooked because of the numerous muscular substitutions we have studied above. first tension of the other two (difficulty and fatigue Extension of the possible. there is no occasion to examine in detail. NERVE WOUNDS These vascular disturbances are chiefly found in those . powerful flexors of the that first phalanx. complete or incomplete inter- ruption. favoured by vaso-motor paralysis. may is be effected by substi- Adduction of the fingers (palmar by the action of the the middle finger. of paralysis of the interossei. we will simply which distinguish in the injuries of the nerve above the epitrochlea from interruptions carpi ulnaris fore-arm below the flexor and the flexor profundus muscles. of paralysis of the two inner heads of the flexor profundus (flexion of the third phalanx on the second : does not take place) . though weak. . We may compare with this fact the frequency of chilblains found in predisposed subjects.— SIMPLE COMPRESSION OR RECENT INTERRUPTION OF THE ULNAR is Paralysis of the ulnar it is often difficult to recognise in these conditions . TYPES OF ULNAR PARALYSIS The ulnar being essentially a nerve of the hand. It must be remembered that flexion of the fingers is preserved by means of the superficial flexor and the two external tendons of the flexor profundus (median). This causes great difficulty in first performing movements require considerable flexion of the phalanges along with exin writing). as in the case of the musculo-spiral nerve. but opposition still exists (median). in the distribution of the nerve. the syndromes resulting from lesion of the nerve at different levels. the posture and the motor disturbances are approximately the same. or laterally. by the lumbricales of the index and Adduction of the thumb has disappeared (although imperfectly replaced by substitution of the long extensor). Minute examination is needed to see that it was weakened this weakening is the result. indicate the slight differences In passing. The various syndromes result mainly from the nature of the inquiry.

ulnar paralysis superficial examination. as are the adductors of the thumb. — Same figure as above. 115. 1 14. The hand somewhat the hypothenar eminence is slightly atrophied. may frequently pass unnoticed on a Fir. two The position is not so clearly characteristic as one might expect from the classical description.. Ulnar griffc is is often scarcely perceptible. 10 .ULNAR NERVE and a methodical examination is '45 required to distinguish them. Hand the ulnar above the epitrochlea (photograph taken in a state of rest. with maximum extension. simple type of ulnar griffc.. In these conditions. — Complete section of after the months wound). flattened . by investi- gation of the prehension sign of the thumb. Ph.

extensors of the last two fingers is due to suppression of the two phalanges the fingers become flexed . . Tonic action of the superficial flexor (second phalanx). If the nerve is injured below the motor branches which it supplies to is the flexor profundus and extensor carpi ulnaris. and there takes place the typical ulnar with semi-flexion of the fourth and particularly the fifth fingers. The other fifth still slightly flexed. hypotonia of the becomes pronounced. as well as but the fingers are extended. whilst the third is but slightly flexed on the second. though in less degree. and merely the result of contraction of the lumbricales.146 NERVE WOUNDS We see when the hand is at rest that the fifth finger is slightly flexed. 116. and that we must of the test last their resistance when extended to ascertain extension two Fig. interossei griffe if ulnar paralysis persists long enough. Note the marked flexion of the second phalanx on the first. owing to the tone of the superficial flexor. of the ulnar —-Lesion previously). affects almost exclusively the second phalanx (superficial flexor) the third phalanx (flexor profundus) remains almost fully extended. note that extension not absolutely complete digit is . paralysis of the flexor profundus (third phalanx). The description just given of ulnar griffe in recent sections or compressions of the nerve. hand and the hand fingers. Nevertheless. is but the partially extended. This slight flexion of the inner interossei. the attitude is not much more is We fourth . above the epitrochlea (complete section three months which gradually appeared about six weeks after paralysis. This flexion . is If the patient requested to extend vigorously his characteristic. also the fourth. the position of the hand slightly different. applies mainly to injuries above the epitrochlea. Typical ulnar griffe phalanges is very feeble.

flexor carpi ulnaris. We do not find the fibrous. is which is effected by the of course retained. on the in the No first . becomes and A. about two months after the wound. 17. irreducible transformation which characterises the . above or below the flexor profundus. supple. Three months after suture. is it is. lesion whether resulting from always slight . thus.) ULNAR NERVE The obvious ulnar griffe occurs earlier and is '47 It more pronounced. (Note the projection of the tendon of the flexor carpi ulnaris. as may happen sometimes in complete and long-standing interruptions. moreover. then. essentially a soft. FlG. suture of the nerve two months after the wound) ulnar griffe has graduallyappeared acquiring the typical form. intractable. longer does it consist of simple flexion of the second phalanx is the third phalanx role also flexed. there is no fibrous contraction whatsoever keeping the fingers flexed. with the growth of the axis-cylinders and the return of tonicity and contractility in the flexor profundus the profundus remains paralysed claw-like attitude of the last two fingers is seen to take shape and to become pronounced. (J. clearly shown course of nerve regeneration epitrochlea. In all these cases. easily reducible S r 'ffi'It is and A. in a section of the ulnar above the we find ulnar griffe but faintly perceptible. it has become modified by progressive flexion of the third phalanx.) profundus. adduction with flexion of the hand. Dejerine and Mouzon. i — . Ulnar paralysis (nerve in course of regeneration) through lesion of the nerve above the epitrochlea (complete section. the flexor profundus having regained its tone and its function*. flexor owing to preservation of the Dejerine and Mouzon. Finally. ulnar griffe caused by recent injury of the nerve. as long as the flexor . is The of the flexor profundus in ulnar griffe .) due entirely to loss of power and tone of the (J- interossei .

resulting from contraction of the muscles and tendons. as in all cases of complete interruption. easily reducible griffe. griffe of neuritic origin. 118 and 119. This It may is be established as an almost absolute principle that every fibrous . with the exception of very slight flexion of the fifth linger caused by fibrous contraction of the tendon. Figs. . from fibrous transformations of the palmar aponeurosis and the adhesions contracted between the tendons and their synovial sheaths. griffe caused by complete section or" nerve in fore-arm a soft. without complete interruption of the nerve it is always accompanied by pain on pressing the muscles and nerve trunk and by some trophic disturbances. — Ulnar is (5 months).i 48 NERVE WOUNDS ulnar griffe of nerve irritation.

during the first two or three months. After two to three months. This hyper-extension maybe limited to or most pronounced in the two fingers. strikingly interossei.ULNAR NERVE II. forming by tendons a sort of band on the dorsal surface of the metacarpals. the . have hyper-extension of the this first phalanges. complete interruption is more Fig. opposes hyper-extension of the fingers. as in the other nerves. at the level of the lesion. an it hyper-extension by passive movements certain patients. to syndrome of interruption from that of compression. the more rapid and complete appearance of the RD . and the analgesia of nerve and muscles. Duchenne of Boulogne has shown that the action of the interossei alone.— SYNDROME 149 OF PROLONGED COMPLETE INTERRUPTION It is distinguish the somewhat difficult. however. may their be quite extraordinary in Indeed. but it may also show itself in the last three or even in last all . 1. we effort. brought on without attempt is when the made to obtain patient tries to extend his fingers or when . 120. which is moreover far rarer in the ulnar than in the musculo-spiral. First. — Hyper-extension in of the last two fingers (by hypotonia of the interossei) prolonged ulnar paralysis. greater rapidity and intensity of hypotonia and muscular atrophy the fixity of sensory disturbances. far The main points in this diagnosis are. shown by muscular atrophy and by interossei is the greater hypotonia of the This hypotonia of the at times so pronounced and accompanied by so much articular relaxation that abnormal movements are produced. the existence of formication in a fixed zone.

articular laxity is This the it far greater in ulnar part of the hand. 121. affording a sensation of extreme laxity and genuine dislocation of the metacarpus. Atrophy and laxity is of the articular ligaments in these cases associated with hypotonia of the muscles. Lateral compression of the hand gives it a cylindrical form. Fig.150 four fingers NERVE WOUNDS when the lumbricales of index and middle finger become incapable of fulfilling their function as substitutes for the interossei. ulnar becomes pronounced. — 2. complete interruption above only. and this attitude is even . result the it assumes the appearance described by writers on the subject. 122. —Long-standing (5 months) ulnar the epitrochlea. The last two fingers are Fig. typical griffe. Palpation of the hand shows such relaxation of the inter-metacarpal ligaments as enables the bones of the metacarpo-phalangeal articulations to move freely upon one another. Dislocation of the metacarpus. griffe At the same time. though should be noted is in the normal of the state that there greater laxity in these same articulations fourth and fifth meta-carpals. flexed almost completely into the palm of the hand. — Flexion of second phalanx paralysis. as a of increasing hypotonia of interossei .

at and the if the in lumbricales finally their also weaken resistance. —Long-standing (five months) ulnar paralysis sort of branny desquamabut the integu- upper third of fore-arm). . irritation of the ulnar that creates the irreducible in some cases. thus pro- ducing a sort of incomplete three-fingered fingered griff?. Only vascular disturbances. 124. if 151 flexor profundus. on the surface Fig. re- and the articulations tain their mobility. In may all also sometimes this —Long-standing (lesion at paralysis be supplied by the ulnar. ordinarily supplied by the median. index becomes flexed. cases gr'iffe arm). (lesion at the tion . is distinctly confined region of the affected nerve. complete months) ulnar middle third of foreinterruption. the nerve is aftccted below the In this the third phalanx naturally participates in the flexion. the easy production of accidental ulcers to the and the slowness of their cicatrisation alone hear witness effects important upon nutrition of the tissues. we must griffes. can be the frequency of chilblains. is The skin dry and often becomes the seat. solely. remains It is flaccid and reducible. normally supplied by the Fig. in a moderate curvature. three-fingered through weakening of the lumbricales or perhaps innervation by the ulnar of the second lumbricalis. nerve Still. median. griffe palmar of a especially. or even four- We calis find that the lumbri- of the middle finger. accentuation of (three the typical griffc. owing the slips of the palmar aponeurosis which unite the third their and fourth fingers bases . all In these cases of complete and long-standing interruption. last Flexion of the to two fingers affects the middle finger slightly.ULNAR NERVE more marked case also. the nails are not deformed. repeat. and particularly cyanosis to the which seen . struck we are by the relatn e unimportance of trophic disturbances. ments remain supple. which fixes the finger and to some ex- tent also the ring-finger. 123. we see that there occurs fifth a slight fibrous contraction of the flexor tendons.

from relaxation ot interossei of and projection ot extensors. in these cases. we have found extremely important vascular disturbances of the offers little finger. though caused by a sort of Fig. which becomes swollen and shining. and as an almost black cyanotic appearance. disuse of the hand may have favoured the appearance of such intense vascular disturbances.152 NERVE WOUNDS In some cases. Hyper-extension of the first phalanges metacarpophalangeal articulations. . hypotonia — in preceding case. —Long-standing (six four-fingered griffe months) ulnar paralysis (wrist wound. Possibly. . exaggerated paralytic stasis. section). however. They are never found in patients treated by massage. 126. mobilisation and electricity. Fig. complete from weakness of the lumbricales flaccid griffe. 125.

Societe de Chirurgie. it. of the second. 12S. does away with the creases of the skin and its vertical The atro- phied interossei produce on the dorsal surface ot the hand actual intermetacarpal furrows . phalanx and extensors the dorsal — Atrophy of the interossei. however. flexors of the Fig. bringing its palmar surface on to the outer side of the index (predominance in of the op- ponens).* meet with the attitude This is a griffk) desort of thumb characterised by extension of the first phalanx ami by semi-flexion in the second. which has the same action. muscular almost devoid of substance. particularly of the palmaris brevis. the adductors thumb disappear. becomes flattened. leav- ing between thumb and in index a deep depression which first palpation of the interosseous space re- veals nothing but a thin sheet Fig. The thenar'eminence in its deep layers. exaggera- tion of these furrows may of produce quite a skeleton hand the . is rare. The ossei. like the inter- though first to a less degree.ULNAR NERVE 3. through slip which the}' send to the extensor tendons. 127. adductors of the thumb and the flexor brevis are. complete . \~ . that we sometimes scribed by Jeanne. It is these cases of atrophy and extreme hypotonia of the adductors of the thumb and inner slip of the flexor brevis. paralysis of these muscles. The flattening of the hypothenar eminence contraction. * Jeanne. for the external slip of the flexor bre\ is is (median). This attitude. 1915. usually capable ot correcting March. the thumb lies close against the index on the same plane though twisted somewhat outwards. 153 Lastly. — Atrophy of the hypothenar eminence. muscular atrophy is is pronounced.

absence of even in the definite paralysis. we the distribution of the nerve.-. pain caused by pressure on the nerve trunk.— SYNDROME IRRInerve irritation OF NERVE TATION Fig. cause very keen suffering. plete hyper-aesthesia pressure on the antibrachial muscles and especially on the hypothenar eminence. fibrous and inextensible . the . and compression be- tween two tors fingers of the adduc- of the thumb. are more or Striking. so clearly significant of paralysis of the ulnar. cure of this It also exists in certain incomplete the us lesions of ulnar to and enables recognise them. of the infiltration of the dermis. the fibrous griffes of the ulnar. III. or even com. — Atrophy of the adductors of the thumb. less It is that.. The may of painful syndrome is more or less pronounced. persists long after the paralysis. however.154 NERVE WOUNDS Atrophy of the interossei. Neuritic ulnar griff. tains the degree of certain cases neuritis It may almost be found paralysis. 129. muscles State . without very it evident though is always accompanied scaly condition by important trophic disturbances. Maximum extension. as the case be . to a more or pains in marked extent. of the woody atrophy and . pain by pressure on the hypothenar and interosseous . more than anyfind spontaneous thing else. 130— The more nails raises the rapid growth of the pulp of the finger into a small sub-ungual and frequently . creates In these cases. The skin.nuscles. Contraction of the flexor tendinis. it seldom. split curved of less Fl p- trie nails. painful anaes- thesia of the skin. atof the median.

the presence of 155 neuritis.ULNAR NERVE painful tumour. 132. irreducible. Fig. — Neuritic. Fig. which is an indication of how- ever slight. —Contraction of the palmar aponeurosis in a neuritic ulnar griffe (four-fingered griffe). . 131. ulnar griff 1 ' : contraction of flexor tendons and palmar aponeurosis.

• paralysis.' ulnar with onl v PartiaI owillii. we need only pinch between two fingers the mass of hypothenar muscles or the adductors of the thumb. in the same case of neuritis combined with fibrous griffe. however. intensify and render irreducible the attitude a griffe.. whilst leaving the motor fibres untouched. or 133. paralysis of the fibrous infiltration griffe of interossei. without combined with of the r palmar aponeurosis .^korl 1 the trophic fibres form a distinct fasciculus motor fibres. touched has not «-^. 134. without paralysis. . cither to the fact that the slight 1 • •. . adhesion of the tendons to the synovial sheaths. the prominences of which stand out like whipcord. Neuritis of the ulnar may show Frc. thicken- ing to and fibrous contraction of the palmar aponeurosis. and contraction . Frequently the griffe is confined to the ulnar part of the hand and fifth finger . are : fibrous contraction of the flexor tendons. may be affirmed that every fibrous and irreducible ulnar griffe is more or less pronounced nerve irritation. we may mention the case of a patient afflicted with . without paralysis. sensation of pain.— Neuritic . or that the which the lesion can reach. . itself . inextensible. comparable Dupuytren's contracture. . This is easily demonstrated whenever we find a fibrous. or even moderate griffe. — middle entire finger in slight it flexion. . Sometimes also invades the palmar aponeurosis and produces a veritable three-fingered or four-fingered griffe.. For instance. to cause a very acute sign of .. These of ulnar It lesions emphasise. reaches only the ring-finger and the at most it involves the Disturbances of sensibility Fig. 01 the a flexor tendons.• irritative lesion _ „_.156 NERVE WOUNDS The main points to note.

there was nerve cellular irritation producing fibrous transformation the synovial sheaths. irritation of the ulnar. the semi-flexion lure represented can be little finger is habitually flexed on the hand obtained only by exercising very strong traction which raises beneath the skin the slight irritation of the ulnar. — Contraction of the palmar aponeurosis which has gradually appeared after I he scarcely perceptible hypo-resthesia. There was no electrical paralysis of the interossci. though not to in the full extent. Nerve irritation of the ulnar is often a serious complication. this through slight nerve ought to mention the special tendency of the ulnar nerve irritation. " accoucheur " type of hand. which. their movements were rendered painful and strictly limited by the fibrous transformation of the hand in its ulnar part. contraction of the flexor tendons and adhesion to To such a degree was this the case that. certainly more serious than total interruption. however. knotty projections of the contracted aponeurosis. through somewhat complex we will study them : separately. may frequently cause states of muscular producing paradoxical attitudes. exactly comparable with that of Dupuytren's contracture. We is to cause. after the diagnosis of ulnar paralysis. On the other hand. contraction of the muscles of the hand found to be affected in most of the cases that produce the . for the muscles possessed their normal to reactions and the patient was able do all the movements. Whereas paralysis from complete . along with complete anaesthesia the ulnar area. component We shall soon see that slight neuritis of the ulnar hypertonia or of contraction. produced a slow and progressive contraction of the palmar aponeurosis. No paralysis . In another case. a slight lesion of the ulnar only after some months Fig. are really These states of hypertonia. . 135. after is all. its probably due to nothing more than slight neuritis of the ulnar or of cervical roots.ULNAR NERVE lesion of the ulnar at 157 the middle third of the fore-arm. in spite of the integrity of the interossei. of the sub-cutaneous tissue and of the palmar aponeurosis.

There may. substitutions. leaving the untouched. above the elbow. sensory or motor region. lesion of the nerve in its internal. extreme hyper-aesthesia of the skin. the fibres destined for the flexor carpi ulnaris for the flexor profundus. and On the other hand. destined for a special trophic. superficial part. the ulnar is composed of distinct fasciculi. functions. superposition of various clinical cases. the sensory fibres and the motor fibres destined for . radiation of the pain over the whole limb even even above the lesion. V. Investigation of the many cases observed during the war has enabled is us to outline the study of this fascicular topography. as also by direct electrical stimulation of the fasciculi of the nerve in the course of surgical operations. as well as those destined for the adductor of the consequently thumb.— DISSOCIATED SYNDROMES Like all the other nerves. IV. intensity of the pain. painful syndromes of the causalgic type.-NEURALGIA OF THE ULNAR sometimes indicated by painful syndromes. After suture. be found.158 NERVE WOUNDS owing to the interruption readily permits of the use of the hand. The possibility of partial lesions producing dissociated syndromes one result of this investigation. profundus and the flexor carpi fasciculi are thus The mutual positions of the principal known by (P. a flexor lesion of the ulnar nerve in the arm. For instance. Marie and Meige. may cause nothing more than paralysis of the interossei profundus and of the flexor carpi ulnaris.) It is now known and lie that. may be indicated solely by paralysis of the interossei and of the hypothenar eminence. affecting the external part of the nerve. occupy the external part of the on the inner surface of the humerus. especially in lesions affecting the ulnar at the upper part of the arm. nerve. the interrupted ulnar nerve will gradually regain whilst neuritis may create irreparable fibrous contractions. On the other hand. however. associated or unassociated with motor disturbances but not accompanied by the trophic disturbances which This neuralgia of the ulnar is seldom as characterise nerve irritation. Slight lesions of the ulnar are of the simple neuralgic type. the flexor ulnaris being preserved. the provocation of pain : by the slightest contacts or by vivid impressions and emotions all these recall the characteristics of median causalgia. neuritis of the ulnar renders the many patient quite its powerless. more intense as that of the median.

and A. flexor — destined for the flexor profundus have will be . and A. we find 1. Dejerine and Mouzon. the interossei of the last spaces that are fibres destined for the interossei most On of the first spaces and for the adductors of the as occupy the external part of the nerve. eminence. which the are characterised by intense sensory and trophic . it in these is again muscles of the hypothenar affected. last interossei the are the most internal. one cannot help fascicular way in which the topography is identical is. indeed. along with relative preservation of the interossei cases. though still covered by the fibres of the flexor carpi ulnaris and of the flexor profundus. fasciculi destined for the interossei representing the deep palmar branch of the ulnar. On the arm. The fibres of the adductors of the . been Ulnar griffe profundus is untouched flexing more pronounced it in cases where the indeed. a study of which has proved to J. supplied by the first dorsal We and two contrasted here give as an instance of dissociated syndromes the following cases. thumb occupy on it the fore-arm the most external position this muscle. to thumb appear According to J. we may sum up From within outwards follows the fascicular topography of the ulnar. Mouzon . entirely 2. The fasciculi of the flexor carpi ulnaris and of the flexor profundus which occupy nerve. as of being struck by the the other nerves. its There so . at the level of the arm the most all external part of the ulnar In the case of the ulnar. represents the inter- osseous of the first space. eminence and the the other hand. In the fore-arm also are found lesions confined to the internal part of the ulnar nerve. to speak. then. in the nerve a sort of relative lengthening of for instance. collaborates with the superficial flexor in the second and third phalanges of the fingers whose extensors are mainly the interossei.) affected by partial traumatisms. disturbances. root constitution the fibres destined for the adductors of the thumb which seem mostly root.— ULNAR NERVE the hypothenar 159 eminence and . for the last interossei. with the root topography of the sensory and motor regions. The The sensory cutaneous branches and the branches of the hypothenar superficial. 4. is also external. occupy the internal part of the nerve they are therefore superficial and more exposed to be (Dejerine. to originate in the eighth cervical root are more external than the fibres of the hypothenar eminence. Dejerine the fascicular topography of the ulnar. of the The fibres destined for the different inter: osseous muscles are also arranged in layers from within outwards fibres 3. This arrangement probably explains why certain lesions of the nerve above the elbow are accompanied by more or less marked ulnar griffe according as the fasciculi attacked or not.

Dejerine. /'. Note : 2. two fingers' breadths above the epitrochlea. 4. 1 1 . Maximum flexion of the fingers. 74th day after his wound . horizontal hatching: anesthesia to pain. an indurated swelling of the ulnar nerve. Partial (farad ic excitability is less manifest in the interossei of the last interspaces than in those of the first). Slow progress as regards movement. A. 1. without RD. electrical RD no appreciable voluntary contraction. That abduction of the little finger is possible (with reference to the axis of the hand). cj 5. five and a half months after the operation.* State of soldier Vid 2 Nov. 3. by bullet (?). to indicate that voluntary contraction is less. Then the indurated nucleus. wounded on the 8th Sept. /. 3. following suture. Soldier Vid . Keloid occupying the internal third of the right ulnar nerve in the arm (partial lesion). by Dr. This projection was adherent to the skin. 5. 30 August. 1915. forming a projection on the inner surface of the ulnar nerve. with appearance of amyotrophy. the normal type (good tone of the flexor carpi ulnaris). swelling. along the track of the bullet. 3 June. no contraction in any of the muscles to stimulation of the nerve above the injury (diadermic stimulation). Contraction to electrical stimulation of the nerve ahove the lesion. there was found to be a notch on the inner third of the ulnar. Immediate ulnar paralysis. . and osseous anaesthesia . Dotted : slight weakening . hi black: complete cutaneous /// and * Figures 101 and 102 and legends are taken from the article by Dejerine. — . in resistance movements. and by electrical stimulation. fingers are flexed as well as those of the first far two. 6 to 8 mm.. That which is anesthetic. Osseous sensibility to tuning-fork. long. and coinciding with the first phenomena of motor restoration. compared with the opposite side).— 160 NERVE WOUNDS Fig. Cutaneous sensibility to pin-prick. //. Muscular contraction in voluntary movements. electrical hypo-excitability. In oblique hatching: osseous hypo-sesthesia (the hatching is closer. There can be lelt. Total in all these muscles. which were interrupted at the level of this notch.. attitudes are not recognised. Attitude of the hand at rest (disturbances of tone). it is only slightly diminished. Note : the hand remains inclined towards the ulnar side.f. (Shown Mauser at the Societe de Neurologie. were not sutured. and particularly of the deep flexors. Presse Medicate.. this abduction is very slight. After extraction of this nucleus. which is greater than the tone of the corresponding interossei. of the 1st Zouaves. Articular sensibility to passive attitudes. 1914. . That there is no actual hyperkeratosis whatsoever in the distribution of the ulnar. That atrophy seems more pronounced in the hypothenar eminence than in the adductors of the thumb. That prominence of the flexor carpi That the phalanges of the last two ulnaris above the pisiform persists. Hatching: voluntary contraction takes place. Gosset. That flexion of the first first phalanx is more pronounced in the last two fingers than in the two. 136. at Sezanne. along the track of the bullet. The fasciculi. J. e. The ball crossed the inner region of the right arm. It was first cut oft flush with the inner surface of the nerve. through the skin.. was extracted. c. The hatchings are closer. d. 1. 40. which seemed to act as a kind of root in the interior of the nerve itself. a. Indurated Operation. Black : RD g. No. . Scarcely any amelioration in the disturbances of objective sensation. 21 Dec 1914 (104th day after the wound). 2.) . Mouzon. 1914. Mine. to indicate that sensation is less. J. That there exists a certain degree of <: ulnar griffe" This attitude seems due to the tone of the flexors of the last two fingers.

Articular sensibility to passive attitudes. Cutaneous sensibility to pin-pricking. e. Maximum flexion of the fingers.1 ULNAR NERVE 161 a. /. />. gi h. Osseous sensibility to tuning-fork. i. c.J\ Voluntary and electrical contractility of the muscles. d. Attitude of the hand at rest. 1 .

In oblique dotted-hatching: very painful paresthesia. strictly so-called (no enlargement of Weber's circles) osseous hyperesthesia.sthesia to pin-prick . slight bony hypo-xsthesia. and was stretched between the external edge of the biceps and the outer bend of the biceps. That flexion of the first phalanx of the fingers is effected better than in the case of Fig. at Suzanne (Somme).. is Note absent. by M. Compression of external surface of left ulnar nerve in the upper arm (partial lesion). but for several weeks movement of the arm was rendered almost impossible by reason of the pains set up in the last two fingers.) Dotted: slight weakening . That projection of the flexor carpi ulnaris above the pisiform quite 2. (The hatching is closer. 30 April. with the exception of a slight swelling and hardening (interstitial sclerosis) of its external part. 1915. Gosset. by the bursting of a shell. The projectile traversed the inner region of the left arm. and also better in the latter fingers than in the former (the outer interossei are more weakened than the inner interossei). h. That atrophy of the adductors of the thumb. 2. on the other hand.. 137. Operation.. and only imperfect flexion in the case of the middle finger. Muscular contraction in voluntary movements and movements of resistance. c. 1 01. b. as in this case. Suppuration of tract and drainage. Case of Corporal Chev . Note : 1." On the other hand. 4. That the hand. 17 May (88th day after the wound). That there is no trace of "ulnar griffe. those of the adductors of the thumb still further. no appreciable voluntary contraction doubtful contraction to electrical Articular sensibility to passive positions no disturbance whatsoever. with the favourable tone of the muscles of the hypothenar eminence. Attitude of the hand at in its entirety. rest (disturbances is of tone). The nerve was normal in calibre. stimulation of the nerve above the lesion 5 partial RD. Maximum flexion of fingers. In oblique cross-hatching : paresthesia. comparison of Figs.. seems more pronounced than atrophy of the hypothenar eminence. deviated towards the radial edge (atony of flexor carpi ulnaris). : A — . : In oblique hatching : painful hypo-a. These pains had 1 — almost disappeared at the time the wounded man entered the hospital. 1915. this abduction seems connected. the branches of the last interosseous spaces being within. partial RD. on the outer surface of the nerve the fasciculi for the flexor carpi ulnaris. and. a. whose role as abductors is intensified when the hand. 5. finds itself deviated towards the radial border. wounded on the 18th Feb. Dotted: painful hyperesthesia. is greater than that of the corresponding slips of the flexor 3. though diminished. These muscles contract to electrical stimulation of the nerve above the lesion (diadermic stimulation) . Hatching : voluntary contraction is possible. k. Resection of this cord. doubtless connected with the pulling on the nerve. without RD. : 1. deep in the ulnar nerve on the arm. The considerable hyperkeratosis that exists throughout the entire paresthetic region of the ulnar nerve. j. the general arrangement of the fasciculi seems to be as follows from within outwards. and which extends right to the region of the median. the cutaneous sensory (dorsal and palmar) branches along with the branches to the hypothenar eminence then the deep branch of the nerve. at the thenar eminence. 71st day after his wound. on the one hand. That abduction of the little finger (as regards the axis of the hand) is very marked . and for the flexor profundus (inner slips). That there is no flexion of the last phalanx in the case of the last two fingers. the flexion folds of the phalanges of the last two fingers are less obvious (the tone of the interossei of the last two outer spaces profundus). 3. Osseous sensibility to tuning fork. of the 228th Infantry. aspect and colour.. and by electrical stimulation. Corporal Chev . Ulnar nerve bent on a very hard fibrous cord which strongly compressed its external surface. with the tonic action of the extensor tendons. electrical hypo-excitability. 101 and 102 shows that. because voluntary contraction is less. <!> e >f>g> Black : . Ulnar paralysis seems to have been immediate. four fingers breadths below the armpit. Cutaneous sensibility to pin-prick. those of the last spaces further without.and lastly.1 62 NERVE WOUNDS Fig. i.

Voluntary and electrical contraction of muscles.K. l ^ e ->J. i. /'. Osseous sensibility to tuning-fork. c. .a. Articular sensibility to passive attitudes. i\ Cutaneous sensibility to pin-prick. Maximum movements of flexion of fingers. b. h. Attitude of the hand at rest.

139. to obtain reduction of griffe. 138. —False . ulnar griffe by cicatricial contraction of the flexors of the last two Relax the contracted muscles. flexing the fingers on the hand or the hand on the wrist. Fig. little more than the indication Fig. fingers.164 NERVE WOUNDS DIAGNOSIS OF ULNAR PARALYSIS Diagnosis of ulnar paralysis requires of a few causes of error.

we were dealing fifth is be reproduced by substitutionary movements. Lateral adduction alone of the is this almost the only movement which absent in certain cases. and perhaps more particularly as regards complete paralysis through lesion of the nerve above the epitrochlea is . In this case. there sible. Finally. finger cannot be substituted . interesting chapter in the study of irritations of the ulnar. so the Whilst all slightly irritated ulnar seems to manifest greater susceptibility of its react readily to their irritation. it is in this case that griffe least It pronounced. Finally. 165 Note the frequent absence of the is typical ulnar griffe. ossei show no 3. is noticed that the griffe fingers. these are far weaker. without deformity of the hand on the fore-arm. apparently inexten- and therefore reminding one of the fibrous griffe in nerve irritation. producing the hypertonic motor fibres and It syndrome. the ulnar would appear to produce them with special frequency. Indeed. the traction movements raise like cords the is contracted muscles and draw on the scar. is a real resisting griffe. but a superficial observation might lead us to imagine that with simple paresis of the nerve. important and nerve. It is unnecessary to add that the hypothenar eminence and the intersign of atrophy.ULNAR NERVE 1. all should be remembered that almost movements of the ulnar may True. As the median seems to respond very frequently to slight irritations of its sensory fibres. to is . owing to paralysis of the flexor profundus. that in the fore-arm. to which we have already called attention. there are often found. It is felt. Just as we may be mistaken in ulnar paralysis so may we regard as last an ulnar griffe the simple cicatricial contraction of the flexors of the two fingers. which may be scarcely perceptible. or the free play is is given to the contracted muscles and it completely reduced. if care taken to flex the fingers on the metacarpus. indeed. ulnar distribution. producing the causalgic syndrome. however. not in the hand . following slight states wounds of this of muscular hypertonia or even of real contraction. motor nerves seem susceptible of producing analogous syndromes. CONTRACTIONS RESULTING FROM SLIGHT NEURITIS OF THE ULNAR Contractions of the hand constitute a very special. we must insist on certain contractions appearing in the They often give rise to appearances which might be griffes mistaken for ulnar and paralyses. 2. Nothing easier than to be mistaken regarding paralysis of the ulnar. when employing traction in order to straighten the the resistance is griffe. indeed.

anaesthesia or hypo-assthesia of the cutaneous area. for instance. Active movements are impossible. in a few minutes or in a few hours. not affect . sweat or trophic disturbances. there is immobilisation of the fingers in extension by the action of the interossei on the second and third phalanges. sometimes indirect compression or lengthening by traction in other cases. Immobilised when extended. frequently amounting to contraction. if by irritation . either immediately or more slowly. are due to contraction of the interossei. the pain disappears as soon as contraction is overcome and the movement carried out . In all cases. Wc fingers. of the palmar interossei little . generally a case of direct lesion of the nerve. We may con- sequently see in one and the same patient different attitudes succeeding The main types we will now review. the different muscles supplied by this nerve have antagonistic functions. immobilising the hand in a All the muscles have retained their normal electrical reactions. pain in the nerve under pressure. producing the " accoucheur's hand " type described by Froment and Babinski. also find that certain cases in which it is impossible to flex the particularly the last two fingers. these clearly demonstrate of these hypertonic syndromes. passive move- ments are difficult and meet with considerable resistance of an elastic type which is non-fibrous and almost always painful. Sometimes we have contraction of the muscles of the hand. but they are contracted.1 66 NERVE WOUNDS . the nerve seems irritated by a process of slight ascending neuritis. forgotten that contraction becomes fixed and intensified by immobilisation. contraction As a rule. and according as any particular group Nor must it be is preponderant we find altogether different attitudes. becomes contraction in extension. The fingers are pressed against one another or even intercrossed by contraction one another. after overcoming it we immobilise it in this attitude. regains its original condition. Nothing could be more variable than the contracted attitudes produced of the ulnar indeed. formication caused by percussion. the hand. the thumb does is immobilised by the adductors. however. As a rule. irritative origin mechanical and often all electrical hyperthe excitability of the contracted muscles. and fixed attitude. note in every case the appearance of muscular We hypertonia. the the the finger is kept in a state of forced adduction. One might pronounce this to be a case of hysterical contraction. did not the attitude of the hand show distinct localisation in the distribution of the ulnar . thumb and finger is is even at forced times confined to the hypothenar eminence little in adduction and obliquely crosses the anterior surface of the other fingers. left to itself. vaso-motor. Contraction in flexion. these fingers do not offer to passive flexion .

Fig.ULNAR NERVE the fibrous and articular resistance 167 find in which we certain cases of Fig. maximum ot voluntary movevery readily be flexed. with extension ot two fingers. in extension for several weeks. Voluntary flexion of the first phalanx is possible and sometimes . — Contraction plexus. epitrochlea. 140. limited to the hypothenal eminence with slight contraction of Ulnar hypo-xsthesia. 141. or slight traction on the lower roots ot the brachial the palmar interossei. contraction in neuritis. Compression of the ulnar and ot the internal cutaneous at the level of the armpit. but they immediately resume their Lesion of the ulnar above the original attitude as though moved by a spring. Ulnar hypo-xsthesia with hypo-xsthesia of the internal cutaneous. Very pronounced trophic change in the little finger nail. of the hand and immobilisation extension occurred. Pain and formication in the nerve as far as the armpit. — Contraction The fingers may . after opining Originally the patient had contraction in flexion of the last two fingers ments. Hypo-xsthesia of the internal cutaneous.

What more than all . of this two typical varieties all may the Sometimes are we have flexion of affects the fingers by the interossei first flexion then almost exclusively the phalanx . Slight wound of the ulnar in the middle part of the arm. In these cases there is often more or less pronounced contraction of the palmar aponeurosis. paralysis Whilst irritation in all these contractions there undoubtedly exists a motor nerve still which causes them. voluntary flexion impossible in a few hours it resumes its original flexed attitude.i68 NERVE WOUNDS exists even permanently. affording the impression of elastic resistance. Contraction of the palmar aponeurosis. which appeared some weeks after the wound. thus showing last full is movement of possible the interossei. Passive extension of the hand is possible though painful . producing an on the hand through attitude which regriffe in sembles. Slight hypo-aesthesia of the median. that of ulnar accompanied by neuritis. consequently the hand remains extended. or else they regain it attitude as slowly after a few minutes. this As a rule. the existence of which intensifies l 1 Fig. second and third but moderately flexed. Contraction. perhaps in most cases not even the most important factor. it clearly indicates irritation of the nerve trunk. has become exaggerated after operation. Passive flexion of the two phalanges initial and even tolerably though moved by a flexion of easy. Soon after we note flexion of the last two fingers contraction of the flexor profundus. Liberation of nerve two months after the wound. Complete ulnar anaesthesia. 142. irritation acts only by causing a sort of muscular hypertonia. . — Contraction of the hand in flexion. we find contraction of the hand along with be described. it is this is not the main factor. an actual predisposition to contraction. flexion of the fingers as well as resistance to passive movements . . but left to themselves the fingers at once resume their spring. In other cases the fingers . though somewhat exaggerated.

and the attitude is reproduced several minutes afterwards. and if we had practised daily mobilisation from the patient had not shown a certain amount of indifference. and intensifies this ncuritic contraction in almost is every case. mobilisation warm water. hypo-aesthesia of its cutaneous area. point to invol vement of the ulnar nerve. profuse sweats noticed in the ulnar part or the hand. ncuritic must be remembered that these great care contractions are almost must be taken to prevent their . the faradic bath with metronome rhythm. From the time when they are slowly. We part if are justified thinking that this they would not exist for the most the outset. the adductors of the thumb almost always escape contraction and retain their movements . Fig. simultaneous contraction of the adductors of the thumb. All the same there is no cicatricial muscular contraction complete extension may be obtained w without great resistance. which the patient finds indispensable in using his hand : out of fifteen cases of contraction in the region of the ulnar. — may . immobilisation. 169 maintains. massage. Pain in the ulnar when pressed on in the middle part of the arm. probably irritated by a process of ascending neuritis. these contractions diminish and in disappear. be thought to be due to muscular contraction. in allowing contraction to take place. for the wound has affected the fore-arm in its inner part. always partially functional under Once contraction has been established. hot baths. only twice have we found immobilisation of the It thumb by the contracted adductors. cyanosis of the little finger. or even willingness. The attitude Flexion or the last two fingers by contraction of the flexors. . This is proved by the habitual preservation of the movements of the thumb even when there is contraction of the interossei. appearance or persistence by practising mobilisation on the patient at an early stage and above all by requiring that he himself should do everything possible. . have in- variably given excellent results.ULNAR NERVE else favours. finally and regularly mobilised. patiently. 14.3.

144. Median Brachial artery Ulnar Musculo-spiral Ext. brings to fibres of the sixth and seventh cervical roots . cutaneous. cut. cut. br. — Deep nerves it of the arm (after Hirschfeld modified). median nerve originates in the brachial plexus from two heads coming from the outer cord along with the musculo- : Lesser int. Musculo-spiral Biceps Fig.CHAPTER VIII MEDIAN NERVE ANATOMY The the outer head. the . Anterior aspect.

carpi rati. longior — \Cy Ulnar N. coming from the inner cord trunk. supplies it with fibres from the eighth cervical and of the nerve descends into the armpit in front of the axillary lying against the It proceeds along the inner side of the arm. branch) Anterior interosseous Pron. head. Flex. radii teres Sup. sublim. Musculo-spiral Post. Flex. Musculo-spiral (ant. Flex. at its lower deep surface and becomes external to it. It it proceeds in front of and outside the ulnar.MEDIAN NERVE inner 171 ulnar. long. outside the brachial artery. which. artery. carpi ulnar Ext. quadratus - Ulnar (dorsal branch) Deep branch Thenar eminence Superficial branch Fig. the ulnar separates itself from the median to reach the epitrochlean groove which is behind. 145. — Deepinerves of the tore-arm and nerves of the hand part. inner side of the biceps. whilst the median slightly inclines . prof. in front of and The median Met!. At this level. branch Pronat. crosses its is (after Hirschteld). along with the first dorsal. which as far as the closely united with lower third of the arm.

particularly for Nerves of the deep layer. become detached lower down. flexor. destined (lower nerve). . muscles of the fore-arm. The median does not supply the adductors of the thumb. nerve. which appears a the wrist and 1. 1. : branches.. I. . 3. 172 NERVE WOUNDS in order to outwards draw nearer it to the middle line of the upper limb at the bend of the elbow. except the palmar cutaneous branch. and disappears beneath the superficial flexor. and divides into its terminal branches the inner trunk and the outer trunk. where II. origi- nating in For the abductor of the thumb For the opponens For the flexor brevis. : Motor Branches The median elbow. branch which descends. by the ulnar. it appears between the tendons of the flexor indicis and the tendon of the flexor carpi radialis. : For the For the All flexor carpi radialis and palmaris longus. is above destined for the hand. to the pronator radii teres. radii proceeds between the two heads of the pronator It teres. but superficial flexor. . the median nerve supplies The its : muscles of the thenar eminence by three external branch and destined . Below the it fore-arm. superficial radii teres Upper nerve Nerves to the For the pronator 2. except a few twigs and the articulation of the fore-arm are exclusively little — All the branches of the median in the motor. in front of the interosseous ligament. which the ulnar supplies in the same way as the interossei. In the fore-arm. under the name of anterior interosseous ends. at the lower part of the becomes superficial. covered by the superficial fleshy body of this muscle. some accessory twigs the flexor of the index. descends in the middle line resting on the flexor profundus. it — In the hand. It also supplies only the superficial part of the flexor brevis the deep head is supplied. It passes on to the wrist under the annular ligament of the carpus occupies the anterior compartment of the radio-carpal canal. these branches originate close to the elbow (Cruveilhier) also . partially at least. comprising : A A A branch which supplies the two external heads of the flexor profundus branch destined for the flexor of the thumb . supplies the pronator quadratus and reaches the proximate articulations of the carpus. where . nerve does not supply any branch whatsoever to the for the brachial artery arm.

the inter-digital nerves of the second and the third space : . branch and ulnar Anastom.) Musculo-cutaneous N.) the palm of the hand.Int. thumb Col. cut. twig) Anastom. from which also : originate the motor branches of the thenar eminence. br (post.. supplies . Fig. br. cut. cut. The external digital collateral nerve of the thumb The internal digital collateral nerve of the thumb The external digital collateral of the index.) _ Int. in the skin of the thenar eminence and of . it is in the fore-arm the median nerve is exclusively motor. Palmar cutaneous branch. 173 originating in its The first two lumbricales. through 3. which 1 it supplies as far as the middle palmar crease 2.-spiral Median N. branch. (anter. br. (ant. (After Sappey. inter. nerve (anter. . Musculo-cutaneous N. The external terminal branch of the median. — This collateral branch appears a little above the wrist and disappears Musculo-spiral N. br. cutan. Sensory Branches Whereas hand 1. Occasionally also supplies the third lumbrical.) Inter. ext. and musc. branch. by branches it inner branch.— Cutaneous nerves of fore-arm and hand. twig) Musculocutaneous N. in the mostly sensory.MEDIAN NERVE 2. Musculo-cutaneous N. 146. cut. br. digital Anterior aspect. (ext. (ant. branch) Collat. nerve (anter. muse. nerve. The internal terminal branch supplies . cutan. (palm.

and the external collateral of the middle finger The internal collateral of the middle finger and the external collateral of the ring-finger. Anastomotic Branch It is useless to along with the musculo-spiral. anastomotic twigs from the ulnar nerve. capable of supplying occasionally substitutionary fibres to the flexor profundus of the middle finger. All the digital collaterals of the fingers. Probably it supplies the median nerve with the motor fibres coming from the sixth and seventh it is the more developed in proportion as the external root . successively send out a dorsal branch for the second phalanx and one for the third phalanx. of the median is slighter and so its persistence. so that. at the middle of the arm. the dorsal surface of the last two phalanges is supplied by the palmar nerves : the thumb and the fifth finger alone form an exception to this rule. or the musculocutaneous. in the complete sections of the median above it. Unlike those of other nerves they have no is This not so in the case of the anastomosis supplied to the median by the musculocutaneous. would explain the possible preservation of some nerve fibres supplying the flexor carpi radialis and the pronator radii teres. except those of the thumb. The median also receives in the arm and the fore-arm some slight cervical roots . interest for the clinician.i 74 NERVE WOUNDS The internal digital collateral of the index . enumerate the terminal anastomoses of the median the ulnar. in the case both of the median and of the ulnar. .

must of . Superficial layer. Flexor carpi means of plied of the flexor profundus sup- — by the ulnar. first of flexing the pha- langes of middle finger and index on the metacarpus. This is not only owing flexors Muscles supplied by the median in the hand. Figs. Fig. In 147. slight flexion of the hand is still possible by the flexor carpi ulnaris. — the ulnar being capable. of the biceps produces supination more pronounced than in the normal state as a result of lack of radii teres. median. Opponens. Flexion is absent in the last two phalanges only . but to actual muscular contraction. etc. Fig. through the interossei. Flexor brevis pollicis. 3. the middle finger can in frequently be flexed paralysis of the 149. in paralysis of the median. and the synergic contraction of the supinator longus and of the extensor ossis metacarpi pollicis. — Deep layer. Abductor pollicis. — to the aponeurotic fibres which unite the It of the middle finger to those of the ring-finger. It 1. Flexor of the thumb.MEDIAN NERVE PHYSIOLOGY Motor Syndrome I. Superficial flexor. the last two slips remains by Muscles supplied by the median in the fore-arm. Pronator quadratus. Deep layer. spite of paralysis of the median. Palmaris longus. On in the other hand. Flexion of hand on fore-arm by the flexor carpi radialis. Pronation by the pronator quad rat us and the pronator electrical stimulation radii teres Babinski found that. fingers which cannot be flexed in paralysis of the median are the thumb. 150. the index and middle finger. Nevertheless. Fig. antagonism of the pronator 2. The radialis. 149 and 150. — Superficial layer. 147. in paralysis of the median. the typical spite of anatomical descriptions. Pronator radii teres. The first two lumbricales. flexion of possible Fig. ficial Flexion of the fingers by the superflexor and the fingers flexor profundus. 148. '75 — The median nerve controls : in the fore-arm is exclusively motor. The two external fasciculi of the flexor profundus.

The me(Han alsQ supplies in the hand rr the first two lumbricales. by the ulnar.. partially at II. The external part of the palm of the : hand. dorsal surface of the second and third phalanges of the index and the middle. by means of the deep head of the flexor brevis. the second phalanx 111 still. In the median. 10 June. against the base of the fingers.— Pseudo-opposition in its in flexors) . as in the ulnar. index and middle finger : external half of the ring-finger 3. a slight flexion • movement of n -i 1 1 is occasionally possible. Dumas. and the external half of the ring-finger. facilitated of tone in the other thenar muscles and by articular laxity. is fully . the thumb is of slight external rotation. energetic contraction of the adductors enables the ulnar it frequently to move to edge of the hand. This is the pseudo-opposition of the thumb by lack described by H. whilst adduction persists. but paralysis of . least. and Porack. . paralysis of the median. The thumb course inwards approaches the little finger skimming the base of the ringers. Claude. muscles of r . but he cannot pinch it between the end of the thumb and the phalanxes of the index . last still less between the capable thumb and the end of the other fingers. The The palmar surface of thumb. though without the reaching the outer side of the 2. (Claude. Paralysis of the median is mainly characterised by loss of the opposition and flexion movements of the thumb. Presse Med. Nevertheless. The patient can grasp an object firmly and press it between the first phalanx of the thumb and the base of the index. Sensory Syndrome The sensory region of the median comprises 1. Then the little ringer is bent inwards to reach the extremity of the pulp of the thumb. compensated . except the adductors and the deep head of the flexor brevis. thumb . 151. total anaesthesia is usually . flexion movements of the thumb (long and short completely suppressed . On the other hand. all —In the hand the median nerve supplies the muscles of the thenar eminence. . by crawling.) motor disturbance whatsoever. however. The are Fig. so to speak. for by integrity the interossei and causes no 1915. 176 NERVE WOUNDS is necessity be admitted that the flexor profundus of the middle finger very often supplied. t hese ..

Usual topography ot" sensory disturbances of tin median. — Anatomical region ot the median.esthesia. Three diagrammatic zones: complete anesthesia. affect the palm of the hand far less than do those of the ulnar. and slight — Trophic Syndrome Trophic disturbances of neuritis of the median. Figs. confined to a portion only of this region. pronounced hypo-.MEDIAN NERVE 177 . Figs.isthesia. 154 and 155. almost always to the index it gradually becomes less pronounced as we approach the regions of the ulnar and the radial. hypo-. they are confined chieflv to the 12 . 152 and 153.

4. median above the epitrochlear muscles Lesions of the median below the epitrochlear muscles Paralysis of the . in very rare cases. Pronation impossible. The main signs of interruption are electrical the early appear- ance and the intensity of the disturbances. Muscular hypotonia is difficult to establish muscular atrophy of the epitrochlear and thenar muscles is more rapid and pronounced in nerve . . however little resistance is offered to it flexion of the hand on the wrist. profuse sweats in the cutaneous region of the nerve. may note in simple lesions of the median. by reason of the preservation of the flexor carpi ulnaris and of the internal fasciculi of the flexor profundus. occurs only by means of the flexor carpi ulnaris they remain flexion of thumb. which is very feeble. but sometimes it is not easy to judge. differentiate it is not easy to between complete interruption and simple compression. 5. Causalgia of the median. It of the is median is not shown when . even more than of the ulnar. caused by various mechanical or chemical irritants. fingers.-COMPLETE PARALYSIS OF THE MEDIAN IN THE ARM ABOVE THE EPITROCHLEAR MUSCLES Paralysis attitude. chiefly the index dryness of the skin. at rest by any special is revealed solely by movement. the deformities of we which are obvious and persistent. Dissociated paralysis of the median. at the end of the fingers. 3. the cyanosis and redness . which found at the level of the We 1. particularly the index they affect the act mainly thumb on the to a less degree and the ring-finger but They second and third phalanges as well as on the nails of these fingers. we may note the appearance. CLINICAL FORMS OF LESIONS OF THE MEDIAN NERVE In the case of the median. or. index and middle finger is impossible . or occasionally of small ulcers. .178 NERVE WOUNDS and the middle finger slightly. of the innervated fingers. Apart from the various neuritic disturbances we shall study later on. interruptions. . . Neuritis of the median. on the other hand. the constancy of is anaesthesia and the fixity of formication lesion. also a tendency to chilblains. I. Finally. will study in succession : 2. of ecchymoses. Muscular atrophy in cases of paralysis of the median is shown mainly by the flattening of the lower part of the fore-arm following atrophy of the pronator quadratus.

is impossible. Fi<. 157. qualify some of these statements. We On must. on account of the apo- FlG. however. 156. . Complete paralysis of the median nerve (resection and suture at the middle third of the arm). (In this case. being affected by movement of the ring-finger. The interossei are capable of flexing the rirst phalanx. whereas the two fingers are strongly flexed by the flexor profundus alone.) — neurotic slip the hand. Maximum flexion of the fingers. flexion of the middle is possible.MEDIAN NERVE extended if *79 last the patient tries to shut his hand. the middle finger may often be slightly flexed. however.. Flexion ol the last two. Complete interruption above the epitrochlea. which is sometimes supplied by the ulnar. by the flexor profundus. — Paralysis of the median nerve. which unites their extensor tendons on the dorsal surface of is It frequently happens that flexion of the middle finger almost complete when the ulnar supplies a branch to its flexor profundus. the one hand.

158 and 159. (Claude. On the left side. 9 15. we notice exten- sion this of the index finger.180 NERVE WOUNDS On the other hand. Presse Med. Again.— Paralysis of" the median (first sign). Impossible phalanx of index and middle finger on the metacarpus..) would seem to be an irrefutable sign of paralysis of the median. that flexion of the middle whereas the two fingers can be flexed (Pitres. Dumas. (M. the patient cannot bring the thumb in front of the middle finger as on the right side. June. It is easy to eliminate the cause of error produced by the action of the interossei and to show is that flexion of the second the the and third phalanges requesting impossible patient fingers by to intertwine of both hands and then to close them. — Complete paralysis of the median nerve. and Mine.) Even more simply we may firmly fix the first phalanx of the index . the It is noticed that index finger and the thumb finger last is remain slight. ordered to Fig. but the last two phalanges remain extended. the interossei are capable of flexing the first Figs. 10 1 and his hand on fingers on his hand. and Porack. Dejerine. his wrist the patient his is flex 160.) if strongly. to flex the index finger. extended.

i 6 i. Finally. (H. the flexor carpi radialis and As the palmaris longus. the patient to flex the others is . the thumb cleaves power of it is the patient is ordered to close his to If flexion and opposition. of these fibres. actual aberrant fibres of the external root of the median. This may be found in three forms. below the twigs destined for the pronator radii teres. and the palmaris longus. indeed we shall see (brachial flexor carpi radialis. seem destined for the pronator radii teres and the flexor carpi radialis. and the palmaris longus.) There may sometimes be observed manifest the epitrochlear muscles . which become prominent wrist. but is cannot it be affirmed that lesion of the nerve partial in all these cases. dissociation in paralysis of the pronator radii teres. alternatively. dissociation 1.) has lost all its fist. whilst the flexors are paralysed. Claude. found that the thumb remains extended and the index finger (first instead of being flexed in opposition in front of the other fingers sign). From lesion of the nerve at the level of the arm. FlG. still and the palmaris longus have partially retained their movements and Integrity of the pronator radii teres. the flexor carpi radialis. giving rise it to a dissociated syndrome. . (Pitres and Testut. at the the flexor carpi radialis. his hand resting on a asked to scratch the table with the nail of the index finger. 2. Indeed may be remembered the anastomosis coming from the musculomost fibres of the fifth and sixth cervicals to the median. —Dissociated paralysis of the median. cutaneous brings plexus) that the external and superior root ol the the median evidently to a large extent supplies the pronator radii teres. the result of lesion of the nerve at the bend of the elbow. preserve slight faradic contractility.MEDIAN NERVE finger flat 1N1 and ask the patient table. We that have observed this several times.

and the pronator radii teres regain their movements before the other flexors. as in ulnar atrophy of the deep muscular layers (adductors of the thumb and deep head of the flexor brevis). the palmaris longus. of the opponens . it is found that the movement is possible this is not done. These disturbances of the median little . Fig. flexion normal projection. but the paralysis chiefly shown by atrophy of first the abductor and . of long standing. are exactly similar to those found in total paralysis is still.182 3. 162. it well to study paralysis of the thenar muscles a it more closely. all the . if the patient is asked to touch with the extremity of the flexed thumb the extremity (if sonic other finger. II. Indeed. still sometimes difficult to discover this. and to compare with ulnar paralysis. pollicis. . really absent is that of opposition . NERVE WOUNDS This dissociation . atrophy of the thenar eminence is is If paralysis is very obvious. replaces the This atrophy is superficial . it induces flattening of the thenar eminence a flat area or even a depression running parallel to the metacarpal. The it is only of the thumb is not movement which is abolished. it is not.— PARALYSIS OF THE MEDIAN IN THE FORE-ARM BELOW THE EPITROCHLEAR MUSCLES in the Lesion of the median fore-arm is indicated solely by paralysis of the thenar eminence and by anaesthesia of the hand. — Atrophy of the thenar eminence in paralysis of the median. is also noted.in the course of progressive regenera- tion of the nerve the flexor carpi radialis. Owing to integrity of the flexor longus paralysis.

We shall return to this point when we discuss diagnosis. there found to be complete paralysis of . have like the ulnar. Finally. really — Normal opposition opposed 164. Fig. 16+. The fingers are completely and the frequency of their functional paralysis. it is effected by flexion of the thumb in the hand and flexion of the fingers over its extremity . but on their dorsal or lateral side it is a case of pseudo-opposition. a pseudo-paralysis caused ana-sthesia of the by hand : no longer feeling his fingers. We mentioned the relative preservation of the pronator radii teres. in . III. the flexor carpi radialis. 163. ringers are opposed at their sides. the patient thinks that they are paralysed and does not even attempt to use them. and dissociated paralyses. far above the wound. by frankly setting the one against the other. possibly in these cases the motor anastomosis of the musculo-cutaneous. 163.— DISSOCIATED PARALYSES OF THE MEDIAN may show partial lesions The median. in a case of section of the median at the wrist. although the flexors are entirely retained. Fig. thumb and fingers no longer meet . supplied in the fore-arm. for instance. — Pseudo-opposition a healthy subject.MEDIAN NERVE 183 same. found. more complete is dissociations may be In certain cases. The Fig. All the same. rotation of the thumb is complete. in certain complete interruptions of the nerve and the palmaris longus sometimes found even in the upper part of the arm fibres originate in the . as in normal opposition. The thumb is flexed by its own flexor. we must here note Fig. at the pulp.

the palmaris longus. the flexor longus In these cases. Wound in the middle of the arm affecting only the inner part of the nerve. Dissociated paralysis of the median nerve. it is rather the muscles of the thumb. however. 166. of the pronator radii teres. radialis. above all. 165. Fig. and. Paralysis of the flexors. the flexor pollicis and the muscles of the thenar eminence occupy the outer part of the median nerve. fibres that supply the flexors. We have noted three cases of this dissociated form . there was somewhat pronounced anaesthesia of the distribution of the median. where the lesion affects the nerve at its external border. and the thenar eminence. . Fascicular topography of the median. are the most . the flexor carpi radialis. — The outer part supplies the pronator radii teres. In other cases. on the other hand. Integrity of the flexor carpi radialis. the carpi radialis. — Fig. the flexors supplied by the median flexion of the index finger is impossible . the first two were Fig. Fig. The inner part supplies the flexors. The internal. flexion of the other fingers takes place solely through the fasciculi of the flexor profundus which is supplied by the ulnar. the flexor carpi the muscles of the thenar eminence. . accompanied by no sensory disturbance whatsoever in the third. 166. the existence of sensory disturbances is not invariable. the lesion affects the inner part of the nerve.1 84 NERVE WOUNDS . The pronator radii teres. 165. the pronator radii teres and the flexor carpi radialis that are paralysed. and of the opponens. of the palmaris longus. It would thus appear that the fibres destined for the pronator radii teres. pollicis is the opponens have retained their movements weakened but not wholly paralysed.

important trophic disturbin gr'iffe ances culminating of the median. Gosset and H.— NEURITIS OF THE MEDIAN An essential distinction must be drawn between neuritis of the median. Meige. accompanied by considerable trophic disturbances. : By By By By spontaneous . and their between the nail and the digital pulp a small cutaneous swelling which. We again find in these cases cutaneous trophic disturbances. even by cutaneous hyper-aesthesia 4. since either may involve injury to them. the nails are striated. Nerve irritation is of the median that of all is characterised. but we must especially note two orders of symptoms : disturbances of the nails 167. both longitudinally and transversely. and the formation of griffe. Flexors of the fingers in the antero-internal region. as other nerve trunks 1. they grow extremely fast. of the median are Sometimes even. to which the name of causalgia has been given. According on applying to the researches of Pierre Marie. ably affected in neuritis of the median. In the pronounced form. and fibrous infiltration of the dermis . A. index and middle finger are always considernails of The — Sub-ungual swelling in neuritis of the median. thumb. bent into actual claws rapid . provoked and increased by the growth of the raises nail. Thenar muscles in the posterior region. in the local electrical stimulation to the nerve trunks. nerve trunks and muscular bellies 3. both frequent and distinctive. pain on pressure of the . Flexor muscles of the carpus in the postero-internal region. scaly desquamation of the skin. and neuralgia of the median. there are : median nerve. neuritis Trophic disturbances of the nails in absolutely constant and very well defined. and often very acute pain 2. IV. four distinct groups of motor fibres Pronator muscles in the antero-external region of the nerve. painful hypo-aesthesia or . in slight . in the arm. is development frequently the seat of somewhat acute pain.MEDIAN NERVE The of these motor syndromes 185 sensory fibres probably hold an intermediate position.

Griffe of the median. it is occasionally found.— 1 86 irritation. events. and it is nerve their special incur- vation that enables us to recognise the existence of this irritation. — Incurvation of the nails in slight neuritis of the median. 169. is far from being as Fig. constant and suggested at It intense as ulnar griffe. fibrous infiltration of the last two phalanges. Glossy of the median caused by neuritis. thumb. i 68. especially of the index. or all consists of fibrous contraction of the flexor tendons and synovial Fig. Immobilisation of the finger in extension. Atrophy and Deformity of the nails. index and middle finger in moderate though This flexion is most pronounced in the last phalanges . in neuritis of this nerve. contraction of the palmar aponeurosis is but faintly perceptible and its . Griffe skin. the nails NERVE WOUNDS alone are affected. sheaths. immobilising irreducible flexion. Still.

— Neuritic griffe of the median. and It deformity. when the musculo-spiral is involved in median. that causalgia has been regarded as peculiar to this nerve. in Neuritis of the median in irritations found both lesions of the nerve. none the the median is true that causalgia of by far the most frequent and characteristic. neuritis of the on the other hand. as a rule. Whilst this fact may not be altogether correct. the fibrous sequelae left arc specially affected. shall now study. popliteal. .MEDIAN NERVE relative integrity contrasts 187 its with the intensity of disturbances in neuritis of the ulnar. 170. As in all other cases by Fin. This we the slight degree of trophic disturbances in its and the intensity of painful phenomena. in such cases. V. somewhat resembles.— CAUSALGIA OF Nerve is THE MEDIAN NERVE Weir Mitchell . it particularly the sciatic and chiefly the internal less is are capable of presenting the same disturbances. it is the second and third digital articulations that of nerve irritation. whilst other nerves. irritation of the median persist long after the paralysis has been cured and in irreducible is may even terminate arm. but. below the elbow. irritations of the median assume with the utmost frequency and to such an extent intensity the type of the causalgia of this so. even from in may it exist apart altogether paralysis. Griff? of the median in flexion is not altogether constant . for in cases of slight neuritis we often find immobilisation of the fingers in extension along with adhesion of the skin to the dorsal surface of the fingers and fibrous transformation of the digital articulations. in the at the wrist. Neuritis of the median : somewhat resembles neuritis of the musculo-spiral but in whereas articular sclerosis is more marked in the case of the first digital these cases articulation. neuralgia of the median causalijic form.

paroxysmal pains both day and night . without all paralysis or anaesthesia. characterised by a sensation of the persistent burning. any Fig. It is not only cutaneous ex- citations of the hand that cause painful paroxysms. to avoid all shock if any one approaches them. and we see them hands be wrapping moist noted of the round It their cloths which they conis stantly renew. If these patients are which some of them keep renewing. intolerable. whence name of causalgia (icavaig. or placing the other arm round it as a shield. they slink away. (Dejerine. persistent. This is not a paralytic posture . an approaching carriage. with short steps.) walking causes in intolerable crudescences these patients. . an unexpected sound. examined. a in brilliant light. but gradually wound pain manifests itself. they seek solitude. 171. we are surprised to find that there is . the banging of a door. The hand is carefully enveloped either with a glove or with wet . the slightest contact. they spread over the upper part of the arm. Thus we find in these patients special symptoms : emaciated by reason of insomnia and loss of appetite. cloths. is What . cause the most atrocious pain. but appearing almost purely painful symptoms and a Immediately after ten or ***** minimum after the of a sudden and accompanied by of trophic disturbances. its it increases during the following days. Cold. movement of . usually reaching culminating point twenty days. any of these may bring on a terrible and painful crisis. the dizzy sense of void a staircase . they will neither talk nor go outside. carefully protecting the hand from all contact by concealing it behind the back. even though the the fore-arm or the wrist. these pains are essentially localised in the hand.NERVE WOUNDS It almost invariably accompanies slight lesion of the nerve. wound is in The pain is a special and a violent one. Strong emotion. even during conversation. but Patients complain of terrible. heat. also to that profuse perspiration takes hand frequently place. they are gloomy and peevish. silence and obscurity they walk slowly. kind is painful simple — Position swinging of the of the hand when re- hand at rest. burning). patients most dread contact with the air and dryness tepid water often of the hand relieves them. but immobilisation caused by pain.

smooth and on the conwith an onion-rind appearance. These disturbances extend beyond the cutaneous region of the median. special lesions are found of neuritis are absent in . firm pressure on the integuments is not very painful. It would seem that the thinness and fragility of the integuments. (J. recognised as such. that on the nerve but slightly.- — .) There thin is neither sclerosis . 1915. 172. and A. though often very intense and . not thickened. whereas the slightest touch of the skin causes is intolerable suffering. on rupture. Fig. often red and almost always moist. insignificant and of a rather Usually the skin trary it is not thickened as in cases of neuritis glossy. not in cases of neuritis. painful Nor is there complete anaesthesia. except near the hand. Oblique hatching Horizontal hatching the heat is not the heat is less distinctly felt. Topography of the disturbances of objective sensibility.MEDIAN NERVE no paralysis esthesia . />. but they arc split and smooth. the constantly damp condition and perhaps more especially the maceration . 8 July. Dejerine and Mouzon. thin. tapering and conical extremities which terminate in quite small and almost triangular in cases nails. hyper- more than this. 189 the hand is simply immobilised as a result of pain. . Presse Med.tsthesia to heat. Whilst the trophic disturbances usual causalgia. a. is thin.. Hyperesthesia to pin-prick. comparable to sudamina which. Hypo-. slight Moreover. It is . pressure on the muscles of the fore-arm deep excitation as not at It is all painful. or striated. Hyperesthesia to slight contact (wisp of cotton wool). fibrous contraction nor articular immobilisation the nails are curved as in neuritis. that is excitation of the surface painful. c. After a few months there can be seen taking place considerable atrophy of the extremities of index and middle finger. left a very painful punctiform cicatrix. from time to time we have seen small subungual ecchymoses or more frequently small cutaneous phlyctens. of the dermis. Trophic and vaso-motor disturbances are special nature. the)- grow is rapidly and produce behind the pulp a cutaneous swelling which extremely painful.

Figs. — Causalgia of the median for is very refractory to treatment . and iodine or salicylic ionisation cause only a few hours' relief. are cases of causalgia in which neurotic lesions are more mani- accompanied infiltration by dryness of the skin. before diminishing and result disappearing. atrophy. it continues finally eight. thinness of the skin. scaly desquamation. fibrous of the dermis and a tendency to ankylosis of the last phalanges.190 NERVE WOUNDS of the continually moistened epidermis. ten. in these conditions it may readily be understood . Rapid growth of nails and sub-iingual swellings. Massage has no whatsoever. favour the appearance of these trophic disturbances. There fest . galvanic electrical stimulation with the positive pole. profuse sweat. Sudamina followed by ulceration. 173 and 174. or even fifteen months. Causalgia of the median nerve. Tapering of the fingers.

conical atrophy Fig.MEDIAN NERVE that there has 191 been strong temptation to practise resection and suture or alcoholisation (Sicard) of the affected nerve. At present. its effect is is not constant. we have found disturbances throughout the entire region of the cervical sympathetic. at wrist or Meige and Mine. Causalgia of the median nerve. Radiotherapy to the nerve causalgia. call forth the idea of sympathetic disturbances. Undoubtedly profuse sweats. there a tendency to regard causalgia as a sympathetic vaso-dilatation or vasoconstriction of the skin. with narrowing and vaso-constriction of the entire brachial artery whose calibre was not more than two or three millimetres and whose pulsations were almost non-existent . who are not paralysed. there was also slight numbness of the surface on the same side. in the Benisty. vaso-motor disturbances in the ear on the affected side. (Comof the last phalanges. 175. fibrous infiltration of dermis and digital articulations. syndrome. — Moreover. one hesitates before subjecting these patients. At the same time.) In causalgia caused by wounds fore-arm. a diminution of sweat. . with incurvation of the nails. to the risks of nerve suture. but it itself or to the roots frequently alleviates only dispels the painful paroxysms and does not calm the continuous dull pain. manifestly proving the existence of reflex excitation of the cervical sympathetic. pare index and middle finger with the comparatively unaffected ring-finger. (Leriche. and the recrudescence of pain through emotion.

—Pseudo-paralysis of the median. Faradisation ot the are intact. or below the epitrochlear muscles. where loss all the disturbances are reduced to cutaneous anaesthesia and to the of opposition of the thumb. when flexion of the first Figs. Lesion of the nerve in the tore- arm. flexors flexors Although the Cutaneous anesthesia and atrophy of the thenar eminence. 176 and 177. the patient cannot close his hand completely.192 All these facts NERVE WOUNDS may justify the intervention proposed by Leriche : denudation of the brachial artery and resection of the sympathetic plexus surrounding it. readily produces movement. Cure effected by a single treatment. We have performed this operation several times with favourable results in cases refractory to all other treatment. DIAGNOSIS OF PARALYSIS OF THE MEDIAN NERVE We need not insist on the possibility of overlooking paralysis of the median. phalanges by the interossei might incline one to believe in the possibility of some slight action of the flexors. . either above the epitrochlear muscles.

To avoid this error. allusion has already Here we would point out a somewhat frequent cause of error. We need only contract the flexors by means of the faradic current to of movement. immediately below the bend of the elbow moreover. the muscles weakened by the wound retain more or less their normal electrical reactions and above is all their faradic excitability.MEDIAN NERVE Wounds often cause. a incapacity of the flexors of the fingers. recognise the functional nature of this paralysis. prove to the patient the possibility '3 . in which the median nerve affected. flexors of the thumb. the index and the middle finger. that to weakening or even complete might erroneously be attributed that the flexors receive their . we must remember nerve twigs very high up. It is also known that there frequently associated with these wounds a certain degree of functional paralysis due to prolonged inaction. to which We refer to functional paralysis of the been made. very from injury to the muscles. 193 is of the fore-arm. nerve lesion. We have met with several of these very curious cases in which the patient thinks that his fingers are paralysed because he neither feels them nor even attempts to use them. following lesion of the median in the fore-arm and caused by anaesthesia of the hand. and effect a speedy cure.

CHAPTER

IX

ASSOCIATED PARALYSIS OF THE MEDIAN

AND ULNAR NERVES
It
is

necessary to
the

make
ulnar.

a special study of the associated paralyses of the

median and

These

paralyses

are

very frequent, and are

Fig. 178.

Paralysis of the

median and the ulnar

— "flat hand."

caused by lesions in the upper arm, where both nerves are close to each
other.

Paralysis of the median and the ulnar. Fig. 179. Hyper-extension of the first phalanges by contraction of the extensors. This movement induces semi-flexion of the second and third phalanges (paralysis of the interossei).

In these cases
also

we

note the association of the

two

paralytic syndromes,

complete

loss

of the

movements of

flexors

and

interossei.

PARALYSIS OF MEDIAN

AND ULNAR NERVES
;

195

Atrophy of the epitrochlcar muscles is complete of the thenar and hypothenar muscles produces the "

flat

the massive atrophy hand " appearance.

Owing
flexors

to atony of the
interossci,

and

the

efforts to

extend the fingers

readily induce an attitude

of hyper-extension of the
first

phalanges, along with

semi-flexion of the second

and
are

third.

Particularly important

the

curious

substitu-

tionary
in

movements found

most cases and first mentioned by H. Claude. Flexion of the hand on
the
wrist
is
;

theoretically
all

suppressed
it

the same,

is

for

the

most

part

possible,

by substitution of

Fig. 180. Flexion of the hand by the extensor ossis metacarpi pollicis and by the short extensor of the thumb. (Claude, Dumas, and Porack, Presse Med.,
10 June, 191
5.)

the

extensor ossis

meta-

carpi pollicis

and the short extensor of the thumb.
is

Finger-flexion

logically impossible.

Patients, however, are capable
to such an extent
is

of performing certain flexion
that
it is

movements

;

this the case,

difficult to believe that

both nerves are paralysed.

They
forcibly

succeed

in

flexing the fingers

by

raising
;

the

hand with the

radial

extensors

the effect of this hollowing of the

hand

is

to stretch the flexor
it

tendons on the

pulley, as
lation,

were, of the radio-carpal articuto exercise traction

and consequently
in

on the

fingers, in a purely

mechanical way.
patients

Again,
1"k..
1

raising the hand, the

S

1

.

— Pseudo-flexion
In
paralysis

allow their fingers to droop under the action
or the
of

of gravity, and this
the flexion attitude.

still

further emphasises

fingers.

the

median and

the ulnar, by torci-

ble straightening of the carpus

This may be seen by turning upwards the palm of the hand; the
action

and mechanical traction of the
flexor tendon*.

of gravity ceases,

and

the

fingers,
of

being flexed only by the hollowing
hand,
It
fall
is

the

back into a state of moderate flexion.
unnecessary to add
that this artificial flexion

of the fingers

is

extremely feeble and cannot be made use of by the patient. When regeneration begins in the median and ulnar nerves, there
observed the progressive appearance of a special four-fingered
g)'tjff''y

is

supple
the

and reducible, characterised by flexion of the

last

two phalanges on

196
first
:

NERVE WOUNDS
it is

produced by tone of the flexors of the
interossei, extensors

fingers, deprived of the

antagonism of the

of the

last

two phalanges.

Paralysis of the median and the ulnar in course of regeneration. Figs. 182 and 183. The " flat " hand has become transformed into a four-fingered griffe once the flexors Note the projection ot the (Soft and reducible griffe.) have regained their tone.
flexor carpi radialis.

Finally, simultaneous irritation of the

median and the ulnar causes a complete
neuritic fibrous four-fingered griffe
;

flat-

tening of the thenar and hypothenar eminences,

atrophy

of

the

interossei,
all

and
give

flexion of the last

two phalanges,

the hand the typical " ape-like hand."

appearance of the

Figs. 184 and 185. Neuritic griffe or the median and the ulnar "simian hand." Fibrous four-fingered griffe. Tendon contraction. Contraction of the palmar aponeurosis.

CHAPTER X

MUSCULOCUTANEOUS NERVE
The
musculocutaneous nerve originates along with the external root of
Its

the median from the outer cord of the brachial plexus.

fibres

arise

almost solelv from the

fifth

and sixth cervical

roots.

Musculo cutaneous nerve
Branch to the coraco-brachialis
Internal cutaneous nerve

Branch

to the biceps

Median nerve
Branch
to brach. ant.

Anastomosis of median an
musculo-cutaneous

Ulnar nerve

Musculo-cutaneous nerve
Musculo-spiral nerve Musculo-spiral (external branch)
Internal cutaneous nerve (internal

branch)

Anterior aspect.
Fig.
i

86.

—Deep nerves of arm

(after Sappey).

The

biceps has been resected
nerve.

to lay hare the

musculocutaneous

At

its

origin in the armpit,

the musculo-cutaneous nerve

is

situated

above and

outside

the

median
far as

and

the

axillary

artery.

It

remains

adherent to the median, as

the union of the upper third and the

middle third of the arm.

198

NERVE WOUNDS
At
this level
it

suddenly changes direction, passes obliquely outward,

crosses

the

coraco-brachialis,

and descends

obliquely

in

front

of

the
to

brachialis anticus,

covered by the biceps, supplying motor branches

these three muscles.
It
is

the musculo-cutaneous

under the biceps that the anastomotic branch breaks away, uniting rising again obliquely it to the median nerve
;

enters this nerve, reaching

it

at the

middle third of the arm.
fibres issuing

Probably it often brings to the median aberrant motor from the fifth and sixth cervical roots.

Posterior surface.

Anterior surface.
Fig. 188.
Fig. 189.

Fig. 187.

Figs. 187 and 188. Sensory region of musculo-cutaneous nerve. Fig. 189. Cutaneous anesthesia in complete section of musculo-cutaneous nerve.

Afterwards the musculo-cutaneous
surface

nerve

appears
the

on

the

external

of the biceps, plunges

underneath

edge

of the supinator
;

longus, and becomes sub-cutaneous near the bend of the elbow
divides

it

then

into

its

two terminal branches,

anterior

and

posterior,

which

descend

in parallel lines

on to the antero-external surface of the fore-arm,

supplying the skin.

Branches
I.

Along the

first
:

part of

its

course, the musculo-cutaneous supplies

only motor-branches

The nerves

to the coraco-brachialis.

musculo-cutanp:ous nerve
The The
2.

[99

nerves to the biceps.
nerves to the brachialis amicus.
biceps, the

Beyond the

musculo-cutaneous

is

no more than

a sensory

nerve where two parallel branches of the bifurcation supply the anteroihternal part of the fore-arm right to the vicinity of the wrist.
3.

Lastly, the musculo-cutaneous, apart from

its

terminal anastomoses,

sends out an important anastomotic branch to the median, meeting; the

Fig. 190.
Fig.
Fig.
190. 191.
of
flexion

Fig. 191.
the

brachialis amicus.

musculo-Bpiral. —Substitution the paralysed musculo-eutaneous by supinator. Energetic of the fore-arm on the arm by Coraco-brachialis — Muscles supplied by musculo-cutaneous. muscles.
the

the

biceps

;

The

deltoid

is

cut in order to expose the deep

latter

about the middle of the arm.

It

seems to be proved
in this;

that,

speaking

generally, this branch
fifth

brings to the median supplementary fibres of the
;

and sixth cervical roots

it

mav

fail

the thinner the external
is.

head of the median, the more developed this branch

which restricted to a tract extending over the antero-external part of the fore-arm. overlap considerably and largely is reduce the region of complete anaesthesia. and the it on the inner side. and without exploring electrical Sensory Syndrome The surface. is by the supinator longus (musculo-spiral). determines paralysis atrophy . internal cutaneous The musculo-spiral behind. of the coraco- brachialis. This is still even forcibly. . the biceps and the brachialis anticus these last two are flexors of the fore-arm on the arm. the flexion of the elbow.200 NERVE WOUNDS PHYSIOLOGY— PARALYSIS OF THE MUSCULO-CUTANEOUS Motor Syndrome The Its musculo-cutaneous interruption is the nerve whose and sole function is to supply the flexors of the fore-arm on the arm. the flexor role of which Paralysis of this nerve thus may thus easily be disregarded if we its confine ourselves to making a simple flexion of the fore-arm without endeavouring to obtain real contraction of the biceps reactions. we must not expect to find so extensive a state of anaesthesia in lesions of this nerve. musculo-cutaneous supplies the integuments its of the antero- external part of the fore-arm and passes slightly on to postero-external Nevertheless. away with proved. It must not be imagined that paralysis of the musculo-cutaneous does possible.

we may. the lower edge of the subscapulars and of the teres minor above. about the middle of the axilla and outside the musculosituated behind the axillary artery. becoming detached along with the musculo-spiral from the posterior secondary trunk. Most of its Supra-scapular nerve Branch to the supra spinatus Muscular branch Branch to the minor teres Branch to the subspinatu. however. (After Sappey. as a terminal branch of this plexus. fibres originate in the fifth cervical root. the long head of the triceps within and behind. with Sappey. and passes towards the posterior part of the shoulder accompanied by the posterior circumflex artery neck of the it passes into the interspace circumscribed by the humerus outwards and forwards. . It immediately proceeds downwards and outwards. By regard reason of it its size and importance. the upper It border of the teres major below (quadrilateral square of Velpeau). 192. Muscular nerve Cutaneous nerve shoulder to Fig. . thus passes round the posterior surface of the surgical neck of the deltoid humerus and reaches the on its deep surface. . spiral nerve. — Circumflex and supra-scapular nerves.) It springs this level it is at from the brachial plexus.CHAPTER XI THE CIRCUMFLEX NERVE The circumflex nerve is generally regarded as a collateral branch of the brachial plexus.

on the external paralyses of surface of the shoulder. branch) Circumflex nerve (cut. which is successively made between the become detached to supply the different portions of the deltoid. the only important offshoots supplied by the circumflex are the deltoid branches I. br. A distinction ascending and the descending branches. and the cutaneous branch to the shoulder. Muscitlo-spiral nerve (ex cut.) -Internal cutaneous (post. This wards. Fig. br. — Superficial nerves of shoulder. arm and elbow. from behind for- Thus we .) Second intercostal nerve Third intercostal nerve Musculo-spiral nerve br. may produce dissociated the circumflex the anterior and exterior fasciculi.202 NERVE WOUNDS Branches Apart from the articular branches and from certain fibres supplied to the subscapulars. (After Sappey.) reached the neck of the humerus. branch) Internal cutaneous neive (ant. see that certain lesions of the nerve. . after it The deltoid branches issue from the circumflex nerve has Supra-acromial branch Circumflex nerve (cutaneous branch) Lesser internal cutaneous (ext. distribution is arranged in vertical segments. are paralysed. whilst the posterior scapular fasciculi are untouched. clavicular and acromial. for instance.) (int. 193. cut. branch) Musculocutaneous nerve LeVeU-LE S/4LLE* Posterior aspect.

THE CIRCUMFLEX NERVE 2. it also appears in fractures of the surgical neck of the humerus by embedding : or compression of nerve it may follow dislocation of the FlG. Atrophy FlG. reality. affecting the fifth cervical root. of the deltoid. PARALYSIS OF THE CIRCUMFLEX Paralysis of the circumflex is not met with the in direct traumatisms of the nerve only. . J95. and emerges between the deltoid and the long head of the triceps. the integuments of the external surface. and in descending branches which are distributed over . which breaks away from the circumflex after its passage into the quadrilateral space it proceeds downwards and outwards. 203 The cutaneous nerve of the shoulder is a collateral sensory branch. they are of root paralysis of the brachial plexus. — Motor area circumflex. it owing to traction in on or contusion of the nerve. — Paralysis of the circumflex. Then it divides into ascending and horizontal branches which supply the cutaneous covering for the shoulder. the same. stretched or torn dislocation away cases by the and . 194. all <>t t lu shoulder. would appear that (Duval most of these cases Guillain) in we are dealing with the lesion of the upper roots of the brachial plexus.

flattens At laxity. of the deltoid . .204 NERVE WOUNDS Lesions of the circumflex are shown solely by paralysis of the deltoid and by sensory disturbances of the shoulder. in vain does the patient attempt to raise the supra-spinatus succeeds in he contracts his shoulder muscles and a faint making only movement of abduction . he partially detaches his arm artificially. and is incapable of introducing any effective substitution for paralysis of the deltoid. paralysis of the cir- Seldom do we find complete anaesthesia as a rule. . shoulder and bending his thorax in such a raised way that the arm the as it were. but the swinging movement imparted the shoulder-blade is nullified by the utter flaccidity Anatomical sensory topography Figs. forwards (clavicular the The disturbances thus produced are all more serious because sub- stitutionary movements scarcely exist at is all in the case of the deltoid. in . of the circumflex nerve (cutaneous nerve of the shoulder). Paralysis of the deltoid produces loss of power to raise the arm outfasciculi). finally. the same time atrophy of the deltoid shoulder and relaxes the joint capsule. — Actual anestheof the cir- sia in section cumflex. wards (by means of the acromial and backwards (scapular fasciculi). The supra-spinatus alone capable of slightly raising the . by the ribs on which it is resting. by raising his is. 196 and 197. arm outwards and forwards. we simply have more or less pronounced hypo-aesthesia of the external surface of the shoulder. fasciculi). with rotation inwards this movement is extremely feeble. — Fig. which often exhibits an abnormal degree of SENSORY DISTURBANCES Sensory disturbances are somewhat reduced cumflex. he contracts the serratus to magnus. The arm remains hanging almost loose alongside the body it . 198.

-cut. Musculo-spiral nerve (ext. on the inner surface of the arm. of shoulder Int. cut. (upper arm branch) Int. N. cut. the lesser internal cutaneous are very in the lesions seldom affected separately on the contrary.) Anterior aspect. 199. N.CHAPTER XII INTERNAL CUTANEOUS NERVE AND LESSER INTERNAL CUTANEOUS NERVE The internal cutaneous nerve and . Supra-acromtal branch Lesser int. N. cut. branch I. originating in the lower secondary trunk slightly internal to the ulnar. branch Muse. Ant.— Cutaneous nerve of shoulder and arm. N. br. cut.) These are exclusively sensory nerves. 1 2nd intercostal Cut. cut. (After Sappey. Ulnar nerve Mus. (ext. Fig. br. N.) ( Post.-spir. they often share of the median and the ulnar. The internal cutaneous descends to the inner part of the arm internal . br.

At the base of the axilla. br. cut. which is distributed over the inner surface of the arm. int. N. N. br.) arm. it supplies the cutaneous branch to the upper Mus. Mus. br. is shown by slight hypo-aesthesia of the inner surface of the fore-arm. ext. J Digital collateral trunks Anterior aspect.) Int. Musculo-cutaneous N.) Mus. Fig. it of the arm. cut. inter- nal twig) Anastom. (ant. (After Sappey. and radial $ Palm. (ext. The lesser internal cutaneous perforates the deep fascia at the upper third of the arm and is distributed over the skin of the inner surface of the arm behind the region of the internal cutaneous (cutaneous branch to the to the level of the epitrochlea.) Int.2o6 to the NERVE WOUNDS median nerve. of Anastom. (ant. Only axilla lesions are which involve the nerve in the neighbourhood of the accompanied with hypo-aesthesia on the inner surface of . N. br.) cut. N. N.) br. cut. of median Collar pollic. cut. N. of mus. 200. usually associated with that of the median and more especially of the ulnar. cut. br. branch. on reaching the middle becomes superficial. (ant. as far as the bend of the elbow. (post. and ulnar cut. cut. of the ulnar nerve perforates the deep fascia and part of the fore-arm. Mus. — Superficial nerves of fore-arm and hand.-spir. Then it proceeds along the basilic vein and at the bend of the elbow divides into its terminal branches which are distributed over the inner and anterior in front . arm) and right A lesion of the internal cutaneous. (brachialis anticus.

— Superficial nerves of fore-arm ami hand. N. Fig. N. N. branch )Tj .' GHn Rail.) Int. br. (ext. cut.ul.)-] I if Jl^fh< Posterior aspect. (post. branch) Muse. > Ulnar nerve (dorsal branch) N. Int. (After Sappey. N. 201. branch) Musculo-spiral N. br. (post. and even this hyperesthesia is greatly lessened owing to the proximity of the lateral cutaneous branches of the second and third intercostal nerves.) . (am. cut. cut. branch) R. ^collat.INTERNAL CUTANEOUS NERVE the 207 arm . (ant.

. Figs. Cutaneous topography of the internal cutaneous and the lesser internal cutaneous (oblique hatching). 204. Fig.208 NERVE WOUNDS Figs. — Fig. The perforating branches of the second and third intercostal nerves supply a triangular area on the postero-internal surface of the arm. 204. — Sensory disturbances in lesions of the internal cutaneous. 202 and 203. 202 and 203. in the region of the lesser internal cutaneous.

Musculo24. 25. Ulnar nerve. 12. Internal cutaneous nerve. Nerve to nerve. 16. 11. seventh. 26. 4.I. 17. 5. Lower branch to sub-scapularis. 9. the Fig. Nerve to the subclavius. Musculocutaneous nerve. All these roots make their way towards the apex of the axilla. and eighth cervical roots and the dorsal. — serratus magnus. spiral nerve. 14 . 13. Anastomoses of nerves of pectoralis major and pectoralis minor. L. Ansa hypoglossi. 205.) 1.CHAPTER XIII BRACHIAL PLEXUS The brachial plexus consists first of the fifth. seventh and tight cervical roots. 19. (After Hirschfeld. 8. 22. Nerve to pectoralis major.20. 15. 2. 18. 3. Fifth. Sub-scapular Nerve to pectoralis minor. Nerve to teres major. Its anastomosis with the lateral cutaneous branch of" the second intercostal nerve. 10. Pneumogastric nerve.21.C. sixth. 6. Median nerve. sixth. First dorsal root. Nerve to latissimus dorsi. Phrenic nerve. 14. 23. 7. Brachial plexus and its collateral branches.

a tolerably simple diagrammatic description of it. 206. TRUNKS two branches. whereas wounds in the axillary region almost invariably cause important injuries that affect several trunks. The brachial plexus thus spreads out into the sub-clavicular region in the form of a triangle. Near the vertebral column. the other posterior. II. The anterior branch of the lower trunk constitutes of the inner . with vertebral base and axillary apex.— SECONDARY Each of the primary trunks soon anterior. I. fifth and sixth cervical roots unite to constitute the upper trunk. — Constitution of the brachial which is plexus. set in tiers and separated from one another.210 NERVE WOUNDS higher ones taking an obliquely descending course.— PRIMARY TRUNKS The The trunk. we can give variations in the constitution of the plexus . The anterior branches of the upper trunk and of the middle trunk to unite to form the upper cord produce the musculo-cutaneous itself nerve and the external or superior root of the median. the roots of the plexus. CONSTITUTION OF THE BRACHIAL PLEXUS at the There are many individual same time. first eighth cervical and the dorsal join to constitute the lower The seventh cervical of itself forms the middle trunk. may be affected separately by traumatism. the lower ones following a direction almost horizontal. the one divides into Fie.

first Situated at to.BRACHIAL PLEXUS cord. the the above. internally. Below the clavicle are found the cords which soon produce the nerves important relation external of the upper limb. the median in front and outside. The three posterior branches unite to form the posterior cord which supplies the circumflex and afterwards constitutes the musculo-spiral nerve. and a little behind the axillary artery. Connexions of the Brachial Plexus On leaving the intervertebral foramina. The artery of the brachial plexus with the axillary and vein are well known. the nerve which separates them from the vein situated musculo-cutaneous is outside and trunks are all around the artery . more . the musculo-spiral behind . It is and converge towards the middle of the slightly outside the Pectoralis minor Musculo-spiral Fig. is Thus the supra-clavicular area essentially that of the primary trunks and of their branches of division. ™ at the level — Connexions of the brachial plexus of the axilla. the roots of the brachial plexus penetrate into the space separating the scalenus anticus from the scalenus medius. scaleni that the primary trunks appear. 207. as the internal 21 I which produces the ulnar and the inner root of the median as well cutaneous and lesser internal cutaneous. Then they cross obliquely the lower part of the supra-clavicular fossa clavicle.

outside this zone. affect isolated nerve trunks . and even a found the roots of the plexus. adhering to wall. In the lower axillary region appear the nerves of the necessary to add that the nerve fibres all converge upon the affecting the especially axilla at this level. in the The The upper branch to the subscapulars. The The nerve to the rhomboids which separates direct from the nerve to the serratus magnus. supra and infra spinati. It is clavicle and in the upper part of the axilla. springing from the higher primary trunk crosses the supra-clavicular fossa. fifth and sixth cervical roots. 2. generally in the anterior branch .. supra-clavicular fossa corresponds to the region of the primary Behind the upper limb. its course the brachial plexus sends out a certain number of fifth important collateral branches. are more rarely affected. most frequently they induce partial lesions and dissociated root paralyses the artery and the axillary vein. on the other hand. groupings of nerve according to the level of the wound. We must remember that the brachial plexus may somewhat diagramlittle matically be divided into four regions. lesions of the plexus will often be severe and very extensive. surface of the artery. trunks and simultaneously supra-clavicular fossa. are found the secondary cords. In the region of the scaleni. which originates in the cervical root. are The trunks. originating nerve to the subclavius rises upper trunk. crosses the entire posterior surface of the brachial plexus and descends along the mid-axillary line. 5. reaches the supra-scapular notch passing beneath the ligament which converts into a foramen the supra-scapular notch whilst the supra-scapular vessels pass above it. behind the clavicle. the thoracic The supra-scapular nerve. passes round the spine of the scapula and terminates in the infra-spinous It supplies the 4. crosses the anterior . fossa. axillary Wounds of the those of the scaleni. affecting several nerve vessels. 3. Branches of the Brachial Plexus Along 1. between the artery and the vein the inner head of the between the artery and the vein. Traumatisms which the different affect the brachial plexus will accordingly affect fibres. It thus penetrates into the supra-spinous fossa. situated much lower. 212 ulnar NERVE WOUNDS runs passing median. region of the .

The The The The nerve to major (external anterior thoracic) separates from the upper cord behind the clavicle. — Circumflex and supra-scapular nerves.) IV C Infrnnr rervi'-jt ganglion Fig.BRACHIAL PLEXUS of the upper trunk and supplies an anastomotic (loop of Henle). nerve to the latissimus dorsi. 9. . 7. 8. lower branch to the subscapular^. (After Sappey. 208. 209. nerve to the teres major. the pectoralis 6. 213 branch to the phrenic Supra-scapular net Branch to supraspinatus l8Cu]ai I ranch Branch to infraspinatus {ranch to teres minor Circumflex nerve Muscular branch Cutaneous twig to shoulder Fig. — Collateral branches of the brachial plexus.

: syndromes resulting from lesion of the roots or primary trunks these result from lesions above the clavicle and affecting the nerve trunks. corresponding to lesions of . originate successively from the fifth and sixth cervical and from the primary and secondary trunks following them. near the origin of the circumflex. We roots must remember that the nerves to the rhomboids. it All the cervical roots. They thus belong to the higher root group. a bony callus. like all the nerves. for carries to the lower cervical ganglion of the sympathetic the cilio-spinal fibres destined for the innervation of the pupil. on the sides of the vertebral column. send out a communicating branch first The branch from the dorsal root is particularly important. of which only They mainly from the syndromes produced by wounds of the a different distribution peripheral nerve trunks in the fact that there of motor and sensory disturbances. study in succession radicular . Wounds of the brachial plexus may affect the roots or the primary trunks as well as the secondary trunks and their branches of division. In the case of the roots and primary . a foreign body. a very Somewhat variable and often complex syndromes summary description can be given. we have radicular distribution in the case of le>ion of the secondary trunks we have a distribution midway between that of the roots and of the peripheral nerves. 2. to the supra- spinatus and the infra-spinatus. The nerves to the latissimus dorsi and the teres major as well as the to the subscapularis originate in the posterior cord. on leaving the intervertebral foramina. trunks. compressed by mass. lower branch The lower trunk supplies only the nerve to the pectoralis minor. to the cervical sympathetic. The nerve to the pectoralis minor (internal anterior thoracic) has origin in the lower cord. may be affected directly by a cicatricial fibrous wound. or between the scaleni. a hematoma of the supra-clavicular fossa or of the But it may also be wrenched by traction on the upper limb. The The plexus syndromes strictly so called. to the subscapulars (upper branch) and to the pectoralis major. or even a simple axilla.2i 4 NERVE WOUNDS These io. differ is result. with or without dislocation. three nerves become detached almost at the same level from its the posterior cord. or by violent downward traction of the shoulder. LESIONS OF THE BRACHIAL PLEXUS The brachial plexus. either in the supra-clavicular fossa. We shall 1. or even on a level with the intervertebral foramina.

On the other hand. by horizontal lines. as a whole and often produce possible to find complete paralysis of the brachial plexus still. We Anterior view.— RADICULAR SYNDROMES (ROOTS AND PRIMARY TRUNKS) character of the radicular syndromes is The general essentially the root distribution of motor and sensory disturbances. have already remarked that the roots and primary trunks are frequently affected separately. on the other hand. however. On the other hand. a great number of muscles are supplied . Fig. the close relations vessels explain of the secondary trunks with the association of lesions axillary the frequent and vascular syndromes which complicate strikingly any clinical investigation. — Root and peripheral sensory regions. parallel to the axis The radicular sensory regions are indicated of the limbs. Posterior view. another. 210. Root istribution. these result from affecting the clavicular region or the upper part of the axilla. it is among them syndromes of partial lesion. I. closely adhering to one plexus. Root distribution. are more frequently affected .BRACHIAL PLEXUS the 215 lesions secondary trunks and of their branches. producing partial paralysis of the brachial The secondary trunks. Peripheral distribution.

. FIFTH AND SIXTH (ERB-DUCHENNE SYNDROME) by its Lesions of the upper radicular group are characterised essentially by terminal branches . CERVICALS.— UPPER I. 21 1. : corresponding to lesions in and sixth cervical roots the upper primary trunk. by two and often three different roots these muscles will often be found. 3. Motor topography. paralysis of the following muscles. Of the fifth — upper radicular group comprised and the first dorsal group. Muscles of the shoulder. partial paralyses of Between the roots. comprised in the lower radicular trunk. Brachialis anticus. Biceps. there are extensive sensory substitutions is anaesthesia therefore resulting from radicular lesions frequently less obvious than anaesthesia from lesions of the trunks. 2l6 NERVE WOUNDS . consequently. cervical root — lower radicular I. shall describe diagrammatically three partial radicular syndromes. Deltoid (circumflex nerve). Anterior view. — Upper radicular group. supplied Deltoid. 2. Fig. We 1. too. Of the seventh Of the eighth cervical root and the middle radicular trunk. Posterior view.. Biceps and brachialis (musculo-cutaneous nerve). Supinator longus (musculo-spiral). Supinator longus. RADICULAR GROUP.

2. — Teres major. the fore-arm on the We is simply attention to the fact that flexion of arm completely suppressed. Atrophy shoulder. Upper radicular paralysis from wrenching of the fifth and sixth cervicals. Atrophy of shoulder. If the lesion affects the roots near their origin we even find paralysis ot the serratus magnus. Supra-spinatus and infra-spinatus. triceps . . — Upper of the radicular paralysis deltoid. 212. brachial is amicus and supinator longus. pronator teres and flexor carpi and supinator brevis the extensor ami flexor . serratus magnus of the shoulder-blade. displacement 213. from of Fig. the nerves of which originate trunk or its in the upper primary branches. radial extensors radialis . displacement of the scapula (rhomboids and shoulder-blade. wound muscles in the'eervical region. There results atrophy of all the scapular muscles. and minor. infra-spinatus. Fig.BRACHIAL PLEXUS 217 have We need not insist on the nature of these paralyses. the upper radicular group partially supplies the following : muscles coraco-brachial radii . which call already been studied. muscles of the thumb. rhomboideus major . Subscapularis. since the biceps and the supinator longus are both paralysed. Impossible to flex the elbow or raise the shoulder. Finally. and the levator anguli scapulae. giving the appearance of winged levator scapulae) and the almost absolute impossibility of imparting to the shoulder-blade the balancing movements which might slightly compensate for paralysis of the deltoid (serratus 3. of the rhomboids. magnus). There is also found paralysis of the following muscles : Pectoralis major (clavicular head only). supra- spinatus. of biceps.

The syndrome produced is almost exactly that of saturnine accompanied by similar integrity of the supinator longus. is which untouched.2l8 NERVE WOUNDS These muscles 4. of is essentially characterised by paralysis the muscles supplied by the musculo-spiral nerve. for. Summarising.— MIDDLE RADICULAR SYNDROME Paralysis of the seventh cervical or of radicular the middle trunk. the thenar and hypothenar eminences. 214. Sensory disturbances. it the hand. but at most extends on to the base of metacarpal. .— LOWER RADICULAR GROUP (ARAN-DUCHENNE SYNDROME) first Lesion of the eighth cervical root and of the dorsal or of the lower primary trunk is characterised by paralysis of the flexores digitorum. are never characterised by so complete an anaesthesia as that of trunk lesions. the interossei. supinator jerk. paralysed. we may state that the muscles supplied by the median belong to the region of the eighth cervical. from is The percussion of the styloid process. lysis. We find a rather well-defined area of hypo-aesthesia regions occupying the C-5 and C-6 does not reach . — Upper radicular paraHypo-a^thesia C-5 and There also persist some very feeble movements of the extensors and the extensor ossis C-6. the flexor carpi ulnaris. III. with the exception of the supinator longus. will be slightly weakened. it is partially supplied by the sixth cervical. it extends over the outer surface of the arm and the fore-arm the first . which take place over an area parallel to the axis of the limb. The sensory region of the seventh cervical is paralysis extremely restricted. The triceps. II. is net completely we remember. as weakened. abolished. whereas the ulnar principally carries fibres of the first dorsal. metacarpi pollicis (supplied partially by the C-6) and even slight movements of extensor indicis and the extensor minimi digiti (C-6 and C-8). Fig. The olecranon reflex is abolished or inverted. It comprises at the most a small tract of slight hypo-aesthesia extending over the dorsal surface of the fore-arm and the external part of the dorsal surface of the hand.

the biceps is weakened and the supialso been affected. whereas ought to be in wholly untouched paralysis limited to the seventh cervical. (Lesion of the seventh . cervical). palmaris longus. Radial extensors Extensors of lingers. Considerable weakening of the triceps. Fig.) In this case the sixth cervical has though the deltoid is almost untouched. cervical. flexor carpi radialis. 215. — Middle radicular group. 216. for nator longus almost it completely paralysed. occupies a track covering the external pan of the fore-arm and stretching forwards and backwards almost 10 the middle line of tore arm and tended in . lysis — Middle radicular para- from wound of the cervical region. somewhat more ex- an isolated lesion of the middle radicular trunk. Paralysis of the radial extensors and extensoics digitorum attitude of musculo-spiral paralysis. Hypo-aesthesia. 217. Fig.BRACHIAL PLEXUS 219 /!' Triceps (incomplete). Integrity of movements in bending the lingers. sixth and seventh cervicals). Weakening ot pro- nation and flexion of the hand (pronators. Sensory topography. FlG. — Middle radicular group (seventh Motor topography.

receive some fibres of . Flexores digitorum. Flexor carpi ulnaris. fibres coming from C-6 and C-~.220 NERVE WOUNDS A lesion of C-8 and D-i as reproduces very nearly the appearance of flattened associated paralysis of the median and the ulnar with hand or or simian griffe. the abductors of the thumb seem to be supplied mainly by C-8. Figs. Fig. They are largely unaffected in lower radicular paralyses. particularly the abductor pollicis. Sensory disturbances are characterised root lesions by a band of in lower hypo-a?sthesia of the inner side of the limb. Into this tract of hypo-assthesia. however. 218 and 219. graphy. in contradistinction to the other interossei. Muscles of the hand. Motor topography. The muscles of the thenar eminence. -Motor topoMuscles of the On the internal surface of the arm. —Lower radicular group C-8 C— 7 and even of C-6 to D-i. however. . 220. Lastly the pronator radii teres and the flexor carpi radialis receive. on the inner side of the arm. for which D-i seems predominant. hand. according we have complete interruption nerve irritation. we note the integrity of the triangular region supplied by the second and third dorsals. mostlv through the external root of the median. Sensory topography.

However. it is . Fig. with fracture of the clavicle. fits 221 the triangular zone responding to the second and third dorsal The ulnar periosteal reflex is abolished. . in these cases it does not come from the radicular lesion itself. Dejerine-Klumkc. as is usually the case in the traumatic wrenching of the roots. triceps and extensor muscles. Paralysis and atrophy of the epitrochlear muscles . This consists of myosis.BRACHIAL PLEXUS there roots. supinator longus. persistence of the movements of flexor carpi radialis and especially of the pronator radii teres. enophthalmos and contraction of the palpebral fissure of the corresponding eye. OCULO-PUPILLARY SYMPATHETIC SYNDROME It may be remembered that the communicating branch supplied dorsal to the lower cervical ganglion by the first root carries to the cervical sympathetic the fibres of the cilio-spinal medullary centre. has determined fibrous contraction of the (lexores digitorum and of the palmar aponeurosis trophic disturbances of the nails. Integrity of the deltoid. affecting the upper cervical roots. Paralysis and atrophy of all the muscles of the hand. The lesion. it is not found in the lower radicular lesions alone it may But be noticed after lesions higher up. of a neuritic type. Lower radicular paralysis from wound in lower cervical region. we have the oculo-pupillary syndrome described by Mme. — If this branch is destroyed by traumatism. . 221. biceps.

Three partial types may be described i. on the upper part of the shoulder (fourth cervical) and on the inner surface of the arm where is found the triangular zone supplied by the second and third dorsal roots. . affected by traumatism same time as the cervical roots. characterised musculo-spiral. II. — Oculo-pupillary myosis. Syndrome of the lower secondary As we more see. Anaesthesia is complete on hand and fore-arm.—TRUNK SYNDROMES OF THE BRACHIAL PLEXUS The syndromes produced by lesions of the secondary trunks and their branches of division closely resemble peripheral syndromes.222 NERVE WOUNDS at the produced by direct lesion of the cervical sympathetic chain. fissure. 222. and of the lesser internal cutaneous. Syndrome of the upper secondary : trunk. 3. from lesion of the first right dorsal root constriction of the palpebral Sinking in of the eye . complete paralysis of the upper limb. along with lesion of the of the ulnar and of the inner head of the internal cutaneous. there is sensation. Syndrome of the posterior secondary trunk (musculo-spiral circumflex trunk). Total Radicular Paralysis Total radicular plexus paralysis — as produced mainly by tearing of the brachial owing to violent traction on arm or shoulder — is characterised by Fig. however. by complete paralysis of the circumflex and the trunk. syndrome (Dejerine-Klumplce syndrome). corresponding to paralysis of the musculocutaneous and of the outer head of the median. The oculo-pupillary phenomena previously described (first dorsal) naturally form part of this syndrome. these syndromes consist of the associated paralysis of two or peripheral nerves. corresponding to paralysis median. 2.

In paralysis of the upper secondary trunk (outer head of the we have found complete paralysis of the pronator paralysis teres and almost complete of the flexor carpi radial is. important lesions affecting almost the branches of the plexus. behind the and at the level of the axilla are not very frequent all more often we Still. as time goes on.BRACHIAL PLEXUS 223 We median) must lay stress on the topography of the inner and outer heads of radii the median. Syndrome of the upper secondary trunk comprising the outer head of the median. — almost complete integrity of the flexor carpi radialis and complete integrity of the pronator radii teres. accompanied by weakening of the Again. in flexor pollicis and of the opponens. and. vascular lesions is association into with extremely of frequent. . at the outset becomes dissociated paralysis the affected branches have resumed their functions. of partial lesion of the brachial plexus . that less we may when find complete paralysis Finally. another case of lesion of the lower secondary trunk (inner head of the median). 224. with preservation of some degree of flexion of the thumb and of opposition. there was paralysis of the flexores digitorum. The clavicle find cases. moreover. secondary trunk comprising the inner head of the median. 223. Fig. or less introducing the clinical picture the complication more pronounced symptoms of iscluemic paral} sis. these branches are unequally affected. — Syndrome of lower Fig.

or simple neuralgic syndromes. There is no need to describe them . It is possible.224 In this NERVE WOUNDS chapter we have contented ourselves with giving a general and systematic summary of the syndromes of the brachial plexus. of course to find the most diverse associations . we also meet with syndromes every clinical variety corresponding to the nature of the lesion : of complete interruption. of compression. their characteristics are exactly the same as those of the various peripheral syndromes. nerve irritation forms. .

the extent of the ischaemic region may vary considerably . by obliteration of an arteries trunk is far from being Only a few obliterations of are accompanied by ischemic phenomena. we feel compelled to devote an entire chapter to it As a rule. In most cases tree from paralysis. after obliteration of the radial by ischemia of hand ami Ischemic upper limb . anastomoses nevertheless. probably transitory . none For instance. we quickly observe the reappearance of the radial pulse. and ulnar arteries.g. such as ligature of the axillary. slight signs most of them showed no disturbance whatsoever. had submitted ligature of the axillary . The mechanism arterial of ischemic paralysis caused clear. three months previously. . yet the symptoms observed were totally different. have seen two patients who. momentarily suppressed by ligature almost normal. we have found no more than five cases of genuine ischemic paralysis. arterial . *5 . both cases the radial pulse was suppressed and both had almost identical vascular tension. brachial artery. radial we have found ischemic paralysis following obliteration of the artery in the anatomic snuff-box.CHAPTER XIV ISCHEMIC PARALYSIS OF THE UPPER LIMB Ischemic that paralysis of the upper limb is too frequently connected with is nerve wounds. In a similar lesion. axillary or Nevertheless. we to . follows obliteration or ligature of a large artery. viz. where the pulse does not or reappear there are but few ischaemic phenomena. In these cases. we sometimes radial find cases where at all. the arterial blood-pressure becomes On are the other hand. scarcely any at all in . lacking. subclavian. the integrity and distribution of the collateral circulation constitute an important individual factor. e. out of thirty-two cases of ligature of the axillary and sub-clavian. accompanied fingers. we have seen paralysis affect only the hand or rise as far as the elbow. paralysis may also be seen after prolonged contraction of the is plaster of Paris applied too tightly the most frequent cause of such paralysis. For instance. we have even met with a very singular case. and even when clearly defined so difficult to diagnose it. some others complained of of ischaemia.

still. he presented an instance of complete ischemic paralysis accompanied by fibrous transformation of the hand. and the patients carefully . Deep freezing pressure. the healthy side Pachon sphygmomanometer. and the patient can though with considerable trouble. wrap the hand in warm gloves or cotton-wool. Sensation has not altogether disappeared we even . the first had a tension of 1 7-8 on of 9-8 with scarcely any oscillations on the ligature however. imperfectly differentiated but each of these stimuli gives rise to a very painful sensation. side The second on the healthy side had a tension of 22-9 on the paralysed side the tension was 1 1-9 with very faint oscillations. move his fingers slightly. sensation these is somewhat better retained than superficial sensation. there was but slight cyanosis and cooling of the hand. Passive movements possible. patients often complain of acute pains or : burning or . either simply is cyanosed or of the reddish soft swelling tissue. Probably the elasticity of the vessels. mention must be made of the more often or less obscure syndromes of ischaemia from lesions : arterial obliteration which accompany nerve particularly lesions in the brachial plexus at the level of the axilla and wounds of the median and ulnar on the inner side of the arm. the presence or absence of atheroma. In the phase we note cedematous infiltration of the ischaemic regions.226 NERVE WOUNDS By . perceptibly stronger than in the former case . CHARACTERISTICS OF ISCH/EMIC PARALYSIS We 1. and above all. . In addition to real ischaemic paralysis. although the resistance caused is by fibrous transformafind. The hand lees is cold. it infiltrated with a which skin is is not confined simply to the sub-cutaneous cellular giving but spreads over the muscles. the : tion of muscles and articulations quickly developed. though remaining dull and dry. . coexistence of very marked hypo-aesthesia and of painful hyper-aesthesia patients complain of a numbed . . tint of the of wine. though the . . Finally. sensations with formication sensations numbness of the hand deep cutaneous stimuli and cold more especially intensify these heat mostly calms them somewhat. as well as the nerve lesions so often associated with arterial lesions. Movement also are still is not completely abolished. feeling in the hand all stimuli of touch or pain-provoking heat are incompletely perceived. the phenomena of vaso-motor spasms play an important part in these cases. the infiltrated them a sort of pasty consistence and thickened. as a rule. may describe first two phases in the evolution of ischaemic paralysis. badly localised.

cutaneous cellular aponeuroses. of the axillary. in a veritable fibrous mass the muscles become a puffy. thesia in the fingers taper off and sometimes become incurved. After a few weeks. are gradually embedded . dead-looking. inert and insensitive appendage. 225 and 226. atrophy. the projections of the muscular bellies disappear. contract and gradually sistence. of a red colour. Figs. After the slightest traumatism sloughy type. movements disappear progressively . appears and becomes complete is the pain also calms down . rigid.ISCHEMIC PARALYSIS OF THE UPPER LIMB the limb. — Ischaemic paralysis following ligature . 227. the nails bend in like claws. we tissues. following the —Topography of anaes- two cases of ischemic paralysis. oedema the begins to diminish but the subtissue. hard and adherent to the subjacent tissues. it or even vivid thin. In true ischemic paralysis the hand is habitually extended] the fin . see fibrous transformation of the infiltrated In the second phase. fibrous contractions. acquire woody con- The skin becomes smooth and violet is shiny. . and the hand gradually transformed into a sort of fibrous. they harden. anaesthesia Fie. their cicatrisation All active or passive is we may find cutaneous ulcers of a dry often a very long process. their topography 2. Fibrous transformation of the hand. the tendons. is 227 Sensory disturbances gradually increase from the root to the extremity of therefore vaguely segmental.

or distorted form. 228. maybe flexed in a fibrous griffe. neuritic griffe which recalls. Too frequently ischaemic paralysis is incurable. On the contrary. Fibrous transformation of the hand. — Ischaemic paralysis following the crushing and obliteration of the brachial artery. massage and mobilisation and galvanic or faradic Fig. Fibrous hand. 229. : is distinguished from nerve lesions by the following Distribution of motor and sensory disturbances corresponding to no peripheral nerve topography. — DIAGNOSIS Ischaemic paralysis characteristics I.— 228 NERVE WOUNDS it slightly flexed. but considerable improve- ment may be obtained by permanent warm covering. the Fig. but in the case of associated nerve lesion. completely immobilised in the position ot ulnar griffe. in pronounced of the median or the ulnar. it is segmentary. hot baths. .- Ischaemic paralysis from lesion of the axillary with association ot nerve disturbances. prolonged electrical stimulation.

at the motor point. as well as by excitation of the . 3. but there is no likewise are somewhat different enormous hypo-excitability which speedily becomes : . that the muscles are not really paralysed but are immobilised infiltration. 229 All these disturbances are pronounced at the periphery and gradually The special puffy or wooded consistence of all the tissues. In some cases : 4. 230. by fibrous Electrical reactions polar inversion. 2. complete inexcitability as long as electrical excitation this is capable of causing muscular contraction.ISCHEMIC PARALYSIS OF THE UPPER LIMB diminish towards the root of the limb. Suppression of the radial pulse. we can obtain movement by exciting the nerve from a distance or muscle itself. Associated with median griffe. 5. —Ischaemic paralysis from lesion of the brachial artery. it is even possible to ascertain that there is : no real paralysis a few imperfect movements continue for a long time we find Fig.

.

The level at which this division takes place is extremely variable .) All sciatic It its original branches are united at the level of the notch. render particularly vulnerable. through the medium of the lumbosacral cord.PART III LOWER LIMB CHAPTER XV SCIATIC The The sciatic is NERVE its by its far the most frequently affected nerve in the lower Limb. It rests on the posterior surface of the femur which is covered by the insertions of the adductors and by the the interspace comprised vastus externus. and the biceps without. originates the fourth and fifth lumbar roots. its the neighbourhood of which branches divides popliteal into two terminal — the external and the internal popliteal. and more particularly in the first. passes round the ischial spine and descends in the the posterior part of the buttock between ischium and the greater trochanter. the length of number and im_ portance of branches which supply the greater part of it the lower limb." (Cruveilhier. second and third sacral roots . it represents " the sacral plexus condensed in one nerve cord. the bulk of its trunk. course. it . covered by the mass of the gluteal muscles and the pyramidalis. It becomes in superficial at the upper end of the popliteal it space. ANATOMY OF THE The It lars:e sciatic SCIATIC NERVE nerve is the longest and most widelv distributed in the human in body. It descends in the posterior part of the thigh into between the semimembranosus and the semitendinosus within. and also below this muscle by the lower part of the gluteus maximus.

to ext. pop. Collateral Branches Along i. head of gastrocnemius N. (per. its course. 232. from each other yet in close apposition. head of gastrocnemius Ext. xt. N. most frequently in the middle region of thigh.232 NERVE WOUNDS be very high.. br. N Fig.) „ . N. H N. to the pyramidalis Inferior gluteal N. (thigh) . The The nerve to the long head of the biceps which appears at a very variable level.. N.. which very high up. rostenor cutaneous N. the trunk of the great sciatic nerve supplies arises : The upper nerve to the semitendinosus. pop. immediately below the tuberosity of the ischium. is the reason the semitendinosus is often untouched in lesions sciatic. N. (After Sappey. pop. to short head of biceps N.. Int. J WllH -t^M It Great sciatic N. in gun-barrel fashion. N. 3. Nerve to the semitendinosus flBKaBI^ / fl . at nerve to the semimembranosus which originates as the the same level and often from the same trunk nerve to the biceps. saph. — Sciatic nerve and why its collateral branches in buttock and thigh. to int. to the semimembranosus ' Iffi/it^Ml Wsi§k 'Um 'S'/ 'iBI JJSH 'wf VN " t0 '° ng head oi bice P s Nerve to the semitendinosus Int. sometimes these two branches distinct rise as may far up as the pelvis.-l 'i Posterior cutaneous N. .) This of the 2.. Superior gluteal N.

. saph. fibularis head of gastrocnemius Int. of the sciatic nerve really N. saph.— EXTERNAL POPLITEAL NERVE away in the The external popliteal breaks neighbourhood of the upper end of the popliteal space. V being flexors of the leg on the thigh. saph. N. flexion. The To these collateral branches must be added another supplied by the sciatic to the adductor the or Gluteus maximus' magnus and articular upper the Small sciatic nerve" nerve -^ [ knee. : the-external popli- the nerve of exten- sion. the origin of which also varies considerably. V. N. internal and the the popliteal.) I. Ext. antagonists of each other teal. Posterior aspect widely distributed representing both — Superficial nerves of the lower limb. (calcaneal branch) -- musculo-spiral. (Froi median and the ulnar. N. nerves. N. above downwards biceps exInt. ening of the lesions of the Int. plains the frequent weakin sciatic. being usually a little below the nerve to the long head. Terminal Branches The division constitute branches Int. popl. NERVE 233 nerve to the short head of the biceps. Saph.SCIATIC 4. semitendinosus are more frequently untouched. homologous part to the terminal of the Post. There these is no need all to dwell on the function of muscles. N. saph. pop. N. whereas the semimembranosus and especially the Ramus communicans Int. Sufficient to note that the order in which these branches breakaway from Int. two distinct Ext. nerve of more and the Fig. two sketches by Hirschfeld. 233. tih.

of rami communicantes tibialis et Iibularis Exter. resting directly on the periosteum of the fibula where it may be Fibular cut. of ant. and musculo. saph. Collateral Branches After sending out an articular branch. 234. N Anter. Muse. —External . Ext. Ext.234 It NERVE WOUNDS proceeds along the internal border of the biceps. of ext. (cut. communicans iibularis Muse -cut. and goes round the neck of this bone to reach the antero-external region of the leg. crosses the outer tuberosity of the tibia covered by the external head of gastrocnemius. it is immediately covered by the aponeurosis and It penetrates into the antero-external compartment of the leg. N. popliteal nerve. passing along a musculo-fibrous canal formed by the origins of the peroneus longus. tib.) Anastom. ant Ram. Inside this canal it divides into its two terminal branches. br. saph. N. (After Hirschfeld. passes behind the head of the fibula. N.) Anastom. pop. Anter. N.cutaneous Anastom. : The ramus communicans fibularis which descends upon the posterior . saph. cut. tib. N. br. At this level it is very superficial. (terminal br. N.) involved in case of fracture the skin. the external popliteal supplies 1. to tib. tibial. and musculo-cutaneous Fig.

of the external and popliteal).facc of the external head sur At this level posterior region of the leg and the heel. appears at the same level as the former which Ext. Iiallucis Ant... digitorum >••-• _. N.) tibial nerve.-- Extensor lonsr. saph. Exter.— Musculo-cutaneous nerve and anterior (After Hirschfekl. -Anterior tibial N. interspace that separates the anterior . pop. tibial N. antero-external region of the distributing itself over the upper part of the Terminal Branches penetrates into the compartment Anterior tibial nerve. the external saphenous (internal it leg anastomoses with branch or external cutaneous nerve of the 2 The peroneal cutaneous and descends outside it. Extensor propr.45 of gastrocnemius and is distributed to the skin u. from the tibial on the inner Side 1. N 41 / Fig. Peroneus longus ^Tibialis anticus Musculo-cutaneous N.SCIATIC NERVE 2. and of the extensors. simplified.-This nerve later outside. then in front of. 235. and descends at fust then lies deeply m the muscular it internal to the anterior tibial artery.

The external branch is which also proceed along the second. it an acute angle from the anterior amidst the fibres of origin of the reaches obliquely the interspace peroneus longus. anastomoses in the covered by the extensor brevis digitorum. 2. It supplies the motor innervation of the extensor brevis digitorum. which produces the external collateral of the collateral of the great toe and the internal second toe. certain cases. NERVE WOUNDS later. supplies The anterior tibial nerve tibialis anticus 1. divides into At termination. In its course the musculo-cutaneous supplies The peroneus longus and the peroneus brevis. possible to meet with a first distinct sensory region for the anterior tibial occupying the dorsal surface of the first metatarsal and of the great toe. external and internal. : It supplies cutaneous twigs to the lower part of the antero-external region of the leg. The internal dorsal cutaneous nerve of the foot. in exist. — The musculo-cutaneous separates tibial. the peroneus longus and the peroneus brevis lying on the outer side. external collateral of the second and the internal collateral of the third . It finally divides at the lower third of the leg into two terminal branches. It becomes superficial at about the lower third of the leg. and most variable fashion. by from its collateral branches means of two branches. mainly supplies articular and periosteal twigs . between the extensor communis on the inner side. The its anterior tibial shares but feebly in the sensory innervation of the It dorsal surface of the foot. are merged it is in the branches of the musculo-cutaneous. proceeds along the first intermetatarsal space. superior and : The The its extensor communis digitorum it pedis . 1. which supplies the internal collateral of the great toe. when they Still. extensor proprius hallucis. which supplies the toe. the nerve passes its beneath the tendon of the extensor hallucis.236 extensor communis. Musculo-cutaneous nerve. The first dorsal interosseous nerve. The internal branch. and outer side. with the terminal branches of the divided into several shoots musculo-cutaneous. more widely distributed. branches of cutaneous sensibility. third and fourth intermetatarsal spaces and anastomose with the branches of the musculo-cutaneous. from the extensor proprius hallucis on the At and the level of the annular ligament of the ankle. 2. two branches. 3. appears on splits external border up into its terminal branches. The second dorsal interosseous nerve. The inferior. In passing through this muscle. and especially the at inter-metatarsal space.

flexor r N. N. N. the dorsal collaterals do not reach the extremity of the Great Int. 237 The middle dorsal cutaneous nerve. >-' Fig. saph. N. sciatic N. Ext.) toes. N.— INTERNAL POPLITEAL NERVE AND POSTERIOR TIBIAL NERVE More bulky continued It traverses than the external popliteal. to flexor longus Post. Calcaneal branch -xter. Outer head of gastrocnemius to soleus pop. the popliteal space and given off in the angle formed by the biceps and the semi-membranosus. to flexor longus hallucis to tibialis posticus N. saph. to long. must be noted in that the fourth dorsal interosseous nerve comes from the external saphenous (internal popliteal). tibial N. pop. >N. Poster. — Internal popliteal nerve and posterior tibial nerve. (After Sappey. The ungual phalanx is supplied by dorsal branches coming from plantar collaterals. pop.' Inner head of gastrocnemius Int. 236.SCIATIC NERVE 2. which supplies only the dorsal its interosseous of the third interspace and It two collateral branches. Exter. the internal popliteal nerve of the trunk of the is is in the direction sciatic. to tibialis posticus N. II. N. N. As the hand. passing downwards below into the . N. tibial.

and r. 237. — External saphenous nerve and ramus communicans (After Hirschfeld. Inter. coram. . saph. Starting from the fibrous arch of the soleus. fib.)-! Exter.) fib. N. saph.238 NERVE WOUNDS two heads of the gastrocnemius and In this course it is space between the passes in under the aponeurotic arch of the soleus. internal surface of the nerve. to inner head of gastrocnemius Exter. to soleus Inter. pop. pop. far. N. to exter. (calcaneal br. N. the popliteal trunk. saph. crossing the posterior and Inter. (calcaneal br. saph. N. N. (post . saph. N. The posterior tibial artery. the internal popliteal takes the name of posterior tibial. Post. N Ram. The arch of the external saphenous vein opens into the popliteal vein. sub-solear aponeurosis it is muscular layer by means of the deep or covered by the soleus and afterwards by the originating in Achilles tendon. of coram. cut. relation to the we then find from without inwards and from behind forwards the nerve. saph. saph. N.) Exter. Fig. exter. N Anastom. tibialis posticus from the flexorcommunisdigitorum closely adheres to this deep . tibial. The posterior tibial nerve descends between the superficial layer and the deep layer of the posterior muscles of the leg. Inter. interspaceseparating the it It lies in the cellular . N. Fib.) iibularis. head of gastrocnemius N. popliteal vessels . the vein and the artery. N. Ext.

4. The The The The The nerve to the inner head of gastrocnemius. It supplies cutaneous branches to the lower part of the . branches toe . it appears on the outer side of the reaches the outer edge of the Achilles tendon and at this level receives an important anastomosis from the ramus communicans fibularis. . supplies tibial an important sensory is branch. and the peroneal artery on the outer side. in the it malleolar region (external calcanean nerves) in front of the malleolus anastomoses with the musculo-cutaneous. At appear the level of the instep. and descends with canal. 5.e. posterior articular nerve of the knee. 6. At the lower part of the leg. nerve to the popliteus with muscular and vascular branches branches grouped by Cruveilhier under the and a branch to the interosseous membrane. it Finally. It also supplies articular name of 7. the outer one becomes the external : it divides into two terminal dorsal collateral of the fifth the inner one. 3. bein«. nerve to the outer head of gastrocnemius. the and the external plantar nerves. nerve to the plantaris. describing a curve round the outer malleolus. In the popliteal space. 2. Near the tuberosity of the fifth metatarsal. artery and internal to It is in this retro-malleolar groove. rejoins the external saphenous vein at it in the middle line. .SCIATIC NERVE crosses the anterior surface of the nerve 239 and becomes internal. at its the entrance of the calcanean groove which forms into its continuation. Collateral Branches I. It finally foot. covered by the superficial aponeurosis which ensheaths it in a fibrous the upper part of the leg. supplies the internal collateral of the fifth toe and the external collateral of the fourth toe. that the posterior tibial nerve divides internal two terminal branches. the nerve of the fourth interosseous space. The external saphenous nerve sends out no sensory twig to the upper part of the leg. i. the external saphenous nerve or saphenous which given off at the upper or middle part of the popliteal space. the posterior tibial Thus the nerve descends almost midway between artery on the inner side. the nerve and the posterior tibial vessels in the internal retro-malleolar groove it. nerve to the soleus. leg. the nerve is behind the deeper and more closely adherent to the bone covered by the tendon of the flexor longus. the : internal popliteal supplies a certain number of muscular branches 1.

—Plantar nerves. to adductor hallucis Br. 240 2. the internal and external plantar nerves. plantar N. 238. . Fig. (After Sappey. NERVE WOUNDS At the level of the leg below the fibular arch of the soleus. distribution communis digitorum. dig. to abd. bi Ext. Ext. to ilexor brevis Ext. vascular branches. Inter. articular branches for the tibiotarsal It also supplies Br. —-Apart from its articular branches.) articulation and sensory branches of but slight importance : the internal supra-malleolar branch and the internal calcaneal! nerve. reach the sole of the foot by the retro-caleanean groove and separate at an acute angle. plantar minimi digiti N. I Collate ral to toes Superficial region. Terminal Branches The two terminal branches. to accessorius Branch to accessorius Br. the internal plantar nerve supplies both muscular and cutaneous branches.. Internal plantar nerve. the posterior tibial nerve which continues the internal . r. somewhat resembles median in the case of the hand. plantar N. min. inner and outer sides of the foot. flexor communis digitorum. to add. (deep branch) N. popliteal supplies : The The The tibialis posticus flexor proprius hallucis . making their way towards the . They separates proceed between the two muscular layers of the sole of the toot lying on the accessorius covered by the belly of the short flexors which them from the interossei and on the tendons of the flexor that of the proprius hallucis and the flexor Their respective and ulnar 1. br Int.

N. deep terminal branch inwards and penetrates the deep 16 . plantar third The an interdigital nerve receives from the external nerve anastomosis analogous to that supplied by the ulnar to the median. bi Deep br. These are the Int. hi Superficial br. By its collateral muscular branches supplies the abductor minimi digiti pedis Its and the flexor brevis minimi curves digiti pedis.) Secondly. terminal branches. by means of their dorsal branches. plant. 2. two in number : The The third internal branch . 239. . N Ex. Flexor brevis digitorum pedis . plant. The cutaneous branches arc of two orders. N.SCIATIC NERVE The muscular branches destined hallucis . dissection of the foot. interdigital nerves and the plantar collaterals springing second and from them. Ext. N. N. External plantar nerve. 1. nerves. obliq.— Plantar (After Sappey. Int. 241 : for the muscles are Abductor Flexor brevis hallucis Accessorius. — The external it plantar nerve also supplies both muscular and cutaneous branches. to interossei abductor transversus N to adductor transversus Deep Fig. calcis to the base of the toes. It is the plantar collaterals that supply. simple collateral branches which perforate the plantar aponeurosis and supply the plantar integuments from the os plantar cutaneous nerves. to to adduc. Firstly. which supplies only the internal plantar collateral of the great toe external branch which supplies the first. the dorsal surface of the ungual phalanges.

Wc use the expression "extension of the foot " for the dorsal raising of the foot. dorsal innervation of the ungual phalanx. The raises posticus supplied external popliteal. . analogous with flexion of the hand. plantar sensory it supplies : The external collateral of the little toe The fourth interdigital nerve with its collaterals An anastomosis to the third interdigital nerve (internal plantar). by the abolition of internal rotation border of the foot. By flexion of the foot we mean the movement of lowering the toes. To those main disturbances is the arch of the foot normally maintained by the tendon Fig. . all branch of the ulnar. tibialis anticus and of the peroneus longus. 240. movements produced added the collapse of by the peroneal group. means of 2. The plantar collaterals. and of elevation of the internal movements produced by the loss tibialis by the of external rotation. its perforating branches.242 NERVE WOUNDS sole. of abduction and of elevation of the external border of the foot. . (internal popliteal) supports and r . all compartment of the proceeds to then. : The The The The tibialis anticus extensor longus digitorum pedis extensor proprius hallucis extensor . * it on v tne inner portion or the plantar arch. . including the dorsal it supply the plantar the adductor by transversus and the adductor obliquus and interossei. anticus . we will study separately the paralyses of each terminal branch. PARALYSIS OF THE SCIATIC Before studying paralysis of the sciatic in the internal popliteal. and the external popliteal. like the deep interossei. . its entirety. brevis digitorum is supplied by the anterior tibial the peroneus brevis and the peroneus longus are supplied by the musculo-cutaneous. the external popliteal and I— PARALYSIS OF THE EXTERNAL POPLITEAL Motor Syndrome The external popliteal supplies the muscles of the antero-external compartment of the leg . and from analogy between the functions of the extensor of hand and fingers. . — Muscles by the of the tibialis . comparing with the synergic movement of raising or extending the toes. through their dorsal branches. On is the other hand. Paralysis of this nerve is indicated by suppression of and extension movements of the foot * the elevation and of the toes. . provide the . the superficial terminal branch of the external .

either by the tary volun- or resulting from electrical it stimuli. beneath the skin the rising of the tendon tibialis : adduction movements without raising the foot are produced by the posticus. The As toes are flexed Pitre from the loss of the antagonism of the extensors. by raising — Steppage in paralysis of the there is distinctly perceived external popliteal. to raise who is seated. To avoid this error. with dorsal tumour of the tarsus. — Paralysis of the external group. 241. Fin. Here we of these buting slight : will mention only one anticus the the possibility of attri- to the tibialis power of adduction possessed tibialis posticus. by adduction and foot . Paralysis of the external popliteal is easy to recognise. we may easily detect the existence of paralysis of the external popliteal by asking the patient. and Testut have observed. Atrophy of the antero-external Foot-drop. and in a characteristic gait steppage. the maining on the ground. Later on we shall see what are the possible errors in diagnosis. popliteal. his toes and keep them heel re- clear of the ground. is sufficient to raise the foot it and keep position at right angles .SCIATIC NERVE This paralysis results in a 2 43 drooping of the foot with the toes pointing : towards the ground. in this the smallest contractions of the tibialis anticus are indicated both the 242. .

244. Moreover. and fibularis (posterior surface) tibial and the (dorsal when it exists is to be found only at the musculo-cutaneous surface of the foot). not is expect to find ramus anterior communicans . in musculo-spiral paralysis. foot. To this latter region are confined the sensory disturbances observed popliteal when is the lesion first of the external . pallor or cyanosis of the integuments produced by Finally. . in branch have origin the upper region of the popliteal peroneal the the cutaneous branch (external surface of the leg) . indeed. comparable with the dorsal tumour of the carpus a rule. Trophic and Vaso-Motor Syndrome Occasionally we find dorsal oedema of the foot. — Sensory : frequently happens. comprising fibularis and their the peroneal cutaneous high space. The antero-external surface of the leg is supplied by the peroneal cutaneous branch. below the two branches for this. it spreads over the dorsal A V surface of the foot with the exception of the internal and external borders and the ungual phalanges. In this sensory distribution several zones must be distinguished. trophic and vaso-motor disturbances of the external popliteal are of slight importance. hypertrichosis. middle of the external surface of the leg and on the dorsal surface of the foot. we may observe a sort of tumour on the dorsum of the tarsus. we must . In some cases the we have found traumatic ulcers on the back of the . As however. the posterior part by the ramus fibularis . cutaneous desquamation. . boot their extremely slow cicatrisation is a sign of trophic disturbances. the ramus rather communicans Figs. complete anaesthesia it not constant. the result of substitution by the internal popliteal.244 NERVE WOUNDS Sensory Syndrome The complete sensory d istribution of the external popliteal comprises a broad tract occupying the entire anteroI external surface of the leg and a part of posterior its surface . if foot-drop is considerable and hypotonia prolonged. communicans is the musculo-cutaneous distributed only over the lower region of the leg and the dorsal surface of the foot. 243 and distribution of the external the popliteal.

The 95th day after suture of By loss complete and the nerve. elevation movement of foot nor extension movement of the first phalanx of the toes. before and after nerve suture in a case of paralysis of the external popliteal with syndrome of complete interruption in section of the nerve a. In the syndrome of compression we note the opposite characteristics. These neuritic. pes euuinus less pronounced. Muscular by shell splinter (Captain C ). but in the horizontal position the Captain can carry out very marked abduction of the foot accompanied by elevation of its external edge (contraction of tarsus steppage. or even simple neuralgic syndromes. walking is easier. we may find the syndrome of complete interruption or of simple compression. Fig. We may also meet with syndromes of nerve irritation. graph taken on the 66th day after the wound.— CLINICAL FORMS OF PARALYSIS OF THE EXTERNAL POPLITEAL all As in the case of nerve trunks. 245. (J. on the 95th day after suture of the nerve. the foot is no longer swinging. equinotoes before nerve suture Photovarus. and A. desquamation. Dejerine and Presse Medicate. atony and droop of foot and basal phalanges of foot swinging. the basal the varus has almost disappeared phalanges are no longer drooping but extended on the metatarsals dorsal swelling of the meta. running is possible. The external . dorsal swelling of the metatarsus. the peroneals). fying the foot-drop By atrophy . are somewhat rare. 191 5.SCIATIC NERVE 245 I. to a definite area By permanence and the fixity of anaesthesia as well as by absence of paresthetic zones. intensi. . however. The syndrome plete terised of comis interruption : charac- Before the operation. — the paralysed nerves simul- taneously with the reappear- ance of muscular tone. rapid muscular By the localisation of the resulting formication . we follow the pro- gression of formication along Attitude of the right foot when walking. particularly the prolonged persistence of muscular tone. 10 May.) Mouzon. muscular fibrous contractions which limit the passive flexion of foot and toes and consequently diminish So far there is neither has disappeared. If nerve regeneration takes place. tendon adhesions. pain by . pressure on muscles and nerve trunks. with cutaneous scaly trophic dis- turbances. b rapid of muscular tone. Return of tone showing attitude of the foot />.

in addition. (J. 20th day after suture of nerve. the points indicate that the sensation of pinprick is. before the operation. irradiations and errors of identification. and A. Dejerine and : Mouzon. 248. particularly disagreeable (paresthesia).— Dissociated paralysis of the external fibres FlG. of the external popliteal (same case as Fig. 247. Oblique hatching with points and crosses hypo-sesthesia with intermittent hyperesthesia . Horizontal hatching: Black: pricking causes no sensation.6. pop. 2nd March. Oblique hatching : diminished sensibility to touch Note first and pin-prick. 247). pin-prick is felt simply as contact. Presse Medicate. 97th day after suture of nerve. b a b a b a Fig. may be affected by dissociated lesions and We will relate two instances of these.246 NERVE WOUNDS and in contradistinction to the internal is popliteal. the anterior fibres . 24. like the musculo-spiral. 19 15. Orifice of bullet. 10 May. Exter.) Finally the external popliteal partial paralysis. the crosses indicate delayed persistent sensations. popliteal. — A B C in B the appearance of a small zone of paresthesia on the dorsal surface of the interosseous space. 1 14th November. State of sensibility to pin-prick before and after suture of the nerve in a case of paralysis of the external popliteal by complete section of the nerve (Captain C ). Fig. with diffusion. 6th December. not a very sensitive or painful nerve. —Sensory distribution of popliteal affecting solely the of the anterior tibial.

embedded in the external and level. the fibres of the peroneals anticus form are behind. In the thigh. II. In another case. Faradic excitation of the external popliteal nerve causes only the projection of the peroneal tendons. behind the head of the fibula. Paralysis of the anterior tibial nerve. behind the head of the The muscular group of the anterior tibial was paralysed . This position corresponds to the very high root origin of the nerve fibres to the tibialis anticus (fourth lumbar). for . — The extensors and the tibialis anticus are paralysed. the region anterior of its tibial is but its possesses no distinctive own. the fibres destined for the tibialis the most external group of the external fasciculi of the sciatic nerve which represent the external popliteal. it is almost absent . Cutaneous anesthesia slightly sensory. without raising.— PARALYSIS OF THE ANTERIOR TIBIAL NERVE may be affected separately after bifurcation The anterior tibial nerve of the external popliteal. Foot-drop with steppage. whereas the peroneals are untouched. posterior part of the external popliteal. We may therefore conclude that.SCIATIC NERVE In the popliteal. Retention of lateral movements by the action oi the of the musculo-cutaneous. together with hyperesthesia of the external part of the cutaneous distribution. the peroneal muscles were not affected. first 247 case a bullet had struck the anterior part of the external fibula. the fibres destined for the anterior tibial are in front. peroneals. The internal part of the distribution of the musculo-cutaneous was devoid of sensation. a small shell splinter. almost at the paralysis same caused accompanied by nerve pains in the peroneal muscles alone. Its paralysis exactly reproduces the type of dissociated paralysis which we have just been studying.of the foot and the toes. 2+9. Integrity FlG.

whilst the other toes can easily be raised. Isolated paralysis of the extensor of the great toe. Fig. toes. Raising the foot is still possible by means of the extensors ami the tibialis . it is recognised mainly 250. hype- resthesia of the dorsal surface of the more first pronounced near the inner edge. At most there is slight foot. periosteal. Finally.-ISOLATED PARALYSIS OF THE MUSCULO CUTANEOUS Isolated lesion of the musculo-cutaneous nerve is shown by paralysis of the peroneals. — Sensory by flaccid ity of the muscle and disappearance . sup- by the anterior tibial nerve . caused by lesion of the anterior tibial at the middle of the leg. of rotation outwards and of elevation of the external edge of the foot. which remains flaccid and half flexed. and more especially a small triangular region of anaesthesia behind the interdigital space. The patient can easily raise the other four — III. for the tibialis anticus and Here we have isolated paralysis of the extensor of the great toe. of its distribution of the faradic contractions for after all the accessorius is but an anterior tibial. NERVE WOUNDS branches anastomose with Its the branches of the of the musculo- terminal branches are more specially articular and comparable the to the terminations posterior branch of musculo-spiral. with loss of abduction.248 cutaneous cutaneous. paralysis of the external popliteal and of the anterior tibial is always accompanied by paralysis is of the extensor brevis digitorum muscle which plied Fig. The anterior tibial nerve may also be affected below the branches destined the extensor longus. 251. accessory synergic muscle of the extensors of the toes.

sciatic np:rve
anticus, but, since

249
lacking, they are

antagonism of the peroneals

is

accom-

panied by a rotation inwards, by adduction and elevation of the inner edge, If there is considerable hypotonia of the effected by the tibialis anticus.
peroneals, paralytic talipes varus

may
is

result,

and the patient walks on the

outer edge of the foot.

The

musculo-cutaneous nerve

sometimes affected below the peroneals, in its sensory part. This
lesion
is

indicated solely by

anaesthesia of the cutaneous

area which comprises almost

Fig. 252. Isolated paralysis of the musculocutaneous, producing, on the left, a deviation
of the foot

Fig. 253.

— Sensory

dis-

tribution of the mus-

inwards (paralytic

talipes varus).

culo-cutaneous.

the entire sensory

distribution of the

external

popliteal

on the dorsal

surface of the foot, with the exception of the small interdigital triangle of interspace specially supplied by the anterior tibial. sometimes happens that the pain caused by pressure on a terminal neuroma or by confinement of the nerve in a cicatrix, or even by simple formication of regeneration in the neuroma and the branches of the nen es,

the

first

It

renders the wearing of boots or shoes and especially of leggings painful.

We

have noted several cases of somewhat severe neuralgia of the mus;

culo-cutaneous, injured in the middle or the lower part of the leg
particularly painful case even necessitated

one

resection

of

the

neuroma and

embedding of the

central end deep in the tissues.

250

NERVE WOUNDS

II.— INTERNAL

POPLITEAL AND POSTERIOR TIBIAL
I.— INTERNAL

POPLITEAL

Motor Syndrome
muscles of the leg and of
Lesions of the internal popliteal produce paralysis of all the plantar muscles.
results disappearance of the
all

the posterior

There

movements that produce flexion or lowering of the foot (gastrocnemius and

soleus)


:

Abolition of flexion of the toes by the

muscles

flexor longus hallucis,
flexor longus digitorum, flexor brevis digitorum.

Collapse of the plantar arch, in
part (tibialis posticus)
siderable

its

inner

together with con-

tion

weakening of rotation and adducmovements, incompletely carried out
tibialis anticus.

by the

Loss of adduction and abduction of the
toes (adductors

and abductors of the
dorsal

first

and

fifth

toe,

and

plantar

inter-

ossei).

Nevertheless, at
Fig. 254.

first,

walking does not
Paralysis
pass unnoticed

Fig. 255.

appear to

be greatly impeded.

Fig. 254. Muscles supplied by the internal popliteal. Superficial layer, gastrocnemius, soleus,
plantaris.

of the internal popliteal

may

on a
foot

superficial examination.

All
flat

Fig. 255.

— Deep

layer.

Popliteus.

we see down

is
;

that the patient puts his
that he does not
lift

the

Tibialis posticus.

digitorum.
hallucis.

Flexor longus Flexor proprius
last

heel from the ground

that he cannot rise

These

three

mus-

on

his toes.

cles are supplied
tibial

by the posterior below the fibrous arch of

The
(Pitres

patient,

when

seated,

is

unable to
fulcrum.

ra ise his heel

by using

his toes as a

the soleus.

and Testut.)

The
of the

internal plantar arch

is

flattened out, being deprived of the support

tibialis posticus,

whilst the antagonism of the peroneals on the other

hand

raises

the outer edge.

The

patient thus walks on a sort of splay-foot,

heavily, without elasticity or spring,
is

and with a degree of uneasiness which

rapidly increased by fatigue of the antagonists.

At rest, the foot is extended, passive hyper-extension appears and may become extreme, as soon as the tone of the muscles of the calf disappears.

SCIATIC NERVE
The
as the

251

toes are in simple extension or even in hyper-extension, according

tone of the flexors and interrossei persists or not.
the patient attempts to raise and stretch his toes,

When

we sometimes
caused by the

find a curious attitude of

extreme hyper-extension of the

toes,

Fig. 256.

Paralysis of the internal popliteal.
tion of the extensors

and

loss

Hyper-extension of the toes by contracof tone of flexors and interossei.

predominating action of the extensors deprived of the antagonistic tone of
the flexors of the toes and of the interossei.

Both the Achillean

reflex

and the plantar

reflex

have disappeared.

Sensory Syndrome

The
foot

sensory region comprises the entire plantar surface
vip to

;

the back and

lower part of the leg
the third the toes.

about the middle third
its
;

;

the outer edge of the

and the outer part of
interdigital

dorsal surface limited by a line

which joins
phalanx of

space

the

dorsal surface

of the

last

If the trunk of the sciatic

is

injured below the origin of the external
its

saphenous, the external edge of the foot and the part close to
surface naturally retain their sensibility.

plantar

Trophic and Vaso-motor Syndrome
In simple paralysis, as the result of compression or complete interruption, trophic and vaso-motor disturbances are almost entirely absent.
It
is

seldom that

we

find

cyanosis of the toes or pronounced cutaneous
is

disturbances; plantar hvper-hydrosis, however,

somewhat frequent

;

the

252

NERVE WOUNDS

frequency of" chilblains on the toes is also to be noted, as is the readiness with which mechanical ulcers appear on the plantar surface. have several times found superficial sores of this kind, caused by

We

injuries

from the boots,

at the level

of the metatarso-phalangeal articulations.

In neuritic types, however, trophic disturbances are very great, affecting
the skin, the muscles and the plantar aponeurosis
nails
;

they also affect the toe-

which are not touched by the external

popliteal.

Fig. 257.
Figs.

Fig. 258.

Fig. 259.

Fig. 260.
:

Sensory area of the internal popliteal comprising the 257, 258, 259, 260. external saphenous ; external surface of the instep {horizontal hatching), outer edge of the foot, dorsal surface of the foot to the third intermetarsal space. The posterior tibial, cutaneous branch (oblique hatching). The external ami internal plantars [crossed hatching) which supply, on the dorsal surface, the last phalanx of the toes.

In the case of the internal popliteal
external
;

we may

say the

same

as for the
less

trophic and
in

especially

vaso-motor disturbances are
nerve than
in

pro-

nounced
popliteal.

isolated paralysis of this

complete paralysis of

the sciatic.

Probably they are modified by substitution of the external

Clinical Types

We meet with
internal popliteal.

both compression and interruption types

in lesions

of the
fre-

Interruption types, moreover, are by far the
to insist

more

quent

;

there

is

no need

on the characteristics by which they are

SCIATIC NERVE
to be recognised
:

253
fixity

early hypotonia

and atrophy,

of sensory disturb-

ances, clearness of

RD,

fixed location of formication, insensibility to pain

Fig. 261.

— Ulcers on the

sole of the foot in a case of interruption ot the posterior tibial.

by pressure on the muscles of the calf and on the muscle masses in the sole
of the foot, as well as on the nerve along
its

entire distribution.

In

contradistinction

to

the

ex-

ternal popliteal, the internal popliteal
is

frequently the seat of neuritic or
lesions

neuralgic

capable

of

repro-

ducing

all

the syndromes of irritation

studied in the case of the upper limb.

The

slight

neuritic

type,

often

without complete
the

paralysis,

though
bellies,

accompanied by pain on pressure on
nerves

and

muscular

always causes slight fibrous contraction
ally

of the Achilles tendon gradu-

producing a certain degree of pes

equinus.

The

grave

neuritic

types

are
in-

rather frequent,

accompanied by

tolerable pains, suppressing sleep

and
;

necessitating
pressure
especially

the use of morphine
the

on

nerve trunks,

and
Fig.
call

on the muscles
the plantar

of the calf

2^2.

Fibrous

contraction

<>t

the

and on

muscles, causes

violent pains.

pes equinus caused by slight neuritic lesion of the internal popliteal at the upper par) of the popliteal space.

and

marked.

Trophic disturbances are very Along with scaly desquamation,

fibrous infiltration ot the skin,

254
and
the claw-like

NERVE WOUNDS
curve of the
nails,

we

find

that grave deformities

supervene.

Fibrous contraction of the calf soon immobilises the foot
forced flexion, suppresses the

in a state

of

movements of

the antagonistic extensors and

very often renders necessary, after cure of the neuritis, tenotomy of the
Achilles tendon.

Contraction of the plantar muscles and of the plantar

aponeurosis along with formation of fibrous cords and nodes, ends in the
claw-like attitude of the foot, and will necessitate, for a few

months

after

cure, both massage and mobilisation of the foot, sometimes even surgical

section of the aponeurotic fibres and of the contracted flexor tendons.

Neuritis of the internal popliteal,

when

intense,
;

is

a very serious type,

capable of producing irreducible deformities

it

is

certainly

more

serious

Fig. 263. Fibrous contraction of the calf and pes equinus. Contraction of the flexors and of the plantar aponeurosis, producing fibrous griffe of the toes neuritis of ,the

internal popliteal.

in

its

consequences than section of the nerve.

Consequently, in two

particularly serious cases,
lesion

we

did not hesitate to practise resection of the

and suture of the nerve. Six weeks afterwards, these two patients were walking without a stick, though there was paralysis of the internal
;

popliteal the immediate disappearance of the pains had permitted of massage and mobilisation of the limb, thus effecting a cure without trophic

disturbances or fibrous contractions.

The simple neuralgic type, accompanied by pain on pressure on the
nerve
trunks and also plantar hyperesthesia,
it
is

serious only because

of

the very long time

takes to cure.
popliteal
this
is

Neuralgia of the internal
causalgia.

frequently

assumes the type of
trophic and vaso-

Next

to the

median,

the nerve most frequently affected.
paralysis
; ;

In these cases,

we

find the

same absence of
less

motor disturbances are
terrible.

still

pronounced

but

the pains are often

These

are

the special violent

pains affecting the entire limb

the first phalanx hyper- on the metatarsus by the pull of the first extensors and . plantar muscles a simple faradic examination will generally reveal neg- lected plantar paralysis. on the other hand. Thus. (J. Frequently too it is an atrophied foot. to the flexor longus digitorum pedis. to set up the following fascicular produce dissociated syndromes topography we find. systematic inspection should the electrical reactions of the be made of the attitude of the foot and . The attitude of the foot is rather characteristic. Dcjerinc and Mouzon.SCIATIC NERVE than by deep pressure. provoked by the most trifling emotions. which receive their branches from the posterior tibial . by the inaction of the flexor interossei of the phalanx the second and third phalanges. of the „-. .) II. outwards. First. in owing to the disappearance of some cases. after a time we may and shorter than is which appears to be smaller. The toes thus seem to be bent back upon themselves. which is supported by the tendons of the tibiales and the foot. Indeed. lesion ot all disturbances are practically repartial anaesthesia of the duced to paralysis of the plantar muscles and sole of the foot.— PARALYSIS OF THE POSTERIOR TIBIAL NERVE soleus tibial. supplied by the internal popliteal. and A. leg. the thick mass of the plantar muscles see atrophy of the foot. above 255 with a burning sensation. tibialis posticus. have retained their movemuscles of the deep ments j the layer. it is a hollow atrophy of the plantar muscles intensifies the concavity of the plantar arch. the calcanean branches and the superficial branch of the external plantar nerve. From the fibrous arch of the assumes the of the name is of posterior onwards the internal popliteal This nerve is very often affected by leg. the nerve to the inner head of gastrocnemius then further out are the fibres to the tibialis posticus. caused by the slightest cutaneous touch far more all. since peroneals. traumatisms in the calf or perforating wounds in the nerve frequently though paralysis overlooked. . are strongly flexed by traction of the flexor longus digitorum. — Anaesthesia caused by the posterior tibial . at the „ upper part . the gastrocnemius and the soleus. are usually untouched. forming a sort . the external saphenous nerve. The extended toes form a special kind of grifft . Partial lesions of the internal popliteal which enable us from within nerves. FlG.. flexor com- munis digitorum pedis and flexor proprius hallucis. . then the plantar . thinner the normal foot. In all wounds of the leg. 264.

On the left^ 268. On the right. the pulp lying on the ball of the toes formed by the metatarsophalangeal articulations. . left foot paralysed in characteristic attitude.256 NERVE WOUNDS of Z. — Normal Figs. 265. 266. projection of the metatarsophalangeal articulations which constitute the anterior end of the arch. The adduction and abduction movements of the toes are suppressed posterior tibial nerve possesses the by paralysis of the interossei. — Fig. by Atrophy of the plantar muscles caused lesion of the posterior tibial at the lower part of the leg.— Attitude compare the normal right foot of the same patient. 267 and foot. Fig. Hyper-extension of the first phalanx. of the foot in paralysis of the posterior tibial. hyper-flexion of the second and third phalanges. Paralysed foot. The same trophic activities as the internal popliteal. Pes cavuswith hyper-extension of the toes caused by lesion of the posterior tibial.

— EXTERNAL SAPHENOUS NERVE for it Of all the branches of the internal popliteal. but the foot. trophic and vaso-motor is disturbances are possible. a rigidity maintained by the hamstring. more pronounced. Note that the anxsthesia does not reach the extremity of the last — portion metatarso-phalangeal two toes. theexternal saphenous nerve. interruption causes anaesthesia. it may be the seat of violent causalgia and of prolonged neuralgic pains. irritation of the nerve often the cause of painful heel. III. on the ground the and of walks of his with difficulty. along with cutaneous hyper-aesthesia so painful at times that the patient does not dare to set his heel Fig. with a steppage gait._PARALYSIS OF THE SCIATIC TRUNK Lesions of the great Progress. the external saphenous alone deserves special mention. however. in an absolutely swinging condition. there is considerable and often widely diffused atrophy of the leg. limited to the external retromalleolar region. articulations. thanks to the rigidity of the possible. frequent appearance of plantar superficial sores caused by injuries from the boot long time to heal. Atrophy is complete. carrying inner weight the body on the Sensory area "t 269. IH. lower limb. followed by the phenomena of regeneration accom- panied by unpleasant formications and cuta- neous paresthesia which the course of the nerve may cause if pain along is anything worn on the foot. sciatic nerve simply internal popliteal with that of the* is combine paralysis of the external popliteal. to the heel and to It is external half of the the outer border usual of the foot. gr'iffe particularly fibrous contraction of the plantar aponeurosis. In these cases. is no more than an insensible inert appendage supporting the weight of the body. with of the toes and muscular sclerosis. Its irritation which often take a very brings out the same nerve disturbances. by the collateral branches 17 . On is the other hand. Like the internal popliteal. may be affected in its superficial course on the posterior surface of the Its calf. for collateral substitution no longer foot To paralysis of the muscles of leg and may be added paralysis of ot the posterior muscles of the thigh supplied the sciatic. the sensory.sciatic nervp: Its 257 ulcers interruption results in the .

neuritic. semi-membran- Preservation of the semi-tendinosus suffices in persistence of flexion of the leg all these cases to assure is on the thigh. motor hranches at different and some- of the semi-tendinosus. affecting either the whole or only part of the nerve distribution. the motor twig of which is given off at the middle of the thigh. paralysis is indicated by is very often affected . They arc indicated by the usual . The sciatic nerve. like or irritated. Considerable atrophy of all the muscles of Paralysis of the posterior the leg. supplied wholly at the upper portion is scarcely ever injured. a semi-membranosus and the long head of the biceps. thi^h. Wound 13 months old. except the semi- and osus. The neuritic types are extremely frequent. the outer side is On the biceps. semi-tendinosus muscles of the tendinosus. below the sciatic notch. Injuries of this nerve neuralgic and causalgic may be interrupted.258 NERVE WOUNDS their These muscles receive what variable levels. 271. the abolition of which therefore exceptional.plied Muscles supby the trunk ot — the sciatic itself. 270. appreciable weakening of the biceps. its branches. The short head of the biceps. supplied The ^The little below. legs. syndromes which we have already studied. compressed may produce all the paralytic. are sometimes paralysed. — Fig. Lesion of the sciatic (complete interruption at the level of the sciatic notch). Fig.

and aponeurotic contractions.SCIATIC NERVE trophic 259 disturbances. and calf. sometimes at the middle or even the upper . They may immediately be recognised. an extremely variable must not be forgotten that bifurcation of the nerve takes place at level. tendon. Here its tendon shows as a very obvious projection on the inner side of the popliteal space. just as in shown by a raising of the common sciatica (Souques). Complete interruption of the sciatic at the upper part of" the leg. . profuse sweats or dryness of the integuments sclerosis of the dermis . The unaffected semi-tendinosus is capable of producing considerable flexion of the leg on the thigh. What It particularly characterises the sciatic by reason of its bulk. combined with pes equinus. simply by pressure on the calf or the sole of the foot. whilst almost invariably they culminate in fibrous contraction of the in fibrous griffe calf. fibrous infiltration and desquamation of the skin. 272. . Fig. we note slight hypertonia of the muscles of the heel. The nerve is is painful under pressure at the level of Valleix's points Lascgue's sign almost always present. intensified and aggravated as usual by disuse on the part of the patient and culminating in permanent flexion of the knee with more or less pronounced pes equinus. the tendon of which is invisible on the surface. It — must be remarked that vaso-motor and trophic disturbances of the in neuritic types are usually sciatic more pronounced lesions of the trunk of the than in wounds of the internal popliteal or of the external popliteal. Paralysis of the biceps and of the semi-membranosus. is. muscular. veritable traumatic sciatica. and sometimes even of the toes. Lastly. the frequency of partial lesions and of dissociated syndromes. Absence of contraction of the biceps. suggesting true pes equinus. which is extremely painful . In some cases rise to is we find that simple contusion of the sciatic nerve gives persistent neuralgia. the cure of which often a very long process. doubtless because of the impossibility of substitution. certain cases of slight neuritis of the sciatic produce the appear- ance of actual contractions leg : contraction of the posterior muscles of the and contractions of the calf.

Fig. NERVE WOUNDS There are indeed cases in which the two branches of the nerve issue from the sciatic notch separate. Even united at the internal in a single trunk. 274. 273. — Severe neuritis of the sciatic nerve. arranged in gun-barrel fashion. the fibres ot the internal popliteal and of the external popliteal retain their relationship. infiltration (Edema of the foot. Predominant cutaneous disturbances scaly skin broad flakes (integrity of the distribution of the internal saphenous). cutaneous desquamation. Fig. off" — Neuritis in We resulting may then observe the most varied dissociations and combinations lesion of the sciatic. peeling of the sciatic.260 part of the thigh. being grouped together and external part of the nerve. fibrous of the dermis. Trophic disturbances of the nails. In some cases we have complete paralysis of the internal popliteal or . cyanosis. from A few instances may be given. and pass on together.

in the other. it is complete in the nerve distribution of both in remains unchanging the region of one of the we appears. that the symptoms of the internal popliteal are always far more intense and . caused l>y slight irritation of the sciatic at the upper part of the thigh. Still. of the external popliteal nerve are in process ot We neuritic may find the association of simple paralytic disturbances in the in region of one of the the region of the other. In other cases. accompanied by simple weakening of the other nerve. We find. a definite area of formication. advancing below the lesion a zone of induced formication which is localised on the dorsal surface of the foot exists . it and of ncuritic or neuralgic irritation must be remembered. at the level of the lesion. find. nerves. un- changing and localised in the sole of the foot . but whereas nerves. whereas the regeneration. in such cases. 275.SCIATIC NERVE 261 of the external popliteal. syndrome of progressive regeneration Even before the muscles show the slightest sign of improvement. on the other hand. paralysis nerves. the conclusion fibres we arrive at is that there an insurmountable obstacle to the fibres of the internal popliteal. we see Fig. that a the sign of formication indicates this difference in evolution. — Contraction of the calf with pes equinus. for instance.

contracture or retraction of the antagonistic muscles. NERVE WOUNDS the signs of irritation of the external popliteal. their atrophy and faradic inexcitability enable us to determine the existence of the lesion error. or . sometimes after the recovery of a nerve lesion. may be regarded as a definite sign that they have been cut. We may also easily recognise cases of incapacity caused . In all cases. widely distributed. times They we are frequent and extremely variable as to their cause. from a wound of the gastrocnemius.262 obvious . and to eliminate all the causes of which we will now enumerate : Hysterical paralysis. seat of the wound in the course of the nerve. by the and character of the wound amination. always more first . and above all. The divided muscles also the contraction. or of the tendo calcis. or rather the group of functional paralyses. . by the partial site destruction of the muscles or by section of the tendons first. secondly. Some- are dealing with genuine hysterical paralysis or simply with the functional inertia of wounded muscles . these being specially easy in the case DIAGNOSIS OF PARALYSIS OF THE SCIATIC AND ITS BRANCHES The The various forms of paralysis of the sciatic are easy to recognise. and resulting particular the almost constant contractions of the calf Achillis. a simple electrical examination with the faradic current will suffice to show the functional nature of the paralysis. the paralysis persists — this is a functional condition. are not apparent at they have to be sought for. not transmitted to the tendon. though often difficult to determine in retracted or contracted muscles. unless there exists an associated nerve lesion. The incapacity results from the pain. and the muscles have retained their this is faradic contractility. . the result of prolonged disuse of the muscle. The sciatic are a frequency and diversity of these dissociated syndromes of the matter of importance. interventions. and which have escaped the more or less still retain some faradic contractility. the topography of the paralysed muscles. Lastly. constitutes the chief difficulty in diagnosis. the contractures and the fibrous cicatricial scleroses of the in muscles. for a precise diagnosis of the nature and seat of the lesion will frequently enable us to carry out partial and conof the servative sciatic. of the os may easily be mistaken for neuritic fibrous contraction but the distinctive pain in cases of neuritis on pressure on the nerve trunks and muscular bellies is here lacking. by electrical ex- The muscular fibres complete destruction of a muscle contract.

normal reflexes. The first and third are generally painless. Slight muscular atrophy from prolonged inaction — Complete anaesthesia <>t the (16 months). polyneuritis from asphyxiating gases. certain forms of these we have found of neuritis peculiar to war must be mentioned polyneuritis resulting from trench dysentery. being accompanied by trophic disturbances together with contraction of the plantar aponeurosis and of the plantar muscles. from frost-bite. though they may predominate on one side the electrical reactions are . on the other hand. two instances of which we have localised to the region of the external popliteal.SCIATIC NERVE more 263 Sometimes a diagnosis of the various organic paralyses of the lower limb is a little. In all these cases. the disturbances are mostly bilateral and symmetrical. neuritis from frost-bite. following a superficial perforating wound of the buttock. lower limb. incapable of using his right lower limb. hops along on his left leg with the help of a stick. of . is very painful. The patient. . polyneuritis three groups polyneuritis. Frequently peripheral neuritis appears almost identical with complete or dissociated paralysis of the sciatic. 276. normal electrical reactions. leaving his right leg to drag behind him. difficult. : Fig. Complete hysterical paralysis of the right lower limb. In addition to the typical forms of which the diphtheritic is the most frequent.

which are flaccid and spasmodic in succession. just as the supinator longus paralysis. the suppression of arterial pulsation. Lesions of the sacral plexus often reproduce the picture of complete or of dissociated paralysis of the sciatic sacral plexus. exaggeration of the reflexes. in saturnine musculo-spiral Finally. . the tibialis anticus is. the cyanosis and fibrous infiltration of the foot. ischaemic paralysis of the foot. above sensibility join with the history in clearing up the diagnosis. resulting from too tight a to bandage or from diagnose. is more or less untouched. when we come to study the lumbo- we shall set forth the special characteristics of these root paralyses. in We difficulty shall return to this point diagnosing root paralysis. the considerable fall of temperature. are characterised by the absence of peripheral signs. the lesions. may also cause errors in diagnosis. in order to diminish the incapacity of the patient. the segmentary distribution of muscular and sensory disturbances . we observe pains that are violent. the integrity of the muscles and their normal electrical reactions. the main of which lies in cases of hematomyelia. may sometimes be very difficult more so as it is rather frequently associated with nerve As in paralysis of a neuritic type. the frequent preservation of an attempt at contraction. Lastly. caused by lumbar commotio or simply by shell explosion. the absence of a wound and the history of the case are usually sufficient to determine the diagnosis. sciatic. . and. Babinski's sign and the We are far more likely to mistake combined them for flexion of thigh and trunk. . Lumbo-sacral hematomyelia. spasmodic and evoked by pressure electrical reactions there are seen marked disturbances of and objective disturbances of sensibility. limited to the lower limb and following on wounds of the cranium.264 profoundly affected NERVE WOUNDS — though. as a rule. the almost invariable all. just as we minimise the wrist drop in paralysis. but the root disthe dissociation of tribution of the motor and sensory disturbances. diminishing from the periphery towards the root of the limb all are important signs that enable us to connect these paralyses with their cause. TREATMENT OF PARALYSIS OF THE SCIATIC Steppage constitutes the main functional drawback in It paralysis of the is trunk of the sciatic or of the external popliteal. and especially to avoid the stretching of the muscles of the antero-external group. Cortical paralysis. association of sphincteric disturbances. hysterical paralysis than for paralysis of a peripheral nerve. may in certain cases be mistaken for paralysis of the These cortical monoplegias. important to musculo-spiral minimise this. The absence of the topography characteristic of peripheral nerve lesion. arterial obliteration.

278. supplied with these very simple contrivances. elastic. . Types of apparatus suppressing steppage Fig.SCIATIC NERVE This is 265 easily effected either application of spring contrivances. by the traction. Meige. Leri. by surgical boots or shoes. or. fastened on the front part of the foot. (A. or by the more simply still. 277. and H. Marie Kir. of a spring or either to a girdle or to a shoulder strap. can take moderately long walks without much fatigue. (P.) It is really surprising to find that patients. in spite of their paralysis they complain of only a very slight degree of incapacity..

(per.CHAPTER XVI SMALL SCIATIC NERVE The roots. along with the great sciatic nerve and the Gluteus max - Gluteus mini- mus Tensor Super. Moreover. sciatic are often described as the two branches of one and the great sciatic. part of The posterior cutaneous nerve descends. . glut fasciae femoris Pyramidalis Great sacrosciatic ligament Long. br. Fig.) inferior gluteal nerve (sacral plexus). (After Hirschfeld. internal to the between the biceps and the semi-tend inosus as far as the middle the popliteal space. 279. (glut. and third sacral issues from the pelvis. simplified. Quadratus femoris Small sciatic N. the inferior gluteal nerve and the small same trunk. br. It small sciatic nerve has its origin in. puden " Great sciatic N. — Nerves or" the gluteal region. second.) Gluteus maxi- mus Small sciatic N. where it divides into its two terminal branches. the first.

sciatic nerve. about the middle part of the . destruction is indicated solely by anaesthesia of the posterior surface of the thigh and of the upper part r d rr 1 Sen Fig. it sends out a series of collateral branc he : two or three in number. calf. The Its posterior cutaneous nerve of the thigh is thus wholly sensory. A A superficial branch which descends right to the the integuments . calf.SMALL SCIATIC NERVE Collateral Branches Along its 267 course. which lower edge of the gluteus maximus to be distributed over gluteal branches. distributed to deep subaponeurotic branch which proceeds along the external saphenous vein and anastomoses with the external saphenous nerve. Terminal Branches 1. on the inner and the outer over the skin of the posterior part of the thigh. . (lismhu s ory tion or tncsmal . The levels side. The turn round the / the skin of the lower and outer part of the buttock . middle of the 2. The perineal branches which are given off at the same level and are distributed over the skin of perineum and scrotum . 280. — of the calf. femoropopliteal branches which appear at variable and are distributed.

6. anil. longus. 5. 9. 281. 15. it also supplies a branch to the femoral artery and the nerve Fig. External 2. . obturator Anterior crural nerve. to the pectineus. at the level of the outer edge of the psoas. to the adductor Branch to the rectus femoris. 4. its Internal saphenous nerve with 13. Sappey. 3. 7. sacral trunk. 16. 20. Nerve to the ilio-psoas. 22. It is under Poupart's ligament that into its it divides many terminal branches. First sacral root. These roots unite near the iliac crest. Branch Branch to the adductor magnus. musculo-cutaneous nerve. n. 12. Nerve to the quadriceps. Branch 2i. 17. and the It passes under Poupart's ligament out- side the vessels from which it is separated by a portion of the psoas. 8. 10. crural — Anterior (After nerve ami 1. Internal musculo-cutaneous nerve. Collateral Branches In its intra-pelvic course the anterior crural supplies the iliacus and the psoas . in nerve crosses obliquely the iliac the angle formed between the psoas iliacus. branch. 18. Branch to the femoral nerve. its tibial patellar branch nerve. The fossa. diverging in every direction across Scarpa's triangle. is very short this fact explains why paralyses of this trunk are so few. Abdomino-pelvic sympathetic.) artery. 14. The course of the nerve trunk then . External cutaneous nerve. Obturator to the adductor brevis. 19.CHAPTER XVII ANTERIOR CRURAL NERVE The anterior crural nerve is formed by the union of three roots springing from the second and particularly the third and fourth lumbars. Lumbo- 23.

N. cut. 1. cut. Twig to sartorius Int.ANTERIOR CRURAL NERVE Terminal Branches. reduce to four groups. Inter. ti ranch to leg J Fig. one branch of which . 282.) The upper cutaneous perforating the sartorius and is branch (middle cutaneous) which over the antero-external it passes through distributed part of the thigh internal to the external cutaneous nerve with which anastomoses . 269 The anterior crural expands into a considerable number of branches which frequently originate in two common trunks and which we may. Mid. The external musculo-cutancous nerve supplies a single muscle. the sartorius. saphen. It supplies three cutaneous branches External cutaneous nerve Middle cutaneous nerve-f Access. to The accessory branch of the internal saphenous. Patellar branch (Inter. saph. N. inter. Inter. by means of several twigs : (short and long branches). saph. N. musculo-cut. cut. (After Sappey. lower cutaneous perforating branch (middle cutaneous) which it at about its middle third. Mill. with Sappey. saph. access N. The descends along the sartorius and perforates be distributed in the supra-patellar region . Int. — Cutaneous branches of the anterior crural.

externus branch to the vastus internus The branch to the crureus. 3. (patellar br. internal articular branch to the knee. and the other the deeper one.. (calc. The nerve to the N. . saph. Post. vein and descends into the — sheath of the femoral vessels in front of the artery it which crosses obliquely so as to it.: . saph. Internal saphenous nerve. both become superficial at the lower and inner part of the thigh 2. V. ace. The The The femoral cutaneous branch tibial cutaneous branch . (After Hirschfeld. The internal nous nerve rejoins the femoral artery Inter. saph. N. the vessels. thigh. Inter. near the opening it in Inter. saph. follows the femoral artery . femoris N. saphe4. The Br. perf. (tibial br The The branch to the vastus . branches. vein and inner part of the thigh and anastomose with the cutaneous branches the upper of the obturator. lie internal to Musculo-cutaneous N. are . At the lower part of the N. Inter. 270 NERVE WOUNDS remains close to the internal saphenous vein. the adductor magnus. it lies along the internal saphenous vein which Its collateral main terminal (tibial) branch accompanies right to the inner side of the foot. Inter. Becoming at the level subcutaneous of the internal tuberosity of the its tibia. branch to the rectus . cutaneous branches front of the distributed which pass in vessels are over Inter. br. The internal femoral vessels and supply the inner side of the knee. branch whose muscular branches pass behind the and are distributed to the pectineus and to the adductor longus. saph. saph. 283. leaves perforates the anterior Fig.) quadriceps from which originate : The Inter. of but slight importance.).. saph.) wall of Hunter's — canal and proceeds along the inner side of the knee. tib.

and the in for the lower limb. plants it paralysed on the ground in hyper- extension. is generally the Injury to the anterior crural nerve is shown solely by paralysis of the pectineus. result of pelvic injuries. in Scarpa's triangle. the crureus flexed ing. entire course. maintained fasciae by contraction of the tensor this femoris and of the gracilis. he brings up the one.an sartenor crural * tonus. As in fracture of the patella. easily . walking backwards is quadriceps. and. He has also a special way of walkadvancing the healthy limb. the slightest thus maintained a kind of hyper-extension. of the tensor femoris. Immediately out is under Poupart's ligament opens nerve its into terminal branches and if the injured. Jj begins to advance the healthy mk supplied by tin. knee. where its ff is protected pelvic it girdle. extension. in front branch passes of the malleolus and first is distributed on the inner side of the foot as far as the base of the metatarsal. loss of abolition Atrophy of the crureus.ANTERIOR CRURAL NERVE It 271 has two terminal branches : The patellar or anterior branch. supplying branches whole inner surface of the branch is Its posterior Its anterior distributed over the internal malleolar region. |( . only are affected. bears the weight of the body but if muscle ceases to function and the patient sinks down on to his suddenly flexion takes place. . the patient can walk. absence of its power of its normal electrical reactions and of the patellar reflex are so many signs that enable us to recognise paralysis of this nerve. it which proceeds along the its internal saphenous vein and accompanies throughout leg. but he does so stiffened his leg by contraction gracilis. some of terminal branches Paralysis of this nerve. which breaks away at the inner side of the knee and supplies the supero-internal part of the leg. of the sartorius and of the quadriceps. PARALYSIS OF THE ANTERIOR CRURAL NERVE Paralysis of the anterior crural nerve is comparatively rare. therefore. |. solely This nerve has quite a short at course it which corresponds crosses to the it point which by the the pelvis. s —Musclea : stable support. pectineus. The tibial to the or lower branch. As with fasciae a rule. on again un- . accompanied by loss of extension of the leg on the thigh.

Paralysis of the right anterior crural nerve by intra-pelvic lesion. — which thrusts inwards the triceps and imparts to it a transverse pull by means of its aponeurotic slip. tractions persist We just sometimes imagine that voluntary muscular conas we may observe electrical pseudo-contractions of the paralysed crural triceps. since lesion of . This error originates in the voluntary or electrical contraction of the tensor fasciae femoris (superior gluteal nerve). Figs. the internal saphenous is the only one the lesion of which of special interest. 285 and 286. for walking. It must not be forgotten that paralysis of the anterior crural is often accompanied by hydrarthrosis of the knee. Of all is the branches of the anterior crural nerve. for in this case the knee remains a state of permanent hyper-extension. . frequent cause of error must be mentioned in summing up anterior A crural paralysis. probably caused partly by the slight and oft-repeated injuries which this articulation now has to sustain and partly by the hyper-extension necessary thigh and on the inner surface of the leg. above Poupart's ligament slight consecutive hydrarthrosis of the right knee. LESIONS OF THE INTERNAL SAPHENOUS NERVE. Disturbances of sensibility are localised on the anterior surface of the A special study must be made of these latter disturbances and of lesions of the internal saphenous.272 as easy as in NERVE WOUNDS walking forwards is difficult.

Above the knee. or to frequent lesions capable of producing the various syndromes of simple anaesthesia. is at times so violent as to cause DIAGNOSIS The diagnosis of paralysis of the anterior crural must be made from 18 functional paralysis and from reflex muscular atrophies which generally . Posterior surface. which follows thigh the same course as the internal saphenous and a rule. neuralgia from nerve even actual causalgia. 2S9. 289. Below the knee. Fig.ANTERIOR CRURAL NERVE the other terminal branches causes no sartorius 273 paralysis of the more than partial and the crural triceps. Sensory region of the anterior crural. inner surface of the leg and spreads It Its distribution covers the entire upwards on to the antero-internal surface of the knee. — Fig. extends over III 4 1 li Anterior surface. 287 and 288. is the also affected as Neuralgia of the internal saphenous considerable inconvenience in walking. Figs. to end near the It is metatarsal. — Sensory disturbances in complete interruption in ot the internal saphenous nerve Scarpa's triangle. region of the anterior crural proper. often somewhat enlarged upper part by simultaneous lesion in of the branch accessory to the internal saphenous. 287. 288. it The long course of the internal saphenous exposes irritation. Inner surface. the internal malleolar region first and over the inner in its side of the foot. Fig. region of the internal saphenous. Fig.

NERVE WOUNDS fractures of the femur and particularly lesions of the knee Particular care roots or with must be taken in dealing with lesions of the lumbar lumbar hematomyelias. which we will study along with the syndromes of the lumbo-sacral plexus. .274 follow joint.

Deep layer. 16. adductor longus (obturator nerve pectineus (crural nerve) hav.Muc o. its tibial branch. 20.312. with its 1' nerve. 8.femoral artery. Branch . 290. . Superficial aver FlGS. Branch to the gracilis. gracilis.. anterior crural 4. 3. Fig. passes behind the ceeds along to common the iliac vessels and proby the brim of the inlet right the subpubic groove. 5. Fig. 18. . Internal 9. Branch to tin.— Anterior crural nerve and obturator nerve. adductor magnus.pelvic sympathetic. appears internal to the psoas. 10. and the Deep layer the sartonus. he crural triceps longus. zi.0 the 15. 1 t . 1. Branch to the adductor raagnuB. Nerve to the ilio-psoas. and the brevis. Internal saphenous nerve. External cutaneous 22. 292.) Fig. Abdomino.. Branch to the adductor brevis. Anterior (After Sappey. been removed. 2 9 ! and 292. third. patellar branch and i+. Nerve to the quadriceps.— Muscles supplied by the obturator nerve. branch of anterior crural. Obturator nerve. ti. irst sacral toot. Superficial layer. 291. Fig. External branch of crural nerve. 2. Lumbo-sacral cord. It and fourth lumbar roots. 290. adductor longus. 6. 7. 23. nerve. 17.CHAPTER XVIII OBTURATOR NERVE The obturator nerve originates in the lumbar plexus from the second. covered parietal peritoneum. . 19. as well as the has been cut to show the obturator externusand the adductor lower part of the adductor magnus and of the gracilis.

protection afforded it by the bones and muscles of the pelvic . on the other nerve essentially Its hand. adduction in not comof the paralysed lesions obturator nerve. Deep branch. The obturator is the nerve of adduction of the thigh. There 1. two terminal branches which passes in front of the adductor brevis and then winds below the adductor longus. It supplies at this level : The The The branch to the gracilis . are Superficial branch. also very effective girdle. 293 and 294. passes behind the adductor brevis and supplies the adductor magnus on which it rests. branch to the adductor longus is .— 276 NERVE WOUNDS On leaving the obturator foramen or even in the subpubic groove its it divides into terminal branches. the adductor magnus also receives some twigs Sensory disturbances appear in a triangular area occupying the inner Lesions of the obturator are even more rare than those of the anterior crural . — This. for the adductor longus receives secondarv innervation from the anterior crural from the sciatic. is to rotate outwards — and to flex the thigh on the pelvis. branch to the adductor brevis . 2. . is As pletely a rule. secondary function Figs. like the latter is it has a somewhat short trunk. surface of the thigh. Branches In its pelvic course it supplies chiefly the branch to the obturator internus. Sensory region of the obturator. A buted cutaneous branch which over the supero-internal distri- surface of the thigh and anastomoses with the internal saphenous.

CHAPTER XIX EXTERNAL CUTANEOUS NERVE OF THIGH The roots. genito-crural. 21. 20. branch. 15.21'. Genital of the external cutaneous. 19'. 20'. crosses the iliac crest. gluteal ami femoral branches branch. 18. Its'gcnital branch. external cutaneous nerve originates in the second and third lumbar 16. crural branch <>t the Obturator nerve. and . 17'. The trunk. Anterior crural nerve. It emerges from the outer edge of the psoas. 17. and 19.

Figs. 296 and 297. . which is frequent. Several cases have been mentioned of lesion of the external-cutaneous oi the external cutaneous. its irritation. IV Anaesthesia of this nerve covers a region corresponding to the outer part of the rather thigh . and known of it ever the description given by W. pressed against the iliacus by the parietal layer of the peritoneum. It then divides into a posterior or gluteal branch which is destined for the integuments of the supero-external part of the buttock and into two femoral branches distributed over the skin of the outer part of the thigh. .278 goes on its NERVE WOUNDS way lying on the inner surface of the pelvis a little below the iliac crest. Roth (1895) under the name of — Sensory region neuralgia paraesthetica. rendering painful the contraction of the extensor since fasciae femoris. accom- panied by painful irritation of the causalgic type. It issues from the pelvis through the iliac Lj' / i notch between the antero-superior spine and the antero-inferior iliac spine. causes the appearance of a somewhat special neuralgia covering the entire outer surface of the thigh.

two terminal branches of the iliac The it is external or crural branch passes under vessels to Poupart's ligament outside which It applied. the anterior surface of this muscle. .CHAPTER XX GENITO-CRURAL NERVE The It genito-crural root. internal or genital branch breaks away the from former it before passing under Poupart's ligament bends back inwards to it reach inguinal canal through the vas deferens. separated consequently from the anterior crural nerve by the tendon of the psoas. and parallel iliac this latter. We that irritate the nerve. in the course of have met with lesions wounds of the abdominal wall. Lesions rare. oval U form. perforates the fascia in front of the vessels and becomes superficial. afterwards it spreads over the integuments of the antero-internal surface of the thigh. in v riG. 2. right it to the antero-inferior spine. they of the show themselves. below which It divides into passes under Poupart's : ligament. . manifesting themselves by painful hyper-aesthesia at the root of the thigh and in the scrotum.298. The the . Sensory region of the genito-crural. covering almost the whole of Scarpa's triangle. genito-crural nerve are very & } for the most part. which passes together with It penetrates into the scrotum and is distributed over the skin of the scrotum and to the contiguous area of the inner surface of the thigh. — sensory disturbances. emerges on descends. \ There in it supplies a small sensory region. 1. its nerve originates almost exclusively in the second lumbar makes to way forwards across the fibres of the psoas.

by way of a perforating branch. over the skin of the lower part of the abdomen. lying the depth of the abdominal wall. to the internal oblique and the inguinal and joins the ilio-hypogastric before leaving the canal. 299 and 300.CHAPTER XXI ILIO-HYPOGASTRIC NERVE The ilio-hypogastric continues the iliac first obliquely towards the crest. It gives off along its course a perforating branch which appears u /^ above the gluteus maximus and supplies the outer and upper part of the buttock.) . supplies a few muscular branches transversalis. transversalis — and the internal oblique. It supplies a musculo-cutaneous V branch or abdominal branch which gives some motor twigs to the internal oblique and to the transversalis. 2. It originates in the first lumbar. The third — genital — branch in pro- ceeds along the upper surface of Poupart's ligament. — (Ed. passing along lumbar root and makes its way its upper border. proceeds like the latter along its lower border. and is distributed. The * ilio-hypogastric and ilio-inguinal * together really act as a true intercostal nerve : their oblique course in the differs in depth of the abdominal from that current in The description of these two nerves some particulars English Text-books. transversalis abdominis. Sensory region of the ilio-hypogastric. between the Figs. the external which are distributed over the supero-internal ILIOINGUINAL The ilio-inguinal appears as a collateral trunk of the ilio-hypogastric. It thus enters the inguinal canal and at emerges to spread out inguinal ring into branches part of the thigh. 3. lying between the internal oblique and the i.

the two lateral perforating cutaneous branches. represent the three perforating brandies of the intercostal nerves. The result of this is a sinuous tract corresponding to the similar sinuosities of the twelfth intercostal nerve. of an oblique tract which passes along the margin of the pelvic girdle but spreads over the root of the lower limb at the points where the three perforating branches emerge. and their terminal branch issuing from the inguinal canal. as does that of the intercostals. . the 281 motor branches supplied to the muscles of the abdomen.ILIOHYPOGASTRIC NERVE wall. Their sensory region consists.

consists of . consisting of the fifth lumbar plexus. . the sacral plexus. two distinct parts: the four roots first. which form actual nerve loops from which the trunks that constitute the peripheral nerves are given off. All the roots of these plexuses are united to one another by vertical anastomoses. —Lumbar plexus. XII D I L Iliohypogastric and ilio-inguina External cutaneous IV L Anterior crural VL Obturator Lumbo-sacral cord Fig. 301. formed by the first lumbar root. and the second and third sacral.CHAPTER XXII LUMBO-SACRAL PLEXUS From It the lumbo-sacral plexus all the nerves of the lower limb originate.

but it also receives an important contribution from the second lumbar and even a more important one from the The anterior crural nerve for the fourth lumbar. The The first lumbar root gives off the ilio-hypogastric ami the ilio-inguinal with the aid of the anastomotic loop originating in the twelfth dorsal. .LUMBOSACRAL PLEXUS LUMBAR PLEXUS 2«3 A very simple description of the common types of lumbar plexus may be given. second lumbar root supplies the external cutaneous and thegenitoin the first crural. It is the fourth lumbar that supplies the obturator which also receives fibres from the third and even from the second lumbar. — Connections between is the lumbar plexus and its branches. Ganglions of the sympathetic Fig. most part formed of the fibres originating in the third lumbar. with the aid of the anastomotic loop originating lumbar. 302.

nerve -Jp?. penis N. cutan. the genito-crural and the obturator on internal border. the external-cutaneous its on its anterior surface. penis Sup. int. 2nd sacral N. Genito-crural N Lumbo-sacral Obturator N. perinei Fig. N. to obtur. the upper root of the sacral plexus. by the plexus the ilio-hypogastric and ilio-inguinal above and the 5th lumbar ganglion Ext. Inf. Sup. -! N. dors. Through the fasciculi of this muscle emerge the different nerves formed . SACRAL PLEXUS The cord sacral plexus consists essentially of the fusion of the lumbo-sacral (fifth lumbar and an anastomotic branch of the fourth lumbar) and . N. Small sciatic N. The the first collateral branches of the plexus are of slight importance .— 28 4 NERVE WOUNDS From the fourth lumbar there also breaks away an anastomotic loop which unites with the fifth lumbar to constitute the lumbo-sacral trunk. anterior crural below appear on its external border. (After Hirschfeld. 1 cord st sacral N. to levator ani Pudic nerve hemorr. perineal N. N. 303. Long pudendal N. N. they are the branches supplied to the quadratus lumborum and to the psoas by two lumbar roots. Dorsal N. — Sacral plexus. to trans.) Collateral branches. on the sides of the vertebral column. The lumbar plexus is covered. by the belly of the psoas muscle. glut.

in the lumbo-sacral cord and the pelvi-rectal space 3. The nerve to the obturator internus. . muscles 4. -> * ««^_. to split up on the deep surface of the gluteus maximus which it supplies by means of a series of ascending and descending first The branches. second and third and are distributed to the pyramidalis. Fig.. Hemor..LUMBO-SACRAL PLEXUS of the nerve.** / Piulic N. quadratus femoris. Small sciatic N. which also originates first sacral. the gluteus medius and the tensor fascia? femoris pyramidalis. Inf. and supplies the obturator internus muscle sacrals. the inferior gluteal nerve.' * /4('A /!•'!'''. Sacro-coccygeal ple> Quatlratus femoris « » \ V|\obt. passes above and proceeds between the gluteus minimus and the gluteus medius. </-'/. It supplies the gluteus minimus. '•• Levator ani inter. accompanies the great sciatic nerve and appears with it below the pyramidalis. which originates in the lumbo-sacral first sacral. 304. &*"** '*.-- \ Int. which originates in the fifth lumbar ami and second sacral. in one bulky trunk the great sciatic important collateral branches : The superior gluteal nerve. 285 : first three sacral roots. and the gemellus superior and gemellus inferior . It is to the somewhat frequent union of this nerve trunk with the . Obturator Lumbo-sacral cord r — Superior gluteal Pyramidalis Superior gemellus Inferior gemellus . The nerves to the pelvi-trochanteric muscles which are given oft from the the first. It supplies several I. issues cord and the the through the great sciatic notch. proceeds forwards into the inferior .' tfff& . — Sacral plexus. Great Sciatic N. divides into an ascending branch and a descending branch which penetrates into the tensor fascia femoris. 2.

constitute quite an inextricable network of nerves which covers the entire posterior surface of the pelvic cavity. N.) according to Cruveilhier's expression. " the sacral plexus condensed in one nerve trunk. Gluteus max -Gluteus minimus -Tensor fasciae femoris Pyramidalis Great sciatic nerve Quadratus femoris Post. —Nerves of the gluteal region.286 NERVE WOUNDS we sometimes give the posterior cutaneous nerve of the thigh that name of small sciatic. forms with and the loop of the fifth sacral the origins of the pudendal plexus. PUDENDAL PLEXUS The anastomotic loop.) -Gluteus maxi- mus Post. cutan. It is. supplies several collateral branches and a terminal branch : The collateral branches are distributed : To the levator ani and the ischiococcygeus ." The original collateral branches of the sacral plexus. (peron. As all a matter of fact. regarded in this case as a terminal branch of the lumbosacral plexus. the great sciatic alone includes in itself the branches of the plexus of which it is the sole terminal trunk. simplified. along with the great trunks of the sciatic. however. br. . This plexus the pudic nerve. which unites the third to the fourth this latter root sacral. cutan Fig. 305. (After Hirscbfelcl.

. at the level of the ^^ ( (\lfi \ \j XII tuberosity of the ischium it divides into its two I terminal perineal branches. always affect several roots at once. bullets or shell splinters penetrating into the spinal canal. LUMBO-SACRAL PLEXUS To The cavity 287 margin (inferior the sphincter ani and the skin of the anal hemorrhoidal or anal nerve). from which tebra. as in the case of the brachial . member that the cul-de-sac of dura mater ends in the vicinity of the second sacral vertebra. course I of the tlural luml. they also. .. be found injured in Obturator their long intra-spinal Indeed. Fractures of the spine. cauda equina. terminal branch of the plexus. There is no occasion to consider here. producing the different syndromes of the cauda equina. the the L nerve and dorsal nerve of the penis. pudic nerve. they form. may fre- and perhaps more quently. cutaneous and genito-crural IV lumboonly Anterior crural 1 sacral plexus are not affected by traumatisms of the pelvic cavity. Along this course. a low the they break away one after Sciatic the other to reach the inter-vertebral foramina. they are FlG - successively intra-dural and 3 extra-dural.. D" Ilio-hypogastric and ilioinguinal HI RADICULAR SYN LUMBOSACRAL PLEXUS The roots of the DROMES OF THE Ext.i We must roots cauda equina...spinal .. depressed fracture of the sacrum.. internal to it crosses the in s^^llWi// I \ fossa the aponeurotic \}j] : (\ Vi XI D sheath of the obturator internus . lie cul-de-sac is re- dotted. 3o6.-Intra. course.. in the canal whole of the spinal which stretches befirst lumbar vercompact bundle. issues from the pelvic below the pyramithe sciatic ischio-rectal dalis.

Sensory topography. Periphera areas. root NERVE WOUNDS and trunk syndromes. areas. the root lesions will for the most part give dissociated peripheral paralyses. —Lumbo-sacral nerves Peripheral and The roots . It is sufficient to compare the principal syndromes of the lumbo-sacral plexus with the syndromes of the root peripheral nerves. peripheral always contain fibres coming from all several rise to consequently. the nerves receive their supply from several consequently no complete paralysis will be observed unless several roots are injured at the same time. On the other hand. Anterior view Figs. Peripheral Root areas. lesions of the roots may be recognised by their special root topography. Whether intra-spinal or extra-spinal. plexus. are characterised by a different . almost roots. likewise. Disturbances of sensation. 307 and 308. Posterior view.288 plexus. radicular areas.

(first and second) have only a very secondary motor role they supply a few fibres to the psoas. — Associated paralysis of the in lesion of the and second lumbar roots. through the *9 . simply an enfeebled condition of these muscles. on to the upper part of the outer surface. fifth It comprises triceps. topography of the dorsal Lastly. anterior crural and of the obturator. the one another in motor and sensory roots may be injured independently of the spinal canal we then find dissociation between the . but fibres from the motor region. to the lower part of the transversalis abdominis and to the anterior muscles of the thigh. on the other hand. Their sensory region comprises the outer surface of the buttock and of the root of the thigh . . LUMBAR ROOTS The upper roots of the lumbar plexus . Injury does not cause Fig 309. occupy a very important all the anterior and internal muscles of the the thigh the crural pectineus and the sartorius. to the quadratus lumborum. motor and the sensory areas. The lower roots of the lumbar plexus (third and fourth lumbar and paralysis. 310. 289 in the they appear form of longitudinal tracts almost parallel to the axis of the limb in the case of the and lower lumbar roots. lumbar). arranged obliquely in the case of the upper lumbar roots which constitute a sort of transition from the almost horizontal roots.LUMBOSACRAL PLEXUS topography from the peripheral distribution sacral . caused by injury of the third and fourth lumbar roots. it spreads over the anterior surface of the thigh and passes slightly beyond. —Root topography first Fig.

312. also in lesions of the first Fig. Like this muscle also belongs upper root group of the limb. Note that the tibialis anticus is supplied almost solely by lumbar fibres. Injury to these roots affects both the area of the anterior crural and that of the obturator. and the whole inner surface of leg and foot. 311. to the posterior muscles of the thigh and to the muscles of the leg. also receive lumbar fibres. giving the atrophied thigh a special appearance. — of which the homologue to the — does in the upper limb. the anterior and inner surface of the knee. Among the muscles in which atrophy and weakness consequent on lesions of the fourth and fifth lumbar roots / i. Fig. The patellar reflex. and in fifth lumbar of the atrophy and paralesions lower part of the lumbar plexus plete Fig. as though it were strangled in its middle part. as well as the inner head of gastrocnemius. fourth and fifth lumbar supinator longus it is it muscle really roots. the fourth and fifth lumbar roots supply a certain number of fibres to the glutei. though fewer in number. fourth and fifth lumbar loots. to the tensor fasciae femoris. 3ii. NERVE WOUNDS the adductors and the gracilis through the obturator nerve. sensory area of the last The lumbar roots spreads obliquely over the outer surface of the thigh. the tibialis anticus is almost entirely supplied by the fourth roots lysis . The extensors and the inner head of gastrocnemius receive — Muscles — and second sacral roots contrasts strikingly with the complete paralysis of the peronei. the communis digitorum and the extensor proprius hallucis. which may consequently be slightly weakened. are its almost com- preservation Fig.290 anterior crural nerve . Finally. supplied by the third. 312."°~ are manifested. It acts as only a few fibres. Though dependent on the external popliteal. Sensory area the of" the third. which . we must extensor j\J" specially note the tibialis anticus .

the ab- ductor and the flexor brevis hallucis. fourth and fifth anterior lumbar roots : the symptoms observed are those of paralysis of the anterior crural and of the obturator. We spects in the Fig. the peronei and the outer head of gastrocnemius would appear to be almost exclusively supplied by sacral fibres. 313. 313 and 314. Indeed.LUMBO-SACRAL PLEXUS corresponds essentially to the third 291 roots. though an unimportant one. hallucis and the head of gastrocnemius. In the same way. of lumbar fibres. at first they seem to spread over almost the whole are surprised to find that the tibialis anticus region of the sciatic and we . inverse dissociation is found in lesions first and second sacral roots . this participation is bar roots particularly obvious in the case of the the extensor extensor inner longus proprius digitorum. SACRAL ROOTS The fibres of the first two sacral roots are distributed over the region of the great sciatic nerve. On the other hand. Fig. the adductores hallucis and the interossei seem to be entirely supplied by the sacral roots. digitorum. the almost complete integrity of the tibialis anticus and the partial preservation of the extensors. the other muscles of the leg also of the lum- receive a few fibres from the lumbar roots . both by anaesthesia of the point of origin of the reflex and by suppression of the motor response. it is the muscles of the internal compartment. Muscles supplied by Note the first and second sacral roots. that appear to receive the principal supply. In the foot. thus see in what main reroot innervation is distin- guished from peripheral innervation Figs. belonging to the region of the be Frequently the tibialis profoundly affected in lesions connected of the solely with the fourth lumbar. with the exception of the tibialis anticus which is exclusively supplied by L4 and L5 . 3 14. On the other hand. lesions we often meet with affecting the third. — lower limb. is and fourtli lumbar always abolished. and we are at first somewhat surprised to find associated there- with both paralysis of the anticus appears to tibialis anticus and weakening of the extensores sciatic.

The lesion of the third sacral root region has been painted with tincture of iodine. . as middle. The The it Achilles reflex (first is and second sacral) is in every case abolished. The anaesthetic Lesion of the first. and that there are even some very feeble contractions of the inner disturbances head of gastrocnemius and of the muscles of the great Sensory of the first and second sacral roots occupy a broad tract which. j third sacral root distributed over the inner part of the buttock far as its descends on to the posterior surface of the thigh. passes on to the anterior surface of the leg and covers both the dorsal surface and the plantar surface of the foot as far as the first intermetatarsal space. 315 and 316. are possible. Figs. it results in . with the postero-external tract on the thigh. There are also some slight exception of the tibialis amicus which is scarcely touched. movements of the extensor hallucis and of the extensor communis a faint suggestion of contraction of the inner head of gastrocnemius and of the flexor brevis hallucis.292 is NERVE WOUNDS touched at all. occupying a triangular sacral. when there is irritation of the roots. extends obliquely to the external surface of the knee and leg. after spreading over the posterior surface of the buttock. that not some faint movements of the extensors toe. second and third sacral roots. the inner region of the buttock and a small Paralysis of all the muscles of the leg. adds to the topography of the first and second. — In this same region. we find hyper-aesthesia or the trophic disturbances characteristic of neuritic lesions. tract just internal to the region of the second When the fourth and fifth sacral roots are injured.

Anaesthesia affects the inner part of the buttock and a tract down the posterior surface of the thigh. which constitutes the area of the third sacral. 320. 319. 318. it reaches the perineal and anal region. fourth and fifth sacral roots. 317. of the third Lesion of the sacral root. 319. and anterior surface receive of the fibres scrotum from the Fig. — Fig. the penis. incontinence of urine and due to paralysis of the sphincters . FlG. and are not anaesthetic. . the lower part and posterior surface of the scrotum the root of the penis and a portion of . tion passes through the first intermetatarsal space and the first interdigital space. vesical paresis. paralysis of the levator ani and of the bulbo-cavernosus and ischio-cavernosus muscles. Plantar anaesthesia in the Fig. — Cutaneous desquamation with Fig. The patient is no longer aware of the passage of urine and faecal matter. The line of demarcapreceding case. its dorsal surface as well as the root Fig. 318. faeces. root topography in irritative lesion of the first and second sacral roots {radiculitis). sacral canal at the level of the third spinous process. 317.LUMBO-SACRAL PLEXUS 293 Fig. — Area — twelfth dorsal first and the lumbar. 320. Area of the third. Fig.

they paralyses. Indeed. is possible as a rule. As a result of lesion of the posterior horns.CHAPTER XXIII DIAGNOSIS OF THE LESIONS OF THE LUMBO that SACRAL PLEXUS The only important diagnosis to be studied is of lumbo-sacral in injuries hematomyelia. lumbar contusions result they may even close at from the explosion of or a a shell mine are hand . .cord segment. 321 and 322. the topography of which is almost the same as that of root anaesthesia. Characterised mainly by anaesthesia to heat and cold . it depends on the site of the wound . Slight hematomyelia affecting chiefly the left lumbar segments and leaving untouched the sacral segments. pro- duces flaccid paralysis accompanied by muscular atrophy and reaction of degeneration resulting cells from lesion of the this of the anterior horns of cord . In the first place. thermal but cold sensations are scarcely perceived at all and pin-prick cause a very painful sensation which the patient compares to burning. however. from the third lumbar vertebra . — the paralysis is distributed like root paralysis. Hematomyelia a lumbo-sacral enlargement has somewhat analogous sympto tomatology of the the lesions It plexus. probably caused by compression and sudden sion. these lesions are not : uncommon vertebral of the lumbar region wounds from bullets or shell splinters. . they are accompanied by sensory disturbances. fractures of the column. for each motor root correexactly to sponds a . Diagnosis. Figs. slight decompres- and accompanied by medullary hemorrhage of the or air-emboli. for whereas the cauda equina descends into the canal.

generally there are to be found on the healthy side some motor showing a certain degree of bilateral spread of the hemorrhagic process. and of the fifth lumbar. no peripheral or root it. On the right. especially of slight hematomyelia. the first rather to the lumbar enlargement of the cord and second lumbar vertebrae. like anaesthesia. sensibility to heat and cold manifestly lessened . 323. is corresponds On the other hand. a lesion of the posterior horns gives to rise a very important and : wholly characteristic of sensibility. widely diffused and persistent sensation. we may pain is retained. find that sensibility to For instance. frequently heat and especially cold are not clearly perceived but give Lastly. a region resembl/ng the distribution of the lower lumbar and the sacral roots. systematised dissociations. scarcely touching at all the layer of white matter. The prognosis of hematomyelia. lesion Whilst a of the anterior horns is shown by the flaccid and atrophic paralysis which always indicates lesion of the lower motor neurone. the cord lesion may rev eal and to cold. sensibility. it a very clearly circumscribed en- croaches slightly upon the neighbouring regions. to heat hematomyelia. Finally it must be remembered that hematomyelia is almost always localised in the grey or sensory disturbances matter of the cord . in slight cases of simply by hyper-aesthesia to pin-prick. the attacked region. itself rise to a painful sense of burning instead. In find anaesthesia symptom to the dissociation lumbar hematomyelia we often painful and thermal stimuli (posterior horns) and above all Lumbar hemaFig.LESIONS OF to THE LUMBO-SACRAL PLEXUS 295 the second sacral. tomyelia. Hypi>-a. lesion Thermal and capable of producing painful anaesthesia. it attacks chiefly the anterior and posterior horns of the cord. not often restricted region. a region resembling the distribution of the first and second lumbar. or else it does not affect certain muscles or certain in cutaneous zones rhagic focus. thus indicating the unequal distribution of the hemorIt is likewise rather rare for dis- turbances to be strictly unilateral.-sthesia. whereas is complete integrity ot sensibility to pressure and of the other deep sensibilities. is . hematomyelia as a rule less is a more diffused process. the first and second Dissociation of sacral. tive In some cases we may observe even more tile Relaconservation ot tacalmost sensibility . in producing a topography to clearly circumscribed than root lesions. Paralysis. as in of deep sensibility (posterior columns). — contrasting with the relative integrity of tactile sensibility On with the preservation of sensibility. The clear dissociation syringomyelia constitutes a pathognomonic sign of hematomyelia is : the left. thus causing a painful.

we see a progressive diminution of the anaesthesia even sometimes region of paralysis and anaesthesia. in a few weeks. or Improvement often passes on to complete cure.296 generally far NERVE WOUNDS more favourable than that of root lesions. well-defined paralysis. but even more commonly. persist. may . In a few months.

.e. a simple liberation or even a performed at the right time.PART IV CONCLUSIONS CHAPTER XXIV PROGNOSIS AND TREAMENT OF PERIPHERAL NERVE LESIONS At the present time. which in our opinion . the empty sheaths of which are alone capable of fibres nerve. approximately the number of spontaneous regenerations without surgical intervention at the same time. towards regeneration by fresh shoots from the axis-cylinders. provided the general condition of the patient enables him to contribute restoration. would in all probability have permitted of a more rapid and complete restoration. It is this wonderful aptitude of the nerves cures. by suppressing the obstacle to the progress of the nerve and bringing about coaptation of the segments of the divided i. on the whole Every peripheral nerve towards this affected by traumatism tends to regenerate. shows a nerve manifestly to be on the way to recovery. months after the wound. statistics. of the central segment containing the nerve fibres along with the peripheral segment. though this may be slow and . The wide-spread destruction of the peripheral nerves is also reparable by nerve grafting which reconstructs the anatomical continuity of the supporting tissues. According to our personal we may estimate at between sixty and seventy per cent. between ten and twenty per cent. the conductor of the regenerating fibres. there are a certain number of these. if . We are now speaking of cases eight to ten made only from in which the neurological examination. we are justified in is affirming that the prognosis of peripheral nerve lesions favourable. basing our opinion on a very large number of observations made since the beginning of the war. guiding the axis-cylinders in their regeneration. that explains the considerable number of spontaneous Surgical intervention itself has no other aim than to favour this natural regeneration. would have gained by such intervention nerve suture.

statistics) approximately (12*9 per cent. there can be no doubt but that early sutures are followed by more rapid regeneration. we may when case. More than half the patients are cured spon- almost all surgical interventions are attended with success. however. taneously .e. Consequently those cases of nerve lesion that thirty or forty per cent. NERVE WOUNDS naturally in such cases one hesitates to have recourse to any intervention not absolutely necessary and which would compel the patient to begin all over again the regenerative process painfully carried through in the course of the preceding months. as one might think. this is is indicated. the cases of failure after We must add that the statistics here given do not deal solely. whom we take this . The number to exceed of irreparable nerve wounds would certainly appear not from eight to ten per cent. Delageniere. Results naturally vary according to the intervention practised. A favourable prognosis for peripheral nerve lesions is. there are only fourteen failures fourteen cases in which there appears no sign of regeneration of the peripheral segment all the rest are on the way to a more or less rapid and complete regeneration. do not appear to be more than Still. and intervention of nerve suture have been very should be resumed. Nevertheless. there does not appear to be any doubt on the matter. necessitate surgical intervention. The results much at questioned all . con- firmed by these figures. and consequently warrant us in looking forward to their cure up to date we have had twenty-two cases of . : practically complete restoration.* Accordingly we may estimate at from twelve to fifteen per cent. which we have been able to follow up. operated on at the right time and under favourable conditions.298 incomplete . with only favourable cases. if After all. either because surgical intervention has encountered insuperable difficulties or because the general condition * Most of these cases were operated on at Le opportunity of thanking for his valuable advice. in our nerve suture. it lay it down as a general principle that the liberation of a nerve. Mans by M. should always be successful if such is not the because resection and suture were necessary. i. we have witnessed the success of nerve sutures practised thirteen and fifteen months after the wound . to us. it is quite possible that suture might successfully be attempted long after this period. Early intervention does not appear to be an indispensable condition . . but with all the cases we have investigated. practised under favourable conditions almost Out of one hundred and eight cases of nerve suture or grafting . such is cases should in become exceptional the neurological examination always made good time. as we see. invariably Nerve suture succeeds. . whether liberation or suture.

motor restoration is invariably the most tardy . may perhaps seem surprising. to note the appearance of the axis-cylinders beyond the suture. It work of restoration step by step it proves to him the success of surgical inter- vention. and thus becomes an important moral factor in the cure. this is we affim that because people are always too precipitate in speaking of the failure It of surgical intervention. mention must be made cases of nerve suture carried out under the best of conditions were succeeded by no sign of regeneration whatsoever in factors contributing to failure. is a serious error. the progress of the axis-cylinders is not more than one to two millimetres per day . it cutaneous paresthesia. the appearance of the first voluntary movements also takes place long after the penetration of the axis-cylinders into the paralysed muscle. four. to affirm. The figures after we have cited. months after nerve suture. to be attributed to nothing else than impatience on the part either of the observer or of the patient besides. on the contrary. permits not only the observer but also the patient to follow the . We shall realise much more its correctly the progress made . the failure of intervention because no movement shows itself. . . and in the case of young patients. and may be compared with those of other neurological centres. or six Consequently.TREATMENT OF PERIPHERAL NERVE of the patients has either annulled or made difficult LESIONS 299 the work of regenera- Amongst the of alcoholism two tion. to discover the sensory signs of regeneration the sensibility of the nerve to pressure and of muscular bellies. few weeks. of all. patients manifestly alcoholic. Tbey are nevertheless correct. Under the most favourable conditions. If they appear to clash with other published statistics. characteristic formication. of a nerve is must not be forgotten that the regeneration invariably an extremely prolonged task. gives him confidence and patience. the sensibility etc. particularly that of Professor Dejerine at the Salpetrierc. is The after a sign of formication here specially important. since enables us. if we try. more particularly the proportion of successes registered nerve suture. three. and to follow their progressive advance in the peripheral trunk.

special cases. that regeneration all either not taking place at or is progressing badly. less It is scarcely ever possible to obtain such certainty in Besides. it must not be forgotten that. suture may be performed successfully. as than two. especially in simple compression and severe neuritis. before deciding to operate. calls for The only fact which necessarily intervention is the absence difficult of regeneration of the peripheral segment. -TIME OF INTERVENTION months at least We On possible.CHAPTER XXV SURGICAL To lay TREATMENT FOR OPERATION is I. is Regeneration assuredly more rapid and easy when the operation fifteen is not delayed too long. were susceptible of spontaneous regeneration for . we must make is absolutely by successive examinations. which prompt operation is necessary. Consequently.. it would appear as though we ought prompt and systematic intervention for every Apart from a few to reject the principle of wound of the peripheral nerves. or partial character of the regeneration. discovered that two or three were often necessary out as to establish the necessity of intervention. the other hand. or else the defective. three or even four months after the wound. we have seen that the majority of nerve lesions. certain. this delay as a rule is we have in no way prejudicial to the success of intervention. already seen. Still. even the diagnosis of complete interruption of a nerve trunk does not inevitably imply the necessity of intervention. even twelve or months after nerve interruption. . I. Manifestly this recommendation must not be accepted as absolute there are cases in .— INDICATIONS down in the indications for operation assuredly the most delicate problem war neurology. an operation must be carried soon as once its necessity has been recognised. about sixty or seventy per cent. Indeed. regeneration is even in these cases spontaneous often possible.

. the electrical and histological examination of the nerve. account must naturally be taken of the as encountered during intervention well as of operative possi- though clinical reasons above all others are the most important. unable to It is is reach the peripheral segment. series of A thorough preliminary examination. many cases. H. less clearly characterised. Bull. felt Evidently no hesitation will be in the presence of a complete section. of regeneration that is is simply difficult to effect. de Med. is however. In this connection. simple extrinsic compression or an interstitial obstacle if the lesion has . and Gosset by using a small the nerve above and below the lesion. capable of affording very important informait though of itself alone is insufficient.. of a total lesion or a partial change. if is Indeed. or even the entire nerve. fasciculi sterilisable electrode* which allows of separate excitation of the different fasciculi of We may thus ascertain if these have remained excitable. No clinical intervention must take place until we have obtained every item of information to prove the existence of complete interruption or non-existent or simple compression. shrivel up. have not been touched by the * Pierre Marie. Jc VAcad. of a particularly dense nerve cicatrix or of bulky neuromata. Meige. This information cannot be supplied by anything but a clinical examination. or rather a minute examina- tions. information given by the anatomical often state of the nerve is somewhat difficult to interpret. Moreover.SURGICAL TREATMENT II. It the existence of an obstacle. exposed during the operation. It proves very clearly that certain fasciculi. so mainly by a examination that the nature of the intervention will be decided. is Evidently this method tion. anatomical examinathere tion of the nerve not sufficient to solve the problem. above must always be remembered that all neuromatous formations imply which the regenerated fibres. meeting of 9 February. liberation . to therefore always necessary remove the obstacle by In liberation if it external to the nerve and by resection if it is interstitial. Marie. almost invariably enable one to decide upon the kind of intervention necessary. Assuredly this clinical information will not always suffice in deciding upon a suture or a lesions bilities .— CHOICE 301 OF INTERVENTION As it is clinical reasons alone clinical can indicate the necessity of intervention. has been recommended. however. metallic Direct electrical examination of the nerve trunk has been carried out by P. destroyed the continuity of the nerve fibres or has changed them locally if the obstacle is permeable or not to the regenerating nerve fibres. it is a matter of absolute importance to find out . 191 5.

recommended by A. is not in course of spontaneous regeneration is. and really satisfactory only if A. fibrous tissue or cicatricial bands. demonstrate its permeability to the axis-cylinders. Liberation. by taking account only of electrical inexcitability. Acad. electrical excitability of the nerve as we know. Histological examination of the nerve.. de Med. NERVE WOUNDS in addition. however. because a nerve or a nerve fasciculus excited. of regeneration consist. well advanced has been in regeneration. The negative information. 302 lesion . It is to be regretted that we cannot obtain any certainty of the integrity of a nerve fasciculus except by subjecting it to the traumatism of a biopsis and suppressing some of in order to its fibres. Jounlan. would seem to be a very doubtful course to adopt. far more questionable even than the former in the is : The existence of nerve fibres in the examined fragments does not prove that the other fasciculi of the nerve are absence of fibres in the fasciculus examined same condition . Staining with osmic acid reveals only myelinised fibres fibres in course now the young 3. we should run the risk of resecting and suturing healthy sensory fasciculi and motor fasciculi. . of the axis- cylinder alone. a few particles of nerve tissue from the peripheral segment below the lesion and there trying is to discover.— SURGICAL INTERVENTIONS on a nerve trunk : There Suture are but three interventions possible Liberation Grafting. meeting of 16 February. Sicard. 1. bony is callus. that it is incapable of being . . Thus. the no proof that the other . This method i. by an actual operative biopsis. 19 15. and Gastaud. the return of tone.* This method consists in removing acid. has not the same value electrical stimulation of the nerve shows no reaction whatsoever and consequently has no value at all if it acts upon sensory fasciculi or upon motor fasciculi in course of regeneration. We cannot therefore conclude. at the outset.. it . 2. — Liberation is consists essentially in dissection of the nerve and in ablation of the causes of compression. II. the appearance of paresthesia are earlier signs. from rapid staining with osmic the existence of myelinised nerve fibres. The * operation a very delicate one. fasciculi are also affected. it has undoubted value by reason of the positive information gives. the sensibility of the nerve to pressure. As this regards the process of injecting methylene-blue into or above the neuroma. formication. Imbert. Sicard. one of the most tardy signs of regeneration .

remember that a good complete suture is far better than a bad liberation.SURGICAL TREATMENT we succeed in completely stripping bare the nerve cord and all 303 Liberating it. it is This intervention is really permissible only when and supple nerve. All the same. We for the should bring into contact with each other a central end. in these cases. There is way of suturing a nerve trunk. if On the other hand. 2. essentially presupposes resection of the cicatricial obstacle and of all tissues which might impede the progress of the axis-cylinders. Seldom does liberation succeed in severe and long-standing cases of neuritis. In all doubtful cases. — Nerve suture but one is indicated in all cases of complete inter- ruption of nerve fibres where no satisfactory regeneration has taken place. Speaking generally. Suture. we their right all places risk the different motor and sensory fasciculi and do defective regeneration. liberation of the nerve is ineffective in cases of severe lesions of the nerve trunk along with rupture of the laminated sheath. and on these liberation has no effect. either permeable to the regenerating axis-cylinders and else the obstacle then useless. and that is by bringing into contact the healthy extremities of the interrupted nerve trunk and sewing them end to end. Almost always in such cases there are interstitial lesions of the nerve. from free adhesions the delicate neurilemma sheath surrounding. as indicated by Delorme. cicatricial nerve keloid and formation of exuberant neuromata the cicatricial obstacle intervention is is . Suture. containing healthy and regularly arranged axis-cylinders. silk or linen thread or it is better to content oneself with a few stitches — even . As a rule. put exactly in we very carefully avoid all torsion of the nerve. the systematisation of which thus left to chance. a process Such a suture almost invariably involves considerable shortening of the which we shall be able to assist by flexion of the neighbouring articulations. by suturing the two healthy segments. in the interior of which there It is restores a mobile. The most effective suture is that which produces the best contact with a minimum of traumatism for the nerve trunk. or does not allow of the passage of the axis-cylinders and liberation will not make it permeable. naturally indicated in all cases of simple compression Its success is : it may be practised in cases of ordinary neuritis. we may with a supple peripheral . away with of nerve. then. and a peripheral end. all the more likely when intervention is prompt. if necessary. found no obstacle to regeneration. offering growth of nerve fibres supple fulfil and readily permeable sheaths. is Any sew suture that does not these conditions defective and almost invariably condemned but to failure. segment on risk serious to a neuroma is richly supplied axis-cylinders we disturbances in the arrangement of the nerve fasciculi.

is is — in spite of a liberation. owing to the proliferaa rule. Lastly.304 catgut NERVE WOUNDS — inserted in the neurilemma. interposition of fragments All other grafting processes are more or less defective. In any case. the only legitimate nerve grafting. two millimetres. it is shrivelled nerve extremities exposes the axis-cylinders to the risk of going astray (Nageotte). as and A. though almost as effectively as. is never effica- difficult — When the distance between the recommended by J.* it If the suture is is tight and we are compelled to go through the nerve. since suppresses part is of the nerve. are sewn on both sides to the central and peripheral segments. segments of the nerve trunk operation too great to permit of direct suture. always the which must be divided. all. neuritis it may even be recommended in certain cases of grave from interstititial lesions. One. strong enough not to tear and readily reabsorbable so as to leave no element of irritation in the is middle of the axis-cylinders. since it inevitably interrupts half of the peripheral segment axis-cylinders. — of fibrous contractions and trophic disturbances which are so Nerve grafting. This consists in uniting the segments of the interrupted nerve by the removed from a sensory nerve. 3. suture which it unites . Regeneration would seem to take place through the graft somewhat more slowly than. better to leave between by the the segments a space of one or even neuroglial proliferation. As it appears to take place from the fourth day onwards (Dustin). Division of the central end should be altogether condemned. In our opinion. which to a considerable length may be removed from the leg. * Catgut should be used exclusively in nerve suture. after infiltration. The musculocutaneous. — (Ed. if this suture is practised. it it Suture by division into two is inevitably partial. we know that union of the central and peripheral segments is extremely rapid. two. there tion of the neuroglial cells .) . by direct suture. hemorrhages or fibrous which. Dejerine and Mouzon. united in a bundle by catgut passed through them. By experiments made on animals. along with an almost or wholly complete interruption. The to divided fragment also should be completely detached and sewn end end with the two segments of the interrupted nerve. is the nerve to which preference is given. no occasion to dread secondary rupture after nerve suture. or more of these fragments. In these cases it is better to run the risks of suture than to see the evolution and prolongation cious to cure. easily filled in Suture as thus interpreted is certainly the best operation for all serious nerve lesions in which. a tight suture must ensure simple coaptation between the segments which crushes against each other the Rather than incur this risk. preferable to use only catgut. there exists an obstacle to regeneration.

sutures by division into two of the upper segment. transplantations of one nerve into the other. purposeless since it merely removes extremity of the regenerating nerve fibres above an interruption without supplying a guiding channel for these fibres . as does a neuroma in the case of an amputation. the scar. For instance. the regeneration of uncertainty. however. is There nothing but nerve tissue that can serve as a conductor for regenerat- ing axis-cylinders. attempts 20 .SURGICAL TREATMENT Pseudo-graftings by interposition between the nerve segments of" 305 some fragments of aponeurotic sheaths. we we may are sometimes simply suture Moreover. has been proposed . it neither liberates nor restores anything but merely effects a chance division into sections of a few nerve fibres. — All that we have said about the main principles show how illogical and ineffective are certain methods once strongly recommended. the removed lateral neuroma will inevitably form again on the same spot. its untouched part bent back loop-fashion to allow of direct suture of the segments shortened In these cases by removal. and more of nerve regeneration is sufficient to . interventions can only be made on the big nerve trunks. cases is which thus becomes a matter of in The only "combing" which can in cases be advocated some the longitudinal incision of the sheath at the level of the interstitial hematomata occasionally found Partial operations. such as the sciatic. it has been enveloped in a peritoneal flap or a layer of amnion . " Combing " of the nerve must also be condemned . such They may is be effected by cleavage of the nerve . Isolation of the nerve by an aponeurotic Hap. it is better. All lateral sutures must be condemned that do not make continuous the axis-cylinders of the central end and the empty sheaths of the peripheral end lateral implantations. when reuniting the cut bundle. We vention must condemn the ablation of the is lateral neuromata the . — For partial lesions. demned to failure. especially transplantations of a motor nerve into a sensory one arc almost such inter- always useless and often mischievous operations. a tatty — covering. catgut has been rolled round the nerve . except in the case of the big nerve trunks. a muscular bed. an interrupted bundle of a partially untouched nerve. practise partial operations. Care must be taken lest liberated or sutured Isolation of the nerves. catgut threads intended to serve as conducting wires (?) are wholly illogical and inevitably con- tendon fibres. Defective operations. nerves should again be embedded and compressed by the fibrous tissue of Several methods of preventing tin's have been recommended. led to of violent contusion. to have recourse to grafting.

we would rightly endeavour to do away with cicatricial fibrous formations round the nerve. we must the tissues into not forget that fibrous tissue . practise mobilisation and massage of the cicatrix very carefully and in good time. especially as the use of foreign must be well understood that the laying bare of the nerve it to a considerable extent and the rolling round of an isolating plate of any kind involves the risk of diminishing vascularisation from the surrounding tissues If and thus compromising regeneration. is certainly the But in all other cases we look upon these proceedings as both useless and harmful. . the best a fatty interposition of a muscular — or better still — method layer. all inflammatory reaction at an end. pain certain cases of more especially in causalgia. in give it as our opinion. fat. though failure has resulted in cases of causalgia painful nerve recovers with extreme rapidity. . peritoneum. should take place only after complete cicatrisation of the wound is and when 2. It many cases. and even harmful bodies. The i. in the In these cases we can and ought to effect isolation of the nerve vicinity of callus or a bony projection . is when the liberated or sutured nerve happens to be periosteal contact bony or capable it secondarily liberated the most frequent instance that of the musculo-spiral from the callus of a fractured humerus.3 o6 NERVE WOUNDS it have even been made to wrap round rubber . This succeeds quite well in serious cases of neuritis complicated with . in these practices are almost regards always useless. a nerve operation. a thin sheet of two united fragments have been brought vein or an artery a few drops of gomenol have been the . that none of these practices. as far as possible. speaking generally. resection and suture of the nerve have been practised. —The failure of all kinds of in treatment and the continuance of intolerable severe neuritis. . Alcoholisation of nerve trunks (Sicard). In our opinion. amnion connective are as likely to be transformed tissue itself. factors in secondary fibrous formations. . In several cases. There surfaces is is but one exception to of involving and that with . blood infiltration being one of the main 3. To make To a very careful hemostasis. into a aluminium or of segment of a injected around the nerve. are to be adopted. and the causalgic the syndrome usually reappears after a few weeks. best means of avoiding cicatricial fibrous formations is : To avoid operating in a septic area. may develop at the expense of all muscle. therefore. cicatricial tissue as the We this rule. have led certain authorities to attempt the physiological interruption of the nerve. trophic disturbances.

although the interpretation of these in their symptoms is probably some- what complex. alcohol. etc. diminution of the pulse. I June. would often appear to reach only more fragile sensory fibres. The same intervention has been proposed the femoral artery in causalgia of the lower limb. Under surround reflex which would result in the suppression of the reactions of the sympathetic which give neuralgia its distinctive these conditions. Pitrcs. and diminution of sweating at this level.). Grinda. At all events. Godlewski. Sicard. which. intermittent redness of ear on the affected side. or else supplied to the nerve by the periarterial sympathetic plexus. t R. This operation which is attributed is based on the special nature of the pain in causalgia. injection of one to two cubic centimetres is made in the nerve itself. 20 April. 1 916. We for rather think there exists sympathetic irritation of a reflex nature. have found such irritation extend over almost the entire region of the cervico-dorsal sympathetic. . Causalgic symptoms would appear to be largely sympathetic nature.SURGICAL TREATMENT Sicard * has 307 recommended alcoholisation of the nerve trunks. surgical exposure. have been successful with this method. of the nerve. this procedure has given some for results in obstinate cases. resection of the sympathetic plexuses brachial the artery characteristics. and Morel state that they Denudation of the arteries (Leriche). Presse Medicate. Presse Me'Jicale. 1916. Tim after There the is thus produced by local neuritis a physiological interruption Sicard. according to Sicard. Benott. numbness of the lower part of the face. Leriche f — For the treatment of causalgia. even in the case of lesion of the median at the wrist (pain over the entire area of" we the median. constriction of the brachial artery. advocated arterial denudation and resection of the perivascular sympathetic plexus. Leriche. to irritation of the sympathetic twigs supplied by the nerve to the neighbouring artery. effected by injecting above the lesion a solution of sixty per cent.

Accelerate regeneration. consequently a utilised.. longitudinal excitation by the negative pole will be used to bring about contraction The galvanic current causes contraction only at the closing and the opening of the Gurrent. 1. Besides. capable of being excited In case of reaction of degeneration. motor point . a gentle and easily borne contraction will be obtained. therefore. however. CHAPTER XXVI ELECTRICAL TREATMENT Electrical treatment may i. is that which is will most readily and least intensity produce muscular contraction. . 3. almost of the always stronger at muscle. We lessen its action on the paralysed muscles. then. and permits of greater intensities being utilised without pain. 2. fulfill three main indications . Practically. The principal role of electrical treatment in paralysis contractility of the paralysed is to maintain muscle until voluntary contraction returns. it may : Maintain contractility of the paralysed muscles. The passing of the current attains this object by artificially bringing about contraction of the muscle. not diffused into the If there is no RD. the least intensity. Soothe the pain. less painful than the sudden application of the current. Consequently it will be a good thing always to effect this gradual application. the positive pole would give the best contraction motor point with it is On the other hand. limited Thus almost exclusively to the paralysed muscles and healthy antagonistic muscles. the muscle can be excited by the faradic current once the muscular groups can be contracted under the faradic current. whereas it it suppressed the is excitation of the healthy antagonistic muscles. is There is polar inversion at the at this point. rhythmic current will be one capable of producing somewhat slow interruptions (metronome have seen that the gradual application of the current did not or undulatory). we . then. the muscle only by the galvanic current. The with current to be used. longitudinal excitation invariably greater than excitation through the the negative pole. either series by employing condensers set in (Lapique) or by the use of metallic undulators.

2. or even twenty-five milliamperes. . Consequently a simple galvanic bath. with negative pole and of moderate intensity. it is by far the best treatment for muscular atrophy.. Better results are frequently obtained from prolonged baths of extremely feeble intensity for instance. The galvanic current is a wonderful pain-allaying sedative. to utilise this current contraction. set to rhythm or. according to the case. produced by stout wire This current of the produces phenomena of vaso-constriction followed by intense. ten. about ten or fifteen milliamperes. is an excitant. whether muscular contraction is caused by the galvanic or by the farad ic current. The rhythmic faradic bath contractions. cicatricial of muscular fibrous of cutaneous adhesions and of the articular fibrous ankyloses produced by neurites. Mention must also be made of the favourable influence of the faradic coils. The simple passing of the electric current appears capable of hastening the regeneration of the nerve. ELECTRICAL TREATMENT shall 309 in effecting be able. with three and four milliamperes lasting . caused by the coil interrupter we shall have recourse to interrupted tetanisation. from five. as well as of contractions from nerve irritation. with a moderate intensity. particularly useful in the treatment of infiltrations. deep vasodilatation and appearing extremely favourable is to the nutrition tissues as well as to regeneration. by the metronome. by an undulator. slow beat. We may advantageously bring about the association of the galvanic . The negative pole. a few daily contractions are sufficient cartmust be taken not to overwork a muscle disturbed in its nutrition. 3. maintaining the nutrition of the tissues and facilitating the resolution of the cicatricial fibrous tissues. on the other hand. the galvanic current. with intensities varying. this association and faradic currents under the galvano-faradic form paralysed muscle whilst avoiding its fibrous allows of excitation of the transformation . which" would react by atrophy to an electrical treatment which is too paralysed muscle. can be made to precede the few rhythmic excitations intended to maintain its contractility. several hours we have obtained sedative results that shorter baths of greater intensity could not have given. though this property is possessed only by the positive pole. — Salicylated or iodised ionization has been employed with . This current is utilised most frequently in the form of positive pole galvanic baths. is generally em- ployed. For this purpose. lasting from fifteen to twenty minutes. better still. strong. only a moderate effort must be required from the As a rule. First then later we shall utilise the brief contractions. though always to a very In any case. current of feeble intensity. Ionization. twenty.

Improvement cases. be Daily massage should * R. in other appears only ofter seven or eight treatments. recommended by Bourguignon. Radiotherapy treatment of certain traumatic lesions of Prcssc Me'JicaU. which the patient must be warned. caused by irritation to be indicated radiotherapy applied to the ganglia the pain results from the state and roots would seem in causalgia. 191 5. though inconstant and often is the lessening of fibrous griffes and muscular contractions result. often very useful in the treatment of Radiotherapy. for each of these methods has given favourable results after the a possibility of other has failed. — Diathermy may The results also be serviceable in painful and sclerosing and in states of ischaemia accompanied by fibrous transformation. is no rare occurrence to find a momentary recrudescence of the pain. to prevent its massage is perhaps as important as electrotherapy. given to every paralysed muscle. interstitial infiltration and connective . — Radiotherapy we irritation. painful neuritis. maintain the contractility of a paralysed muscle. sometimes remarkable. has acted rather upon violent neuralgias of a causalgic type than duller pains in of nerve several We have seen upon the more though especially cases of causalgia of the median nerve frequently the violent painful paroxysms alone have disappeared whilst the dull pains continued. when of reflex hyper-excitability of the ganglion cells which appears to be present MECHANOTHERAPY— MASSAGE— GYMNASTICS-PROSTHESIS However great the therapeutical resources of electricity in that all its forms. in the Descamps. neuritis. Cestan and the nervous system. NERVE WOUNDS in the treatment of neuritic pains and fibrous Some good negative pole) effected is results have been obtained by ionization (i% KI solution. we must not forget massage and mechanotherapy are absolutely necessary to supplement them. is have obtained .310 widely varying results formations. To fibrous transformation. It is probable that radiotherapy applied to the in lesion acts on the inflammatory element tissue proliferation the nerve. The diminution of pain fleeting . It it is sometimes shown after the first treatment . 25 November. . On this point we are unable to afford any precise indication. Radiotherapy may take place either on the nerve lesion itself and the course of the affected nerve or on the roots and spinal ganglia which supply the nerve. confirm the statistics published by Cestan and Descamps * though in our opinion radiotherapy cures effected . a more constant Diathermy.

it is often necessary to make use of appliances of an elementary its is prosthetic nature. In addition to the passive mechanotherapy represented by massage and mobilisation. Other appliances have as their object the avoidance of fibrous contractions and All these appliances should be removable without any difficulty . Gymnastics of the wounded limbs. Finally. And is It logical to utilise the sclerolytic quality of thiosinamin in the treatcicatricial ment of the fibrous lesions compressing the injured nerve or creating an interstitial obstacle to regeneration of the axis-cylinders. a hot bath and faradic current combined. both in order to keep the limb in right place and to permit of its being used in a normal fashion . SCLEROLYTIC MEDICINAL TREATMENT some mention mu->t be made of the treatment of nerve wounds by thiosinamin or fibrolysin (salicylate of thiosinamin). lastly. both general and is thus of the utmost importance. of articular fibrous ankyloses and muscular contractions might easily be avoided by daily mobilisation. this principally the case in with apparatus intended to correct flexion of the hand paralysis and also steppage in paralysis of the external of the appearance of griffis. One must have witnessed the disastrous results of prolonged immobilisation in cases of peripheral and neuritis to understand the supreme importance of active movements. unless this The same may be said of mobilisation which in cases of neuritis accompanied by a tendency to A great number of neuritic griffes. they may readily be improvised with the aid of elastics or springs. This muscles ration . . latter also it maintains the contractility and nutrition of the paralysed helps forward a return of the earliest movements after regene- it facilitates and provokes the important substitutionary movements muscles . in every form. to cutaneous adhesions and to articular sclerosis latter is . we must also insist on the importance of the active mechano- therapy effected by gymnastics. Inactivity of the wounded limbs and moral inertia of the patient form the main cause of the irreducible deformities. the functional paralyses that accompany or follow organic paralysis paralyses. in the case of paralysed it mobilises the articulations and integu- ments. it really intolerable. . should be practised daily fibrous ankylosis. In cases of neuritis both massage and mobilisation are invariably more easy and efficacious as well as less painful after the limb has been subjected to a hot bath. musculo-spiral popliteal. or better still. must be given in spite of the pain. the neuritic contractions.ELECTRICAL TREATMENT 311 A fortiori massage is indispensable in nerve irritations that have a tendency to fibrous contraction of the muscle. particular.

to be specially indicated compression.s. 191 5. q. neuromata of attrition and neuritic types. 11 November. is inaccessible to surgical it ment . Thiosinamin would seem infiltration of the nerve. or better intra-muscular injections. in or every other day. syndromes of where fibrous treat- being interstitial. be utilised The following formula may Thiosinamin Antipyrin Distilled water . 15 7*5 in subcutaneous. NERVE WOUNDS Cazamian * has mentioned good results thereby . Twenty-five or either daily thirty consecutive injections in doses of two cubic centimetres.. grammes. grammes.. which are so to mobilise and require so long a time. to still. .— 3 i2 P. Presse Me'dicale. in several instances he would appear to have effected the disappearance of the nerve tumour and also a certain functional improvement.. * Cazamian. it would also in appear as though cases had a favourable action on the difficult fibrous sequelae of nerve irritation. 150 grammes.

73. 239 Current. 77. 218 Arteries. 91 of hand in flexion. 2 1 Alcohol. 201 branches. 3. 130 of Leri. 5. 181. 204 of cutaneous area. 176. 117. 15. 21. 78 Cazamian. 23 Contraction. 21 Compression of nerve. and terminal branches. massive. 33. 195 273 271-272 Club-foot. 90 from nerve irritation. Claude. 180. 66. 30 muscular. 37-40 galvanic. 55 Anterior tibial nerve. 90 Cluzet. 59 13. 82. 306 Amesthesia. in electro-physiology. faradic. 203-204 in paralysis of. 73 Contracture. 147. 59 Bielchowski. 55. Clironaxie. 84 of interossei and hypothenar eminence.1 1 INDEX Brachial plexus. 214-215 primary and secondary trunks. 1 87—19 277 of hand. 60. Sollier's. xii. 24 club-foot from. deep and cutaneous. 295 in musculo-spiral paralysis. 247-248 Aponeuroses. 312 Cestan. Wallerian. 14. 107 in section of circumflex. 210 radicular syndromes (roots and primary trunks). skin. 168 from lesion of posterior tibial. sensory disturbances 204 271 diagnosis of paralysis paralysis of. 131 of Marie and Meige. 166 Benoit. Bergonie. 93. 209 Action. 40-45 I! 1) Babinski. 2 Contractility. denudation of. 61. 265 Appendages. fibrous. method Bordier. 131 of Robin-Chiray. 40. of muscles. 215-224 lesions of. 193 peripheral. injection of. 88-91 functional. 268of. Andre-Thomas. 82. 86. 304 . Broca. S8. 49 branches of. 97 thermal. 74 13 Dejerine. 86. 23. polar. 49 Causalgia. 2 Cruveilbier. of muscle. 307 Decalcification. 310 Charcot clinic. 245. 92 segmentary. xii. 191 Atropy. 265 of Mauchet and Anceau. 62. 307 Athanassio-Benisty. 265 of Le>i and Dagnan-Bouveret. 5c. 88. 310 189. 83 from neuritis. 82. 29 Aran-Duchenne syndrome. mechanical. xii. 212-214 connexions of. of. 188. 65. 57-58 Circumflex nerve. 160. Bourguignon. 30 Degeneration. 255 in complete section of ulnar. vii 53-59 Chronaximetrc of Lapicque. 31-33 chloroform. 142 in lumbar hematomyelia. 159. 246. xii. 86 complete ulnar. Contusion ot nerve. xii Cardot. 231. 202-203 paralysis of. 29 Apparatus. collateral xii. 75 Anterior crural nerve. 166 of external cutaneous nerve of thigh. 11. 255. paralysis ot.

68-69. 280-281 280-281 Indications for operation. 93 Hypertrichosis. of paralyzed muscles. salicylated. cutaneous. 272of Ionization. 49. loop of. lesions Glioma.3H Delherm. 244 trophic and vaso-motor syndrome. cutaneous. 52 Genito-crural nerve. 233 clinical forms of paralysis of. 55-57 Lejars. 234- and terminal branches. Excitation. 250-251 sensory syndrome. 310 Disturbances. 241 External popliteal nerve. atrophy of. 237-239 Excitability. 70. Integuments. 156. 82. 97 of. 70. 216 of. 310 Diagnosis of nerve lesions. xii Lemoing's glove. 310 Desquamation. 3io» 3 11 Lapicque. in treatment neuritic pains. 48 Jumenti£. 24. paradox 39 Erb-Duchenne syndrome. latent faradic." 19 Gosset. longitudinal reaction 45 Dubois. 157 Dustin. 25 thermal. 11 Godlewski. 225-229 Fibrous Foix. 73. 40 Jeanne. xii.145-169. 27 Doumer-Huet. 37-40 40 40-45 Internal plantar nerve.255. 28 vaso-motor. selective. 205 lesions of. 242 sensory syndrome. 270 Hyperesthesia. incisures of. 153 Jolly. 192. 18 provoked by pressure. 15 INDEX H Hjematomyelia.96. 299 Ilio-inguinal nerve. 307 "Goniometer. 149 Dupuytren's contracture. 310 . 29 Hypoassthesia. Diathermy. galvanic. 9-1 1. 25 Internal cutaneous nerves. xii K Galvano-tonus. 206 Grinda. of. 308- Ilio-hypogastric nerve. 206-207 Examination. 40 Delorme. 13 Granular bodies. 307 Gymnastics. 109-110 Ischemic paralysis. 13! Electrical treatment 309 in paralysis. 302 Descamps. 253 motor syndrome. 254 slight neuritic type. 239242 grave neuritic type. 304 Lantermann. infiltration of muscles. 213 Histology. 279 v. 32. 253 trophic and vaso-motor syndrome. 301 Grafting of nerve. 79 Henle. faradic. 53-59 Lasegne's sign. 92 Head. 37. 257 252 Internal saphenous nerve. 1. 12. 242-243 paralysis of. 245 collateral and terminal branches. 257. 70 49 Formication. 304 Hypothenar eminence. Keloids. 24c Internal popliteal nerve. nerve. 96-98.98. 58-59 External cutaneous nerve of thigh. 5 Griffe. 34 Froment. 251- 237 motor syndrome. 307 Lesser internal cutaneous nerve. xii. 5-15 Hunter's canal. 259 Laugier. 19. 166 Jarkovski. Engelmann. 191. 251 collateral simple neuralgic type. 223 of upper limb. 4. 244 External saphenous nerve. 130 Leriche. examination of. 39. 86. 3. 33 Duchenne of Boulogne. 277-278 External plantar nerve. lesions 2 73. 53 Erb. 73 or'. 15 Glossy-skin. 69 Hypertonia. xii. 72. 32.

29 Nerve. 15. Obturator nerve. 282-286 diagnosis of the lesions or. 268. 310 sensory branches. alcoholization of. 174 anatomy of 170 causalgia of. xii. sections of. 245. 60. 24 sensibility to pressure. 294-296 radicular syndromes of. 23. Poupart's. 187-193 N Nageotte. 7 anatomy of. 82-91 Neuroma. 130. xii. internal cutaneous. 287-289 below radial extensors. 302 Ligament. 272. 275 sciatic. 1 14 below supinator longus. 300 . 112 paralysis of. 305 choice of. 306 Neuritis. 81-82 paralysis. 42. 1 24 1 Median nerve. 147. anastomotic branches. defective and partial. Meige. 185-187 paralysis below epitrochlear 182-183 dissection of. anatomy 99 diagnosis or musculo-spiral 126 1 of. P. complete paralysis above epitrochlear muscles. 266 ulnar. 23 Mouzon. 177 Median and ulnar nerves. 9. isolation of.. 183-185 motor branches. 77. 102 motor syndrome. 275 superficial ami deep branches. 201 external cutaneous nerve of thigh. 279 3*5 continue J paralysis Musculo-spinal nerve below 1 extensor 16 communis digitorum. hypertonia and contraction from. 7 branches. 289-290 Lumbo-sacral plexus. 49. CEderaa. 7-16. fibrous contraction of. 14. 302 Nerves. 52 xii. 1-4. 99-103 motor syndrome. interosseous. 109 M Marchi. 24 median. 21. 303 muscles. 104-117 194-196 40. 205 lesser internal cutaneous. 301 Massage. 302 grafting. 176 trophic syndrome. 277 genito-crural. 138 Muscular atrophy. Nerve trunks.1 — INDEX Letievant. 41. 35-36 Neurotropism. 175 neuritis of. Motor points. 160. 129 trophic syndrome. 117. 104 paralysis above supinator longus. 2 contraction and hypertonia. 1 15 motor branches. 191. 121 syndrome of regeneration. 102 sensory syndrome. 197 tone. 1. 104 partial paralysis of triceps. 82. 6. 173 sensory syndrome. 109 treatment. 310 Mechanotherapy. 301 xii. 108 anastomotic branch. 5 Marie. xii Liberation of nerve. 108 Operations. 170 musculo-cutaneous. 246. 103 O paialysis. 65. 43 280 206 descent of. 248-249 motor and sensory syndromes. 304 Muscle. 40. 107 syndrome of compression. 73. 268 circumflex. musculo-spiral. 159. 118 syndrome of interruption. 130. 132 21-22 Musculo-cutaneous nerve. 231 small sciatic. mechanical contractility of. 23 Muscles. 200 paralysis of. 4. 197 obturator. 178-182 diagnosis of paralysis of. 199 isolated paralysis of. 279 ilio-hypogastric. 19 syndrome of nerve irritation. 99 anterior crural. changes in. 172 304 Nails. 33. 198. 117. Morel. 27 of hand. 200 Musculo-spiral nerve. ascending. 276 dissociated paralysis of. musculo-spiral. 300 no time of. 307 suture of. 189. 301 indications for. 302 sensory branches. 77. associated paralysis of. 305-306 liberation of. 117. total paralysis of. 99-131 physiology of. paralysis paralysis Lumbar roots. dissociation of extensor 16 digi- communis torum. 192 dissociated paralysis of.

132 contractions resulting from slight neuritis of. xii Societe de Neurologie de Paris. 191. 50 negative. 308 Triangle. 12. 69. muscular. 31 deep. 33 Sheaths. 63-66 fibrous transformation. 47 nerve irritation. 231 collateral and terminal branches. crutch. collateral and terminal branches. 18-30 apparatus for. 273. spontaneous. 46. 311-312 Thomsen's disease. 37 bipolar. 95 functional. 80-8 Peroncito. 65 Palsy. 297-299 and . 34 osseous. 15 Pudendal plexus. Trophic changes. time of. 257-262 Sclerolytic neuralgia of. 4. 51 positive. 262-264 paralysis of. 45. 136 Sacral roots. 92 diagnosis of. 310 Reaction of degeneration. 21. Scarpa's. 52 myotonic. of muscle to pressure. 264-265 Sciatic trunk. 28 Ulnar nerve. 306. 266-267 Societe de Chirurgie de Paris. 253. 29 Sicard. 165 physiology of. 303-304 Syndrome of nerve interruption. action. 135-136 sensory syndrome. treatment of. 1 30-1 31 central. 255 Pseudo-^r^. 261 Petres. 33 of nerve on pressure. 93-96 hysterical. 300 choice of. 95. 250 Thenar eminence. xii Pole. 164 Pseudo-neuroma. 259. 24 Testut. 99 "Saturday night. 96 musculo-spiral. electrical. xii. 164-165 from pseudarthrosis. 136 sensory branches of. 20 U Ulceration. 2. 82.. 67-73 regeneration. 129-130 136-165 Suture of nerve. 23. 30 Radiotherapy. paralysis Prosthesis.2 3 1 316 INDEX Sensibility. 22. 311 of. 144 Surgical intervention. Revue Neurologiqut. 95 simple compression of. 48 Reflexes. 158 neuritis of. dissociated. 23 Treatment. 3. of. 97 ischaemic. 142 . 48 of exhaustion. 45 partial. paralysis of. 39 complete. 278 xii 165 dissociated syndromes. anatomy of. 68. 291—293 Schwann. 5. 302. 257 Stimulation. 133-134 motor syndrome of ulnar paralysis. anatomy. 88. 1 Sciatic nerve. 182 Thiosinamin in treatment of nerve wounds. 61-63 prognosis Peripheral nerve lesions. 268. 25. 307 Small sciatic nerve. 31 1-3 1 ruption. 154 trophic and vaso-motor syndrome. unipolar. 250. 24. 48 Tone. 8 Pes equinus. 232233 diagnosis of paralysis of. 144 syndrome of prolonged complete inter- medicinal treatment of nerve wounds. sweat. 301-307 treatment ulnar. 286-287 Tendons. 242-257 treatment of paralysis of. 65. 37 104-128 pseudo-. 307 Philippeaux. xii Steppage. 33 Pain. 243. synovial. 73-79 Posterior tibial nerve. W. 279 R Radiograph of hand. 141 simple compression or recent interruption of. Roth. sheath of. 191." 99 Paralysis. 243. 26 longitudinal. 140 atrophy of. 158 motor branches of. 149 syndrome of nerve irritation. 51 of of of of compression. 65 provoked by pressure. 80 47 Reaction. cutaneous. 69. 23 attitude. 29 Tenotomy. 243.

Mitchell. LONDON AND BECCLES. 201 date of.INDEX Upper limb. 187 of. Weiss. xii. 228-229 or. points. 66. Valleix. 18 1 18 THE END I'RINTED IN GREAT BRITAIN BY \VI LL1AM CLOWI-S AND SONS. quadrilateral square of. 27 Velpeau. 7 investigation of first sequelae nerve disturbances of. 70.. 53 Wound. ischemic paralysis characteristics of. examination 17 of. 71-72. 3*7 225 Velter. Weir xii S. LIMITED. >ii W Waller. . 259 Vaso-motor changes. 226-228 diagnosis of. xii Vulpian.

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